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THE  UNIVERSITY 


OF  ILLINOIS 
LIBRARY 


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MET 

v.  52 


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Net  Price. 


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Discount  in  Lois,  25-150, _ 45% 

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From  Nov.  I,  S®903  Suhjscf  to  Chang®  Without  Notice 

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WRITE  FOR 

PRICES  KND  CIRCULARS 

Nearest  District  OSes  or  to  any  Electrical  Supply  House. 

Eastern  District,  Edison  Building,  New  York. 

New  England  District,  3S  Pearl  Street,  Boston. 

Central  District,  Rialto  Building,  Chicago. 

Southern  District,  Cotton  Exchange,  New  Orleans. 
Mountain  District,  Denver  Col. 

Pacific  District,  San  Erancisco,  Cal. 

Northwestern  District.  Portland,  Ore. 
Canadian  District,  Toronto,  Can. 


EDISON  GENERAL  ELECTRIC  CO. 


REGENERATOR. 


county.  Mr.n,’  dioioe  and  valuable  presents 
were  received.  An  elegant  luncheon  was 
served.  in  which  about.  150  invited  guests  j 
participated.  The  bride  and  groom  left  to  I 
spend  a  portion  of  their  honeymoon  in  Cin-  , 
cinnati.  j 

The  marriage  of  Mr.  Michael  Long  to  Miss 
Lizzie  F'arreil  took  place  last  W  ednesday  ! 
morning  at  St.  Patrick  Church.  The  brine  I 
was  dressed  in  beautiful  cream-colored  silk.  I 
In  the  evening  the  couple  gave  a  reception 
to  their  many  friends  at  the  residence  of  the 
bride  in  Clifton. where  dancing  was  indulged 
in  until  the  w-ee small  hours.  A  large  num¬ 
ber  of  invited  guests  was  present. 

Danvillf,  Ind.,  October  31.— Mr.  Oscar  Mc- 
Yey  and  Miss  Bertie  Conaroe.  two  well- 
known  young  society  people  of  tit  is  place 
Were  married  last  evening  at  Miss  Conaroe  s 
home,  on  South  Washington  street.  Elder  A. 
J.  Frank,  of  the  Christiaan  Church,  officiating. 
The  pleasant  affair  was  largely  attended  by 
hosts  of  friends  from  abroad.  Mr.  and  Mrs. 
McVey  will  beat  home  to  their  friends  in 
thi3  city  on  and  after  November  15. 

Mt.  Healthy.  Ohio,  October  29. — Mr.  Chas. 
Hill  and  Miss  Edna  Earle  Seward,  well- 
known  young  people  of  this  place,  were  mar¬ 
ried  Tuesday.  The  wedding  was  a  quiet  one, 
attended  only  by  the  relatives.  Kev.  E.  E. 
Curry,  of  the  Christian  Church,  performed 
the  ceremony,  which  occurred  at  8  o’clock-. 
Mr.  and  Mrs.  Hill  will  reside  at  Mt.  Healthy. 

Mr.  Joseph  Eckert  and  Miss  Til  lie  Brosey 
were  married  October  28.  Mr.  and  Mrs.  Eck¬ 
ert  will  make  their  home  in  Cincinnati. 

Galion,  Ohio,  October  30.— Mrs.  Frank 
Ristine.  of  this  city,  was  married  at  Chicago 
last  Wednesday  morning  to  Mr.  John  Mc¬ 
Cormick.  Chief  Billing  Clerk  of  the  Chicago 
and  Kansas  City  Railroad.  There  is  a  tinge 
of  romance  connected  with  tiie  nuptials 
from  the  fact  that  the  groom  was  an  intimate 
acquaintance  of  the  bride  in  her  girlhood 
days.  Mrs.  Ristine  comes  from  one  of  the 
wealthiest  families  in  this  city,  the  Longs, 
fend  her  many  friends  here  wish  the  couple  a 
long  and  happy  life. 

Bucybtjs.  Ohio.  October  SO.— Captain  J.  F. 
Reiser.  Postmaster  at  Upper  Sandusky,  was 
married  last  Tuesday  evening  to  Mrs.  Win. 
fstremmel,  of  this  city,  at  the  residence  of  Mr. 
and  Mrs.  Fred  Keiu.  After  the  usual  mar¬ 
riage  banquet  the  newly  wedded  couple  left 
for  their  new  home  at  Upper  Sandusky. 

Mrs.  Chas.  Flocken  and  Miss  Lena  Walt  her 
were  married  at  the  residence  of  the  bride’s 
parents  on  W  ednesday  evening.  Both  are 
popular  young  people  of  this  city,  and  they 
cave  the  best  wishes  of  their  many  friends. 

Newark,  Ohio,  October  29.— Two  brilliant 
matrimonial  events  took  place  here  to-day, 
both  being  witnessed  by  many  guests.  The 
first  was  at  the  home  of  Mr.  and  Mrs.  H.  A.  j 
Montgomery,  when  their  daughter.  Miss 
Ida.  was  joined  in  wedlock  to  Dr.  J.  B.  Chase, 
of  Philadelphia,  a  prominent,  physician. 
Rev.  J.  H.  Gardner  performed  the  ceremony. 

The  second  was  at  the  farm  home  of  Mr. 
and  Mrs.  D.  T.  Franks,  the  contracting  par¬ 
ties  being  their  daughter.  Miss  Dora,  and 
Mr.  Frank  Otfenhaugh.  Both  of  these  wed¬ 
dings  were  leading  events  of  the  day. 

Marietta,  Ohio,  October  31.— One  of  the 
most  notable  society  events  of  the  week  was 
the  marriage  of  Miss  Maggie  Reckard. 
daughter  of  Mr.  and  Mrs.  J.  L.  Reckard.  to 
Mr,  Arthur  G.  Smith,  of  Evistis.  Fla.,  at  the 
home  of  the  bride,  on  Green  street.  Rev.  C. 
E.  Dickinson  officiating.  The  bride  wore  a 
becoming  toilet  of  white  satin,  en  traine.  and 
looked  a  picture  of  loveliness,  i'he  maids  of 
honor  were  Miss  Nellie  ila. 
cothe,  and  Miss  NinaEuij 
The  happy  couple  departed 
for  their  future  home.  1J 
good  wishes  follow  them. 

Paulding.  Ohio,  Octo 
wedding  occurred  at  tl 
Church,  in  this  city,  tj 
contracting  parties 
Allen  and  Miss  Est$ 

A  large  number. 


of  Ohilli- 
JPittsburg. 
evening 
'  Lfic  y 


mer  and  L.  I.  Arron;  Mansfield,  John 
Weaver.  George  Rhien.  jr„  Jerry  Haggerty. 
Plenry  Webber  and  daughter. 

4  very  pretty  wedding  was  solemnized 
Wednesday  evening  at  the  Baptist  Church, 
in  which  Mr.  0.  E.  Williams,  of  Columbus, 
and  Miss  Bertha  Sorrick.  daughter  of  John 

H.  Sorrick. .  were  the  contracting  parties. 
About  200  friends  were  present  to  witness  the 
ceremony.  The  ushers  were  J.  F.  Doran. 
Charles  Mai  ret.,  W.  H.  Spicer  and  11. 1).  Cole. 
After  the  ceremony  a  reception  was  held  at 
the  handsome  home  of  t lie  bride’s  parents  on 
South  High  street.  The  house  was  superbly 
decorated  with  potted  plants  and  cut  flowers. 
Mr.  Williams  is  train-dispatcher  in  the  em¬ 
ploy  of  the  Cleveland.  Akron  and  Columbus 
Railway.  Trie  bride  is  the  only  daughter  of 
Mr.  John  Sorrick.  and  is  well  known  and 
highly  esteemed  among  the  young  people  of 
the  city. 

New  Vienna,  Ohio.  October  31.— At  8  o’clock 
on  Thursday  evening.  October  30.  Mr.  Nor¬ 
wood  Clitlord  Henning  and  Miss  Jessie  L. 
Harrison  were  united  in  marriage  in  the 

I. .G.  O.  F.  temple  of  this  place.  Rev.  Deem, 
of  the  M.  E.  Church,  officiating.  The  main 
lodge  room,  wnere  the  ceremony  took  place, 
was  artistically  decorated  with  trailing 
vines  and  blooming  plants.  The  contracting 
parties  stood  beneath  a  floral  umbrella, 
while  the  minister,  in  the  beautiful  cere¬ 
mony  of  the  ritual  of  the  M.  E.  church,  pro 
nounced  them  husband  and  wife.  I  hen  at 
once  they  led  the  way  to  the  adjoining  ban¬ 
quet  room,  where  an  elegant  wedding  supper 
was  served  to  the  159  invited  guests,  the 
bride  was  becomingly  attired  in  cream  cash¬ 
mere  anil  natural  flowers,  i  he  presents  were 
numerous  and  valuable.  Among  those  in  at¬ 
tendance  from  a  distance,  were:  Mr.  and 
Mrs.  W.  L.  Flenning.  Mr.  and  Mrs.  E.  8., 
Crawford  and  Mr.  C.  W.  Snyder.  Mt.  Oreb. 
Ohio;  Dr.  Scott  and  wife  and  Mr.  John  Henn¬ 
ing.  of  Martinsville,  Ohio:  Miss  Grace  Henn¬ 
ing,  of  A  andalia.  Ill.;  Dr.  Carter  and  wife,  of 
Hamilton,  Ohio;  Mr.  John  Carter,  of  Sabina. 
Ohio, 

Kenton.  Ohio,  October  39.— A  pleasant 
wedding  occurred  in  this  city  last  Tuesday, 
the  contracting  parties  being  Miss  Effie,  the 
accomplished  daughter  of  Mr.  and  Mrs.  Na- 
tnan  Ahlefeld.  and  Mr.  Jap  Andrews,  a 
prominent  young  business  man  of  Goshen. 
Jnd.  The  wedding  took  place  at  Nigh  noon 
at  the  elegant  home  of  Mr.  and  Mrs.  Ahle¬ 
feld.  It  was  a  quiet  home  affair,  the  guests 
being  limited  to  near  relatives  and  a  few  in¬ 
timate  friends.  The  house  was  becomingly 
decorated  with  plants  and  cut  flowers,  and 
presented  quite  a  festive  appearance.  Rev.  S. 

J.  Bogle,  pastor  of  the  Presbyterian  Church, 
was  the  officiating  minister.  Miss  Kate  Ahle¬ 
feld  and  Master  Kent  Melhorn  were  the  at¬ 
tendants.  After  the  ceremony  a  sumptuous 
wedding  feast  was  served.  They  lefi  on  the 
afternoon  train. forChicago.  From  there  they 
will  soon  go  to  Gosiien,  Ind.,  where  they  will 
make  their  home.  They  received  many  costly 
and  elegant  presents  from  relatives  and 
friends.  Hie  guests  from  a  distance  who  at¬ 
tended  the  wedding  were:  Mr.  L.  A.  Wilcox, 
ot  Grand  Rapids.  Mich. :  Mr.  and  Mrs.  Peter 
Ahlefeld.  of  Ada,;  Mrs.  S,  Andrews,  of  North 
Washington. 

Washington.  Ind.,  October  31— On  Tues¬ 
day  last  occurred  the  marriage  of  Mr.  Chas. 
G.  Gardiner  to.  .Miss  Jennie  Wells  Aikmen. 
both  of  this  city.  The  ceremony  was  per¬ 
formed  by  Rev.  0.  Helvetia,  pastor  of  the 
Presbyterian  Church,  at  11  a.  in.,  at  the  home 
oi  Mr.  Hiram  Hyatt,  uncle  of  the  bride.  This 
is  an  important  union  of  two  representatives 
of  the  old  pioneer  families  of  Indiana,  the 
groom  being  the  son  of  Hon.  W.  R.  Gardi¬ 
ner.  and  a  promising  young  barrister.  The 
bride,  a  pretty  brunette,  is  a  grand  daughter 
of  Colonel  John  Vantrus.  The  bride  was  at. 
red  in  a  silver  gray  si  Ik  gown  madeinPc' 

,d  carried  a  handsome  bunch  of  K  * 
es.  Miss  Lillie  Smith,  of  Vince.’ 
t7n  ^aalvred  silk,  and  Mr.  Join' 
re  the  attend- 


Powell  and  Fosterl 
Halloween  party 
Friday  evening. 

Arthur  Cleveland 
mouth  after  a  visit 
and  Mrs,  A.  B.  Clev 
A  number  of  visitl 
New  Richmond  sptl 
with  the  K.  of  P.  as  if 

ATIl 

Mrs.  judge  d  1 

several  days sd 
New  York  Cill 
M  rs.  J  udfge 
day  from  a  protracted! 
Amherst.  Mass, 

Mrs.  J.  B.  Allen  t. 
Blanche  Racer,  are  a) 
rietta. 

Mrs.  Charles  B.  H 
Iowa,  is  visiting  her 
Jewett,  of  Athens. 

Mrs.  E.  J.  J  ones  is  vis  i 
field,  Ohio. 

Mrs.  Rev.  W.  A.  T 
Pollock,  of  Thornvilb 
Mrs.  Charles  E.  FI 
Mrs.  R.  \V.  Chambe 
Iowa. 

Superintendent  W. 
ville  schools,  and  wif: 
pleasant  visit  to  his 
Jacob  Lash,  of  Athens 
Miss  Pearl  McVay, 
ston  High  School,  rett 
to  her  parents.  Mr.  ai 

AK  l| 


ANIEL  EDWAlJ 
turned  to  IndisJ 
a  t  visit  with  }  j 

erick. 

Mrs.  I).  J.  Kurtz,  ofj 
of  Ex-Governor  andj 
Charlie  Benson,  f . 
the  office  of  tbeS- 
Washington,  is  ; 
in  this  city. 

Mrs.  John 
town,  Penn., 

Miss  May  J 
with  her  uncle. , 

Mi.  B.  C.  Plenj 
tion  of  Home  M] 
at  Buffalo.  N.  Y  j 
Mr.  and  Mrs,* 
from  their  wed<l 
be  at  home  at  N  j 
Invitations  aij 
Miss  Francis  LoJ 
Dexter  Alien. 

Mr.  and  Mrs. 
and  is  well  kin/ 

Mrs.  Dr.  Wo  cl 
guest  of  her  si  j 
South  College  : 

John  BuctitfJ 
guest  of  Ins  p‘, 
tel,  during  tb| 

Miss  Maudj 
the  guest  of , 

Adolph  avel 
Mr.  and  }* 
are  visitj 
street. 


LIBRARY 
OF  THE 

UNIVERSITY  OF  !LL!NO'r 


THE  NEW  YORK  MEDICAL  JOURNAL,  JULY  5,  1890. 


Fig.  1. 


DR.  TAYLOR’S  CASE  OF  MULTIPLE  NEURITIS  OF  SYPHILITIC  ORIGIN 


THE 


v 


NEW  YORK 


MEDICAL  JOURNAL. 


A 


WEEKLY  REVIEW  OE  MEDICINE. 


EDITED  BY 

FRANK  P.  FOSTER,  M.D. 


VOLUME  L1I. 

JULY  TO  DECEMBER ,  1890 ,  INCLUSIVE. 


NEW  YORK: 

I).  APPLETON  AND  COMPANY, 

1,  3,  and  5  BOND  STREET. 

1890. 


Copyright,  1890, 

BY  D.  APPLETON  AND  COMPANY. 


/  . 
b  / 


LIST  OF  CONTRIBUTORS  TO  VOLUME  LII. 

{EXCLUSIVE  OF  ANONYMOUS  CORRESPONDENTS.) 


Those  whose  names  are  marked  with  an  asterisk  have  contributed  editorial  articles. 


ABBE,  ROBERT,  M.  D. 
ABERCROMBIE,  JOHN,  M.  D.,  London, 
England. 

ADAMS,  M.  M.,  M.  D.,  Greenfield,  Ind. 

*  ARMSTRONG,  S.  T.,  M.  D. 

ASCII.  MORRIS  J.,  M.  D. 

ASHMEAD,  ALBERT  S.,  M.  D. 

AULDE,  JOHN,  M.  D.,  Philadelphia. 
BALLOU,  WILLIAM  R.,  M.  D. 
BARKER,  FORDYOE,  M.  D.,  LL.  D. 
BARR,  S.  DICKSON,  M.  D.,  York,  Pa. 
BIGGS,  HERMANN  M.,  M.  D. 
BILLINGS,  JOHN  S.,  M.  D.,  LL.  D.,  U. 
S.  Army. 

BOSWORTH,  FRANCKE  H.,  M.  D. 
♦BRADLEY,  ELIZABETH  N.,  M.  D. 
♦BRANNAN,  JOHN  W.,  M.  D. 
BRIDDON,  CHARLES  K.,  M.  D. 

BRILL,  N.  E.,  M.  D. 

BROWN,  F.  TILDEN,  M.  D. 

BROWN,  MOREAU  R.,  M.  D.,  Chicago.. 
BRUSH,  E.  F.,  M.  D.,  Mount  Vernon, 
N.  Y. 

♦BRYSON,  LOUISE  FISKE,  M.  D. 
BUCKMASTER,  A.  IL,  M.  D. 

BULL,  CHARLES  STEDMAN,  M.D. 
BULL,  THOMAS  M.,  M.  D. 

CARROLL,  ALFRED  L.,  M.  D. 
CHAPIN.  WARREN  B„  M.  D. 
CHEATHAM,  W.,  M.  D.,  Louisville,  Ky. 
CLAIBORNE,  JOHN  HERBERT,  M.  D. 
CLARK,  BRANCH,  M.  D. 

CORNING,  J.  LEONARD,  M.'D. 

COWL,  W.  Y.,  M.  D. 

♦CRANDALL,  F.  M.,  M.  D. 

CROOK,  JAMES  K.,  M.  D. 
CROSSLAND,  J.  C.,  M.  D.,  Zanesville,  O. 
♦CURRIER,  ANDREW  F.,  M.  D. 
DELAVAN,  D.  BRYSON,  M.  D. 
DODGE,  C.  L.,  M.  D.,  Kingston,  N.  Y. 
DONALDSON,  FRANK,  M.  D.,  Balti¬ 
more. 

DOUGLAS,  J.  H.,  M.  D.,  Fordham,  N.  Y. 
DOUGLAS,  RICHARD,  M.  D.,  Nash¬ 
ville,  Tenn. 

DUANE,  ALEXANDER,  M.  D. 

DUNN,  JOHN,  M.  D.,  Richmond,  Va. 
DUNNING,  L.  H.,  M.  D.,  Indianapolis. 
EDEBOHLS,  GEORGE  M.,  M.  D. 
EDGAR,  J.  CLIFTON,  M.  D. 
EDWARDS,  LANDON  B.,  M.  D.,  Rich¬ 
mond,  Va. 

ELDER.  THOMAS  A.,  M.  D.,  Seaton,  Ill, 
ELIOT,  ELLSWORTH,  Je.,  M.  D. 
ELIOT,  GUSTAVUS,  M.  D.,  New  Haven, 
Conn. 

ELLIS,  JAMES  N.,  M.  D.,  Richmond,  Va. 
EMERSON,  J.  H.,  M.  D. 

ESKRIDGE,  J.  T.,  M.  D.,  Denver,  Col. 
FAULKNER,  RICHARD  B.,  M.  D.,  Alle¬ 
gheny,  Pa., 

FERGUSON,  JOHN,  M.  D.,  L.  R.  C.  P., 
L.  F.  P.  S.,  Toronto,  Canada. 

FITCH,  C.  W.,  M.  D.,  Bridgeport,  Conn. 
FLINT,  WILLI  A  M  H.,  M.  D. 

♦FOSTER,  FRANK  P.,  M.  D. 

♦FOSTER,  MATTHIAS  L.,  M.  D. 
FRIEDENWALD,  HARRY,  M.  D.,  Bal¬ 
timore. 

GEER,  N.  M.,  M.  D.,  Toronto,  O. 
GERSTER,  ARPAD  G.,  M.D. 

GIBIER,  PAUL,  M.  D. 

•GIBNEY,  V.  P.,  M.D. 

GILLIAM,  D.  TOD,  M.  D.,  Columbus,  O. 


GILLIAM,  E.  M.,  M.  D.,  Columbus,  0. 

GLEITSMANN,  J.  W.,  M.  I). 

GOLDENBERG,  HERMAN,  M.  D. 

GOULEY,  JOHN  W.  S.,  M.  D. 

♦GRANGER,  REED  B.,  M.  D. 

HALL,  W.  H.,  M.  D.,  Saratoga  Springs, 
N.  Y. 

HAMILTON,  WILLIAM  D.,  M.  D.,  Co¬ 
lumbus,  0. 

HAMMOND,  C.  N.,  M.  D.,  Bentley 
Creek,  Pa. 

HAMMOND,  WILLIAM  A.,  M.  D., 
Washington. 

HARDIE,  T.  MELVILLE,  M.  B.,  Chi¬ 
cago. 

HARTLEY,  FRANK,  M.D. 

HENSON,  J.  W.,  M.  D.,  Richmond,  Va. 

HIGGINS,  CARTER  B.,  M.  D.,  Peru,  Ind. 

HOLT,  L.  EMMETT,  M.  D. 

HUBER,  F.,  M.D. 

INGALS,  E.  FLETCHER,  M.  D.,  Chi¬ 
cago. 

INGRAM,  FRANK  II.,  M.D. 

JACKSON,  GEORGE  THOMAS,  M.  D. 

JACOBI,  ABRAHAM,  M.D. 

JARVIS,  N.  S.,  M.  D.,  U.  S.  Army. 

JENKINS,  WILLIAM  T.,  M.  D. 

JONES,  J.  D.,  M.  D.,  Utica,  N.  Y. 

JUDSON,  A.  B.,  M.  D. 

KAMMERER,  FREDERICK,  M.D. 

KAY,  THOMAS  W.,  M.  D.,  Scranton,  Pa. 

KENNEDY,  JAMES,  M.  D.,  San  Anto¬ 
nio,  Tex. 

KEYES,  EDWARD  L.,  M.  D. 

KLOMAN,  WILLIAM  C.,  M.  D.,  Balti¬ 
more. 

KNIGHT,  CHARLES  H.,  M.  D. 

KNOTT,  The  Hon.  J.  PROCTOR,  Ken¬ 
tucky. 

KRAUSS,  WILLIAM  C.,  M.D.,  Buffalo. 

LAN GM AID,  S.  W.,  M.  D.,  Boston. 

LAPLACE,  ERNEST,  M.  D.,  Philadel¬ 
phia. 

LE  FEVRE,  EGBERT,  M.  D. 

LIPPINCOTT,  J.  A.,  M.  D.,  Pittsburgh, 
Pa. 

LOEBINGER,  HUGO  J.,  M.  D. 

LOOMIS,  ALFRED  L.,  M.  D.,  LL.  D. 

MaoCOY,  ALEXANDER  W.,  M.  D., 
Philadelphia. 

♦MACDONALD,  BELLE,  M.  D. 

♦MACDONALD,  HENRY,  M.D. 

♦MacDONNELL,  R.  L,  M.  D.,  Mont¬ 
real,  Canada. 

MACKENZIE,  JOHN  N.,  M.  D.,  Balti¬ 
more. 

MacPHERSON,  J.  D.,  M.D. 

MADDEN,  THOMAS  M.,  M.  D.,  Dublin, 
Ireland. 

MARCY,  HENRY  O.,  M.  D.,  LL.  D., 
Boston. 

MARLOW,  F.  W.,  M.  D.,  Syracuse,  N.  Y. 

MARSHALL,  CUVIER  R.,  M.  I).,  Phila¬ 
delphia. 

MARTINEZ,  JUAN  JOSE,  M.  D.,  Gra¬ 
nada.  Nicaragua. 

♦MATTISON,  J.  B.,  M.  D.,  Brooklyn. 

MAJOR,  GEORGE  W.,  M.  D.,  Montreal. 

MoKEE,  E.  S.,  M.  D.,  Cincinnati. 

MELTZER,  S.  J.,  M.  D. 

MEMMINGER,  ALLARD,  M.  D.,  Charles¬ 
ton,  S.  C. 

MILLIKEN,  S.  E  ,  M.  D. 

MILLS,  WESLEY,  M.  D.,  Montreal. 


MOORE,  II.  B.,  M.  D.,  Colorado  Springs, 
Col. 

MORRIS,  ROBERT  T.,  M.  D. 
O’DANIEL,  W.  A.,  M.  D.,  Macon,  Ga. 
OSLER,  WILLIAM,  M.  D.,  Baltimore. 
OTIS,  WILLIAM  K.,  M.  D. 

PARKE,  J.  RICHARDSON,  M.  D. 
PAYNE,  S.  M.,  M.  D. 

♦PETERSON,  FREDERICK,  M.D. 
PFAFF,  O.  G.,  M.  D.,  Cincinnati. 
♦PHELPS,  A.  M.,  M.  D. 

PHILLIPS,  DAVID,  M.  D. 

POST,  SARAH  E.,  M.  D. 

PRINCE,  A.  E.,  M.  D.,  Jacksonville,  Ill. 
PRITCHARD,  WILLIAM  B.,  M.  D. 
PURDY,  CHARLES  W.,  M.  D.,  Chicago. 
♦RABIN OVITCII,  LOUISE  G.,  M.  D., 
Philadelphia. 

RAKE,  BEAVEN,  M.  D.,  Trinidad. 
RAYNOR,  F.  0.,  M.  D.,  Brooklyn. 
RHEIN,  M.  L.,  M.  D.,  D.  D.  S. 

RHETT,  R.  B.,  Je.,  M.  D.,  Charleston 
S  C 

RICHMOND,  CHARLES  H.,  M.  D.,  Li¬ 
vonia,  N.  Y. 

RIDLON,  JOHN,  M.D. 

♦ROBINSON,  CHARLES  H.,  F.  R.  C. 

S.  I.,  Dublin,  Ireland. 

ROBINSON,  F.  B„  B.  S.,  M.  D.,  Toledo,  O. 
ROBSON,  A.  W.  MAYO,  Leeds,  Eng. 
♦ROOSEVELT,  J.  WEST,  M.  D. 
RUSSELL,  T.  H.,  M.  D.,  New  Haven, 
Conn. 

SAWYER,  AMOS,  M.  D.,  Hillsboro,  Ill. 
SAYRE,  REGINALD  H.,  M.  D. 
SCHWEIG,  HENRY,  M.D. 

SCOTT,  M.  T.,  M.  D.,  Lexington,  Ky. 
SEIBERT,  A.,  M.  D. 

SHROPSHIRE,  W.,  M.  D.,  Huntsville, 
Tex. 

SHULTZ,  REUBEN  C.,  M.  D. 
SKINNER,  W.  W.,  M.  D.,  Saranac  Lake,. 
N.  Y. 

SMITH,  THEOBALD,  Ph.  B.,  M.  D., 
Washington. 

SOLIS-COHEN,  SOLOMON,  M.D.,  Phil¬ 
adelphia. 

SPEER.  A.  T.,  M.  D.,  Newark,  O. 
STEARNS,  HENRY  S.,  M.  D. 
STEWART,  WILLIAM  B.,  M.  D.,  Phila¬ 
delphia. 

STICKLER,  JOSEPH  W.,  M.  D.,  Orange, 
N.  J. 

♦STIMSON,  LEWIS  A.,  M.  D. 
STOWELL,  CHARLES  IL,  M.  D.,  Wash¬ 
ington,  D.  C. 

STOWELL,  WILLIAM  L.,  M.  D. 
SULLIVAN,  J.  D.,  M.  D.,  Brooklyn. 
SWAIN,  II.  L.,  M.  D.,  New  Haven,  Conn. 
SYMONDS,  BRANDRETH,  M.  D. 
TAYLOR,  GEORGE  IL,  M.  D. 

TAYLOR,  HENRY  LING,  M.  D. 
♦TAYLOR,  ROBERT  W.,  M.  D. 
THAYER,  WILLIAM  H.,  M.  D.,  Brook¬ 
lyn. 

THOMAS,  F.  S.,  M.  D.,  Charleston,  W. 
Va. 

THOMPSON,  W.  GILMAN,  M.  D. 
TOMPKINS,  E.  L.,  M.  D.,  Washington. 
TOUSEY,  SINCLAIR,  M.  D. 

TYNDALE,  J.  HILGARD,  M.  D. 
TYNER,  T.  J.,  M.  D.,  Austin,  -Tex. 
UPSON,  HENRY  S„  M.  D.,  Cleveland,  0. 
VAN  ARSDALE,  W.  W.,  M.  D. 


IV 


LIST  OF  ILLUSTRATIONS  IN  VOLUME  LI I. 


[N.  Y.  Med.  Jodb. 


VANCE,  REUBEN  A.,  M.  D.,  Cleve¬ 
land,  O. 

VANDER  POEL,  S.  <  >.,  M.  D. 
VANDERVOORT,  JOHN  L.,  M.  D. 
VEEDER,  A.T.,  M.  D.,  Schenectady,  N.Y. 
VINEBERG,  HIRAM  N  ,  M.  D. 

Von  DONHOFF,  EDWARD,  M.  D. 

Von  URFF,  C.  A.,  M  D.,  Brooklyn. 

Von  WEDEKIND,  LUTE  L.,  M.  D.,  U. 
S.  Navy. 

♦WALKER,  D.  ERNEST.  M.  D. 
WALKER,  H.  O.,  M.  D.,  Detroit. 


WATSON,  B.  A.,  M.  D.,  Jersey  City. 
WEBSTER,  DAVID,  M.  D. 

WEED,  CHARLES  R.,  M.  D.,  Utiea,  N.  Y. 
WEEKS,  JOHN  E.,  M.  D. 

WESTBROOK,  GEORGE  R.,  M.  D., 
Brooklvn. 

WHITAKER,  F.,  M.  D.,  Point  Pleasant, 
N.  J. 

WHITFORD,  AVILLIAM.  M.  D.,  Chicago. 
WHITMAN,  ROYAL,  M.  D„  M.  R.  C.  S. 
WICKHAM,  WILLIAM,  M.  I).,  Youngs¬ 
town,  O. 


WILCOX,  REYNOLD  AY.,  M.  D. 
WILLIAMS,  HERBERT  F.,  M.  D., 
Brooklyn. 

AVILMER,  WILLIAM  HOLLAND,  M.  D., 
AVashington. 

WOOD,  CASEY  A.,  M.  D.,  Chicago. 
WOOD,  WILLIAM  B.,  M.  D. 

AVRIGIIT,  JONATHAN,  M.  D.,  Brook¬ 
lyn. 

♦WYCKOFF,  RICHARD  M.,  M.  D., 
Brooklyn. 

WYETH,  JOHN  A.,  M.  D. 


LIST  OF  ILLUSTRATIONS  IN  VOLUME  LII. 


PAGE 

Multiple  Neuritis  of  Syphilitic  Origin.  Two  Illustrations, 

Facing  1 

Congenital  Malformation  of  the  Fingers.  Two  Illustra¬ 


tions . 23 

A  New  Ophthalmoscope.  Two  Illustrations .  139 

Invagination  of  the  Bowel.  Two  Illustrations .  145,  146 

Paranephritic  Cysts.  Two  Illustrations .  148 

Reflex  Amblyopia.  Six  Illustrations .  152,  153 

Investigations  in  Strabismus.  Two  Illustrations .  180 

Willett’s  Operation  for  Talipes  Calcaneus.  Seven  Illus¬ 
trations  .  199-201 

Muscular  Dystrophy.  Three  Illustrations .  202-204 

A  Vaporizer,  Sublimer,  and  Air  Sterilizer .  210 

Amygdalotome .  236 

Homonymous  Hetniopic  Hallucinations  Diagram .  241 

Prince’s  Curved  Turbinated  Forceps .  242 

New  Naso-pharyngeal  Scissors .  251 

Nasal  Hydrorrhcea.  Three  Illustrations .  267 

Myxoma  of  the  Epiglottis.  Two  Illustrations .  268-269 

Pseudo-hypertrophic  Paralysis.  Five  Illustrations  .  . .  285-287 

Cutting  Instruments  for  Nasal  Work .  335 

A  Case  of  Brain  Surgery.  Three  Illustrations .  338-340 

Myxoma  of  the  Naso-pharynx .  342 

Uterus  Bilocularis  Unicollis.  Two  Illustrations.  . .  352 

Paralysis  Agitans.  Two  Diagrams  and  One  Illustra¬ 
tion .  395-396 

Tuberculosis  of  the  Pharynx.  Two  Illustrations .  405 

The  Rawhide  Plate.  Four  Illustrations .  431-432 


PAGE 

The  Universal  Needle  Forceps .  446 

A  Retinoscope  and  Strabismometer  combined .  474 

Adjuster  for  approximating  the  Edges  of  Wounds .  474 

Mercier’s  Rectangular  Sound .  478 

Gouley’s  Cysto-pylometer.  First .  479 

Gouley’s  Cysto-pylometer.  Second .  479 

Mercier’s  Elbow  Catheters . 480 

Mercier’s  Invaginated  Catheter .  481 

Gouley’s  Intravesical  Prostatectome . 482 

New  Lateral-traction  Hip  Splints.  Five  Illustrations,  512-513 
Lateral  Curvature  of  the  Spine.  Five  Illustrations.  . .  540-542 

Cardiac  Medicaments.  Diagram .  598 

Subtnembranous  Treatment  of  Diphtheria.  Five  Illustra¬ 
tions .  625-626 

Simultaneous  Disease  of  the  Hip  and  Knee.  Five  Illus¬ 
trations  .  656-657 

Rupture  of  the  Short  Head  of  the  Biceps .  665 

Fracture  of  the  Sternal  End  of  the  Clavicle.  Two  Illus¬ 
trations . .  665,666 

Injuries  to  the  Vertebrae  in  Children.  Two  Illustra¬ 
tions .  667 

Jejuno-ileostomy  with  Senn’s  Bone  Plates .  678 

Cartilage  Scissors . 676 

Curved  Gouge .  676 

Nasal  Splint .  676 

Nasal  Crown  Drill .  694 

The  Manikin  in  the  Teaching  of  Practical  Obstetrics.  Thir¬ 
teen  Illustrations .  702-707 


THE  NEW  YORK  MEDICAL  JOURNAL,  July  5,  1890. 


Original  Communications. 


A  CONTRIBUTION  TO 

THE  STUDY  OF  MULTIPLE  NEURITIS 
OF  SYPHILITIC  ORIGIN* 

By  R.  W.  TAYLOR,  M.  D., 

SURGEON  TO  CHARITY  HOSPITAL,  NEW  YORK. 

Among  the  man)*  yet  unwritten  chapters  on  the  ulterior 
effects  of  syphilis  upon  diatheses  and  dyscrasise,  on  its 
symbiosis  with  other  morbid  processes  and  conditions,  and 
on  the  various  tissues,  notably  cerebro-spinal,  arterial,  mus¬ 
cular,  visceral,  dermal,  and  mucous,  is  the  one  which  shall 
establish  its  relation  to  the  morbid  process  in  the  peripheral 
nerves,  which  is  found  early  and  late  in  its  course,  and 
even  perhaps  many  years  after  it  has  seemingly  disappeared 
from  the  economy.  While  our  knowledge  of  the  syphi¬ 
litic  affections  of  the  brain  and  spinal  cord  is  very  extensive 
and  in  some  instances  full  and  systematic,  that  relating  to 
the  effect  of  the  disease  upon  the  peripheral  nerves  is  nota¬ 
bly  fragmentary  and  unsatisfactory.  This  is  especially  the 
case  as  to  the  relation  which  syphilis  bears  as  an  aetiologi- 
cal  factor  in  the  causation  of  multiple  neuritis,  a  subject 
which  has  as  yet  received  the  attention  of  only  a  few  ob¬ 
servers.  The  reasons  why  the  multiple  neuritis  of  syphilitic 
origin  is  so  little  known  are,  first,  that  our  knowledge  of 
the  general  subject  is  yet  in  its  infancy ;  second,  that  cases 
in  which  syphilis  is  a  causative  factor  (at  least  seemingly) 
are  very  rare ;  and,  thirdly,  that  its  connection  with  the 
nerve  disorder  is,  for  various  reasons,  such  as  the  incom¬ 
pleteness  of  the  history  of  the  case,  the  possible  late  evolu¬ 
tion  of  the  neuritis,  and  the  absence  of  concomitant  or  com- 
mensurative  symptoms  or  lesions  is  overlooked. 

Our  knowledge  of  multiple  neuritis  may  be  said  to  have 
been  formulated  and  systematized  within  the  past  live  or 
six  years,  though,  of  course,  the  observations  and  studies 
of  many  physicians  over  a  long  stretch  of  years  led  up  to 
the  era  of  light.  It  is  a  subject  of  congratulation  that 
American  observers  have  played  no  small  part  in  the  study 
of  this  subject,  and  have  aided  materially  in  its  partial 
crystallization.  As  it  stands  to-day,  the  subject  of  multiple 
neuritis  is  weakest  in  the  direction  of  aetiology  and  patho¬ 
logical  anatomy,  but  hopeful  signs  are  to  be  seen  on  all 
sides,  and,  as  time  goes  on,  anomalous  facts  will  be  recon¬ 
ciled  and  lacunae  will  be  filled. 

In  this  paper  I  wish  mainly  to  put  on  record  a  case 
carefully  observed  for  many  years,  in  which,  coincidently 
with  the  evolution  of  secondary  syphilitic  manifestations,  a 
nervous  disorder  began  and  has  since  continued  unchanged, 
attended  with  marked  symptoms  and  leading  to  peculiar 
mutilations.  It  is,  in  my  judgment  and  in  that  of  friends 
well  versed  in  neurology,  a  well-marked  instance  of  multi¬ 
ple  neuritis.  Seeing  that  this  paper  is  an  avant-courier  in 
this  particular  branch  of  the  subject  of  multiple  neuritis,  I 


*  Read  before  the  American  Association  of  Genito-urinary  Surgeons 
at  its  fourth  annual  meeting,  June  4,  1890. 


have  thought  it  worth  while  also  to  present  a  resume  of  its 
literature. 

In  the  year  1879  Buzzard  *  published  a  lecture  in  which 
was  detailed  a  case  of  sciatica  with  muscular  wasting  and 
weakness  of  the  limbs,  which  that  author  considered  to  be 
caused  by  syphilis.  In  1881  Ormerod  f  presented  to  the 
Pathological  Society  of  London  a  case  of  painful  enlarge¬ 
ment  of  the  median  nerve  of  the  upper  extremity,  which  he 
thought  was  the  result  of  hereditary  syphilis.  This  com¬ 
munication  was  followed  by  a  second  consideration  of  this 
subject  by  Buzzard,  J  who  detailed  the  history  of  a  case  in 
which  there  was  paralysis  of  the  muscles  of  the  face  and  of 
both  the  upper  and  lower  extremities  and  of  the  trunk, 
with  disseminated  anaesthesia. 

The  next  paper  on  this  subject  was  by  Ehrmann  #  in 
1886,  and  it  was  followed  by  a  communication  by  C.  K. 
Mills  ||  before  the  American  Neurological  Association. 
Then,  in  1888,  Laschkewitch  A  published  a  clinical  lecture 
upon  this  subject,  which  is  very  unsatisfactory,  for  the  rea¬ 
son  that  the  history  of  syphilis  in  the  case  was  not  well 
established.  In  this  same  year  Leyden  ()  published  two 
lectures  on  inflammation  of  peripheral  nerves,  in  which 
he  speaks  of  a  case  in  which  he  thought  the  nerve  af¬ 
fection  was  caused  by  syphilis.  Finally,  in  the  recent 
excellent  compendium  of  Bowlby  J  we  find  a  section 
upon  neuritis  of  syphilitic  origin,  in  which  the  cases  of 
Buzzard  and  Ormerod  are  given  and  a  personal  case  briefly 
detailed. 

The  foregoing  are  the  only  communications  I  can  find 
after  a  tolerably  extended  search  in  medical  literature.  As 
a  further  evidence  of  the  paucity  of  knowledge  of  the  in¬ 
fluence  of  syphilis  in  the  production  of  neuritis,  I  may  say 
that  the  author  of  the  admirable  Middleton  Goldsmith  lect¬ 
ures  $  upon  multiple  neuritis  which  have  done  so  much  to 
enlighten  the  medical  mind,  both  at  home  and  abroad,  does 
not  recognize  syphilis  as  a  cause,  nor  does  he  quote  a  case 
in  which  such  a  relation  was  claimed,  though  he  recognizes 
in  his  category  of  causes  the  direct  action  of  such  iufectious 
diseases  as  diphtheria,  variola,  typhoid  and  typhus  fevers, 
tuberculosis,  and  malaria. 

In  addition  to  the  setiological  bearing  of  my  case,  I 
shall  call  especial  attention  to  certain  features  of  resem- 

*  Clinical  Lecture  on  Cases  of  Neuritis,  Syphilitic  and  Rheumatic. 
Lancet ,  March  1,  1879. 

f  British  Med.  Journal ,  1881,  vol.  i,  p.  88. 

x  Harveian  Lectures  on  Some  Forms  of  Paralysis  dependent  upon 
Peripheral  Neuritis.  Lancet ,  November  28  and  December  1,  1885. 

#  Ein  Fall  von  halbseitiger  Neuritis  spinaler  Aeste  bei  recenter 
Lues.  Wiener  mediz.  Blatter ,  1886,  Nos.  46  and  47. 

||  Notes  of  Some  Cases  of  Multiple  Neuritis  (or  Myelitis)  of  Syphi¬ 
litic  Origin,  with  Remarks  on  the  Difficulty  of  diagnosticating  Multiple 
Neuritis  from  Some  Forms  of  Myelitis.  Medical  News ,  August  20, 1887 
and  N.  Y.  Medical  Journal ,  July  3,  1887. 

A  Neuritis  multiplex  chronica  luetica.  Russ.  Med.,  St.  Petersburg, 
1888,  vol.  i,  pp.  87  to  90. 

Q  Die  Entziindung  der  peripheren  Nerven,  deren  Pathologie  und 
Behandlung.  Berlin,  1888,  p.  26. 

|  Injuries  and  Diseases  of  Nerves  and  their  Surgical  Treatment, 
Philadelphia,  1890,  p.  460  et  scq. 

$  Med.  News ,  vol.  1,  1887,  Nos.  6,  7,  8,  and  9. 


2 


TAYLOR:  MULTIPLE  NEURITIS  OF  SYPHILITIC  ORIGIN 


[N.  Y.  Med.  Jock., 


blance  between  its  lesions  and  those  of  leprosy,  which  open 
up  a  subject  now  little  known  and  understood. 

The  history  of  my  case  is  as  follows: 

The  patient  is  a  female,  married,  a  domestic,  born  in  Nor¬ 
way,  and  forty  years  of  age.  While  she  can  not  be  called 
stupid,  she  is  far  from  being  very  bright  and  may  be  said  to  be 
rather  weak-minded.  She  has  been  in  America  since  her 
twenty-fourth  year,  and  has  no  knowledge  of  ever  having  seen 
or  having  come  in  contact  with  lepers  or  having  lived  in  the 
vicinity  of  such  sufferers.  She  entered  Charity  Hospital  in 
•June,  1882,  and  has  been  under  my  observation  for  long  and 
.'short  periods  until  1887,  and  has  since  been  seen  by  me  fre¬ 
quently  from  time  to  time  until  now.  It  was  very  difficult  even 
in  1882  to  get  a  clear  chronological  history  of  her  illness,  and 
to-day  it  is  almost  impossible.  It  thus  happens  that  when  at 
Bellevue  Hospital,  within  two  years,  she  stated  that  she  was 
Infected  with  syphilis  fifteen  years  ago,  and  she  gave  other  in¬ 
correct  information  as  to  the  early  phases  of  her  syphilis.  In 
early  life  she  had  measles,  scarlatina,  pertussis,  and  diphtheria, 
but  she  grew  up  a  strong  and  healthy  woman.  When  she  en¬ 
tered  Charity  Hospital  in  1882  she  gave  us  the  impression  that 
she  had  been  syphilitic  then  eight  years,  though  various  very 
cogent  facts  showed  quite  clearly  that  infection  took  place  at  a 
much  later  period.  She  maintained  that  her  infection  began 
during  her  first  pregnancy,  more  than  eight  years  before,  but  it 
seems  very  probable  that  after  parturition  she  had  a  simple  ery¬ 
thematous  and  furuncular  eruption  upon  the  legs,  with  an  ex¬ 
acerbation  of  a  mild  form  of  rheumatism,  from  which  she  had 
suffered  for  years.  Certain  it  is  that  her  second  child,  like  the 
first,  was  free  from  syphilis,  and  that  she  had  not  taken  anti¬ 
syphilitic  remedies,  which  had  induced  a  latent  condition  of  the 
disease.  Her  third  child  was  also  free  from  syphilis,  and  she, 
before  and  just  after  its  birth,  showed  no  evidence  of  the  dis¬ 
ease.  When  she  came  to  Charity  Hospital  she  brought  with 
her  a  baby  girl  (the  first  and  only  offspring  of  a  second  hus¬ 
band)  which  was  two  months  old  and  was  suffering  from 
marked  hereditary  syphilis.  The  condition  of  the  child  clearly 
pointed  to  activity  of  syphilis  in  the  mother.  The  latter  had 
had  no  miscarriages  after  the  birth  of  her  second  and  third 
healthy  children  and  before  the  birth  of  the  fourth  and  syphi¬ 
litic  child.  These  facts,  therefore,  go  to  show  that  syphilitic 
infection  took  place  in  the  mother  between  the  dates  of  birth 
of  her  third  and  fourth  children.  Syphilis  was  probably  con¬ 
tracted  from  the  second  husband,  who  went  to  sea  during  the 
woman’s  fourth  pregnancy  and  has  never  been  heard  from  since. 

A  careful  consideration  of  all  facts  convinces  me  that  the 
woman  was  infected  rather  less  than  two  years  prior  to  her 
first  entry  into  Charity  Hospital  in  1882,  therefore  that  she  has 
now  been  syphilitic  about  ten  years.  I  am  thus  careful  in  stat¬ 
ing  the  case  because  the  woman  has  told  so  many  different 
stories,  and  it  is  important,  in  the  study  of  her  syphilitic  history, 
to  be  correct  as  to  its  chronology. 

In  June,  1882,  she  had  a  typical  syphilitic  iritis  and  the 
copper-colored  stains  of  a  vanished  eruption  over  the  body,  and 
particularly  over  the  legs.  She  also  suffered  from  rheumatism, 
which  was  worse  at  night.  The  truth  was  that  the  woman 
gave  ample  evidence  of  being  in  the  power  of  active  syphilis 
which,  owing  to  absence  of  treatment,  had  run  on  unchecked. 
She  was  thin  and  weak,  and  responded  badly  to  medicine. 

Early  in  the  year  1882  (in  the  last  half  of  the  second  year 
of  syphilis)  she  noticed  that  the  sensation  on  the  backs  of  both 
hands  was  impaired,  and  when  she  had  been  in  the  hospital  a 
few  weeks  we  found  marked  analgesia  and  anaesthesia  over  the 
backs  of  the  fingers,  hands,  and  wrists,  particularly  upon  the 
left  side.  At  this  time  she  had  pain  in  the  eyes  and  dimness  of 


vision,  and  the  ophthalmoscope  showed  double  neuro-retinitis. 
Under  “  mixed  treatment  ”  and  local  mercurial  inunctions  the 
morbid  process  in  the  eyes  was  promptly  arrested  and  cured. 
But  little  effect  was  produced  upon  the  causes  underlying  the 
analgesia,  which  extended  slowly  up  the  arms.  During  this  time 
she  also  suffered  from  headaches,  which  were  sometimes  re¬ 
lieved  by  the  iodide  of  potassium,  at  others  by  nervine  stimu¬ 
lants  (valerian,  ammonia,  etc.).  It  was  noted  that  toward 
Christmas,  1882,  the  analgesia  had  extended  up  the  arms  as  far 
as  the  elbows,  and  that  it  was  complete  on  the  extensor  surfaces 
and  was  encroaching  on  the  flexor  surfaces. 

In  reviewing  the  case  up  to  January,  1883,  it  was  evident 
that  the  treatment  (which,  by  the  way,  it  was  necessary  to  dis¬ 
continue  from  time  to  time)  bad  improved  the  patient’s  nutri¬ 
tion,  had  cured  her  iritis  and  neuro-retinitis,  had  at  times  re¬ 
lieved  her  rheumatism  and  headaches,  but  had  had  little,  if 
indeed  any,  effect  upon  the  sensory  disturbances  going  on  in  the 
upper  extremities. 

It  should  be  stated  that  coincidently  with  the  analgesic 
symptoms  pains,  dull  and  aching  and  severe  and  lancinating, 
were  complained  of  in  the  arms,  together  with  a  feeling  of 
numbness  and  heaviness. 

In  February,  1883,  a  new  order  of  phenomena  was  noted. 
The  patient  began  to  complain  of  tenderness,  pain,  and  swelling 
in  the  left  heel,  and  soon  after  in  the  corresponding  foot.  This 
pain  extended  up  to  the  knee  and  was  dull  and  seemingly  deep- 
seated  in  character.  It  sometimes  coexisted  with  the  similar 
pains  in  the  arms,  and  at  others  those  of  one  region  ceased,  and 
again  they  seemed  at  times  to  oscillate  between  the  upper  and 
lower  extremities.  At  this  time  diffuse  hyperplasia  was  noted 
on  the  prominences  of  both  cheeks,  and  a  similar  condition  was 
found  on  the  region  of  the  left  ankle.  The  appearances  were 
those  of  acute  diffuse  gummatous  infiltration  into  the  skin,  as 
well  as  into  the  subcutaneous  tissue.  At  this  time  also  there 
were  tender  spots  of  periostitis  over  the  cranium  and  the  head¬ 
ache  was  sometimes  severe.  In  May,  1883,  she  weaned  her 
baby,  which  under  treatment  had  become  healthy  and  bloom¬ 
ing.  At  the  end  of  1883,  a  little  less  than  two  years  from  the 
date  of  onset  of  the  sensory  disturbances,  it  was  found  that  the 
analgesia  and  anaesthesia  had  extended  up  each  arm  to  the 
shoulder,  being  complete  on  the  extensor  surfaces  and  partial 
on  the  flexor  surfaces.  At  this  time  also  an  analgesic  spot  was 
found  on  the  dorsal  aspect  of  the  left  shoulder.  During  all  this 
period  of  increasing  nervous  disturbance  the  patient  had  com¬ 
plained  of  little,  if  any,  impairment  of  muscular  power.  She 
took  care  of  her  baby  and  at  times  assisted  in  the  general  care 
of  the  ward,  but  toward  the  end  of  1883  she  burned,  scratched, 
scalded,  and  in  many  ways  injured  and  bruised  her  fingers, 
owing  to  the  loss  of  sensation  and  tactile  sense.  At  this  time 
also  she  began  to  complain  of  numbness  in  the  feet,  and  par¬ 
ticularly  in  the  toes. 

In  January,  1884,  the  following  condition  was  noted:  Be¬ 
ginning  at  the  toes,  the  analgesia  extended  up  both  legs,  but 
more  markedly  on  the  outer  and  anterior  aspects,  nearly  to 
Poupart’s  ligament.  Though  analgesic,  there  were  spots  and 
patches  in  which  some  sensibility  to  light  and  hard  pressure 
could  be  felt.  During  this  year  the  patient  complained  at  in¬ 
tervals  of  numbness  of  the  upper  and  lower  extremities,  and 
often  said  that  her  arms  felt  as  heavy  and  unwieldy  as  if  they 
were  dead.  Though  the  analgesia  was  complete  from  the 
shoulder  down,  the  prick  of  a  pin  could  be  felt  in  the  palm  of 
the  hand.  It  was  noted  at  this  time  that  examinations  were 
made  of  the  nerves  forming  the  brachial  plexus,  and  that  it 
could  not  be  determined  that  they  were  perceptibly  thickened. 
For  months  the  patient  suffered  paroxysmally  with  severe  head¬ 
aches,  which  prevented  sleep  at  night.  In  the  summer  of  1884 


July  5,  1890.J 


TAYLOR:  MULTIPLE  NEURITIS  OF  SYPHILITIC  ORIGIN. 


3 


the  degenerative  changes  began  in  the  fingers,  owing  to  bruises, 
burns,  and  to  the  development  of  panaritium,  and  they  contin¬ 
ued  to  attack  one  finger  after  another  during  the  following  four 
years.  These  degenerative  changes  began  in  indolent  ulcers 
and  bullae,  resulting  from  various  traumatisms  which  showed  no 
tendency  to  heal,  but  caused  the  tissues — dermal,  fibrous,  and 
bony — to  slowly  melt  away  by  molecular  necrosis.  In  this  way 
first  the  skin  and  fibrous  tissues  disappeared,  and  then  portions 
of  the  bone  in  spicula  and  in  the  form  of  detritus.  When  the 
degeneration  was  not  very  active  and  extensive,  healing  oc¬ 
curred — as,  for  instance,  when  the  tip  of  a  thumb  was  attacked 
— but  in  most  instances  unsightly  and  painful  deformities  were 
produced,  which  required  surgical  intervention  to  bring  about 
sightly  and  tolerably  serviceable  stumps.  It  was  frequently 
remarked  that  fingers  and  toes  which  had  been  the  seat  of  ob¬ 
stinate  ulcers  usually  healed  kindly  after  amputation,  partial  or 
complete,  followed  by  proper  dressing. 

An  inspection  of  the  engravings  will  show  the  appearances 
of  the  hands  and  feet  as  they  exist  to-day.  On  the  right  hand 
(see  Fig.  1)  the  soft  parts  of  the  last  phalanx  have  disappeared ; 
of  the  index  finger  nearly  all  of  the  first  phalanx  is  absent,  and 
a  characteristic  ulcer  may  be  seen  over  its  dorsum.  The  last 
phalanx  and  a  part  of  the  second  of  the  middle  finger,  the  last 
phalanx  of  the  ring  finger,  and  half  of  the  little  finger  are  shown 
to  be  absent.  On  the  left  hand  there  is  loss  of  the  distal  part 
of  the  thumb  ;  on  the  index  finger  the  nail  and  its  bed,  destroyed 
by  panaritium,  may  be  seen;  the  middle  finger  has  disappeared, 
owing  to  successive  amputations;  and  the  two  remaining  fingers 
are  in  fair  condition. 

The  appearances  of  the  feet  are  well  shown  in  Fig.  2,  and 
do  not  need  further  specification.  The  deformity  was  great 
and  unsightly,  and  it  grew  more  marked  as  years  went  on 
by  the  gradual  contraction  of  the  flexor  muscles,  giving  the 
hands  the  appearance  of  claws.  A  person  unfamiliar  with 
the  case  might  readily  take  it  to  be  one  of  anaesthetic  leprosy, 
and,  indeed,  several  very  competent  men  leaned  toward  this 
opinion. 

During  the  years  1884  to  1886  the  patient  was  in  and  out 
of  the  hospital  at  irregular  periods,  and  the  treatment  was  far 
from  being  as  systematic  and  thorough  as  it  should  have  been. 
She  at  one  time  suffered  from  left  bursitis,  at  another  she  was 
attacked  with  gummatous  infiltration  in  both  legs,  and  later 
an  iritis  appeared  again  in  the  left  eye,  which  had  been  attacked 
some  years  before.  Then  keratitis  attacked  this  eye,  and  in 
its  train  left  a  leucoma.  During  this  period  also  the  patient 
suffered  from  several  mild  attacks  of  facial  erysipelas,  and  as  a 

« 

consequence  the  atrophy  of  the  skin  of  the  face,  which  had 
taken  place  some  years  before,  became  more  pronounced,  and 
as  a  result  a  double  ectropion  was  produced,  so  that  the  patient 
can  not  close  her  eyes  without  the  aid  of  her  fingers. 

It  may  be  well  to  mention  the  fact  that  the  aching  pains  and 
numbness  in  the  limbs,  which  began  as  early  as  1882,  were  com¬ 
plained  of  during  the  years  above  mentioned. 

The  foregoing  facts  will,  I  think,  give  a  very  clear  idea 
of  the  course  of  the  disease  in  this  patient  and  of  the  ravages 
produced  by  it.  From  1877  until  now  (June,  1890)  the 
woman’s  condition  was  not  materially  altered.  By  reason 
of  the  mutilations  of  the  hands  she  has  been  unable  to  gain 
her  living,  and  is  capable  of  very  little  and  rather  limited 
manual  labor.  She  can  walk  fairly  well.  In  this  condition 
she  oscillates  from  one  charitable  institution  to  another; 
within  a  year  or  two  she  has  been  in  Bellevue  Hospital, 
under  the  care  of  my  friend  Dr.  C.  L.  Dana,  who  has  kindly 
given  me  the  notes  of  her  case  taken  by  him.  She  is  to¬ 


day  fairly  well  nourished,  has  a  good  appetite  and  average 
strength ;  her  mental  state  is  fully  as  good  if  not  even 
better  than  it  was  when  I  saw  her  first  in  1882.  There  is 
diminished  sensation  of  the  cornea,  but  the  patient  can  feel 
an  object  placed  against  it.  She  is  in  no  manner  hysterical. 
She  can  not  move  the  muscles  of  the  face  to  any  extent  so 
as  to  frown  or  wrinkle  the  forehead,  which  she  could  do 
fairly  well  several  years  ago.  Sensation  is  diminished  in  a 
marked  manner  over  the  distribution  of  the  supra-orbital 
frontal  and  nasal  nerves,  though  there  is  still  some  sensation 
over  the  bridge  of  the  nose.  The  sensation  over  the  dis¬ 
tribution  of  the  occipital  nerve  is  still  good,  though  over  the 
rest  of  the  face  sensation  is  altogether  absent,  except  over 
the  distribution  of  the  mental  nerve,  where  it  is  still  good. 
There  is  good  power  in  both  arms  and  legs  and  no  diminu¬ 
tion  of  muscular  sense  nor  ataxia.  There  is  now  some  tac¬ 
tile  sensation  in  these  parts,  though  markedly  diminished. 
Sensation  on  the  trunk  is  present,  though  much  blunted; 
there  is  a  total  loss  of  sensation  from  the  shoulders  down, 
except  a  small  fold  at  the  elbow  and  a  narrow  strip  on  the 
inside  of  the  arms  below  the  axillae.  On  the  lower  limbs 
there  is  a  total  loss  of  sensation  as  far  as  Poupart’s  ligament 
anteriorly,  and  up  to  the  fold  of  the  buttock  posteriorly. 
Plantar  reflex  is  absent,  though  the  patellar  reflex  is  present. 
There  is  no  ankle  clonus,  though  there  is  some  at  the  pa¬ 
tellae.  The  sense  of  taste  is  unimpaired  and  the  vision  is 
not  perfect. 

During  all  these  years  headache  has  been  a  rather  con¬ 
stant  symptom,  and  it  has  usually  been  benefited  by  large 
doses  of  iodide  of  potassium  and  of  the  mixed  treatment. 
At  times  the  patient  has  suffered  from  intermittent  fever  of 
the  tertian  and  quartan  types. 

The  clinical  history  of  this  case  is  so  clear  and  full  that 
I  think  it  needs  no  further  elaboration.  Its  symptoms  and 
course  point  unmistakably  to  degenerative  changes  in  the 
nerves  of  the  face  and  upper  and  lower  extremities. 
Throughout  its  whole  course  the  case  presented  no  symp¬ 
toms  pointing  to  lesions  of  the  brain  and  spinal  cord,  there¬ 
fore  I  think  there  can  be  no  doubt  that  it  is  an  excellent 
instance  of  multiple  neuritis.*  This  brings  us  to  the  ques- 


*  Cases  of  neuritis  affecting  the  upper  and  lower  extremities  and 
leading  to  deformities  similar  to  those  of  my  case  have  been  published 
by  several  observers  ;  but  in  these  there  was  no  history  of  syphilis,  nor 
did  any  of  their  symptoms  point  to  the  origin  of  the  affection  in  lep¬ 
rosy.  Hiickel  publishes  two  such  cases  (Zwei  Falle  von  schweren  sym- 
metrischen  Panaritien  auf  trophoneurotischer  Grundlage,  Munchener 
medicin.  Wochenschrift,  July  2  and  9,  1889) — one  of  a  woman  thirty- 
eight  years  old,  and  a  second  of  a  man  aged  thirty-seven  years.  In 
both  cases  there  were  anaesthesia  and  analgesia  with  chronic  sym¬ 
metrical  ulcerative  and  necrotic  processes  and  atrophy  and  paresis  of 
muscles.  The  upper  extremities  in  both  cases  were  involved  before 
the  lower  ones  were  attacked.  Some  of  the  cases  reported  by  Morvan 
and  others  are  similar  in  their  clinical  history  and  in  the  deformities 
thus  produced.  The  reader  is  referred  to  the  following  articles  upon 
this  subject:  Le  panaris  nerveux,  La  France  medicate,  1881,  ii,  pp. 
326-331,  by  Quinquaud ;  De  la  paresie  analgesique  k  panaris  des  ex- 
tremites  superieures  ou  pareso-analgesie  des  extremites  superieures, 
Gazette  hebdomadaire  de  med.,  Paris,  1883,  2.  S.,  xx,  pp.  680,  690,  and 
624,  by  Morvan ;  Nouveaux  cas  de  pareso-analgesie  des  extr6mit6s 
superieures,  Gazette  hebdomadaire  de  med.,  Paris,  1886,  2.  S.,  xxiii,  pp. 
621,  637,  and  666,  also  by  Morvan.  (The  disease  described  in  these  two 


4 


TAYLOR:  MULTIPLE  NEURITIS  OF  SYPHILITIC  ORIGIN. 


[N.  Y.  Mbd.  Jour., 


tion  of  aetiology.  As  the  literature  and  our  knowledge  of 
syphilitic  multiple  neuritis  were  almost  wholly  wanting  dur¬ 
ing  the  early  years  of  this  case,  I  was  for  a  time  uncertain 
as  to  its  real  nature.  But,  as  contributions  have  appeared 
and  our  knowledge  of  the  general  subject  has  expanded,  my 
conviction  has  grown  strong  that  the  chronic  morbid 
changes  in  the  nerves  of  this  patient  were  caused  by  syphi¬ 
lis.  A  brief  review  of  the  case  shows  that  about  eighteen 
months  after  syphilitic  infection  analgesia  appeared  in  the 
backs  of  the  hands  of  this  woman.  This  symptom  in  her 
was,  as  I  myself  observed,  precisely  similar  to  what  we  oc¬ 
casionally  see  in  recently  syphilitic  women,  particularly 
those  suffering  from  a  chlorotic  condition  or  from  a  neurotic 
or  hysterical  state.  In  most  women  this  analgesia  of 
the  secondary  stage  of  syphilis  is  transitory  in  character 
and  disappears  in  one  or  more  months,  and  in  exceptional 
cases  is  found  to  relapse.  In  the  present  case  the  disturb¬ 
ances  in  the  portions  of  the  nerves  situated  in  the  dorsum 
of  the  hands  did  not  end  there,  but  increased  until  the 
fingers  were  involved,  and  they  also  slowly  spread  up  the 
arms  even  as  far  as  the  trunk.  L^ter  on  a  similar  disturb¬ 
ance  appeared  and  ran  a  similar  course  in  the  legs.  Coin¬ 
cident!)’  with  the  development  and  course  of  this  nervous 
affection  we  find  that  the  woman  presents  at  all  stages  un¬ 
mistakable  lesions  of  syphilis  in  other  parts  of  the  body, 
such  as  the  eyes,  the  subcutaneous  connective  tissues,  and 
the  fibrous  tissues.  Certainly  no  history  of  concomitant 
symptoms  in  a  case  could  be  clearer  and  more  satisfactory. 
The  next  question  which  arises  is,  What  was  the  nature  of 
the  lesion  of  the  nerves?  From  a  study  of  this  case,  aided 
by  our  knowledge  of  the  tendency  of  syphilis  to  produce 
inflammation  in  connective  tissues,  I  am  led  to  believe  that 
the  morbid  change  begins  as  a  low  grade  of  inflammatory 
process  in  the  fibrous  elements  and  envelopes  of  the  nerves, 
and  that,  as  this  increases,  hyperplasia  of  these  elements  oc¬ 
curs,  which  results  in  compression  and  degeneration  of  the 
nerve  tissues.  This  conclusion  is  warranted  by  the  knowl¬ 
edge  we  possess  of  the  pathological  anatomy  of  multiple 
neuritis.  It  is  very  probable  that  the  neuralgias  of  syphilis 
are  due  to  hyperaemia  and  inflammatory  changes  in  the 
nerves,  and  that  these  conditions,  demanding  prompt  relief, 
by  reason  of  their  severity,  are  usually  dissipated  by  active 
mercurialization  before  structural  degeneration  of  the  nerve 
tissues  has  taken  place.  In  this  connection,  I  think,  a  brief 
history  of  the  following  case  will  be  of  interest: 

A  merchant,  aged  thirty-six,  large  and  robust,  but  a  little 
flabby,  a  good  liver,  and  a  fair  drinker,  presented  an  infecting 
chancre  of  sixteen  days’  incubation  early  in  September,  1889. 
Late  in  October  secondary  manifestations — roseola,  malaise, 
pain  in  joints,  and  erythema  of  the  pharynx — appeared.  He  was 
at  once  placed  upon  an  active  syphilitic  treatment,  which  he 
followed  with  considerable  regularity  for  three  months.  At 
the  end  of  this  time  he  became  negligent  and  indulged  too 
much  at  the  table,  partook  of  too  much  wine,  and  took  very 
little  exercise.  Toward  the  end  of  March,  1890,  he  caught  a 


articles  has  been  called  Morvan’s  disease.)  Sur  un  cas  de  panaris  anal- 
gesique,  Annales  de  dermat.  et  syphiligrapkie,  1885,  p.  282,  by  Broca; 
and  Nouveau  cas  de  panaris  analgesique,  Gazette  hebdomadaire  de  med., 
1887,  p.  345,  by  Colleville. 


severe  cold  from  exposure,  and  began  to  feel  a  slight  tender¬ 
ness  on  sitting  and  in  walking  in  the  left  large  sciatic  nerve. 
Regarding  it  as  an  ephemeral  trouble,  he  kept  at  business  until 
the  pain,  which  was  continuous  day  and  night,  became  so 
severe  that  he  was  forced  to  take  to  his  bed.  Under  the  influ¬ 
ence  of  local  mercurial  frictions,  with  continuous  dry  heat,  to¬ 
gether  with  full  doses  of  iodide  of  potassium  internally,  respect¬ 
ively  thirty  and  fifteen  grains,  the  severity  of  the  pain  was 
checked  and  he  was  able  to  go  about  with  a  stick  in  less  than  a 
fortnight.  While  confined  to  bed  he  had  experienced  pain  in 
the  parts  supplied  by  the  anterior  cutaneous  nerve  of  the  same 
side.  At  this  time  he  called  attention  to  a  number  of  ill- 
defined  red  patches  on  the  inner  surface  of  the  same  leg  and 
upon  the  calf.  Upon  examination,  I  found  six  subcutaneous, 
not  well  circumscribed,  doughy  masses  of  infiltration,  which 
were  decidedly  tender  on  pressure  and  the  seat  of  soreness  in 
walking.  Urgency  of  business  caused  this  gentleman  to  go 
about  sooner  than  was  prudent,  and  he  became  somewhat 
worse.  His  sciatica  remained  in  a  subdued  condition,  being 
merely  a  tenderness,  but  the  pains  in  the  anterior  cutaneous 
nerves  became  rather  worse.  Then  the  subcutaneous  nodules 
became  darker  in  color,  quite  clearly  circumscribed,  and  the 
seat  of  pain  and  tenderness;  in  other  words,  they  developed 
into  an  eruption  of  typical  precocious  gummata.  The  iodide 
was  given  internally  in  fair  quantity,  and  equal  parts  of  mercu¬ 
rial  and  belladonna  ointments  were  applied  to  the  gummata  by 
means  of  a  bandage  and  a  closely-fitting  stocking.  The  result 
was  that  the  pain  in  both  nerves  and  gummata  grew  slowly 
but  surely  less,  and  that  the  gummata  became  less  painful  and 
were  slowly  absorbed.  No  local  treatment  was  used  for  the 
neuralgia  of  the  cutaneous  nerves,  but  it  subsided  coincidently 
with  the  absorption  of  the  subcutaneous  nodules,  some  of  which 
seemed  fully  two  inches  in  thickness. 

It  is  interesting  to  note  that,  synchronously  with  the 
appearance  of  the  neuritic  phenomena,  typical  dry  onychia 
and  separation  of  the  nails  began  on  several  fingers  of  both 
hands  and  on  several  toes  of  both  feet.  These  likewise 
showed  signs  of  improvement  under  the  local  use  of  mer¬ 
curial  ointment  and  the  general  treatment.  I  may  here  re¬ 
mark  that  it  has  often  struck  me  very  forcibly  that  some 
of  the  earlier  nail  lesions  of  syphilis  seem  to  be  the  result 
of  tropho-neurosis,  while  others  are  due  to  inflammatory 
and  infiltrative  processes. 

In  this  case  we  find  that,  shortly  after  the  onset  of  neu¬ 
ralgia  of  the  sciatic  nerve  in  a  patient  suffering  from  early 
an4  active  syphilis,  true  subcutaneous  gummatous  nodules, 
which  we  know  have  their  nidus  in  the  connective  tissue 
structures,  are  developed,  and  that  the  nerve  changes  and 
subdermal  changes  are  coincidently  relieved  and  cured  by 
active  antisyphilitic  medication,  local  and  general.  I 
think,  therefore,  taking  all  the  facts  into  consideration,  that 
the  conclusion  is  warranted  that  syphilis  caused  the  nerve 
affection  and  the  subcutaneous  new  growths  by  reason  of 
its  known  tendency  to  produce  hyperaemia  and  hyperplasia 
of  the  connective  tissues. .  In  this  connection  I  may  say 
that  I  have  recently  had  under  observation  a  syphilitic  lady 
who  suffered  from  neuralgia  of  the  anterior  crural  nerves 
and  precocious  gummata  of  the  legs,  both  of  which  disap¬ 
peared  under  antisyphilitic  treatment. 

Why  syphilis  causes  neuralgias  in  some  cases  and  anal¬ 
gesia  and  anaesthesia  in  others  is  a  problem  yet  to  be 
solved.  With  only  nine  cases  at  our  disposal  it  is  evident 


July  5,  1890.] 


TAYLOR:  MULTIPLE  NEURITIS  OF  SYPHILITIC  ORIGIN. 


5 


that  the  chapter  on  the  symptomatology  of  multiple  neuri¬ 
tis  of  syphilitic  origin  can  not  now  be  written.  It  is  worth 
while,  therefore,  I  think,  to  present  a  brief  aud  clear  synop¬ 
sis  of  the  cases  of  other  observers,  since  it  will  be  of  inter¬ 
est  in  connection  with  my  own  case  and  of  aid  to  others  in 
the  study  of  this  affection.* 

Ehrmann’s  case,  observed  in  Neumann’s  clinic,  is  re¬ 
ported  in  order  to  show  conclusively  that,  in  the  active  and 
earlier  stages  of  syphilis,  the  peripheral  nerves  may  be  af¬ 
fected  by  neuritis.  Its  history  is  as  follows : 

A  man,  thirty-eight  years  old,  entered  the  hospital  on  the 
16th  of  December,  presenting  a  hard  chancre  and  generalized 
secondary  eruptions.  In  his  urine  a  large  quantity  of  albumin, 
cylindrical  epithelium,  red  and  white  blood-corpuscles,  and  epi¬ 
thelium  from  the  pelvis  of  the  kidney,  were  found.  Under  the 
influence  of  hot  baths  and  iodide  of  potassium  internally  he 
seemed  better  in  about  six  weeks,  and  the  albumin  was  no 
longer  found  in  the  urine.  A  little  later  on  he  became  jaun¬ 
diced,  and  on  the  29th  of  April  periostitis  of  the  left  tibia  caused 
the  resumption  of  the  iodide.  Then,  in  a  short  time,  perios¬ 
titis  of  the  external  malleolus  of  the  left  side,  pain  in  the  tendo 
Achillis  and  in  the  gastrocnemii  muscles,  and  swelling  and  pain 
in  both  cuboid  bones,  were  complained  of.  Then  it  is  noted  that 
pains  were  felt  in  the  first  and  second  phalanges  of  the  left  ring 
finger,  and  a  sensation  of  tingling  on  the  ulnar  side  of  the  left 
forearm  and  in  the  ring  and  little  fingers  of  the  same.  Careful 
examination  of  the  brachial  plexus  showed  that  the  nerves  were 
very  sensitive  to  pressure  in  their  whole  length,  notably  the 
ulnar  nerve.  This  sensibility  was  well  marked  at  the  internal 
condyle,  but  it  was  still  more  pronounced  in  the  middle  of  the 
anterior  surface  of  the  forearm ;  was  very  active  at  the  ulnar 
side  of  the  palm,  from  whence  it  extended  to  the  ring  and  little 
fingers.  Pressure  upon  the  median  nerve  caused  much  less  pain, 
but  none  in  the  radial.  Examination  showed  that  the  nerves 
on  the  left  side  were  much  more  distinctly  felt  than  those  of 
the  right  and  unaffected  side.  The  interosseous  spaces  of  the 
left  hand,  between  the  metacarpals  of  the  ring  and  little  fin¬ 
gers,  were  visibly  depressed,  and  all  the  muscles  supplied  by 
the  ulnar  nerve  were  atrophied.  Extension  of  the  ring  and 
little  fingers  was  incomplete  at  the  phalangeal  articulations, 
and  they  could  not  be  moved  the  one  on  top  of  the  other,  nor 
could  the  patient  place  the  ring  finger  over  the  middle  finger. 

Tests  of  sensibility  showed  hypersestbesia  of  all  the  ulnar 
side  of  the  forearm,  especially  at  its  lower  portion.  On  the 
bend  the  hyperaasthetic  zone  included  the  parts  supplied  by  the 
ulnar  and  median  nerve,  and  slight  punctures  with  a  needle  pro¬ 
duced  small  bullae,  surrounded  with  a  red  areola.  Ehrmann 
looks  upon  this  fact  as  evidence  of  vaso  motor  disturbance. 
Heat  and  cold  produced  pain  in  the  hyperaesthetic  zone.  The 
electrical  irritability  of  the  ulnar  and  median  nerves  was  dimin¬ 
ished  ;  patellar  reflex  was  well  marked  on  both  sides,  and  the 
tendon  reflex  of  the  upper  extremities  was  the  same  on  both 
sides.  A  fair  amount  of  improvement  was  produced  by  the 
iodide,  in  doses  of  thirty  grains  daily,  but  the  symptoms  were 
still  manifest  in  July. 

*  In  this  connection  it  is  well  to  remember  that  cases  of  syphilis  in 
which  one  or  more  fingers  of  both  hands  have  become  cold  and  livid, 
and  even  ulcerated,  have  been  reported  by  Hutchinson  {Med.  Times 
and  Gazette,  1884,  i,  p.  347),  by  Klotz  {American  Journal  of  the  Medi¬ 
cal  Sciences ,  Aug.,  1889),  by  Baron  d’Ornellas  {Annafes  de  dermatologie 
et  de  syphiligraphie,  June,  1888,  p.  35  et  seq .),  and  by  J.  E.  Morgan 
{Lancet,  July  6,  1889).  In  the  present  state  of  our  knowledge  an  oblit¬ 
erating  arteritis  is  the  ascribed  cause  of  this  condition.  The  relation 
of  the  nervous  system  to  it  is  yet  to  be  determined. 


Buzzard’s  first  case  was  that  of  a  man,  aged  thirty-one,  who 
suffered  from  pain  in  the  right  leg  along  the  course  of  the  sci¬ 
atic  nerve  and  its  branches.  The  patient  had  lost  flesh  aud  the 
leg  was  weak  and  withered.  The  history  of  syphilis  was  not  at 
all  clear,  and  the  diagnosis  of  a  specific  origin  of  the  trouble 
was  based  largely  upon  a  putative  node  on  the  right  femur. 
Under  the  influence  of  iodide  of  potassium  the  pain  ceased  and 
the  node  was  absorbed. 

Buzzard’s  case,  in  his  second  contribution,  was  as  follows: 
W.  H.,  a  workingman,  aged  forty-four,  of  previous  good  health, 
in  January,  1873,  had  double  facial  paralysis,  total  absence  of 
power  of  voluntary  contraction  in  the  muscles  of  either  leg,  the 
grasp  of  both  hands  was  entirely  lost,  and  there  was  partial 
paralysis  of  respiration  and  deglutition.  There  was  incomplete 
paralysis  of  the  right  external  rectus  muscle  and  of  the  soft 
palate,  especially  on  the  left  side.  There  was  but  little  move¬ 
ment  of  the  diaphragm  and  very  imperfect  action  of  the  inter¬ 
costal  muscles,  'there  was  more  or  less  anaesthesia  of  the 
body,  extremities,  and  face.  A  sense  of  numbness  and  weight 
was  complained  of  in  each  leg;  the  brain  and  viscera  were 
seemingly  in  normal  condition.  This  condition  began  a  month 
previous,  with  numbness  in  the  finger-ends  and  weakness  in  the 
legs,  together  with  a  pin-and-needle  sensation  and  numbness  in 
the  calves,  thighs,  and  buttocks.  In  a  few  days  he  could  use 
neither  arms  nor  legs.  Owing  to  the  syphilitic  history  obtained, 
he  was  treated  with  the  iodide  of  potassium,  and  later  with 
mercury.  Improvement  soon  began,  and  in  six  months  the 
patient  was  able  to  resume  his  employment,  and  later  on  was 
pronounced  to  be  entirely  recovered. 

Ormerod’s  case  was  that  of  a  woman,  aged  twenty-three, 
who  presented  an  enlargement  of  the  left  median  nerve  in  the 
upper  arm.  The  nerve  was  thicker  than  a  quill,  and  the  mus¬ 
cles  supplied  by  it  were  wasted.  The  two  last  joints  of  the 
index  and  middle  fingers  and  the  last  joint  of  the  thumb  were 
anaesthetic.  The  skin  of  the  last  joint  of  the  index  finger  had 
been  red,  glossy,  and  ulcerated,  but  the  condition  had  passed 
away  under  treatment.  There  had  been  an  attack  of  pain  in 
the  nerve  five  years  ago,  but  this  had  passed  off",  leaving  no  per¬ 
manent  damage.  Two  and  a  half  years  ago  the  pain  had  re¬ 
curred,  leaving  the  present  condition.  The  patient  presented 
several  unequivocal  signs  of  congenital  syphilis.  In  favor  of 
this  view  were  the  facts  that  no  other  cause  could  be  assigned, 
that  the  ulcer  had  healed  under  iodide  of  potassium,  and  that 
deafness  had  much  increased  during  the  few  months  preceding 
the  last  attack  of  neuritis. 

In  the  discussion  of  this  case  Mr.  Jonathan  Hutchinson 
stated  his  belief  that  the  patient’s  condition  was  probably 
dependent  upon  syphilis,  but  he  had  never  seen  a  similar 
case  in  congenital  syphilis,  although  he  had  seen  an  example 
of  neuritis  of  one  of  the  nerves  of  the  arm  from  the  ac¬ 
quired  disease. 

Dr.  Mills  regarded  cases  of  pure  and  simple  multiple 
neuritis  as  rare.  He  reported  three  with  a  distinct  syphilitic 
history.  He  frequently  found  certain  cases  of  paralysis  in 
which  a  clear  history  of  syphilis  or  of  chronic  alcoholism, 
or  both,  was  present.  These  two  factors  were  so  often  con¬ 
joined  in  the  history  of  the  same  case  that  it  was  sometimes 
difficult  to  separate  such  cases  into  two  subdivisions,  one  of 
which  represented  a  type  clearly  syphilitic  and  the  other 
clearly  alcoholic.  Sometimes  he  had  been  able  to  do  this. 
His  three  cases,  of  which  he  presented  the  notes  (which, 
unfortunately,  are  not  published),  presented  the  usual  feat¬ 
ures,  sensory  and  paralytic,  of  multiple  neuritis,  and  he  re- 


6 


GERSTER:  APPENDICITIS  AND  PERITY PELITIC  ABSCESS. 


[N.  Y.  Med.  Jour., 


marks  that  this  affection,  when  due  to  alcohol,  is  almost 
similar  in  its  symptomatology.  Specific  treatment  bene¬ 
fited  the  former  but  had  no  effect  upon  the  latter.  Mills 
states  that  in  these  cases  there  are  points  of  resemblance 
between  neuritis,  myelitis,  and  poliomyelitis.  He  believes 
that  there  are  no  clear  diagnostic  points  between  these  af¬ 
fections  which  would  enable  us  to  say  positively  that  here 
wras  a  case  of  multiple  neuritis,  there  one  of  diffuse  myelitis, 
and,  still  further,  one  of  myelitis  anterior.  There  were 
symptoms  which  rendered  the  diagnosis  probable,  but  more 
could  not  be  said  in  certain  cases  with  safety. 

Leyden’s  case  is  reported  in  a  very  cursory  manner.  It  is 
as  follows:  A  healthy  young  man,  accustomed  to  muscular  ex¬ 
ercise,  was  attacked  by  terrible  pains  and  paretic  weakness  of 
the  arms,  with  distinct  atrophy  and  pathological  conditions  with 
the  electric  current.  When  he  consulted  Leyden  he  presented 
a  florid  secondary  eruption,  therefore  his  neuritic  symptoms 
were  ascribed  to  syphilis.  Later  on  the  patient  had  a  specific 
affection  of  the  liver,  and  was  finally  cured  of  his  syphilis,  as 
well  as  of  the  neuritis. 

Bowlby  *  speaks  of  the  case  of  a  man,  aged  fifty-four,  who 
had  suffered  from  syphilis  for  many  years,  in  whom  a  gradual 
paralysis  of  the  parts  supplied  by  the  ulnar  nerve  had  com¬ 
menced  ten  years  before  he  came  under  observation.  The  hand 
was  clawed,  the  interossei  muscles  and  those  forming  the  ball 
of  the  little  finger  were  extremely  wasted,  and  there  was  very 
definite  atrophy  of  the  ulnar  side  of  the  forearm.  The  skin 
supplied  by  the  ulnar  nerve  was  quite  anaesthetic.  This  nerve 
could  be  felt  behind  the  elbow  as  a  thick,  hard  cord,  not  less 
than  four  or  five  times  its  natural  size,  the  thickening  extending 
along  the  trunk  for  about  two  inches.  It  was  slightly  painful 
and  tender. 

Several  gentlemen  of  prominence  who  have  seen  my 
case  were  disposed  to  consider  it  to  be  one  of  leprosy.  In 
the  light  of  the  history  given,  I  think  such  a  diagnosis  is 
untenable.  In  this  connection,  however,  I  have  thought  it 
worth  while  to  summarize  the  following  case,  in  which  a 
coincidence  of  leprosy  and  syphilis  in  the  same  subject  is 
claimed.  With  this  view  I  am  not  at  all  in  accord,  and  I 
think  that  the  facts  which  I  have  brought  forward  in  this 
essay  will  convince  others,  as  they  have  convinced  me,  that 
in  Kaposi’s  case  the  nervous  symptoms  were  produced  by 
syphilis  alone. 

Kaposi’s  case,f  shown  before  the  Imperial  Society  of 
Vienna  in  1888,  was  that  of  a  man,  aged  thirty-one  years, 
born  of  healthy  parents  in  a  country  where  lepra  is  not 
epidemic.  In  1884  he  contracted  syphilis.  After  several 
years  passed  in  Asia  he  returned  to  Germany  for  treatment 
of  his  syphilis.  At  that  time  he  presented  new  lesions — 
ulceration  of  the  palmar  surface  of  the  right  index  fingers, 
pains  radiating  from  that  finger  to  the  shoulder,  red  spots 
upon  the  right  hand,  anaesthesia  of  the  index  finger,  and 
hyperaesthesia  of  the  other  fingers  of  this  hand.  Later  on 
new  patches,  similar  to  gummata,  .appeared.  The  circum¬ 
ference  of  the  right  arm  became  less  than  that  of  the  left, 
while  at  the  right  wrist  the  circumference  was  a  little  greater 
than  that  of  the  left.  The  right  index  finger  was  longer 

*  Loc.  cit.,  p.  463. 

f  L&pre  et  syphilis  chez  le  meme  individu.  La  Semaine  medicate, 
1888,  p.  487. 


than  that  of  the  left,  and  it  presented  a  fusiform  thicken¬ 
ing.  The  right  hand  was  covered  with  irregularly  distrib¬ 
uted,  diffuse  patches.  The  movements  of  the  right  arm 
were  impaired,  though  muscular  contractions  were  normal. 

There  was  infiltration  in  the  right  superciliary  region 
from  the  middle  of  the  brow  to  the  external  angle  of  the 
eye,  which  at  its  internal  edge  was  hard  and  elastic  and 
became  soft  as  it  progressed  outward.  This  infiltration, 
like  that  of  the  hand,  was  painful  on  pressure  but  in  parts 
anaesthetic.  Around  it  was  a  zone  of  hyperaesthesia.  There 
were  anaesthetic  patches  also  on  the  hand. 

Kaposi,  in  considering  the  aetiology  of  this  case,  says 
that  the  view  that  it  might  be  due  to  syphilitic  neuritis 
could  surely  be  excluded  for  the  reason  that  a  spinal  nerve 
can  not  be  affected  by  syphilis  unless  it  is  in  contact  with 
a  gumma.  Further,  he  thinks  that  if  syphilitic  neuritis  did 
exist  it  was  not  because  of  the  cutaneous  lesions,  for  he 
does  not  think  that  they  were  of  syphilitic  origin.  Lupus 
was  also  excluded  by  him. 

The  clinical  tableau,  consisting  of  the  anaesthesia,  the 
rapid  succession  of  the  eruptions,  the  nature  of  the  infil¬ 
tration,  the  neurotic  symptoms,  and  the  functional  troubles, 
he  thinks  prove  conclusively  that  it  was  due  to  anaesthetic 
leprosy. 

Kaposi  states,  however,  that  neither  he  nor  his  assist¬ 
ants  could  find  the  bacillus  of  leprosy,  but  he  explains  this 
by  the  fact  that  the  disease  was  as  yet  in  its  initial  stage. 
Further,  he  states  that  Hansen  says  that  bacilli  are  never 
found  in  anaesthetic  leprosy. 

Kaposi  looks  upon  this  case  as  one  showing  the  exist¬ 
ence  of  syphilis  and  leprosy  in  the  same  individual,  and 
states  that  it  is  the  only  example  of  this  morbid  coincidence 
which  he  has  seen. 

Danielssen  once  successfully  inoculated  a  leper  with 
syphilis. 

40  West  Twenty-first  Street. 


ESSAY  UPON  THE  CLASSIFICATION  OF 
THE  VARIOUS  FORMS  OF 

APPENDICITIS  AND  PERITYPHLITIC  ABSCESS, 

WITH  PRACTICAL  CONCLUSIONS* 

By  ARPAD  G.  GERSTER,  M.  D., 

SURGEON  TO  THE  GERMAN  AND  MOUNT  SINAI  HOSPITALS  ; 

PROFESSOR  OF  SURGERY  AT  THE  NEW  YORK  POLYCLINIC. 

Up  to  within  a  recent  period  of  time  it  was  the  preva¬ 
lent  belief  that  perityphlitic  suppuration  was  located  retro- 
peritoneally,  and  most  generally  in  the  iliac  fossa,  whence 
it  found  its  way  to  the  surface  by  pushing  aside  the  perito¬ 
neal  reflection  corresponding  to  Poupart’s  ligament.  Wil¬ 
lard  Parker’s  method  of  incising  perityphlitic  abscess  was 
based  upon  this  view. 

It  can  not  be  denied  that  the  development  of  most  cir- 
cumappendicular  abscesses  seems  to  confirm  this  view,  and 
that  the  rules  laid  down  by  Parker  for  the  treatment  of  this 
group  of  suppurative  processes  have  yielded,  and  continue 
to  yield,  very  satisfactory  results  in  very  many  instances. 

*  Read  before  the  New  York  Surgical  Society,  May  14,  1890. 


July  5,  1890.] 


OERSTER:  APPENDICITIS  AND  PERITYPELITI C  ABSCESS. 


7 


Still,  it  must  be  said  that  the  exceptions  to  Parker’s  type 
are  considerable  in  number.  Formerly  they  were  classed 
as  cases  of  general  or  localized  “  idiopathic  peritonitis.” 
Their  treatment  was  non-surgical,  and  their  issue  very  un¬ 
certain  and  often  fatal. 

We  owe  the  better  understanding  of  the  elements  of  this 
phenomenon  to  Treves  and  Weir,  but  principally  to  McBur- 
ney,  who  demonstrated  that  in  the  vast  majority  of  instances 
the  formation  of  abscess  in  the  right  iliac  fossa  was  due  to  in- 
traperitoneal  inflammatory  processes,  mostly  of  the  vermi¬ 
form  appendix,  and  commonly  accompanied  by  ulceration, 
necrosis,  and  perforation  of  this  viscus.  The  frequency  of 
the  location  of  perityphlitic  abscess  near  the  parietes  of  the 
right  iliac  fossa  is  explained  by  the  frequency  of  the  super¬ 
ficial  situs  of  the  appendix  in  this  region.  In  these  cases 
the  type  of  development  so  well  described  by  Parker  will 
prevail.  But  in  a  very  large  proportion  of  instances  the 
vermiform  appendix,  either  congenitally  or  in  consequence 
of  acquired  peculiarity,  occupies  a  deep  situation,  and  in 
these  cases  an  appendicular  perforative  process  is  sure  to 
cause  a  deep-seated  intraperitoneal  abscess,  more  or  less 
distant  from  the  surface,  hence  infinitely  more  grave  and 
dangerous  both  as  regards  its  deleterious  possibilities  and 
the  difficulty  of  diagnosis  and  surgical  management.  As 
soon  as  it  became  clear  that  widely  different  intraperitoneal 
forms  of  suppuration  might  be  caused  by  extension  from 
the  appendix,  and  that  their  manner  of  development  was 
wholly  unforeseen  and  unaccountable,  a  violent  oscillation 
in  therapy  was  initiated  by  those  who  proposed,  in  all  cases 
where  the  appendix  was  suspected  of  causing  trouble,  a  bold 
exploration  by  abdominal  section,  and  the  extirpation  of  the 
appendix,  or  evacuation  at  all  hazards  of  the  purulent  col¬ 
lection,  wherever  it  might  be  found,  and  all  this  without 
delay. 

Though  this  bold  course  of  therapy  has,  in  spite  of  its 
experimental  character,  yielded  very  good  results  in  the 
hands  of  various  surgeons,  and  although  its  adoption  was 
absolutely  necessary  for  establishing  a  clearer  understand¬ 
ing  of  the  nature  of  the  morbid  process  in  question,  never¬ 
theless  it  must  be  remembered  that  a  vast  proportion  of 
perityphlitic  abscesses  do  not  need  operative  invasion  of  the 
free  peritoneal  cavity  for  their  successful  cure,  and  that  a 
sweeping  advice  to  the  general  profession  to  open  the  peri¬ 
tonaeum  in  every  case  where  appendicular  trouble  is  sus¬ 
pected  is,  for  obvious  reasons,  fraught  with  much  unwar¬ 
rantable  danger. 

Formerly  it  was  considered  purely  accidental  whether 
an  intraperitoneal  abscess  would  appear  here  or  there,  and 
the  variability  of  the  surroundings  and  location  of  these  ab¬ 
scesses  was  deemed  so  irregular  and  erratic  that,  to  the  au¬ 
thor’s  knowledge,  no  attempt  was  ever  made  to  study  the 
question  whether  a  certain  order  of  development  did  not 
prevail  even  in  those  forms  of  perityphlitic  abscess  which 
could  not  be  classed  with  the  well-known  inguinal  type  de¬ 
scribed  by  Parker.  If  some  light  could  be  thrown  upon  the 
detailed  nature  of  these  seemingly  erratic  forms  of  eircum- 
appendicular  abscess,  instead  of  the  crude  general  advice  to 
“perform  laparotomy,”  more  precise,  hence  safer,  methods 
of  treatment  would  suggest  themselves. 


Let  us  first  emphasize  the  fact  that  all  intraperitoneal 
abscesses  are  of  visceral  origin,  and  that  perityphlitic  ab¬ 
scess  in  particular  is  due  to  inflammatory  processes  located 
in  the  vermiform  appendix.  Though  not  always,  this  form 
of  abscess  is  mostly  established  within  the  peritoneal  sac. 

The  proof  of  this  assertion  has  been  so  manifold  that  it  is 
only  necessary  to  refer  to  the  numerous  cases  of  early  appen¬ 
dicitis  reported  by  McBurney  and  other  observers,  in  which,  on 
laparotomy,  the  free  appendix  was  found  to  be  tightly  dis¬ 
tended  by  a  copious  exudate,  and  more  or  less  erect  by  dint  of 
its  extreme  distention ;  its  walls  thickened,  hypermmic,  occa¬ 
sionally  exhibiting  unmistakable  signs  of  circumscribed  necrosis 
with  perforation  imminent.  This  distension  was  uniformly 
produced  by  occlusion  toward  the  gut.  Occasionally  decay  had 
progressed  to  actual  perforation  and  the  formation  of  incipient 
abscess,  surrounded  by  a  protective  barrier  of  recent  adhesions 
of  the  vicinal  serous  surfaces.  The  appendix  was  invariably 
found  to  be  the  starting  point  of  the  trouble,  and  the  affection, 
with  rare  exceptions,  always  intraperitoneal.  Aside  from  the 
numerous  instances  in  which  the  intraperitoneal  and  appendicu¬ 
lar  character  of  perityphlitis  was  established  by  positive  observa¬ 
tion,  the  following  case  may  serve  to  show  that  the  retroperito¬ 
neal  space  back  of  the  iliac  fossa  is  not  the  seat  of  abscess  in 
typical  cases  of  perityphlitis.  In  the  spring  of  1887  Dr.  Lell- 
mann,  then  ou  duty  in  the  German  Hospital,  requested  the  au¬ 
thor  to  operate  on  a  case  of  perityphlitis  pertaining  to  his  service. 
The  operation  was  delayed  twenty-four  hours  on  account  of  a 
misunderstanding,  and  the  next  day — a  dense,  painful  tumor 
being  found  in  the  right  iliac  region — incision  according  to  Par¬ 
ker  was  done,  in  spite  of  the  circumstance  that  the  size  of  the 
swelling  had  somewhat  diminished  since  the  previous  day.  The 
peritoneal  lining  of  the  iliac  fossa  was  easily  stripped  up  two 
inches  beyond  the  external  iliac  vessels,  so  that  the  tumor  was 
freely  raised  with  it  from  the  underlying  tissues.  No  sign  of 
inflammation  was  found,  and,  as  the  case  was  mending,  it  was 
not  deemed  prudent  to  incise  the  peritonaeum.  The  very  deep 
wound  was  drained  and  closed,  but  no  pus  appeared.  Simul¬ 
taneously  with  the  healing  of  the  incision  the  tumor  disap¬ 
peared,  and  the  man  was  discharged  cured  within  a  fortnight 
after  the  operation. 

We  need  not  do  more  than  hint  at  the  causes  of  appen¬ 
dicular  inflammation.  Let  us  first  mention  the  impaction  of 
foreign  bodies  entering  from  the  gut,  acute  or  chronic  forms 
of  catarrhal  or  ulcerative  (typhoid)  enteritis,  transmitted 
from  the  colon  and  leading  to  simple  hypertrophy  or  to 
ulceration,  both  of  these  causing  irregular  constriction  mostly 
in  the  vicinity  of  the  attachment  of  the  appendix.  Another 
not  infrequent  cause  of  stenosis  is  the  doubling  upon  itself 
and  fixation  of  the  appendix  in  this  position.  Stenosis  by 
flexion  is  thus  produced  (F.  W.  Murray,  JN.  Y.  Med.  Jour., 
May  24,  1890,  p.  564).  With  the  establishment  of  hyper¬ 
trophy  and  stenosis  a  loss  of  contractile  power  is  associated, 
leading  to  more  or  less  complete  retention  and  to  the  in- 
spissation  of  faecal  matter,  which  finally  assumes  the  shape 
of  one  or  more  globular  concrements.  As  long  as  the  com¬ 
munication  with  the  colon  is  fairly  open,  no  local  symptoms 
need  prevail.  As  soon  as  the  stenosis  becomes  considerable, 
the  well-known  signs  of  appendicitis  make  their  appearance. 
If  they  are  due  to  a  passing  state  of  catarrhal  hyperaemia, 
their  acuteness  will  varjr  in  proportion  with  the  intensity  of 
the  stenosis.  Thus,  with  the  cessation  of  causal  intumes- 


8 


GERSTER:  APPENDICITIS  AND  PERITYPHL1TIC  ABSCESS. 


[N.  Y.  Med.  Jour., 


cence  and  the  elimination  of  the  stenosis  maintained  by 
it,  all  trouble  may  seemingly  or  really  disappear.  A  case 
reported  by  Shrady  *  aptly  illustrates  this  train  of  symp¬ 
toms  : 

A  physician  had  had  four  distinct  attacks  of  appendicitis,  in 
all  of  which  the  question  of  operation  arose.  Dr.  Shrady  had 
seen  the  patient  at  New  York  in  three  of  the  attacks,  all  of 
which  were  well  pronounced,  while  the  fourth  occurred  in 
Paris,  where  the  patient  was  seen  by  a  distinguished  surgeon, 
who  made  a  like  diagnosis.  There  also  the  question  of  an  op¬ 
eration  came  up.  Each  attack  was  attended  with  all  the  usual 
severe  symptoms  which  would  appear  to  usher  in  the  formation 
of  an  abscess;  there  was  dullness,  tenderness,  more  or  less  ri¬ 
gidity,  and  some  oedema  in  the  neighborhood  of  the  caecum.  In 
each  attack  the  advisability  of  operation  was  freely  discussed. 
The  patient  was  willing  to  take  the  risks,  but  in  each  instance 
the  symptoms  gradually  disappeared,  and  he  recovered.  He 
asked  Dr.  Shrady,  should  he  survive  him,  to  examine  his  appen¬ 
dix,  which  was  done  when  death  occurred,  some  time  subse¬ 
quently,  *of  another  cause.  The  appendix  was  found  perfectly 
sound.  There  was  not  the  slightest  appearance  of  any  inflam¬ 
mation  around  it;  it  was  not  even  thickened. 

Where  ulcerative  processes  have  led  to  the  formation  of 
a  permanent  cicatricial  contraction,  the  appendical  trouble 
is  apt  to  persist  even  after  the  cessation  of  the  causal  dis 
order  of  the  intestine.  Passing  states  of  local  intumescence 
are  then  more  likely  to  lead  to  complete  occlusion  of  the 
communication  between  gut  and  appendix,  with  serious 
consequences.  But  even  in  these  cases  temporary  improve¬ 
ments  are  possible  with  the  diminution  of  the  acute  swell¬ 
ing  of  the  cicatricial  mass. 

Before  attempting  a  practical  classification  of  the  phases 
of  appendicitis  and  of  the  localities  in  which  circumap- 
pendicular  suppuration  is  to  be  observed,  this  fact  has  to  be 
pointed  out:  that,  unfortunately,  the  acuteness  or  mildness 
of  the  local  or  general  symptoms  is  not  an  invariable  index 
of  the  ultimate  gravity  of  a  given  case.  Sometimes  fatal 
cases  will  set  in  with  a  very  deceptive  mildness  of  appear¬ 
ances.  On  the  other  hand,  a  very  alarming  beginning  may 
be  followed  by  resolution  or  a  tractable  state  of  affairs. 
Hence  it  must  be  insisted  on  that,  in  reference  to  this 
trouble,  all  therapeutic  advice  has  only  a  conditional  value 
— to  be  weighed  and  accepted  or  rejected  by  the  surgeon 
in  each  separate  case. 

A.  Acute  Appendicitis  ( without  Tumor). 

(a)  Simple  Appendicitis  ( No  Tumor). — Anatomy  teaches 
that  in  the  supine  body  the  attachment  of  the  vermiform 
appendix  can  be  found  directly  underneath  a  point  located 
two  inches  from  the  anterior  superior  spine  of  the  ilium, 
on  a  line  connecting  this  bony  prominence  with  the  navel. 
Whenever  acute  and  persistent  pain  appears  in  this  region, 
accompanied  by  fever  and  retching,  the  pain  being  marked¬ 
ly  increased  by  palpation  of  this  area,  trouble  of  the  appen¬ 
dix  can  be  confidently  diagnosticated.  In  women,  biman¬ 
ual  palpation  ought  to  exclude  the  presence  of  an  inflam¬ 
matory  process  of  the  displaced  uterine  appendages. 

*  George  F.  Shrady,  Meeting  of  Practitioners’  Society  of  N.  Y.  Med. 
Record ,  April  26,  1890,  p.  479. 


Though  the  local  and  general  symptoms  may  be  very 
alarming,  tumor  can  rarely,  if  ever,  be  detected  in  the  early 
stages  of  the  affection.  Meteorism  is  also  absent. 

In  view  of  the  impossibility  of  foretelling  whether,  in  a 
given  case,  spontaneous  evacuation  of  the  contents  of  the 
appendix  or  perforation  is  to  take  place,  and  in  the  latter 
case  whether  a  superficial  or  a  deep-seated  abscess  is  to 
develop;  and,  considering  the  fact  that  laparotomy  fol¬ 
lowed  by  excision  of  the  appendix  has  yielded  uniformly 
good  results  if  done  before  the  access  of  perforation,  it  is 
safe  to  follow  McBurney’s  advice,  which  recommends  lapa¬ 
rotomy  and  removal  of  the  appendix  whenever  severe  symp¬ 
toms  persist  and  increase  for  more  than  forty -eight  hours. 

The  steps  of  the  operation  are  these :  A  longitudinal 
incision,  four  or  five  inches  long,  parallel  with  and  just 
outside  of  the  outer  margin  of  the  right  rectus  muscle.  Hav¬ 
ing  opened  the  peritonaeum,  the  appendix  is  found,  which 
will  be  rendered  easy  by  first  ascertaining  the  location  of 
the  caput  coli.  The  mesentery  of  the  appendix  is  included 
in  a  double  ligature  of  stout  catgut  and  divided.  Then 
the  root  of  the  appendix  is  secured  by  two  ligatures,  be¬ 
tween  which  the  viscus  is  cut  olf.  The  mucous  lining  of 
the  stump  is  either  seared  with  the  thermo-cautery,  or,  after 
careful  disinfection,  is  touched  with  a  few  drops  of  perchlo- 
ride-of-iron  solution  and  dried  off.  Then  the  stump  is 
dropped  back  and  the  external  wound  is  closed. 

Case. — Miss  F.  L.,  aged  twenty,  has  had  altogether  sixteen 
or  eighteen  attacks  of  appendicitis  within  two  years.  Charac¬ 
teristic  local  pain,  irregular  fever  with  temperatures  reaching 
104°  F.,  no  tumor.  Uterine  appendages  normal. 

April  20,  1890. — Laparotomy.  The  free  appendix  is  found 
very  much  thickened,  its  distal  half  distended  and  bent  upon 
itself,  containing  a  quantity  of  foetid  serum.  It  was  removed. 
Uninterrupted  recovery. 

(6)  Perforative  Appendicitis  ( No  Tumor). — Sudden  in¬ 
crement  and  extension  of  the  local  pain  followed  by  symp¬ 
toms  of  collapse,  such  as  profuse  cold  sweating,  a  thready 
pulse,  anxious  expression,  pallor,  frequent  vomiting,  and  the 
appearance  of  meteorism  are  indications  that  perforation 
and  infection  of  the  peritonaeum  have  taken  place.  This 
rarely  occurs  before  two  or  three  days  after  the  inception 
of  the  trouble.  The  violence  of  the  symptoms  will  depend 
on  these  factors.  If  the  extent  of  the  perforation  is  small, 
and  only  a  small  quantity  of  the  infectious  contents  of  the 
appendix  has  made  its  way  into  the  peritonaeum,  a  limit¬ 
ing  barrier  of  protective  adhesions  may  be  thrown  about 
the  infected  area  within  an  hour  or  so.  In  this  case  the 
alarming  features  of  the  case  will  somewhat  subside  and  a 
tumor  is  apt  to  develop.  If,  on  the  other  hand,  the  per¬ 
foration  is  large  or  multiple,  a  considerable  volume  of  in¬ 
fectious  material  will  suddenly  escape.  Lively  peristaltic 
action  will  widely  distribute  it,  and  more  or  less  extensive 
local  or,  in  the  worst  cases,  general  septic  peritonitis  will 
be  established. 

The  absence  of  tumor  in  conjunction  with  very  acute 
local  and  general  symptoms  represents  an  extremely  grave 
combination  of  things,  its  meaning  being  a  generalizing 
peritonitis.  In  these  cases  the  prognosis  is  very  doubtful, 
and  it  will  be  extremely  difficult  to  save  the  patient,  even 


July  5,  1890.] 


GERSTER:  APPENDICITIS  AND  PERITYPHLITI C  ABSCESS. 


9 


by  the  most  resolute  measures.  If  laparotomy  is  imme¬ 
diately  done,  the  focus  laid  open,  wiped  out  clean,  the  ap¬ 
pendix  removed,  and  the  cavity  packed  and  drained,  some 
chances  may  still  be  present  for  the  patient’s  recovery. 
But  where,  on  account  of  delay,  numerous  and  widely  dis¬ 
seminated  abscesses  have  established  themselves  in  the  more 
remote  parts  of  the  peritoneal  cavity,  the  patient’s  death  is 
nearly  certain.  Prolonged  exposure,  the  impossibility  of  a 
sufficient  evacuation  and  drainage  of  the  foci  which  are 
found,  finally  the  overlooking  of  distant  foci  located  in  the 
loins,  in  front  and  behind  the  liver,  will  sufficiently  explain 
this  fact. 

Case  I. — William  Sachse,  aged  forty-eight,  liquor-dealer,  was 
treated  since  September,  1889,  in  the  internal  department  of  the 
German  Hospital  for  alcoholic  neuritis.  No  habitual  constipa¬ 
tion. 

March  23,  1890. — Sudden  chill.  Temperature,  105°.  Slight 
amygdalitis.  No  abdominal  symptoms.  The  temperature  re¬ 
mained  high,  although  the  patient’s  bowels  were  well  purged 
with  calomel  on  March  25th.  Had  a  chill  in  the  preceding 
night,  another  one  in  the  afternoon,  complaining  the  first  time 
of  bellyache. 

27th. — Pain  well  marked  in  ileo-csecal  region.  Was  trans¬ 
ferred  to  surgical  service.  Temperature,  104-4°  F.  Meteorism, 
intense  pain  in  ileo-caecal  region,  but  no  tumor  and  no  dullness. 
Vomited  only  once.  Laparotomy  at  3  p.  m.  McBurney’s  in¬ 
cision.  Peritonaeum  filled  with  turbid  serum.  Omentum 
widely  adherent  to  caecum,  in  front  of  which  an  adherent  and 
very  much  thickened  and  elongated  vermiform  appendix  was 
found.  On  freeing  this,  a  large,  irregular  abscess  cavity  was 
opened,  which  did  not  anywhere  approach  the  parietes,  and 
which  was  situated  below  and  behind  the  caecum,  its  walls  being 
formed  everywhere  by  intestines.  At  the  root  of  the  appendix 
a  large  perforation  was  seen,  with  three  globular  faecal  concre¬ 
ments  lying  in  front  of  and  outside  of  it.  The  appendix  con¬ 
tained  three  more  globular  concrements  of  the  size  of  a  small 
marble.  The  appendix  was  isolated,  tied,  and  cut  off.  Another 
large  abscess  situated  in  the  median  line,  and  a  third  one  in 
Douglas’s  pouch,  were  opened,  irrigated,  and  drained.  Hasty 
partial  closure  of  incision  after  packing  and  diainage  of  the  ab¬ 
scesses  on  account  of  collapse.  In  the  night  the  temperature 
rose  to  106°  F.,  and  the  patient  expired  toward  midnight.  Post¬ 
mortem  examination  revealed  three  more  abscesses,  one  situated 
high  up  behind  the  liver. 

Case  II. — David  Danziger,  tailor,  aged  twenty-two.  Gen¬ 
eral  peritonitis  due  to  perforative  appendical  trouble  of  six  days’ 
duration.  Laparotomy  January  29,  1889,  at  Mt.  Sinai  Hospital. 
Seven  abscesses  were  opened  and  drained.  Patient  seemingly 
improved,  the  quality  of  the  pulse  improving.  Vomiting  ceased, 
but  he  collapsed  suddenly  thirty  hours  after  the  operation  and 
died.  Post-mortem  examination  revealed  three  perihepatic 
abscesses. 

B.  Acute  Appendicitis  with  Tumor;  Perityphlitic  Abscess. 

Whenever  perforation  of  the  free  appendix  occurs,  the 
invasion  of  the  peritonaeum  is  regularly  signalized  by  the 
usual  symptoms  of  perforative  peritonitis.  As  before  men¬ 
tioned,  a  circumvallation  by  adhesions  will  form  in  those 
cases  in  which  only  a  small  quantity  of  infectious  material 
has  escaped.  This  seems  to  be  the  usual  course  of  events. 
Occasionally,  however,  the  inflamed  parts  of  the  appendix 
will  first  become  adherent,  and  then  be  perforated.  In  these 
cases  the  alarming  intermezzo  possessing  the  typical  aspect 


of  perforative  peritonitis  will  be  missed,  and  the  abscess 
will  develop  without  a  tendency  to  meteorism  and  collapse, 
and  with  a  gradual  but  steady  growth  of  the  mainly  local 
symptoms.  The  complex  of  symptoms  has  little  of  the 
character  pertaining  to  peritonitis,  and  resembles  that  of  an 
ordinary  abscess. 

By  contiguous  extension,  which  is  mostly  slow,  these 
abscesses  may  assume  very  large  proportions.  Neglected 
for  a  long  time,  especially  if  they  are  limited  by  intestines 
only,  their  secondary  rupture,  followed  by  a  chill  and  further 
extension,  or  even  their  generalization,  may  occur.  This, 
however,  is  not  common  in  the  early  stages  of  the  process. 
The  only  case  of  this  kind  observed  by  the  author  occurred 
nineteen  days  after  the  inception  of  the  trouble. 

Case. — H.  D.,  clerk,  aged  twenty,  subject  to  alvine  slug¬ 
gishness,  contracted,  after  a  more  than  usually  severe  spell  of 
constipation,  a  deep-seated,  hard,  painful,  perityphlitic  swelling. 
Cathartics  failed  to  relieve  the  bowels,  and,  high  fever  with 
vomiting  having  set  in,  the  author  was  consulted. 

May  1,  1878. — Typical  swelling  of  a  cylindrical  shape  was 
made  out  in  the  right  groin,  and  a  number  of  repeated  large  in¬ 
jections  of  tepid  water  into  the  gut  were  employed  without 
success. 

3d. — The  peritoneal  symptoms,  notably  vomiting,  became 
very  distressing,  wherefore  this  therapy  was  abandoned  and 
opium  treatment  begun.  At  the  same  time  an  ice-bag  was 
placed  over  the  swelling.  The  change  effected  a  decided  im¬ 
provement  in  the  subjective  symptoms,  but  the  swelling  con¬ 
tinued  to  increase  and  the  fever  remained  unrelieved. 

17th. — Spontaneous  evacuation  of  a  large,  formed  stool  oc¬ 
curred. 

19th. — The  general  condition  becoming  very  poor,  incision 
was  urged,  but  was  firmly  declined  by  patient  and  parents. 
Suddenly,  in  the  night  of  the  same  day,  perforative  symptoms 
developed.  The  patient  died,  May  20th,  of  septic  peritonitis. 
Post-mortem  examination  demonstrated  an  internal  perforation 
of  the  abscess,  and  putrid  septic  peritonitis.  Had  the  patient 
consented  to  the  operation,  the  case  might  have  turned  out  dif¬ 
ferently.  Perforation  took  place  on  the  nineteenth  day  after 
the  invasion. 

The  presence  of  a  tumor,  which  always  indicates  the  ex¬ 
istence  of  protective  adhesions,  implies  a  certain  amount  of 
temporary  security  and,  under  certain  circumstances ,  may 
justify  a  short  delay  of  the  operation. 

Types  of  Acute  Perityphlitic  Abscess. 

Although  the  classification  of  perityphlitic  abscess  ac¬ 
cording  to  location  can  not  be  made  with  geometrical  pre¬ 
cision,  yet  it  will  be  found  that  most  cases  can  be  naturally 
massed  in  a  series  of  roughly  defined  groups.  The  small 
number  of  intermediate  or  transitory  forms  does  not  vitiate 
the  practical  value  of  this  grouping,  upon  the  right  under¬ 
standing  of  which  must  be  based  some  important  variatiot  s 
of  the  operative  technique. 

It  is  the  author’s  wish  to  firmly  maintain  the  importance 
of  the  principle  that  every  intraperitoneal  abscess  should, 
if  possible,  be  opened  and  drained  without  invading  the 
normal  peritoneal  cavity — that  is,  through  existing  planes 
of  adhesion  to  the  parietes.  With  few  exceptions,  all  peri¬ 
typhlitic  abscesses  have  such  an  approachable  side.  To 
study,  to  ascertain,  and  to  utilize  them  is  the  duty  of  the 


10 


GERSTER:  APPENDICITIS  AND  PERIT  Y PE  LIT  I G  ABSCESS. 


[N.  Y.  Med.  Jouk., 


conscientious  surgeon.  It  is  idle  to  state  that  safely  incis¬ 
ing  and  draining  an  abscess  through  a  laparotomy  wound — 
that  is,  through  the  free  peritoneal  cavity — is  an  easy  or 
indifferent  matter.  No  competent  person  will  believe  it. 

1.  Ilio-inguinal  Type  (Willard  Parker’s  abscess). — The 
normal  situation  of  the  caput  coli  and  appendix  vermiformis 
near  the  parietes  of  the  right  iliac  fossa  has  the  consequence 
that  the  great  majority  of  circumappendicular  suppurative 
processes  will  naturally  establish  themselves  so  as  to  have 
for  one  of  their  limiting  walls  the  parietal  peritonaeum  of 
that  region.  This  has  led  to  the  erroneous  belief  that  peri- 
typhlitic  abscess  is  normally  located  behind  the  peritoneal 
lining  of  the  iliac  fossa. 

This  situation  involves  the  great  practical  advantage 
that  the  abscess  can  be  permitted  to  assume  certain  propor¬ 
tions  so  as  to  render  its  incision  simple  and  free  from  the 
danger  of  invading  the  normal  peritoneal  cavity.  There¬ 
fore,  when  an  immovable  tumor  develops  in  the  right  iliac 
fossa  soon  after  the  inception  of  the  malady,  it  is  safe  to 
wait  a  few  days  until  the  abscess  has  assumed  a  certain  size. 
On  the  fourth,  fifth,  or  sixth  day  it  may  be  safely  incised. 
Searching  for  pus  with  a  hollow  needle  is  superfluous  when 
the  abscess  is  superficial — that  is,  immediately  beneath  the 
parietes ;  dangerous  if  it  is  deep-seated,  as  the  gut  might 
be  thus  injured  or  the  healthy  peritonaeum  infected. 

Case. — Francisca  Bertrand,  aged  forty-five,  was  taken  ill 
with  fever  early  in  July,  1882,  and  developed  a  deep-seated, 
painful  swelling  in  the  left  iliac  fossa,  with  high  fever  and  peri- 
tonitic  symptoms.  On  the  afternoon  of  August  5th  probatory 
puncture  brought  out  some  pus,  wherefore,  with  the  aid  of  the 
family  physician,  Dr.  Assenheimer,  incision  was  practiced  by 
Hilton’s  method.  A  large  quantity  of  pus  escaped,  and  a  drain¬ 
age-tube  and  antiseptic  dressing  were  applied.  In  the  follow¬ 
ing  night  very  acute  peritonitis  set  in,  to  which  the  patient  suc¬ 
cumbed  August  6th.  No  doubt  the  reflection  of  the  perito¬ 
naeum  was  injured,  and  part  of  the  pus  must  have  entered  the 
peritoneal  cavity. 

The  only  safe  way  of  opening  these  abscesses  is  by 
methodical  and  careful  dissection,  layer  by  layer  being 
divided  by  an  ample  incision  placed  through  the  longer  axis 
of  the  tumor.  The  vicinity  of  pus  will  become  manifest 
by  the  discoloration  and  condensation  of  the  tissues.  When 
the  abscess  is  opened  and  the  bulk  of  its  contents  has  es¬ 
caped,  a  gentle  exploration  by  the  index-finger  is  advisable 
to  detect  recesses  or  a  foreign  body.  But  all  rough  treat¬ 
ment  of  the  walls  of  the  cavity  by  scraping,  tearing,  or  rude 
squeezing  is  reprehensible,  as  it  may  lead  to  inward  rupture. 
For  the  same  reason  search  for  and  removal  of  the  ulcer¬ 
ated  or  necrosed  appendix  from  the  abscess  is  to  be  avoided 
as  unnecessary  and  dangerous.  Two  drainage-tubes  are 
slipped  into  the  cavity  and  fastened  in  the  usual  manner. 
They  will  facilitate  irrigation  without  causing  undue  dis¬ 
tention.  A  daily  change  of  dressings  will  be  required  for 
the  first  week  or  ten  days.  As  soon  as  the  discharge  be¬ 
comes  scanty  and  serous,  the  tube  should  be  removed. 

The  ilio-inguinal  type  is  undoubtedly  and  fortunately 
the  most  common  form  of  perityphlitic  abscess,  and  its  time- 
honored  therapy  as  laid  down  by  Parker  will  have  to  be 
retained  as  safe  and  successful. 


In  sixteen  cases  of  the  ilio-inguinal  group  operated  on  by 
the  author  according  to  Parker’s  plan,  only  one  terminated 
fatally,  by  erysipelas.  The  patient  was  under  treatment  for 
hip-joint  disease  when,  unfortunately,  the  complication  with 
perityphlitic  abscess  set  in. 

Case. — Ernestine  S.,  servant-girl,  aged  nineteen,  admitted 
March  2,  1880,  to  the  German  Hospital,  with  the  diagnosis  of 
hip-joint  disease,  the  symptoms  of  which  were  indubitably  pres¬ 
ent.  Emaciating  fever,  and  the  characteristic  flexion  and  ad¬ 
duction  of  the  thigh,  together  with  swelling  of  the  gluteal  and 
infrapubic  regions,  seemed  to  admit  of  no  doubt.  Examination 
under  ether,  however,  revealed  a  fluctuating  swelling  of  the 
right  groin,  which  yielded  pus  on  puncture,  and  was  incised.  A 
large  quantity  of  pus  and  the  stem  of  an  apple  or  pear  were 
evacuated.  Another  incision  below  Poupart’s  ligament  estab¬ 
lished  drainage  of  an  abscess  communicating  with  the  peri¬ 
typhlitic  gathering.  The  lower  extremity  was  put  into  Buck’s 
extension,  and  the  cavities  were  daily  irrigated.  Operative 
measures,  directed  against  the  profuse  discharge  from  the  lower 
incision — that  is,  drainage  or  exsection  of  the  hip  joint — were 
contemplated,  when  the  girl  contracted  erysipelas,  and  died  of 
it  in  May,  1880.  Post-mortem  examination  established  the  fact 
of  hip-joint  suppuration*,  a  communication  of  the  perityphlitic 
abscess  with  the  joint  being  found,  by  way  of  the  iliac  bursa. 

2.  Anterior  Parietal  Type. — Next  in  frequency  to  the 
ilio-inguinal  form  of  perityphlitic  abscess  is  the  type  ac¬ 
cording  to  which  the  bulk  of  the  purulent  collection  is 
found  immediately  behind  the  anterior  abdominal  parietes 
of  the  right  side.  Frequently  this  is  associated  with  a  more 
or  less  apparent  ilio-inguinal  tumor,  and  might  be  looked 
upon  as  its  extension.  The  swelling  is  generally  found  be¬ 
hind  the  right  rectus  muscle,  its  shape  vertically  elongated, 
its  upper  limit  occasionally  extending  beyond  the  level  of 
the  navel  to  the  hypochondrium,  its  proximal  margin  to  or 
beyond  the  median  line.  When  an  unmistakable  continua¬ 
tion  of  the  tumor  can  be  traced  into  the  right  iliac  fossa, 
the  abscess  can  be  safely  opened  above  Poupart’s  ligament, 
as  in  the  preceding  group.  But  occasionally  the  upper  ex¬ 
tension  will  require  a  separate  incision. 

Case  I. — Abraham  Jacobson,  tailor,  aged  twenty-two.  Peri¬ 
typhlitic  abscess  of  six  days’  duration,  the  iliac  tumor  extending 
inward  and  upward  to  the  inner  margin  of  the  rectus  muscle, 
the  space  above  Poupart’s  ligament  feeling  empty. 

November  19,  1888. — Typical  incision  at  Mount  Sinai  Hos¬ 
pital,  a  little  below  and  to  the  inward  of  the  anterior  superior 
spine;  drainage.  Retention  of  pus  in  the  upper  pocket,  hence, 
November  26th,  second  direct  incision.  •  Rapid  improvement. 

January  17th. — Discharged  cured. 

Case  II. — David  Frank,  butcher,  aged  forty-two.  Perity¬ 
phlitic  abscess  of  eight  days’  duration;  tumor  extended  upward 
along  the  line  of  the  rectus  muscle  to  within  a  hand’s  breadth 
of  the  costal  margin. 

December  8 ,  1889. — Incision  two  inches  and  a  half  to  the  in¬ 
ward  of  the  anterior  superior  spine.  Evacuation  of  about  a 
quart  of  pus;  depth  of  abscess,  twelve  inches;  though  the 
wound  was  doing  well,  surgical  delirium  set  in,  and  the  patient 
was  transferred  to  his  home  December  24th,  where,  as  his 
:’amily  attendant  reported,  he  soon  recovered  entirely. 

Wheu  it  is  found  that  the  iliac  fossa  is  normal  and  en¬ 
tirely  void  of  resistance,  and  a  circumscribed  tumor  ean 
clearly  be  felt  some  distance  from  the  ilium  and  Poupart’s 


July  5,  1890.] 


GERSTER:  APPENDICITIS  AND  PERI  TYPE  LITIG  ABSCESS. 


11 


ligament,  it  is  necessary  to  ascertain  where  to  make  a  safe 
incision.  If  the  extent  of  the  tumor  is  great,  a  direct  in¬ 
cision  might  be  confidently  made.  But  if  the  superficial 
extremity  of  the  tumor  is  small,  it  will  be  safer  to  first  open 
the  peritoneal  cavity  in  the  median  line  by  a  small  incision, 
and  digitally  explore  the  exact  relations  and  extent  of  the 
adhesion.  Having  thus  located  the  abscess,  the  exploratory 
cut  is  closed,  and  the  abscess  is  incised  by  a  direct  route. 

Case  I. — Hiss  Evelyne  H.,  school-teacher,  aged  twenty-three. 
Perityphlitic  abscess  of  two  weeks’  duration.  Small  tumor  to 
the  right  of  median  line,  underneath  right  rectus  muscle.  Iliac 
fossa  empty.  Per  vaginam,  tumor  was  felt  adherent  to  anterior 
abdominal  wall,  and  with  it  bimannally  movable  backward  and 
forward. 

March  7,  1890. — Exploratory  laparotomy  in  median  line  be¬ 
low  the  navel.  Just  to  the  right  of  incision,  partly  solid,  partly 
fluctuating  mass  could  be  felt,  its  walls  being  evidently  formed 
of  intestine,  among  which  the  empty  appendix  was  seen  firmly 
attached.  By  passing  the  finger  around  the  attachment  of  the 
tumor  to  the  anterior  abdominal  wall,  it  was  found  that  the  iliac 
fossa  contained  healthy  intestine,  and  that  the  tumor  was  in 
no  wise  connected  with  it.  Fixation  of  tumor  by  fingers  in  ab¬ 
domen  ;  puncture  through  abdominal  wall ;  foetid  pus.  Closure 
of  laparotomy  wound  by  suture.  It  was  sealed  with  a  strip  of 
rubber  tissue  moistened  with  a  little  chloroform.  Incision  of 
abscess  along  the  line  of  puncture  ;  evacuation  of  five  ounces  of 
pus.  Uninterrupted  recovery.  Discharged  cured,  April  10, 
1890. 

Case  II. — Mark  Beermann,  hat-maker,  aged  nineteen.  Peri¬ 
typhlitic  abscess  of  seven  days’  standing.  Somewhat  movable 
tumor  underneath  right  rectus  muscle  on  a  level  with  umbilicus. 
Iliac  fqssa  normal. 

November  30 ,  1889. — At  Mount  Sinai  Hospital,  median  ex¬ 
ploratory  laparotomy.  Location  of  adhesion,  which  was  very 
limited,  was  established  by  digital  exploration.  Closure  of 
laparotomy  wound.  Incision  and  drainage  of  abscess.  Dis¬ 
charged  cured  January  11,  1890. 

Perityphlitic  abscess  of  the  anterior  type  may  extend  to  and 
beyond  the  median  line,  when  it  will  hold  close  relations  with 
and  may  perforate  into  the  bladder. 

Case.— Henry  Marks,  aged  seventeen,  suffered  from  habitual 
constipation  and  frequent  attacks  of  colic.  In  June,  July,  and 
August,  1878,  severe  attacks  of  colic  were  noted  and  overcome 
by  the  use  of  purgatives. 

August  25th. — Dr.  L.  Weiss,  the  family  attendant,  made  out 
typhlitis  and  ordered  a  laxative,  which,  however,  failed  to  re¬ 
lieve  the  patient.  Thereupon  opium  was  methodically  exhibited 
until  September  6th,  when  the  patient  had  a  spontaneous  and 
copious,  formed  evacuation. 

September  7th. — The  temperature  rose  to  104°  F. ;  the  ex¬ 
ternal  swelling  in  the  right  groin  became  very  marked. 

10th. — The  author  saw  the  patient  in  consultation  with  Dr. 
Weiss.  A  uniform  puffy  swelling  was  found  occupying  the  right 
groin,  and  was  extending  beyond  the  median  line  of  the  abdo¬ 
men.  Frequent  urination  distressed  the  patient  a  good  deal, 
who  exhibited  the  usual  hectic  symptoms  of  long-continued  sup¬ 
puration.  Deep  fluctuation  was  made  out,  and  evacuation  of 
the  abscess  was  determined  upon.  The  transversalis  fascia  being 
gradually  exposed,  it  was  found  infiltrated  and  firmly  attached 
to  the  underlying  tissues.  A  probatory  puncture  made  in  the 
bottom  of  the  wound,  close  to  the  os  ilium,  gave  pus,  where¬ 
upon  the  abscess  was  freely  incised,  and  a  large  quantity  of 
matter  was  voided.  No  foreign  body  could  be  found.  Digital 
exploration  demonstrated  a  long  sinuosity  extending  toward  the 


median  line  to  a  pocket  occupying  the  prevesical  space.  A 
drainage-tube  was  placed  into  the  main  abscess,  another  one 
was  carried  into  the  prevesical  space,  and  the  wound  was 
dressed  with  carbolized  gauze.  The  patient’s  wretched  condi¬ 
tion  at  once  commenced  to  improve;  appetite  and  sleep  re¬ 
turned,  and  the  profuse  night-sweats  disappeared. 

20th. — The  drainage-tubes  became  disarranged,  and  were 
found  slipped  out  of  the  wound.  Difficulty  was  experienced  in 
replacing  them,  and  symptoms  of  retention,  with  renewed  pain 
and  fever,  set  in  again. 

23d. — The  author  again  saw  the  patient,  and  replaced  the 
tubes.  A  considerable  quantity  of  pus  was  found  in  the  pre¬ 
vesical  pocket.  From  this  date  on  uninterrupted  improvement 
was  noted,  and  the  patient  got  up  October  10th.  October  20th, 
the  tubes  were  withdrawn,  and  October  30th  the  fistula  was 
closed . 

In  this  case  imminent  perforation  of  the  bladder  wall 
was  prevented  by  timely  incision. 

3.  Posterior  Parietal  Type. — Whenever  perforative  pro¬ 
cesses  occur  in  an  appendix  located  near  the  posterior 
parietes  of  the  peritoneal  cavity — for  instance,  near  the  right 
sacro-iliac  synchondrosis  or  the  lumbar  region — the  result¬ 
ing  abscess  will  naturally  have  a  deep  situation.  Cases 
will  occur  in  which  incision  of  such  an  abscess  can  not  be 
made  unless  it  be  done  through  a  laparotomy  wound.  But 
there  can  be  no  doubt  that  in  a  certain  proportion  of  these 
cases  a  safe  incision  may  be  made  from  behind. 

Case  I. — James  Solomon,  schoolboy,  aged  thirteen,  April  18, 
1889.  Perityphlitis  of  five  days’ standing.  In  consultation  with 
Dr.  W.  Morse,  an  indistinct,  very  deep-seated,  and  painful 
tumor  was  felt  in  the  region  of  the  sacro-iliac  juncture  of  the 
right  side.  By  April  22d  the  tumor  had  considerably  enlarged, 
and  seemed  to  lie  just  beneath  the  right  rectus  muscle.  At 
Mount  Sinai  Hospital  laparotomy  was  done  the  same  day  over 
the  site  of  the  swelling,  which  wras  found  to  hold  no  connection 
whatever  with  the  anterior  abdominal  wall,  but  was  firmly  ad¬ 
herent  to  the  posterior  wall  of  the  pelvis.  The  ascending  colon 
formed  the  outer  wall  of  the  tumor.  The  appendix  could  no¬ 
where  be  found,  and  was  undoubtedly  imbedded  in  the  mass  of 
the  tumor.  The  anterior  wound  was  closed,  and  a  long  hollow 
needle  was  thrust  into  the  region  of  the  tumor  from  behind, 
entering  the  pelvis  a  little  to  the  inward  of  the  line  of  the  pos¬ 
terior  superior  spine,  its  direction  being  downward  and  forward. 
Pus  was  gained  at  great  depth,  and  the  abscess  was  incised  and 
drained  from  there  by  a  rather  long  and  deep  incision.  All  the 
febrile  symptoms  disappeared,  and  the  boy  was  discharged  cured 
June  3,  1889. 

Case  II. — Samuel  Gross,  tailor,  thirty-three  years  old,  was 
laparotomized  at  Mount  Sinai  Hospital,  January  27,  1889,  for 
internal  obstruction  of  six  days’  standing.  Fsecal  vomiting  was 
present,  with  enormous  tympanites  due  to  intestinal  paralysis. 
The  cause  of  the  obstruction  was  found  in  a  very  long  and  much 
distended  appendix  vermiformis,  the  apex  of  which  was  firmly 
attached  to  the  under  surface  of  the  right  half  of  the  transverse 
mesocolon.  Through  the  loop  thus  formed  about  three  feet  of 
the  ileum  had  slipped  and  had  become  strangulated.  Corre¬ 
sponding  to  the  attachment  of  the  apex  of  the  appendix  a  mass¬ 
ive  swelling  was  felt  occupying  the  space  behind  the  colon,  and 
when  the  adhesion  was  severed,  pus  welled  up  from  a  small 
aperture  corresponding  to  the  site  of  the  attachment.  This  led 
into  an  abscess  cavity  which  wTas  carefully  evacuated.  The  ap¬ 
pendix  being  removed,  the  intestines  were  replaced  with  con¬ 
siderable  difficulty.  The  patient  died  an  hour  and  a  half  after 


12 


OERSTER:  APPENDICITIS  AND  PERI  T  Y  PH  LI  TIC  ABSCESS.  [N,  Y.  Mud.  Jour., 


the  operation.  (For  complete  history,  see  N.  Y.  Med.  Journal, 
May  4,  1889,  page  478.) 

Case  III. — Mr.  M.  G.,  aged  sixty-two,  had  been  suffering 
from  habitual  and  very  obstinate  constipation  for  years.  In 
May,  1880,  profuse  diarrhoea  set  in,  and  could  not  be  controlled 
by  any  of  the  usual  dietetic  and  therapeutic  measures.  A  grave 
deterioration  of  the  general  condition  developed,  and  the  patient 
lost  very  much  flesh  in  spite  of  forced  feeding. 

August  31st. — Fever  set  in,  and  the  presence  of  a  painful 
swelling  in  the  iliac  fossa  was  made  out. 

September  3d. — The  author  saw  the  case  in  consultation  with 
Dr.  W.  Balser  and  Dr.  L.  Conrad.  A  large  fluctuating  swelling 
occupied  the  right  half  of  the  pelvis,  and  tympanitic  percussion 
sound  was  noted  in  the  lumbar  region.  Two  incisions  were 
made — one  above  Poupart’s  ligament,  another  in  the  lumbar 
region — and  an  enormous  amount  of  gas,  pus,  and  faecal  matter 
was  evacuated.  Profuse  secretion  and  diarrhoea  continued,  and 
the  patient  died  September  22d. 

Post-mortem  examination  revealed  a  tight  cancerous  strict¬ 
ure  of  the  ileo-caecal  valve,  and  an  enormous  dilatation  of  the 
lower  portion  of  the  ileum,  which  resembled  thick  gut.  Large 
masses  of  impacted  faecal  matter  were  found  in  this  pouch,  which 
was  adherent  to  the  posterior  parietal  peritonaeum,  and  was 
freely  communicating  through  a  number  of  ulcerous  defects  with 
the  abscess  cavity. 

4.  Rectal  Type. — It  is  a  good  rule  never  to  neglect  to 
examine  the  rectum  of  a  patient  suffering  from  perforative 
appendicitis.  A  long  appendix  may  become  fixed  and  per¬ 
forated  in  the  small  pelvis,  and  an  abscess  is  then  apt  to 
develop  in  close  vicinity  to  the  rectum,  whence  it  can  be 
safely  opened  and  evacuated.  The  objection  that  faeces 
might  enter  the  abscess  has  thus  far  not  been  verified  by 
experience. 

Case. — August  Petry,  clerk,  aged  eighteen,  was  admitted, 
November  10,  1887,  to  the  German  Hospital  with  symptoms  of 
perforative  peritonitis.  General  tympanites  prevailed,  and  a 
tumor  could  not  be  felt  anywhere,  but  intense  pain  was  com¬ 
plained  of  nn  pressure  in  the  right  iliac  fossa.  The  poor  state 
of  the  patient  forbade  operative  interference,  and  opiates  and 
stimulants  were  exhibited.  By  November  13th  the  patient  had 
fairly  rallied.  An  examination  of  the  rectum  disclosed  the  pres¬ 
ence  of  a  fluctuating  swelling  corresponding  to  its  anterior  wall. 
An  incision  evacuated  a  large  mass  of  pus,  and  a  drainage-tube 
was  placed  into  the  cavity  and  brought  out  through  the  anus. 
The  tube  was  not  borne  well.  It  excited  tenesmus,  and  was  re¬ 
peatedly  expelled.  As  the  patient  was  doing  very  much  better, 
and  the  tumor  had  disappeared,  it  was  left  off  without  ill  con¬ 
sequences.  The  patient  was  discharged  cured  November  27, 
1887. 

5.  Mesocoeliac  Type. — To  characterize  that  most  serious 

form  of  circumappendicular  abscess,  the  walls  of  which  are 
composed  entirely  of  agglutinated  iutestines,  and  which 
hold  no  immediate  relation  whatever  with  the  parietes  of 
the  abdominal  cavity,  the  term  “  mesocoeliac  ”  was  chosen 
(from  al  kolX'uu,  the  intestines,  and  Iv  yeocy,  betweeu).  The 
abscess  is  found  occupying,  as  it  were,  the  middle  of  the 
peritoneal  sac.  Hence,  to  reach  and  evacuate  this  form  of 
abscess,  the  free  peritoneal  cavity  must  be  opened,  and  the 
collection  of  pus  must  be  reached  by  separating  the  adherent 
coils  of  gut  which  inclose  it.  ’ 

We  owe  the  development  of  the  technique  of  the  evacua¬ 
tion  of  these  abscesses  mainly  to  McBurney,  whose  pro¬ 


cedure  is  as  follows:  A  longitudinal  incision,  as  for  simple 
appendicitis,  is  made  parallel  to  and  along  the  outer  border 
of  the  right  rectus  muscle.  The  abnormal  cohesion  and  re¬ 
sistance  of  the  implicated  intestines  will  point  out  the  site 
of  the  abscess.  The  protruding  normal  coils  of  gut  should 
be  packed  away  under  a  protective  bulwark  of  sponges  held 
in  situ  by  the  assistants’  hands,  so  that,  if  the  abscess  is 
opened  unawares,  no  pus  should  soil  the  healthy  perito¬ 
naeum.  Two  of  the  nearest  coils  are  now  gently  and  cau¬ 
tiously  separated  by  gradual  traction,  exercised  by  the  oper¬ 
ator’s  fingers,  until  a  small  quantity  of  pus  is  seen  exuding. 
It  is  desirable  to  let  the  pus  escape  slowly,  so  as  to  have 
ample  time  to  sponge  it  away  as  it  pours  out ;  otherwise  the 
whole  field  might  be  overwhelmed  and  contaminated  by  a 
sudden  flood  of  matter. 

Note. — It  seems  that  exhausting  the  abscess  through  a  small  aper¬ 
ture  by  means  of  a  syringe  would  be  an  improvement  upon  the  mop¬ 
ping  up  by  sponges. 

As  soon  as  the  bulk  of  pus  has  been  removed,  the  cavity 
is  wiped  out  clean  with  sponges  dipped  in  an  antiseptic 
solution,  and  now  the  adherent  intestines  are  still  more 
separated  to  permit  the  surgeon  to  inspect  its  interior.  If 
the  appendix  is  loose  and  easily  to  be  got  at,  it  can  be 
removed,  but,  if  it  is  found  closely  adherent  and  very  brit¬ 
tle,  it  is  better  to  remove  only  so  much  of  it  as  will  come 
away  easily.  A  good-sized  drainage-tube  is  placed  into  the 
bottom  of  the  cavity,  which  is,  in  addition,  loosely  filled 
with  strips  of  iodoform  gauze.  These  and  the  rubber  tube 
are  brought  out  near  the  lower  angle  of  the  wound,  and  the 
abdominal  incision  is  closed  in  the  usual  manner.  If  the 
case  is  progressing  well,  the  packing  can  be  withdrawn  on 
the  third  day,  as  by  that  time  protective  adhesions  will 
have  formed  between  the  adjoining  coils  of  gut.  The 
drainage-tube  is  to  be  removed  as  soon  as  the  secretions 
become  serous  and  scanty. 

C.  Chronic  or  Relapsing  Appendicitis  and  Perityphlitic 

Abscess. 

It  was  shown  how  simple  catarrhal  conditions  of  the 
mucous  lining  of  the  appendix  may  lead  to  more  or  less 
complete  occlusion  of  the  exit  of  this  viscus.  The  reten¬ 
tion  of  the  secretions  will  then  cause  distension  and  the 
train  of  symptoms  characteristic  of  appendicitis.  With  the 
diminution  of  the  catarrhal  swelling  of  the  mucous  mem¬ 
brane,  a  restitution  ad  integrum  will  take  place.  Usually 
the  symptoms  produced  by  this  form  are  mild  and  tracta¬ 
ble.  Bland  laxatives  and  opiates,  rest  in  bed,  with  some 
form  of  local  applications,  generally  bring  about  a  lasting 
recovery. 

Where  ulcerative .  processes,  prolonged  inflammation, 
or  the  doubling  of  the  appendix  upon  itself,  have  caused 
the  formation  of  cicatricial  matter — hence  permanent  steno¬ 
sis  of  greater  or  lesser  intensity — the  recurrence  of  severe 
obstructive  symptoms  will  be  more  frequent,  the  intervals 
between  the  attacks  shorter  and  shorter,  and  the  tendency 
to  the  formation  of  adhesions  more  pronounced.  Thus  the 
very  chronicity  of  the  process  will  yield,  in  its  tendency  to 
the  formation  of  adhesions,  a  certain  protective  character. 


July  5,  1890.] 


GERSTER:  APPENDICITIS  AND  PERITYPHLITIC  ABSCESS. 


13 


Should  perforation  occur,  these  adhesions  fulfill  a  most  im¬ 
portant  function  in  preventing  general  septic  peritonitis. 
The  number  of  relapses  of  appendicitis  may  be  very  great ; 
in  one  of  the  author’s  cases  sixteen  were  counted.  With  the 
increase  of  the  cicatricial  stenosis,  the  formation  of  concre¬ 
tions,  and  the  loss  of  contractile  power  of  the  appendix, 
the  tendency  to  ulcerative  or  gangrenous  lesions  becomes 
more  and  more  pronounced,  and  finally  culminates  in  per¬ 
foration. 

As  we  have  no  means  of  ascertaining  the  exact  condition 
of  the  appendix,  frequent  recurrence  and  increasing  severity 
of  the  disorder  clearly  justify  an  attempt  at  its  removal. 
The  term  “attempt”  is  used  here  purposely  to  signify  that 
such  endeavors  may  occasionally  be  baffled  by  intricate  and 
close  adhesions,  which  a  prudent  surgeon  may  prefer  not 
to  disturb  for  fear  of  lacerating  the  gut.  It  may  be  said, 
however,  that,  should  the  first  attempt  fail,  a  second  one 
may  be  crowned  with  success.* 

All  surgeons  admit  the  occurrence  of  the  spontaneous 
evacuation  of  perity phlitic  abscesses  into  an  adjoining  part 
of  the  gut.  Occasionally  perforations  into  the  bladder, 
rectum,  or  even  the  pleura,  have  been  observed  and  de¬ 
scribed.  If  such  an  evacuation  into  the  gut  is  followed  by 
a  perfect  obliteration  of  the  cavity  and  fistula,  no  relapse 
will  occur.  Should  evacuation  be  imperfect,  inspissation  of 
the  retained  pus  and  a  temporary  dormancy  of  the  acute 
signs  of  the  process  will  result,  until  some  local  irritation 
again  provokes  rapid  intumescence,  followed  by  evacuation 
of  the  surplus  contents  of  the  abscess.  This  process  may 
be  repeated  a  number  of  times,  as  a  result  of  which  a  thick 
mass  of  cicatricial  matter  will  be  deposited  around  the 
focus.  Cases  of  this  order  demand  surgical  interfefence. 

Case. — Miss  Caroline  D.,  aged  fourteen,  had  had  within 
two  years  three  attacks  of  peritvphilitis  with  well-marked  ilio¬ 
inguinal  tumor,  which  never  disappeared  completely.  On  April 
24,  3888,  Dr.  L.  Arcularius  presented  her  to  the  author,  who 
advised  an  operation.  A  small  immovable  tumor  could  be  felt 
occupying  the  iliac  fossa.  On  May  1,  1888,  an  incision  was 
made,  and  a  small  cavity  of  the  size  of  a  chestnut  was  laid  open. 
Its  walls  consisted  of  a  massive  deposit  of  cicatricial  matter,  its 
contents  of  a  putty-like  mass  of  inspissated  pus,  surrounded  by 
a  coating  of  deciduous  granulations.  When  all  the  soft  matter 
was  scooped  out,  a  narrow  sinus  was  traced  to  a  depth  of  an 
inch  and  a  half  beyond  the  bottom  of  the  cavity.  The  wound 
was  packed,  and  was  kept  open  with  considerable  difficulty 
during  the  entire  summer,  small  quantities  of  feculent  matter 
escaping  from  time  to  time.  In  the  course  of  the  following 
winter  the  tumor  gradually  shrank  away,  the  discharge  dried 
up,  and,  the  tube  being  removed,  permanent  healing  took 
place. 

Had  the  outer  opening  been  permitted  to  heal,  recur¬ 
rence  of  the  abscess  would  have  probably  followed,  as  clos¬ 
ure  of  the  communication  with  the  gut  came  about  with  a 
great  deal  of  hesitancy.  The  same  state  of  affairs  may  and 
does  often  prevail  in  abscesses  that  are  evacuated  by  the 
surgeon,  and  in  which  the  outer  opening  shows  a  more 

*  I  take  the  liberty  of  referring  to  a  verbal  communication  of  Dr. 
F.  Lange,  who  informed  me  that  he  once  had  to  abstain  from  removing 
the  appendix  through  an  anterior  incision.  Later  on  the  organ  was 
successfully  removed  through  a  posterior  wound. 


pronounced  tendency  to  closure  than  the  sinus  leading  from 
the  abscess  cavity  to  the  gut.  Thus  the  presence  of  a  how¬ 
ever  minute  faecal  fistula  that  has  not  healed  soundly  may 
bring  about  a  number  of  recurrences  in  the  tract  of  the 
old  abscess.  It  stands  to  reason  to  say  that  inadequacy, 
both  as  regards  the  quality  and  duration  of  drainage  of 
the  abscess  cavity,  has  a  most  important  influence  upon  the 
retardation  of  the  closure  of  the  faecal  sinus.  Hence  the 
tendency  to  relapses  will  be  very  pronounced  in  cases 
where  evacuation  of  the  primary  abscess  took  place  spon¬ 
taneously. 

Case. — Frank  Kennedy,  printer,  aged  twenty-five,  had  suf¬ 
fered  since  childhood  from  a  number  of  attacks  of  smart  pain 
in  the  right  groin  accompanied  by  fever.  In  the  early  part  of 
1885  he  acquired  an  oblique  inguinal  hernia  of  the  right  side, 
and  was  ordered  to  wear  a  truss,  the  pressure  of  which,  if  the 
pad  became  displaced  outward,  caused  intense  suffering,  so 
that  he  had  to  abandon  its  use  from  time  to  time.  In  June, 
1885,  during  a  severe  attack  of  fever,  an  abscess  broke  open 
two  inches  and  a  half  below  the  anterior  superior  spine.  Since 
then  healing  and  reopening  of  the  sinus  had  occurred  four 
times.  On  March  3,  1886,  a  dense  deep-seated  tumor  could  be 
felt  in  the  right  groin,  independent  of  the  hernia,  which  could 
be  easily  replaced.  Following  the  existing  sinus,  the  center  of 
the  indurated  mass  was  laid  open  by  a  large  incision  running 
parallel  with  Poupart’s  ligament.  At  the  depth  of  two  inches 
a  globular  smooth-walled  cavity  was  exposed,  within  which, 
imbedded  in  frail  granulations,  a  stratified  coprolithon  of  the 
size  of  an  unshelled  almond  was  found.  A  channel  of  the  di¬ 
ameter  of  a  goose-quill  was  seen  leading  from  this  cavity  in¬ 
ward  and  downward,  into  which  could  be  slipped  twelve  inches 
of  a  slender  drainage-tube.  When  water  was  thrown  in  through 
this  tube,  diluted  faecal  matter  regurgitated.  Under  the  micro¬ 
scope  this  matter  was  seen  containing  granules  of  amylum  and 
fat  with  fat  crystals  arranged  in  the  shape  of  sheaves.  The 
wound  was  kept  packed  with  gauze  till  March  25th,  and  was 
healed,  seemingly  from  the  bottom,  by  April  14th.  On  Novem¬ 
ber  15, 1886,  the  fistula  reopened,  and  the  proposition  was  made 
to  the  patient  to  expose  the  site  of  the  faecal  sinus  from  within 
by  laparotomy,  and  to  deal  with  it  by  extirpation  of  the  appen¬ 
dix  or  enterorrhaphy.  He  declined  to  take  the  risk,  and  pre¬ 
ferred  to  wear  a  tube  permanently.  Sparse  quantities  of  a  fecu¬ 
lent,  orange-colored  serum  continued  to  escape  from  time  to 
time  until  the  end  of  1888,  when  the  tube  could  not  be  replaced 
once,  and  was  abandoned.  As  it  seems,  permanent  healing 
then  took  place. 

The  proposition  made  to  this  patient  to  close  bis  faecal 
fistula  by  laparotomy  and  an  appropriate  dealing  with  the 
involved  gut,  contains  the  essence  of  a  plan  the  adoption 
of  which  might  be  necessary  in  order  to  bring  about  the 
speedy  cure  of  an  apparently  interminable,  most  disagree¬ 
able,  and  loathsome  ailment.  But  the  necessity  for  the 
adoption  of  such  extreme  measures  must  be  very  rare  in¬ 
deed. 

On  the  whole,  it  may  be  said  that  the  recurrence  of  an 
evacuated  perity  phlitic  abscess  is  comparatively  rare,  and 
that,  if  it  is  due  to  the  presence  of  a  faecal  fistula,  its  lasting 
cure  can  in  most  instances  be  effected  by  prolonged  and  ef¬ 
ficient  drainage  of  the  outer  wound. 

Another  cause  of  prolonged  suppuration  within  and 
around  an  incised  pcrityphlitic  abscess  is  the  formation  of 
one  or  more  extraperitonea]  burrows  and  cavities,  located 


14 


SHROPSHIRE:  ERYSIPELAS  AND  THE  BICHLORIDE  OF  MERCURY.  [N.  Y.  Med.  Jour., 


between  the  several  layers  of  the  abdominal  wall,  which  are 
the  direct  consequence  of  inadequate  measures  at  drainage. 
The  primary  cause  of  the  abscess  may  be  eliminated,  the 
perforative  aperture  of  the  appendix  or  gut  may  long  since 
have  permanently  closed,  and  yet  frequent  relapses  of  sup¬ 
puration  will  keep  the  patient  confined  to  the  bed.  How 

to  deal  with  a  case  of  this  kind  mav  be  seen  from  the  fol- 

•/ 

lowing  history  : 

Mrs.  E.  T.,  aged  thirty-two,  was  operated  for  perityphlitic 
abscess  by  a  prominent  gynaecologist  of  this  city  in  the  latter 
part  of  the  summer  of  1887.  Four  weeks  after  the  operation 
the  drainage-tube  was  withdrawn,  and  the  wound  healed  prompt¬ 
ly,  but  a  reaccumulation  and  evacuation  of  pus  soon  followed, 
and  symptoms  of  recurrent  retention  were  observed  on  an  aver¬ 
age  every  four  or  six  weeks  until  January  13, 1889,  when,  by  the 
same  practitioner,  bloody  dilatation  was  done  with  the  confident 
expectation  of  lasting  success.  These  hopes,  however,  remained 
unfulfilled.  Up  to  March  1,  1889,  three  more  recrudescences 
occurred  which  were  closely  observed  by  the  author.  Each  time 
symptoms  of  retention  were  present,  though  a  large  and  long 
drainage-tube  was  constantly  in  situ ,  reaching  to  the  bottom  of 
the  wound.  Circumscribed  swellings  occurred  then  once  above, 
another  time  to  the  inner  side  of  the  sinus,  and  pus  was  seen 
welling  up  on  pressure  from  the  drainage-tube.  It  was  decided 
to  find  and  remove  the  cause  of  this  distressing  condition  by  an 
operation,  which  was  done  March  11,  1890,  in  the  presence  of 
Dr.  Lange  and  Dr.  Bull,  of  this  city.  The  tract  within  which 
had  lain  the  drainage-tube  was  exposed  to  its  bottom  by  an  incis¬ 
ion  nine  inches  long,  and  running  parallel  withPoupart’s  ligament. 
Carefully  examined,  it  was  found  to  be  soundly  and  firmly  closed 
at  the  bottom,  no  manner  of  communication  existing  with  the 
gut,  though  it  was  evident  that  only  a  thin  layer  of  tissue 
separated  the  cavity  from  the  peritoneal  sac.  On  the  lateral 
aspect  of  the  smooth  lining  of  the  old  drainage  track,  and  not 
far  from  the  bottom,  two  minute  apertures  were  seen  inosculat¬ 
ing,  into  which  the  probe  passed  for  a  distance  of  two  and  four 
inches,  respectively,  the  longer  track  leading  toward  the  navel, 
the  shorter  upward  toward  the  crest  of  the  ilium.  When  these 
narrow  tracts  were  slit  up,  each  of  them  was  found  terminating 
in  a  small  pocket  containing  granulations  and  pus.  These  sinuses 
were  located  within  the  abdominal  parietes,  between  the  mus¬ 
cular  and  peritoneal  layers.  Unavoidably,  the  peritoneal  cavity 
was  opened  in  two  places,  but,  as  no  tumor  could  be  felt  within, 
these  apertures  were  not  enlarged.  The  very  large  wound  was 
purposely  left  open,  and  the  dressing  consisted  in  an  iodoform- 
gauze  packing.  Uninterrupted  healing  followed,  though  it  took 
a  long  time  on  account  of  the  size  of  the  wound. 

June  3d. — The  patient  was  discharged  cured,  and  has  re¬ 
mained  well  ever  since  then. 

Conclusions. — 1.  Mild,  presumably  catarrhal,  forms  of 
appendicitis  require  no  operative  measures,  but  dietetic  and 
medicinal  treatment  by  opiates,  laxatives,  rest,  and  local  ap¬ 
plications. 

2.  The  more  severe  and  persistent  forms  of  appendicitis 
may  render  excision  of  the  appendix  advisable,  especially 
if  frequent  recurrence,  with  increase  of  the  violence  of  the 
symptoms,  is  observed. 

3.  Most  perityphlitic  abscesses  hold  close  relations  with 
one  or  another  of  the  abdominal  parietes.  The  location  of 
the  parietal  adhesions  of  the  abscess  is  to  be  first  ascer¬ 
tained,  if  necessary,  by  exploratory  laparotomy,  and  the 
abscess  is  to  be  then  incised  and  drained  through  the  area 


of  adhesion,  thus  avoiding  infection  of  the  sound  perito¬ 
naeum. 

4.  Perityphlitic  abscesses  that  possess  no  parietal  adhe¬ 
sions  and  have  a  mesocoeliac  situation  between  free  coils  of 
intestine  must  be  reached  by  laparotomy  through  the  unin¬ 
volved  peritoneal  cavity.  Precautions  have  to  be  taken  not 
to  infect  the  normal  peritonaeum. 

5.  Recurrence  of  suppuration  in  the  groin,  following 
spontaneous  or  artificial  evacuation  of  a  perityphlitic  ab¬ 
scess,  may  be  due  either  to  the  persistence  of  a  small  faecal 
fistula,  or  to  the  presence  of  secondary  intraparietal  sinuses 
caused  by  inadequate  drainage  and  retention. 

In  the  first  case  prolonged  and  efficient  drainage  is  to 
be  employed  for  a  long  time  before  resorting  to  artificial 
closure  of  the  faecal  fistula  by  laparotomy  and  enterorrhaphy 
or  otherwise. 

In  the  second  case  all  sinuses  and  pockets  have  to  be 
found  by  free  and  careful  dissection,  and,  when  they  have 
been  slit  up  and  scraped,  the  wound  is  to  be  treated  by 
the  open  method  to  effect  a  sound  cure. 


ERYSIPELAS 

TREATED  WITH  THE  BICHLORIDE  OF  MERCURY, 
AND  THE  RESULT  IN  FOUR  CASES. 

By  W.  SHROPSHIRE,  M.  D., 

HUNTSVILLE,  TEXAS. 

Not  having  seen  any  mention  of  the  treatment  of  ery¬ 
sipelas  by  the  local  application  of  the  bichloride  of  mer¬ 
cury,  I  desire  to  give  the  results  of  my  efforts  with  the 
remedy,  and  hear  the  opinions  of  others  with  a  more  ex¬ 
tended  practice  than  my  own,  when  they  have  tried  it  to 
their  own  satisfaction.  The  following  report  will  show  the 
method  of  application  and  results  obtained  : 

Case  I.  March  23 ,  1889. — I  was  called  to  see  Minnie  R., 
aged  one  year,  who,  two  weeks  prior  to  that  date,  had  received 
a  scald  on  the  right  leg,  which  healed  cleverly  till  a  week  subse¬ 
quent,  when  erysipelas  set  in  and  spread  rapidly  up  the  leg  and 
over  the  thigh,  etc.  The  family  physician  was  called  in  and 
prescribed  a  four-  or  five-per-cent,  aqueous  solution  of  carbolic 
acid  to  be  continuously  applied  to  the  inflamed  area,  which  was 
done  till  I  saw  her,  when  I  found  the  child  suffering  from  car¬ 
bolic-acid  poisoning,  and  the  erysipelas  having  spread  over  the 
whole  of  the  thigh,  half  the  nates,  and  a  portion  of  the  abdo¬ 
men,  and  was  rapidly  spreading.  It  was  of  the  variety  which 
has  a  vesicular  eruption  over  the  inflamed  area.  Her  tempera¬ 
ture  was  102,8°,  pulse  170,  weak  and  thread-like.  I  prescribed 
quin,  sulph.,  gr.  §;  tine,  ferri.  chlor.,  rqij,  every  three  hours,  and 
the  application  of  a  saturated  solution  of  ferri  sulph.  locally  by 
keeping  a  cloth  wet  with  the  solution  and  applied  to  the  in¬ 
flamed  area. 

21t,th. — Temperature,  102-4°:  pulse,  160  and  fair;  symp¬ 
toms  of  carbolic-acid  poisoning  gone;  inflammation  rapidly 
spreading  and  looking  quite  angry,  and  she  was  quite  restless 
through  the  night.  The  iron  and  quinine  internally  were  con¬ 
tinued,  and  the  local  application  was  changed  to  hydrargyri  chlo. 
cor r os.,  aminon.  chlo.,  aa  gr.  vijss.,  dissolved  in  one  quart  of 
water,  applied  by  keeping  a  cloth  wet  with  the  solution  and 
applied  to  the  inflamed  surface,  especially  the  spreading  edges. 

25th. — Temperature,  101°  ;  pulse,  140.  Rested  some  during 


July  5,  1890.] 


SOLIS-OOHEN:  STANDARDIZATION  OF  OALENIOAL  PREPARATIONS. 


15 


the  night;  ate  some.  Inflammation  spreading  only  in  the  in¬ 
guinal  region,  where  the  application  was  imperfect,  and  subsid¬ 
ing  elsewhere.  Treatment  continued. 

26th. — Temperature  normal ;  inflammation  subsiding  rapid¬ 
ly;  nospread  since  last  visit.  Treatment  was  discontinued  on 
the  27th,  and  tonic  of  ferri.  sulph.,  quin,  sulph.,  aa  gr.  |;  acid 
citric,  gr.  jss.,  ter  die,  substituted.  Four  days  later  I  saw  the 
child  in  the  yard  playing  with  others,  apparently  perfectly  well. 

Case  II.  July  9th. — Was  called  to  see  John  G.,  aged  thirteen 
years.  The  day  before  he  had  noticed  an  inflammation  on  the 
posterior  aspect  of  the  shoulder  at  the  margin  of  the  axilla  and 
soon  became  feverish,  both  spots  growing  rapidly  worse.  I 
found  him  with  a  temperature  of  104'8°,  as  I  supposed,  partially 
due  to  malarial  complication,  and  an  area  of  about  fourteen  or 
sixteen  square  inches  of  erysipelatous  inflammation  in  the  situ¬ 
ation  mentioned,  belonging  to  the  same  type  as  No.  1,  that 
characterized  by  a  vesicular  eruption.  I  prescribed  quin,  sul., 
gr.  v,  every  four  hours,  and  the  topical  application  of  a  1-to- 
2,000  solution  of  the  bichloride  of  mercury  as  applied  in  Case  I. 

10th. — Temperature,  105°  ;  pulse,  134.  Area  of  inflammation 
greatly  increased,  and  a  new  place  on  the  elbow  of  the  same 
side.  I  ordered  acetanilide,  gr.  iv,  not  to  be  repeated;  con¬ 
tinued  the  quinine  in  five-grain  doses,  and  changed  the  bichlo¬ 
ride  solution  from  1  to  2,000  to  1  to  1,000  and  applied  as  before. 

11th. — Temperature,  10U40  ;  patient  bathed  in  perspiration 
and  the  inflammation  not  spreading  but  subsiding.  Treatment 
was  continued. 

12th. — Temperature,  99°.  Inflammation  greatly  diminished. 
Treatment  was  discontinued  on  the  13th,  and  a  tonic  of  iron, 
quinine,  and  strychnine  was  ordered  for  a  week,  before  which 
time  the  boy  came  to  my  office  apparently  quite  well. 

Case  III. — Mr.  K.,  about  twenty-two  years  old,  called  at 
my  office  showing  about  half  of  his  forearm  covered  with  ery¬ 
sipelatous  inflammation  of  the  non-vesicular  variety,  which  had 
begun  the  day  before  at  a  tick  bite  near  the  wrist.  I  prescribed 
the  bichloride  of  mercury,  gr.  viij  to  one  pint  of  water,  to  be 
applied  as  in  the  former  cases.  On  the  following  morning  he 
complained  of  considerable  pain  from  the  application  of  the 
solution — so  much  so  that  he  could  not  sleep  the  night  previous, 
but  there  was  no  spread  of  inflammation.  I  ordered  morph, 
sulph.,  gr.  vij  to  the  pint  of  solution,  to  be  applied  as  before. 
Two  days  later  he  showed  me  his  arm,  and  where  the  inflam¬ 
mation  had  existed  there  were  quite  a  number  of  pustules  very 
much  like  those  caused  by  the  local  application  of  ol.  tiglii.  I 
ordered  it  rubbed  with  carbolized  vaseline,  and  heard  nothing 
more  of  the  case. 

Case  IV. — Mr.  M.,  aged  about  thirty-five,  called  at  my  office 
and  showed  an  area  of  eighteen  or  twenty  square  inches  of  ery¬ 
sipelatous  inflammation  on  his  right  forearm,  with  red  lines 
running  from  the  inflamed  area  toward  the  body.  It  was  of 
the  non-vesicular  variety.  I  prescribed  the  bicbloride-of-mer- 
cury  (1  to  1,000)  aqueous  solution,  to  be  applied  locally,  as  in 
other  cases.  Six  hours  later  I  was  called  to  see  him,  when  he 
complained  that  the  medicine  burned  too  severely  to  be  borne, 
and  I  ordered  a  solution  of  sulphate  of  morphine,  seven  grains 
to  the  pint,  and  heard  nothing  more  of  the  case  till  three  days 
later,  when  he  showed  me  his  arm,  then  apparently  perfectly 
healthy. 

Cases  III  and  IV  are  reported  from  memory,  but  Cases 
I  and  II  are  taken  directly  from  my  case  register.  I  treated 
two  other  cases  with  the  same  remedy,  but  one  was  never 
seen  after  it  was  prescribed  for  ;  and  the  other  was  so  com¬ 
plicated  by  other  diseases  that  it  is  unworthy  of  being  re¬ 
ported. 

Aside  from  the  clinical  evidence  of  these  cases,  we  have 


certain  well-established  facts,  and  good  reason  for  the  treat¬ 
ment  of  erysipelas  with  the  topical  application  of  the  bi¬ 
chloride  of  mercury.  That  erysipelas  is  an  inflammation  of 
the  skin,  and  the  work  of  a  specific  micro-organism,  is  gen¬ 
erally  acknowledged  ;  and  that  the  bichloride  of  mercury  is 
one  of  the  most  powerful  germicides  is  equally  as  generally 
conceded.  With  these  facts  in  view,  the  rational  treatment 
of  the  disease  is  to  apply  the  remedy  to  the  cause  ;  so  the 
question  is  bow  to  apply  it  in  sufficient  quantity  to  kill  the 
micro-organisms  and  not  hurt  the  patient  or  endanger  his 
life  ;  and  I  think  it  is  fairly  solved  by  the  cases  reported. 

It  may  be  advisable  to  remove  the  sebum  off  the  skin 
with  soap  and  water  before  applying  the  solution  of  bi¬ 
chloride  ;  but,  in  the  majority  of  cases,  the  corrosive  nature 
of  the  drug  is,  I  think,  sufficient  to  remove  the  sebum  with¬ 
out  the  use  of  any  adjuvant.  In  addition  to  the  benefit  of 
the  bichloride,  in  the  above-given  plan  of  treatment,  the 
continued  application  of  cold  water  to  the  heated  and  in¬ 
flamed  surface  relieves  the  suffering  and  checks  the  inflam¬ 
matory  process.  I  hope  others  will  try  the  treatment  and 
report  the  result  of  the  same,  for  if  the  remedy  proves  as 
efficient  in  all  cases  as  it  seems  to  have  done  in  those  here 
reported,  it  certainly  is  to  be  preferred  to  the  necessarily 
very  painful  and  somewhat  dangerous  treatment  by  hypo¬ 
dermic  injections  of  an  aqueous  solution  of  carbolic  acid, 
from  the  fact  that  it  is  both  less  dangerous  and  painful,  and, 
when  compared  with  other  treatments,  its  efficacy  places  it 
first.  I  will  suggest  a  strength  of  1  to  2,000  for  young 
children  and  1  to  1,500  for  adults  as  probably  the  best  to 
use. 


THE  STANDARDIZATION  OF 
GALENICAL  PREPARATIONS.* 

By  SOLOMON  SOLIS-OOHEN,  M.  D., 

PROFESSOR  OF  CLINICAL  MEDICINE  AND  APPLIED  THERAPEUTICS, 
PHILADELPHIA  POLYCLINIC. 

The  question  of  the  uniformity  and  reliability  of  the 
medicinal  preparations  employed  in  the  treatment  of  disease 
is  one  of  considerable  importance  to  physicians  and  their 
patients.  So  far  as  it  is  practicable,  it  is  certainly  desirable 
that  tinctures,  fluid  extracts,  and  the  like,  should  represent 
a  definite  strength  not  merely  of  the  crude  drug,  but  of 
those  constituents  of  the  drug  upon  which  its  therapeutic 
and  toxic  activities  depend.  We  have  all  experienced  the 
embarrassment  which  attends  the  use  of  a  preparation  of 
unknown  power,  for,  on  the  one  hand,  our  dose  may  be  too 
small  to  accomplish  the  desired  result,  and,  on  the  other 
hand,  it  may  be  so  large  as  to  be  dangerous.  So  long  as 
the  Pharmacopoeia  of  the  United  States  fails  to  prescribe  a 
uniform  and  exact  standard  for  such  drugs  as  opium,  bella¬ 
donna,  aconite,  nux  vomica,  conium,  and  others  which 
might  be  mentioned,  this  danger  and  uncertainty  must  re¬ 
main.  In  the  case  of  a  drug  like  opium,  in  which  the  phar- 

*  We  greatly  regret  that  our  engagements  prevented  the  publication 
of  this  article  before  the  time  of  meeting  of  the  Pharmacopoeial  Con¬ 
vention.  Doubtless,  however,  the  Committee  of  Revision  may  yet  be 
able  to  give  due  consideration  to  its  arguments,  and  certainly  the  medi¬ 
cal  profession  must  feel  interested  in  them  at  all  times. — Editor. 


16 


S 0 LIS- COHEN :  STANDARDIZATION  OF  GALENICAL  PREPARATIONS.  (N.  Y.  Med.  Joub., 


macist  is  allowed  to  use  his  discretion  as  to  whether  it  shall 
represent  twelve  per  cent.,  or  anything  between  that  and 
sixteen  per  cent,  of  its  most  powerful  alkaloid — a  range  of 
variation  of  twenty-five  per  cent,  if  we  take  the  highest 
figure,  and  of  thirty-three  per  cent,  if  we  take  the  lowest 
figure — it  is  obvious  that  the  physician  is  unable  to  pre¬ 
scribe  an  accurate  dose,  and  must  perform  a  series  of  tenta¬ 
tive  experiments  with  each  new  preparation  that  is  ordered. 
Not  only  will  there  be  a  different  therapeutic  and  toxic 
value  to  the  preparations  obtained  from  different  druggists, 
but  unless  each  druggist  adopts  for  himself  a  definite  stand¬ 
ard,  be  that  the  highest  or  the  lowest  required  by  the  Phar¬ 
macopoeia,  preparations  obtained  from  the  same  druggist  at 
different  times  will  likewise  vary. 

It  would  seem,  then,  the  obvious  duty  of  the  Pharmaco- 
poeial  Convention  to  adopt  one  definite  morphine  strength 
for  opium  preparations,  and  for  physicians  to  demand  of 
druggists  absolute  conformity  with  the  pharmacopceial  re¬ 
quirements.  But  as  regards  opium  we  are  much  more  for¬ 
tunate  than  with  other  drugs  possessing  equally  dangerous 
properties,  if  given  in  excessive  doses.  With  opium,  at  least, 
we  can  guess  within  thirty-three  per  cent,  of  its  strength, 
but  with  belladonna,  to  take  but  one  example  out  of  many, 
we  can  not  guess  even  that. 

In  a  paper  recently  read  before  the  Philadelphia  County 
Medical  Society,  Dr.  H.  H.  Rusby  states  that  the  percent¬ 
age  of  total  alkaloids  in  belladonna  leaves  may  vary  as 
much  as  two  hundred  and  fifty  per  cent.,  and  that  the 
physical  properties  of  the  drug  give  no  indication  of  its 
alkaloidal  value,  some  of  the  worst-appearing  leaves  giving 
the  best  assay. 

Now  it  is  true  that  the  physician  who  desires  to  pro¬ 
duce  an  atropine  effect  can  attain  his  object  most  readily 
and  satisfactorily  by  administering  a  salt  of  the  alkaloid  ; 
but  atropine  does  not  represent  belladonna.  There  are 
cases  of  daily  occurrence  in  which  we  desire  to  administer 
the  galenical  preparation  and  not  the  alkaloid.  It  is  in 
these  cases  that  the  constant  uncertainty  concerning  the  ac¬ 
tivity  of  the  preparation  employed  leads  to  the  double 
danger  of  failing  to  secure  the  effect  desired  if  we  use  a 
small  dose,  and  of  poisoning  our  patient  if  we  use  a  large 
one,  with  the  preparation  unexpectedly  more  active.  It  is 
reasonable  to  suppose  that  whatever  constituents  of  the 
drug  give  it  its  therapeutic  powers  will  be  found  associated 
in  about  the  same  proportion,  and  that  the  total  alkaloidal 
strength  will  represent  the  total  therapeutic  value.  It  cer¬ 
tainly  will  represent  the  total  toxic  activity.  It  is  further 
evident  that  what  the  physician  is  concerned  with  is,  not 
the  quantity  of  crude  drug  to  be  used  by  the  pharmacist, 
but  the  strength  of  the  finished  product  which  he  pre¬ 
scribes.  That,  with  one  lot  of  leaves,  one  fourth  of  the 
quantity  of  crude  drug  prescribed  by  the  Pharmacopoeia 
will  produce  a  fluid  extract  or  tincture  of  sufficient  thera¬ 
peutic  activity,  or  that,  in  another  case,  four  times  the 
pharmacopceial  quantity  will  be  required,  is  a  matter  of  ab¬ 
solutely  no  consequence  to  physicians.  What  they  have  a 
right  to  demand  of  the  Pharmacopoeial  Convention  and  of 
the  intelligent  pharmacists  who  will  assist  in  its  delibera¬ 
tions,  is  to  lay  down  a  broad  principle  that  in  every  possi¬ 


ble  case  the  preparations  to  be  prescribed  by  physicians  and 
taken  by  patients  shall  have  a  uniform  and  definite  strength  ; 
and  it  will  then  become  the  duty  of  the  Committee  on  Re¬ 
vision,  with  the  aid  of  its  experts,  to  ascertain  the  best 
method  of  putting  this  principle  into  practical  application. 
But  it  must  be  distinctly  understood  that  the  standard  ap¬ 
plies  to  the  finished  official  preparation,  for  this  is  what  the 
physician  prescribes.  Of  what  advantage  is  it  to  know  that 
tincture  of  nux  vomica  represents  so  many  parts  in  a  hun¬ 
dred  of  a  drug  whose  alkaloidal  strength  has  a  range  of 
variation  of  fifty  per  cent?  And  as  this  variation  is  incura¬ 
ble,  it  is  obvious  that  parts  in  a  hundred  must  be  varied  in 
an  inverse  ratio  to  produce  a  preparation  of  standard 
strength.  The  fact  that  a  certain  firm  of  manufacturing 
chemists — it  may  be  with  far-sighted  business  instinct,  it 
may  be  with  a  professional  pride  and  honor  which  should 
not  be  unexpected  from  those  having  such  intimate  rela¬ 
tions  with  the  medical  profession — has,  without  waiting  for 
the  Pharmacopoeial  Convention,  instituted  for  itself  a  series 
of  elaborate  and  expensive  experiments,  and  put  upon  the 
market  preparations  of  guaranteed  strength,  such  as  the 
Pharmacopoeia  should  require  from  all  manufacturing  houses 
and  from  all  retail  pharmacists;  this  fact — humiliating  as 
it  is  to  scientific  men,  who  should  not  have  allowed  manu¬ 
facturers  to  take  the  lead  in  so  important  a  reform — should 
certainly  not  act  prejudicially  to  the  adoption  of  the  princi¬ 
ple  contended  for.  On  the  contrary,  the  writer,  who  has  a 
very  wholesome  aversion  to  indorsement  of  any  kind  of 
patented  or  trade-marked  preparations  or  appliances,  would 
feel  that  he  was  doing  an  injustice  to  the  enterprise  and 
scientific  spirit  of  Messrs.  Parke,  Davis,  &  Company,  if  he 
did  not  mention  that  house  with  due  credit  and  praise,  and 
express  the  satisfaction  which  he  has  derived  from  the  use 
of  their  standard  preparations  in  contradistinction  to  the 
disappointment  which  has  often  attended  his  use  of  the  un¬ 
certain  preparations  of  the  Pharmacopoeia.  As  a  matter  of 
course,  since  the  point  has  been  raised,  the  name  which 
this  house  has  applied  to  its  line  of  assayed  preparations 
should  not  be  admitted  into  the  Pharmacopoeia  any  more 
than  such  names  as  “  antipyrine,”  “  antifebrin,”  “salol,” 
and  the  like  ;  though  there  is  this  difference  to  be  observed 
to  the  credit  of  our  American  manufacturers :  that  their 
names  are  not  trade-marked,  while  those  of  the  German 
houses,  whose  preparations  are  so  extensively  sold  in  this 
country,  are,  under  the  laws  of  the  United  States,  which 
afford  permanent  protection  to  trade-marks,  equivalent  to  a 
perpetual  patent  right. 

The  principle  advocated  by  those  who  desire  to  have 
uniform  standards  of  strength  of  pharmacopoeial  prepara¬ 
tions  is  so  obviously  correct  that  it  is  hard  to  avoid  repeti¬ 
tion  and  superfluous  iteration  in  its  presentation  ;  the  mere 
statement  of  it  should  suffice,  without  argument. 

The  time  is  near  at  hand  for  the  assembling  of  the 
Pharmacopoeial  Convention,  and  it  is  the  duty  of  physi¬ 
cians  to  consider  the  subject  very  carefully  and  to  express 
their  views  publicly,  in  order  that  a  due  weight  of  profes¬ 
sional  opinion  may  be  brought  to  bear  upon  the  delibera¬ 
tions  of  the  convention ;  to  secure  the  removal  of  the  con¬ 
ditions  of  uncertainty  which  are  not  only  a  discredit  to  the 


July  5,  1890.] 


COR  RESP  ON  PENCE. 


17 


two  learned  professions  of  medicine  and  pharmacy,  but,  in 
addition,  always  a  disadvantage,  and  sometimes  a  danger  to 
the  community  at  large. 


LETTER  FROM  LONDON. 

Hospital  Administration  Inquiry.  —  The  Scheme  for  a  New 

University  for  London. —  The  British  Medical  Association 

Meeting  at  Birmingham. — Public  Exhibitions  of  Hypnotism. 

London,  June  2,  1890. 

A  select  committee  of  the  House  of  Lords  is  at  present  en¬ 
gaged  in  inquiring  into  the  mode  of  administration  and  manage¬ 
ment  of  the  leading  hospitals  of  London.  One  of  the  chief  osten¬ 
sible  reasons  for  the  appointment  of  the  committee  was  the  al¬ 
leged  abuse  of  the  out-patient  departments  by  the  public,  and 
there  can  be  no  doubt  that  there  has  been  for  some  time  a  good 
deal  of  outcry  in  the  ranks  of  the  profession  on  this  subject. 
That  the  hospitals  may  be  and  occasionally  are  abused  there  can 
be  but  little  doubt,  but  I  am  inclined  to  think,  from  a  not  incon¬ 
siderable  experience,  that  there  is  a  great  deal  of  exaggeration 
on  the  subject;  what  is  really  wanted  is  some  reform  in  regard 
to  the  way  that  letters  of  recommendation  are  given  by  the  sub¬ 
scribers  to  the  hospitals,  as  most  of  the  “ineligibles”  are  attend¬ 
ing  with  subscribers’  letters.  If,  as  the  outcome  of  the  present 
inquiry,  subscribers’  letters  should  be  altogether  abolished,  the 
committee  will  not  have  sat  in  vain.  Another  matter  in  which 
a  good  result  may  be  expected  is  in  putting  a  stop  to  that  in¬ 
discriminate  starting  of  special  hospitals  from  which  we  have 
suffered  most  heavily  and  are  still  suffering.  It  is  really  the 
special  hospitals  which  are  the  greatest  sinners  in  competing 
with  the  general  practitioners,  for  they  are  often  officered  by 
men  of  no  very  high  standard  of  professional  morality,  who 
would  not  hesitate  to  transfer  a  patient  who  could  afford  to  pay 
to  their  own  houses  or  see  him  in  a  private  room  at  the  hos¬ 
pital,  without  giving  one  moment’s  thought  to  the  fact  that 
they  were  deliberately  robbing  another  man  of  a  patient.  If 
there  is  a  danger  that  the  inquiry  may  imperil  the  material  at 
present  at  the  disposal  of  the  general  hospitals  for  clinical  pur¬ 
poses  (and  no  doubt  this  danger  exists)  there  is,  on  the  other 
hand,  the  possibility  that  it  may  be  the  means  of  opening  up  to 
us  the  immense  resources  of  our  workhouse  infirmaries  for  that 
purpose — a  thiDg  which  many  of  us  have  been  longing  for  for  a 
considerable  period  and  which  now  seems  to  be  coming  within 
the  domain  of  practical  politics.  Already  we  have  the  fever 
hospitals  made  available  for  clinical  purposes  in  a  somewhat  re¬ 
stricted  sense,  and  at  the  present  moment  the  post-graduate 
course  includes  a  weekly  visit  to  one  of  the  largest  of  the  Lon¬ 
don  workhouse  infirmaries. 

We  are  rapidly  approaching  a  settlement  of  the  question 
which  has  so  long  been  agitating  us — viz.,  how  to  provide  an 
attainable  degree  in  medicine  for  our  London  students;  the  exist¬ 
ing  University  of  London  has  been  given  the  chance  of  remodeling 
itself  so  as  to  enable  this  to  be  accomplished,  and  warned  that 
if  it  does  not  do  it  it  will  be  made  to  stand  on  one  side  while 
Parliament  takes  the  matter  in  hand  ;  it  can  be  readily  under¬ 
stood,  therefore,  that  the  university  has  aroused  itself  and  is 
making  a  very  real  attempt  to  provide  a  solution  of  the  diffi¬ 
culty  that  will  be  agreeable  to  all  parties.  One  of  the  chief  diffi¬ 
culties  is  that  there  are  two  teaching  bodies — viz.,  University 


College  and  Kings  College — which  are  equipped  for  giving  in¬ 
struction  in  all  branches  of  education,  and  that  they  claim  a  dis¬ 
tinct  position  in  the  new  university,  while,  as  regards  their 
medical  faculty,  the  nine  other  medical  schools  strongly  object 
to  any  privileges  being  granted  to  the  two  bodies  named  in  re¬ 
spect  of  their  medical  sections  which  are  not  also  granted  to  all 
alike,  and  in  this  they  are  strongly  supported  by  the  Colleges  of 
Physicians  and  Surgeons;  the  latter  bodies  are  trying  to  obtain 
a  joint  control  of  the  examinations  with  the  university,  and 
there  is  evidently  much  to  be  said  in  support  of  their  contention. 
It  is  expected  that  the  university  will  promulgate  a  scheme  in 
the  course  of  a  very  few  days,  and  it  is  certain  that  the  very  great 
desire  on  the  part  of  all  concerned  to  obtain  a  settlement  of 
this  vexed  question  will  secure  for  it  a  most  favorable  consid¬ 
eration. 

Our  societies  have  almost  concluded  their  sessions;  the 
Clinical  and  Pathological  have  held  their  last  meeting,  and  the 
Royal  Medical  and  Chirurgical  will  hold  its  last  meeting  next 
week,  and,  notwithstanding  the  inconvenience  experienced  at 
the  commencement  of  the  session  by  the  new  premises  of  the 
latter  society  not  being  ready  for  occupation,  the  amount  of 
work  performed  by  the  leading  societies  will  not  be  less  than 
that  of  past  years,  though  there  have  not  been  any  great  dis¬ 
cussions  such  as  those  on  tubercle  bacilli  or  Charcot’s  joint  dis¬ 
ease,  only  to  cite  two  of  the  more  recent  instances;  two  com¬ 
mittees  are  at  work,  however,  which  will  no  doubt  supply  ma¬ 
terial  for  excellent  discussions  at  future  meetings.  The  Clinical 
Society  has  a  committee  at  work  on  the  period  of  incubation  of 
the  various  infectious  disorders — an  inquiry  which  was  really 
undertaken  more  than  ten  years  ago,  but  somehow  was  allowed 
to  lapse  and  was  practically  re-undertaken  a  little  more  than  a 
year  ago.  Dr.  Dawson  Williams,  who  is  the  secretary  and  the 
moving  spirit  in  it,  has  given  notice  that  the  report  will  be 
ready  for  presentation  at  an  early  meeting  of  the  next  session. 
The  other  investigation  is  undertaken  by  the  Royal  Medical  and 
Chirurgical  Society  and  is  on  the  health  resorts  of  Great  Brit¬ 
ain;  the  leading  men  on  the  committee  are  Dr.  Hermann 
Weber,  Dr.  Dickinson,  Dr.  Mitchell  Bruce,  Dr.  Penrose,  and 
Dr.  A.  E.  Garrod,  and  it  is  believed  that  their  report  will  be 
ready  for  presentation  during  the  forthcoming  session. 

Our  medical  colleagues  in  Birmingham  are  making  great 
preparations  for  the  meeting  of  the  British  Medical  Association, 
which  is  to  be  held  there  in  August  under  the  presidency  of  Dr. 
Wade,  and  the  programme  which  has  already  been  put  forth 
shows  that  the  meeting  will  not  be  behind  any  of  its  predeces¬ 
sors  in  scientific  interest.  There  had  been  some  talk  of  holding 
the  meeting  this  year  in  London,  where  the  association  has  not 
been  received,  I  think,  for  nearly  twenty  years,  but  the  agita¬ 
tion  last  autumn  which  terminated  in  the  resignation  of  some 
seventy  members  caused  the  leaders  of  the  association  to  go 
elsewhere,  though  the  actual  loss  to  the  association  was  exceed¬ 
ingly  small  and  has  since  been  further  lessened  by  the  return 
of  a  considerable  number  to  the  fold.  I  am  told  that  these 
disputes  and  secessions  are  periodical,  that  the  discontented 
persons  always  return  sooner  or  later,  and  that  this  is  a  far 
smaller  secession  than  either  of  its  two  predecessors.  The  num¬ 
ber  of  members  of  the  association  is  now  greater  than  it  has 
been  at  any  previous  time. 

A  protest  is  being  raised — not  before  it  was  wanted — against 
the  spread  of  hypnotic  experiments  in  public  performances. 
An  anonjmous  writer  in  a  medical  journal  last  week  put  it 
very  well  when  he  said :  “  Hypnotism  is  apt  to  be  a  dangerous 
mental  poison,  and  as  such  it  needs  to  be  fenced  round  with  as 
many  restrictions  as  the  traffic  in  other  kinds  of  poison.  Nar¬ 
cotics  of  any  kind  are  not  to  be  handled  by  the  ignorant,  and 
are  liable  to  reckless  abuse  by  the  feeble  in  mind  or  body.” 


18 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jock., 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  JULY  5,  1890. 


SOME  UNUSUAL  MODES  OF  INFECTION  WITH  SYPHILIS. 

An  examination  of  the  medical  literature  of  the  past  would 
show  a  long  list  of  sources  of  mediate  infection  with  syphilis; 
hut  to  this  already  extensive  and  varied  collection  Dr.  R.  W. 
Taylor  has  added  a  number  of  novel  and  striking  ones,  the 
details  of  which  he  has  presented  in  an  interesting  paper  read 
at  the  Fourth  Annual  Meeting  of  the  American  Association  of 
Genito-urinary  Surgeons,  and  published  in  the  June  number  of 
the  Journal  of  Cutaneous  and  Genito-urinary  Diseases.  From 
this  article  it  appears  that  the  popular  and  apparently  innocent 
gum-chewing  craze  may  be  accompanied  by  the  hidden  danger 
of  syphilitic  infection.  A  lady  who  had  become  infected  with 
syphilis  from  a  towel  which  had  been  secretly  used  by  her 
maid  subsequently  had  a  sore  mouth  and  tongue,  aud  while  in 
this  condition  she  got  into  the  habit  of  using  chewing-gum. 
On  two  occasions  she  had  temporarily  placed  her  bolus  on  some 
article  of  furniture,  and  it  had  been  taken  up  by  mistake  and 
chewed  for  some  time  by  another  lady.  This  second  lady  had 
abraded  her  lip  while  brushing  her  teeth  a  short  time  before, 
and  on  this  wound  a  typical  indurated  chancre  appeared,  ac¬ 
companied  by  marked  enlargement  of  the  submaxillary  and 
cervical  glands.  In  due  time  roseola  and  rheumatoid  pains 
ushered  in  the  secondary  period  of  syphilis.  All  other  possible 
sources  of  infection  had  been  very  carefully  excluded. 

In  many  cases  of  syphilis  it  is  very  difficult  to  trace  the 
source  of  infection,  even  when  the  patient  is  truthfully  endeav¬ 
oring  to  assist  the  physician  in  this  task ;  and  this  difficulty  is 
often  owing  to  the  fact  that  the  questions  asked  do  not  elicit 
the  desired  information.  We  must  sometimes,  with  tact  and 
prudence,  inquire  concerning  certain  unnatural  practices,  about 
which  some  men  have  no  shame,  while  others  are  very  sensi¬ 
tive.  The  necessity  of  this  is  shown  by  a  case  in  which  an 
eminent  practitioner  pronounced  a  man  free  from  syphilis  be¬ 
cause  he  had  not  been  exposed  in  the  usual  way  for  fully  two 
years,  and  yet,  on  examining  into  his  history  more  thoroughly, 
it  was  ascertained  that,  while  going  home  one  night  slightly 
under  the  influence  of  liquor,  he  had  been  accosted  by  a 
stranger,  who  led  him  into  a  secluded  spot,  where  he  per¬ 
formed  upon  him  one  of  these  unnatural  practices.  Two 
weeks  later  three  excoriations  appeared  on  the  penis,  and  later 
on  developed  into  indurated  nodules,  and  the  secondary  mani¬ 
festations  of  syphilis  appeared  in  due  time.  Many  men  seem 
to  consider  that  indulgence  in  these  unnatural  practices  does  not 
come  under  the  head  of  exposure  to  syphilis,  and  so  they  often 
unintentionally  mislead  their  physician.  There  is  a  class  of 
men,  chiefly  young — although  older  ones  are  among  their  num¬ 


ber — who  are  the  victims  of  sexual  perversion,  and  who  grant 
to  and  receive  from  men  libidinous  favors  in  revolting  and  un¬ 
natural  practices.  They  patrol  dark  and  unfrequented  streets, 
and  prove  a  constant  annoyance  to  the  police  after  dark  by 
“  hanging  around  ”  our  public  parks  and  haunting  the  public 
places  of  urination,  and  also  the  water-closets  in  hotels.  In 
December,  1888,  Dr.  Taylor  presented  to  the  New  York  Der¬ 
matological  Society  one  of  these  men,  who  was  suffering  from 
a  well-marked  chancre  of  the  tonsil  and  general  syphilitic 
manifestations.  lie  had  undoubtedly  received  his  infection 
from  a  man  who  had  a  hard  chancre,  and  there  is  no  knowing 
how  many  men  he  had  infected  before  his  tonsillar  chancre 
caused  such  pain  and  uneasiness  as  to  disable  him  for  his  favor¬ 
ite  pursuit.  In  any  future  legislation — if  there  ever  is  any — for 
the  prevention  of  venereal  diseases  in  this* country  or  State, 
these  persons  should  be  prominently  remembered.  The  mem¬ 
bers  of  this  promising  fraternity  are  well  known  to  the  police, 
who,  having  as  a  rule  an  antipathy  to  them,  keep  a  sharp  eye 
upon  them,  causing  them  to  keep  moving,  and  in  every  pos¬ 
sible  way  interfering  with  their  beastly  pursuits. 

A  much  less  revolting  but  still  very  important  mode  of 
syphilitic  infection  next  received  the  author’s  attention — viz., 
by  post-mortem  examinations  on  those  who  have  died  while 
the  disease  was  still  active.  Two  very  striking  cases  were  re¬ 
lated,  and  they  certainly  point  to  the  importance  of  such  a 
mode  of  infection. 

The  cases  cited  were  both  observed  in  physicians.  In  the 
first  one  the  physician  held  an  autopsy  on  a  person  who  had 
died  of  syphilis  maligna  and  tuberculosis,  eight  hours  after 
death;  and  during  the  examination  he  broke  the  end  of  one 
finger-nail  and  tore  the  flesh.  The  raw  surface  healed  in  five 
days,  but  on  the  fifteenth  day  after  the  autopsy  redness  and  a 
slight  fissure  developed  at  this  spot,  and  within  two  weeks  there 
was  an  exuberant  vegetating  chancre,  with  epitrochlear  and  ax¬ 
illary  adenopathy.  In  forty-five  days  general  syphilitic  mani¬ 
festations  appeared.  While  he  had  been  attending  the  patient 
there  had  been  no  lesions  which  might  possibly  have  conveyed 
syphilitic  infection,  and  he  was  sure  that  he  had  not  been  ex¬ 
posed  to  syphilis  in  any  manner  for  at  least  eight  weeks  prior 
to  the  autopsy.  In  the  second  case  the  unfortunate  victim  was 
a  healthy  man,  twenty-six  years  of  age,  of  temperate  habits  and. 
having  a  good  family  history.  On  November  29, 1887,  he  made 
an  autopsy,  nine  hours  after  death,  of  a  prostitute  who  had  died 
of  cerebral  apoplexy.  She  had  scars  on  her  body,  which  were 
no  doubt  syphilitic  lesions.  At  the  time  there  was  a  small 
crack  just  under  the  third  finger-nail,  and  this  he  covered  with 
collodion.  On  December  21st  he  performed  another  autopsy, 
five  hours  after  death,  upon  a  man  who  had  died  of  acute  alco¬ 
holism  with  cirrhosis  of  the  liver  and  kidneys.  He  also  had  a 
fracture  of  the  jaw  with  a  large  and  very  foul  external  wound. 
About  three  or  four  days  after  this  second  autopsy  a  fungous 
growth  appeared  about  the  nail  on  the  physician’s  third  finger, 
and  this  would  not  heal,  although  various  methods  of  treatment 
were  adopted.  On  January  23,  1888,  he  took  a  Turkish  bath, 
and  on  the  following  day  felt  feverish  and  much  depressed.  In 


July  5,  1890.] 


MINOR  PARAGRAPHS. 


19 


the  evening  a  rash  appeared  on  the  arms  and  hands.  Thinking 
that  he  was  suffering  from  septic  matter  absorbed  at  the  time 
of  the  second  autopsy,  he  sought  advice,  and  was  greatly  sur¬ 
prised  to  learn  that  he  had  been  infected  with  syphilis.  All 
other  sources  of  infection  were  carefully  excluded.  He  had 
evidently  been  infected  at  the  time  of  the  first  autopsy,  so  that 
fifty-four  days  elapsed  between  the  infection  and  the  systemic 
outburst.  This  length  of  time  would  fully  cover  the  two  clas¬ 
sical  periods  of  incubation  observed  in  the  development  of  syphi¬ 
lis,  while  the  time  between  the  second  autopsy  and  the  evi¬ 
dence  of  infection  was  far  too  short  for  syphilis.  It  was  worthy 
of  note  that  both  these  autopsies  had  been  made  within  a  com¬ 
paratively  short  period  after  death  ;  and  it  is  probable  that,  if 
infection  does  occur  in  this  way,  it  is  only  when  the  examina¬ 
tion  is  made  soon  after  death,  and  before  cadaveric  changes 
have  taken  place,  for  the  latter  probably  destroy  the  syphilitic 
virus. 

Dr.  Taylor  related  the  histories  of  cases  showing  syphilitic 
infection  from  a  caustic-holder,  a  handkerchief,  a  bathing-suit, 
a  syringe,  a  pair  of  drawers,  a  whistle,  a  tongue- scraper,  a  razor, 
a  pillow,  etc.,  and  called  attention  to  the  liability  of  such  infec¬ 
tion  from  water-closets.  He  thought  the  profession  was  far 
too  skeptical  in  regard  to  this  source,  for  he  had  seen  many 
cases  of  hard  chancre  the  bearers  of  which  had  told  him  that 
they  frequently  renewed  their  dressings  and  inspected  the  dis¬ 
eased  organ  while  sitting  upon  a  water-closet  seat.  Then  there 
were  cases  of  mucous  patches  and  condylomata  lata  of  the 
scrotum  which,  unless  great  care  was  exercised,  must  come  in 
contact  with  the  water-closet  seat.  There  was  also  a  method 
of  infection  that  had  not  before  been  described,  but  which  the 
author  had  observed  in  at  least  a  dozen  cases.  It  generally  oc¬ 
curred  in  this  way :  A  man,  fearing  to  contract  the  venereal 
disease,  or  for  other  reasons,  contented  himself  with  digital 
fondling  of  the  female  genitals.  In  this  way  his  fingers  might 
become  soiled  with  the  secretion  from  syphilitic  excoriations, 
and  the  virus  might  be  transferred  from  his  fingers  to  some 
other  part  of  his  body — generally  by  scratching  or  picking.  In 
this  way  chancres  might  be  produced  on  the  tip  of  the  nose, 
the  chin,  the  cheek,  the  neck,  or  arm.  It  was  highly  probable 
that  many  chancres  about  the  face  in  men  originated  in  this 
manner. 

The  author  concludes  by  pointing  out  the  necessity  for 
greater  care  on  the  part  of  physicians  in  explaining  to  their 
syphilitic  patients  how  they  may  become  disseminators  of  in¬ 
fection,  and  the  means  to  be  taken  to  prevent  that  great  disas¬ 
ter  to  others. 

MINOR  PARAGRAPHS. 

POTASSIUM  TELLURATE  IN  THE  NIGHT-SWEATS  OF 

PHTHISIS. 

In  the  Wiener  Minische  Wochenschrift  for  June  5th  Dr.  Ed¬ 
mund  Neusser  relates  his  experience  with  potassium  tellurate 
as  a  remedy  for  the  night-sweats  of  consumptives.  He  used  it 
in  the  form  of  a  pill,  giving  at  first  0-02  gramme  (about  a  third 
of  a  grain)  at  a  dose.  In  most  of  his  cases  this  proved  sufficient, 
but  a  few  patients  began  to  sweat  again  after  a  time,  and  with 


them  he  doubled  the  dose,  generally  with  good  results.  In  but 
few  instances  were  any  toxic  effects  observed;  even  with  doses 
of  a  grain,  it  was  only  after  their  prolonged  use  that  anything 
of  the  kind  occurred,  and  then  the  symptoms  were  only  those 
of  moderate  disturbance  of  digestion.  An  objection  to  the  em¬ 
ployment  of  the  remedy,  however,  is  the  fact  that  it  imparts  an 
intense  garlicky  odor  to  the  breath,  but  generally  this  is  not 
perceived  by  the  patient,  although  two  of  the  patients  com¬ 
plained  of  a  sulphurous  or  camphoraceous  odor  of  the  eructa¬ 
tions. 


WILLIAM  CULLEN  AS  A  STUDENT. 

In  the  last  number  of  the  Asclepiad  the  editor,  Dr.  Benja¬ 
min  Ward  Richardson,  gives  us  an  entertaining  and  instructive 
article  entitled  William  Cullen,  M.  D.,  F.  R.  S.,  and  the  Growth 
of  Physical  Medicine,  illustrated  with  two  portraits  of  the  great 
nosologist.  In  his  youth  Cullen  was  an  exceedingly  studious 
and  discreet  person.  Speaking  of  him  at  the  age  of  twenty, 
when  be  was  employed  in  an  apothecary’s  shop,  Dr.  Richard¬ 
son  says  of  him :  “  Let  the  subject  of  conversation  with  him  be 
one  on  which  he  has  little  or  no  knowledge,  he  will  listen  and 
take  no  part ;  but  speak  to  him  at  some  subsequent  period  on 
the  same  subject,  and  beware,  or  he  will  confound  you  with 
his  information.” 


THE  LADIES’  HEALTH  PROTECTIVE  ASSOCIATION  OF 

NEW  YORK. 

We  have  more  than  once  spoken  of  the  good  work  done  by 
this  energetic  association,  and  the  appearance  of  its  report  for 
the  years  1888  and  1889  reminds  us  of  its  wide  field  of  operations 
and  of  their  value  as  labor  supplementary  to  that  of  the  sanitary 
officials.  The  report  deals  with  gas-houses,  slaughter-houses, 
manure  and  stable  refuse,  street-cleaning,  school  hygiene,  the 
Croton  water,  women  as  factory  inspectors,  police  matrons, 
tenement  houses,  public  sewers,  etc. — not  in  a  prolix  or  tedious 
way,  but  with  the  utmost  brevity  consistent  with  the  impor¬ 
tance  of  those  subjects  and  with  a  freedom  from  querulousness 
that  is  very  commendable. 


THE  INTERNATIONAL  ATLAS  OF  RARE  SKIN  DISEASES. 

We  have  received  parts  i  and  ii  of  this  very  valuable  publi¬ 
cation  from  the  American  publishers,  the  J.  B.  Lippincott  Com¬ 
pany,  of  Philadelphia.  Reserving  them  for  further  mention, 
we  will  simply  note  that  the  work  is  edited  by  Mr.  Malcolm 
Morris,  of  London ;  Dr.  P.  G.  Unna,  of  Hamburg ;  Dr.  H.  Le- 
loir,  of  Lille;  and  Dr.  L.  A.  Duhrjng,  of  Philadelphia ;  that  the 
text  is  in  the  English,  French,  and  German  languages  ;  that  two 
parts  are  to  be  issued  annually;  and  that  the  work  is  to  be  had 
in  this  country  only  of  the  Lippincott  Company,  and  only  by 
subscription. 


“  ORISTRY.” 

According  to  the  Boston  Medical  and  Surgical  Journal ,  Dr. 
J.  L.  Williams,  of  Boston,  proposes  the  adoption  of  this  term  to 
signify  the  rapidly  widening  specialty  of  the  dental  and  oral 
surgeon.  The  word  is  compounded  of  the  initial  part  of  oral 
and  the  terminal  part  of  dentistry. 


SPECIAL  BERLIN  CLINICS  FOLLOWING  THE  CONGRESS. 

A  correspondent  informs  us  that  many  of  the  professors 
and  Docenten  of  the  university  intend  to  hold  special  courses  of 
from  three  to  four  weeks’  duration  immediately  on  the  close  of 
the  Tenth  International  Congress.  He  adds  that  strangers  will 


20 


ITEMS.— LETTERS  TO  THE  EDITOR. 


[N.  Y.  Med.  Joub., 


find  the  various  announcements  on  the  bulletin-boards  of  the 
Charit6  Hospital  and  the  University  Clinics. 


A  NOVEL  FORM  OF  MEMORIAL. 

A  piece  of  ground  for  athletics,  of  twenty-seven  acres,  on 
the  banks  of  the  Charles  River,  has  been  presented  to  Harvard 
University  by  Mr.  H.  L.  Higginson,  of  Boston.  The  field  will 
be  known  as  the  Soldiers’  Field,  and  will  contain  a  memorial  in 
honor  of  seven  friends  of  the  donor,  who  died  in  or  as  a  result 
of  the  War  of  the  Rebellion.  One  of  these  seven  was  that  rare 
and  true  man,  Dr.  Edward  B.  Dalton,  for  many  years  the  Sani¬ 
tary  Superintendent  of  the  New  York  Board  of  Health. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  July  1,  1890  : 


DISEASES. 

Week  ending  June 24. 

Week  ending  July  1. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

7 

1 

11 

6 

Scarlet  fever . 

33 

4 

34 

10 

Cerebro-spinal  meningitis . 

0 

0 

1 

0 

Measles . 

297 

16 

276 

25 

Diphtheria . 

90 

26 

84 

23 

Varicella . 

12 

0 

1 

0 

The  Honorary  Degree  of  LL.  D.  has  been  conferred  by  Lafayette 
College  on  Dr.  Ezra  M.  Hunt,  of  Trenton,  N.  J.,  and  by  Yale  Univer¬ 
sity  on  Dr.  Francis  Delafield,  of  New  York. 

Change  of  Address. — Dr.  Thomas  Linn,  from  Paris,  France,  to  No. 
16,  quai  Massena,  Nice. 

The  Death  of  Dr.  Edward  Malone,  of  Brooklyn,  occurred  on  June 
16th.  The  deceased,  who  was  fifty-two  years  old,  was  born  in^Ireland, 
but  came  to  this  country  while  yet  a  lad.  He  was  educated  in  Paris 
and  New  York.  In  the  late  war  he  served  with  the  Eleventh  Brigade, 
New  York  State  Volunteers. 

The  Death  of  Dr.  Gustavus  A.  A.  Krehbiel  took  place  at  his  home, 
in  New  York,  on  the  17th  of  June,  when  he  was  forty-nine  years  old. 
He  was  a  native  of  Bavaria,  a  graduate  of  the  University  of  Munich, 
and  for  a  time  a  practitioner  in  Vienna.  He  came  to  this  country  about 
fifteen  years  ago,  and  took  a  high  position  as  a  physician. 

The  Death  of  Dr.  Willis  F.  Westmoreland,  of  Milledgeville,  Ga., 

is  announced  as  having  taken  place  on  Friday,  June  27th,  at  the  age  of 
fifty-two.  The  deceased  was  one  of  the  founders  of  the  Atlanta  Medi¬ 
cal  and  Surgical  Journal ,  and  for  many  years  a  member  of  the  faculty 
of  the  Atlanta  Medical  College.  During  the  late  civil  war  he  served 
on  the  medical  corps  of  the  Confederate  Army. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  June  28,  1890 : 

Page.  John  E.,  Berryville,  Va.  ;  Kennedy,  Robert  M.,  Pottsville,  Pa. ; 
Whitfield,  James  M.,  Richmond,  Va. ;  Stone,  Lewis  H.,  Litchfield, 
Conn.,  commissioned  assistant  surgeons  in  the  Navy. 

Atlee,  Louis  W.,  Assistant  Surgeon.  Detached  from  the  U.  S.  Steamer 
Marion,  and  granted  three  months’  leave. 

Marine-Hospital  Service. —  Official  List  of  Changes  of  Stations  and 
Duties  of  Medical  Officers  of  the  United  States  Marine-Hospital  Service 
for  the  three  weeks  ending  June  21,  1890 : 

Gassaway,  J.  M.,  Surgeon.  When  relieved  at  Cairo,  Ill.,  to  proceed  to 
New  Orleans,  La.,  and  assume  command  of  the  Service  at  that  sta¬ 
tion.  June  4,  1890. 

Stoner,  G.  W.,  Surgeon.  Granted  leave  of  absence  for  three  days. 
June  18,  1890. 

Wasdin,  Eugene,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  fourteen  days.  June  6  and  10,  1890. 


White,  J.  H.,  Passed  Assistant  Surgeon.  To  proceed  to  Savannah, 
Ga.,  on  special  duty.  June  9,  1890. 

Heath,  F.  C.,  Assistant  Surgeon.  Granted  leave  of  absence  for  fifty- 
eight  days.  June  10,  1890. 

Magruder,  G.  M.,  Assistant  Surgeon.  Granted  leave  of  absence  for 
twenty  days.  June  2,  1890.  Ordered  to  examination  for  promo¬ 
tion.  June  6,  1890. 

Woodward,  R.  M.,  Assistant  Surgeon.  Relieved  from  duty  at  Chicago, 
Ill.,  to  assume  command  of  Service  at  Cairo,  Ill.  June  4,  1890. 

Condict,  A.  W.,  Assistant  Surgeon.  .  Upon  expiration  of  leave  of  ab¬ 
sence,  to  report  to  medical  officer  in  command  at  Chicago,  Ill.,  for 
duty.  June  4,  1890. 

Resignation. 

Heath,  F.  C.,  Assistant  Surgeon.  Resignation  accepted  by  the  Presi¬ 
dent,  to  take  effect  August  31,  1890.  June  10,  1890. 

Society  Meetings  for  the  Coming  Week : 

Tuesday,  July  8th :  Medical  Societies  of  the  Counties  of  Chautauqua 
(annual),  Clinton  (semi-annual — Plattsburg),  Greene  (quarterly), 
Jefferson  (semi-annual — Watertown),  Madison  (annual),  Oneida  (an¬ 
nual — Utica),  Ontario  (annual — Canandaigua),  Schuyler  (semi-an¬ 
nual),  Tioga  (semi-annual — Owego),  and  Wayne  (annual),  N.  Y. ; 
Norfolk,  Mass.,  District  Medical  Society  (Hyde  Park). 

Wednesday,  July  9th:  Tri-States  Medical  Association  (Port  Jervis, 
N.  Y.) ;  Franklin,  Mass,  (quarterly — Greenfield),  Hampshire,  Mass, 
(quarterly — Northampton),  and  Worcester,  Mass.  (Worcester),  Dis¬ 
trict  Medical  Societies. 

Thursday,  July  10th :  Medical  Society  of  the  County  of  Fulton  (semi¬ 
annual),  N.  Y. 

Saturday,  July  12th  :  Worcester,  Mass.,  North  District  Medical  So¬ 
ciety. 


Setters  to  %  debitor* 


NITROGLYCERIN  IN  GAS  POISONING. 

1619  John  Street,  Baltimore,  June  24,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sib:  I  have  just  successfully  treated  another  case,  the  pa¬ 
tient  being  almost  moribund,  of  poisoning  by  illuminating  gas 
with  the  subcutaneous  injection  of  nitroglycerin,  -fo.  The 
symptoms  were  not  quite  so  threatening  as  in  the  case  I  de¬ 
scribed  in  your  issue  of  October  26,  1889,  yet  sufficiently  so  to 
he  alarming,  and  the  result  was  fully  as  prompt  and  happy  as  in 
the  former  case. 

I  have  observed  the  report  of  three  other  successful  cases  by 
this  treatment,  which  is  surely  sufficient  to  attract  the  attention 
of  medical  men  likely  to  meet  with  such  cases,  and  to  induce 
them  to  give  it  a  trial. 

The  suggestion,  made  by  Dr.  F.  X.  Dooley,  of  Washington, 
D.  O.,  in  your  issue  of  February  8,  1890,  that  this  treatment 
should  be  embodied  in  our  visiting  lists,  is  an  excellent  one,  and 
should  be  acted  on. 

In  my  paper  of  October  26,  1889,  I  stated  that  the  idea  was 
original  with  me  and  that,  to  my  knowledge,  the  remedy  had 
not  been  used  previously  for  the  treatment  of  such  cases.  Since 
the  publication  of  my  paper  Dr.  Crossland,  of  Zanesville,  Ohio, 
has  published  a  paper  in  which  he  states  he  made  use  of  the 
same  treatment  some  months  before  I  did.  I  do  not  wish  to 
detract  in  the  slightest  from  Dr.  Crossland's  merit,  but  I  do  say 
that  the  idea  was  entirely  original  with  me  and  that  I  promptly 
published  my  success  for  the  benefit  of  my  brother  practition¬ 
ers.  thereby  eliciting  Dr.  Crossland’s  case,  which  otherwise 
would  in  all  probability  never  have  been  given  to  the  pro¬ 
fession.  Wtilliam  C.  Kloman,  M.  D. 


July  5,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


21 


Iprocecbtngs  of  Societies. 

NEW  YORK  ACADEMY  OF  MEDICINE. 

Meeting  of  May  1 ,  1890. 

The  President,  Dr.  Alfred  L.  Loomis,  in  the  Chair. 

This  meeting  was  devoted  to  the  discussion  of  the  Relation  of 
Peripheral  Irritations  to  Disease,  continuing  the  consideration 
of  the  subject  adjourned  from  the  stated  meeting  of  March  20th. 

The  Relation  of  Diseased  Conditions  in  the  Upper  Air 
Passages  to  So-called  Nasal  Reflexes. — This  was  the  title  of 
a  paper  by  Dr.  F.  H.  Bosworth.  He  did  not  agree  with  an 
ancient  writer  who  had  believed  that  all  diseases  came  from  the 
nasal  passages,  neither  did  he  believe  that  the  nose  was  abso¬ 
lutely  the  direct  cause  of  a  large  number  of  diseases  which  were 
now  recorded  in  the  category  of  nasal  reflexes.  Furthermore, 
he  thought  it  was  still  an  open  question  whether  these  diseases, 
when  met  with  in  connection  with  intranasal  disorders,  should 
properly  be  classed  as  reflexes.  It  was  certain  that  many  of  the 
affections  termed  reflex  must  be  regarded  as  directly  symptom¬ 
atic.  As  to  the  question  of  hay  fever  and  asthma,  he  did  not 
believe  that  intranasal  disease  was  the  cause  of  every  case  of 
these  two  diseases.  The  position  taken  by  the  speaker  on  this 
question,  briefly  stated,  was  as  follows:  First,  that  the  special 
morbid  lesion  which  gave  rise  to  a  paroxysm  of  perennial  asth¬ 
ma  was  a  dilatation  of  the  blood-vessels  which  circulated  in  the 
mucous  membrane  lining  the  bronchial  tubes,  the  result  of  vaso¬ 
motor  paresis.  This  vaso-motor  paresis  differed  from  inflam¬ 
mation  in  that,  while  constituting  apparently  its  first  stage,  it 
showred  no  tendency  to  go  farther.  Muscular  spasm,  therefore, 
according  to  the  old  teaching,  played  no  part  whatever  in  pro¬ 
ducing  an  asthmatic  attack.  Again,  there  were  two  predispos¬ 
ing  causes  of  asthma:  First,  that  condition  of  the  general  sys¬ 
tem  which  we  called  neurosis,  under  the  influence  of  which  an 
individual  became  liable  to  vaso-motor  disturbances  in  one  por¬ 
tion  of  the  body  or  another.  This  the  speaker  regarded  as  a 
good  definition,  from  a  pathological  point  of  view,  of  what  was 
called  neurosis.  So  far  as  clinical  observation  taught,  the  one 
pathological  lesion  which  characterized  the  direct  manifestation 
of  a  neurosis  was  a  vaso-motor  paresis  in  one  portion  of  the  body 
or  another.  In  asthmatics  this  vaso  motor  paresis  involved  the 
blood-vessels  which  circulated  in  the  mucous  membrane  of  the 
bronchial  tubes.  The  second  predisposing  cause  of  asthma  was 
a  chronic  inflammatory  process  involving  some  portion  of  the 
upper  air-tract.  In  chronic  inflammation  the  prominent  feature 
was  vascular  dilatation.  The  whole  mucous  membrane  of  the 
upper  air-tract  w-as  very  closely  and  intimately  related.  A  hy- 
persemiaof  the  blood-vessels  of  the  nose  showed  a  marked  tend¬ 
ency  to  be  followed  by  a  similar  condition  of  the  mucous  mem¬ 
brane  of  the  bronchial  tubes.  This  was  necessarily  a  corollary 
of  what  was  now  recognized  as  the  great  respiratory  function 
of  the  nasal  passages,  by  which  the  temperature  and  moisture 
of  the  inspired  air  were  nicely  regulated  and  adjusted  before  its 
entrance  into  the  bronchial  tubes.  Asthma,  as  before  remarked, 
was  not  in  all  cases  caused  by  an  intranasal  condition,  but  an 
intranasal  morbid  condition  played  an  exceedingly  important 
part  in  its  development.  In  the  author’s  original  paper — Asth¬ 
ma,  with  an  Analysis  of  Eighty  Oases — forty  six  were  reported 
as  cured  and  twenty-six  improved,  the  treatment  being  largely 
intranasal.  Now,  if  out  of  eighty  cases  forty-six  could  be  cured 
and  twenty-six  improved  by  the  local  treatment  of  the  nose, 
there  could  be  no  question  that  we  had  established  the  fact  that 
a  very  large  majority  of  cases,  if  not  all,  were  dependent  upon 
an  intranasal  lesion,  and  by  this  dependence  he  did  not  mean 


cause,  but  that  the  two  affections  were  so  closely  related  that 
the  asthma  could  be  very  materially  affected  and  controlled  by 
medication  to  the  nose.  As  regarded  hay  fever,  this  was  con¬ 
sidered  as  practically  one  and  the  same  disease  with  asthma,  and 
was  to  be  treated  in  the  same  way.  In  regard  to  certain  nerv¬ 
ous  diseases,  such  as  epilepsy,  he  had  seen  nothing  in  his  own 
practice  which  warranted  the  belief  that  that  disease  should  be 
looked  upon  as  a  nasal  reflex.  He  believed  that  an  intranasal 
condition  was  capable  of  proving  a  marked  source  of  irritation 
in  any  of  the  nervous  affections,  the  removal  of  which  would 
modify  the  symptoms,  but  that  epilepsy  had  ever  been  cured  by 
intrauasal  treatment  was,  he  thought,  open  to  very  serious 
question.  Of  chorea,  he  had  only  known  of  three  cases  which 
had  been  sufficiently  long  under  treatment  to  warrant  the  state¬ 
ment  that  they  had  been  permanently  relieved  by  intranasal 
treatment.  He  did  not  want  to  be  understood  as  saying  that 
there  was  any  connection,  reflex  or  otherwise,  between  chorea 
and  disease  of  the  upper  air  passages.  The  good  results  in  these 
cases  could  be  explained  by  the  fact  that  the  removal  of  the 
morbid  conditions  in  the  air  passages  of  young  patients  was 
often  followed  by  marked  improvement  in  the  general  health. 

Reflex  Chorea. — Dr.  A.  Jacobi,  in  the  course  of  his  remarks 
on  the  relation  of  this  trouble  to  peripheral  irritations,  thought 
that  quite  a  large  number  of  cases  of  chorea  minor  were  due  to 
cerebral  lesions,  and  had  more  or  less  pronounced  forms  of  epi¬ 
lepsy  complicating  them.  Other  cases  might  result  from  apo¬ 
plexy,  tumors,  cysts  of  the  brain,  diseased  cerebral  arteries,  in¬ 
flammatory  conditions  of  the  spinal  cord,  sclerosis,  embolisms, 
and  so  on.  Then  blood  diseases — such  as  rheumatism,  anaemia, 
nerve  inflammations,  disorders  of  digestion  or  the  sexual  appa¬ 
ratus,  fissures  of  the  anus,  or  cicatricial  contractions — might  be 
looked  upon  as  entering  into  the  causation  of  chorea  minor.  It. 
was  possible  that  cases  following  pericarditis  were  brought  about 
through  reflex  action.  Others  might  be  due  to  nasal  irritation. 
Many  children  developed  a  train  of  slight  symptoms  which  were 
put  down  simply  as  bad  habits  and  for  which  they  got  punished 
until  the  persistency  and  aggravation  of  the  symptoms  led  to  a 
proper  diagnosis.  Some  of  these  patients  would  be  found  to  be 
suffering  from  a  nasal  catarrh.  Many  of  these  got  better  in 
warm  weather  and  worse  in  winter.  Looking  carefully  at  such 
children,  it  would  be  seen  that  there  existed  a  number  of  symp¬ 
toms  common  to  each  case,  such  as  nasal  catarrh  with  thicken¬ 
ing  of  the  mucous  membrane  and  a  discharge.  The  glands  around 
the  neck  were  swollen,  particularly  those  near  the  aDgle  of  the 
jaw.  One  or  both  nostrils  would  be  found  impervious,  and  some 
ozaena  might  be  noticeable.  There  was  generally  more  or  less 
pharyngeal  catarrh,  with  reddened  mucous  membrane,  the  hy¬ 
pertrophied  tonsils  showing  a  number  of  follicular  cavities,  in¬ 
terspersed  with  small  white  dots  formed  by  the  dried-up  exuda¬ 
tion  of  muco-pus.  These  symptoms  were  pretty  constant  in 
what  he  would  term  local  chorea.  He  had  seen  many  cases  in 
which  the  head  and  shoulders  would  be  thrown  about  in  choreic 
spasms  and  in  which  the  condition  resulted  directly  from  irri¬ 
tation  of  the  nose  or  trigeminal  nerve.  Many  of  these  cases 
were  very  unyielding  except  a  correct  diagnosis  was  made. 
Medicinal  treatment  did  not  avail,  and  no  headway  was  made 
toward  a  cure  unless  the  nasal  irritation  was  removed.  The 
convulsive  processes  usually  began  in  the  right  hand,  extended 
to  the  left,  and  then  all  over  the  body.  He  was  in  the  habit  of 
treating  his  cases  mildly.  The  actual  cautery  might  be  used, 
but  many  patients  got  well  if  the  parts  were  kept  clean.  A 
weak  salt  water  wash  with  a  small  portion  of  alum,  used  every 
day,  would  do  better  than  more  vigorous  treatment.  In  a  num¬ 
ber  of  cases  he  had  begun  by  resection  of  the  tonsils,  and  where 
hypertrophy  existed  a  cure  could  not  be  effected  unless  this  was 
done. 


22 


PROCEEDINGS  OF  SOCIETIES. 


The  Relation  of  Peripheral  Irritation  to  Diseases  of  the 
Womb  and  its  Appendages. — Dr.  Charles  C.  Lee  read  a  pa¬ 
per  with  this  title.  He  said  that  in  no  part  of  the  body  was  the 
relation  of  existing  disease  and  peripheral  irritation  more  fre¬ 
quent  and  complex  than  in  the  womb  and  its  appendages,  hence 
he  bad  found  the  subject  delegated  to  him  no  easy  task.  This 
condition  naturally  resulted  from  the  greater  sensitiveness  of 
the  nervous  system  of  women  than  that  of  men,  and  the  extreme 
potency  of  the  uterus  as  a  factor  in  the  production  of  reflex  ir¬ 
ritation  in  other  organs.  The  speaker  called  attention  to  a  few 
of  the  well-marked  neuroses,  or,  if  the  term  was  preferable,  the 
hvstero-neuroses,  which  he  thought  would  best  illustrate  the 
subject.  Omitting  chorea,  of  which  many  cases  were  recorded 
as  intimately  dependent  upon  uterine  and  ovarian  disease,  the 
speaker  said  that  the  most  frequent  illustrations  of  peripheral 
irritation  resulting  from  intrapelvic  disease  in  women  were  (a) 
disturbances  of  surface  temperature  ;  (b)  neuralgias,  such  as 
spinal  irritation,  spinal  ache,  sciatica,  and  migraine ;  ( c )  special 
forms  of  headache,  such  as  pressure  on  the  vertex  while  the  rest 
of  the  head  was  unaffected  ;  ( d )  neuroses  of  the  gastro-intestinal 
canal,  including  the  familiar  example  of  the  persistent  vomiting 
of  early  pregnancy  ;  ( e )  neurotic  conditions  of  the  breast,  some¬ 
times  of  the  most  aggravated  character ;  (f)  genito-reflex  irri¬ 
tation  of  the  respiratory  tract,  producing  not  only  occasional 
dyspnoea,  but  unmistakable  attacks  of  asthma ;  ( g )  hysterical 
affections  of  the  joints  and  of  the  organs  of  special  sense.  The 
speaker  did  not  attempt  any  minute  subdivision  or  illustration 
of  these  general  groups,  but  adverted  to  only  two  points  of  prac¬ 
tical  importance  :  First,  it  was  futile  to  treat  these  evidences  of 
peripheral  irritation  as  diseases.  Like  all  neuroses,  they  were 
symptomatic  only  of  some  more  deeply  seated  disease  elsewhere, 
and  only  by  combining  the  appropriate  local  treatment  of  that 
with  improvement  of  the  patient’s  general  health  could  we  hope 
to  achieve  success.  Secondly,  it  was  a  striking  clinical  fact  that 
mal-conditions  of  the  uterus  exercised  far  more  influence  in 
these  directions  than  disease  of  the  tubes  or  ovaries.  Undoubt¬ 
edly  we  often  found  an  oophoritis,  or  the  evidence  of  cystic  or 
sclerotic  degeneration  of  the  ovaries,  in  these  cases.  And  in 
like  association  we  also  found  the  various  forms  of  salpingitis. 
But  however  thoroughly  these  were  treated,  the  neurotic  com¬ 
plication  would  almost  surely  persist  until  the  accompanying 
disease  of  the  womb  had  disappeared.  Whatever  diseased  con¬ 
dition  of  the  uterus  existed,  this  would  have  to  be  remedied  be¬ 
fore  the  patient  could  be  cured.  As  had  been  previously  stated, 
in  neurotic  conditions  ablation  of  the  uterine  appendages  was 
not  only  commonly  useless,  but  often  left  the  patient  worse  than 
she  was  before.  That  the  appendages  should  be  removed  if  in¬ 
tractable  disease  of  their  structure  was  unquestionable,  to  as¬ 
sume  any  other  ground  would  be  absurd.  But,  short  of  those 
conditions,  they  should  be  left  where  nature  placed  them,  and, 
even  when  removed,  in  the  treatment  of  such  conditions  as  were 
now  under  consideration  the  accompanying  uterine  disease  must 
receive  the  most  anxious  care. 

The  Relation  of  Peripheral  Irritation  to  Disease,  con¬ 
sidered  from  a  Therapeutic  Standpoint.  —  Dr.  Simon  Ba¬ 
ruch  read  a  paper  on  this  subject.  He  thought  the  most  im¬ 
portant  element  in  the  discussion  of  the  above  question  was  the 
influence  of  its  decision  upon  our  therapeutic  procedures. 
Whether  peripheral  irritations  were  aetiological  factors  by  rea¬ 
son  of  sympathetic  effect,  as  was  formerly  taught,  or,  as  a  more 
refined  pathology  and  more  scientific  inquiry  into  pathological 
processes  claimed  to  have  been  ascertained,  it  was  due  to  reflex 
agencies,  acting  through  the  spinal  cord,  the  chief  aim  of  thera¬ 
peutic  endeavor  must  be  at  the  point  of  irritation.  He  consid¬ 
ered  it  just  as  important  to  adopt  local  treatment,  whether  the 
peripheral  irritation  produced  symptoms  through  mechanical 


[N.  Y.  Mkd.  Jour. 

. ? 

or  reflex  channels,  but  that  it  was  always  well  to  distinguish 
those  conditions.  The  speaker  related  the  history  of  a  cure  of 
time  epilepsy,  which  verified  the  foregoing  statement  in  regard 
to  treatment:  A.  K.,  aged  sixteen,  a  robust  boy,  had  been  suf¬ 
fering  from  distinct  attacks  of  grand  mal  since  the  summer  of 
1884.  The  exhibition  of  bromides  had  resulted  in  the  absence 
of  attacks  for  over  a  year,  but  finally  they  returned  with  greater 
frequency  despite  the  increased  quantities  of  bromide  adminis¬ 
tered.  It  had  occuiTed  to  the  speaker  that  an  enchondroma  on 
the  left  side  of  the  anterior  portion  of  the  septum,  which  filled 
the  entire  fossa  in  front,  projecting  the  ala  far  beyond  its  nor¬ 
mal  line,  might  be  a  peripheral  irritant  bearing  astiological  illa¬ 
tion  to  the  epilepsy.  After  failure  with  the  galvano-cautery, 
the  growth  was  removed  with  a  Bosworth  saw.  The  bromides 
were  continued  until  September,  1889,  the  patient  not  having 
had  an  attack  since  a  week  after  the  operation,  which  was  in 
April  of  1886.  The  bromides  had  been  discontinued  for  the 
past  seven  months  with  no  return  of  the  attacks;  this  immunity 
for  over  four  years  could  most  probably  be  regarded  as  recov¬ 
ery  from  the  disease.  Similar  cases  were  on  record  in  recent 
literature.  A  disease  like  epilepsy,  in  the  presence  of  which 
one  stood  almost  helpless,  demanded  the  most  careful  search 
for  possible  aetiological  factors.  If  irritation  of  the  probe  in 
the  nose  produced  the  paroxysm  of  migraine,  asthma,  or  neu¬ 
ralgia,  we  had  evidence  that  could  be  obtained  in  no  other 
organ,  and,  in  addition,  if  we  succeeded  in  removing  attacks, 
either  artificially  or  spontaneously  produced,  by  complete  co¬ 
caine  anaesthesia  of  the  sensitive  areas,  the  aetiological  connec¬ 
tions  were  demonstrated  beyond  a  doubt  and  the  line  of  treat¬ 
ment  clearly  mapped  out.  It  therefore  became  a  duty  to  search 
for  abnormal  conditions  in  all  those  functional  nervous  disturb¬ 
ances  which  had  been  reported  as  possibly  connected  with  nasal 
irritation.  In  other  organs  the  difficulty  of  discovering  points 
of  irritation  was  not  so  marked,  because  interference  with  their 
function  became  more  or  less  burdensome  and  called  for  reme*- 
dy  in  a  large  proportion  of  cases.  The  eye,  for  instance,  did 
not  brook  infringement  upon  its  normal  condition  without. pro¬ 
test — a  protest  which  might  or  might  not  he  heeded  according 
to  the  intelligence  of  the  patient  and  his  capacity  for  resisting 
encroachments  upon  normal  functions.  The  speaker  himself 
had  been  cured  of  weekly  attacks  of  migraine  by  having  his 
error  of  refraction,  unequal  myopic  astigmatism,  corrected.  If 
we  did  not  succeed  in  relieving  patients  of  the  functional  nerv¬ 
ous  diseases  for  which  the  ophthalmic  examination  was  advised, 
we  at  least  might  be  content  that  no  damage  had  been  inflicted  by 
the  correction  of  any  error  of  refraction  that  might  have  caused 
distress  from  eye  strain.  From  a  therapeutic  standpoint  the  eye} 
as  a  source  of  peripheral  irritation,  demanded  as  careful  and 
painstaking  investigation  as  did  the  nose.  Fortunately,  we  had 
in  these  organs  means  of  ascertaining  positively  the  existence  of 
points  of  peripheral  irritation  and  of  remedying  them  harmless¬ 
ly.  The  existence  of  peripheral  irritation  in  the  utero-ovarian 
system  had  long  been  a  vexed  question.  While  the  speaker  was 
convinced  that  a  lacerated  cervix  was  frequently  an  aetiological 
factor  of  pronounced  type,  and  while  he  advised  removal  of  the 
local  pathological  conditions  connected  with  the  latter  as  a  sine 
qua  non  to  the  improvement  of  the  health  of  many  suffering 
women,  he  was  also  convinced  that  these  lesions  rarely,  if  ever, 
gave  rise  to  the  functional  nervous  troubles  that  had  been  at¬ 
tributed  to  them.  The  latter  might  almost  invariably  be  traced 
to  conditions  of  general  ill-health  and  anaemia,  resulting  from 
the  local  processes,  which  gave  rise  to  muco-purulent  dis¬ 
charges,  to  infection  from  raw  surfaces  on  the  cervix,  and  to  in¬ 
terference  by  pain  with  comfortable  locomotion,  rather  than  to 
the  pressure  of  cicatricial  plugs.  The  speaker  had  searched  the 
literature  on  the  subject  industriously  for  the  clinical  proof 


July  5,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


23 


that  the  removal  of  the  uterine  appendages  had  been  instru¬ 
mental  in  relieving  pronounced  functional  nervous  diseases,  and 
he  was  convinced  that  the  ablation  of  diseased  ovaries  and 
tubes  did  contribute  to  the  improvement  of  health  in  a  certain 
proportion  of  cases.  But  he  could  not  bring  himself  to  the  be¬ 
lief  that  the  removal  of  those  organs  not  presenting  palpable 
and  well-defined  pathological  changes  was  ever  called  for. 
Serious  psychoses  might  be  traced  to  peripheral  irritation  result¬ 
ing  from  wounds  of  the  head,  some  of  which  had  been  cured  by 
excision  of  the  scars.  The  relation  of  peripheral  irritation  ex¬ 
isting  in  the  gastro-intestinal  tract  to  diseases  elsewhere  was 
well  known.  The  •speaker  summed  up  his  views  on  the  thera¬ 
peutic  relation  of  peripheral  irritation  to  disease  as  follows : 
First,  that  the  existence  of  peripheral  irritation  as  an  setio- 
logical  factor  was  well  established.  Secondly,  that  there  need  be 
no  conjecture  in  the  search  for  such  causes  of  functional  nerv¬ 
ous  diseases  in  many  cases,  because  we  had  means  in  at  least  the 
more  recently  discovered  sources,  the  eye  and  nose,  of  detect¬ 
ing  and  testing  their  existence.  Thirdly,  all  harmless  methods 
of  treatment  should  be  exhausted  before  mutilating  procedures 
were  adopted.  Fourthly,  that  whenever  there  was  a  doubt,  the 
local  condition  should  receive  the  benefit  of  that  doubt,  and 
treatment  should  be  directed  to  the  improvement  of  the  general 
health. 

Dr.  Jacobi  said  that,  while  he  had  emphasized  his  belief 
that  there  could  exist  cases  of  very  intense  chorea  minor  due 
to  nasal  reflexes,  it  was  of  course  important  to  be  very  careful 
in  making  the  diagnosis.  There  was  nothing  easier  than  to  be 
mistaken  in  serious  cases.  They  were  imbued  with  the  notion 
that  reflex  irritation  meant  a  great  deal.  He  had  his  grave 
doubts  as  to  the  influence  of  peripheral  irritation  in  producing 
any  central  disease.  It  had  been  customary  with  many  of  them 
— and  they  had  been  led,  too,  by  illustrious  men — to  believe  that 
there  was  a  great  deal  of  sexual  irritation  in  phimosis,  and  that 
to  this  condition  might  be  traced  many  cases  of  paralysis  in 
infants  and  older  children.  He  had  never  seen  such  a  case. 
He  had  given  the  subject  generally  nearly  twenty-one  years  of 
attention,  and  he  was  now  sure  that  he  never  should  see  such  a 
case.  They  had  heard  of  brain  disease  following  or  being  pro¬ 
duced  by  genital  irritation.  If  a  patient  suffered  from  toothache 
or  some  severe  peripheral  neuralgia,  such  symptoms  might  be 
really  the  local  or  reflex  irritation  marking  the  commencement 
of  some  central  disease  which,  when  it  made  its  appearance,  was 
often  considered  the  cause  of  the  neuralgic  manifestations. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  PAEDIATRICS. 

Meeting  of  April  10,  1890. 

Dr.  L.  Emmett  Holt  in  the  Chair. 

A  Case  of  Cerebro-spinal  Meningitis.— Dr.  J.  Lewis  Smith 
presented  an  infant  whose  symptoms  he  described  in  detail  and 
from  which  he  had  inferred  that  it  had  suffered  from  cerebro¬ 
spinal  meningitis. 

Dr.  A.  Jacobi  thought  that  the  case  had  been  one  rather  of 
some  form  of  common  meningitis.  He  also  thought  that  there 
existed  considerable  of  the  rhachitic  element  in  the  baby.  There 
were  some  spots  over  the  occipital  bone  which  were  still  soft. 
There  was  a  very  perceptible  pulse  over  the  large  fontanels 
which  negatived  the  idea  of  existing  inflammatory  fluid.  He 
should  be  disposed  to  place  such  a  patient  on  antirrhachitic  treat¬ 
ment,  give  more  animal  diet,  and  certainly  give  phosphorus,  say 
T5A  grain  three  times  a  day.  Under  such  treatment  he  should 
expect  to  see  a  decided  improvement  in  the  child  within  four 
or  six  weeks. 


Mulberry  Stone  in  a  Young  Child ;  No  Symptoms.— 

Dr.  Hance  presented  a  calculus  which  he  had  removed  from  a 
girl  twenty  months  of  age  who  had  died  from  pulmonary  tu¬ 
berculosis  and  whooping-cough.  During  life  the  presence  of 
the  stone  had  not  been  indicated  by  any  symptoms,  and  was 
only  found  accidentally  in  making  post-mortem  section.  It  was 
a  question  whether  the  accretion  was  congenital.  There  were 
no  signs  of  pyelitis. 

Dr.  A.  Jacobi  said  the  stone  was  of  the  mulberry  variety 
and  consisted  of  oxalate  of  lime.  It  was  somewhat  rare. 

Congenital  Malformation  of  the  Fingers.— Dr.  Walter 
L.  Carr  narrated  the  history  and  presented  photographs  of  a 
case  of  congenital  deformity  of  the  fingers  of  both  hands  in  a 
girl  of  two  years  of  age.  The  mother  had  stated  that  the  child 
was  born  with  the  membranes  wrapped  around  the  hands,  and 
that  when  cut  away  the  fingers  were  found  to  be  marked.  The 
deformed  fingers  were  peculiar  in  the  numbers  of  annular  con¬ 
strictions.  The  index  and  third  fingers  of  the  left  hand  and  the 
middle  finger  of  the  right  hand  showed  this  marking.  On  the 
right  hand  the  index  and  third  fingers  were  only  the  stumps  of 
the  intra-uterine  amputations.  The  middle  finger  of  the  left 
hand  was  deformed  in  the  same  way  and  constricted  near  its 
extremity.  The  thumbs  and  little  fingers  were  not  malformed. 


The  child  was  very  active  and  ran  around,  taking  hold  of  every¬ 
thing  in  the  room.  Her  grasp  was  firm  and  the  condition  of 
her  hands  did  not  interfere  with  her  play.  Later  in  life  the 
deformity  might  prevent  her  from  doing  such  work  as  sewing, 
though  with  training  she  might  overcome  the  difficulty  of  hold¬ 
ing  the  needle.  If  she  used  her  left  hand  she  might  have  no 
trouble  at  all,  as  the  index  finger  was  strong. 

Empyema  complicated  with  Pulmonary  (Edema. — Dr. 
F.  Huber  read  a  paper  with  this  title.  (To  be  published.) 

Impacted  Urethral  Calculus  in  a  Boy  of  Three  Years 
of  Age. —  A  paper  with  this  title  was  read  by  Dr.  F.  M.  Cran¬ 
dall.  (To  be  published.) 

Two  Fatal  Cases  of  Acute  Primary  Pneumonia  in  In¬ 
fants,  without  Fever. — The  Chairman  read  a  paper  with  this 
title.  (To  be  published.) 

Dr.  A.  Jacobi  asked  to  what  cause  the  chairman  attributed 
the  low  temperature. 

The  Chairman  replied :  In  the  first  case,  to  the  intensity  of 
the  process,  associated,  as  it  was,  with  the  gangrenous  condition 
in  the  lung.  As  to  the  cause  in  the  second  case,  he  had  no  ex¬ 
planations  to  offer.  It  had  struck  him  as  interesting  to  gee  two 
children  die  of  pneumonia  within  a  week  of  each  other  with 
none  of  the  ordinary  symptomsof  the  disease.  Might  not  these 
cases  have  been  of  long  standing?  He  bad,  during  the  past 
two  weeks,  seen  several  cases  where  babies  had  been  brought 
in  without  very  high  temperature,  and  yet  the  autopsies  had 


24 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jour., 


shown  quite  extensive  infiltration,  in  one  instance  involving  the 
whole  of  both  lower  lobes. 

Dr.  Jacobi  said  there  were  three  classes  of  pneumonia  in 
which  very  high  temperatures  need  not  be  expected:  1.  That 
of  old  age.  2.  The  pneumonia  of  infants.  3.  Pneumonia  oc¬ 
curring  in  infants  who  had  had  other  diseases  by  which  they 
were  reduced. 

The  Use  of  Spirits  and  Malted  Drinks  in  Nursing 
Women. — Dr.  Jacobi  opened  a  discussion  on  this  subject.  He 
thought  th8  question  intimately  connected  with  that  of  diet 
generally,  as  to  whether  it  was  possible  for  foreign  substances 
in  the  blood  to  get  into  the  secretions  of  the  mammae,  and  from 
there  into  the  digestive  organs  of  the  baby.  The  speaker  then 
dealt  at  length  with  the  whole  subject  of  the  chemical  and 
physiological  experiments  on  milk  secretion.  He  pointed  out 
that  the  character  and  quality  of  the  breast  secretions  of  the 
mother  were  subject  by  many  causes  to  continual  variation. 
As  long  as  the  milk  was  a  real  secretion  there  was  but  little 
danger  that  any  deleterious  matter  which  might  be  floating  in 
the  blood  would  get  admixed  with  the  mammary  secretion,  but 
as  soon  as  the  woman  became  anaemic  or  got  below  par  the 
secretion  would  no  longer  be  simply  milk,  but  part  of  it  would 
be  serum  and  other  material  foreign  to  its  normal  composition. 
Whatever  floated  in  the  serum  would  find  its  way  into  the 
mammae  and  into  the  baby.  This  could  be  seen  when  we  com¬ 
pared  colostrum  with  milk.  Conditions  of  the  mother’s  milk, 
which  in  the  later  months  of  the  child’s  nursing  life  would  be 
absolutely  devoid  of  danger,  might,  immediately  after  birth  and 
while  the  milk  still  contained  colostrum,  produce  much  mis¬ 
chief.  i 

Discussing  then  the  subject  of  alcohol,  the  speaker  said  that 
the  difficulty  at  once  presented  itself  as  to  the  woman’s  exact 
condition.  Some  women  could  take  a  certain  quantity  of  spirits, 
while  a  feeble  person  taking  the  same  quantity  might  produce 
results  deleterious  to  the  baby.  It  had  been  stated  that  the 
nursing  woman  must  not  have  spirits,  but  that  she  must  have 
beer.  Most  of  those  who  insisted  upon  this  point  were  the  nurses 
themselves.  Blood  saturated  with  alcohol  could  not  be  good 
nutriment  for  the  foetus,  and  the  same  was  true  of  the  baby ; 
and  supposing  the  milk  secreted  to  be,  from  any  disturbance  in 
the  health  of  the  mother,  partly  serum,  then  alcohol  taken  by 
her  would  certainly  be  found  in  the  mother’s  milk.  It  might 
be  true  that  this  could  only  be  urged  in  the  case  of  those  who 
were  habitual  drunkards,  but  he  saw  in  the  best  families  wet- 
nurses  who  would  get  drunk,  and  who  would  in  that  way  be 
certainly  likely  to  injure  the  baby.  It  had  been  stated,  among 
other  things,  that  alcohol  increased  the  quantity  of  miik  se¬ 
creted.  This  had  been  also  denied.  There  was  only  one  reme¬ 
dy  which,  in  the  speaker’s  knowledge,  would  influence  the  se¬ 
cretion  of  miik  and  cause  its  increase,  and  that  was  salicylate 
of  sodium.  Alcohol,  when  taken,  acted  as  the  carbohydrates 
generally  did.  It  had  a  certain  amount  of  nutritive  action,  but 
when  given  in  larger  quantities  it  was  not  utilized  in  the  milk 
production.  This  disposed,  in  the  speaker’s  mind,  of  any  idea 
of  the  necessity  of  giving  malt  liquors  or  spirits.  There  might, 
however,  exist  a  necessity  for  its  use  on  general  medical  prin¬ 
ciples.  When  stimulation  was  required,  wine  or  beer  might  be 
indicated.  The  most  that  could  be  urged  in  favor  of  its  general 
use  was  that  a  small  quantity,  if  regularly  given,  would  not  be 
harmful.  If  it  was  expected  that  the  hops  in  beer  would  act  as 
a  stomachic,  it  might  be  given  with  two  or  three  of  the  meals. 
Whatever  the  carbohydrates  in  alcoholic  drinks  could  do  might 
be  done  equally  well  by  carbohydrates  administered  in  some 
other  form.  Whatever  beer  could  do  might  be  done  just  as 
well  by  milk  and  farinaceous  foods,  both  supplying  the  large 
amount  of  albumin  necessary.  A  woman  who  was  not  nursing, 


required  ninety  grammes  of  albumin  daily,  and  one  who  nursed 
one  hundred  and  sixty  grammes.  A  greater  amount  of  milk 
and  farinaceous  food  in  the  woman’s  diet  would  supply  this 
extra  seventy  or  eighty  grammes.  He  should  prefer  those  foods 
which  contained  a  large  amount  of  albuminoids,  such  as  oat¬ 
meal  and  barley. 

Dr.  E.  L.  Partridge  said  it  seemed  to  him  that  benefit  did 
arise,  or  at  least  an  increase  in  the  quantity  of  milk  might  be 
obtained,  from  the  use  of  alcohol  and  malted  liquors  given  in 
certain  ways.  Many  nursing  women  were  below  par  and  were 
probably  benefited.  This  fact  might  account  in  a  great  measure 
for  their  empirical  use.  High-pressure  nui*sing  by  the  use  of 
stimulants  was  extremely  undesirable,  and  would,  he  believed, 
determine  functional  disorders  of  the  heart  or  pelvic  organs, 
and  bring  about  injury  to  the  child.  In  cases  where  this  high- 
pressure  nursing  had  to  be  resorted  to,  it  was  better  to  make 
use  of  artificial  feeding  instead,  for  this,  properly  conducted, 
would  be  more  beneficial  at  least  to  the  child.  As  to  any  mis¬ 
chievous  influences  on  the  child  from  the  moderate  use  of  stimu¬ 
lants  in  the  mother,  he  had  been  unable  to  trace  such  in  his  ex¬ 
perience. 

Dr.  A.  Seibert  said  that  it  seemed  to  him  that  in  consider¬ 
ing  this  question  it  was  well  to  bear  in  mind  not  only  the  im¬ 
mediate  effects  of  the  alcohol  on  the  mother  and  child,  but  also 
the  bacteria  which  formed  in  some  of  the  alcoholic  beverages, 
especially  beer,  taken  by  the  mother,  and  which  he  believed 
entered  the  milk  and  then  the  stomach  of  the  infant,  causing 
intestinal  and  other  troubles. 

Dr.  E.  H.  Grandin  said  his  personal  experience  would  lead 
him  to  disagree  with  the  remarks  of  the  gentleman  who  had  last 
spoken.  He  had  never  been  able  to  trace  any  injury  to  the 
nurse  or  child  from  allowing  the  former  a  judicious  quantity  of 
malt  liquors.  As  regarded  the  neces>ity  for  the  use  of  alcohols, 
he  should  venture  to  dissent  from  the  opinion  of  Dr.  Jacobi.  He 
had  found  that  these  amemic  women  who  possessed  but  little 
true  glandular  tissue  in  the  marnmie,  and  made  such  poor 
nurses,  could  be  made  to  give  good  milk  in  fair  quantity  by  the 
judicious  administration  of  malted  liquors  in  the  form  of  ale, 
porter,  or  stout.  The  women  who  possessed  good  breasts  and 
plenty  of  milk  and  who  could  be  taught  to  nurse  their  babies  at 
regular  intervals,  he  had  not  found  in  need  of  malt  or  alcohol. 
Those  who  were  too  feeble  to  nurse  without  stimulants  he  al¬ 
lowed  to  have  it,  and  with  direct  benefit  rather  than  injury  to 
the  child,  their  use  not  only  increasing  the  quantity  but  the 
quality  of  the  milk  given.  He  had  never  seen  a  single  instance 
where  he  could  trace  any  gastro-intestinal  disturbance  to  the 
use,  in  moderation,  of  malt  liquors. 

Dr.  Jacobi  said  it  appeared  to  him  that  the  opinions  of  all 
the  gentlemen  who  had  spoken  were  about  the  same.  They 
all  agreed  that  liquors  were  unnecessary  and  mostly  injurious, 
or  that  they  ought  to  be  used,  if  at  all,  for  stomachic  or  tonic 
purposes.  If  medical  men  in  general  practice  were  guided  by 
such  opinions,  they  would  be  pretty  sure  to  do  what  was  right 
for  the  woman. 


Reports  on  |i repress  of  UJebirim. 

PHYSIOLOGY. 

Br  LOUISE  G.  RABINOVTTCH,  M.  D., 

PHILADELPHIA. 

The  Fate  of  Sugars  and  their  Effect  on  the  Organism. — M.  Alber- 

toni  {Jour,  de  med.,  chir.  et  pharm.,  No.  V,  1889)  considers  the  question 
of  the  absorption  of  sugars  which  are  ingested  in  considerable  quantities 


July  5,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


25 


as  food  to  be  important ;  it  concerns,  he  thinks,  both  physiology  and 
pathology,  as  far  as  it  relates  to  the  pathogenesis  of  diabetes. 

With  reference  to  the  absorption  of  glucose,  the  works  of  Funke, 
von  Becker,  Smith,  Meade,  Aurep,  and  Tappeiner  are  mentioned,  with 
the  objection,  however,  that  the  animals  experimented  upon  by  these 
authors  were  under  special  or  artificial  conditions,  and  that  in  general 
their  works  show  only  that  glucose  is  absorbed  in  the  gastro-intestinal 
tract,  without  specifying  the  quantity  and  limits  of  absorption,  especial¬ 
ly  in  the  normal  state  of  the  system. 

On  the  ground  of  his  experiments,  M.  Albertoni  thinks  it  is  incorrect 
to  admit  that  the  absorption  is  regulated  by  the  physical  laws  of  density 
of  liquids.  The  object  of  his  work  is  to  determine  the  rapidity  and  in¬ 
tensity  of  absorption  of  glucose  solutions  of  different  degrees  of  con¬ 
centration  introduced  into  the  gastro-intestinal  tract  under  normal  con¬ 
ditions. 

The  author  experimented  on  dogs  which  were  deprived  of  food  for 
twenty-four  hours.  The  amount  of  sugar  in  the  solution  ingested  or  in¬ 
jected,  and  the  time  that  it  remained  in  the  gastro-intestinal  tract,  hav¬ 
ing  been  known,  he  was  enabled  to  judge  of  the  amount  of  sugars  ab¬ 
sorbed  for  a  given  time  by  collecting  the  remaining  liquids  in  the  same 
tract  after  sacrificing  the  animal  and  testing  the  liquid,  previously  puri¬ 
fied,  by  means  of  different  chemical  methods. 

An  elaborate  table  of  experiments  is  given,  and  the  author  concludes 
that  the  rapidity  and  intensity  of  the  absorption  of  glucose  are  consider¬ 
ably  greater  than  they  have  been  supposed  to  be.  According  to  the 
table,  the  absorption  of  glucose  in  an  hour  amounts  to  from  sixty  to 
sixty-five  grammes,  and  during  the  subsequent  hours  the  quantity  ab¬ 
sorbed  diminishes  ;  the  explanation  of  this  is,  as  alleged,  that,  the  organ¬ 
ism  being  saturated  with  glucose  to  a  given  point,  its  absorbing  property 
for  the  glucose  diminishes. 

The  statement  as  regards  absorption  is  true  of  glucose  solutions  of 
less  as  well  as  of  greater  density  than  that  of  the  blood,  the  fact  being 
more  conspicuous,  however,  in  the  former  case.  The  sugar  solution  re¬ 
maining  in  the  stomach  unabsorbed  diminishes  always  in  density,  which 
may  become  inferior  to  that  of  the  blood,  but  is  superior  to  that  of  the 
plasma. 

The  glucose  disappears  from  the  stomach  independently  of  the 
quantity  of  water  in  which  it  is  dissolved,  and  disappears  in  greater 
quantity  than  the  water  that  holds  it  in  solution,  without  respect  to 
whether  the  solution  is  of  less  or  greater  density  than  the  water. 

It  is  probable,  Professor  Albertoni  thinks,  that  the  absorption  is  ac¬ 
complished  in  the  stomach  itself ;  it  always  contains  the  unabsorbed 
mass  of  liquid.  He  seeks  confirmation  of  the  statement  in  one  of  the 
experiments  in  which  the  vagi  were  cut  through  ;  because  of  the  in¬ 
duced  pyloric  insufficiency,  the  intestine  contained  much  more  liquid 
and  glucose  than  in  any  other  experiment. 

The  effect  of  sugars  on  the  circulation  is  under  consideration  in  the 
second  part  of  the  work,  and  this  is  stated  to  be  the  first  work  on  the 
subject. 

A.  Action  on  the  Blood-pressure. — The  author  published  his  first 
work  concerning  the  question  some  years  ago,  in  which  he  endeavored 
to  show  that  saccharose  and  glucose  injected  into  the  blood  in  moderate 
doses  augmented  the  blood-pressure,  and  that  this  was  manifested  in¬ 
stantly,  lasting  as  long  as  the  blood  contained  an  excess  of  sugar.  The 
degree  of  augmentation  of  blood-pressure  is  not  in  relation  with  the 
quantity  injected,  but  its  duration  is,  for  the  organism  needs  a  longer 
time  to  eliminate  the  excess  of  sugar. 

It  is  known  now,  the  author  alleges,  that  maltose  is  formed  at  the 
same  time  with  the  glucose,  and,  having  used  pure  maltose  in  his  ex¬ 
periments,  he  found  this  substance  to  act  like  glucose  and  saccharose. 

The  results  of  the  experiments  are  given  in  a  table  which  shows  the 
decided  augmentation  of  blood-pressure,  the  mechanism  of  which  is  ex¬ 
plained  as  follows  : 

1.  The  augmentation  of  blood-pressure  is  brought  about  neither  by 
the  influence  of  the  vaso-motor  centers  nor  by  the  action  on  the  capil¬ 
laries  themselves  ;  the  vessels  dilate  relatively  after  injection  of  glu¬ 
cose,  and  the  blood-pressure  augments  whether  a  section  is  made  of  the 
cord  beneath  the  calamus  or  of  the  cord  and  the  vagi. 

2.  The  augmentation  of  pressure  is  not  dependent  upon  paralysis  of 
the  vagi,  since  it  remains  the  same  after  section  of  these  nerves,  and, 


in  case  of  the  pressure  being  augmented  by  glucose  injections,  the 
pressure  increases  progressively  after  the  section  of  the  nerves. 

The  heart  is  the  organ  that  shares  in  this  augmentation  of  blood- 
pressure  ;  the  increased  frequency  of  the  heart-beats  is  not  the  essential 
factor  necessary  to  accomplish  this,  for  in  dogs  whose  vagi  are  cut  the 
pressure  increases  after  injection  of  glucose  without  the  pulse  becom¬ 
ing  more  frequent.  It  is  the  increased  systolic  excursion  that  main¬ 
tains  the  elevation  of  pressure.  This  fact  was  evident  from  experiments 
on  frogs  whose  heart-beats  were  obtained  by  Marey’s  apparatus.  A 
few  drops  of  a  one-per-cent,  glucose  solution  were  poured  on  the  cardiac 
muscle,  and  the  elevation  of  blood-pressure  was  most  conspicuous.  The 
reasoning  does  not  hold  good  if  the  increased  pressure  is  explained 
by  the  presence  of  an  additional  amount  of  liquid  in  the  shape  of  the 
solution  in  the  blood  ;  for,  firstly,  the  added  mass,  from  four  to  eight 
grammes,  which  suffices  to  augment  considerably  the  pressure,  is  too 
small  to  be  looked  upon  as  a  cause  of  augmentation  ;  secondly,  the 
coexisting  vascular  dilatation  would  compensate  sufficiently  for  the 
additional  liquid  mass. 

The  supposition  that  the  phenomenon  might  be  due  to  the  fever  in¬ 
duced  by  the  injection  into  the  blood  is  to  be  excluded  with  certainty, 
for  the  effects  are  instantaneous  and  last  as  long  as  there  is  an  excess 
of  sugar  in  the  blood. 

B.  The  Action  on  the  Frequency  of  the  Pulse — This  augments  with 
the  blood-pressure,  the  ratio  being  20  to  40  pulsations  a  minute,  accord¬ 
ing  to  what  animal  is  used  after  an  injection  of  from  15  to  30  grammes 
of  glucose,  maltose,  or  saccharose.  It  lasts  until  the  excess  of  sugar  is 
eliminated  from  the  blood.  This  augmentation  in  the  frequency  of  the 
pulse  is  not  met  with  in  either  rabbits  or  dogs  whose  cervical  vagi  are 
cut. 

The  author  experimented  on  human  subjects,  administering  sugar 
by  the  mouth  ;  he  concludes  that  a  slight  augmentation  in  the  frequency 
of  the  pulse  is  noticed,  which  is  manifested  more  or  less  quickly  ac¬ 
cording  to  different  accidental  and  secondary  circumstances.  In  cases 
where  there  was  nausea  the  pulse  failed  to  become  more  frequent. 

The  foods,  the  author  concludes,  containing  starches  and  sugar  have 
certainly  an  analogous  action  on  the  organism,  and  this  explains  certain 
physiological  phenomena  subsequent  to  meals. 

C.  Action  on  the  Blood-vessels  and  the  Velocity  of  the  Circulation. — 
The  action  of  glucose  on  the  vessels  is  determined  by  observing  the 
change  in  volume  of  the  organs,  and  the  quantity  of  blood  flowing  out 
from  an  opened  vessel  in  a  unit  of  time. 

That  sugar  dilates  the  blood-vessels  was  inferred  from  the  augmen¬ 
tation  of  the  limbs  in  volume ;  this  was  verified  by  means  of  Roy’s 
apparatus,  and  the  quantity  of  blood  shed  from  a  given  vessel  in  a  unit 
of  time  was  double  the  normal.  The  rapidity  of  the  circulation  was 
decidedly  increased. 

I).  The  Influence  of  Sugars  on  the  Urinary  Secretion. — A  number 
of  authors,  it  is  said,  are  of  the  opinion  that  in  diabetes  the  extraordi¬ 
nary  increase  of  the  amount  of  urine  is  dependent  upon  the  elimination 
of  sugar ;  special  researches  on  the  subject  have  been  made  only  recently 
by  Richet,  Moutard-Martin,  and  the  author  himself.  According  to  Richet 
and  Moutard-Martin,  a  small  amount  of  sugar  in  the  blood — 050  gramme 
to  the  animal’s  kilogramme  of  weight — is  sufficient  to  induce  a  notice¬ 
able  polyuria.  It  is  not  to  be  attributed  to  the  water  absorbed  with  the 
solution,  for  ten  times  the  volume  of  pure  water  injected  will  not  pro¬ 
duce  the  same  effect. 

The  author  professes  to  have  investigated  the  question  before  the 
authors  named  ( Giomal .  di  quest,  acc .,  v.  v,  xxix,  p.  178),  and  to  have 
endeavored  to  point  out  that  the  duration  and  intensity  of  the  induced 
polyuria  varied  according  to  the  quantity  of  sugar  injected.  The  poly¬ 
uria  and  glycosuria  are  not  dependent  upon  spinal  irritation,  which 
might  give  similar  results  y  the  same  phenomena  are  observed  in  dogs 
with  the  spinal  cord  divided  below  the  calamus. 

Neither  is  the  fact  to  be  attributed  to  the  increased  blood-pressure, 
for  the  same  is  the  case  in  rabbits,  which  present  no  modification  of 
blood-pressure. 

The  dilatation  of  the  renal  vessels  and  the  increased  rapidity  of  the 
circulation  determined  by  the  glucose  are  said  to  account  partly  for  the 
polyuria.  Besides  the  indications  of  these  facts  by  the  angeiometer, 
there  is  some  special  effect  of  the  sugar  on  the  uriniferous  tubules. 


26 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jodr., 


Munk  is  quoted  as  having  shown  on  an  isolated  kidney  that  the  ad¬ 
dition  of  a  half  per  cent,  of  sugar  to  the  blood  led  to  the  production 
of  eight  times  the  normal  amount  of  urine. 

Maltose  is  assimilated  in  the  same  proportion  as  glucose ;  this  is  in 
accordance  with  the  results  of  Dastre  and  Bourquelot. 

Morphine  and  chloral  interfere  with  the  effects  of  sugar  on  the  cir¬ 
culation,  and  have  but  little  influence  on  the  polyuria  and  glycosuria. 
Since  these  drugs  are  used  in  diabetes,  their  effect  was  tested  by  ad¬ 
ministering  them  before  injecting  the  sugar  in  small  doses.  They 
seemed  to  check  the  polyuria  and  glycosuria  to  some  degree,  but  this 
was  not  the  case  when  large  doses  of  sugar  were  given. 

The  experiments  show  that  sugars  are  not  only  foods,  but  at  the 
same  time  agents  modifying  the  functional  actions  of  the  organism. 
Sugars  entering  the  blood  after  meals  affect  the  circulation  in  a  way 
opposite  to  the  enfeebling  action  of  some  albuminoid  derivatives  of 
peptones  that  can  be  formed  in  the  process  of  digestion  (the  peptin  of 
Albertoni,  the  peptonin  of  Brieger). 

Cohnheim  is  quoted  as  saying  that  the  accumulation  of  sugar  in  the 
blood  is  the  center  of  all  the  phenomena  of  diabetes,  and  it  is  presumed 
that  the  same  phenomena  may  be  induced  artificially  by  injecting  sugar 
into  the  blood.  The  quantitative  modifications  of  the  urinary  secretion 
and  the  changes  in  the  circulatory  apparatus  are  equally  produced  and 
are  transitory  in  diabetic  patients. 

It  remains  to  decide,  the  author  remarks,  what  the  reasons  are  for 
the  accumulation  of  glucose  in  the  blood  of  diabetic  patients. 

Some  Results  of  Sphygmometric  Experiments. — After  the  descrip¬ 
tion  of  his  sphygmometer  and  the  conveniences  of  its  use,  M.  A.-M.  Bloch 
( Comptes  rendus  de  la  soc.  debiol.,  No.  26,  1889)  mentions  the  precau¬ 
tions  necessary  for  obtaining  accurate  results,  and  represents,  in  figures 
that  are  of  relative  more  than  of  absolute  value,  the  following  results 
of  the  experiments  on  his  own  person  relating  to  the  influence  of  in¬ 
gested  food  on  the  arterial  tension : 

Arterial  tension. 


7.00  p.  m.  (immediately  before  dinner) .  575  grammes. 

7.30  “  (immediately  after  dinner)  .  575  “ 

7.45  “  675  “ 

8.00  “  750  “ 

8.20  “  . '725  “ 

8.45  “  650  “ 

9.00  “  700  “ 

9.15  “  650  “ 

9.30  “  625  “ 

10.30  “  575  “ 


The  increase  of  arterial  tension  after  meals  is  especially  noticeable 
if  coffee  is  taken  at  that  time. 

The  table  shows  a  rapid  augmentation  of  arterial  pressure  during 
the  hour  following  meals ;  then  there  is  gradual  fall  to  the  initial  stand¬ 
ard  after  the  lapse  of  about  three  hours.  The  700-gramme  pressure 
found  at  nine  o’clock  is  thought  to  depend  upon  some  respiratory  or 
other  accident,  investigation  of  which  has  not  been  made. 

In  the  following  table  the  author  represents  more  striking  results  : 

11.45  a.  m .  550  grammes. 

1.00  p.  m.  (immediately  after  meals,  coffee  included).. . .  625  “ 

1.30  “  650  “ 

1.45  “  800  “ 

2.15  “  775  « 

3.00  “  550  “ 

This  shows  augmentation  of  arterial  tension  beginning  after  meals, 
continuing  the  hour  following,  and  attaining  800  grammes,  to  reach  to 
the  initial  figure  550  at  3  p.  m.  Moderate  gymnastic  exercise  is  stated 
to  lower  arterial  pressure,  and  after  the  augmentation  the  initial  stand¬ 
ard  of  arterial  pressure  is  reached  at  a  shorter  period  if  exercise  is 
taken  after  meals. 

It  is  further  suggested  that  the  least  irregularity  in  the  respiration 
is  very  apt  to  modify  the  results  profoundly,  though  this  is  only  for  a 
short  time.  The  author  confirms  the  statement  by  having  obtained  an 
arterial  pressure  of  625  grammes  at  the  time  of  violent  effort,  and  that 
of  800  grammes  immediately  after  the  exertion. 

In  conclusion,  the  statement  is  made  that,  for  the  purpose  of  ob¬ 


taining  correct  pressure-records  in  the  sick,  it  is  necessary  to  take 
strictly  into  consideration  the  hour  of  the  day,  the  ingestion  of  food,  and 
the  physical  exertion  that  preceded  the  sphygmometrical  operation. 
The  respiration  is  to  be  inspected  carefully  during  the  experiment ;  of 
much  importance  is  the  attitude  of  the  patient ;  it  must  be  absolutely 
the  same  whether  the  results  are  to  be  compared  with  those  found  in 
the  normal  person  or  in  the  patient  himself. 

Electrical  Discharges  of  the  Human  Skin  under  the  Influence  of 
Different  Forms  of  Psychical  Activity  and  of  Excitation  of  the  End  Or¬ 
gans. — Professor  Jean,  of  Tarchanoff  (ibid.)  describes  the  method  of 
observation  in  his  experiments  by  means  of  either  Meissner’s  or  Wiede¬ 
mann’s  galvanometer.  After  mentioning  the  necessity  of  securing  per¬ 
fect  tranquillity  of  the  subject  and  quiescence  in  the  operating-room, 
he  summarizes  the  results  under  the  following  sections : 

1.  Excitation  of  the  Sense  Organs. — Any  slight  irritation  is  apt,  after 
a  latent  period  of  from  one  to  three  seconds,  to  bring  about  a  cutaneous 
current  that  develops  and  increases  gradually ;  its  existence  is  indi¬ 
cated  by  the  deviation  of  the  galvanometric  needle.  The  direction  of 
the  current  indicates  that  the  cutaneous  regions,  rich  in  sudoriparous 
glands — such  as  the  palm  of  the  hand  and  the  sole  of  the  foot — become, 
during  the  period  of  excitation,  negative  in  comparison  with  parts  poor 
in  the  same  glands.  In  the  hand,  as  well  as  in  the  foot,  an  ascending 
cutaneous  current  is  developed ;  it  persists  for  a  considerable  period, 
several  minutes  after  which  time  it  declines  by  a  gradually  diminishing 
curve  of  oscillations.  Frequent  repetition  of  the  excitation  leads  to  final 
non-responsiveness.  The  same  results  are  obtained  when  the  agent  of 
excitation  is  electricity,  thermic  or  painful  impressions,  the  sound  of  an 
electric  bell,  the  visual  impression  of  light,  or  odorous  substances  acting 
on  the  corresponding  organ  of  perception.  Under  the  various  conditions 
the  difference  of  the  manifestation  of  the  cutaneous  electric  current  is 
quantitative  and  not  qualitative.  The  manifestation  of  the  current,  the 
author  thinks,  depends  upon  the  activity  of  the  sudoriparous  glands,  for 
the  reason  that  the  current  is  insignificant  in  regions  where  these  glands 
are  scarce. 

2.  Psychical  Representation  of  Different  Sensations  and  Emotions. — 
Imagination  of  any  irritation,  warmth,  pain,  joy,  etc.,  is  sufficient  to  make 
the  applied  galvanometer  indicate  development  of  an  electrical  cutaneous 
current  that  often  even  surpasses  in  intensity  that  obtained  by  imme¬ 
diate  and  real  excitation.  The  kind  of  imaginary  excitation  has  some¬ 
thing  to  do  with  the  intensity  of  the  current,  thus  :  The  current  is  of 
greater  intensity  when  a  feeling  of  warmth  than  when  that  of  cold  is 
imagined. 

3.  Intellectual  Work. — The  intensity  of  the  cutaneous  current  caused 
by  mental  work  is  in  proportion  to  the  difficulty  with  which  the  same 
is  performed.  The  marked  influence, of  mental  work  on  the  manifes¬ 
tation  of  the  cutaneous  current  is  evident  from  the  fact  that,  in  cases  of 
subjective  exhaustion,  or  overexcitation,  when  artificial  irritation  re¬ 
mains  fruitless  in  causing  the  current,  the  latter  appears  readily  in  case 
the  person  in  question  is  made  to  perform  hard  mental  work,  such  as 
solving  a  difficult  arithmetical  problem. 

A  person  in  a  condition  of  expectant  attention,  it  is  remarked,  is 
unsuitable  for  experimentation,  since  this  condition  causes  the  galva¬ 
nometric  needle  to  be  in  constant  oscillation. 

4.  Voluntary  Muscular  Innervation. — Each  muscular  contraction  is 
followed  by  a  cutaneous  current  over  the  entire  body.  That  not  the 
muscular  contraction  itself,  but  the  voluntary  psychical  effort  used  for 
the  accomplishment  of  the  latter,  is  the  immediate  cause  of  the  current 
the  author  proves  by  the  fact  that  a  voluntary  movement  of  a  toe  is 
sufficient  to  excite  a  cutaneous  current  in  the  hand,  which  continues 
even  after  the  toe  is  perfectly  immobilized,  and  the  intensity  of  this 
current  is  in  proportion  to  the  degree  of  the  voluntary  effort  used. 

The  conclusion  follows  that  all  nervous  and  psychical  efforts  in  man 
are  accompanied  by  electrical  cutaneous  phenomena,  or  discharges,  that 
represent  the  physical  manifestation  of  the  cutaneous  glandular  ac¬ 
tivity  always  going  on  during  nervous  or  psychical  function.  Accord¬ 
ing  to  the  author,  the  glandular  system  plays  the  role  of  a  thermic  and 
chemical  regulator.  In  fact,  he  says,  each  nervous  or  psychical  act  is 
the  source  of  an  increase  of  heat  and  of  products  of  disintegration,  car¬ 
bon  dioxide  being  one  of  those  that  must  be  eliminated.  The  sudori¬ 
parous  cutaneous  glands  participating  in  all  nervous  and  psychical 


July  5,  1890.] 

functions  diminish,  at  the  same  time,  the  body  temperature,  augment 
evaporation,  and  in  this  way  free  the  body  from  the  different  products 
of  disintegration,  the  accumulation  of  which  would  do  harm  to  the 
organism. 

It  is  to  be  admitted  that  there  is  an  intimate  anatomical  correlation 
between  the  nervous  centers  of  sensorial,  psychical,  and  voluntary  motor 
activity  and  the  nervous  centers  of  the  cutaneous  and  other  glands ; 
and  that  the  cutaneous  glandular  apparatus  is  the  safety-valve  against 
exaggerated  body  heat  and  harmful  products  of  accumulation  that  result 
from  nervous  and  psychical  activity. 

The  Precritical  Discharges  in  Acute  Diseases. — M.  Albert  Robin 
(idem,  No.  15,  1889)  professes  to  have  demonstrated  the  following 
before  the  appearance  of  MM.  Roger  and  Gaume’s  work  relating  to  the 
same  question : 

In  typhoid  fever  the  organism  is  the  seat  of  retention  of  toxic  prod¬ 
ucts  ;  the  degree  of  retention  is  in  proportion  to  the  gravity  of  the 
disease ;  the  defervescence,  and  even  the  convalescence,  is  subordinate, 
in  the  majority  of  cases,  to  the  true  discharge  of  the  toxic  products. 

The  reality  of  the  retention  has  been  proved  by  the  following  facts  : 

1.  Extractive  matter  in  the  blood  is  in  direct  proportion  to  the  grav¬ 
ity  of  the  disease.  In  benign  forms  of  disease  the  quantity  of  the  ex¬ 
tractive  ingredients  in  the  blood  is  always  higher  than  under  normal 
conditions. 

2.  Diminution  of  the  urinary  extractives  coincides  with  augmenta¬ 
tion  of  the  blood  extractives,  and  at  the  same  time  with  aggravation  of 
he  disease. 

The  subordination  of  the  critical  phenomena  to  the  urinary  dis¬ 
charges  the  author  demonstrates  as  follows  : 

1.  The  urinary  eliminations  follow  an  ascending  course,  beginning 
with  the  attack;  if  50  grammes,  on  an  average,  are  excreted  during  the 
period  of  the  attack,  there  are  56-50  grammes  during  the  period  of  de¬ 
fervescence,  and  60'13  grammes  during  the  period  of  convalescence. 

2.  All  phenomena  of  a  critical  character  are  accompanied  by  an  ex¬ 
cess  of  eliminated  urinary  solids.  To  decide  whether  the  eliminated 
sweat  during  an  attack  is  indifferent  or  critical,  it  suffices  to  find  out 
whether  there  is  diminution  or  augmentation  of  the  quantity  of  urine 
and  its  solids ;  diminution  shows  that  it  is  indifferent,  and  a'  gmentation 
that  it  is  critical  sweat. 

3.  The  first  thermic  signs  of  defervescence  are  preceded,  in  75  out 
of  100  cases,  by  an  augmented  elimination  of  urinary  solids  ;  this  takes 
place  twenty-four  hours  before  defervescence.  In  23  out  of  100  cases 
this  augmented  elimination  continued  during  the  first  day  of  deferves¬ 
cence.  In  24  out  of  100  cases  it  preceded  the  period  of  defervescence  for 
from  forty-eight  to  Seventy-two  hours.  It  was  absent  in  eighteen  per 
cent,  only,  of  which  six  per  cent,  belonged  to  cases  of  benign  relapses 
during  the  course  of  a  benign  attack  ;  eight  per  cent,  belonged  to  very 
mild  forms,  and  four  per  cent,  to  intermediate  types.  If,  instead  of 
taking  a  hundred  typhoid  cases  in  general,  the  same  number  of  grave 
cases  is  considered,  the  author  says  he  has  demonstrated  that  the  dis¬ 
charges  he  calls  precritique  are  observed  to  be  constant.  Aside  from 
the  importance  of  these  discharges  from  the  physio-pathological  stand¬ 
point  of  the  crisis,  their  precritical  existence  may  be  a  clinical  guide  in 
the  prognosis,  for  often  the  classical  signs  of  defervescence  are  pre¬ 
ceded  by  it  several  days  in  advance. 

4.  A  more  or  less  sudden  abortion  of  a  grave  attack  of  typhoid 
fever  is  the  consequence  of  a  brisk  elimination  of  the  debris  of  organic 
disintegration. 

5.  The  period  of  convalescence  includes,  too,  a  precritical  discharge, 
for  in  seventy-five  per  cent,  of  typhoid  cases  the  quantity  of  eliminated 
disintegrated  matter  was  augmented  about  twenty-four  hours  before 
the  time  when  the  evening  and  morning  temperature  did  not  go  higher 
than  38°  C. 

6.  The  elimination  of  creatin  does  not  reach  its  maximum  until  the 
third  or  fourth  week  of  the  disease.  The  maximum  is  often  found  at 
the  time  of  the  subsidence  of  the  grave  symptoms. 

7.  Elimination  is  performed  by  the  kidneys,  which  are  assisted  by 
the  same  process  in  other  organs. 

8.  In  ordinary  forms  of  typhoid  fever  the  waste  elimination  is  a 
progressively  ascending  one  in  the  various  successive  periods ;  this  is 
not  the  case  in  fever  with  relapses,  which  leads  one  to  infer  that  the  re- 


27 

lapse  occurs  because  of  the  imperfect  waste  excretion  during  the  first 
subsidence. 

9.  The  critical  influence  of  certain  intestinal  hemorrhages  and  that 
of  epistaxis  seem  to  be  destined  to  excrete  poisonous  matter  from  the 
circulatory  system  briskly. 

The  author’s  experiments  related  to  typhoid  fever  and  other  acute 
diseases,  in  all  of  which  the  waste  excretion  was  found  to  be  reduced. 

In  conclusion,  the  author  says  that  the  so-called  typhoid  state,  being 
of  much  importance  in  the  prognosis  of  the  disease,  is  caused  by 
retarded  excretion  of  waste  matter;  this  is  due  either  to  an  excessive 
production  or  to  an  absolute  or  relative  insufficiency  of  excretion.  It 
is  an  external  expression  of  the  self-intoxication  from  what  he  formu¬ 
lates  as  augmented  disintegration,  diminished  oxidation  with  retention 
of  waste  products. 

The  importance  that  he  ascribes  to  his  researches  is  that  they  en¬ 
able  one  to  institute  a  mathematically  rational  treatment  in  the  different 
periods  of  the  acute  diseases.  To  the  author  himself  this  guide  has 
proved  of  good  service  at  the  bedside.  The  results  were  communicated 
to  the  Biological  Society  in  1886. 


Jfitstfllang. 


The  American  Society  of  Microscopists  will  hold  its  next  meeting  in 
Detroit,  on  the  12th,  13th,  14th,  and  15th  of  August. 

The  general  session  for  the  reading  of  papers  will  be  held  in  the  new 
building  of  the  Detroit  College  of  Medicine,  corner  of  St.  Antoine  and 
Catherine  Streets  and  Gratiot  Avenue. 

The  Mayor  of  Detroit  will  deliver  the  address  of  welcome,  to  be  fol¬ 
lowed  by  the  response  of  the  president  of  the  society.  The  Tuesday  af¬ 
ternoon  session  will  be  devoted  to  the  reading  of  papers  and  society 
business.  In  the  evening  a  conversazione  will  be  held  at  hotel  head¬ 
quarters.  On  Wednesday  evening  the  president  will  read  his  annual 
address,  on  The  Influence  of  Electricity  on  Protoplasm.  The  Thursday 
afternoon  session  will  be  devoted  to  the  various  technological  features 
of  microscopy,  such  as  the  preparing,  staining,  and  mounting  of  speci¬ 
mens,  section-cutting,  manipulative  methods,  etc.  In  the  evening  there 
will  be  an  exhibition  of  microscopes  and  objects,  popular  in  character 

The  programme  includes  the  following  titles  :  Micrometry,  by  Pro¬ 
fessor  William  A.  Rogers,  of  Waterville,  Me.;  Uniformity  in  Tube 
Length,  by  Professor  Simon  H.  Gage,  of  Ithaca,  N.  Y. ;  Fees  of  Experts 
with  the  Microscope,  by  C.  M.  Yorce,  Esq.,  of  Cleveland,  Ohio ;  The 
Full  Utilization  of  the  Capacity  of  the  Microscope,  and  Means  of  obtain¬ 
ing  the  Same,  by  Edward  Bausch,  Esq.,  of  Rochester,  N.  Y.  ;  The 
Structure  of  Protoplasm,  and  Microscope  Objectives,  by  Professor  T.  J 
Burrill,  of  Champaign,  Ill.  ;  Abnormal  Forms  in  the  Diatoms,  and  Con¬ 
clusions  therefrom,  and  Review  of  Some  of  the  Generic  and  Specific  Dis¬ 
tinctions  in  the  Family  Coscinodiscece,  by  the  Hon.  Jacob  D.  Cox  of 
Cincinnati ;  The  Microscopic  Identification  of  Hair,  The  Effect  of  Curva¬ 
ture  of  the  Cover  Glass  upon  Micrometry,  Description  of  Scale  (5),  manu¬ 
factured  by  Marshall  D.  Ewell,  in  pursuance  of  Resolution  of  A.  S.  M. 
adopted  in  1889,  A  New  Form  of  Stage  Micrometer,  Some  Experiments 
to  Determine  the  Limit  of  Vision  as  Related  to  the  Size  of  the  Object 
observed,  and  A  Review  of  Some  of  the  Medico-legal  Questions  in¬ 
volved  in  the  Cronin  Case,  by  Professor  Marshall  D.  Ewell,  of  Chicago  ; 
Observations  on  the  Blood  in  Health  and  Disease,  by  Dr.  Simon  Flex- 
ner,  of  Louisville  ;  The  Transition  from  Columnar  to  Stratified  Epithe¬ 
lium,  and  Picric  and  Chromic  Acid  for  the  Rapid  Preparation  of  Tissues 
for  Classes  in  Histology,  by  Professor  Gage  ;  The  Rotifera  of  Central 
Michigan,  and  Recent  Methods  of  investigating  Microscopical  Animals, 
by  Professor  D.  S.  Kellicott,  of  Columbus,  Ohio  ;  Some  Methods  of 
treating  Nerve  Tissue,  by  Dr.  William  C.  Krauss,  of  Buffalo  ;  An  In¬ 
fallible  Method  of  preparing  Injecting  Gelatin  and  injecting  Small  Ani¬ 
mals,  and  Observations  on  Mounting,  by  Dr.  R.  N.  Reynolds,  of  Detroit ; 
Resume  of  the  Past  Year’s  Advance  in  Microscopy,  by  Dr.  Lee  H. 
Smith,  of  Buffalo  ;  and  A  New  Flash  Light  in  Photography  as  applied 
to  Microscopy,  Postal  Cards  and  Vegetable  Fibers,  The  Possibilities  of 


MISCELLANY. 


28 


MISCELLANY. 


[N.  Y.  Med.  Joor. 


the  James  Cement,  with  Many  Fine  Specimens,  by  Dr.  Thomas  Taylor, 
of  Washington. 

Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  June  27th : 


CITIES. 

Week  ending- 

Estimated  poj 
lation. 

Total  deaths  i 
all  causes 

Cholera.  1 

|  Yellow  fever. 

H 

z 

O. 

r 

Varioloid. 

Varicella. 

Typhus  fever. 

Enteric  fever.  ^ 

Scarlet  fever.  | 

Diphtheria.  1 

Measles. 

Whooping- 

cough. 

New  York,  N.  Y . 

June  21. 

1,617,000 

773 

3 

11 

09 

10 

Q 

Chicago,  Ill . 

June  21. 

Lioo'ooo 

292 

°7 

i 

7 

9 

l 

Philadelphia,  Pa . 

May  31 . 

L064,277 

482 

H 

1 

q 

3 

O 

Brooklyn,  N.  Y . 

June  21. 

'859,612 

370 

1 

5 

15 

3 

2 

Baltimore,  Md . 

June  21. 

500,343 

254 

4 

1 

0 

2 

Boston,  Mass . 

June  21. 

420,000 

166 

3 

5 

~T 

Cincinnati,  Ohio . 

June  20. 

325,000 

146 

1 

3 

5 

New  Orleans,  La. . . . 

June  14. 

254,000 

173 

1 

9 

1 

Detroit,  Mich . 

June  14. 

250,000 

68 

o 

1 

9 

Washington,  D.  C  .. . 

June  21. 

250,000 

121 

1 

Cleveland,  Ohio . 

May  31. 

2101.31  C 

86 

6 

1 

1 

1 

Cleveland,  Ohio . 

June  7. 

240,310 

116 

7 

1 

1 

2 

Milwaukee,  Wis . 

June  21. 

240,000 

63 

3 

6 

Pittsburgh,  Pa . 

June  21. 

240,000 

159 

9 

9 

12 

Louisville,  Ky . 

June  21. 

227,000 

74 

3 

Newark,  N.  J . 

June  14. 

197,360 

71 

i 

3 

2 

Kansas  City,  Mo . 

June  21. 

180,000 

58 

3 

9 

1 

Denver,  Col . 

June  20. 

150’000 

52 

9 

1 

Providence,  R.  1 . 

June  21. 

130J100 

45 

1 

'2 

Indianapolis,  Ind.... 

June  20. 

129,346 

35 

Toledo,  Ohio . 

June  21. 

92,000 

29 

i 

7 

Fall  River,  Mass . 

June  21. 

69,000 

17 

Nashville,  Tenn . 

June  21. 

68, .531 

34 

2 

Charleston,  S.  C . 

June  21. 

60,145 

1 

i 

1 

¥ 

Manchester,  N.  H _ 

June  21. 

43,000 

Portland,  Me . 

June  21. 

42,000 

13 

1 

Binghamton,  N.  Y\  . . 

June  21. 

35,000 

10 

1 

Yonkers,  N.  Y . 

June  20. 

31,000 

12 

Auburn,  N.  Y . 

June  21. 

26,000 

14 

2 

Newton,  Mass . 

June  14. 

22,011 

7 

Newton,  Mass . 

June  21. 

22,011 

5 

Rock  Island,  Ill . 

June  15. 

16,000 

4 

1 

Pensacola,  Fla . 

June  14. 

15,000 

t> 

u 

1 

i 

Foreign  and  American  Brandy. — In  the  course  of  an  editorial  reply 
to  an  inquiring  correspondent,  The  Sanitarian  for  June  says : 

“  Pure  brandy  has  the  distinctive  odor  of  the  essential  oil  of  grapes, 
huile  de  Cognac.  But  the  misfortune  is  that  this  oil  is  largely  used  to 
Counterfeit  brandy  by  giving  odor  to  other  distillations.  Moreover,  in 
France  especially,  brandy  is  frequently  distilled  from  poor  wine  or  the 
juice  of  bad  grapes,  such  as  have  failed  in  maturing  or  become  acid 
and  unfit  for  wine — or  anything  else.  It  seems  almost  needless  to  re¬ 
mark  that  all  such  brandy  is  of  poor  quality — no  matter  how  exqui¬ 
sitely  it  may  be  flavored — but  it  is  abundant.  Time  is  an  essential 
element  in  the  production  of  good  wine  and  brandy  alike — time  after 
fermentation  and  distillation  required  for  the  combination  of  the  con¬ 
tained  ethers  and  essential  oils  produced  by  fermentation  and  distilla¬ 
tion.  But,  besides,  there  is  an  acquired  art  in  regulating  the  distilla¬ 
tion  of  brandy,  the  flavor  being  influenced  by  the  greater  or  less  rapid¬ 
ity  of  conducting  the  process.  When  this  is  lacking,  as  it  too  often  is 
under  inexperienced  manufacturers,  the  product  is  of  inferior  quality 
and  subjected  to  such  additional  treatment  as  may  improve  the  flavor 
but  aggravate  the  quality.  English  brandy  is  usually  prolific  in  fusel 
oil.  The  foregoing  remarks  apply  more  or  less  to  all  imported  wines 
and  liquors ;  substitution  and  adulteration  are  common  practices,  and 
the  difficulty  in  obtaining  those  that  are  pure  is  greater  than  it  is 
among  American  manufacturers.  Indeed,  it  has  long  since  been  dem¬ 
onstrated  that  almost  everywhere  south  of  the  fortieth  degree  of  lati¬ 
tude  in  the  United  States  the  soil  and  climate  are  well  adapted  to  the 
cultivation  of  the  vine ;  and  forty  years’  experience  in  California  par¬ 
ticularly,  since  Longworth  so  successfully  exhibited  the  results  of  even 
a  less  favored  region,  there  has  been  no  lack  of  ambitious  manufactur¬ 
ers,  until  some  of  our  domestic  wines  and  brandies  will  favorably  com¬ 
pare  with  even  the  choicest  importations.  True  it  is,  as  above  implied, 
that  the  different  conditions  of  climate — not  always  appreciable — sea¬ 
son,  and  soil,  the  different  modes  of  culture  of  the  vine,  the  different 
management  in  the  processes  of  fermentation  and  distillation,  and  the 
different  means  of  preserving  both  fermented  and  distilled  liquors — all 
contribute  to  the  results.  But  the  Californians  have  not  been  slow  in 
the  acquisition  of  all  such  knowledge,  and  it  is  now  concentrated  to 


such  a  degree  that  they  can  well  afford  to  challenge  comparison.  Judged 
by  samples,  of  which  we  have  availed  ourselves  of  the  opportunity  to 
examine,  the  wines  and  stronger  liquors  sold  by  the  California  Vintage 
Company,  New  York,  will  compare  favorably  with  the  same  varieties 
from  any  other  source.” 


ANSWERS  TO  CORRESPONDENTS. 

No.  323. — We  do  not  understand  that  the  requirements  of  the  act 
apply  to  physicians  already  in  practice  in  the  State. 

No.  32j. — The  action  of  the  two  drugs  is  not  antagonistic. 

No.  325. — Two  specimens  of  the  urine  are  examined  at  the  same 
time.  Yeast  is  added  to  one  of  them,  and  the  bottle  is  corked  loosely 
and  kept  in  a  warm  place  for  twenty-four  hours.  The  other  one  is  kept 
at  the  same  temperature,  but  without  the  addition  of  yeast.  Then  the 
specific  gravity  of  each  of  the  specimens  is  taken,  when  it  will  be  found 
that  the  fermented  specimen  has  lost  in  density,  and  each  degree  of 
density  lost  represents  the  original  presence  of  a  grain  of  glucose  in 
each  fluidounce  of  the  urine.  For  example,  if  the  specific  gravity  of 
the  unfermented  specimen  is  P030,  and  that  of  the  fermented  specimen 
1'020,  the  urine  contained  ten  grains  of  glucose  in  each  fluidounce. 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed :  (1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal ,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  typesetters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  tfy?y  may  be  creditable  to  their  authors ,  are 
not  suitable  for  publication  in  this  journal ,  either  because  they  are 
too  long ,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases ,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters ,  whether  intended  for  publication  or  not ,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor ,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  bicsiness  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  July  12,  1890. 


<$ rtgina l  (Commumniti on s. 


ACCIDENTAL  SUFFOCATION 
AS  A  CAUSE  OF  SUDDEN  DEATH* 

By  HERMANN  M.  BIGGS,  M.D.,  and 
WILLIAM  T.  JENKINS,  M.  D., 

coroner’s  physician. 

The  subject  of  sudden  death  and  its  causes  does  not 
often  receive  from  physicians  much  consideration,  largely, 
perhaps,  because  they  are  accustomed  to  consider  that  their 
responsibility  has  reached  an  end  when  death  has  occurred, 
or  at  least  in  these  cases  the  responsibility  is  then  delegated 
to  the  proper  officials. 

Something  more  than  a  year  ago  one  of  us  published  a 
paper  directing  especial  attention  to  one  of  the  most  fre¬ 
quent  causes  of  sudden  death,  and  one  which  has  received 
but  insufficient  recognition — viz.,  the  rupture  of  aortic 
aneurysms.  In  that  paper  attention  was  called  to  the  in¬ 
frequency  of  the  determination  of  the  cause  of  sudden  death 
by  physicians  other  than  the  coroners’  physicians.  In  cases 
of  sudden  death  among  the  poorer  classes  the  physician 
who  may  be  called  does  not  interest  himself  sufficiently  in 
the  case  to  request  an  autopsy,  and  among  the  better 
classes,  even  if  the  physician  desires  an  examination,  the 
friends  usually  object  to  its  being  made.  The  prevailing 
opinion  among  physicians  is  that  the  cause  of  sudden  death 
in  a  large  proportion  of  instances  is  some  form  of  heart 
disease  (especially  disease  of  the  myocardium)  or  cerebral 
haemorrhage,  and  to  one  of  these  causes  death  in  such  cases 
is  usually  ascribed. 

We  desire  in  this  paper  to  direct  attention  to  the  fre¬ 
quency  of  accidental  suffocation  as  a  cause  of  sudden  death 
and  to  report  a  series  of  cases,  some  of  which  have  consid¬ 
erable  interest  because  of  their  uniqueness. 

In  children  it  appears  to  us  that  no  other  cause  com¬ 
pares  with  this  in  frequency  in  the  production  of  sudden 
death,  and  among  adults  it  is  far  more  common  than  is 
generally  supposed.  Excepting  in  those  cases  of  accidental 
suffocation  where  death  results  from  the  lodgment  of  for¬ 
eign  bodies  in  the  air-passages,  the  cause  of  death  must 
often  be  determined  by  the  detailed  history,  obtained  only 
after  careful  questioning  of  the  friends,  by  the  external  ap¬ 
pearances  of  the  body,  by  the  general  evidences  of  death 
from  suffocation,  found  in  the  internal  organs,  and  by  the 
absence  of  any  other  determining  cause  for  death. 

In  many  cases  the  history,  if  carefully  drawn  out,  will 
show  that  the  subject  was  an  epileptic  or  an  alcoholic  and 
was  found  lying  on  the  face  dead.  If  the  subject  is  an  in¬ 
fant,  the  history  will  probably  show  that  the  position  in 
which  the  child  was  found  was  such  that  there  was  obstruc¬ 
tion  in  some  way  of  the  openings  of  the  mouth  and  nares. 
It  is  very  painful  to  the  mother  and  often  quite  unneces¬ 
sary  to  bring  out  this  fact  too  clearly. 

The  external  appearances  are  often  of  great  value  in  de¬ 
termining  the  cause  of  death.  In  death  from  suffocation 
© 


the  blood  usually  remains  fluid,  and  suggillation  is  very 
much  marked.  The  position  of  the  livor  mortis  on  the  an¬ 
terior,  posterior,  or  lateral  surfaces  of  the  body  often  gives 
the  key  at  once  to  the  posture  of  the  body  at  the  time  of 
death,  and  its  absence  at  certain  points  on  these  surfaces 
indicates  the  points  of  pressure  here,  and  sometimes  from 
the  stamp  thus  produced  on  the  soft  parts  the  character  of 
the  object  producing  the  pressure  may  be  determined.  In¬ 
ternally  the  blood  is  found  to  be  fluid,  the  heart  is  in  dias¬ 
tole,  the  lungs  and  bronchial  mucous  membrane  are  deeply 
congested,  there  are,  perhaps,  petechial  haemorrhages  in  the 
pleura  and  the  pericardium,  and  there  is  a  general  congestion 
of  the  abdominal  organs.  The  history  in  such  cases,  with 
the  external  and  internal  appearances  just  detailed,  point  in 
the  most  unmistakable  manner  to  death  from  suffocation. 

The  illustrative  cases  reported  in  this  paper,  as  well  as 
all  those  upon  which  it  is  based,  occurred  in  the  services  of 
the  coroners’  physicians,  and,  with  one  or  two  exceptions, 
all  occurred  in  the  service  of  Dr.  Jenkins. 

Cases  of  accidental  suffocation,  for  convenience,  may  be 
grouped  under  the  following  heads  : 

1.  Accidental  suffocation  produced  by  the  lodgment  of 
foreign  bodies  in  the  larynx  or  trachea. 

2.  Cases  of  accidental  suffocation  of  infants  by  obstruc¬ 
tion  of  the  mouth  and  nares. 

3.  Accidental  suffocation  in  epileptics  during  convul¬ 
sions  and  in  alcoholic  subjects  during  intoxication. 

4.  Various  other  causes  producing  closure  of  the  air-pas¬ 
sages,  including  submersion,  inhumation,  strangulation,  etc. 

This  fourth  class  of  cases  will  not  be  considered  in  this 
paper. 

The  cases  grouped  under  the  first  head,  the  lodgment  of 
foreign  bodies  in  the  larynx  or  trachea,  may  be  divided,  for 
convenience,  into  those  occurring  in  children  and  those  oc¬ 
curring  in  adults;  the  former  are  by  far  the  most  common. 
In  them  the  foreign  body  in  a  large  proportion  of  cases  is 
some  object  that  the  child  has  found  and  put  into  its  mouth 
(in  accordance  with  the  habit  so  common  in  children),  and 
which  has  been  drawn  into  the  larynx  during  some  sudden 
inspiratory  effort.  The  object  may  also  be  some  article  of 
food.  In  adults  the  foreign  body  is  almost  invariably  an 
alimentary  bolus,  and  usually  meat.  The  rapidity  with 
which  death  occurs  in  these  cases  depends  upon  the  com¬ 
pleteness  of  the  obstruction  of  the  air-passages  and  the  vio¬ 
lence  of  the  reflex  symptoms.  If  the  obstruction  is  not 
complete,  it  is  often  made  complete  by  spasm  of  the  glottis. 
In  such  cases  death  apparently  often  occurs  within  five 
minutes ;  it  is  rarely  more  than  ten,  and  not  infrequently  it 
is  instantaneous. 

One  or  two  of  the  cases  reported  in  this  paper  illustrate 
the  occurrence  of  instant  death  by  lodgment  of  a  foreign 
body  in  the  larynx,  and  the  following  case,  published  by 
Perrin,*  also  shows  the  manner  of  death :  An  old  man, 
aged  sixty-eight  years,  fell  suddenly  as  if  struck  by  light¬ 
ning  while  leaving  a  cafe.  At  the  autopsy  an  alimentary 
bolus  composed  of  pancake  was  found,  filling  the  post¬ 
pharyngeal  cavity  and  extending  forward  to  the  orifice  of 


*  Read  before  the  New  York  Clinical  Society,  January  24,  1890. 


*  Reported  in  Poulet’s  Foreign  Bodies  in  Surgery. 


30 


BIGGS  AND  JENKINS:  ACCIDENTAL  SUFFOCATION. 


[N.  Y.  Med.  Jouk., 


the  glottis ;  the  epiglottis  was  raised.  Numerous  cases  simi¬ 
lar  to  this  have  been  reported.  In  them  there  are  fre¬ 
quently  no  signs  or  symptoms  of  obstruction  of  the  air- 
passages  during  life,  and  in  fact  death  is  so  nearly  instanta¬ 
neous  that  there  is  no  time  for  the  manifestation  of  signs 
or  symptoms  of  any  kind.  In  these  cases  the  post-mortem 
appearances  do  not  suggest  that  asphyxiation  was  the  cause 
of  death,  and  the  nature  of  the  cause  will  almost  certainly  es¬ 
cape  recognition  at  the  autopsy  unless  the  possibility  of  acci¬ 
dental  suffocation  is  kept  in  mind  and  the  larynx  is  removec 
and  examined.  (As  a  rule  in  this  country,  unless  there  is 
something  to  direct  attention  to  the  larynx,  it  is  not  re¬ 
moved  or  examined  in  autopsies.) 

In  those  cases  where  death  is  instantaneous,  or  almost 
instantanedus,  it  apparently  is  the  result  of  reflex  inhibition 
of  the  heart’s  action  through  the  fibers  of  the  pneumogastric 
nerve.  Certainly  it  is  not  produced  by  asphyxiation. 

Not  only  may  death  be  produced  by  the  entrance  of 
solid  foreign  bodies,  but  numerous  cases  have  been  recorded 
where  it  has  resulted  from  the  entrance  into  the  larynx  or 
trachea  of  fluids.  In  such  cases  death  results  either  from 
the  filling  up  of  the  bronchi  and  trachea  with  fluid  or  from 
the  intensity  of  the  reflex  phenomena  and  the  spasm  of  the 
glottis.  In  fact,  in  all  cases  of  foreign  bodies  in  the  larynx 
these  latter  symptoms  are  the  most  alarming  ones. 

Guyon*  reports  a  case  where  instant  death  resulted 
from  the  cauterization  of  the  larynx  by  dilute  ammonia. 
Death  was  apparently  caused  by  spasmodic  contraction  of 
the  glottis. 

A  case  is  reported  from  the  Italian  by  Poulet,f  in  which 
a  child  was  found  chewing  some  coal.  The  mother  surprised 
him  and  made  him  drink  some  water  hurriedly.  Part  of 
the  fluid  fell  into  the  trachea  and  rapidly  produced  death. 

The  opening  of  large  abscesses  or  tubercular  cavities 
into  the  bronchi  or  trachea  may  sometimes  produce  death 
in  the  same  manner  as  in  the  introduction  of  fluids  from 
without;  numerous  such  cases  are  on  record.  Reasoning 
a  priori ,  it  would  seem  as  if  a  simple  spasm  of  the  glottis 
could  not  result  in  death,  because  the  spasm  would  be  re¬ 
lieved  before  complete  asphyxiation  had  occurred.  The  fact, 
however,  seems  to  be  that,  although  this  is  perhaps  in  part 
true,  yet  sometimes,  when  the  spasm. is  relieved,  the  respira¬ 
tory  centers  have  become  so  benumbed  from  the  action  of 
carbonic-acid  gas,  or  the  want  of  oxygen,  that  no  further 
efforts  at  respiration  are  made.  The  motor  center  of  the 
larynx  is  probably  far  more  tolerant  of  carbonic-acid  gas  or 
want  of  oxygen  than  the  respiratory  center,  and  motor  im¬ 
pulses  may  continue  to  be  sent  out  from  this,  producing 
spasm  of  the  glottis,  even  after  the  irritability  of  the  respir¬ 
atory  center  had  been  completely  lost.  Benumbing  of  the 
respiratory  center  would  seem  to  be  the  cause  of  death  in 
those  cases  where  death  occurs  during  the  operation  of 
tracheotomy,  when  respiration  ceases  and  the  action  of  the 
heart  continues,  but  respiration  can  not  be  re  established 
even  after  the  air-passages  are  opened  and  the  obstruction 
is  removed. 

In  almost  all  the  cases  where  foreign  bodies  are  drawn 

*  Diet,  encycbp. ,  art.  Larynx. 

f  Foreign  Bodies  in  Surgery. 


into  the  larynx  the  immediate  cause  of  the  obstruction  is 
some  sudden  inspiration — in  laughing,  coughing,  shouting, 
or  something  causing  surprise  or  fright,  or  some  sudden  start. 

Cases  of  Sudden  Death,  from  the  Lodgment  of  Foreign  Bodies  in 
the  Larynx  or  Trachea. 

Case  I. — A  boy,  aged  fifteen  years,  was  playing  in  one  of 
the  city  parks  during  recess  for  dinner  ;  suddenly  he  fell  to  the 
ground,  became  deeply  cyanosed,  and  grasped  his  throat.  His 
companions  thought  he  was  having  a  convulsion.  A  physician 
was  sent  for,  but  before  his  arrival  the  boy  was  dead.  Death 
occurred,  probably,  within  five  minutes.  He  was  removed  to 
his  home,  and  death  was  ascribed  to  heart  disease.  At  the 
autopsy  a  collar-button  was  found  in  the  larynx,  with  the  head 
below  the  vocal  cords  and  the  base  of  the  button  resting  upon 
the  cords.  The  opening  in  the  glottis  was  completely  closed. 
Aside  from  this,  the  organs  showed  the  lesions  usually  found  in 
death  from  suffocation. 

Case  II. — A  school-boy,  aged  ten  years,  acting  as  monitor 
of  his  class,  was  suddenly  seized  with  difficulty  of  breathing, 
became  quickly  unconscious,  and  died.  The  teacher,  who  was 
a  physician,  thought  the  boy  had  had  an  epileptic  convulsion. 
The  boy  had  been  eating  some  bread  and  butter.  At  the  autopsy 
his  face  was  still  deeply  cyanosed,  and  there  was  found  in  the 
larynx  a  mass  of  soft,  fatty  matter  that  melted  at  the  tempera¬ 
ture  of  the  human  body.  The  usual  lesions  in  death  from 
asphyxiation  were  found  in  the  other  organs. 

Case  III. — A  child,  aged  about  five  years,  while  playing 
about  his  father’s  knee  on  the  sidewalk  and  eating  an  orange, 
suddenly  became  cyanosed,  the  respiration  became  difficult,  and 
he  fell  to  the  sidewalk.  The  father,  supposing  he  was  having  a 
convulsion,  took  him  into  a  drug-store  and  gave  him  a  hot  bath. 
In  about  five  minutes  the  child  was  dead.  Several  physicians 
were  present,  who  expressed  the  opinion  that  the  child  died 
from  heart  disease.  At  the  autopsy  the  face  was  still  deeply 
cyanosed.  The  usual  lesions  in  death  from  asphyxiation  were 
found ;  in  addition,  the  bronchial  glands  were  greatly  enlarged 
and  the  left  primary  bronchus  was  somewhat  compressed.  Just 
above  the  bifurcation  of  the  trachea  there  was  an  opening, 
through  which  a  bronchial  gland  had  been  discharged  into  the 
trachea  and  had  lodged  just  at  the  bifurcation  of  the  tra¬ 
chea  in  the  opening  of  the  left  primary  bronchus.  The  gland 
was  enlarged  and  the  center  cheesy.  Around  the  cheesy  center 
a  suppurative  inflammation  had  occurred,  which,  extending 
through,  had  produced  ulceration  in  the  wall  of  the  trachea, 
and  thus  the  loosened  cheesy  mass  had  made  its  way  into  the 
trachea.  A  case  quite  similar  to  this  was  reported  in  the 
Deutsche  medicinische  Wochenschrift  of  1887,  which  occurred 
in  a  hospital  while  the  physician  was  in  the  ward.  A  diagnosis 
of  obstruction  in  the  air-passages  was  made,  tracheotomy  was 
immediately  performed,  the  cheesy  gland  removed,  and  recovery 
took  place. 

Case  IV. — A  child,  aged  three  years,  left  his  bed  in  the 
morning  and  was  eating  a  piece  of  cake ;  on  returning  to  his  bed 
he  suddenly  showed  great  difficulty  in  respiration.  The  mother 
thought  the  child  had  drawn  a  piece  of  cake  into  the  larynx, 
and  introducing  her  finger  into  the  throat,  felt  the  head  of  what 
was  apparently  a  screw.  She  sent  for  a  friend  and  they  en¬ 
deavored  to  dislodge  the  screw,  but  in  doing  so  held  the  head 
backward  with  the  face  turned  up.  A  physician  was  sent  for, 
rat  before  his  arrival  the  child  was  dead.  At  the  autopsy  a 
screw  was  found  lodged  in  the  larynx,  with  the  head  resting 
upon  the  vocal  cords  and  the  shaft  extending  down  into  the 
trachea. 

Case  V. — A  boy,  aged  about  five  years,  while  playing  with 


July  12,  1890.] 


BIOGS  AND  JENKINS:  ACCIDENTAL  SUFFOCATION. 


3L 


a  small  rubber  balloon  with  a  whistle  attachment,  suddenly  drew 
the  balloon  and  whistle  into  his  throat.  It  was  so  lodged  that 
with  each  expiration  the  balloon  was  partially  inflated ;  before 
it  could  be  removed  the  boy  was  dead. 

Case  VI. — A  girl,  aged  about  ten  years,  was  holding  a  jack 
in  her  mouth,  when  a  sudden  inspiration  drew  it  into  the  larynx, 
where  it  became  tirmly  fixed,  and  before  it  could  be  removed 
death  had  occurred. 

Case  VII. — A  man,  aged  about  forty-five,  who  had  been  in¬ 
dulging  freely  in  liquor,  after  ordering  and  partaking  of  part  of 
a  steak  in  a  restaurant,  suddenly  fell  from  his  chair  to  the  floor 
and  died;  death  was  almost  instantaneous,  and  was  supposed 
to  be  due  to  heart  disease.  The  history  led  to  the  suspicion  that 
death  had  been  produced  by  the  lodgment  of  a  foreign  body  in 
the  larynx,  and,  on  opening  the  trachea,  a  large  piece  of  meat 
was  found  lodged  firmly  in  the  larynx  between  the  vocal  cords. 

Case  VIII. — A  man,  aged  forty  years,  on  the  evening  of 
election  day,  after  receiving  pay  for  his  services  for  the  day, 
proceeded  to  a  restaurant  to  procure,  as  he  said,  “  a  square 
meal  ” ;  suddenly  he  became  deeply  cyanosed,  showed  difficulty 
of  respiration,  and  fell  to  the  floor.  Before  help  could  reach 
him  he  was  dead.  At  the  autopsy  a  large  piece  of  meat  was 
found  lodged  partly,  in  the  pharynx  and  partly  in  the  larynx. 
There  were  areas  of  livor  mortis  scattered  all  over  the  body  ex¬ 
ternally,  and  the  internal  organs  showed  the  usual  lesions  found 
in  death  from  asphyxiation. 

Case  IX. — A  man,  aged  about  forty,  unknown,  died  suddenly 
in  a  restaurant  while  eating,  and  was  removed  to  the  morgue. 
After  a  complete  autopsy,  with  the  exception  of  the  examina¬ 
tion  of  the  larynx,  no  sufficient  cause  for  death  was  found.  The 
history  then  being  obtained  that  death  had  occurred  in  a  restau¬ 
rant,  the  larynx  and  trachea  were  opened  and  a  large  piece  of 
meat  was  found  extending  from  the  pharynx  into  the  larynx  and 
partially  through  the  glottis. 

Case  X. — An  inmate  of  an  insane  asylum  was  sent  to  the 
morgue,  with  the  history  of  having  choked  at  the  table.  A 
piece  of  meat  was  said  to  have  been  removed  from  the  larynx. 
At  the  autopsy  the  usual  lesions  in  death  from  asphyxia  were 
found,  and  an  additional  piece  of  meat  was  found  in  the  trachea. 

Case  XL — An  unknown  man  was  leaving  a  restaurant  after 
eating  his  dinner,  when  he  fell  to  the  floor,  became  deeply 
cyanosed,  showed  difficulty  of  respiration,  and  soon  died,  lie 
was  removed  to  the  morgue,  and  at  the  autopsy  a  piece  of  meat 
was  found  in  the  larynx. 

Case  XII. — A  man,  aged  forty,  had  been  eating  at  the  free- 
lunch  counter  of  a  saloon  after  taking  a  drink.  As  he  left  the 
saloon  he  fell  to  the  ground  suddenly  dead.  At  the  autopsy  a 
mass  of  crackers  and  cheese  was  found  in  the  larynx. 

Case  XIII. — A  negro  child,  aged  about  one  year,  was  left 
with  its  bottle.  The  child’s  movements  attracted  its  mother’s 
attention.  Then  she  noticed  that  the  rubber  nipple  was  miss¬ 
ing  from  the  bottle,  and  that  the  child  was  apparently  struggling 
for  breath.  A  physician  was  summoned,  but  before  he  arrived 
the  child  was  dead.  He,  however,  removed  the  rubber  nipple 
from  the  larynx  on  the  end  of  his  finger. 

Case  XIV. — A  patient  was  admitted  to  Bellevue  Hospital 
suffering  from  compound  fracture.  It  was  decided  to  be  best  to 
operate  immediately,  and  ether  was  administered.  The  patient 
vomited  somewhat  while  under  the  influence  of  the  anaesthetic, 
and  suddenly  stopped  breathing;  all  attempts  to  restore  respi¬ 
ration  failed.  The  patient  died.  At  the  autopsy  a  mas3  of 
vomited  matter  was  found  firmly  lodged  in  the  larynx. 

The  cases  in  the  second  class — those  of  accidental  suffo¬ 
cation  of  infants  by  closure  of  the  mouth  and  nares — are  ex¬ 
ceedingly  common,  and  the  cause  of  death  usually  entirely 


escapes  observation.  The  most  common  method  of  pro¬ 
duction  of  death  in  these  cases  is  the  “overlying”  of  in¬ 
fants  while  sleeping  in  bed  with  their  parents.  The  usual 
history  is,  that  the  mother  gave  the  child  her  breast  during 
the  night;  she  remembers  nothing  more;  but  when  she 
awakened  in  the  morning  the  child  was  dead.  As  has  been 
noted  by  Tidy  and  by  Jenkins,  these  cases,  which  occur  for 
the  most  part  among  the  lower  classes,  occur  much  more 
frequently  on  Saturday  night  or  on  a  night  after  a  holiday. 
At  these  times  the  mothers  are  likely  to  be  partially  stupefied 
by  liquor;  they  are  less  thoughtful  of  their  children  and 
their  sleep  is  deep.  The  mother  turns  partly  on  her  side 
toward  the  child,  the  breast  falls  on  the  child’s  face,  ob¬ 
structing  the  entrance  to  the  air-passages,  and  asphyxiation 
is  gradually  produced.  The  mother  sleeps  too  soundly  to 
be  awakened  by  the  movements  of  the  child.  Sometimes 
suffocation  results  from  the  bed-clothing  being  thrown  over 
the  child’s  head,  or  from  its  slipping  off  from  the  pillow 
underneath  the  clothes.  These  cases  are  too  common  to  be 
mentioned  in  detail. 

There  are  also  many  peculiar  forms  of  suffocation  occur¬ 
ring  in  infants  and  children,  of  which  the  four  cases  detailed 
below  are  good  examples  ;  the  cause  of  death  in  such  cases  is 
often  apparent : 

Case  XV. — Two  children  slept  together  in  a  crib;  one  was 
three  years  old,  the  other  about  five  months ;  in  the  morning 
the  elder  one  was  found  lying  across  the  face  of  the  younger, 
and  the  latter  was  dead. 

Case  XVI. — A  child,  aged  six  months,  was  left  by  its  mother 
sitting  in  a  high  chair.  The  chair  was  a  combination  high  chair 
and  carriage,  was  placed  on  rather  a  broad  platform  (so  that  it 
could  not  be  turned  over  easily),  and  under  this  platform  were 
wheels;  connecting  the  two  arms  of  the  chair  in  front  of  the 
seat  was  a  guard  to  hold  the  child  on  the  seat ;  the  mother  had 
left  the  child  sitting  in  the  chair,  and  when  she  returned,  at  the 
end  of  a  few  minutes,  found  the  child  dead,  suspended  with  its 
face  resting  on  the  seat  of  the  chair  and  with  the  occiput  under 
the  guard. 

Case  XVII. — A  woman,  aged  twenty-five,  an  epileptic,  fell 
from  a  chair  with  her  child  in  her  arms;  she  was  found  a  short 
time  later  in  an  unconscious  condition,  overlying  the  child, 
which  had  died  from  suffocation. 

Case  XVIII. — A  child,  aged  about  eight  months,  was  left 
alone  with  a  handkerchief  to  suck;  the  parents  returned  after 
three  quarters  of  an  hour  and  the  child  was  dead,  having  drawn 
nearly  the  whole  handkerchief  into  its  throat;  vomiting  had 
thus  been  produced,  and  this,  with  the  handkerchief,  had  caused 
suffocation. 

Case  XIX. — Two  negro  infants  were  left  sleeping  quietly  in 
a  bed  made  upon  some  chairs  at  3  a.  m.  by  the  woman  having 
charge  of  them.  At  6  a.  m.  they  were  found  dead,  covered  over 
by  the  bed-clothing.  The  circumstances  attending  the  case 
showed  that  death  was  accidental  (Dr.  Weston’s  case). 

Cases  of  the  third  class — those  of  accidental  suffocation 
of  epileptics  during  convulsions,  and  alcoholics  during  pro¬ 
found  intoxication — are  comparatively  common,  and  the 
cause  of  death  when  the  detailed  history  is  known  is  appar¬ 
ent.  The  nature  of  death,  however,  is  very  likely  to  escape 
the  observation  of  physicians  who  are  not  accustomed  to 
dealing  with  medico-legal  cases,  as  they  do  not  ascertain, 
as  a  rule,  by  careful  questioning,  the  details  in  the  history. 


32 


TAYLOR:  THE  BRANDT  REMEDIAL  METHODS  FOR  PELVIC  AFFECTIONS.  [N.  Y.  Med.  Jouk., 


The  history  in  all  these  cases  of  suffocation  during  epi¬ 
leptic  convulsions  takes  one  of  two  forms: 

1.  The  patient  falls  on  his  face  in  a  convulsion  and  re¬ 
mains  lying  in  such  a  position  that  the  mouth  and  nares  are 
•closed,  or  while  lying  in  this  position  something  is  drawn 
into  the  larynx. 

2.  Patient  has  a  convulsion  while  in  bed,  and  during  it 
turns  over  on  the  face  and  remains  lying  in  this  position 
during  the  unconscious  stage,  and  thus  becomes  suffocated. 

A  number  of  cases  are  detailed  below  which  illustrate 
the  method  of  death  in  this  class : 

Case  XX. — A  young  man,  aged  twenty-one,  after  spending 
the  evening  freely  drinking  with  his  companions,  was  found  the 
next  morning  dead  in  bed,  lying  on  his  face.  His  companions, 
who  were  in  the  same  room,  had  heard  no  disturbance  during 
the  night.  The  autopsy  revealed  only  the  lesions  usually  found 
in  death  from  asphyxiation,  and  it  was  only  after  careful  inquiry, 
directed  by  these  lesions,  that  it  was  discovered  that  he  had 
been  found  lying  on  his  face  in  the  bed.  A  small  nodule  was 
found  in  the  dura  on  the  left  side;  possibly  owing  to  this  or  to 
the  effects  of  alcohol,  an  epileptiform  convulsion  had  resulted, 
and  death  was  thus  produced  from  suffocation. 

Case  XXI. — A  girl,  aged  twelve,  an  epileptic,  was  found  by 
her  family  in  the  morning  dead  in  her  bed,  lying  on  her  face. 

Case  XXII. — A  young  woman,  aged  twenty-one,  an  epilep¬ 
tic,  was  found  dead  in  her  bed  in  the  morning,  lying  on  her 
face. 

Case  XXIII. — A  girl,  aged  eighteen,  with  the  same  history. 

Case  XXIV. — A  woman,  aged  thirty-five,  an  epileptic,  was 
found  in  the  evening  by  her  child  on  its  return  from  school, 
lying  on  her  face  on  the  floor  dead. 

Case  XXV. — Young  woman,  aged  twenty-eight,  an  epilep¬ 
tic,  while  passing  from  one  room  to  another  quickly,  during  con¬ 
siderable  excitement,  suddenly  fell  on  the  floor  on  her  face,  and 
when  assistance  reached  her,  several  minutes  later,  was  dead. 

Case  XXVI. — A  German,  aged  thirty-five,  an  officer’s  serv¬ 
ant,  during  severe  depression  attempted  suicide  by  shooting 
himself  in  the  head.  The  hall  lodged  in  the  brain  and  was 
found  there  encapsulated  years  afterward.  After  this  he  be¬ 
came  epileptic,  and  while  vomiting,  during  a  convulsion,  as¬ 
phyxiation  was  produced  by  the  passage  of  food  into  the  larynx. 

Case  XXVII. — A  noted  case  has  been  reported  by  Dr.  Jane¬ 
way  of  death  from  suffocation  in  an  epileptic  who  had  a  con¬ 
vulsion  in  a  stable  yard,  and,  falling  upon  his  face  upon  the 
ground,  was  suffocated  by  manure  drawn  into  his  larynx.  At 
the  autopsy  the  larynx  was  found  closed  by  masses  of  manure. 

Case  XXVIII. — A  young  man,  aged  twenty-three,  an  epi¬ 
leptic,  was  found  dead  in  the  morning,  lying  partly  on  the  cot 
on  which  he  slept  and  partly  on  a  chair.  The  imprint  of  the 
cane  seat  of  the  chair  was  on  the  right  side  of  his  face  and  neck, 
and  the  discoloration  here  corresponded  to  ihe  opening  in  the 
cane  bottom  of  the  chair  on  which  he  rested. 

The  face  was  deeply  cyanosed,  and  at  the  autopsy  nothing 
was  found  excepting  the  lesions  common  in  death  from  asphyxi¬ 
ation. 

Case  XXIX. — A  young  man,  an  epileptic,  went  out  at  night 
into  a  stable  yard  to  defecate.  Just  after  completing  the  act 
he  apparently  fell  forward  in  a  convulsion,  with  his  face  down¬ 
ward,  into  a  watering  trough,  which  contained  water  only  four 
or  five  inches  in  depth.  Here  he  was  found  some  hours  later 
dead. 

Death  while  a  person  is  in  a  state  of  profound  intoxica¬ 
tion  is  less  frequent  than  death  during  an  epileptic  convul¬ 


sion,  but  its  mechanism  is  the  same.  The  following  case 
illustrates  this  form  very  well : 

Case  XXX. — A  German  man,  aged  thirty,  came  home  great¬ 
ly  intoxicated  and  threw  himself  prone  on  the  bed.  He  was 
found  dead  in  this  position  some  hours  after  by  his  friends. 
Death  had  resulted  from  suffocation. 

The  cases  grouped  under  the  fourth  head — those  of  sub¬ 
mersion,  strangulation,  inhumation,  etc. — form  a  separate 
class  ;  the  cause  of  death  is  usually  apparent,  and  their  con¬ 
sideration  will  be  omitted  here. 

In  conclusion,  the  following  remarks  are  suggested  : 

1.  Accidental  suffocation  is  a  common  cause  of  sudden 
death,  especially  in  children,  and  the  cause  of  death  usually 
escapes  recognition. 

2.  Death  produced  by  the  lodgment  of  foreign  bodies 
in  the  larynx  or  trachea  occurs  rapidly,  and  is  sometimes 
almost  instantaneous.  The  foreign  body  may  be  liquid  as 
well  as  solid. 

3.  When  death  is  instantaneous,  it  is  probably  the  re¬ 
sult  of  reflex  inhibition  of  the  heart’s  action. 

4.  In  children  the  foreign  body  is  usually  some  play¬ 
thing  that  has  been  placed  in  the  mouth,  while  in  adults  it 
is  almost  invariably  an  alimentary  bolus,  frequently  meat. 

5.  The  accidental  suffocation  of  infants  in  bed  by  the 
bed-clothing  and  by  “  overlying”  is  a  very  common  occur¬ 
rence  among  the  lower  classes. 

6.  Death  often  results  from  suffocation  during  epileptic 
convulsions  and  during  profound  alcoholic  intoxication. 

58  East  Twenty-fifth  Street. 


THE  BRANDT  REMEDIAL  METHODS  FOR 

PELVIC  AFFECTIONS. 

By  GEORGE  H.  TAYLOR,  M.  D. 

The  communication  of  Dr.  J.  II.  Boldt  in  the  June 
number  of  the  American  Journal  of  Obstetrics  explaining 
and  advocating  certain  unique  manual  processes  for  the 
cure  of  affections  of  the  contents  of  the  female  pelvis  ap¬ 
pears  to  invite  examination,  perhaps  criticism.  I  will  there¬ 
fore  proceed  to  bestow’  such  notice  on  the  remedial  system 
referred  to  as  its  pretensions  seem  to  call  for. 

The  purpose  of  Dr.  Boldt’s  article  is  to  show  the  reme¬ 
dial  pow'er  as  well  as  the  availability  of  local  massage  and 
allied  manual  methods  for  removing  malpositions,  conges¬ 
tions,  functional  irregularities  and  defects,  and  even  more 
severe  and  advanced  pathological  conditions  of  the  uterus 
and  its  appendages. 

It  is  due  that  reasons  be  given  why  any  reference  to  the 
subject  introduced  by  Dr.  Boldt’s  article  is  required.  The 
peculiar  practice  described  at  length  and  with  sufficient 
minuteness  by  Dr.  Boldt  was  ostensibly  inaugurated  by  T. 
Brandt,  a  non-medical  Swede,  the  author  of  a  thin  volume, 
of  which  Dr.  Boldt’s  communication  is  a  resume.  The 
curative  plan  shown  may  appear  plausible  and  even  prac¬ 
tical  to  the  inexperienced  and  to  those  inclined  to  medical 
novelties.  Positive  and  vehement  assertions  in  medical 
matters,  especially  when  backed  by  a  formidable  array  of 


July  12,  1890.]  TAYLOR:  THE  BRANDT  REMEDIAL  METHODS  FOR  PELVIC  AFFECTIONS. 


33 


successful  cases,  readily  usurp  the  place  of  scientific  state¬ 
ment  and  real  merit.  A  tendency  to  accept  and  follow  au¬ 
thority,  or  what  seems  such,  is  an  instinct  often  insufficiently 
held  in  check  by  the  reflective  powers. 

A  conspicuous  evidence  of  this  tendency  is  now  before 
me.  A  book  just  published  from  the  pen  of  Dr.  Herman 
Nebel  at  Wiesbaden,  Germany,  not  only  strongly  advocates 
the  Brandt  system,  but  cites  a  long  list  of  presumably  re¬ 
spectable  physicians  in  that  country  who  have  wholly  or  in 
part  adopted  in  actual  practice  the  same  remarkable  cura¬ 
tive  methods  for  the  special  class  of  cases  before  mentioned. 
This  shows  the  importance  of  an  intelligent  presentation  of 
the  difficulties  which  the  Brandt  and  similar  methods  have 
no  adaptation  to  overcome  and  which  must  remain  to  tor¬ 
ment  both  victims  and  advocates. 

A  further  need  for  comment  arises  from  the  liability  of 
the  casual  reader,  who  finds  it  impossible  to  keep  himself 
“  posted  ”  on  all  phases  of  medical  subjects,  to  confound  the 
principles  and  methods  set  forth  by. Brandt  with  certain 
others  which  are  in  fact  diametrically  and  unreservedly 
opposed  thereto.  It  will  become  necessary  in  the  course 
of  the  present  article  to  give  an  intimation  at  least  of  the 
nature  of  these  opposing  principles. 

History  repeats  itself  even  in  affairs  of  the  female  pel¬ 
vis.  The  Brandt  system,  if  such  it  may  be  called,  is  devoid 
even  of  the  questionable  merit  of  novelty.  Remedial  pro¬ 
cesses  substantially  identical  with  those  described  by  Dr. 
Boldt  and  Mr.  Brandt,  with  such  elaboration  of  detail,  were, 
to  my  personal  knowledge,  much  in  vogue  forty  years  ago 
in  this  country.  It  may  not  be  without  interest,  perhaps 
may  combine  entertainment  with  warning,  to  advert  to  a 
bit  of  this  history. 

The  inception  of  a  practice  of  local  “  massage  ”  for 
remedying  various  ills  of  the  generative  intestine  dates  back 
to  the  appearance  in  this  country  of  the  elder  J.  II.  Ben¬ 
nett’s  book  on  the  uterus,  which  was  1850.  This  work 
was  extensively  regarded  as  affording  the  last  words  to  be 
said  on  what  has  since  become  developed  into  the  many- 
sided  and  almost  unlimited  subject  of  gynaecology.  Ben¬ 
nett’s  local  methods  of  uterine  therapeutics  were  generally 
adopted  and  often  administered  with  more  vigor  than  dis¬ 
cretion.  These  methods  were,  of  course,  subject  to  “im¬ 
provements”;  among  these  improvements  were  local  “mas¬ 
sage  ”  and  a  multitude  of  allied  processes  which  were  re¬ 
garded  as  modes  of  securing  the  same  effects.  Afterward 
local  massage  became  a  practical  substitute  for,  rather  than 
an  auxiliary  to,  direct  medication  of  accessible  portions  of 
the  generative  intestine.  Under  the  prevailing  hypothesis 
of  the  nature  of  diseases  of  these  parts  of  the  body  nice 
questions  of  aetiology  were  not  troublesome. 

Then,  as  now,  there  was  abundant  scope  for  the  uterine 
specialist,  for  then,  as  now,  there  were  women  who  preferred 
remedies  to  preventives,  who  preferred  the  chances  of  “  cure  ” 
to  the  immunity  offered  through  a  wise  discretion  as  to 
self-care.  No  one  supposes  that  the  average  chronic  “  female 
disease”  is  inevitable;  but,  unfortunately,  the  avoidance  of 
this  class  of  affections  has  been  and  is  but  little  discussed. 
Uterine  specialists  exist  in  response  to  the  perennial  de¬ 
mand,  and  the  demand  must  continue  till  displaced  by  ex¬ 


emption,  arising  from  the  intelligence  necessary  for  every 
woman  on  this  subject. 

At  the  period  referred  to,  chronic  uterine  affections 
assumed  a  degree  of  prevalence  typified  by  epidemics.  Es¬ 
tablishments  devoted  principally  or  wholly  to  this  frail  part 
of  the  female  organism  were  judiciously  located  in  this 
State  and  in  parts  of  New  England.  Uterine  defects  and 
uterine  cobbling  were  decidedly  the  fad.  I  knew  of  doc¬ 
tors  wdthout  diplomas  but  with  overwhelming  patronage. 
The  lack  of  authorization  appeared  to  be  no  bar  to  success ; 
and  is  not  success  sufficient  evidence  of  both  ability  and 
merit?  I  was  told  of  an  omnibus  line  ending  a  short  dis¬ 
tance  from  this  city  which  was  literally  crowded  with  women 
going  to  and  returning  from  an  eminent  specialist.  His 
methods  consisted  mainly  in  pushing  up  and  properly  pois¬ 
ing  the  recalcitrant  parts  and  executing  at  the  same  time  in¬ 
terior  local  massage  “from  three  to  forty-five  minutes,”  to  be 
frequently  repeated.  One  more  reference,  out  of  several  I 
might  give,  will  complete  the  surfeit  of  the  reader  and  show 
the  ease  with  which  a  certain  kind  of  popularity  has  in  times 
past  been  acquired.  This  specialist  had  a  large  establish¬ 
ment  in  a  central  part  of  this  State.  He  had  no  medical  or 
much  other  education.  The  two  hundred  women  almost 
constantly  present  for  years  received  personal  attention 
from  himself,  assisted  by  one  or  two  female  helpers.  His 
processes  are  well  described  in  Dr.  Boldt’s  article.  He 
withdrew  from  practice,  without  diminution  of  patronage  or 
popularity,  only  when  his  pecuniary  ambition  had  become 
fully  gratified.  These  facts  were  derived  in  part  from  per¬ 
sonal  interviews  with  the  “  doctor,”  in  part  from  ex-patients. 
Other  establishments,  including  the  uterine  specialty  with 
a  broader  pathological  scope,  added  the  therapeutic  attrac¬ 
tions  of  electricity,  various  kinds  of  baths,  etc. 

We  may  call  attention  to  the  intrinsic  nature  of  the  dif¬ 
ficulties  presenting  in  these  cases  of  disease  and  malposition 
of  the  pelvic  organs,  the  better  to  understand  the  adapta¬ 
tion  and  want  of  adaptation  of  “  massage  ”  and  other  reme¬ 
dies  for  their  removal. 

Can  poising  the  uterus,  however  dexterously,  upon  the 
tip  of  an  operator’s  finger,  can  maintaining  it  in  such  posi¬ 
tion  “from  three  to  forty-five”  or  any  number  of  minutes, 
not  forgetting  due  interior  combined  with  exterior  massage, 
afford  any  considerable  and  practical  information  as  to  why 
this  organ  so  insists  on  taking  a  downward  or  lateral  excur¬ 
sion  ;  why  it  doubles  upon  itself?  How  does  toying  with 
these  perverse  parts  check  or  reverse  their  erratic  tenden¬ 
cies  ?  How,  even,  can  prolonged  sustentation  of  the  uterus 
in  an  elevated  and  natural  position,  supposed  to  be  secured 
by  instruments,  unravel  the  mystery  of  the  causes  of  dislo¬ 
cation  and  deformity  of  the  pelvic  contents  ?  Local  “  mas¬ 
sage  ”  sustains  nothing  ;  the  pessary  is  only  thrust  between 
organs  and  parts;  the  supporter  is  buckled  outside  the  same 
region  ;  but  how  does  either  add  to  the  physiological  sus¬ 
taining  power?  They  only  seem  to  the  uninquiring  to  do 
so,  but  without  scientific  warrant.  The  downward  tendency 
is  not  abated,  only  obstructed  by  local  barriers.  These 
have  no  physiological  adaptation  to  lessen  the  weight  of  the 
pelvic  contents,  which  is  evidently  the  same  with  and  with¬ 
out  so-called  supports.  Even  though  the  fibers  forming  the 


34 


TAYLOR:  THE  BRANDT  REMEDIAL  METHODS  FOR  PELVIC  AFFECTIONS.  [N.  Y.  Mkd.  Jour.’ 


organs  within  the  pelvis  should,  by  massage  or  any  other 
means,  become  increased  in  tenacity  and  contractile  power, 
no  sustaining  power  is  assured  thereby,  because  of  want  of 
mechanical  relationship.  To  expect  the  uterus,  ovaries,  and 
tubes  to  hold  themselves  up  through  an  exertion  of  their 
own  intrinsic  mechanical  power  is  like  inviting  a  man  to 
lift  himself  over  a  fence  by  the  straps  of  his  boots. 

Divulsion  of  morbidly  adhering  parts  is  said  by  Brandt 
to  be  achieved  by  his  system  of  “  massage.”  Does  this 
strenuous  result  give  the  least  assurance  of  removal  or  even 
abatement  of  morbid  continuous  contact?  Or  that  the  same 
consequence  from  the  same  cause  is  not  imminent  ?  So,  too, 
mechanical  straightening  of  an  incurved  uterus,  removal  of 
cervical  stenosis,  and  the  crowding  into  place  of  a  fugitive 
ovary  are  but  temporary  expedients,  and,  however  frequent¬ 
ly  repeated,  can  in  no  degree  diminish  the  erratic  tendencies 
and  habits  of  these  respective  parts.  The  unsubjugated  or¬ 
gans  will  continue  to  manifest  mechanical  improprieties,  will 
stray  in  forbidden  directions,  and  get  themselves  figurative¬ 
ly  ground  between  upper  and  nether  millstones.  The  sim¬ 
ple  fact  that  there  is  no  room  above,  or  in  any  other  loca¬ 
tion  than  that  assumed,  is  strangely  overlooked. 

Similar  difficulties  are  encountered  in  attempts  to  cor¬ 
rect  morbid  conditions  affecting  the  substance  of  the  pelvic 
contents.  We  may  pertinently  inquire,  Whence  the  excess, 
both  solid  and  fluid,  of  materials  which,  more  than  any  other 
single  fact,  characterizes  the  morbid  state  of  these  parts  in 
its  inception,  development,  and  differentiation?  Is  quality 
as  well  as  position  independent  of  exterior  influences,  that 
its  aberration  should  permit  of  remedies  essentially  local 
in  their  effects  ?  Do  gentle  “  squeezing,”  “  malaxation,” 
dexterous  manipulating,  and  frequent  coaxing  of  the  gener¬ 
ative  intestine  in  some  inexplicable  and  mysterious  way  en¬ 
gage  the  collateral  circulation,  and  so  open  thereto  a  broad¬ 
er  and  more  active  connection  ?  Are  the  chemical  qualities 
of  the  local  ingredients  (always  suspicious  in  disease)  great¬ 
ly  improved  by  local  massage  ?  If  so,  what  prevents  imme¬ 
diate  return  of  degeneration  on  suspending  the  fructifying 
agent  ? 

Above  all,  are  the  means  in  question  effective  for,  or  do 
they  even  conduce  to,  a  substantial  and  permanent  re-enforce¬ 
ment  of  the  vito-mechanical  processes  engaged  in  the  nor¬ 
mal  return  from  the  pelvic  organs  of  their  venous  blood, 
and  with  it  all  ingredients  whose  prolonged  presence  is  un¬ 
wholesome  ? 

But  a  fair  estimate  of  the  difficulties  in  the  way  of  the 
Brandt  system,  and  of  other  systems  having  similar  pur¬ 
poses  and  limitations,  does  not  end  by  proposing  negations. 
We  should  note  the  injuries,  positive  and  probable,  which 
they  are  capable  of  inflicting ;  for,  though  healthy  organs 
may  not  directly  suffer  from  the  processes  described  by 
Brandt,  it  must  be  admitted  that  the  frequent  repetition  of 
such  handling  might  prove  rather  rough  for  those  in  an  un¬ 
healthy  condition.  The  thinned  walls  of  the  distended 
capillaries,  which  have  lost  their  contractility  and  bear  but 
a  slow  and  turgid  stream,  are  not  able  to  resist  forcible  me¬ 
chanical  impressions.  Only  such  motor  causes  as  operate 
at  and  beyond  the  venous  outlets  of  the  local  vessels  can  be 
mechanically  advantageous.  Local  massage  can  not  extend 


its  influence  in  any  effective  degree  to  the  point  where,  if 
anywhere,  it  is  required.  Inferior  degrees  of  the  process 
are  supererogatory  or  injurious,  for  renewal  of  local  fluids 
and  local  nutrition  necessarily  depends  on  the  facility  of  the 
venous  exit.  The  tendency  to  deterioration  of  the  pent-up 
local  fluids  can  not  be  averted  by  merely  local  measures, 
however  deftly  applied. 

Other  difficulties  inhere  in  the  local  plan  under  consid¬ 
eration.  Whether  such  treatment  be  regarded  as  affording 
local  stimulation,  inc.itation,  sedation,  or  other  nominal  ef¬ 
fects,  the  production  of  these  theoretical  benefits  is  by  no 
means  the  limit  of  its  influence.  Other  effects,  counter  to 
those  desired,  inflicting  far-reaching  evil  consequences,  are 
necessary  coincidents,  not  only  defeating  the  main  pur¬ 
pose,  but  even  adding  new  pathological  consequences ;  for 
the  therapeutic  plan  described  is  a  direct  means  of  intro¬ 
ducing  and  establishing  new  but  unwholesome  relations 
between  the  local  parts  and  the  organism  at  large,  the  re¬ 
verse  of  those  which  obtain  in  health.  The  pelvis  becomes 
a  focus  or  center  of  the  consciousness  toward  which  the  feel¬ 
ings  and  thoughts  converge,  in  due  response  to  physiological 
impressions.  The  pelvic  organs  are  also  resolved  into  a 
point  toward  which  the  circulation  becomes  actively  direct¬ 
ed,  in  further  response  to  the  same  law.  The  local  sensa¬ 
tions  and  the  local  blood  suffer  morbid  increase,  and  no 
counteracting  influence  accompanies  these  effects.  This 
morbid  action  is  maintained  by  the  frequent  repetitions  of 
the  local  remedy  which  is  usually  demanded,  and  is  there¬ 
fore  liable  to  become  permanent.  Even  the  most  healthy 
pelvic  organs  can  not  long  resist  the  disease-producing  in¬ 
fluences  to  which  these  parts  are  not  infrequently  subjected 
in  disease. 

The  advocates  of  local  massage  usually  insist  on  the  co¬ 
incident  use  of  specialized,  prescribed  exercises,  adapted  to 
further  the  effects  and  to  correct  the  deficiencies  of  massage 
alone.  But,  however  elaborate  and  complicated  these  sub¬ 
sidiary  processes  may  be,  they  fail  to  afford  any  suggestion 
as  to  the  fundamental  and  continually  operating  sources  of 
this  class  of  affections,  and  little  relevancy  is  apparent  be¬ 
tween  the  processes  prescribed  and  the  morbid  conditions 
to  be  combated.  Besides,  the  invalids  suffering  pelvic 
troubles  are  usually  disabled,  and  therefore  often  incapable 
of  voluntary  action,  and,  as  is  well  known,  are  liable  to  in¬ 
jury  from  volitional  activities.  All  consideration  for  this 
class  is,  by  the  scheme  referred  to,  omitted. 

These  difficulties  are  insignificant  in  comparison  with 
the  misdirection  of  the  medical  purpose  and  medical  en¬ 
deavor  incident  to  the  Brandt  system  ;  for  pelvic  affections 
of  the  ordinary  chronic  description  are  not  self-produced  and 
self-sustained  or  independent,  but,  from  beginning  to  end, 
depend  on  adequate  causes.  These  are  the  primary  factors ; 
the  manipulation  is  secondary  thereto  and  dependent  there¬ 
on.  The  remedy  under  discussion  is  directed  to  the  sec¬ 
ondary  factor;  to  consequences  in  place  of  causes  ;  to  sub¬ 
ordinate  features  and  evidences,  while  the  potential  and 
continuously  operating  sources  on  which  these  depend  are 
quite  omitted  from  consideration  and  remain  unremedied. 
Pelvic  affections,  whatever  their  form  of  manifestation  and 
however  aggressive  their  symptoms,  have  their  potentiality 


July  12,  1890.]  TAYLOR:  THE  BRANDT  REMEDIAL  METHODS  FOR  PELVIC  AFFECTIONS. 


35 


in  their  sources.  These  sources  should  therefore  become 
the  chief  object  of  medical  solicitude,  for  remedies  di¬ 
rected  either  to  morbid  location  of  the  pelvic  organs,  to 
the  tangible  and  ocular  evidences  of  disease,  to  the  local 
pain,  or  to  all  of  these  combined,  may  be  powerless  to  reacli 
the  sources  of  these  symptoms.  There  is,  in  general,  a 
marked  disparity  between  the  immediate  effects  and  the 
ultimate  consequences  of  remedies  employed  on  this  prin¬ 
ciple.  It  is  unreasonable  to  expect  radical  effects  of  the 
restorative  order  from  remedies  whose  scope  is  thus  re¬ 
stricted. 

The  full  force  of  these  statements  appears  only  when 
the  mechanico-physiology  of  the  pelvis  and  its  important 
organs  become  well  understood.  The  location  and  the 
condition  of  these  organs  are  dominated  by  environment 
to  such  a  degree  at  least  as  to  determine  the  state  of  their 
health,  whether  good  or  ill.  The  contents  of  the  pelvis 
may  be  displaced  in  whole  or  in  part  by  causes  having 
their  seat  in  the  environment  of  these  organs,  and  perform¬ 
ing  the  function  of  sustentation,  and  not  otherwise.  Other 
ill  manifestations  have  a  similar  source.  These  exist  by 
reason  of  their  nurture  from  environment,  and  necessarily 
disappear  when  their  sources  are  removed. 

The  importance  of  environment  is  tacitly  conceded 
wheuever  pessaries  are  thrust  under  and  between  the  pelvic 
contents ;  and  in  a  very  odd  way  when  the  trunk  space  is 
diminished  by  a  tight  exterior  band — both  under  the  mis¬ 
taken  idea  that  the  pelvic  contents,  in  opposition  to  me¬ 
chanical  laws  and  common  sense,  may  in  these  ways  be  urged 
upward.  The  first  condition  for  securing  an  improved  loca¬ 
tion  for  pelvic  contents,  or  any  of  the  parts  thereof,  is  to 
provide  space  therefor.  The  same  remark  applies  with 
equal  force  to  deformities  of  these  organs — such  as  retro¬ 
flexion,  and  even  stenosis. 

The  nature  of  the  mechanism  and  the  forces  which  at  any 
time  control  the  pelvic  contents,  solid  and  fluid — in  other 
words,  the  pelvic  environment — may  be  briefly  shown.  The 
lateral  walls  of  the  pelvis  are  bony,  fixed,  and  not  subject 
to  change  of  any  kind.  In  the  inferior  direction  are  the 
vagina,  practically  open  and  unresisting,  and  the  perinaeum, 
of  only  slight  mechanical  stability.  These  together  are 
quite  incapable  of  resisting  any  continuous  impinging  force ; 
they,  in  fact,  yield  on  moderate  pressure.  The  only  re¬ 
maining  boundary  is  the  superior — that  opposed  to  the  in¬ 
ferior  boundary  of  the  abdomen.  This  boundary  is  nominal 
and  does  not  exist  as  a  practical  fact,  for  the  pelvic  cavity 
is  mechanically  continuous  with  that  of  the  abdomen  ;  the 
two  designations  relate  to  parts  of  the  one  cavity  of  the 
trunk.  The  two  classes  of  viscera,  the  abdominal  or  digest¬ 
ive  and  the  pelvic,  are  in  practical  contact.  And,  as  be¬ 
fore  intimated,  the  superimposed  portions,  by  their  facile 
glidings,  turnings,  wedgings,  and  insinuating  moldings  to 
the  presenting  irregularities  of  the  pelvic  contents,  exercise 
a  force  on  the  latter  which,  when  morbid,  is  shown  in  symp¬ 
toms  pertaining  to  the  inferior  and  dominated  parts.  The 
dominating  force  is  healthful  or  otherwise,  according  to  cir¬ 
cumstances.  The  nature  of  this  force  is  made  clear  by  a 
single  suggestion. 

If  the  abdominal  mass  be  suddenly  raised,  say  to  the  ex¬ 


tent  of  an  inch,  does  any  one  suppose  that  a  vacuum  would 
be  caused  in  that  perpendicular  space  as  broad  as  the  pel¬ 
vic  diameter  ?  By  no  means.  Any  one  understanding  the  ac_ 
tion  of  a  pump  knows  that  an  upward  force  is  exerted  on  the 
inferior  parts  to  a  degree  far  in  excess  of  that  required  to 
raise  them  into  the  occupancy  of  such  space.  The  force  in 
this  way  rendered  active  is,  indeed,  practically  irresistible. 
The  pelvic  contents  may  therefore  be  easily  and  certainly 
controlled  as  to  location  by  mechanical  causes  and  condi¬ 
tions  whose  location  is  above,  not  below  them. 

This  statement  of  physiological  fact  is  undoubted  as 
relates  to  health  ;  that  is,  for  all  except  the  suffering  class. 
The  loss  of  health  of  the  pelvic  organs  is  therefore  evidence 
of  defects  of  the  mechanico-physiological  function  whereby 
sustentation  is  naturally  maintained.  The  restoration  of 
such  function  is  the  only  actual  remedy  possible,  since  other 
morbid  phenomena  are  mainly  derivative,  secondary,  and 
incapable  of  existence,  except  on  condition  of  the  defects 
described. 

For  those  who  have  had  no  practical  experience  in  ren¬ 
dering  available  for  remedial  purposes  the  source  of  power 
now  referred  to,  further  elucidation  of  the  principles  brought 
into  action  may  be  needful.  It  will  be  noted  that  sponta¬ 
neous,  constant  fluctuations  of  the  capacity  of  the  cavity  of 
the  trunk  characterize  all  animals,  from  man  down,  including 
all  species.  These  fluctuations  of  space,  produced  by  changes 
of  exterior  boundaries  of  the  included  space,  are  rhythmic, 
and  synchronous  with  inspiration  and  expiration  of  a  corre¬ 
sponding  amount  of  air.  These  fluctuations  do  not  cause 
interior  vacant  spaces,  but  measure  the  fifteen  to  thirty 
cubic  inches  of  air  to  which  they  correspond.  Not  one 
fifth  of  the  trunk  capacity  for  fluctuation  is  usually  called 
into  use  ;  there  is  hence  an  enormous  reserve  of  mechanical 
capacity  and  of  the  forces  which  control  it.  In  birds  the 
mecbanico-anatomical  conditions  are  such  that  the  exterior 
fluctuation  is  almost  wholly  at  the  posterior  part  of  the 
trunk,  the  portion  corresponding  to  the  perinaeum  in  other 
animals.  In  quadrupeds  the  lower  abdomen,  including  the 
pelvis,  which  is  an  offset  from  the  abdominal  cavity,  en¬ 
gages  in  the  constant  rhythmic  fluctuations.  This  is  very 
obvious  when  the  creature  is  at  rest  or  in  moderate  exer¬ 
cise.  The  whole  trunk  engages  in  increasing  the  amount  of 
fluctuations  of  the  space  it  includes  when  under  the  stress 
of  vigorous  exercise.  In  neither  case  are  these  fluctuations 
limited  to  the  chest. 

The  location  of  the  fluctuating  area,  and  consequently 
of  adjacent  interior  parts,  is  easily  seen  to  be  different  in 
the  persons  of  women  suffering  from  pelvic  diseases,  pelvic 
malpositions,  in  all  ruptured  persons,  and  in  those  liable  to 
fall  under  these  categories.  In  these  cases  the  rhythmic 
movements  of  exterior  fluctuation  of  the  walls  of  the  trunk 
are  both  restricted  and  perverted.  The  most  casual  obser¬ 
vation  shows  that  in  all  examples  of  either  of  these  cases 
there  is  little  if  any  movement  of  the  inferior  portion  of  the 
walls  of  the  trunk.  The  non-fluctuating  area  includes  the 
lower  abdomen,  and  consequently  the  pelvic  space,  which  is 
a  mechanical  offset  therefrom. 

The  respiratory  rhythm  and  fluctuation  of  trunk- space 
is,  in  pelvic  diseases,  morbidly  restricted  to  the  upper  por- 


36 


TAYLOR:  THE  BRANDT  REMEDIAL  METHODS  FOR  PELVIC  AFFECTIONS.  [N.  Y.  Med.  Jour., 


tion  of  the  trunk.  It  fails  to  extend  through  the  mass  of 
its  contents,  and  to  include  the  pelvic  viscera.  But  few  of 
the  muscles  normally  adapted  to  that  use  engage  in  the  act. 
The  lower  abdominal  and  the  pelvic  contents  are  left  mo¬ 
tionless,  while  the  restricted  movements  are  morbidly  trans¬ 
ferred  to  the  opposite  extremity  of  the  common  cavity — 
that  is,  to  the  apex  of  the  chest. 

The  above-described  perversion  and  restriction  of  the 
natural  and  necessary  action  of  the  organic  mechanism  en¬ 
tail  the  disadvantages  which  result  in  morbid  position  and 
morbid  phenomena. 

The  fluctuations  of  space  within  the  cavity  of  the  trunk 
bear  a  close  resemblance  to  the  action  of  a  pump,  and  may 
be  described  as  a  continuous  lift.  All  organs  within  the 
cavity  of  the  pelvis  are  subjected  to  this  lifting  force.  It 
affords  sustentation  to  these  organs  and  maintains  wholesome 
mechanical  interrelations  between  them.  As  long  as  this 
act  supplies  due  and  constant  upward  tension ,  malposition 
and  deformity  can  not  exist.  The  remedy  for  morbid  loca¬ 
tion  of  the  pelvic  contents  is  hence  to  supply  the  upward 
tension  which  is  naturally  due  them. 

But  it  is  not  enough  that  sustaining  energy  be  supplied 
to  the  contents  of  the  pelvis.  There  is  practically  no 
vacant  space  into  which  the  pelvic  contents  can  possibly 
ascend  till  such  space  is  provided.  The  uterus  and  ovaries 
can  not  be  impelled  by  physical  force  into  preoccupied  lo¬ 
cations.  They  will  pass  into  such  positions  only  in  propor¬ 
tion  as  the  parts  above  them  recede.  No  other  force  is 
required. 

It  follows  that  the  sustaining  force,  to  effect  the  desired 
purpose,  must  extend  equally  to  the  abdominal  contents; 
in  fact,  the  efficient  sustentation  reaches  the  peivic  contents 
through  the  abdominal.  The  whole  mass  of  the  common 
cavity  engages  in  the  fluctuating  motion  superinduced  by 
the  muscular  walls  of  the  trunk. 

The  natural,  incessant,  mechanical  fluctuations  of  the 
walls  of  the  trunk  at  their  inferior  boundary,  as  above  de¬ 
scribed  and  as  witnessed  in  the  lower  animals  and  the  healthy 
of  the  human  species,  have  a  further  physiological  purpose 
not  less  important  than  that  above  shown.  By  this  me¬ 
chanical  action  a  constant  and  perfect  drainage  of  the  pelvic 
contents  is  secured.  It  is  in  vain  to  expect  the  return  of 
health  in  these  parts  while  the  return  circulation  is  imper¬ 
fect  and  obstructed. 

The  venous  blood,  and  indeed  all  excess  of  local  inter¬ 
stitial  as  well  as  vascular  fluids,  are,  by  the  means  described, 
returned  to  the  general  system.  The  influence  of  the  same 
vito-mechanical  acts  extends  to  whatever  morbid  ingre¬ 
dients  these  fluids  may  bear.  The  return  circulation  from 
both  the  head  and  the  pelvis  is  secured  by  essentially  the 
same  mechanism.  Neither  part  has  control  of  its  own  venous 
contents;  these  in  both  cases  are  dominated  by  mechanism 
at  a  distance,  urging  the  whole  venous  mass  of  blood  toward 
the  common  center.  The  mechanical  influence  extends, 
when  its  degree  is  normal  and  healthy,  to  the  remotest  capil¬ 
laries,  and  maintains  them  clear  of  obstructions. 

The  mechanico-physiological  facts  above  set  forth,  so 
far  from  being  obscure  and  open  to  question,  are,  on  the 
contrary,  patent  to  all  observers.  They  are  too  common  I 


and  well  known  and  universally  accepted  to  invite  opposi¬ 
tion  or  even  attention.  Their  acceptance,  however,  affords 
a  complete  rationale  of  the  mechanical  control  of  the  pel¬ 
vic  mass  and  parts  and  of  the  pelvic  fluids.  The  action  of 
this  mechanism  is  functional ;  it  extends  to  and  is  unequiv¬ 
ocally  connected  with  the  cavity  of  the  pelvis.  The  func¬ 
tion  described  maintains  the  position  of  the  organs  of  the 
pelvis  as  a  mass  and  as  separate  parts.  It  also  maintains 
the  nutritive  activities  of  the  same  organs  by  withdrawing 
their  venous  circulation,  which  is  the  indispensable  condi¬ 
tion  for  admission  of  the  arterial.  The  conclusion  is  irre¬ 
sistible  that  defects  of  this  raising  and  sustaining  function 
result  in  defects  of  position — that  is,  malposition  of  parts; 
and  that  defects  of  local  nutrition,  through  lack  of  insuffi¬ 
cient  change  of  local  fluids,  inevitably  result  in  nutritive 
perversion,  or  its  synonym,  disease. 

It  is  not  difficult  to  understand  the  commanding  thera¬ 
peutic  value  of  the  physiological  facts  and  principles  above 
explained.  But  persons  with  only  the  slight  acquaintance 
with  them  here  afforded,  and  no  experience  adapted  to  con¬ 
firm  them,  may  be  forgiven  if  they  harbor  some  doubt  until 
such  facts  and  principles  have  been  verified,  if  possible^ 
through  personal  experience  and  by  adequate  tests.  The 
mechanico-physiological  function  brought  to  view  is  practi¬ 
cally  identical  with  that  of  respiration,  and  consequently  be¬ 
yond  question.  What  the  inquirer  wants  to  know  is  whether 
the  power  and  the  scope  of  the  organic  mechanism  extend  in 
fact  to  the  interior  of  the  pelvis;  and  whether,  if  this  be 
the  case,  such  power  is  both  adapted  and  adequate  to  control 
the  position  and  the  condition  of  the  pelvic  organs ;  and 
whether  such  control  is  capable  of  transforming  the  patho¬ 
logical  into  a  physiological  state.  It  is  further  desirable  to 
know  whether  these  principles  are  susceptible  of  being  car¬ 
ried  out,  proved,  and  confirmed  by  actual  practicable  pro¬ 
cesses,  which  effectually  raise  to  and  sustain  in  natural  posi¬ 
tion  the  previously  depressed  deformed  parts  fixed  by  mor¬ 
bid,  perhaps  old,  adhesions.  It  is,  again,  of  the  utmost  conse¬ 
quence  to  learn  whether  the  pent-up,  restrained,  deteriorating 
fluid  contents  of  these  local  parts  may  be  sent  freely  along 
their  natural  channels  and  become  submitted,  with  that  of  all 
parts,  to  the  powerful  chemistry  of  the  whole  organism. 
To  all  such  inquiries  I  give  an  emphatic  affirmative  reply. 

Many  experienced  physicians  join  me  in  this  affirmation. 
They  have  reduced  to  successful  every-day  practice  the  prin¬ 
ciples  herein  set  forth,  and  with  most  unalloyed  satisfac¬ 
tion.  They  have  found  their  former  methods  in  great  de¬ 
gree  superseded,  substituted  by  those  more  radical  and 
permanent.  As  for  myself,  after  being  well  trained  in  the 
ways  of  the  brightest  and  best  of  the  lights  of  gynaecology, 
now  departed  forever,  these  ways  and  methods  were  gradu¬ 
ally  displaced  by  those  arising  from  a  broader  consideration 
of  physiological  facts.  The  mechanico  physiological  meth¬ 
ods,  as  they  developed,  proved  to  be  both  speedy  and  posi¬ 
tive  as  well  as  permanent  in  their  effects.  My  personal  tests 
of  the  merit  of  the  principles  here  presented  extend  over 
thirty  years,  and  include  the  severest  and  least  curable  forms 
of  cases  not  remedied,  and  often  irremediable,  by  any  less 

direct  and  thorough  curative  methods. 

©  • 

To  assist  the  inquirer  to  a  more  vivid  and  comprehensive 


July  12,  1890.]  TAYLOR:  THE  BRANDT  REMEDIAL  METHODS  FOR  PELVIC  AFFECTIONS . 


37 


estimate  of  the  mechanico-physiological  methods  for  pelvic 
affections,  I  may  be  indulged  in  making  a  further  exposition 
of  them.  Not  only  is  the  pelvic  cavity  at  the  base,  and  in  one 
sense  a  part  of  the  abdominal  cavity,  but  its  walls  may  easily 
be  conceived  as  being  extended  on  all  sides  so  as  to  be  con¬ 
tinuous  with  and  include  those  of  the  base  of  the  abdomen. 
Being  therefore  sections  of  the  same  parts,  they  are  neces¬ 
sarily  subject  to  the  same  laws  and  functions. 

It  will  be  seen  that  the  extension  to  which  attention  is 
now  invited  includes  the  region  of  hernia.  An  analogy  be¬ 
tween  hernia  and  pelvic  affections  becomes  evident  on  due 
reflection.  The  intestine  or  omentum  in  the  protruded  sac 
parallels  the  morbid  descent  of  the  pelvic  contents.  The 
two  are,  in  fact,  quite  the  same,  the  pelvic  organs  obscuring 
the  {Displacement  of  the  overlying  intestines.  Both  are 
consequences  of  unsustained  weight  of  digestive  organs. 
In  the  one  case  an  artificial  receptacle  is  formed  by  violent 
distension  of  a  portion  of  the  wall ;  in  the  other  case  the 
receptacle  is  ready-formed  and  natural.  Both  are  parts  of 
the  same  peritonaeum. 

Hernia  occurs  at  points  of  least  resistance.  So  does 
prolapse  of  pelvic  organs.  Hernial  protrusion  is  caused  by 
persistent  pressure  of  a  knuckle  of  intestine,  due  to  immo¬ 
bility  of  the  abdominal  mass;  prolapse  of  the  contents  of 
the  pelvic  cavity  has  the  same  antecedent  condition. 
Strangulation  of  hernia  results  from  defective  communica- 
tion  between  the  contents  of  the  sac  and  those  of  the  abdo¬ 
men  ;  chronic  disease  of  the  pelvic  organs  betokens  a  similar 
lack.  The  very  narrow  neck  of  hernia  renders  the  obstruc¬ 
tion  more  complete  and  the  symptoms  more  acute  than  is 
incident  to  the  pelvic  superior  opening. 

The  nature  of  the  mechanical  problem  presented  in  both 
strangulation  of  hernia  and  the  suffering  pelvic  contents 
may  now  be  separated  from  other  considerations,  and  the 
remedial  needs  may  thereby  be  better  understood.  The 
problem  is  not  what  it  is  ordinarily  assumed  to  be.  It  is 
not  a  problem  of  mechanical  pushing  in  and  holding  up  of 
merely  the  insignificant  amount  of  obtrusive  flesh,  but  of 
restoring  pre-existing  physiological  and  mechanico  physio¬ 
logical  connections — of  re-establishing  normal  relations  of 
parts,  all  of  which  are  within  the  peritonaeum. 

Defect  of  those  spontaneous  organic  motions  which  in¬ 
here  in  all  healthy  animals  during  life  is  the  potential  fac¬ 
tor  or  cause  in  both  classes  of  cases.  The  restoration  of  the 
normal  degree  and  form  of  the  same  actions  is  the  indis¬ 
pensable  condition  of  cure ;  and  for  this  there  can,  in  the 
nature  of  things,  be  no  complete  remedial  substitute. 

This  spontaneous  organic  motion  is  subject  to  augmen¬ 
tation  as  well  as  restriction.  The  former  is  remedial,  as  the 
latter  is  the  opposite.  Through  artificial  devices  and  meth¬ 
ods  the  fluctuation  of  capacity  of  the  trunk  may  be  enor¬ 
mously  increased.  The  power  which  urges  upward  the  con¬ 
tents  of  the  trunk,  including  those  of  the  pelvis,  then  be¬ 
comes  very  much  in  excess  of  wbat  is  required  to  draw  up 
the  retroflexed  uterus,  to  divulse  adhering  parts,  and  to  re¬ 
turn  the  escaped,  strangulated  intestine  to  the  abdominal 
cavity,  in  spite  of  the  size  it  may  have  acquired  and  the  re¬ 
sistance  of  the  canal  through  which  it  must  repass.  Should 
the  reader  desire  the  practical  data,  enabling  him  to  verify 


the  above  statements,  he  will  be  provided  with  such  in  the 
form  of  a  monograph  (gratuitously)  by  making  application 
at  71  East  Fifty-ninth  Street,  New  York. 

The  fact  that  pelvic  affections  of  women  are  usually  very 
slowly  acquired  aud  chronic  does  not  affect  the  nature  of 
the  essential  defect,  or  the  nature  of  the  means  adapted  to 
effect  their  removal.  This  fact  only  emphasizes  the  necessit  v 
of  cultivation  of  the  defective  power  to  raise  it  to  the  de¬ 
sired  standard.  Remedial  attention  bestowed  on  subor¬ 
dinate  factors  or  consequences  of  the  initial  defect  are 
necessarily  incapable  of  reaching  the  dominating  factor. 
The  propriety  of  this  class  of  remedies,  mainly  palliative,  is 
subject  to  the  judgment  of  the  physician. 

To  aid  the  inquirers  to  greater  familiarity  with  the  prin¬ 
ciples  of  the  mechanical  order  involved  in  hernia  and  ill 
conditions  of  the  pelvic  organs,  I  will  point  out  further 
mechanical  analogies.  The  walls  of  the  cavity  of  the  trunk 
may  be  represented  by  the  bulb  of  a  common  syringe.  An 
indentation  by  the  fingers  of  such  a  bulb  excludes  its  fluid 
contents  to  an  extent  equal  to  the  indentation.  The  re¬ 
moval  of  the  pressure  allows  the  force  residing  in  the  instru¬ 
ment  to  draw  up  the  contents  of  the  pipe  or  neck.  If  the 
bulb  has  a  very  thin,  unresisting  area,  a  defect  near  its  neck, 
that  area  would  bulge  out  on  compression  of  other  parts, 
especially  if  the  pipe  be  obstructed;  the  same  area  would, 
by  its  oscillations,  indicate  all  variations  of  degree  of 
compression.  No  one  would  doubt  but  that  all  these 
changes  of  form  would  exactly  indicate  and  be  due  to  cor¬ 
responding  changes  in  the  motor  source,  which  in  this  case 
is  the  changing  pressure  of  the  fingers  and  the  contents  of 
the  cavity.  The  outward  impulsion  of  the  thinned  part  of 
the  bulb  practically  removes  undue  pressure  from  the  whole 
remaining  interior.  So,  too,  when  removal  of  pressure  of 
the  fingers  allows  the  elastic  force  to  assert  itself,  such  force 
becomes  manifest  only  at  the  protruded  part,  which  is 
drawn  in  to  the  same  extent  and  by  the  same  force  as  caused 
the  outward  protrusion. 

Let,  now,  this  weakened  and  yielding  portion  of  the 
bulb  be  conceived  as  so  changed  in  shape  as  to  consti¬ 
tute  a  true  sac  and  neck.  It  will  be  readily  admitted  that 
it  is  still  a  part  of  the  common  cavity,  and  that  the  force, 
which  for  convenience  rather  than  accuracy  may  be  called 
suction,  extends  to  the  fluids  contained  within  this  branch¬ 
ing  sac,  through  its  neck,  in  precisely  the  same  degree  as 
though  there  were  no  neck.  Moreover,  this  point  offering- 
no  resistance,  the  whole  motor  energy  and  motor  effect  of 
the  elastic  bulb  is  manifested  here;  and  should  the  pipe  be 
closed,  the  extended  portion  of  wall  would  instantly  be 
sucked  in — returned.  We  may  next  conceive  the  transverse 
area  of  the  neck  and  its  communication  with  the  sac  as  be¬ 
ing  indefinitely  small — less  than  the  diameter  of  the  finest 
needle.  This  supposition  w'ould  make  no  difference  with 
the  nature,  or  the  amount,  or  the  direction  of  the  forces  en¬ 
gaged,  or  with  the  effect  of  suction  on  the  fluid  contents. 
There  is  still  a  communication  between  the  sac  and  the  ab¬ 
dominal  cavity  by  means  of  and  through  the  wet  tissues, 
even  in  the  absence  of  pervious  vessels.  The  least  differ¬ 
ence  of  pressure  in  the  two  cavities  causes  transfer  of  fluid 
inward ,  as  previously  it  did  outward.  Strangulation  does 


38 


LE  FEVRE:  DIGITALIS  IN  CARDIAC  DISEASE. 


[N.  Y.  Med.  Jolb., 


not  obliterate,  but  only  obstructs  communication,  and  indi¬ 
cates  the  immediate  need  of  reversing  its  direction.  The 
moment  the  experimenter  applies  this  fact  to  practice  he 
obtains  direct  evidence,  through  sight  and  touch,  by  the 
cessation  of  vomiting  and  of  pain,  that  transfer  of  fluids  is 
progressing.  The  observer  will  remark  the  very  insig¬ 
nificant  amount  of  solids  in  the  sac  after  drainage  of  its 
fluids  and  the  ease  with  which  these  slip  back  through  the 
neck,  however  tortuous  its  cause  or  sharp  the  constricting 
pillars. 

Hernial  cases,  which  are  more  visible,  tangible,  and  im 
minent  than  those  appertaining  to  the  pelvis,  demonstrate 
more  clearly  the  actuality,  and  even  the  great  excess,  of  up¬ 
lifting  force,  easily  and  quickly  available,  and  that  the  usual 
obstacles  are  insuflicient  to  resist  its  remedial  efficacy.  But 
pelvic  cases,  in  which  malposition  is  symbolized  by  hernial 
protrusion,  and  ill-condition  by  strangulation,  are  in  gen¬ 
eral  very  chronic.  This  fact,  to  a  certain  extent,  modifies 
the  purpose  of  the  remedy.  An  adequate  uplifting  and 
suction  force  is  still  demanded ;  but  there  is  also  required 
such  increase  of  the  natural  mechanico-physiological  powers 
which  produce  these  effects  as  can  be  secured  only  by  due 
cultivation  of  the  instruments  of  this  force.  Nothing  less 
is  worthy  the  name  of  “  cure  ”  in  these  classes  of  cases. 

The  mechanico-physiological  and  the  mechanico-patho- 
logical  relations  of  the  contents  of  the  female  pelvis  will 
now  admit  of  distinct  and  intelligible  statement. 

No  distinct  mechanical  supports  of  the  contents  of  the 
pelvis  exist  in  anatomy,  and  none  are  required.  Malposi¬ 
tions  and  ill-conditions  do  not  occur  in  consequence  of  such 
deficiency,  nor  can  local  ill-conditions  of  the  pelvic  contents 
be  rectified  by  an  artificial  supply. 

The  “  strengthening  ”  of  the  pelvic  organs,  were  this 
possible,  by  local  massage,  or  remedies  having  a  similar  pur¬ 
pose,  can  not,  in  the  nature  of  things,  reach  the  sources  of 
the  local  manifestations,  which  exist  in  environments,  and 
alone  are,  therefore,  incapable  of  securing  permanent  re¬ 
sults. 

Sustentation  of  the  contents  of  the  female  pelvis  is,  on 
the  contrary,  functional  and  automatic.  It  does  not  reside 
in  or  appertain  to  the  sustained  organs,  but  exists  in  their 
environment.  The  same  physiological  facts  have  equal 
application  to  conditions  as  well  as  positions.  Both  are 
dominated  by  forces  exterior  to  the  organs  imperiled. 

The  amount  of  mechanical  force  latent  in  the  mechan¬ 
ism  of  the  organism  is  greatly  in  excess  of  that  needed  for 
restoring  natural  and  desirable  position  of  pelvic  organs. 
To  convert  the  available  into  sustained  and  constant  force 
adapted  to  the  same  uses  requires  due  cultivation  of  the 
instruments  of  such  force  by  art. 

The  remedial  aim  in  these  cases  should  be  to  restore  the 
natural  degree  of  fluctuation  of  space  in  the  cavity  of  the 
trunk;  to  secure  this  fluctuation  of  space  at  the  inferior 
portion  of  this  cavity.  This  necessarily  causes  its  diminu¬ 
tion  at  the  opposite  or  upper  end  of  the  same  cavity  ;  a 
transfer  of  the  involuntary  organic  act  from  the  top  to  the 
bottom  of  the  common  trunk  cavity.  Medication  unrelated 
to  this  purpose  is  proper  to  the  extent  that  local  palliative 
medication  is  legitimate. 


WIIAT  IS  ACCOMPLISHED  BY  THE 
USE  OF  DIGITALIS  IN  CARDIAC  DISEASE  ?* 
By  EGBERT  LE  FEYRE,  M.  D. 

In  bringing  before  you  to-night  this  well-worn  topic  I 
feel  almost  like  offering  an  apology.  Still,  at  times  it  seems 
necessary  to  review  the  grounds  of  our  beliefs,  and  have 
clearly  fixed  the  limitations  of  the  power  of  the  different 
remedies  to  combat  the  effects  of  organic  diseases. 

The  heart  is  an  organ  whose  parenchyma  consists  of  the 
peculiar  fibers  that  have  the  characteristics  of  both  striped 
and  involuntary  muscles,  and  the  function  of  the  organ  is 
to  propel  the  blood  through  the  systems  over  which  it  pre¬ 
sides.  The  muscular  fiber  may  be  diseased  or  the  mechan¬ 
ism  may  be  altered,  but,  until  the  heart  is  unable  to  so  dis¬ 
tribute  the  blood  as  to  meet  the  requirements  of  the  sys¬ 
tem  at  large,  the  patient  is,  in  a  great  majority  of  cases, 
ignorant  of  any  morbid  process. 

In  common  with  all  muscular  tissue,  that  of  the  heart 
has  the  inherent  tendency  to  increase  in  size  and  strength 
when  the  work  that  it  is  called  upon  to  do  is  increased. 
That  this  compensating  hypertrophy  may  occur,  the  nerv¬ 
ous  mechanism  of  the  heart  must  be  adequate,  and  the 
quantity  and  quality  of  nutritive  fluid  equal  to  the  increased 
demands.  In  cardiac  diseases  this  conservative  process  is 
the  one  thing  to  be  desired,  and,  when  obtained,  to  be 
guarded  and  kept  to  the  point  where  the  heart  is  able  to  so 
perform  its  function  as  to  meet  the  fastidious  and  exacting 
demands  of  the  organism. 

To  understand  the  action  of  digitalis  in  cardiac  diseases, 
it  is  necessary  to  observe  its  effects  upon  the  normal  heart. 
When  given  in  physiological  doses,  it  increases  the  force 
and  completeness  of  the  ventricular  contractions ;  a  larger 
blood-wave  is  thrown  into  the  vessels,  while  the  number  of 
beats  per  unit  of  time  is  lessened.  If  the  doses  are  in¬ 
creased,  “the  systole  becomes  abnormally  energetic,  so  that 
the  ventricles  become  white  as  the  last  drop  of  blood  is 
squeezed  out  of  them,”  and  the  heart  during  diastole  does 
not  dilate  uniformly,  the  contracted  portions  showing  as 
white  patches.  Two  theories  have  been  advanced  to  account 
for  the  slowing  of  the  heart  by  digitalis.  According  to  the 
mechanical  theory,  the  heart  contracting  more  completely, 
a  larger  amount  of  blood  is  thrown  into  the  aorta  and  pul¬ 
monary  artery  at  each  beat.  As  the  escape  of  blood  through 
the  capillaries  is  not  proportionally  increased,  with  the  sub¬ 
sequent  heightening  of  the  resistance  in  these  vessels,  each 
wave  demands  more  power  to  force  it  from  the  ventricles, 
and  the  heart  is  slowed  in  accordance  with  the  physical  law. 
What  is  gained  in  power  is  lost  in  speed.  If  this  was  the 
true  explanation,  “  then  the  curve  of  the  sphygmographic 
tracing  would  be :  Ascent  very  oblique,  height  of  curve 
small,  and  line  of  descent  very  oblique  also.”  The  direct 
opposite  of  this  occurs. 

The  advocates  of  the  other  theory  claim  that  it  exerts  an 
inhibitory  action  on  the  heart  through  some  portion  of  the 
nervous  system.  The  experiments  of  Boehm,  Dybkowsky, 

*  Read  before  the  Society  of  the  Alumni  of  Bellevue  Hospital,  May 
V,  1890. 


July  12,  1890.] 


LE  FEVRE:  DIGITALIS  IN  CARDIAC  DISEASE. 


39 


Pelikcn,  and  Ackerman  prove  that  it  is  not  through  the 
pneumogastrics  nor  the  spinal  cord,  as  the  heart  was  slowed 
by  its  use  after  the  destruction  of  the  cord  and  the  division 
of  the  vagi  or  the  paralyzing  of  their  peripheral  ends  by 

atropine. 

Wood  has  concisely  stated  the  status  of  our  present 
knowledge:  “Digitalis  in  moderate  doses  stimulates  the 
musculo-motor  portion  of  the  heart  (probably  its  contained 
ganglia),  increases  the  activity  of  its  inhibitory  apparatus, 
and  causes  contraction  of  the  arterioles,  probably  by  an  ac¬ 
tion  on  the  vaso-motor  centers  in  the  cord.” 

Does  digitalis  exert  any  influence  upon  those  nutritive 
changes  that  produce  hypertrophy  or  cause  its  restoration 
when  the  compensation  has  been  ruptured  ?  It  was  for¬ 
merly  supposed  that  the  semilunar  valves  closed  the  open¬ 
ings  of  the  coronary  arteries,  so  that  they  were  filled  during 
diastole  only.  This  has  been  disproved.  The  flow  of 
blood  in  these  arteries  is  increased  in  common  with  that  in 
the  systemic’ circulation  by  the  augmented  power  of  the 
systole.  During  diastole,  the  greater  the  arterial  tension  in 
the  aorta  the  more  rapid  is  the  flow  of  blood  through  the 
cardiac  blood-vessels,  and  the  nutrition  of  the  heart  is  pro¬ 
portionally  increased.  One  of  the  most  noted  effects  of 
digitalis  is  its  influence  in  raising  the  blood  pressure  in  the 
aorta. 

“  The  branches  and  capillaries  of  the  coronary  arteries 
lie  within  the  layers  of  the  muscular  fibers  and  are  sur¬ 
rounded  by  primitive  bundles  of  fibers,  while  the  lymphatics 
lie  between  the  layers.”  This  peculiar  arrangement  has  an 
important  bearing  on  the  nutrition  of  the  cardiac  muscle. 
Digitalis,  by  its  action  on  the  musculo-motor  portion  of  the 
heart,  causes  a  more  complete  contraction  of  these  encir¬ 
cling  fibers,  forcing  the  blood  into  the  veins  and  accelerating 
the  extravascular  circulation,  producing  nutritive  changes 
analogous  to  those  of  the  faradaic  current  on  voluntary 
muscles. 

Important  as  the  above-mentioned  factors  are,  the  power 
of  digitalis  over  cardiac  nutrition  can  only  be  explained  by 
the  theory  that  it  acts  on  the  trophic  centers  and  nerves, 
placing,  as  it  were,  the  cardiac  muscle  fiber  in  a  condition 
to  appropriate  the  elements  of  the  blood  needed  for  its 
growth. 

When  the  valvular  mechanism  is  deranged  the  heart 
adapts  itself  to  the  change  by  the  corresponding  increase 
in  power  of  those  parts  whose  work  is  increased.  The 
prognosis  and  treatment  of  valvular  lesions  depend  on  the 
orifice  affected,  the  character  and  extent  of  the  lesion,  and 
especially  on  the  effect  that  the  modification  in  the  move¬ 
ment  of  blood  through  the  heart  has  on  the  work  and  nu¬ 
trition  of  the  entire  cardiac  muscle.  Each  lesion  of  the 
valves  adds  its  own  peculiar  factor  to  the  problem.  In 
mitral  stenosis  without  insufficiency  there  is  rarely  dilata¬ 
tion  of  the  cavity  of  the  auricle,  as  the  pressure  in  the  pul¬ 
monary  veins  is  not  sufficient  to  produce  overdistension 
during  diastole,  even  when  the  cavity  is  not  thoroughly 
emptied  during  systole.  Consequently,  the  primary  result 
of  this  lesion  is  simple  hypertrophy. 

As  long  as  the  auricle  is  able  to  empty  itself  through 
the  narrowed  orifice,  there  is  no  interference  with  the  pul¬ 


monary  circulation,  as  regurgitation  into  the  pulmonary  veins 
is  prevented  by  the  auricular  systole  beginning  in  the  circu¬ 
lar  bands  which  surround  the  mouths  of  the  veins.  It  is 
only  when  the  auricle  is  unable  to  empty  itself  that  pulmo¬ 
nary  engorgement  is  produced.  In  simple  mitral  stenosis 
there  is  no  hypertrophy  of  the  left  ventricle.  Until  the 
hypertrophy  fails  to  compensate  there  is  no  indication  for 
the  use  of  digitalis.  Some  have  advocated  the  use  of  digi¬ 
talis  in  this  lesion  on  the  theory  that  its  inhibitory  action 
allows  the  auricle  more  time  to  empty  itself. 

In  mitral  insufficiency  the  regurgitant  current  is  forced 
into  the  distensible  auricle  with  a  pressure  equal  to  the 
power  of  the  ventricle.  This,  together  with  the  blood 
poured  in  from  the  pulmonary  veins,  causes  primary  dilata¬ 
tion  with  coincident  hypertrophy  of -the  auricle.  On  ac¬ 
count  of  the  increased  capacity  of  the  auricle,  there  is 
forced  into  the  ventricle  an  amount  of  blood  sufficient  to 
overdistend  its  cavity  and  add  to  its  work  in  emptying 
itself ;  as  a  result,  hypertrophy  follows.  The  extent  of  ven¬ 
tricular  hypertrophy,  and  whether  or  not  it  is  accompanied 
by  dilatation,  determines  the  seriousness  of  the  valvular 
lesion.  The  most  important  factor  of  mitral  insufficiency  is 
its  effects  on  the  pulmonary  circulation  and  right  heart. 
The  blood  that  regurgitates  through  the  mitral  orifice,  by 
partially  filling  the  cavity  of  the  auricle,  prevents  the  emp¬ 
tying  of  the  pulmonary  veins.  As  a  result,  the  tension  in 
the  pulmonary  artery  is  raised,  and  more  power  is  needed 
by  the  right  ventricle  to  empty  itself.  To  meet  this  de¬ 
mand  the  muscle  hypertrophies,  the  pulmonary  circulation 
is  restored,  and  the  mitral  lesion  is  compensated  for  as  long 
as  the  power  of  the  right  ventricle  is  sufficient. 

When  the  compensation  ceases,  the  failure  is  shown 
first  by  interference  with  the  pulmonary  circulation,  and 
then  by  dilatation  of  the  right  ventricular  cavity.  If  the 
dilatation  is  so  great  that  the  tricuspid  valves  can  not  close 
the  auriculo-ventricular  orifice,  regurgitation  follows,  with 
retarded  venous  circulation,  while  at  the  same  time  the  left 
ventricle  is  imperfectly  filled  and  pressure  in  the  aorta 
falls. 

Digitalis  can  not  cure  the  organic  lesion  of  the  mitral 
valves  that  causes  these  changes.  When  the  work  of  the 
right  ventricle  is  further  increased  by  some  intercurrent 
pulmonary  disease — as  bronchitis — digitalis,  by  its  tonic  ac¬ 
tion,  aids  the  heart  to  meet  the  emergency.  When  the  bur¬ 
den  has  become  too  great  and  dilatation  is  present,  digitalis, 
by  increasing  the  power  of  the  ventricular  contraction,  re¬ 
stores  for  the  time  being  the  pulmonary  circulation,  and,  by 
diminishing  the  relaxation  of  the  cavities,  the  tricuspid 
valves  again  become  sufficient  to  close  the  orifice.  For  these 
beneficial  results  to  become  permanent,  the  muscle  of  the 
right  heart  must  again  hypertrophy  enough  to  recompensate 
the  mitral  lesion,  plus  the  dilatation  of  the  right  ventricular 
cavity.  Digitalis  aids  in  this,  but,  above  all,  the  nutrient 
fluid  must  be  in  quantity  and  quality  sufficient  for  the  in¬ 
creased  demands  of  the  enlarged  muscle. 

Uncomplicated  aortic  stenosis  does  not  call  for  digitalis 
until  the  power  of  the  ventricle  fails.  This  is  shown  by  an 
irregular  action  of  the  heart — an  imperfect  filling  of  the 
aorta,  often  accompanied  by  a  mitral  systolic  murmur,  which 


40 


SYMONDS:  TESTS  FOE  SUGAR  IN  THE  URINE. 


[N.  Y.  Med.  Jock., 


shows  that  dilatation  of  the  ventricle  has  occurred  and  the 

auriculo-ventricular  orifice  has  been  stretched  to  such  a 

degree  that  the  valves  are  insufficient.  Digitalis  must  be 

<dvcn  to  restore  the  tone  of  the  muscle.  It  must  be  carried 
© 

far  enough,  if  possible,  to  bring  the  size  of  the  cavity  to  the 
point  where  the  mitral  valves  will  again  close  the  orifice. 

In  aortic  regurgitation  the  conditions  differ  from  lesions 
at  other  valves.  Normally  the  left  ventricle  at  each  contrac¬ 
tion  forces  its  contents  into  the  aorta  against  a  pressure  of 
250  mm.  of  mercury.  In  insufficiency  of  the  aortic  valves 
with  diastole  the  blood  is  forced  back  into  the  relaxed  and 
distensible  ventricle  with  a  pressure  equal  to  a  column  of 
blood  3*21  metres  in  height.  This,  according  to  Pascal’s 
law,  exerts  a  dilating  pressure  on  the  entire  ventricular 
wall.  The  size  of  the  opening  determines  the  rapidity  with 
which  the  pressure  in  the  aorta  and  that  in  the  ventricle 
become  equal.  As  the  capacity  of  the  auricle  equals  that 
of  the  ventricle,  at  the  auricular  systole  six  ounces  of  blood 
are  forced  by  the  hypertrophied  auricle  into  the  already 
filled  ventricle.  When  the  leak  at  the  aortic  orifice  is  at 
first  small  in  amount,  then  coincident  with  the  dilatation 
occurs  the  compensating  hypertrophy,  which,  when  perfect, 
counteracts  the  distending  tendency  of  the  two  streams  of 
blood.  When  the  insufficiency  occurs  suddenly,  or  when 
the  compensation  is  incomplete,  then  the  hydrostatic  press¬ 
ure  of  the  regurgitant  stream  soon  overcomes  the  resistance 
of  the  muscle  and  produces  so  great  a  dilatation  that  the 
mitral  valves  become  incompetent  temporarily,  relieving 
during  systole  the  overburdened  ventricle. 

In  this  lesion  there  is  constant  danger  of  death  from 
sudden  dilatation  and  syncope.  The  safety  of  the  patient 
depends  upon  the  ability  of  the  heart  to  maintain  its  hyper¬ 
trophy.  The  lowering  of  the  pressure  in  the  aorta  has  a 
deleterious  effect  upon  the  circulation  in  the  coronary  arte¬ 
ries,  so  that  there  is  in  addition  the  danger  of  degeneration 
in  the  heart  muscle  itself  from  malnutrition. 

Many  writers  maintain  that  it  is  dangerous  to  give  digi¬ 
talis  in  aortic  regurgitation,  as  the  tendency  to  death  from 
syncope  is  increased  by  the  lengthening  of  the  diastole  and 
the  consequent  increase  in  the  amount  of  regurgitation.  If 
digitalis  merely  slowed  the  heart,  the  objection  would  hold 
good;  but  with  its  inhibitory  action  it  also  has  the  power 
to  delay  the  relaxation  of  the  cardiac  muscle,  especially 
during  the  first  part  of  diastole.  It  is  this  power  which 
exerts  control  over  the  dilating  pressure  of  the  regurgitant 
stream  and,  by  maintaining  for  a  longer  time  the  pressure  in 
the  aorta,  increases  the  blood-supply  of  the  cardiac  muscle. 
In  aortic  regurgitation  the  dose  must  be  as  small  as  possible 
in  order  to  obtain  the  desired  therapeutic  effect. 

In  treating  the  degenerations  of  the  cardiac  muscle  inde¬ 
pendent  of  valvular  disease  two  things  are  to  be  considered  : 
1st,  to  lighten  the  work  of  the  heart ;  2d,  to  increase  its  nu¬ 
trition.  Digitalis  in  these  cases  not  only  acts  as  a  stimulant 
to  temporarily  arrest  the  failure  of  the  degenerated  muscles, 
but  also  produces  nutritive  changes.  At  the  same  time,  by 
the  action  of  the  drug  upon  the  blood-vessels,  the  tension 
in  the  aorta  is  raised  and  the  work  of  the  heart  is  increased. 
This  can  be  counteracted,  to  a  certain  degree,  by  the  use  of 
the  vaso-raotor  dilators. 


In  the  cardiac  dilatation  which  follows  the  hypertrophy 
caused  by  renal  and  arterial  diseases,  digitalis  must  be 
given  with  extreme  caution,  for,  by  its  power  to  raise  the 
blood  pressure,  rupture  of  a  diseased  artery  (especially  in 
the  brain)  may  be  induced.  Although  dilatation  is  usually 
the  result  of  valvular  lesions,  or  dependent  on  one  or  the 
other  form  of  degeneration  of  the  myocardium,  still  cases  are 
constantly  occurring  which,  in  their  auscultatory  signs,  simu¬ 
late  those  of  organic  causation.  They  occur  in  those  cases 
attended  by  extreme  muscular  debility  and  relaxation.  The 
murmurs  heard  in  the  mitral  area  are  due  to  imperfect  or 
rregular  contractions  of  the  ventricle,  which  allow  a  tem¬ 
porary  insufficiency  of  the  mitral  valves;  or,  by  the  stretch¬ 
ing  of  the  papillary  muscles  and  chordte  tendineie,  the  valves 
are  carried  too  far  into  the  auricle,  an  audible  regurgita¬ 
tion  being  produced.  Digitalis,  by  its  tonic  and  trophic 
action,  causes  the  murmurs  to  disappear,  and,  with  good 
blood,  may  be  said  to  cure  the  disease. 

The  beneficial  effect  of  digitalis  in  that  condition  known 
as  “irritable  heart”  may  be  explained  by  its  power  to 
strengthen  the  musculo-motor  apparatus  and  render  it  less 
susceptible  to  reflex  irritations. 


TESTS  FOR  SUGAR  IN  THE  URINE.* 

By  BRANDRETH  SYMONDS,  A.  M.,  M.  D. 

In  opening  this  discussion,  the  methods  by  which  we 
detect  the  presence  of  glucose  in  the  urine  must  first  be 
considered,  for  it  is  upon  the  delicacy  and  accuracy  of  our 
tests  that  the  value  of  our  clinical  investigations  will  depend. 
Nearly  all  the  tests  for  glucose  depend  upon  its  property 
of  abstracting  oxygen  in  the  presence  of  an  alkali.  Among 
these  reduction  tests,  so  called,  are  Fehling’s  solution,  Ny- 
lander’s  solution,  indigo-carmine,  picric  acid,  and  safranin. 
This  reducing  action  is  by  no  means  peculiar  to  glucose 
among  the  constituents  of  urine.  Of  normal  ingredients, 
uric  acid,  creatinin,  and  pyrocatechin  possess  it,  the  first  to  a 
slight  degree  only.  Among  the  bodies  occasionally  present 
in  the  urine  may  be  mentioned  oxybutyric  acid  ;  urochloralic 
acid,  which  is  derived  from  chloral ;  glycuronic  acid,  from 
camphor ;  turpenoglycuronic  acid,  from  turpentine ;  Mar¬ 
shall’s  glycosuric  acid  ;  and  Kirke’s  uroleucic  and  uroxanthic 
acids.  Besides  these,  many  drugs  form  reducing  substances 
during  excretion,  such  as  morphine,  chloroform,  salicylic 
acid,  cubebs,  copaiba,  glycerin,  liydroquinone,  and  carbolic 
acid.  Of  these  substances,  some  have  a  limited  range  of 
reducing  power,  while  others  affect  all  the  tests  mentioned. 
Although  these  reduction  tests  may  be  nearly  faultless  in 
point  of  delicacy,  it  is  evident  from  what  has  been  said  that 
their  accuracy  is  not  great.  To  take  them  up  in  detail : 

1.  The  Well-known  Fehling's  Solution. — This  possesses 
all  the  disadvantages  of  its  class,  being  readily  reduced  by 
other  substances  than  glucose.  It  has  the  further  disadvan¬ 
tage  of  spoiling  rapidly,  although  Schmiedeberg’s  modi¬ 
fication,  in  w'hich  mannite  is  used  instead  of  Rochelle  salt, 


*  Read  before  the  Society  of  the  Alumni  of  Bellevue  Hospital  at  its 
first  annual  reunion. 


July  12,  1890.] 


SYMONDS:  TESTS  FOE  SUGAR  IN  THE  URINE. 


41 


is  said  to  keep  well.  The  ordinary  solution  has  to  be 
divided  into  two  parts  in  order  to  prevent  decomposition, 
and  then  mixed  at  the  moment  of  using.  This  is  certainly 
an  awkward  proceeding.  On  the  score  of  delicacy  it  leaves 
hardly  anything  to  be  desired,  as  it  will  detect  one  twen¬ 
tieth  per  cent,  of  glucose  in  urine,  though  not  very  dis¬ 
tinctly.  In  order  to  do  this,  the  upper  layers  of  the  urine 
must  be  boiled  and  then  a  few  drops  of  a  proved  sample  of 
Fehling’s  solution  are  to  be  added.  The  upper  layers  are 
again  boiled  and  the  reduction  occurs.  It  has  been  said  that 
glucose  is  the  only  substance  that  will  reduce  Fehling’s  solu¬ 
tion  in  the  cold.  This  is  certainly  incorrect,  for  chloral  will 
reduce  it  readily  in  the  cold,  and  chloral  is  probably  ex¬ 
creted  in  part  as  such. 

2.  Nylander's  Solution.  —  This  is  a  modification  of 
Boettger’s  test  and  consists  of  2  grammes  of  bismuth  sub¬ 
nitrate  and  4  of  Rochelle  salt,  dissolved  in  100  c.  c.  of  a 
ten-per-cent,  solution  of  sodium  hydrate.  On  boiling  with 
glucose,  a  dark-brown  or  black  precipitate  of  metallic  bis¬ 
muth  and  bismuth  suboxide  is  produced.  It  has  the  advan¬ 
tage  over  Fehling’s  solution  of  not  spoiling.  I  have  kept  it 
in  an  ordinary  colorless  bottle  exposed  to  sun  and  air  during 
several  of  the  hot  months  without  any  discoverable  alteration. 
It  is  not  so  readily  reduced  as  Fehling’s  solution,  not  being 
affected  by  chloral,  pyrocatechin,  or  glycosuric  acid.  It  is, 
however,  less  delicate  than  Fehling’s  solution,  detecting  only 
one  tenth  per  cent,  of  glucose,  and  that  imperfectly.  The 
most  delicate  method  of  applying  the  test  is  to  till  a  test-tube 
about  half  full  of  urine  and  then  add  about  one  third  of 
the  solution.  Boil  the  upper  layers  and  note  the  reduction. 
Although  less  delicate  than  Fehling’s,  it  is  the  only  one  of 
the  reduction  tests  which  I  constantly  employ.  It  is  less 
cumbersome  and  gives  results  which  are,  I  think,  suffi¬ 
ciently  good  for  ordinary  clinical  work.  It  is  occasionally 
reduced  by  other  substances  than  glucose.  It  is  reduced 
by  glucose  in  the  cold,  and  also  by  normal  urine. 

3.  An  alkaline  solution  of  indigo-carmine  when  boiled 
with  glucose  becomes  decolorized,  changing  from  blue  to 
purple,  then  red,  and  finally  yellow.  This  play  of  colors  is 
due  to  deoxidation,  and  they  can  be  restored  in  the  inverse 
order  by  shaking  the  solution  with  the  air  and  thus  obtain¬ 
ing  oxygen.  The  alkali  used  must  not  be  caustic,  for  both 
potassic  and  sodic  hydrate  change  the  color  without  the 
aid  of  glucose.  The  one  commonly  used  is  sodic  carbonate. 

This  test  will  readily  detect  very  small  quantities  of 
glucose,  but,  unfortunately,  is  reduced  by  prolonged  boiling 
with  perfectly  normal  urine.  Oliver  maintains  that  it  is 
perfectly  reliable,  but  also  says  that  urine  normally  contains 
half  a  grain  of  glucose  to  the  ounce,  or  one  tenth  of  one 
per  cent.,  which  can  safely  be  denied. 

4.  The  same  objection  applies  to  picric  acid,  which, 
when  boiled  with  glucose  and  an  alkali,  is  reduced  to  the 
dark-red  picramic  acid.  This  red  color  occurs  also  with 
normal  urine,  the  creatinin  which  is  regularly  present  being 
sufficient  to  develop  it.  On  the  score  of  both  accuracy  and 
delicacy,  this  test  must  be  laid  aside. 

5.  With  safranin  I  have  not  had  much  experience.  In 
the  presence  of  glucose  and  an  alkali  the  red  color  is 
changed  into  a  dirty  white.  This  alteration  is  produced 


likewise  by  prolonged  boiling  with  albumin,  though  normal 
urine  does  not  cause  it.  Whether  it  would  be  produced 
by  glycosuric  acid  or  some  of  the  other  reducing  substances 
occasionally  present  in  the  urine  I  can  not  say.  As  it  is  a 
reduction  test  it  seems  reasonable  to  suppose  that  the  change 
would  occur.  It  is  quite  delicate,  readily  indicating  one 
tenth  per  cent,  of  glucose. 

6.  In  this  class  must  be  placed,  I  think,  Molisch’s  test 
with  alpha-naphthol  or  thymol.  Into  2  or  3  c.  c.  of  urine 
are  put  three  or  four  drops  of  a  twenty-per-cent,  solution  of 
alpha-naphthol  in  alcohol.  Sulphuric  acid  is  then  added 
to  an  excess  of  three  or  four  times  the  bulk.  A  beautiful 
violet  color  forms  which,  on  large  dilution  with  water,  falls 
as  a  violet  precipitate.  If  thymol  is  used  instead  of  alpha- 
naphthol,  a  red  color  results,  followed  by  a  reddish  precipi¬ 
tate.  These  colors  and  precipitates  are  readily  produced 
in  normal  urine  by  this  test,  and  Molisch  of  course  states 
that  normal  urine  contains  sugar.  In  order  to  ascertain  the 
worth  of  this  method  I  took  2  c.  c.  of  normal  urine,  which 
showed  no  reaction  with  phenylhydrazin,  and  obtained  from 
it  an  abundant  violet  precipitate.  I  then  took  2  c.  c.  of 
water  containing  one  one-hundredth  per  cent,  of  glucose. 
On  applying  Molisch’s  method  I  obtained  a  violet  precipi¬ 
tate  about  one  fifth  in  amount  of  that  obtained  from  normal 
urine.  This,  I  think,  is  a  crucial  test  and  one  that  demon¬ 
strates  the  worthlessness  of  the  method  for  clinical  pur¬ 
poses.  It  is  undoubtedly  a  delicate  reaction  for  sugar,  but 
it  also  reacts  with  other  substances  normally  present  in  the 
urine. 

All  of  these  reduction  tests  have  only  a  negative  value, 
and  for  that  some  of  them,  such  as  Fehling’s,  can  hardly  be 
surpassed.  Fehling’s  will  indicate  one  twentieth  per  cent, 
of  glucose,  and  I  think  we  need  nothing  more  delicate  than 
that.  But  a  positive  result  with  any  of  them  is  valueless, 
since  they  can  be  so  readily  affected  by  other  reducing  sub¬ 
stances  than  sugar  which  may  be  present  in  the  urine. 
During  the  past  year,  as  Examiner  for  the  Mutual  Life  In¬ 
surance  Company,  of  New  York,  I  have  had  seven  or  eight 
cases  in  which  Fehling’s  and  Nylander’s  solutions  were  both 
reduced  by  urine,  which  urine,  on  subsequent  examination 
by  phenylhydrazin  and  by  fermentation,  was  shown  to  be 
entirely  -free  from  sugar.  I  can  recall  one  case  in  particular 
in  which  the  reduction  of  Fehling’s  solution  was  equivalent 
to  over  one  per  cent,  of  glucose.  Without  further  investiga¬ 
tion  these  would  doubtless  have  been  regarded  as  cases  of 
glycosuria,  and  on  that  ground  would  have  been  refused 
insurance.  Frank  Donaldson,  Sr.,  has  reported  a  more 
striking  case,  in  which  the  precipitation  of  Fehling’s  solu¬ 
tion  was  equivalent  to  over  eight  per  cent,  of  glucose. 
Marshall  subsequently  examined  the  urine  and  isolated  the 
reducing  substance.  This  he  called  glycosuric  acid,  not 
because  it  has  the  remotest  connection  with  glucose,  but  on 
account  of  the  similarity  of  its  action  on  Fehling’s  solution. 

There  are  but  two  methods  which  give  reliable  positive 
results — fermentation  and  phenylhydrazin.  In  the  former 
the  urine  is  fermented  and  the  carbon  dioxide  given  off  is 
collected  and  measured.  A  gramme  of  glucose  when  fer¬ 
mented  will  form  about  250  c.  c.  of  carbon  dioxide  at  ordi¬ 
nary  temperature  and  pressure.  A  very  convenient  appa- 


42 


JONES:  TREPHINING  FOR  PARALYSIS  OF  SPEECH. 


[N.  Y.  Mko.  Jour., 


ratus  for  collecting  and  measuring  this  is  Einhorn’s  tubes. 
As  urine  will  absorb  about  its  own  volume  of  carbon  dioxide, 
and  as  yeast  always  contains  a  little  sugar,  the  method  is 
not  very  delicate.  I  think  that  about  the  best  that  can  be 
alleged  for  it  is  its  ability  to  demonstrate  one  tenth  per 
cent,  of  glucose.  Another  application  of  fermentation  is  by 
taking  the  specific  gravity  before  and  after  fermenting. 
This  is  even  less  delicate  than  the  preceding. 

The  other  reliable  positive  method  is  by  the  phenyl- 
hydrazin  test.  This  was  first  devised  by  Fischer,  and  has 
since  been  strongly  indorsed  by  von  Jaksch  and  Ultzmann. 
The  original  method  of  applying  it  was  to  dissolve  2 
grammes  of  phenylhydrazin  hydrochloride  and  1*5  gramme 
of  sodium  acetate  in  20  c.  c.  of  water.  Then  mix  with 
50  c.  c.  of  urine,  and  heat  in  a  water-bath  for  twenty  or 
thirty  minutes.  Ultzmann,  as  reported  by  Bond,  has  modi¬ 
fied  it  in  a  very  simple  way.  According  to  his  method,  put 
in  an  ordinary  test-tube  about  half  an  inch  of  the  phenyl 
salt.  This  is  a  brownish-white,  scaly  substance,  having  a 
strong  odor  of  aniline.  On  top  of  this  put  another  half¬ 
inch  of  sodium  acetate,  and  fill  the  tube  half  full  of  urine. 
Shake  until  the  sodium  acetate  is  dissolved,  and  then  gently 
heat.  When  the  whole  mass  is  hot,  boil  from  half  a  min¬ 
ute  to  a  minute.  This  method  is  much  less  cumbersome 
than  the  original,  and  is  nearly  if  not  quite  as  good.  In 
both  methods  albumin,  if  present,  should  first  be  removed 
by  boiling  and  filtering  or  decanting,  as  it  forms  a  sediment 
which  may  mask  the  result.  The  result  of  these  manipu¬ 
lations  is  the  formation  of  phenylglucosazone,  which  crystal¬ 
lizes  out  aud  can  be  found  in  the  precipitate.  This  is  a 
definite  chemical  compound,  having  the  formula  C  H  N  O  . 
It  forms  acicular  crystals  of  a  golden-yellow  color,  which 
can  easily  be  recognized  under  the  microscope.  They  have 
a  marked  tendency  to  collect  in  radiating  clusters,  or  in 
sprays  that  resemble  a  feather  or  a  twig  of  spruce,  or  in 
sheaves  like  those  of  wheat.  They  are  almost  insoluble  in 
water,  but  readily  soluble  in  alcohol.  They  fuse  at  204°  to 
205°  C.  Similar  compounds  are  formed  with  lactose,  galac¬ 
tose,  and  maltose.  None  of  these,  except  lactose,  occur  in 
the  urine.  The  fusing  point  of  phenyllactosazone  is  200°  C. — 
so  near  that  of  phenylglucosazone  that  it  is  valueless  for  ordi- 
dinary  differentiation.  But  lactose  occurs  only  in  the  urine 
of  nursing  women  during  acute  suppression  of  lactation. 
Consequently  its  liability  to  interfere  is  very  slight.  Tyro- 
sin  forms  somewhat  similar  clusters,  but  the  crystals  are 
colorless.  I  think  it  may  safely  be  asserted  that  the  crys¬ 
tals  of  phenylglucosazone  are  characteristic,  and  a  positive 
indication  of  the  presence  of  glucose.  The  limitation  by 
lactose  is  so  slight  that  it  may  usually  be  ignored.  I  have 
tried  this  method  with  a  number  of  drugs  which  are  ex¬ 
creted  in  the  urine,  and  in  no  case  have  I  obtained  any 
similar  formation.  The  list  includes  morphine,  atropine, 
phenacetin,  antipyrine,  acetanilide,  chloral,  quinine,  and 
chloroform.  The  presence  of  chloral  is  objectionable,  be¬ 
cause  it  forms  an  abundant  precipitate  of  reddish-brown 
globules,  which  tends  to  mask  the  crystals  of  phenylglucosa¬ 
zone.  These  globules  resemble  those  of  phenylhydrazin, 
which  are  often  found  in  the  deposit,  owing  to  an  excess  of 
the  salt.  They  are  freely  soluble  in  alcohol,  from  which 


they  redeposit  on  evaporation  in  the  same  form.  As  regards 
delicacy,  this  test  can  hardly  be  excelled.  I  have  found 
distinct  crystals  in  a  urine  which  contained  only  one  one- 
hundredth  of  one  per  cent,  of  glucose,  but  then  only  after 
standing  for  forty-eight  hours.  When  glucose  is  present  to 
the  amount  of  one  tenth  per  cent.,  the  crystals  can  be  seen 
within  fifteen  minutes  after  boiling  by  Ultzmann’s  method, 
but  they  are  then  quite  small,  and  it  is  better  to  wait  for 
half  an  hour.  One  twentieth  per  cent,  can  be  discovered 
after  standing  three  to  four  hours. 

This  method  or  fermentation  should  be  employed  in  all 
cases  where  glycosuria  is  inferred  from  the  examination  of 
the  urine  alone.  Otherwise  we  shall  certainly  be  deceived 
at  times  by  the  behavior  of  other  substances  than  glucose 
which  give  rise  to  similar  reactions  with  the  ordinary 
tests. 

345  West  Fifty-sixth  Street. 


A  CASE  OF 

TREPHINING  FOR  PARALYSIS  OF  SPEECH 
FOLLOWING  AN  INJURY. 

By  J.  D.  JONES,  M.  D., 

UTICA,  N.  Y. 

Although  I  have  to  preface  the  narration  of  the  fol¬ 
lowing  case  with  the  humiliating  confession  that  I  erred 
in  the  diagnosis,  still  I  believe  that  enough  may  be  learned 
from  it  to  justify  its  publication.  During  this,  which  may 
be  termed  an  era  of  special  activity  in  brain  surgery,  I 
believe  that  not  only  the  successful  and  brilliant  results 
should  be  published,  but  the  failures,  and  wrorse  than  fail¬ 
ures — the  fatal  results — as  well.  It  is  only  in  that  way 
that  we  can  arrive  at  correct  statistics  of  the  mortality  of 
the  operation  and  gain  correct  data  as  to  when  to  operate 
and  when  to  leave  alone.  Judging  from  the  cases  pub¬ 
lished  in  the  journals  during  the  last  two  years,  one  would 
infer  that  the  operation  was  almost  devoid  of  danger  and 
that  the  results  are  almost  uniformly  successful.  A  note 
published  nine  months  or  a  year  after  the  operation  would 
often  tell  a  different  story.  I  propose  to  follow  that  plan 
in  this  instance. 

Mary  B.,  aged  twenty-six,  single,  of  healthy  parentage,  had 
enjoyed  previous  good  health,  but  was  of  questionable  morals, 
and  occasionally  drank  to  excess.  After  a  three-days’  absence 
from  home  on  one  of  these  sprees  she  was  found  in  an  out¬ 
house  in  another  part  of  the  city,  unable  to*speak  or  move,  but 
conscious.  She  was  carried  to  the  city  hospital,  where,  accord¬ 
ing  to  her  mother,  she  had  several  convulsions  limited  to  the 
right  side.  I  first  saw  her  October  16,  1889,  at  her  home, 
about  four  days  after  the  receipt  of  her  injuries.  Her  condi¬ 
tion  then  was  as  follows:  She  had  complete  motor  paralysis  of 
the  right  leg  and  arm,  the  right  side  of  the  face  was  paralyzed, 
the  tongue  deviated  to  the  right,  she  felt  the  prick  of  a  pin  over 
the  paralyzed  area,  but  sensation  did  not  seem  to  be  very  quick, 
though  no  very  accurate  tests  were  applied  to  determine  the 
degree  of  impairment.  She  could  not  utter  a  word  except  “  No,’’ 
which  was  the  universal  answer  to  every  question.  She  ap¬ 
peared  to  be  rational  and  to  understand  everything  that  was 
said  to  her.  Her  pulse  and  temperature  were  normal,  and  re¬ 
mained  so  to  the  time  of  the  operation.  There  was  a  largo 


July  12,  1890.] 


BALLOU:  GIANT-CELLED  SARCOMA  OF  THE  FINGER. 


43 


ecchymotic  spot  above  and  back  of  the  left  eye.  There  was  no 
wound  of  the  soft  parts  and  no  depression  could  be  felt  in  the 
bone.  There  were  “black  and  blue”  marks  on  other  parts  of 
the  body.  There  was  a  conclusive  history  of  traumatism.  That, 
with  the  location  of  the  extravasation  on  the  left  side  of  the 
head,  with  the  right-sided  motor  paralysis,  and  paralysis  of 
speech,  led  to  the  diagnosis  of  pressure  by  a  blood-clot,  probably 
from  a  fracture  of  the  inner  table.  She  gradually  recovered 
the  use  of  the  leg  and  arm,  the  former  first,  but,  with  the  ex¬ 
ception  of  the  addition  of  “I  can’t”  to  her  vocabulary,  her 
speech  remained  unimproved.  On  two  occasions  she  had  at¬ 
tacks  of  transient  delirium  with  hallucinations  of  sight,  but  they 
were  not  attended  with  any  rise  of  temperature,  and  both  sub¬ 
sided  within  twelve  hours  of  their  onset.  She  also  had  twitch¬ 
ing  of  the  right  arm  occasionally,  which  was  controlled  by 
small  doses  of  bromide  of  potassium. 

In  the  latter  part  of  February,  1890,  Dr.  W.  E.  Ford,  of 
this  city,  saw  her  in  consultation  with  me,  and  agreed  that  the 
symptoms  pointed  to  pressure  on  the  center  for  speech  and 
motor  area  on  the  left  side  by  a  clot  probably,  and  advised  an 
operation.  Accordingly,  the  operation  was  performed  on  March 
15th  with  the  assistance  of  Dr.  Ford,  Dr.  Schuyler,  Dr.  Weed, 
and  Dr.  Brown.  The  center  for  speech  was  located  by  the 
rules  given  by  Dr.  Dana  in  the  Medical  Record  of  January  12, 
1889.  The  head  was  shaved  and  thoroughly  disinfected.  The 
skull  was  marked  with  the  center-pin  of  the  trephine  before 
making  the  incision.  A  horseshoe  flap,  with  the  convexity  di¬ 
rected  downward  and  backward  for  drainage,  was  raised.  An 
inch  trephine  was  applied  with  the  center-pin  at  the  point  pre¬ 
viously  marked  on  the  bone.  On  removing  the  trephine  after 
making  a  few  quarter  turns  an  alarming  haemorrhage  took  place 
from  the  hole  made  by  the  center-pin.  We  thought  at  the 
time  that  the  screw  had  failed  to  hold  the  pin,  allowing  it  to 
penetrate  the  bone  prematurely  and  so  wound  a  vessel  in  the 
dura.  So  the  button  of  bone  was  hurriedly  removed  ;  the  blood 
poured  into  the  opening  so  freely  that  it  was  even  then  impos¬ 
sible  to  decide  its  source.  The  dura  was  opened,  the  finger  in¬ 
troduced  between  the  dura  and  pia,  and  the  former  pressed 
firmly  against  the  skull ;  in  that  way  the  hemorrhage  was 
stopped.  On  subsequently  examining  the  button  of  bone  it  was 
evident  that  the  bleeding  came  from  one  of  the  large  veins  of 
the  diploe,  which  had  been  pierced  squarely  by  the  center-pin, 
and  it  was  the  finger  hooked  over  the  mouth  of  this  that 
checked  the  hfemorrhage.  The  pia  mater  was  opened,  but  no 
clot  was  found.  The  brain  tissue  in  this  locality,  however,  was 
evidently  diseased.  There  was  no  haemorrhage  of  any  moment 
from  the  dura  or  pia  mater.  As  the  brain  tissue  had  been  ex¬ 
amined  with  the  handle  of  the  scalpel,  no  sutures  were  put  in 
the  coverings.  They  were  simply  adjusted.  After  all  bleeding 
had  been  stopped,  the  wound  was  dusted  with  iodoform,  a  drain¬ 
age-tube  was  introduced  into  the  most  dependent  part,  and  the 
flap  closed  with  interrupted  silk  sutures  and  an  antiseptic  dress¬ 
ing  applied.  She  rallied  well  from  the  operation. 

March  16th ,  A.  M. — Pulse,  112  ;  temperature  (by  the  mouth), 
99*5°.  Vomiting  freely  from  the  ether.  P.  1/.,  pulse,  114; 
temperature,  100° ;  delirious. 

17th,  A.  M. — Pulse,  120 ;  temperature,  100°.  Wound  dressed. 
No  discharge.  It  is  evidently  aseptic.  P.  M.,  pulse,  112;  tem¬ 
perature,  100°.  She  rested  well  during  the  day.  Vomiting  has 
ceased. 

18th,  A.  M. — Pulse,  108;  temperature,  100-2°.  She  was 
delirious  during  the  latter  part  of  the  night.  P.  M.,  pulse,  108  ; 
temperature,  100-2°. 

19th,  A.  M. — Pulse,  102;  temperature,  100-5°,  highest  tem¬ 
perature  reached.  Delirious  during  the  night;  appears  dull 
this  morning.  Redressed  the  wound.'  No  discharge.  Removed 


the  drainage-tube  and  introduced  a  twist  of  absorbent  cotton 
soaked  in  a  solution  of  bichloride  (1  to  2,000)  to  keep  the  ex¬ 
ternal  opening  patent.  P.  M.,  pulse,  90;  temperature,  99-5. 
Doing  well. 

20th. — Pulse,  88;  temperature,  99-2°.  Rested  well  last 
night. 

21st. — Pulse,  84;  temperature,  98*5°.  During  the  night  she 
had  several  convulsive  seizures  limited  chiefly  to  the  right  side. 
In  those  I  saw  the  twitching  was  confined  to  the  right  arm  and 
right  side  of  the  face,  but  the  right  leg  also  was  said  to  have 
been  drawn  up  in  some  of  them.  The  wound  was  redressed. 
The  sutures  were  all  removed,  as  it  had  healed  firmly  all  around 
except  where  the  drainage-tube  had  been.  She  was  put  on 
bromide  of  potassium  (ten  grains)  repeated  two  or  three  times 
in  the  early  evening. 

22d. — She  had  one  fit  at  eleven  o’clock  last  night.  Pulse, 
90 ;  temperature,  99'5°. 

23d. — Pulse,  84;  temperature,  98-8°.  Doing  well.  She  sat 
up  to  have  her  head  dressed  to-day. 

21+th. — Pulse,  90 ;  temperature,  98-5°,  and  it  remained  nor¬ 
mal  after  this.  She  looks  bright.  Her  recovery  has  been  un¬ 
interrupted  since.  By  April  5th  the  opening  for  drainage  had 
granulated  even  with  the  surface,  and  she  was  going  about 
feeling  well. 

With  regard  to  her  speech.  As  I  said  before,  her  vo¬ 
cabulary  was  limited  to  “No”  and  “I  can’t,”  and  she 
couldn’t  repeat  a  word  spoken  to  her.  I  spent  considerable 
time  on  various  occasions  trying  to  have  her  repeat  some 
simple  monosyllable.  She  would  try  hard  for  a  while,  then 
become  irritable,  and  end  with  the  invariable  “  No,  I  can’t.” 
On  the  third  day  after  the  operation  she  greeted  me  with 
“  Good  morning,”  and  addressed  me  by  name.  She  can 
now  repeat  any  word  spoken  to  her.  She  already  has  quite 
an  extended  vocabulary  of  names  of  articles  of  food,  bed¬ 
clothing,  etc. — names  she  hears  repeatedly  and  which  she 
uses  correctly.  She  also  counts  readily.  I  am  unable  to 
explain  the  connection  between  the  operation  and  the  im¬ 
provement  in  speech,  and  simply  relate  the  facts. 

The  most  interesting  point  in  connection  with  the  case 
is  the  diagnosis.  Was  there  any  way  of  determining  in 
this  case  whether  the  symptoms  depended  on  pressure — as 
by  a  clot — external  to  the  surface,  or  to  a  lesion  of  the 
cortex  itself?  We  thought  it  was  the  former;  it  proved  to 
be  the  latter. 

Considering  her  age,  with  the  history  of  an  injury  and 
with  the  ecchymosis  in  the  position  to  explain  the  paralytic 
symptoms  present,  even  in  the  absence  of  an  external  wound 
and  such  palpable  evidence  of  fracture  as  depression,  the 
presumption  was  certainly  in  favor  of  our  interpretation  of 
the  symptoms,  and  the  operation  therefore  was  indicated 
and  justifiable. 


GIANT-CELLED  SARCOMA  OF  THE  FINGER 

OF  UNUSUAL  SIZE.* 

By  WILLIAM  R.  BALLOU,  M.  D. 

The  rarity  of  osteosarcoma  of  the  fingers  and  the  beau¬ 
tiful  specimen  which  I  will  show  with  the  patient  from 

*  Read  before  the  Society  of  the  Alumni  of  Bellevue  Hospital,  May 
7,  1890,  and  the  specimen  and  patient  shown. 


44 


POST:  THE  BORDERLAND. 


[N.  Y.  Med.  Jour., 


whom  it  was  removed,  led  me  to  present  the  history  of  the 
following  case  : 

Mrs.  L.,  Italian,  aged  twenty-nine,  came  under  my  care  at 
Bellevue  Dispensary  on  August  18,  1889,  for  the  treatment  of  a 
large  tumor  of  the  left  hand.  The  family  history  was  negative, 
as  was  also  that  of  syphilis  or  injury. 

About  a  year  and  a  half  before,  the  first  interplialangeal 
articulation  of  the  left  ring  finger  began  to  increase  in  size,  but 
was  not  painful.  From  that  time  till  the  middle  of  July,  one 
month  before  I  saw  her,  it  had  remained  of  about  the  size  of  an 
English  walnut,  when  it  began  to  enlarge  rapidly  and  developed 
spontaneous  pain. 

At  the  time  she  came  under  observation  the  tumor  was 
nearly  of  the  size  of  my  closed  fist,  measured  in  its  greatest  cir¬ 
cumference  eleven  inches,  and  involved  the  distal  half  of  the  left 
fourth  metacarpal  bone,  the  whole  of  the  first  and  part  of  the 
second  phalanges.  The  tip  of  the  finger,  as  you  see,  projected 
from  the  mass  of  the  tumor.  It  was  generally  hard,  with  some 
fluctuating  areas  which  proved  to  be  cystic  in  nature.  The  su¬ 
perficial  veins  were  dilated  and  tortuous,  and  the  growth  had 
pushed  the  middle  and  little  fingers  widely  apart,  and  interfered 
greatly  with  the  use  of  the  hand.  Careful  search  failed  to  show 
any  enlarged  glands. 

A  diagnosis  of  chondrosarcoma  was  made,  my  belief  being 
that  it  had  at  first  been  a  chondroma  of  innocent  form,  which 
for  some  reason  had  taken  on  malignant  action.  Immediate 
amputation  was  advised,  the  operation  to  include  the  finger,  its 
corresponding  metacarpal  bone,  and  other  fingers  if  the  growth 
was  found  to  involve  any  other  structures  on  dissection. 

On  August  20,  1889,  the  amputation  was  done  under  cocaine 
with  the  assistance  of  several  of  my  students.  The  tumor  was 
first  freed  from  the  surrounding  structures  and  the  metacarpal 
bone  sawn  through  below  the  growth.  The  vessels  were  large 
and  the  haemorrhage  profuse.  After  their  ligation  the  re¬ 
mainder  of  the  metacarpal  bone  was  removed  with  a  rongeur 
forceps,  a  drainage-tube  introduced,  and  the  wound  closed.  It 
healed  kindly,  and  a  very  comely  and  useful  hand  was  the  result. 
The  tumor  was  kindly  examined  by  my  friend  Dr.  H.  M.  Biggs, 
of  the  Carnegie  Laboratory,  who  pronounced  it  a  beautiful  speci¬ 
men  of  giant-celled  sarcoma  springing  from  bone. 

At  the  present  time  the  patient  is  in  good  condition,  has  no 
pain,  or  the  slightest  suspicion  of  recurrence,  and  has  almost 
perfect  use  of  the  hand. 

102  East  Thirty-first  Street. 


THE  BORDERLAND. 

By  SARAH  E.  POST,  M.  D. 

The  interest  in  occult  psychic  phenomena  seems  on  the 
increase  rather  than  on  the  wane.  Scribner's  Magazine  for 
March  has  a  charmingly  written  paper  upon  The  Hidden 
Self,  by  William  James,  brother  to  the  novelist;  while  the 
Forum  for  April  contains  two  papers  of  considerable  inter¬ 
est — The  True  and  the  False  in  Spiritualism,  by  Mr.  Hodg¬ 
son,  and  a  paper  upon  the  relations  of  Hypnotism  and 
Crime,  by  Charcot.  Last  year,  too,  we  had  a  series  of  pa¬ 
pers  dealing  with  the  usual  phenomena  of  hypnotism  in  the 
North  American  Review. 

The  last-named  series  described  experiments  with  which 
we  are  familiar.  The  patient  having  been  thrown  into  the 
hypnotic  condition,  the  operator,  technically  known  as  the 
agent,  by  means  of  the  sense  of  sight  or  hearing  or  in  some 


other  clearly  material  way,  communicated  to  him  sugges¬ 
tions  in  the  form  of  trains  of  thought  with  a  natural  con¬ 
clusion  or  in  the  form  of  direct  commands.  As  a  result,  the 
subject  would  believe  absurd  propositions,  perform  ridicu¬ 
lous  actions,  or  even  commit  crime.  In  the  course  of  these 
papers  Mr.  C.  distinctly  says  that  he  has  never  succeeded 
in  conveying  suggestions  in  any  but  tangible  ways.  For 
instance,  if  the  patient  had  his  back  to  him  he  could  not 
secure  his  co-operation  without  the  aid  of  the  voice.  The 
influence  of  his  mind,  unaided  by  the  ordinary  senses,  was 
unable  to  communicate  or  to  impress  itself  upon  the  mind 
of  the  other;  in  fact,  the  tone  of  the  statement  made 
upon  this  point  is  such  as  to  lead  to  the  inference  that  the 
writer  disbelieves  in  such  unembodied  transmission  of  mind 
force. 

A  curious  point  about  hypnotics  is  that  the  person  hyp¬ 
notized  is  of  a  different  disposition  from  the  person  nnhyp- 
notized.  This  fact  is  the  feature  of  Mr.  James’s  paper.  In 
certain  easily  hypnotized  persons  it  has  even  been  found 
possible  to  produce  two  distinct  conditions  of  hypnotiza- 
tion,  so  that  the  person  has  three  separate  lives  or  planes  of 
consciousness,  not  any  one  of  which  infringes  upon  or  is 
cognizant  of  the  other.  A  still  more  curious  thing,  per¬ 
haps,  is  the  fact  that  only  one  of  these  planes  of  conscious¬ 
ness  wakes  to  activity  at  a  time. 

When  hypnotized  in  the  first  degree  the  subject  resumes 
memory  and  impulses  belonging  to  this  state  at  the  point 
where  they  were  dropped  at  the  end  of  the  previous  seance. 
A  similar  resumption  occurs  when  the  subject  is  hypnotized 
in  the  second  degree;  and  similarly,  the  unhypnotized  indi¬ 
vidual  knows  nothing  of  what  has  passed  during  the  other 
two  phases  of  his  existence  and  is  a  quite  different  person — 
a  very  stupid  person,  by  the  way,  as  a  rule.  Mr.  James  sug¬ 
gests  that  the  familiar  sensation  of  having  been  previously 
in  the  same  place  or  surrounded  by  the  same  circumstances 
is  perhaps  due  to  the  intruding  of  a  second  or  hidden  plane 
of  consciousness  into  the  affairs  of  ordinary  life.  He  sug¬ 
gests  also  that  dreams,  often  so  erratic  and  contrary  to  or¬ 
dinary  experience,  may  be  due  to  activity  of  this  hidden 
self.  As  in  the  old  Herman  tales,  the  puppets  and  the  play¬ 
things  come  out  from  their  receptacles  and  hold  high  revel 
while  sleep  rules  the  master  of  the  house. 

Just  here  we  would  like  to  call  attention  to  the  fact  that 
some  hypnotics  in  France  have  been  controlled  by  minds  at 
a  distance;  they  have  been  even  incited  to  actions  by  will 
power  exerted  miles  away;  and  this  brings  us  to  another 
phase  of  psychic  control,  the  domain  of  telepathy.  By  the 
way,  the  word  telepathy  is  not  found  in  Webster’s  diction¬ 
ary,  edition  of  1886.  From  an  analysis  of  its  root-forms, 
however,  we  arrive  at  the  fact  that  it  means  to  suffer  or  to 
experience  from  a  distance  or  at  a  distance.  Telephone  and 
telegraph  are  similarly  constructed  words,  telephone  mean¬ 
ing  to  speak  from  afar  ;  telegraph,  to  write  from  afar ;  and 
telepathic  (we  have  not  yet  arrived  at  the  noun  telepath), 
suffering  or  experiencing  from  afar.  In  the  line  of  these 
experiences  comes  the  presentiment  that  some  one  ap¬ 
proaches  or  is  near.  Instances  have  been  given  in  which 
highly  nervous  invalids  have  even  known  the  personality  of 
the  approaching  guest  by  telepathic  instinct.  Mr.  Hodg- 


July  12,  1890.] 


POST:  TllE  BORDERLAND. 


45 


son  suggests  that  the  phenomena  of  clairvoyance  and  slate 
writing  are  of  this  character,  the  medium  or  slate  writer 
really  obtaining  her  ideas  from  the  minds  of  those  present. 
It  is  said  that  the  agent  in  this  ease  need  not  even  have  the 
matter  by  which  the  subject  is  impressed  actively  before 
his  consciousness  ;  he  may  at  the  time  even  be  “  thinking 
of  something  else.” 

We  have  then  recognized  as  demonstrated  phenomena, 
mind  control  by  means  of  hypnotism  and  suggestion  through 
ordinary  channels,  and  mind  impression  or  control  either 
directly  or  by  channels  which  we  do  not  know.  I  do  not, 
however,  find  recognized  by  any  of  these  writers  a  third 
phenomenon  which  I  am  assured  exists.  This  is  direct  mus¬ 
cular  control  by  a  foreign  mind.  In  the  case  of  certain 
hypnotized  people  it  has  been  possible  to  slow  the  heart  by 
telepathic  suggestion  on  the  part  of  the  operator.  These 
cases  have  never  received  an  adequate  explanation.  Appar¬ 
ently  there  was  no  mental  state  in  the  subject  which  in¬ 
duced  the  inhibition ;  it  was  a  direct  result  of  control.  To 
this  example  I  can  add  a  case  of  my  own  more  fully  reported 
in  the  North  American  Review  for  April,  1889. 

The  place  was  the  sitting-room  of  a  woman’s  boarding¬ 
house.  None  but  women  were  present.  The  experiment  was  in 
the  form  of  a  game  in  the  course  of  which  the  subject,  blind¬ 
folded,  found  different  hidden  articles,  the  suggestion  being 
supposably  conveyed  from  the  mind  of  the  operator  through 
her  hands  lightly  laid  on  the  subject’s  back.  The  subject  suc¬ 
ceeding  in  these  ordinary  manoeuvres  of  the  game,  a  more  diffi¬ 
cult  test  was  proposed.  The  subject  advanced  to  the  middle  of 
the  room,  bent  her  head  and*  gave  no  further  response,  and  the 
experiment  was  declared  to  have  failed.  The  evidence  carried 
by  this  series  of  experiments  has  to  do  entirely  with  that  one 
which  failed.  Subjects  being  usually  hypnotized,  it  is  seldom 
we  have  the  opportunity  to  get  their  side  of  the  story.  This 
subject  was  not,  however,  hypnotized,  and  her  description  of  the 
experiment  is  as  follows:  “Learning  that  all  that  was  required 
of  me  was  to  follow  suggestions,  I  promised  co-operation.  I 
stated  at  first  that  I  would  make  no  resistance  ;  that  if  the  op¬ 
erator  could  make  me  know  what  I  was  to  do  by  means  of  her 
hands  on  my  back,  I  would  do  it.  I  further  prepared  myself  by 
putting  all  ideas  out  of  my  mind,  for  I  thought,  unless  I  am 
alert  and  attentive,  I  shall  not  be  able  to  understand  what  it  is 
I  am  to  do.  My  thought  was  that  I  might  receive  a  finished 
idea  or  project  which  would  outline  what  I  was  to  do.  In¬ 
stead,  during  the  earlier  experiments,  I  felt  nothing  but  a  loss 
of  equilibrium ;  1  took  steps  in  this  direction  or  that  to  save 
myself  from  falling  down.  I  do  not  remember  the  sensations 
which  preceded  or  accompanied  putting  out  the  hand  to  grasp 
the  hidden  objects,  but  I  found  the  things  without  knowing 
that  I  was  looking  for  them.  During  the  last  experiment,  how¬ 
ever,  I  did  have  an  idea,  and  it  came  about  in  this  way.  I  ad¬ 
vanced  to  the  middle  of  the  room  in  response  to  the  loss  of 
equilibrium  as  before.  I  bent  my  head  and  then  commenced  to 
feel  a  puckering  up  of  the  mouth,  and  I  said  to  myself:  ‘I  am 
afraid  they  are  going  to  make  me  kiss  some  one.  I  hope  not, 
for  I  shall  not  be  able  to  do  it.’  Then  I  reasoned  with  myself 
about  having  so  foolish  an  idea.  I  said  to  myself :  ‘  Put  it  away 
or  you  will  not  be  able  to  receive  the  impression  they  are  try¬ 
ing  to  give  to  you.’  I  did  then  succeed  in  again  abstracting 
my  mind  so  that  no  memory  of  the  kiss  remained,  but  no 
further  impulse  came  to  me.  I  stood  in  the  center  of  the 
room  motionless,  not  even  the  loss  of  equilibrium  reassert¬ 
ing  itself.”  The  subject  had  been  directed  to  kiss  one  of  the 


young  ladies  in  the  room ;  she  had  advanced  to  her  side,  but 
had  remained  standing,  and  the  experiment  was  declared  to 
have  failed. 

The  subject  was  at  that  time  at  least  a  fairly  intelligent 
person,  and  her  evidence  is  perhaps  as  good  as  that  of  any 
which  can  be  obtained  upon  these  matters.  The  subject 
was  positive  that  the  idea  of  kissing  followed  the  contrac¬ 
tion  of  the  orbicular  muscle,  and  was  apparently  suggested 
by  it.  The  muscular  act,  like  those  of  the  preceding  experi¬ 
ments,  was  not  induced  by  any  idea  or  conscious  mental 
effort  on  her  part. 

The  proposition  of  muscular  control  by  the  intervention 
of  a  foreign  mind  is  startling  in  its  far-reaching  importance. 
It  will  be  borne  in  mind  that  the  subject  is  undisturbed,  is 
unconscious  of  control  until  it  reveals  itself  by  the  finished 
act.  Even  then  he  or  she  may  not  be  completely  conscious 
unless  the  action  excites  repugnance  in  the  mind.  A  whole 
series  of  experiences  will  range  themselves  under  this  head¬ 
ing  if  its  existence  be  once  admitted. 

Undoubtedly  the  possibility  of  extraneous  muscle  con¬ 
trol  is  in  a  high  degree  abnormal ;  it  is  one  of  the  phases  of 
hysteria.  James  defines  hysteria  as  the  power  of  concen¬ 
trating  or  splitting  up  consciousness.  By  this  process  con¬ 
sciousness  may  be  withdrawn  from  certain  brain  areas  or 
independent  realms  of  consciousness  may  exist  within  the 
same  brain.  While  this  faculty  is  undoubtedly  rare  among 
us,  it  is  not  rare  among  Eastern  peoples,  abstraction  being 
there  a  highly  prized  faculty  of  the  mind.  Insensibility  to 
pain  and  the  various  phenomena  of  stoicism  can  perhaps  be 
traced  to  this  source. 

The  mechanism  of  extraneous  muscle  control  must  be  in 
the  highest  degree  problematic,  as  it  implies  either  a  spirit¬ 
ual  entity  capable  of  taking  possession  of  another’s  body,  or 
some  as  yet  unrecognized  medium  of  force. 

The  applications  of  this  power  should  be,  like  those  of 
the  phenomena  of  hypnotism,  limited  to  therapeutic  pur¬ 
poses.  While  in  a  state  of  health  extraneous  muscle  control 
must  be  undesirable.  We  have  heard  of  suggestion  used  for 
moral  ends.  The  refractory  boy  or  girl  is  gently  hypno¬ 
tized  and  persuaded  to  the  adoption  of  wholesome  ideas. 
But  it  will  be  recognized  that  the  appeal  is  in  this  case  to 
the  mind  of  the  subject.  The  phenomenon  belongs  to  the 
first  class  of  cases  we  have  here  considered.  In  the  class 
now  under  consideration  the  appeal  is  directly  to  the  irre¬ 
sponsible  body.  It  is  apparent  that  under  ordinary  circum¬ 
stances  nothing  but  harm  can  result  from  such  control. 
We  believe  that  in  sickness,  however,  this  power  is  and 
should  be  utilized  for  good.  The  “  control  ”  of  the  good 
doctor  and  good  nurse  is,  I  believe,  often  of  this  character. 
We  are  ourselves  conscious  of  having  controlled  vomiting  in 
patients  by  our  own  mental  efforts  at  a  time  when  the  pa¬ 
tients’  mental  processes  were  of  too  unreliable  a  character  to 
be  considered  a  factor  in  the  result. 

The  value  of  moral  ideas  or  prejudices  also  becomes 
very  apparent  in  this  connection.  The  subject  in  the  ex¬ 
periment  narrated  interfered  with  the  control  from  the  fact 
that  the  action  required  was  repugnant.  Deep-rooted 
prejudices  in  favor  of  right  living  will  be  the  best  protec¬ 
tion  against  harmful  extraneous  control. 


46 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jocr., 


the 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  ^  Fbank  P.  Foster,  M.  D 


NEW  YORK,  SATURDAY,  JULY  12,  1890. 


RECENT  MEDICAL  LEGISLATION  IN  NEW  YORK. 

Last  winter  an  effort  was  made  to  secure  the  repeal  of  the 
act  making  it  necessary  for  persons  about  to  study  medicine  to 
pass  a  preliminary  examination  by  the  Board  of  Regents  of  the 
University,  or  under  their  direction.  The  effort  failed,  bu^ 
certain  modifying  bills  were  passed,  and  have  received  the 
Governor’s  signature,  effecting  the  following  changes:  1.  Tbe 
examination,  although  still  called  “preliminary,”  may  be 
passed  at  any  time  during  the  student’s  first  year  of  study  with¬ 
in  the  State.  2.  It  may  be  conducted  by  the  college  faculty 
“  in  accordance  with  the  standard  and  rules  of  the  said  re¬ 
gents.”  3.  The  examination  is  not  required  if  the  candidate 
possesses  qualifications  which  the  regents  consider  and  accept 
as  fully  equivalent  to  those  demanded  in  their  examination. 
I  he  regents  were  to  meet  on  the  13th  of  June  to  decide  upon 
these  equivalents,  and  it  was  their  announced  intention  to 
notify  the  various  medical  schools  promptly  of  any  conclusion 
at  which  they  might  arrive.  According  to  the  original  act,  the 
possession  of  a  degree  in  arts,  science,  or  philosophy  from  an 
institution  duly  authorized  to  confer  the  same  exempts  the 
holder  from  the  examination^ 

The  new  medical  practice  act  goes  into  effect  on  the  1st  of 
September,  1891.  Its  provisions  are  substantially  as  follows: 
Three  separate  boards  of  medical  examiners,  each  consisting  of 
seven  members,  are  to  be  appointed  by  the  Regents  of  the  Uni¬ 
versity  from  nominees  of  the  three  State  medical  societies. 
One  board  is  to  represent  the  Medical  Society  of  the  State  of 
New  York,  the  second  the  Homoeopathic  Medical  Society  of  the 
State  of  New  York,  and  the  third  the  Eclectic  Medical  Society 
of  the  State  of  New  York.  The  appointments  are  to  be  made 
annually.  The  regents  are  empowered  to  fill  vacancies  and 
to  make  appointments  on  their  own  motion  in  case  nomina¬ 
tions  are  not  made  by  tbe  societies,  and  each  examination 
conducted  by  a  board  must  be  under  the  supervision  of  an 
examiner  appointed  by  the  regents  and  not  himself  a 
member  of  either  board.  The  regents  are  also  to  select 
the  examination  questions,  which  are  to  relate  to  anat¬ 
omy,  physiology  and  hygiene,  chemistry,  surgery,  obstet¬ 
rics,  pathology  and  diagnosis,  and  therapeutics,  “including 
practice  and  materia  inedica.”  The  questions  are  to  be  the 
same  for  all  tbe  boards,  except  in  therapeutics,  in  which  they 
are  required  to  be  “  in  harmony  with  the  tenets  of  the  school 
selected  by  the  candidate.”  The  examinations  are  to  be  con¬ 
ducted  in  writing,  and  the  regents  are  to  license  the  successful 
candidates.  After  the  date  on  which  the  act  goes  into  effect, 
nobody  can  begin  the  practice  of  medicine  in  the  State  until  he 


has  received  the  regent’s  license.  He  has  first  to  apply  to  the 
regents  for  the  examination  and  license,  paying  a  fee  of  $25 
and  furnishing  satisfactory  proof  (by  affidavit,  if  the  regents 
require  it)  that  he  is  more  th\in  twenty-one  years  old  and  of 
good  moral  character,  has  a  medical  diploma  or  license,  and 
studied  medicine  three  years,  “including  three  courses  of  lect¬ 
ures  in  different  years  in  some  legally  incorporated  medical 
college  or  colleges  ”  before  the  diploma  or  license  was  con¬ 
ferred  upon  him.  The  regents  are  authorized  to  accept  licenses 
from  other  State  boards  maintaining  an  equal  standard,  to¬ 
gether  with  a  fee  of  $10. 

We  have  lately  received  a  number  of  inquiries  as  to  these 
legislative  provisions,  and  some  of  our  correspondents  have 
asked  for  our  opinion  as  to  their  effects.  As  to  certain  matters 
of  detail,  it  can  hardly  be  said  beforehand  what  the  results  will 

ft 

be.  A  great  deal  depends  on  the  quality  of  the  supervision 
exercised  by  the  regents. 


THE  GERMAN  SURGICAL  SOCIETY. 

A  condensed  report  of  the  proceedings  of  the  nineteenth 
congress  of  the  German  Surgical  Society,  held  on  the  9th,  10th, 
11th,  and  12th  of  April,  has  been  issued  in  the  form  of  a  sup¬ 
plement  to  the  Centralblatt  fur  Chirurgie  for  June  21st.  It 
makes  a  pamphlet  of  104  large  octavo  pages,  printed  with  the 
clearness  and  precision  characteristic  of  the  productions  of 
Messrs.  Breitkopf  &  Ilartel.  On  the  first  page  we  find  a  table 
of  contents  in  which  the  papers  ar,e  classified  under  the  heads 
of  general  pathology  and  therapeutics,  the  head  and  face,  the 
vertebral  column  and  the  neck,  the  chest,  the  gastro-enteric 
canal  and  the  liver,  tbe  urinary  and  sexual  organs,  and  the 
limbs  ;  and  the  papers  are  published  in  this  order.  It  does  not 
appear  that  the  papers  were  read  in  an  order  corresponding  to 
this  classification,  although  that  may  have  been  the  case,  and 
such  a  procedure  would  have  been  quite  in  keeping  with  the 
regard  for  system  usually  displayed  by  our  German  colleagues. 
At  all  events,  their  systematic  arrangement  in  the  report  and 
that  of  their  titles  in  the  table  of  contents  must  prove  conven¬ 
ient  to  a  reader  seeking  for  a  particular  item  in  the  proceed¬ 
ings,  and  it  would  have  been  an  additional  aid  if  the  page  num¬ 
bers  had  been  placed  after  the  titles. 

The  report  is  to  be  commended  not  only  for  this  judicious 
arrangement  of  the  matter,  but  also  for  the  admirable  brevity 
with  which  the  abstracts  of  papers  and  the  substance  of  the  re¬ 
marks  made  in  the  discussions  are  given.  The  pith  of  about 
sixty  papers  and  demonstrations  is  got  into  a  little  over  a  hun¬ 
dred  pages,  along  with  that  of  the  discussions.  It  is  particu¬ 
larly  in  the  latter  that  condensation  is  shown  ;  rarely  does  the 
summary  of  a  discussion  take  up  so  much  space  as  half  a  page. 
This  shows  either  that  the  participants  in  the  meeting  were  re¬ 
markably  considerate  or  that  the  reporter  was  a  master  of  his 
art;  for  we  can  not  assume  that  anything  of  real  importance 
was  omitted  or  slighted,  although  it  does  look  a  little  odd  to 
see  under  the  last  heading  (Demonstration  of  a  Preparation  of 
Congenital  Sarcoma  of  the  Dorsum  of  the  Foot)  only  the  terse 
statement  “It  was  a  small-celled  spindle-cell  sarcoma.” 


July  12,  1890.] 


MINOR  PA  RA  O  RA  PHS.— ITEMS. 


47 


Among  tlie  names  well  known  in  this  country  we  find  the 
following  in  the  report :  Mikulicz,  Bruns,  Krause,  Trendelen¬ 
burg,  Ivraske,  Rydygier,  Riedel,  Lauenstein,  Konig,  Ponfick, 
Madelung,  Braun,  Thiersch,  Krdnlein,  and  Helferich  as  those  of 
authors  of  papers,  and  von  Bergmann,  Heidenbain,  and  Baum¬ 
gartner  as  those  of  participants  in  the  discussions.  Some  of 
the  noticeable  titles  were :  The  Proportion  of  Haemoglobin  in 
the  Blood  in  Surgical  Diseases,  Actinomycosis,  Ether  and 
Chloroform  Narcosis,  The  Treatment  of  Tubercular  Affections 
with  Iodoform  Injections,  Massage,  Trephining,  The  Operative 
Surgery  of  the  Vertebral  Canal,  Perityphlitis  (three  papers), 
The  Radical  Operation  for  Hernia,  Operations  for  Intestinal 
Stenosis,  Resection  and  Restoration  of  the  Liver,  Spiral  Fract¬ 
ures,  Neuropathic  Diseases  of  the  Bones  and  Joints,  and  The 
Treatment  of  Club-foot.  Trendelenburg  showed  a  remarkable 
operating-table,  three  woodcuts  of  which  are  given  in  the  re¬ 
port.  It  is  evident  that  the  meeting  brought  out  some  of  the 
best  work  of  the  best  men  in  Germany,  and  that  the  society 
is  one  of  great  usefulness. 


MINOR  PARAGRAPHS. 

THE  REMUNERATION  OF  MEDICAL  EXAMINERS  IN  LIFE 

INSURANCE. 

It  was  an  interesting  discussion  from  more  than  one  point 
of  view  that  took  place  at  a  meeting  of  the  Section  in  State 
Medicine  of  the  Royal  Academy  of  Medicine  in  Ireland,  pub¬ 
lished  in  this  issue.  Many  of  our  readers  will  probably  be  sur¬ 
prised  to  learn  of  the  state  of  things  mentioned  by  Sir  William 
Stokes — namely,  the  payment  of  medical  examiners  in  life  in¬ 
surance  by  fees  proportionate  to  the  amount  of  the  policy  to  be 
taken  by  the  applicant.  It  seems  to  us  that  the  profession  in 
Ireland  ought  not  to  fail  in  their  efforts  to  have  such  an  illogical 
system  done  away  with.  We  are  not  aware  that  it  has  ever 
been  in  use  in  this  country. 


ANTISEPSIN. 

In  the  Lancet  for  June  7th  Dr.  Cattani  is  quoted  concern¬ 
ing  the  antipyretic  properties  of  paramonobromacetanilide,  or 
antisepsin.  Its  use  in  pneumonia  with  high  temperature  and  in 
typhoid  fever  shows  that  its  power  to  reduce  body  heat  is  equal 
to  that  of  acetanilide.  It  likewise  has  antineuralgic  properties. 
In  the  treatment  of  haemorrhoids  and  other  anal  lesions  its  ef¬ 
fects  are  marked  when  administered  in  the  form  of  supposi¬ 
tories.  As  an  antiseptic  application  to  wounds  and  offensive 
ulcers,  it  has  had  some  use  with  good  results,  the  lesions  gen¬ 
erally  healing  quickly. 


AN  INTERESTING  LITERARY  REPRODUCTION. 

A  Newcastle-on-Tyne  publishing  firm,  Messrs.  Mawson, 
Swan,  and  Morgan,  announce  the  fac-simile  reproduction  of  an 
old  manuscript  volume  entitled  Ye  Apothecarie;  his  Booke  of 
Recepts  agaynst  alle  maner  of  sickenesses;  allso  howe  to  bake 
meates,  to  make  Uskabaugbe,  to  die  clothe  orwoole,  and  divers 
usefull  thinges  besydes.  The  manuscript  dates  back  about 
three  centuries. 

THE  PUBLICATION  OF  PATIENTS’  NAMES  IN  CLINICAL 

HISTORIES. 

We  have  before  pointed  out  the  impropriety  of  publishing 
patients’  full  names  in  the  histories  of  their  cases.  There  is 


seldom  if  ever  any  good  reason  for  doing  it,  and  it  must  often 
do  violence  to  feelings  that  medical  men  are  bound  to  respect. 
An  esteemed  correspondent  has  suggested  to  us  to  call  attention 
to  the  matter  again,  and  we  do  so  with  the  feeling  that  it  is  one 
of  no  trifling  importance. 


COD-LIVER  OIL  AS  A  VERMIFUGE. 

In  a  recent  number  of  the  Union  medicate  we  find  the  fol¬ 
lowing  formula  for  an  enema  of  cod-liver  oil  for  the  removal  of 
the  Oxyuris  vermicularis :  Cod-liver  oil,  40  grammes  (about  10 
drachms);  the  yolk  of  an  egg;  water,  125  grammes  (about  4 
ounces).  In  case  of  failure,  an  enema  of  pure  cod-liver  oil  is 
recommended. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York— We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  July  8,  1890  : 


DISEASES. 

Week  ending  July  1. 

Week  ending  July  8. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

11 

6 

8 

0 

Scarlet  fever . 

34 

10 

43 

2 

Cerebro-spinal  meningitis . 

1 

0 

2 

2 

Measles . 

276 

26 

271 

23 

Diphtheria . 

84 

23 

74 

23 

Varicella . 

1 

0 

4 

0 

The  Chicago  Gynaecological  Society. — A  meeting  held  on  the  13th 
of  June  was  devoted  entirely  to  the  memory  of  the  late  Dr.  William  H. 
Byford,  who  was  one  of  the  founders  of  the  society.  The  programme 
included  an  address  by  Dr.  H.  P.  Merriman  and  remarks  by  Dr.  N.  S. 
Davis,  Dr.  H.  A.  Johnson,  and  Dr.  John  E.  Owens. 

The  Rush  Medical  College,  of  Chicago. — Dr.  Henry  M.  Lyman  has 
been  appointed  professor  of  the  principles  and  practice  of  medicine, 
and  Dr.  James  H.  Etheridge  professor  of  gynaecology. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army ,  for  the  two  weeks  ending  July  5 ,  1890 : 

Suter,  William  N.,  First  Lieutenant  and  Assistant  Surgeon,  is,  by  di¬ 
rection  of  the  Secretary  of  W ar,  granted  leave  of  absence  for  two 
months,  to  take  effect  August  6,  1890.  Par.  3,  S.  O.  149,  A.  G.  O., 
June  26,  1890. 

Borden,  William  C.,  Captain  and  Assistant  Surgeon,  is,  by  direction 
of  the  Secretary  of  War,  granted  leave  of  absence  for  three  months 
and  fifteen  days,  to  take  effect  as  soon  as  his  services  can  be  spared. 
Par.  11,  S.  0.  146,  A.  G.  O.,  June  23,  1890. 

Died. 

Culbertson,  Howard,  Captain  (retired),  died  June  18,  1890,  at  Zanes¬ 
ville,  Ohio. 

Appointments. 

To  be  Assistant  Surgeons,  with  the  rank  of  First  Lieutenant : 

Keefer,  Frank  R.,  of  Pennsylvania,  June  6,  1890,  vice  Woodruff,  pro¬ 
moted. 

Raymond,  Thomas  U.,  of  Indiana,  June  6,  1890,  vice  Newton,  resigned. 
Snyder,  Henry  D.,  of  Pennsylvania,  June  6,  1890,  vice  Wilson,  re¬ 
signed. 

Smith,  Allen  M.,  of  New  York,  June  6,  1890,  vice  Mattheivs,  pro¬ 
moted. 

Heyl,  Ashton  B.,  of  Pennsylvania,  June  6,  1890,  vice  Hall,  pro¬ 
moted. 

Clarke,  Joseph  T.,  of  New  York,  June  6,  1890,  vice  Porter,  resigned. 
Greenleaf,  Charles  R.,  Major  and  Surgeon,  will,  by  direction  of  the 
Secretary  of  War,  attend  the  encampment  of  the  Pennsylvania  Na¬ 
tional  Guard  at  Mount  Gretna,  Pennsylvania,  from  the  18th  to  the 
26th  of  July,  1890,  for  the  purpose  of  accompanying  the  Surgeon- 
General  of  Pennsylvania  in  his  inspection  of  the  camp.  Par.  11, 
S.  O.  144,  A.  G.  0.,  June  20,  1890. 


48 


ITEMS.— LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES.  [N.  Y.  Mkd.  Jour., 


Taylor,  Marcus  E.,  Captain  and  Assistant  Surgeon.  Leave  of  absence 
for  one  month,  on  surgeon’s  certificate  of  disability,  is  hereby 
granted,  with  permission  to  go  beyond  the  limits  of  this  Division, 
and  to  apply  for  an  extension  of  five  months.  Par.  1,  S.  0.  46, 
Division  of  the  Pacific,  San  Francisco,  Cal.,  June  13,  1890. 

Kimball,  James  P.,  Major  and  Surgeon.  By  direction  of  the  Acting 
Secretary  of  War,  leave  of  absence  for  four  months  is  granted,  to 
take  effect  when  an  officer  of  the  Medical  Department  is  assigned 
by  his  department  commander  to  relieve  him.  Par.  6,  S.  0.  162, 
A.  G.  0.,  July  1,  1890,  Washington,  D.  C. 

Ball,  Robert  R.,  First  Lieutenant  and  Assistant  Surgeon,  is  relieved 
from  duty  at  Fort  Riley,  Kansas,  and  will  report  in  person  to  the 
commanding  officer,  Fort  Spokane,  Washington,  for  duty.  Par.  7, 
S.  0.  151,  A.  G.  0.,  June  28,  1890,  Washington,  D.  C. 

Corbusier,  William  H.,  Captain  and  Assistant  Surgeon,  is  relieved 
from  duty  at  Fort  Lewis,  Colorado,  and  will  report  in  person  to  the 
commanding  officer,  Fort  Wayne,  Michigan,  for  duty.  Par.  7,  S.  0. 
151,  A.  G.  0.,  June  28,  1890,  Washington,  D.  C. 

By  direction  of  the  Secretary  of  War,  the  following-named  Assistant 
Surgeons  (recently  appointed)  will  report  in  person  for  duty  to  the 
commanding  officers  of  the  posts  designated  opposite  their  re¬ 
spective  names : 

Keefer,  Frank  R.,  First  Lieutenant,  Fort  Leavenworth,  Kansas. 
Raymond,  Thomas  U.,  First  Lieutenant,  Fort  Sherman,  Idaho. 
Snyder,  Henry  D.,  First  Lieutenant,  Fort  Reno,  Indian  Territory. 
Smith,  Allen  M.,  First  Lieutenant,  Fort  Snelling,  Minnesota. 

Heyl,  Ashton  B.,  First  Lieutenant,  Fort  Niobrara,  Nebraska. 
Clarke,  Joseph  T.,  First  Lieutenant,  Fort  Riley,  Kansas. 

Par.  6,  S.  0.  151,  A.  G.  0.,  June  28,  1890,  Washington,  D.  C. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  July  5 ,  1890 : 

Page,  J.  E.,  Assistant  Surgeon.  Ordered  to  hospital,  Mare  Island,  Cal. 
Kennedy,  R.  M.,  Assistant  Surgeon.  Ordered  to  the  League  Island 
Navy  Yard,  Ya. 

Society  Meetings  for  the  Coming  Week : 

Tuesday,  July  15th :  Medical  Society  of  the  County  of  Otsego  (annual 
— Cooperstown),  N.  Y. 


Ecttfrs  to  tbe  (Sbtior. 


NITROGLYCERIN  IN  GAS  ASPHYXIA  AND  POISONING. 

143  North  Seventh  Street,  Zanesville,  0.,  July  7,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  I  see  cases  of  gas  poisoning  successfully  treated  by 
nitroglycerin  are  being  reported;  therefore  a  few  remarks 
relative  to  that  subject  will  not  be  inappropriate.  Since  the 
publication  of  my  article  in  your  issue  of  December  14,  1889,  I 
have  received  a  letter  from  a  personal  friend,  in  which  bespoke 
of  a  case  that  he  had  successfully  treated  with  nitroglycerin  sub¬ 
sequent  to  the  publication  of  my  article.  It  will  be  pertinent 
here  to  describe  a  case  within  my  knowledge.  One  day  last 
autumn,  as  I  was  passing  along  the  street  where  several  men 
were  engaged  in  putting  down  new  gas-pipes,  I  noticed  a  man 
lying  inclined  against  a  tree,  apparently  asleep,  but  whom  I 
surmised  to  be  asphyxiated  by  the  escaping  gas.  He  was  re¬ 
ceiving  no  attention  whatever. 

I  examined  him  and  found  notbiug  except  a  shallow  and  ir¬ 
regular  respiration  to  indicate  that  any  condition  other  than 
that  of  natural  sleep  existed. 

The  superintendent  of  the  gas  company  informed  me  that 
the  man  had  been  “gased,’’  as  he  termed  it,  and  had  been  car¬ 
ried  aside  to  wait  till  noon,  when  a  wagon  would  be  brought  to 


convey  him  to  his  home.  The  superintendent  gave  me  the  fol¬ 
lowing  information :  This  man  was  very  susceptible  to  gas. 
During  a  period  of  fifteen  years,  which  time  he  had  been  in  the 
employ  of  this  company,  he  had  been  asphyxiated  some  ten  or 
twelve  times.  He  usually  remained  unconscious  for  several 
hours — generally  six  or  eight.  This  condition  had  become  so 
familiar  to  his  fellow-laborers  and  his  family  that  its  occurrence 
gave  them  no  alarm.  He  retained  the  ability  to  swallow,  and 
they  were  in  the  habit  of  giving  him  whisky.  During  some  of 
his  former  asphyxiations  he  had  had  a  physician,  who,  by  the 
use  of  medicines  and  the  battery,  had  failed  to  abridge  the  period 
of  unconsciousness.  They  did  not  deem  it  necessary  at  this  time 
to  employ  medical  aid,  and  by  the  use  of  whisky  he  recovered 
in  the  usual  time.  He  would  no  doubt  have  recovered  as  soon 
without  the  whisky,  as  I  could  see  no  indication  for  it. 

It  seems  to  me  there  should  be  a  division  of  these  cases  into 
those  of  asphyxia  and  those  of  real  poisoning.  In  asphyxia, 
recovery  is  rapid.  In  poisoning,  the  poison  has  a  firm  hold  on 
the  system  and  is  not  eliminated  for  several  hours.  Whether 
there  is  any  pathological  difference  or  not  except  in  degree  1 
do  not  know,  but  the  fact  that  one  person  will  recover  in  an 
hour  or  two,  while  another  with  the  same  treatment  will  re¬ 
main  comatose  for  twenty-two  hours,  I  think  is  sufficient  to 
justify  the  distinctions  mentioned.  To  substantiate  my  claim  of 
originality  in  the  treatment,  I  have  simply  to  say  that  I  used  it 
for  the  first  time  in  gas  poisoning  on  November  20,  1888 — almost 
a  year  before  it  was  used  by  any  odo  else,  so  far  as  reported. 

I  did  not  report  my  case  sooner  because  I  had  been  using 
nitroglycerin  as  a  stimulant  some  time  before  I  treated  my  case, 
and  was  not  aware  that  it  had  any  other  property  than  that  of  a 
stimulant,  nor  do  I  now  know  its  modus  operandi  if  it  is  other 
than  by  stimulation.  J.  (J.  Crossland,  M.  D. 


IJroteebtnjjs  of  Societies. 

NEW  YORK  ACADEMY  OF  MEDICINE. 

Meeting  of  June  5,  1890. 

The  President,  Dr.  A.  L.  Loomis,  in  the  Chair. 

Bacteriological  Researches  in  Yellow  Fever.— In  a  paper 
with  this  title,  Dr.  G.  M.  Sternberg,  of  the  United  States  Army, 
said  that  in  1879  he,  as  a  member  of  the  Yellow-Fever  Commis¬ 
sion  sent  to  Havana  by  the  National  Board  of  Health,  had  de¬ 
voted  himself  especially  to  a  search  for  the  specific  infectious 
agent  in  the  blood  of  patients  in  various  stages  of  yellow  fever. 
The  result  of  this  research  had  been  negative.  Extended  re¬ 
searches  made  during  the  past  two  years  by  the  most  approved 
bacteriological  methods  had  fully  confirmed  this  negative  result. 
Exceptionally  micro-organisms  were  found  in  cultivations  from 
the  blood  and  tissues,  eveti  when  the  autopsy  was  made  very 
soon  after  death,  but  the  bacillus  encountered  most  frequently 
had  been  identified  as  the  Bacterium  coli  commune  of  Escherich, 
which  was  constantly  present  in  the  intestine  of  healthy  per¬ 
sons,  and  consequently  could  not  be  the  specific  pathogenic  agent 
in  yellow  fever.  Other  micro-organisms  associated  with  this 
were  found  so  exceptionally  and  in  such  small  numbers  that  no 
special  significance  could  be  attached  to  their  presence.  The 
examination  of  thin  sections  of  the  liver,  kidney,  and  other  or¬ 
gans,  stained  by  the  most  approved  methods  for  demonstrating 
micro-organisms,  gave  results  corresponding  with  those  obtained 
by  cultivation  methods. 

That  various  micro-organisms  were  present  in  small  numbers 


July  12,  1890.] 


PliOOEEDINGS  OF  SOOtETIES. 


49 


in  the  liver  and  kidney  (and  presumably  in  other  organs)  at  the 
time  of  death  was  shown  by  preserving  fragments  of  considera¬ 
ble  size  in  an  antiseptic  wrapping  which  destroyed  all  micro¬ 
organisms  which  might  have  accidentally  fallen  upon  the  sur¬ 
face  of  the  fragment  aud  prevented  the  entrance  of  germs  from 
without.  Such  a  fragment  preserved  for  forty  eight  hours  at  a 
temperature  of  27°  C.  (80’6°  F.)  always  contained  a  large  num¬ 
ber  of  bacilli  of  different  species  which  had  evidently  developed 
Irom  scattered  bacilli  present  in  the  organ  from  which  it  was 
taken  at  the  autopsy.  These  bacilli  were  for  the  most  part 
anaerobics,  or  facultative  anaerobics,  and  did  not  give  rise  to  a 
putrefactive  odor.  The  tissue  containing  them  had  a  very  acid 
reaction.  Putrefactive  organisms  were  also  present,  and  pieces 
of  tissue  kept  for  a  longer  time  gave  evidence  of  putrefactive 
decomposition. 

The  micro-organisms  present  in  fragments  of  liver  and  kid¬ 
ney  preserved  in  the  way  indicated  had  been  carefully  studied, 
and  numerous  comparative  researches  had  been  made,  since  his 
return  from  Havana,  which  showed  that  those  most  constantly 
and  abundantly  present  were  not  peculiar  to  yellow  fever.  In 
cases  of  accidental  death  and  of  death  from  other  diseases  frag¬ 
ments  of  liver  preserved  in  the  same  way  had  contained  the 
same  micro-organisms.  His  bacillus  n— a  large  anaerobic  bacil¬ 
lus,  which  for  a  time  he  had  thought  might  be  the  specific  germ 
he  had  been  in  search  of — he  had  found  in  these  comparative  re¬ 
searches,  and  been  obliged  to  exclude  it  from  further  considera¬ 
tion  from  an  aetiological  point  of  view.  One  bacillus,  however, 
which  was  fuund  in  a  considerable  number  of  cases  of  yellow 
fever,  in  pieces  of  liver  preserved  in  an  antiseptic  wrapping,  al¬ 
though  not.  in  very  great  numbers,  had  not  been  found  in  his 
comparative  autopsies.  This  was  a  non-liquefying  bacillus  w  Inch 
resembled  the  colon  bacillus  in  its  growth  in  flesh-peptone-gela- 
tin  and  in  its  morphology,  although  it  was  somewhat  larger. 
It  was  also  more  pathogenic,  especially  for  rabbits.  This  was 
his  bacillus  x.  Not  having  excluded  it  by  his  comparative  re¬ 
searches,  he  looked  upon  it  as  being  possibly  the  specific  yellow- 
fever  germ,  but  he  had  not  been  able  as  yet  to  obtain  any  sat¬ 
isfactory  experimental  evidence  that  such  was  the  case.  This 
same  bacillus  was  found  in  the  contents  of  the  intestine  where 
it  was  associated  with  a  variety  of  other  bacilli,  some  of  which 
were  strict  anaerobics  and  some  facultative  anaerobics.  The 
most  constant  and  abundant  of  these  was  the  Bacterium  coli 
commune  of  Escherich. 

Comparatively  few  liquefying  bacilli  weie  found  in  the  con¬ 
tents  of  the  intestine  or  stomach,  or  in  cultivations  from  pieces 
of  liver  and  kidney  preserved  for  forty-eight  hours  in  an  anti¬ 
septic  wrapping.  The  bacillus  of  Dr.  Paul  Gibier  had  been 
found  in  the  contents  of  the  intestine  in  a  limited  number  of 
cases,  but  it  had  been  absent  in  a  majority  of  the  cases  in  which 
the  speaker  had  made  autopsies — forty-three  in  all — and,  when 
present,  had  not  been  abundant  as  compared  with  the  non-lique- 
fving  bacilli.  And  it  was  not  found  in  any  considerable  number 
of  cases  in  his  cultivations  from  fasces  collected  during  the  life¬ 
time  of  the  patient.  There  was  therefore  no  good  reason  for  sup¬ 
posing  that  this  bacillus  had  anything  to  do  with  the  {etiology 
of  yellow  fever.  And,  as  a  result  of  his  extended  cultivation  ex¬ 
periments,  he  felt  justified  in  asserting  that  yellow  fever  was 
not  due  to  a  liquefying  aerobic  micro-organism. 

The  micrococcus  which  Dr.  Domingos  Freire  had  presented 
to  him  as  his  yellow-fever  germ  at  the  time  of  the  speaker’s 
visit  to  Brazil  grew  readily  in  flesh-peptone  gelatin,  and  caused 
liquefaction  of  this  medium.  Its  presence  would  therefore  be 
readily  ascertained  by  the  culture  methods  which  he  had  em¬ 
ployed.  It  had  not  been  present  in  a  single  instance  in  his  culti¬ 
vations  from  the  blood  and  tissues  or  from  the  contents  of  the 
intestine.  It  was  therefore  excluded  from  consideration  as 


being  concerned  in  the  {etiology  of  yellow  fever.  The  Tetragenus 
febris  farce,  of  Dr.  Carlos  Finlay,  of  Havana,  was  a  common  at¬ 
mospheric  organism  in  that  city  which  the  speaker  had  obtained 
in  cultivations  from  the  surface  of  the  body  of  patients  suffer¬ 
ing  from  various  diseases,  and  of  healthy  persons.  He  had  not 
obtained  it  in  his  cultivations  from  the  blood  and  tissues,  and 
considered  it  definitely  excluded  as  the  possible  {etiological 
agent  in  the  disease  under  consideration. 

The  morphological  characters  and  mode  of  growth  in  various 
culture  media  of  the  different  micro-organisms  referred  to,  and 
of  others  encountered  in  his  bacteriological  researches,  would 
be  demonstrated  by  projecting  upon  a  screen  his  micro-photo- 
graphs  and  photographs  of  colonies  and  test-tube  cultures.  A 
detailed  report  containing  a  full  account  of  the  researches  made 
during  the  past  two  years  in  Havana,  Cuba,  and  Decatur, 
Alabama  (1888),  was  now  nearly  completed,  and  would  be  sub¬ 
mitted  to  the  President  within  a  short  time. 

The  President,  in  closing  the  meeting,  said  that  this  was  the 
last  meeting  in  the  old  building.  It  was  now  about  twenty 
years  since  it  became  the  property  of  the  Academy,  during 
which  time  the  membership  had  more  than  doubled;  the  library 
had  been  increased  more  than  two  thousand  volumes;  eight 
sections  in  the  different  departments  of  medicine  and  surgery 
had  been  organized  and  were  doing  efficient  work.  Here  had 
been  fought  and  settled  many  scientific  and  ethical  questions. 
Clouds  had  darkened  the  skies,  but  they  had  been  dispelled  by  the 
intelligence  and  wise  councils  of  the  fellowship  of  the  Academy. 
This  building  was  left  with  a  united,  enthusiastic  fellowship 
which  numbered  nearly  seven  hundred.  As  the  Academy  en¬ 
tered  its  new  building,  let  it  be  with  the  resolve  that  it  should 
be  a  place  for  better  scientific  work,  and  where  should  be  culti¬ 
vated  more  largely  the  social  side  of  our  professional  life. 


ROYAL  ACADEMY  OF  MEDICINE  IN  IRELAND. 

SECTION  IN  STATE  MEDICINE. 

The  President,  Dr.  A.  W.  Foot,  in  the  Chair. 

Meeting  of  Friday ,  February  7,  1890. 

The  Medical  Selection  of  Lives  for  Assurance. — Instead 
of  the  usual  introductory  address,  the  president  of  the  Section 
read  a  paper  on  this  subject.  The  responsible  and  often  diffi¬ 
cult  duties  of  a  medical  examiner  were  very  different  from  those 
of  an  ordinary  practitioner.  The  questions  set  forth  in  the  pro¬ 
posal  sheet  were  regarded  by  some  as  vexatiously  minute  and 
unnecessarily  numerous;  but  the  reader  anticipated  that  ere 
long  the  companies  would  require  information  as  to  the  condi¬ 
tion  of  the  retina,  the  state  of  arterial  tension,  the  integrity  of 
the  various  reflexes,  the  centesimal  excretion  of  urea,  the  nutri¬ 
tion  of  nerves  and  muscles  as  estimated  by  electricity,  micro¬ 
scopic  details  of  urinary  sediments,  and  a  statement  of  the  res¬ 
piratory  capacity.  Referring  to  the  proposal  forms,  he  criticised 
the  tenacity  with  which  companies  clung  to  the  ideal  configura¬ 
tion  of  an  apoplectic  person,  as  short,  stout,  thick,  and  red. 
He  maintained  that  there  were  no  external  indications  of  the 
arterial  degeneration  which  was  the  proximate  cause  of  cerebral 
hemorrhage.  Meanwhile  there  was  little,  if  any,  attention 
paid  to  the  significance  of  aural  discharges,  to  that  of  recurrent 
erysipelas  (especially  facial),  to  that  of  latent  disease  of  the 
rectum,  and  to  cases  of  fecal  obstruction.  The  embarrassments 
which  the  conscientious  discharge  of  an  examiner’s  duty  might 
involve  were  illustrated,  and  the  severance  of  life-long  friend¬ 
ships  in  consequence  was  cited.  Several  points  of  a  practical 
nature  were  made  in  reference  to  consumptive  lives,  and  the 
means  adopted  to  blind  examiners.  The  important  subject  of 
“habits”  with  reference  to  the  use  of  alcohol  was  fully  treated 


50 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mkd.  Joor., 


of.  The  question  of  the  acceptance  of  an  albuminuric  life  was 
discussed,  and  the  rejection  of  it  under  any  circumstances 
recommended.  In  like  manner,  persons  with  chronic  mitral 
regurgitation  were  considered  unsound  from  an  assurance  point 
of  view,  though  in  private  practice  they  might,  with  care  and 
attention,  live  long  and  efficiently. 

Professor  Purser  said  that  the  medical  man  should  state,  in 
the  clearest  language,  what  he  believed  to  be  the  condition  of 
the  applicant’s  health,  and  it  was  for  the  company  then  to  settle 
whether  they  would  reject  him  altogether  or  take  him  with  an 
addition,  to  be  determined  with  the  aid  of  an  actuary.  It  was 
difficult  to  know  what  value  to  put  on  family  history.  Often  it 
was  difficult  to  say  what  a  patient  died  of ;  and,  again,  post¬ 
mortem  examinations  disclosed  that  the  causes  were  different 
from  what  the  doctor  thought.  He  did  not  think  that  the 
Registrar- General’s  returns  were  sufficiently  accurate  to  found 
scientific  conclusions  upon  them.  As  regarded  renal  disease,  if 
he  found  an  applicant  had  albuminuria  he  advised  that  the  case 
should  be  postponed  for  three  or  six  months,  or  a  year;  and  if 
there  was  albumin  in  the  urine  when  he  came  up  again  he  was  re¬ 
jected,  but  if  not  he  was  accepted.  No  matter  how  long  a  person 
might  live  who  had  albuminuria,  he  did  not  think  such  an  appli¬ 
cant  safe  to  accept  on  any  terms.  For  a  considerable  period  of 
his  experience  in  examining  during  the  past  twenty  years  it  had 
been  left  optional  by  the  company  to  examine  the  urine  for  al¬ 
bumin,  and  his  practice,  accordingly,  had  been  to  examine  it  only 
where  he  had  reason  to  suspect  there  was  something  the  matter 
with  the  kidneys;  but  for  some  years  past  he  had  been  obliged 
to  examine  for  sugar  and  albumin  in  every  case,  and  in  a  con¬ 
siderable  proportion  of  the  applicants,  in  whom  there  was  no 
reason  to  suspect  anything  the  matter  with  their  kidneys,  he 
had  found  albumin,  and,  though  apparently  in  perfect  health, 
they  were  rejected. 

Dr.  McSwiney  said  that,  though  he  was  not  an  examiner 
for  an  insurance  office,  cases  had 'come  under  his  observation 
upon  reference,  as  an  independent  physician,  on  the  question  of 
suitability  for  assurance.  He  asked  what  effect  the  opium  habit 
ought  to  have  in  determining  the  question.  Having  regard  to 
the  advances  in  surgical  science,  he  also  asked  whether  hernia, 
which  was  now  so  successfully  cured  by  the  radical  method, 
would  involve  rejection  ;  and  also  as  to  the  conclusion  to  be 
drawn  from  the  presence  of  haemorrhoids,  which  might  be  re¬ 
garded  as  symptomatic  of  other  disease.  Organic  valvular  dis¬ 
ease  was  another  point  upon  which  he  desired  a  definite  opinion. 

Dr.  Bewley,  as  an  examiner  for  an  insurance  company,  said 
that  he  had  met  with  two  cases  of  primary  syphilis  followed  by 
eruptions.  He  submitted  that  an  applicant  so  suffering  ought 
not  to  be  considered  on  a  par  with  a  man  who  never  had  had 
syphilis. 

Dr.  E.  MacDowel  Oosgrave  said  insurance  offices  were 
now,  as  a  rule,  alive  to  the  importance  of  the  symptom  of  al¬ 
bumin  in  the  urine  ;  so  that,  at  any  rate  in  all  cases  of  policies 
for  over  £500,  the  compulsory  examination  of  the  urine  was 
the  rule.  One  company,  with  which  he  was  himself  connected, 
had  solved  the  difficulty  in  dealing  with  slight  deviations  from 
health  in  a  peculiar  and  satisfactory  way.  Instead  of  loading 
the  premiums,  a  policy  was  issued  at  the  ordinary  rates,  but  the 
amount  of  the  policy  was  payable  on  a  sliding  scale.  Thus, 
where  the  amount  was  £1,000  and  the  expectation  of  life 
twenty-five  years,  if  healthy,  the  policy  was  issued  upon  the 
terms  that  if  the  insured  died  in  the  first  year  the  liability  of 
the  company  would  be  only  £800 ;  but  each  year  of  life  in¬ 
creased  the  policy,  so  that  in  twenty-five  years  the  policy  was 
for  £1,000.  Thus  there  was  no  “  loading”  for  lives  which  lived 
the  full  expectation.  The  plan  seemed  to  work  well,  and  less¬ 
ened  the  difficulties  of  the  examiner. 


Sir  William  Stokes  said  there  were  some  practical  difficulties 
in  the  way  of  carrying  out  some  of  Dr.  Foot’s  suggestions — for 
instance,  in  the  case  of  females,  however  theoretically  desirable 
an  examination  of  the  rectum  might  be,  it  was  impracticable. 
Nothing  could  be  more  pernicious  and  unfair  than  making  the 
doctor’s  fee  for  examination  proportionate  to  the  amount  of 
money  insured  ;  because  the  medical  man  who  discharged  his 
duty  must  necessarily  have  the  same  trouble  in  examining  a 
person  seeking  to  insure  for  only  £100  as  in  the  case  of  a  per¬ 
son  insuring  for  £10,000 ;  and  he  thought  the  medical  profession 
ought  to  make  a  stand  on  the  point.  His  experience  did  not 
coincide  with  Professor  Purser’s  in  meeting  persons  who  told 
the  truth  as  regarded  their  habits  of  life,  especially  persons  of 
intemperate  habits.  He  had  known  three  cases  of  intemperate 
or  free  drinkers  who  had  exercised  self-denial  for  months,  and 
had  then  gone  before  a  doctor  and  denied  that  they  were,  or 
had  been,  of  intemperate  habits,  and  so  passed  as  first-class 
lives ;  but  immediately  afterward  reverted  to  their  old  habits, 
got  ill,  and  died.  Notwithstanding  the  advances  in  surgery,  he 
would  not  recommend  a  person  with  hernia  as  a  first-class  life ; 
he  would  be  extremely  apprehensive  of  the  result  of  the  opera¬ 
tion  for  the  radical  cure.  Even  after  a  successful  operation 
the  hernia  might  come  back  again,  perhaps  in  a  form  more 
difficult  to  deal  with  than  before.  Neither  would  he  ac¬ 
cept  a  person  afflicted  with  haemorrhoids  as  a  first-class  life. 
The  operation  only  dealt  with  the  existing  condition  of 
the  parts  the  seat  of  the  disease,  and  not  with  the  conditions 
which  brought  about  the  disease.  He  would  not  recommend 
cases  of  albuminuria  to  be  taken  under  any  circumstances, 
the  presence  of  albumin  being  sufficient  indication  of  “some¬ 
thing  rotten  in  the  state  of  Denmark  ”  in  connection  with  the 
kidneys. 

Dr.  Donnelly,  Dr.  W.  Stoker,  Dr.  F.  Nixon,  and  Sir  O. 
Cameron  having  made  some  remarks,  Dr.  Foot  replied.  He 
concurred  with  Professor  Purser  as  to  the  duty  of  a  medical 
man  to  regard  the  interests  of  his  company  as  paramount.  He 
rejected  albuminurics  and  risky  lives,  acting  on  the  principle 
that  it  was  better  to  have  a  few  good  sound  lives  whose  premi¬ 
ums  were  sure  for  years  than  to  pass  lives  at  high  premiums 
which  might  be  lost  at  any  time.  It  was  difficult  in  some  cases 
to  give  a  decisive  opinion  “yes”  or  “no”  in  answer  to  the 
question  whether  a  particular  life  was  a  good  one  or  not,  so 
many  circumstances  had  to  be  considered  and  weighed  ;  but  the 
company  required  that  he  should  come  to  a  definite  conclusion 
without  setting  out  his  reasons.  It  was  important  to  ascertain 
about  scarlatina  and  infantile  diseases ;  for  instance,  scarlatina 
was  less  likely  to  lead  to  renal  complications  in  a  child  than  in 
an  adult.  As  regarded  the  opium  habit  or  morphinism,  the 
point  had  been  settled  in  the  case  of  the  Earl  of  Mar,  that  it 
did  not  shorten  life.  Hernia  cases  were  suspicious,  though  a 
great  many  people  wore  trusses  without  need  of  them.  Haem¬ 
orrhoids  always  suggested  an  examination  of  the  rectum,  for 
cancer  of  the  rectum  had  often  been  called  piles.  He  was 
against  passing  cases  of  organic  disease  of  the  heart.  Syphilis 
was  an  unfavorable  condition  ;  but  it  was  a  matter  of  judgment 
how  far  the  life  might  be  shortened,  and  in  such  cases  a  consul¬ 
tation  would  be  desirable.  He  concurred  as  to  the  absurdly 
small  fees  for  examining  cases  for  policies  of  small  amount.  As 
regarded  females,  as  a  rule  men  insured  for  women,  not  women 
for  men ;  but  there  were  ways  of  examining  the  urine  or  the 
rectum,  and  if  there  was  a  question  of  fissure  or  piles,  an  exami¬ 
nation  should  be  made.  He  was  not  so  trustful  as  Professor 
Purser,  and  he  believed  that  alcoholism  and  morphinism  were 
habits  deteriorating  the  organ  of  truth.  Tobacco,  taken  in  large 
quantities,  especially  the  coarse,  common  tobacco,  handicapped 
the  nervous  system. 


July  12,  1890.] 


BOOK  NOT1  OKS. 


51 


§00 h  IVotrccs. 


A  Guide  to  the  Diseases  of  Children.  By  James  Frederic 
Goodhart,  M.D.,  F.  R.  0.  P.,  Physician  to  Guy’s  Hospital 
and  Lecturer  on  Pathology  in  its  Medical  School,  etc.  Re¬ 
arranged,  revised,  and  edited  by  Louis  Starr,  M.  L).,  Clin¬ 
ical  Professor  of  Diseases  of  Children  in  the  Hospital  of  the 
University  of  Pennsylvania.  Second  American  from  the 
Third  English  Edition,  with  Numerous  Formulas  and  Illus¬ 
trations.  Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1889. 
Pp.  13  to  772. 

The  English  editions  of  this  work  made  many  friends.  In 
a  new  dress  it  can  scarcely  he  less  welcome,  though  much  less 
convenient  and  pleasant  to  study.  The  chapters  on  general 
non-infectious  diseases  are  of  particular  interest,  as  well  as  the 
author’s  views  of  nervous  disorder  during  childhood.  Skin  dis¬ 
ease  receives  little  more  than  passing  mention,  the  ground  be¬ 
ing  so  well  covered  throughout  the  extensive  literature  of  the 
subject.  The  dietetics  of  childhood  is  considered  in  every  de¬ 
partment,  and  constitutes,  as  elsewhere,  one  of  the  most  impor¬ 
tant  elements  of  hygiene.  The  book  is  the  record  of  careful  ob¬ 
servations  and  well-weighed  conclusions. 


Psychology  as  a  Natural  Science  applied  to  the  Solution  of  Oc¬ 
cult  Psychic  Phenomena.  By  C.  G.  Raue,  M.  D.  Phila¬ 
delphia:  Porter  &  Coates.  1889.  Pp.  8-9  to  541. 

This  exposition  of  psychology  has  evidently  been  under¬ 
taken  with  much  earnestness  of  purpose.  In  parts  it  is  suggest¬ 
ive,  with  sentences  here  and  there  capable  of  serving  as  texts 
for  the  sermons  of  other  writers  on  psychology.  At  the  same 
time  the  line  of  argument  is  old,  very  old,  and  not  in  touch  with 
the  spirit  of  modern  investigation.  It  is  impossible  to  see 
wherein  the  book  can  be  of  any  particular  value  to  the  nine¬ 
teenth-century  doctor,  whose  aim  is  to  study  the  orderly  ar¬ 
rangement  of  facts  according  to  an  underlying  principle. 


The  Cure  of  CrooJced  and  Otherwise  Deformed  Noses.  By  John 
B.  Roberts,  A.  H.,  M.  D.,  Professor  of  Anatomy  and  Sur¬ 
gery  in  the  Philadelphia  Polyclinic.  Philadelphia  :  P.  Blakis¬ 
ton,  Son,  &  Co.,  1889.  Pp.  7  to  24. 

In  many  cases  the  disfigurement  caused  by  a  deformed  nose 
is  the  cause  of  more  distress  to  the  patient  than  a  more  serious 
but  concealed  defect  might  be,  and  he  has  a  right  to  expect 
from  the  surgeon  the  best  efforts  consistent  with  safety  to  re¬ 
lieve  this  mental  distress.  To  the  surgeon,  then,  who  will  de¬ 
termine  to  relieve  this  form  of  suffering  to  the  best  of  his  ability 
we  commend  this  little  monograph,  which  contains  the  results 
culled  by  the  author  from  his  experience. 


Clinical  Lectures  on  Varicose  Veins  of  the  Lower  Extremities. 

By  William  H.  Bennett,  F.  R.  C.  S.,  Surgeon  to  St. 

George’s  Hospital,  etc.  With  Three  Plates.  London: 

Longmans,  Green,  &  Co.,  1889.  Pp.  ix  to  93. 

It  is  only  too  frequently  the  case  that  much  labor  is  devoted 
to  the  study  of  rare  forms  of  disease,  while  little  attention  is 
paid  to  the  common  forms,  because  they  are  usually  considered 
uninteresting.  Still,  it  is  his  success  or  failure  in  the  latter 
which,  as  a  rule,  makes  or  mars  a  physician’s  reputation,  and 
Mr.  Bennett  has  proved  in  this  book  that  careful  study  of  ordi¬ 
nary  cases  will  make  them  interesting  and  bring  to  light  new 
features  in  their  diagnosis  and  treatment.  The  work  presents 


the  most  thorough  consideration  of  the  subject  of  varicose  veins 
that  we  have  met  with,  and  is  particularly  valuable  regarding 
the  diagnosis  of  the  incipient  stage  and  the  various  forms  of 
treatment.  It  is  divided  into  four  lectures,  the  first  devoted 
mainly  to  the  causes  and  complications  of  varicose  veins;  the 
second,  to  the  incipient  stage  and  to  varix  at  the  saphenous 
opening;  the  third,  to  non-operative  treatment ;  and  the  last  to 
operative  treatment.  It  is  essentially  practical  and  strongly 
commends  itself,  especially  to  the  general  practitioner. 


fttudes  de  clinigue  infantile.  Syphilis  hereditaire  precoce ; 
laryngite  syphilitique  ;  broncho-pneumonie  par  infection  in- 
testinale;  prophylaxie  de  la  roug6ole  et  de  la  diphtherie  a 
l’Hospicedes  enfants-assist6s.  Par  le  Dr.  Sevestre,  m6decin 
de  l’Hospice  des  enfants-assist^s.  Paris :  E.  Lecrosnier  et 
Babe,  1889.  Pp.  3  to  141.  [Publications  du  Progres  medi¬ 
cal .] 

This  work  consists  of  four  monographs.  That  on  hereditary 
syphilis  is  devoted  chiefly  to  symptomatology,  and  fairly  pre¬ 
sents  our  present  knowledge  upon  that  subject.  That  upon  the 
laryngeal  manifestations  of  the  disease  in  infants  is  of  special 
interest,  as  it  treats  in  detail  of  a  subject  upon  which  very  little 
has  been  written. 

Several  cases  of  diarrhoea  with  consecutive  pneumonia  are 
interesting,  but  are  capable  of  an  entirely  different  interpreta¬ 
tion  from  that  put  upon  them  by  the  author.  The  proposition 
that  pulmonary  congestion  and  broncho-pneumonia  may  result 
from  infection  due  to  decomposition  of  the  contents  of  the  in¬ 
testine  in  foetid  diarrhoea  requires  much  more  evidence  for  its 
proof  than  the  author  adduces. 

Perfect  isolation  as  the  chief  prophylactic  measure  in  measles 
and  diphtheria  the  author  has  found  most  satisfactory. 

The  Pharmacopoeia  of  the  London  Skin  Hospital.  Edited  by 
James  Startin,  Senior  Surgeon  to  the  Hospital.  London  : 
Harrison  &  Sons.  Pp.  23. 

This  little  book  is  doubtless  useful  to  the  attendants  at  the 
London  Skin  Hospital.  It  contains  a  few  of  the  formulas  to  be 
found  in  all  the  recent  text-books;  some  good,  some  poor. 
There  is,  or  should  be,  little  popular  demand  for  books  of  this 
class,  excellent  as  they  may  be  in  themselves  and  for  the  pur¬ 
pose  for  which  they  were  primarily  compiled. 


Transactions  of  the  American  Association  of  Obstetricians  and 

Gynecologists.  Vol.  II.  For  the  Year  1889.  Philadelphia: 

W.  J.  Dornan,  1889.  Pp.  xxxviii-397. 

The  second  meeting  of  this  association  was  fully  equal  to 
the  former  one  in  point  of  interest  and  enthusiasm.  The  pre¬ 
dominant  subject  of  the  volume  is  abdominal  surgery;  in  fact, 
it  overshadows  all  the  others.  One  finds  many  positive  state¬ 
ments  in  the  discussions  of  this  subject,  sometimes  defended 
with  great  ardor.  It  is  well  to  have  convictions,  but  it  is  also  well 
to  remember  that  there  are  few  methods  of  practice  in  abdomi¬ 
nal  or  any  other  department  of  surgery  which  are  insusceptible 
of  change  or  improvement.  In  other  words,  abdominal  sur¬ 
gery  is  not  completed.  Equally  good  results  are  obtained  by 
those  who  base  their  practice  upon  antisepsis  and  by  those  who 
do  not.  There  are  those  who  make  a  good  argument  against 
the  necessity  of  the  over- careful  toilet  of  the  peritomeum,  the 
necessity  or  the  efficiency  of  its  irrigation  with  hot  water,  and  the 
harmfulness  of  blood-serum  or  blood-clot  in  moderate  quanti¬ 
ties;  and  these  are  matters  which  have  been  deemed  fundamen¬ 
tal  by  most  of  the  disputants  in  the  discussions  under  consid¬ 
eration. 


52 


BOOK  NOTICES.— REPORTS  ON  THE  PROGRESS  OF  MEDICINE.  |N.  Y.  Med.  Jock., 


Spinal  Concussion:  surgically  considered  as  a  Cause  of  Spinal 
Injury,  aud  neurologically  restricted  to  a  Certain  Symptom 
Group,  for  which  is  suggested  the  Designation  Erichsen’s 
Disease,  as  one  Form  of  the  Traumatic  Neuroses.  By  S.  V. 
Clevenger,  M.  D.,  Consulting  Physician,  Reese  and  Alexian 
Hospitals;  late  Pathologist,  County  Insane  Asylum,  Chicago, 
etc.  With  Thirty  Wood  Engravings.  Philadelphia  and 
London  :  F.  A.  Davis,  1889.  Pp.  v-359.  [Price,  $2.50.] 

This  book  purports  to  be  on  spinal  concussion,  a  subject 
which  deserves  careful,  conscientious  observation  on  the  part  of 
an  author,  combined  with  persistent  study  of  the  observations 
of  others.  In  other  words,  the  ideas  and  observations  of  vari¬ 
ous  writers  should  be  concisely  and  critically  arranged  together 
with  the  author’s  own  experience,  so  as  to  make  the  work  a 
unit.  It  is  to  be  regretted  that  this  has  not  been  done  in  the 
present  work.  The  larger  part  is  devoted  to  translations  and 
quotations  from  various  writers,  with  some  additions  by  the 
author,  but  with  little  attempt  at  unification  It  is  little  more 
than  an  imperfect  collection  of  writings  on  the  subject.  An  en¬ 
tire  chapter  is  given  to  the  subject  of  electro-diagnosis,  and 
most  of  it  might  have  been  omitted  with  propriety.  A  bitter 
attack  upon  the  scientific  and  medical  institutions  of  the  coun. 
try  is  not  likely  to  prove  conducive  to  the  popularity  of  the 
book,  and  the  interjection  of  references  to  private  differences 
with  the  local  authorities  does  not  appear  to  be  in  good  taste. 
Still,  if  the  work  furnished  any  real  advance  in  the  study  of  this 
important  subject,  these  faults,  as  well  as  the  boastful  style, 
might  be  overlooked.  The  book  is  well  got  up  typographically 
and  the  cuts  are  excellent. 


The  Clinical  Use  of  Prisms  ;  and  the  Decentering  of  Lenses. 

Bv  Ernest  E.  Maddox,  M.  D.,  late  Syme  Surgical  Fellow, 

Edinburgh.  Bristol:  John  Wrisrht  &  Co.,  1889.  Pp.  iv-7 

to  113. 

This  little  book  is  written  from  a  practical  point  of  view, 
and  is  intended  to  be  an  aid  to  precision  in  the  use  of  prisms 
rat  her  than  a  demonstration  of  the  author’s  mathematical  talent. 
While  it  is  worthy  of  the  perusal  of  those  skilled  in  this  branch 
of  ophthalmology,  it  is  adapted  to  the  needs  of  practitioners 
who,  though  not  so  skilled,  dabble  in  this  form  of  practice.  A 
resume  of  the  writings  of  Dr.  Stevens  on  this  subject  is  given  in 
the  appendix. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

Intestinal  Anastomotic  Operations  with  Segmented  Rubber  Rings, 
with  some  Practical  Suggestions  as  to  their  Use  in  other  Surgical  Op¬ 
erations.  By  A.  V.  L.  Brokaw,  M.  D.,  St.  Louis,  Mo.  [Reprinted  from 
the  Transactions  of  the  Southern  Surgical  and  Gynecological  Associa¬ 
tion.] 

New  Methods  of  performing  Pylorectomy,  with  Remarks  upon  In¬ 
testinal  Anastomotic  Operations.  By  A.  V.  L.  Brokaw,  M.  D.,  St.  Louis, 
Mo.  [Reprinted  from  the  St.  Louis  Courier  of  Medicine.] 

Some  Points  on  the  Perinasum  and  Forceps,  with  a  Description  of  a 
New  Method  of  assisting  the  Perinaeum,  and  a  New  Combined  Axis 
Traction  Forceps  to  be  used  as  an  Alternative  for  Craniotomy.  By  T. 
J.  McGillicuddy,  M.  D.  [Reprinted  from  the  American  Journal  of  Ob¬ 
stetrics  and  Diseases  of  Women  and  Children .] 

Two  Cases  of  Resection  of  the  Caecum  for  Carcinoma,  with  Remarks 
on  Intestinal  Anastomosis  in  the  Ueo-caecal  Region.  By  N.  Senn,  M.  D., 
Ph.  D.,  Milwaukee.  [Reprinted  from  the  Journal  of  the  American  Medi¬ 
cal  Association.] 

L’intoxication  chronique  par  la  morphine  et  ses  diverses  formes. 
Par  le  Dr.  L.  R.  Regnier,  ancien  interne  en  medeeine  des  hopitaux  de 
Paris.  Paris:  E.  Lecrosnier  et  Bab6,  1890.  Pp.  5  to  171.  [Publica¬ 
tions  du  Progres  mkdicall] 

The  Condition  of  the  Blood  in  Chlorosis.  Notes  on  the  Course  and 


Secondary  Symptoms  of  Chlorosis.  By  Charles  N.  Dowd,  M.  D.  [Re¬ 
printed  from  the  American  Journal  of  the  Medical  Sciences.] 

Du  role  physiologique  et  therapeutique  de  l’azote  gazeux,  considdre 
principalement  daDS  les  eaux  minerales  des  Pyrenees.  Par  le  Docteur 
E.  Duhourcan.  [Extrait  de  la  Revue  des  Pyrenees  et  de  la  France  me- 
ridionale.] 

Uric-Acid  Diathesis  in  Affections  of  the  Eye,  Ear,  Throat,  and  Nose. 
Bv  W.  Cheatham,  M.  D.,  Louisville,  Ky.  [Reprinted  from  the  Ameri¬ 
can  Practitioner  and  News.] 

Reciprocal  Responsibilities.  An  Address  delivered  on  the  part  of 
the  Faculty  at  the  Forty-first  Commencement  Exercises  of  the  Medical 
Department  of  Georgetown  University,  at  Lincoln  Hall,  on  May  5, 1890. 
By  Swan  M.  Burnett,  M.  D.,  Ph.  D.,  Washington. 

Climatology  and  Diseases  of  Southern  California.  By  F.  D.  Bullard, 
A.  M.,  M.  D.  [  Reprinted  from  the  Southern  California  Practitioner.] 

Les  bacteries  et  leur  role  dans  l’6tiologie,  l’anatomie  et  l’histologie 
pathologiques  des  maladies  infectieuses.  Par  A.  V.  Cornil,  Professeur 
d’anatomie  pathologique  &  la  Faculte  de  medeeine  de  Paris,  et  V.  Babes, 
Professeur  it  la  Faculte  de  medeeine,  etc.  Troisieme  edition,  refondue 
et  augmentee,  contenant  les  methodes  speciales  dela  bacteriologie.  385 
figures  en  noir  et  en  plusieurs  couleurs  intercalees  dans  le  texte  et  12 
planches  hors  texte.  Tome  Premier.  Pp.  vii-582.  Tome  Second. 
Pp.  608.  Paris:  Felix  Alcan.  1890.  [Prix,  40f.] 


geports  on  tjp  JJroigrtss  of  JjJebinm. 


OPHTHALMOLOGY. 

By  CHARLES  STEDMAN  BULL,  M.  D. 

Enophthalmia  Traumatica. — Gessner  (Arch,  of  Ophthal.,  xviii,  3) 
reports  three  cases  of  this  peculiar  result  of  external  injury,  and  adds 
some  remarks  on  the  genesis  and  disturbance  of  mobility  connected 
with  enophthalmia.  These  cases  were  all  observed  by  Nieden,  who 
excluded  the  presence  of  microphthalmia  on  account  of  the  equality  of 
the  cornea,  refraction  and  acuteness  of  sight  in  both  eyes.  Nieden 
thought  that  the  enophthalmia  was  due  to  atrophy  of  the  retro-bulbar 
tissue,  owing  to  strong  and  prolonged  compression.  Gessner,  on  the 
contrary,  regards  the  orbital  injury  as  the  cause  of  the  enophthalmia. 
Contused  wounds  of  the  orbital  margin  usually  involve  the  periosteum 
and  bone,  and  the  subsequent  inflammatory  reaction  is  readily  propa¬ 
gated  to  the  orbital  cellular  tissue.  He  thinks  that  the  enophthalmia 
is  produced  by  the  mechanical  falling  back  of  the  globe  into  the  orb¬ 
ital  cavity,  the  contents  of  which  have  been  reduced  by  cicatricial  con¬ 
traction  of  the  retro-bulbar  cellular  tissue ;  and  this  may  be  aided  by  a 
certain  pressure  of  the  lids.  An  inflammatory  participation  of  the  ocu¬ 
lar  muscles  is  improbable,  on  account  of  the  absence  of  disturbance  of 
motility. 

Two  Cases  of  Detachment  of  the  Chorioid  after  Cataract  Extrac¬ 
tion  ;  Spontaneous  Recovery. — Groenouw  (Arch,  of  Ophthal .,  xviii,  3) 
reports  two  cases  of  this  disease  because  of  the  extreme  rarity  of  cho- 
rioidal  displacement.  The  detaclnnent  simulated  very  strongly  the  ap¬ 
pearances  of  chorioidal  tumor.  They  were  probably  haemorrhagic  ex¬ 
travasations  excited  by  the  extraction,  and  lying  between  the  chorioid 
and  sclera,  bulging  forward  the  retina  and  chorioid,  and  simulating  a 
tumor.  There  was  not  even  a  simple  detachment  of  the  retina  without 
a  simultaneous  detachment  of  the  chorioid  ;  the  immobility  of  the  tumor, 
the  absence  of  varicose  vessels  aud  of  any  elevation  or  fold  upon  the 
surface,  and,  above  all,  the  shimmering  chorioidal  pigment,  necessarily 
pointed  to  a  detachment  of  the  chorioid.  The  cause  of  the  detachment 
is  to  be  sought  in  the  vacuum  following  the  sudden  extraction  of  the 
lens,  though  probably  some  pre-existing  disease  of  the  chorioid  is  also 
necessary.  The  diagnosis  between  tumor  and  detachment  of  the  cho¬ 
rioid  can  only  be  accurately  made  by  following  the  case  for  some  time. 

Non-metallic  Foreign  Bodies  in  the  Cornea. — Ritter  (Arch,  of 
Ophthal .,  xviii,  3)  here  discusses  the  subject  of  the  presence  of  animal 


July  12.  1890.] 


A  E  PORTS  ON  THE  PROGRESS  OF  MEDICINE. 


53 


and  vegetable  particles  lodged  in  the  cornea,  and  the  mutual  action  of 
the  foreign  body  and  the  epithelium  upon  each  other.  Ilia  first  exami¬ 
nation  revealed  the  presence  of  micro-organisms.  The  root  bacillus  was 
very  frequently  found,  and  its  growth,  like  a  nerve-plexus,  is  so  char¬ 
acteristic  that  it  can  not  be  mistaken.  The  hay  bacillus  is  also  fre¬ 
quent  on  foreign  bodies  in  the  cornea ;  it  is  as  long  as  the  root  bacillus, 
but  finer,  and  forms  long,  jointed  fibers,  growing  in  gray,  round  colo¬ 
nies,  and  rapidly  liquefying  the  gelatin.  Two  other  corneal  micrococci 
greatly  resemble  the  hay  bacillus  ;  one,  the  diplococcus  cinerareus  cor- 
neae,  grows  rapidly,  and  soon  liquefies  the  gelatin.  The  second,  coccus 
cinerareus  corneal,  is  single,  with  gray,  roundish  colonies  quickly  lique¬ 
fying.  A  large  number  of  micro-organisms,  which  occur  in  the  soil 
and  in  the  air  and  water,  also  flourish  on  foreign  bodies  in  the 
cornea.  They  are  to  be  regarded  here  as  saprophytes,  and  have 
either  attained  the  cornea  with  the  foreign  body,  or  else  in  some 
manner  reached  the  conjunctival  secretion  and  thence  remained 
clinging  to  the  foreign  body.  They  live  here  upon  and  in  the 
corneal  epithelium,  and  their  final  action  is  to  loosen  the  foreign  body 
from  its  seat. 

Peculiar  Course  of  a  Retinal  Glioma. — Hosch  (Arch,  of  Ophthal., 
xviii,  3)  reports  an  interesting  case  occurring  in  a  boy,  aged  three  years 
and  a  half,  whom  he  first  saw  in  September,  1885.  Both  eyes  were  in¬ 
volved  by  the  disease,  and  enucleation  was  therefore  not  advised.  Six 
months  later  the  child  was  reduced  to  the  condition  of  a  skeleton.  The 
right  eye  protruded  far  forward,  the  cornea  was  opaque,  and  the  con¬ 
junctiva  red  and  chemotic.  The  sight  of  the  left  eye  seemed  fairly 
good,  and  the  ophthalmoscopic  appearances  of  the  disease  were  about 
the  same  as  at  the  first  examination.  The  child  died  a  month  later, 
and  both  eyes  were  enucleated  and  subjected  to  examination,  and  the 
results  are  here  given.  The  relatively  slight  extension  of  the  glioma  in 
the  left  eye  explains  the  prolonged  preservation  of  sight.  The  neo¬ 
plasm  extending  from  the  retina  into  the  papilla,  and  excavating  it 
deeply,  had  evidently  pushed  the  nerve  fibers  to  one  side,  without  de¬ 
stroying  them,  so  that  the  peripheral  portions  of  the  retina  still  preserved 
some  perception  of  objects.  It  was  an  interesting  fact  to  observe  that 
the  tumor  encroached  upon  the  optic  nerve  and  yet  spared  the  retina 
and  vitreous.  The  extensive  proliferation  of  pigment  here  met  with 
sharply  defined  the  limits  of  the  neoplasm  and  extended  far  behind  the 
excavation  into  the  papilla.  The  course  of  the  disease  in  the  left  eye 
varied  greatly  from  the  common  run  of  cases.  While  the  disease  pro¬ 
gressed  as  usual  in  the  right  eye,  the  pathological  process  in  the  left 
eye  clung  to  the  neighborhood  of  the  posterior  pole  without  affecting 
the  entire  retina  early  in  the  disease,  and  detaching  it  from  the  chorioid, 
as  almost  invariably  happens.  It  is  scarcely  possible  that  the  tumor 
can  have  crossed  over  from  the  right  eye  through  the  chiasm,  for  the 
gliomatous  elements  would  then  have  increased  as  the  brain  was  ap¬ 
proached.  which  was  not  the  case.  It  must,  therefore,  be  concluded 
that  the  disease  affected  both  eyes,  running  the  usual  course  in  the 
right  eye,  while  in  the  left  it  remained  localized  around  the  papilla,  and 
then  very  slowly  extended  into  the  optic  nerve. 

Unequal  Accommodation  in  Healthy  Eyes  and  in  Anisometropia. — 
Fick  (Arch,  of  Ophthal .,  xviii,  3)  concludes  from  his  observations  that 
the  axiom,  that  unsymmetrical  accommodation  is  impossible,  is  false, 
and  must  be  erased  from  the  text-books  on  ophthalmology.  Into  its 
place  steps  the  fact  that,  even  under  physiological  conditions,  the  accom¬ 
modation  of  one  eye  can  act  independently  of  that  of  the  other ;  inde¬ 
pendent,  however,  only  within  certain  limits.  This  unequal  accommo¬ 
dation  can  only  be  obtained  by  a  perceptible  and  sometimes  a  painful 
exertion,  and  the  eyes  only  bring  it  into  use  in  so  far  as  it  is  indispensa¬ 
bly  necessary  in  the  interest  of  the  act  of  vision.  In  fitting  anisome- 
tropes  with  glasses,  three  points  should  be  considered:  1.  The  breadth 
of  accommodation  in  both  eyes  singly.  2.  The  valuation  of  accommo¬ 
dation  in  one  eye  when  that  of  the  other  remains,  as  far  as  possible, 
unchanged.  3.  The  alterations  of  refraction  needed  for  the  least  try¬ 
ing  combined  binocular  reading.  Fick  believes  that  meridional  asym¬ 
metrical  accommodation  is  possible,  and  that  the  asthenopia  of  many 
astigmatics  is  caused  by  the  effort  to  compensate  for  the  corneal  astig¬ 
matism  by  meridional  asymmetrical  accommodation. 

The  Cause  of  Senile  Cataract. — Schoen  (Arch,  of  Ophthal .,  xviii,  3) 
draws  the  following  conclusions  from  his  investigations :  1.  The  pro¬ 


cess  heretofore  distinguished  as  senile  cataract  begins  always  as  equa¬ 
torial  cataract,  with  fine  white  dots  or  streaks  (never  with  clefts).  2. 
Nuclear  sclerosis  never  appears  without  equatorial  cataract.  On  the 
other  hand,  the  statistics  show  three  hundred  and  seventy-seven  eyes 
with  equatorial  cataract  without  nuclear  sclerosis.  The  latter  is  with¬ 
out  doubt  secondary.  3.  Nuclear  sclerosis  is  associated  with  equatorial 
cataract  first  after  the  age  of  sixty.  4.  More  than  half  (sixty  per 
cent.)  of  the  patients  with  cataract  have  still  normal  acuteness  of 
vision,  wherefore  changes  in  the  center  of  the  lens  may  be  excluded. 
5.  Anterior  cortical  cataract  is  rarely  associated  with  equatorial  cataract 
before  the  age  of  fifty.  6.  Cataracta  simplex  is  not  peculiar  to  old  age, 
but  frequently  occurs  in  its  incipiency  in  young  people  from  twenty  to 
thirty  years  of  age.  The  designation  “  senile  ”  should  therefore  be 
dropped,  and  “simplex”  employed  in  its  place.  7.  Three  fourths  of 
the  total  number  of  cataractous  eyes  are  hypermetropic  or  astigmatic. 
8.  Equatorial  cataract  begins  chiefly  in  the  horizontal  meridian.  9.  The 
macroscopic  dots  and  stripes  correspond  to  the  insertion  of  the  anterior 
and  middle  zonular  fibers.  10.  The  microscopical  changes  likewise  are 
arranged  around  the  base  of  these  fibers. 

The  Degeneration  of  the  Center  of  the  Retina  in  Old  People. — 
Hirsehberg  (Ctrlbl.  f.  prakt.  Aug.,  September,  1889)  states  that, 
when  healthy  people  of  an  advanced  age  lose  their  acuteness  of  vision 
for  fine  objects,  so  that  they  either  can  not  read  at  all  or  do  so  with 
great  difficulty,  while  they  still  possess  excellent  eccentric  vision  and 
find  their  way  about  without  difficulty,  there  will  be  found  at  the  center 
of  the  fundus  in  both  eyes  small,  circumscribed,  bright  spots  of  discolor¬ 
ation,  and  in  some  of  these  small  crystals  may  be  seen.  The  visual 
tests  show  diminution  of  the  central  acuity  of  vision  to  fg  and  even 
less,  and  a  defect  in  the  center  of  the  visual  field.  The  process  is 
slowly  progressive  and  the  vision  steadily  diminishes.  In  the  center  of 
the  retina  are  seen  rose-colored  spots,  in  which  are  white  spots  with 
crystals  ;  and  in  the  vicinity  are  recent,  grayish-blue  spots  behind  the 
vessels.  At  the  periphery  there  are  black  spots.  The  change  is  not 
limited  to  the  retinal  center.  Treatment  is  futile,  but  the  disease  does 
not  proceed  to  blindness. 

A  Case  of  Detachment  of  the  Retina  treated  by  Schoeler’s  Injection 
Method,  with  Fatal  Result.  —  Gelpke  (Ctrlbl.  f.  prakt.  Aug.,  Sep¬ 
tember,  1889)  reports  a  distressing  case  of  this  kind  occurring  in  a  ro¬ 
bust  elderly  man  of  sixty-six  years.  The  detachment  had  occurred  in 
a  hitherto  perfectly  healthy  eye  without  any  known  cause.  Three  drops 
of  tincture  of  iodine  were  injected  into  the  vitreous  according  to  Scho- 
ler’s  method,  all  the  steps  before,  during,  and  after  the  operation  being 
carried  on  under  the  most  rigid  antiseptic  rules.  In  spite  of  everything, 
an  infectious  purulent  chorioiditis  was  set  up  in  the  eye,  and  two  days 
later  this  was  followed  by  a  purulent  meningitis,  which  caused  the  pa¬ 
tient’s  death  on  the  sixth  day. 

The  Treatment  of  Detachment  of  the  Retina. — Ulrich  (Kl.  Mon.  f. 
Aug.,  September,  1889)  gives  in  detail  his  method  of  treating  cases  of 
detached  retina.  The  first  condition  of  a  successful  treatment  in  the 
first  stage  is  rest  in  bed  and  the  use  of  salicylate  of  sodium  as  an  absorb¬ 
ent.  In  addition  to  this  comes  the  pressure  bandage  whenever  it  can 
be  borne.  It  should  not  be  removed  except  when  the  patient  is  in  bed. 
The  salicylate  of  sodium  should  be  "given  in  sixteen-grain  doses  (one 
gramme)  every  hour  for  four  or  five  hours,  and  every  third  day  it  should 
be  omitted  for  a  day.  After  the  first  month  of  this  continuous  treat¬ 
ment,  the  treatment  is  modified  in  such  manner  that  the  patient  passes 
one  week  in  every  month  in  bed,  and  during  this  period  he  takes  six 
times  five  grammes  of  salicylate  of  sodium.  In  the  interval  moderate 
exercise  may  be  allowed. 

Extirpation  of  the  Lacrymal  Gland  causing  Atrophy  of  the  Optic 
Nerve  through  Haemorrhage  into  the  Orbit. — Gifford  (Amer.  Jour,  of 
Ophth .,  September,  1889)  reports  a  case  of  this  nature  in  a  man  aged 
sixty.  History  of  dacryocystitis  on  left  side  for  a  year,  with  moderate 
stricture  of  the  lacrymal  canal  and  ectropium  of  lower  lid.  The  upper 
canaliculus  was  slit  and  the  usual  probing  and  syringing  treatment  car¬ 
ried  on  for  ten  days  with  improvement.  Then  a  stationary  period  be¬ 
gan  and  lasted  for  several  days,  and  it  was  decided  to  extirpate  the 
lacrymal  gland,  which  was  done  under  ordinary  antiseptic  precautions. 
The  incision,  an  inch  long,  was  made  just  below  the  eyebrow  at  the 
outer  side,  and  was  inclosed  with  an  interrupted  suture.  There  was  an 


54 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jouk., 


unusually  free  hemorrhage  during  the  operation,  and  the  bandage  had 
to  be  changed  twice  in  thirty  hours,  on  account  of  oozing  from  the 
wound.  When  the  dressing  was  changed  the  second  time,  the  oozing 
had  ceased,  but  the  upper  lid  was  so  infiltrated  with  blood  that  the  eye¬ 
lids  could  not  be  opened.  The  wound  healed  without  a  trace  of  reaction, 
but  the  upper  lid  and  conjunctiva  were  full  of  coagulated  blood,  the 
skin  was  of  a  purple  hue,  and  the  patient  complained  of  a  dull  pain  in 
and  around  the  orbit.  Four  weeks  later  there  was  complete  left  ptosis, 
the  left  eye  was  completely  motionless,  the  pupil  was  moderately  di¬ 
lated,  the  direct  light  reflex  was  absent,  the  media  were  clear,  the  retina 
was  filled  with  haemorrhages,  not  fresh,  but  old  and  partially  absorbed. 
The  vessels  were  small  and  the  optic  papilla  was  completely  white.  No 
record  is  made  of  the  testing  of  the  vision,  but  in  the  history  the  man 
states  that  the  eye  was  blind. 

The  Restoration  of  the  Eyelids  and  the  Disadvantages  of  Cutaneous 
Grafts. — V alude  {Arch,  d'ophthal.,  July- August,  1889)  thinks  that  the 
disadvantages  of  blepharoplasty  by  means  of  a  facial  flap  are  as  fol¬ 
lows  :  1.  It  may  leave  a  second  deformity  much  more  considerable  than 
the  first  if  union  does  not  take  place,  and  especially  if  the  flap  becomes 
gangrenous.  2.  It  can  not  succeed  if  the  neighboring  parts  consist  of 
cicatricial  tissue  of  feeble  vitality.  3.  It  produces  in  the  face  seams  and 
cutaneous  folds  which  are  shocking  additional  deformities.  On  the  other 
hand,  the  advantages  of  this  form  of  blepharoplasty  may  be  stated  as  fol¬ 
lows  :  1.  Even  if  the  result  of  the  operation  is  a  failure,  the  consequent 
inconvenience  is  almost  nil.  No  tissue  is  lost,  and  any  other  operation 
may  be  essayed.  2.  The  cutaneous  graft  may  always  be  procured  with 
the  same  facility.  3.  No  new  deformity  is  added  to  the  physiognomy. 
Valude  thus  voices  the  general  opinion  of  the  Paris  Surgical  Society  in 
regard  to  skin  grafts  :  1.  When  the  cicatricial  skin  is  thin,  elastic,  shin¬ 
ing,  very  dry,  slightly  vascular,  entirely  fibrous,  adherent  to  the  subcu¬ 
taneous  layers,  or  separated  from  them  by  a  loose  cellular  tissue,  skin 
grafting  should  not  be  attempted.  2.  If,  on  the  contrary,  the  cicatrix 
only  involves  the  superficial  layers  of  a  thick  skin,  if  it  is  furnished  with 
a  well-nourished  panniculus  adiposus,  without  adhesions  to  underlying 
parts,  the  skin  grafting  is  indicated.  3.  Even  when  the  anatomical  con¬ 
ditions  are  not  very  favorable,  the  cicatricial  tissue  may  be  utilized  for 
grafts,  though  they  must  be  very  small.  4.  Cicatricial  tissue  may  unite 
by  first  intention  with  analogous  tissue  and  with  healthy  tissues.  5. 
Cicatricial  flaps  are  exempt  from  several  inconvenient  accidents  which 
frequently  involve  those  taken  from  healthy  parts  ;  they  lie  flat,  do  not 
rise  above  the  surrounding  part3,  and  do  not  swell  and  form  nodules,  as 
healthy  skin  grafts  often  do.  6.  When  the  face  has  been  greatly  dis¬ 
figured  by  a  scar,  and  only  part  of  it,  as  the  eyelids,  is  to  be  repaired, 
it  is  better  to  employ  a  cicatricial  graft. 

The  Heredity  of  Myopia. — Motais  {Arch,  d'ophthal.,  July-August, 
1889),  from  an  examination  of  all  the  members  of  330  families  of 
young  myopes,  draws  the  following  conclusions : 

1.  The  hereditary  influence  of  myopia  is  manifest. 

2.  It  existed  in  216  families  out  of  330,  or  65  per  cent. 

3.  Hereditary  myopia  is  distinguished  from  acquired  myopia  by  its 
early  appearance,  its  rapid  development,  and  by  frequent  and  serious 
complications. 

4.  Myopia  is  usually  transmitted  from  father  to  daughter  (86  per 
cent.)  and  from  mother  to  son  (79  per  cent.);  hence  hereditary  myopia 
is  crossed  from  the  sexual  standpoint. 

5.  The  principal  conditions  which  favor  the  hereditary  transmission 
of  myopia  are:  1.  The  use  of  the  eyes  in  an  unfavorable  hygienic  en¬ 
vironment  either  at  school  or  at  home.  2.  Astigmatism  of  a  certain 
degree  (above  D.  0‘75),  14  per  cent.  3.  Microsemia  or  lowering  of  the 
orbital  arch,  30  per  cent. 

6.  The  deduction  of  the  exact  demonstration  of  hereditary  myopia 
to  a  great  extent  (65  per  cent.),  and  of  the  serious  nature  of  the  affec¬ 
tion,  should  be  carefully  impressed  upon  all  who  are  engaged  in  the 
education  of  children. 

The  Extirpation  of  the  Orbital  Lacrymal  Glands  for  Incurable 
Lacrymation  in  Cases  of  Granular  Conjunctivitis.  —  True  {Arch, 
d'ophthal.,  July- August,  1889)  draws  the  following  conclusions  from  his 
observations:  1.  In  certain  cases  incurable  lacrymation  and  granular 
conjunctivitis  are  intimately  connected  together,  and  can  not  be  cured 
in  any  other  way  than  by  extirpation  of  the  orbital  portion  of  the 


lacrymal  gland.  2.  This  operation  immediately  puts  a  stop  to  the 
epiphora,  and  causes  a  rapid  amelioration  in  the  granular  conjuncti¬ 
vitis.  3.  The  extirpation  of  the  lacrymal  gland  is  of  great  value  in 
incurable  lacrymation,  and  is  especially  indicated  in  old  or  chronic 
granular  conjunctivitis  with  stenosis  of  the  lacrymal  passages. 

Anomalies  of  Development  of  the  Eyes  in  an  Epencephalic  Mon¬ 
ster,  accompanied  by  an  Orhito-buccal  Hare-lip. — Panas  (Arch,  d'oph¬ 
thal.,  September-October,  1889)  gives  the  following  anatomical  descrip¬ 
tion  of  a  rare  case :  1.  The  orbito-buccal  hare-lip  results  from  the 
non-union  of  the  embryonic  lacrymal  fissure.  2.  The  ascending  apoph¬ 
ysis  of  the  superior  maxilla,  which  forms  such  a  large  part  of  the 
excretory  lacrymal  passages,  arises  from  the  external  frontal  bud  or 
boss,  and  does  not  unite  with  the  body  of  the  superior  maxilla  until 
much  later.  Hence  this  apophysis  belongs  to  the  intermaxillary  bone 
and  not  to  the  superior  maxilla.  3.  The  presence  of  two  amniotic 
bands  on  both  cornem  can  not  be  doubted,  and  it  is  curious  to  note  the 
correlation  of  this  fact  with  the  malformation  of  the  two  eyeballs  and 
with  the  presence  of  a  dermoid  growth  upon  the  microphthalmic  right 
eye. 

A  Clinical  Study  of  Some  Sympathetic  Affections  of  the  Eyes ; 
their  Treatment  hy  Massage  of  the  Painful  Points.— Chibret  (Arch, 
d'ophthal.,  September-October,  1889)  presents  the  following  conclusions : 
1.  There  are  certain  sympathetic  affections  of  the  eye,  especially  kera¬ 
titis  and  iritis,  which  have  been  hitherto  unrecognized.  2.  These  dis¬ 
eases  resist  all  the  usual  methods  of  treatment.  3.  They  may  attack 
either  the  cornea  or  the  iris.  4.  They  are  always  painful,  and  some¬ 
times  excessively  so.  5.  The  essential  characteristic  of  these  affec¬ 
tions  is  that  the  points  of  emergence  of  the  supra  orbital  or  external 
nasal  are  very  painful.  6.  Massage  of  the  points  of  emergence  of  these 
nerves  always  causes  a  diminution  of  the  pain  and  an  immediate  ame¬ 
lioration  of  the  sympathetic  affection,  no  matterhoAvchronic.it  may 
be.  7.  The  laceration  or  elongation  of  these  nerves  would  probably 
bring  about  an  equally  good  result. 

The  Connection  between  Diseases  of  the  Eyes  and  Diseases  of  the 
Nose. — Despagnet  {Rec.  d'ophthal.,  September,  1889)  considers  that 
many  cases  of  obstinate  lacrymation  are  due  to  trouble  in  the  nose. 
In  all  these  cases  we  meet  with  a  hypertrophy  of  the  inferior  turbi¬ 
nated  bones  which  compresses  the  end  of  the  nasal  duct  and  finally 
obstructs  it  altogether.  When  this  condition  is  relieved  the  lacryma¬ 
tion  disappears.  He  recommends  the  galvano-cautery  for  the  treat¬ 
ment  of  this  hypertrophy.  Many  cases  of  granular  conjunctivitis  and 
keratitis  are  due  entirely  to  the  existence  of  a  catarrhal  rhinitis.  Se¬ 
cretions  from  this  conjunctivitis  and  this  form  of  rhinitis  have  been 
examined  microscopically,  and  a  special  microbe  has  been  discovered, 
which  has  been  cultivated. 

Suture  of  the  Cornea  in  Extraction  of  Cataract. — Mendoza  (Rec. 
d'ophthal.,  September,  1889)  thus  formulates  the  advantages  of  this 
method  of  operating:  1.  It  absolutely  prevents  incarceration  and  her¬ 
nia  of  the  iris.  2.  It  avoids  the  irritation  which  is  caused  by  pro¬ 
longed  closure  of  the  lids,  and,  by  permitting  free  motion  to  the  lids, 
facilitates  the  removal  of  the  secretions  and  thus  keeps  the  eye  in  a 
more  complete  condition  of  asepsis.  3.  It  brings  about  perfect  coapta¬ 
tion  of  the  edges  of  the  corneal  wound.  4.  The  latter  may  thus  be  kept 
clean  much  more  readily.  5.  When  irrigation  of  the  anterior  chamber  is 
indicated  it  is  rendered  more  easy  and  less  dangerous  by  the  possibility 
of  half  opening  the  wound  by  pulling  on  the  thread  of  the  inferior  flap. 
6.  It  admits  of  the  eye  being  left  without  occluding  bandage  imme¬ 
diately  after  the  operation,  when  inflammation  of  the  lids  or  of  the 
lacrymal  sac  necessitates  frequent  cleansing.  7.  The  prompt  re-estab¬ 
lishment  of  the  anterior  chamber  renders  possible  the  use  of  atropine 
soon  after  the  operation  without  any  danger  of  inducing  hernia  of  the 
iris.  8.  The  patient  is  enabled  to  be  out  of  bed  soon  after  the  opera¬ 
tion,  or,  at  the  latest,  on  the  next  day.  9.  There  is  no  danger  of  re¬ 
opening  of  the  corneal  Avound. 

The  Number  and  Caliber  of  Nerve  Fibers  in  the  Oculomotorius  in 
the  New-born  and  Adult  Cat. — Schiller  (Rec.  d'ophthal.,  October,  1889) 
concludes  from  his  investigations  that  the  number  of  the  fibers  of  the 
oculomotorius  of  the  cat  increases  but  little  or  none  during  life.  The 
apparently  somewhat  increased  number  of  fibers  found  in  the  adult 
cat  is  probably  due  to  the  fact  that  in  the  new-born  animal  some  fibers 


July  12,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


55 


are  overlooked  in  the  counting  owing  to  their  extreme  tenuity,  and  that 
they  are  confounded  with  the  neuroglia.  The  caliber  of  the  fibers  in 
the  adult  animal  is  from  six  to  eight  times  greater  than  in  the  new-born 
animal.  Forel  adds  that  a  continuation  of  these  investigations  will 
probably  end  in  proving  that  the  number  of  the  cellular  elements  of 
the  cerebro-spinal  nervous  system  does  not  increase  during  life.  These 
investigations  have  also  strengthened  the  belief  that  there  are  no  anas¬ 
tomoses,  either  large  or  small,  in  the  nerve  centers,  and  that  each  nerve 
fiber  is  but  the  prolongation  of  one  cell,  and  ends  in  free  arborescent 
filaments.  This  would  imply  a  nerve  force  reacting  from  one  nerve 
element  to  another  by  contiguity  or  simple  proximity,  the  nerve  fiber 
conducting  this  influence  from  its  cellule  to  the  point  of  its  terminal 
ramification,  or  vice  versa. 

The  Treatment  of  Circumorbital  and  Ocular  Migraine. — Galezowski 
( Rec .  d'ophthal.,  October,  1889)  strongly  recommends  the  use  of  static 
electricity  in  the  treatment  of  migraine.  The  attack,  even  at  its  height, 
disappears  immediately  after  the  application  of  the  current,  even  when 
the  sitting  has  lasted  only  ten  minutes.  Of  course,  the  neuralgia  must 
be  idiopathic  if  any  beneficial  result  is  to  be  gained  from  electricity. 

The  Relative  Importance  of  the  Different  Forms  of  Refractive 
and  Muscular  Error  in  the  Causation  of  Headache. — Marlow  ( Ophth . 
Rev.,  December,  1889)  draws  the  following  conclusions  from  a  review 
of  his  cases  :  1.  Headaches  are  frequently  the  result  of  errors  of  re¬ 
fraction  and  muscular  insufficiency.  2.  Refractive  error  or  ametropia 
is  a  more  common  factor  in  the  production  of  headaches  than  muscular 
defect.  3.  Defective  muscular  action  or  insufficiency  is  more  certain 
to  produce  headache  than  ametropia.  4.  Astigmatism  is  the  most 
powerful  and  common  refractive  factor  in  the  production  of  headaches ; 
and,  of  the  different  forms  of  astigmatism,  compound  hypermetropic 
astigmatism  is  the  most  important  in  this  regard.  5.  A  combination 
of  insufficiency  of  the  internus  or  externus  with  overbalance  of  the 
superior  rectus  is  a  common  variety  of  muscular  defect.  6.  Overbal¬ 
ance  of  the  superior  rectus  is  decidedly  more  certain  to  produce  head¬ 
ache  than  any  other  form  of  muscular  defect  or  of  ametropia.  7.  A 
combination  of  overbalance  of  the  superior  rectus  with  astigmatism  is 
the  most  powerful  cause  of  ocular  headache. 

Recovery  from  Hemianopsia,  with  Subsequent  Necropsy. — Doyne 
{Ophth.  Rev.,  December,  1889)  reports  a  case  of  an  old  man  who  had 
a  sudden  attack  of  right  homonymous  hemianopsia.  The  fields  of  vis¬ 
ion  recovered  in  the  course  of  two  weeks,  but  subsequently  a  quadrant 
of  the  opposite  side  of  each  field  was  lost.  Death  occurred  some  weeks 
later  from  cerebral  apoplexy.  At  the  autopsy,  in  addition  to  the  exten¬ 
sive  extravasations  which  caused  death,  there  was  found  asymmetrical 
softening  on  both  sides  of  the  brain  in  the  cortex  of  the  occipital  lobe, 
one  evidently  more  recent  than  the  other. 

Homonymous  Hemianopsia  ;  Recovery  ;  Subsequent  Death  and  Ne¬ 
cropsy. — Anderson  {Ophth.  Rev..  December,  1889)  reports  the  case  of  a 
man,  aged  forty-one,  who  complained  of  failure  of  vision  for  six  weeks, 
with  severe  frontal  headache,  much  failure  of  memory,  and  mental  de¬ 
pression.  He  could  not  see  to  the  right  side,  and  his  speech  had  altered. 
No  loss  of  gross  motor  power  or  of  general  or  special  sensation,  ex¬ 
cept  as  regards  vision.  The  gait  and  reflexes  were  normal.  The  ocu¬ 
lar  and  pupillary  movements  were  normal,  and  the  media  and  fundus 
were  healthy.  Vision  and  accommodation  were  normal.  The  right 
halves  of  both  visual  fields  weie  lost  up  to,  but  not  including,  the  line 
through  the  fixation  point.  Anderson  concluded  that  the  patient  had 
an  intracranial  growth,  situated  in  the  medulla  of  the  left  occipital  lobe, 
and  that  a  haemorrhage  had  taken  place  into  the  tumor  recently. 
Within  two  weeks  the  headache  and  mental  symptoms  had  much  sub¬ 
sided,  and  there  was  only  very  slight  contraction  of  the  right  halves 
of  the  visual  fields.  Two  months  subsequently  he  h&d  a  transient  attack 
of  left  hemiplegia,  which  soon  passed  off.  Three  weeks  after  the  oc¬ 
currence  of  the  hemiplegia  the  lower  quadrants  of  the  right  halves  of 
both  visual  fields  were  deficient  nearly  to  the  vertical  line  through  the 
fixation  point.  Vision  was  still  good,  and  the  fundus  was  normal. 
Rapid  mental  deterioration  ensued,  and  he  died,  demented,  three  months 
later.  There  was  a  recent  blood-clot  in  the  posterior  cornu  of  the  left 
lateral  ventricle,  with  haemorrhage  and  softening  of  the  tissue  external 
to  this,  involving  the  whole  of  the  angular  gyrus  up  to  its  surface.  The 
angular  gyrus  was  replaced  by  gliomatous  tissue. 


The  Size  of  the  Cornea  in  Relation  to  Age,  Sex,  Refraction,  and 
Primary  Glaucoma. — Priestley  Smith  {Ophth.  Rev.,  December,  1889) 
gives  an  account  of  certain  facts  obtained  by  measurement  of  the  cor¬ 
nea  in  a  large  number  of  human  eyes.  The  normal  cornea  was  exam¬ 
ined  in  a  thousand  eyes,  representing  all  periods  of  life  from  five  to 
ninety  years.  Age,  sex,  and  refraction  were  noted  in  every  case.  It 

was  found  that  the  cornea  attained  its  full  diameter  very  early  in  life _ 

many  years  before  the  rest  of  the  body  completed  its  growth.  The  de¬ 
velopment  of  the  cornea  is  also  precocious  in  relation  to  that  of  the  eye 
as  a  whole.  Classification  according  to  sex  showed  a  slight  but  proba¬ 
bly  real  difference  in  each  life  period,  the  cornea  of  the  male  being,  on 
the  average,  about  one  tenth  of  a  millimetre  the  larger.  Classification 
according  to  refraction  showed  the  unexpected  fact  that  the  size  of  the 
cornea  bears  no  relation  to  the  refraction,  being  no  smaller  in  hvper- 
metropia,  no  larger  in  myopia,  than  in  emmetropia.  This  was  further 
proved  by  comparison  of  ninety  highly  hypermetropic  with  ninety 
highly  myopic  eyes.  The  size  of  the  cornea  is  determined  early  in  life, 
and  is  not  affected  by  the  greater  or  smaller  extension  of  the  posterior 
hemisphere  which  may  occur  later.  The  cornea  is  full  grown  at  the 
age  of  five  years  or  earlier.  Sixty-nine  persons  having  primary  glau¬ 
coma  in  one  or  both  eyes  were  examined.  The  number  of  glaucoma¬ 
tous  eyes  was  ninety-nine ;  healthy  eyes,  thirty-two.  Comparing  the 
glaucoma  group  with  the  same  life  periods  in  the  healthy  group,  the 
small  corneae  formed  twenty-six  per  cent,  of  the  one  and  four  per  cent, 
of  the  other.  Among  the  one  thousand  eyes  of  healthy  persons,  there 
was  not  one  cornea  so  small  as  ten  millimetres,  while  there  were  nine 
such  in  the  much  smaller  glaucoma  group.  A  definite  relation  between 
the  small  cornea  and  primary  glaucoma  was  thus  proved  to  exist.  The 
explanation  lay  in  an  undue  proximity  between  the  lens  and  the  sur¬ 
rounding  structures.  Further  observations  show  that  the  smallness  of 
the  cornea  precedes  the  glaucoma  and  is  not  caused  by  it. 

How  far  forward  is  the  Fundus  Visible  with  the  Ophthalmo¬ 
scope  1 — Groenouw  {Arch,  fur  Ophthal .,  xxxv,  3)  answers  this  ques¬ 
tion  as  follows:  The  anterior  limit  of  the  fundus  visible  with  the 
ophthalmoscope  lies  about  8'5  millimetres  behind  the  margin  of  the 
cornea;  in  myopes  somewhat  farther;  in  hvpermetropes  somewhat 
less.  The  possible  error  scarcely  amounts  to  more  than  one  millimetre 
in  all  these  three  conditions.  In  aphakia  this  distance  is  reduced  to 
6’5  millimetres. 

The  Treatment  of  Symblepharon. — Snellen  {Ophth.  Rev^  December, 
1889)  describes  an  operation  for  the  cure  of  symblepharon  which  has 
given  very  satisfactory  results.  His  plan  is  to  thoroughly  free  the  ad¬ 
herent  lid,  leaving  any  conjunctiva  present  attached  to  the  globe.  A 
thin  flap  of  skin  of  the  required  size  is  then  dissected  from  the  cheek, 
having  a  narrow  pedicle  close  to  the  border  of  the  lid  near  the  outer 
canthus ;  a  button-hole  being  made  beneath  this  flap  from  the  inner 
surface  of  the  eyelid,  the  flap  is  drawn  through  and  attached  to  the 
raw  surface  of  the  lid.  The  operation  has  proved  of  value  also  in  en¬ 
larging  a  socket  for  the  reception  of  an  artificial  eye. 

A  New  Operation  for  Ptosis. — Snellen  {Ophth.  Rev.,  December, 
1889)  has  recently  adopted  the  following  operation  for  cases  of  ptosis. 
A  ligature  is  passed  from  without  inward  through  the  entire  thickness 
of  the  lid  at  the  upper  edge  of  the  tarsus ;  the  lid  is  then  everted  and 
the  needle  passed  outward  through  all  the  tissues,  except  the  skin,  at  a 
point  near  the  upper  limit  of  the  conjunctival  sac,  and  made  to  per¬ 
forate  the  skin  near  the  original  puncture.  The  ends  of  the  ligature 
are  then  tied  over  beads  on  the  surface  of  the  lid.  Three  such  lisa- 
tures  are  employed,  disposed  rather  toward  the  nasal  side,  on  account 
of  the  position  of  the  levator. 

The  Treatment  of  Episcleritis. — Snellen  {Ophth.  Rev.,  December, 
1889)  recommends  the  injection,  once  or  twice  a  week,  of  a  solution  of 
corrosive  sublimate  (1  to  5,000)  beneath  the  swollen  and  thickened 
conjunctiva  and  episcleral  tissue  by  means  of  a  Pravaz’s  syringe,  the 
eye  being  cocainized. 

The  Retinal  Circulation  in  Anaemia  following  Chronic  Haemor¬ 
rhages  and  in  Chlorosis,  and  its  Dependence  upon  the  Constitution  of 
the  Blood. — Raehlmann  {Kl.  Mon.  f.  Aug.,  December,  1889)  formulates 
the  following  propositions  as  a  result  of  investigations:  1.  In  most  of 
the  cases  which  show  arterial  pulsation  the  number  of  corpuscular  ele¬ 
ments  of  the  blood  is,  on  an  average,  less  than  in  normal  blood ;  and 


56 


MISCELLANY. 


[N.  Y.  Mkd.  Jour. 


that  the  latter  is  in  many  cases  markedly  diminished,  in  others  slightly, 
but  in  all  perceptibly.  2.  In  such  cases  the  individual  blood-corpuscles 
are  almost  invariably  smaller  in  volume  than  normal  blood-corpuscles. 
3.  They  are  generally  poorer  in  ha?moglobin  and  consequently  specific¬ 
ally  lighter,  and  do  not  sink  as  readily  in  watery  solutions  as  do  normal 
blood-corpuscles,  and  therefore  move  more  easily  and  rapidly  in  such 
solutions.  4.  In  many  cases  of  amemia,  which  show  a  typical  marked 
pulsation  in  the  retinal  arteries,  all  three  factors  exist,  viz. :  diminution 
in  the  number  of  the  corpuscles,  loss  of  haemoglobin,  and  diminution  in 
their  weight  and  volume. 

Ophthalmoscopic  Appearances  at  the  Periphery  of  the  Fundus. — 

Magnus  {Arch,  fur  Ophthal.,  xxxv,  3)  draws  the  following  conclusions 
from  his  observations:  1.  The  ciliary  body  is  partially  visible  on  oph¬ 
thalmoscopic  examination,  and  appears  as  a  peripheral  pigmented 
band  with  a  radiate  or  shaggy  margin.  2.  The  region  encroaching 
posteriorly  on  the  margin  of  the  ciliary  body  is  very  often  of  a  much 
brighter  color  than  the  rest  of  the  fundus.  In  this  discolored  periphe¬ 
ral  zone  very  many  fine  parallel  chorioidal  vessels  are  usually  visible. 
3.  At  the  periphery  of  the  fundus,  along  the  border  of  the  ciliary  body, 
we  meet  with  peculiar  pathological  foci  in  an  otherwise  normal  fundus, 
both  in  young  and  old  persons.  4.  These  foci  appear  either  as  small 
oval  or  circular  white  spots,  or  as  a  network  of  fine  white  lines,  or  they 
blend  into  a  broad  belt  surrounding  the  entire  periphery  of  the  fundus. 

5.  In  the  region  of  these  foci  pigment  is  usually  present,  arranged  with 
a  certain  regularity  around  the  peripheral  border  of  the  diseased  focus. 

6.  In  the  eyes  of  young  persons  the  cause  of  these  pathological  appear¬ 
ances  is  usually  found  to  be  a  high  degree  of  myopia.  '7.  In  a  highly 
myopic  eye  the  peripherical  atrophic  belt  is  a  characteristic  appear¬ 
ance.  8.  Posterior  staphyloma  and  changes  at  the  periphery  of  the 
fundus  usually  appear  together  in  most  of  the  cases.  9.  In  the  eyes  of 
old  people,  if  they  are  not  highly  myopic,  these  peripherical  foci  are 
senile  changes. 

The  JStiology  of  Neuroparalytic  Keratitis. — Yon  Hippel  {Arch,  fur 
Ophthal.,  xxxv,  3)  draws  the  following  conclusions  from  his  investiga¬ 
tions :  1.  The  theory  of  the  existence  of  trophic  fibers  running  in  the 
center  of  the  trigeminus  can  not  be  harmonized  with  the  results  of 
many  autopsies.  2.  The  purely  traumatic  theory  of  causation  is  un¬ 
tenable.  3.  The  theory  of  evaporation  is  capable  of  explaining  the  ap¬ 
pearance  of  the  inflammation  in  every  case.  4.  A  diminished  power  of 
resistance  to  injuries  does  not  exist.  A  non-sensitive  eye  is  more  ex¬ 
posed  to  desiccation  from  evaporation  than  a  normal  eye.  5.  A  wire 
network  has  the  power  of  directly  hindering  the  evaporation.  6.  A 
wire  guard  can  not,  however,  prevent  the  occurrence  of  inflammation. 

7.  A  moist  atmosphere  hinders  the  appearance  of  neuroparalytic  kera¬ 
titis.  8.  Micro-organisms  are  not  always  found,  and  can  not  therefore 
be  regarded  as  an  setiological  factor. 


JJlisrell  ang. 


Sound  Advice  for  the  Profession. — The  following  lay  sermon  to  the 
profession  is  to  be  found  in  the  preface  of  a  curious  old  medical  work 
entitled  Vade  Mecum  or  a  Companion  for  a  Chirurgion  fitted  for  times 
of  peace  and  war ,  by  Thomas  Brugis,  Doctor  in  Physick.  London. 
Printed  by  T.  H.  for  Thomas  Williams,  at  the  sign  of  the  Bible  in  Little 
Britain,  1652. 

“  Presume  not  too  much  on  thy  own  wisdome  and  vertue,  lest  thou 
beest  lifted  up  with  a  vain  confidence,  and  puffed  up  with  pride,  for 
when  men  are  carried  with  an  inordinate  and  blind  love  of  themselves, 
they  are  soon  persuaded  that  there  is  nothing  in  them  worthy  to  be  dis- 
pised,  yea,  they  think  that  their  ignorance  is  wisdom,  insomuch  that 
knowing  nothing,  they  suppose  they  know  all  things,  and  having  no 
dexterity  to  performe  any  one  commendable  work,  they  presume  very 
inconsiderately  to  set  their  hand  to  every  great  matter ;  but  the  more 
care  and  diligence  they  bestow,  being  let  with  a  desire  to  shew  great 
skill,  and  thinking  to  win  honour  and  renown,  so  much  the  more  they 
discover  their  ignorance  and  blockishnesse,  purchasing  to  themselves 


shame  and  infamy  :  For  a  man  to  know  himself  to  be  ignorant,  is  the 
best  science  and  necessary  for  men,  that  without  it  they  cannot  be 
truly  skillfull ;  for  as  I  said  before,  the  ignoraflt  person  that  knoweth 
not  himselfe  to  be  such  an  one,  but  supposeth  he  knoweth  that  which 
he  doth  not,  indeed  is  as  unteacbable  as  a  beast  can  be  ”  .  .  . 

“  Socrates,  who  by  the  oracle  was  declared  to  be  the  widest  man  then 
living,  was  greatly  commended  by  the  ancients,  because  he  said  he  knew 
but  onely  one  thing :  viz.,  That  he  was  ignorant  and  knew  nothing. 

“  Now  a  word  or  two  to  the  patient :  Thou  seest  in  every  village  a  sort 
of  Mountebanks,  Empericks,  Quacksalvers,  Paracelsians  (as  they  call 
themselves),  Wizards.  Alcumists,  Poor  vicars,  cast  apothecaries,  and 
physitians  men.  Barbers  and  Good  wives  that  professe  great  skill  go 
with  the  name  of  Doctor,  which  title  perhaps  they  bought  at  some  be¬ 
yond  sea  University,  where  they  bestow  this  degree  upon  such  people 
for  their  money ;  the  phrase  they  use  is  ‘  Accipiamus  pecuniam,  demit- 
tamus  asinum,’ and  so  with  title  of  Doctor  Asse;  away  he  flies  into 
all  countries  possessing  the  people  with  stories  and  false  tales,  and  leads 
them  to  the  destruction  of  their  bodies,  if  not  of  souls  too,  that  an  able 
Physitian  or  Chyrurgion,  who  hath  undergone  a  great  deal  of  hardship 
to  benefit  himself  in  his  art  can  scarcely  maintain  himself,  or  know  who 
shall  be  his  patients.” 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called,  to  the  follow¬ 
ing  : 

A  uthors  of  articles  intended,  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti¬ 
cles,  we  alivays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed :  {1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  {2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  {3)  an  / 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  hi  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  pyroperly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  partiadar  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  July  19  1890. 


lectures  nn'tj  g^bbrcsses. 
HYPERTROPHY  OF  THE  PROSTATE  GLAND. 

AN  ADDITION  TO  McGUIRE’S  OPERATION* 

By  ROBERT  T.  MORRIS,  M.  D. 

(tentlemen  :  This  patient,  who  is  about  sixty  years  of 
age,  is  suffering  from  an  obstruction  at  the  neck  of  the 
bladder.  For  more  than  a  year  he  has  been  obliged  to 
draw  his  urine  with  a  catheter,  and  lately  it  has  become  a 
difficult  matter  tor  him  to  pass  the  instrument  into  the  blad¬ 
der.  The  patient  has  been  under  the  care  of  a  well-known 
general  practitioner,  who  has  exhausted  the  ordinary  re¬ 
sources  for  relief  in  such  cases,  and  now  that  the  patient  is 
suffering  from  an  aggravated  chronic  cystitis,  with  fre¬ 
quently  recurring  septic  symptoms,  be  asks  for  the  adoption 
of  radical  measures  for  relief. 

■*  ^or  Past  tvvo  days  the  patient  has  been  under  pre¬ 
paratory  treatment.  His  bowels  have  been  opened  freely 
m  order  to  facilitate  the  elimination  of  septic  products 
through  the  emunctories.  Hot  tobacco  fomentations  have 
been  applied  over  the  hypogastric  region  for  the  purpose  of 
quieting  the  inflamed  and  irritable  bladder,  and  I  know 
of  nothing  else  so  effective.  A  leaf  of  tobacco  is  moistened 
in  hot  water  and  placed  over  the  hypogastric  region.  A 
towel  wrung  out  in  hot  water  is  placed  over  the  tobacco, 
and  over  all  we  need  some  material  like  oiled  silk  or  dry 
rown  wrapping-paper,  to  prevent  evaporation. 

In  order  to  limit  fermentation  of  the  urine,  the  patient 
has  been  given  ten  grains  each  of  boric  and  benzoic  acids 
internally  three  times  a  day,  and  his  muddy  urine  has 
cleared  up  very  nicely  under  this  practical  internal  antisep¬ 
tic  treatment.  In  addition  to  the  steps  which  have  been 
employed  in  this  case,  it  is  usually  a  good  plan  to  have  the 
patient  draw  his  urine  at  least  once  daily  while  he  is  in  the 
knee-elbow  position,  for  by  this  procedure  he  can  remove 
residual  urine  that  could  not  otherwise  be  obtained. 

I  will  not  stop  to  explain  the  differential  diagnosis  be¬ 
tween  tumors  of  the  bladder  and  prostatic  hypertrophy,  but 
will  state  that  in  this  case  the  lateral  lobes  are  markedly 
but  evenly  enlarged.  It  is  not  the  size  of  the  gland  that 
causes  disturbance,  but  the  character  of  the  enlargement. 

A  few  men  possess  a  series  of  prostatic  tubules  dorsad  of  the 
urethra,  which  form  the  so-called  third  lobe,  and  when  we 
have  median  centric  hypertrophy,  a  small  third  lobe  may  act 
as  a  ball  valve  in  shutting  off  the  entrance  to  the  urethra. 
Ihen,  again,  when  one  of  the  lateral  lobes  is  much  larger 
than  its  fellow,  a  tortuous  urethral  canal  must  be  the  result, 
and  it  frequently  requires  much  skill  to  pass  an  instrument 
into  the  bladdei.  In  addition  to  the  obstacles  enumerated, 
we  often  find  the  mouths  of  the  prostatic  ducts  so  much  en¬ 
larged  that  they  will  admit  the  tip  of  a  catheter,  and  no  one 
but  the  specialist  knows  what  dangers  await  the  patient  if 
he  is  to  have  numerous  examiners. 


*  Abstract  of  a  lecture  delivered  at  the  Post-graduate  Medical 
School,  May,  1890. 


The  prostate  gland  in  various  animals  develops  and  de¬ 
generates  coincidently  with  the  testicles,  and  it  is  at  about 
the  time  when  the  testicles  normally  atrophy  in  man  that 
prostatic  hypertrophy  occurs.  This  condition  is  found  in  a 
relatively  small  number  of  men,  however,  and  is  really  a  de¬ 
generative  process,  consisting  in  elongation  of  the  prostatic 
tubules  and  increase  in  the  unstriped  muscular  fibers,  the 
prostatic  secretion  at  the  same  time  becoming  thin  and  wa¬ 
tery.  As  degeneration  continues,  the  tubules  and  muscular 
fibers  are  replaced  by  connective  tissue,  and  when  this  pro¬ 
cess  occurs  in  limited  areas  we  have  the  so-called  fibrous 
tumors  of  the  prostate  which  are  sometimes  supposed  to  be 
homologous  to  fibroid  tumors  of  the  sister  organ. 

The  patient  now  being  fully  under  the  influence  of  ether, 
I  pass  a  double-current  catheter  into  the  bladder  and  wash 
it  clean  with  a  copious  stream  of  Thiersch’s  solution  (sali¬ 
cylic  acid,  gr.  j ;  boric  acid,  gr.  v  ;  water,  f  f  j). 

The  stop-cock  on  the  discharge  pipe  of  the  catheter  is 
then  closed  and  the  bladder  fills  with  about  twelve  ounces 
of  the  solution,  which  is  allowed  to  remain. 

A  rubber  bag  which  will  hold  twelve  ounces  of  water  is 
oiled,  slipped  into  the  lower  rectum,  and  then  distended 
with  air,  so  that  on  percussing  the  abdomen  I  find  that  the 
fundus  of  the  distended  bladder  has  been  carried  well  above 
the  pubes  by  the  lifting  bag  in  the  rectum.  The  skin  about 
the  pubic  region  has  been  previously  shaved  and  scrubbed 
with  bichloride-of-mercury  solution,  and  inserting  the  knife 
through  this  clean  skin  just  over  the  symphysis  pubis,  I 
make  a  cephalad  incision  four  inches  in  length.  The  next  cut 
severs  the  tissues  of  the  linea  alba  and  the  transversalis  fascia 
and  exposes  loose  fat  which  lies  upon  the  bladder.  This  is 
picked  up  and  snipped  away  with  scissors  in  such  a  careful 
way  that  the  surrounding  areolar  tissues  are  not  disturbed, 
for  we  must  remember  that  urine  would  enter  a  little  rent 
and  infiltration  might  lead  to  failure  of  the  operation.  The 
danger  of  opening  the  peritonaeum  is  spoken  of  only  by  au¬ 
thors  who  have  not  had  an  opportunity  to  look  at  the  peri¬ 
tonaeum  in  this  region.  The  next  step  in  the  operation  con¬ 
sists  in  passing  a  couple  of  temporary  sutures  through  the 
muscular  wall  of  the  bladder  and  fastening  them  to  the  skin 
in  order  to  prevent  the  bladder  from  dropping  back  out  of 
sight  when  the  fluid  which  distends  it  runs  out.  The  scalpel 
is  now  passed  through  the  bladder  wall  at  a  low  median 
ventrad  point,  and  my  finger  instantly  inserted  into  the  open¬ 
ing  prevents  the  escape  of  fluid  until  I  can  explore  the  in¬ 
terior  of  the  distended  bladder.  There  is  no  calculus  to  be 
round.  Phosphatic  calculi  are  very  much  commoner  in  these 
cases  of  enlarged  prostate  than  is  generally  supposed,  be¬ 
cause  various  salts  are  precipitated  when  the  residual  urine 
ferments  and  becomes  strongly  alkaline.  Many  a  practi¬ 
tioner  is  to-day  baffled  by  a  case  of  catarrhal  cystitis  in  con¬ 
junction  with  an  hypertrophied  prostate,  because  he  does 
not  suspect  that  calculi  have  formed  in  the  patient’s  blad¬ 
der. 

This  patient  has  an  unusually  hypertrophied  third  lobe 
to  his  prostate,  and  there  is  no  well-defined  pedicle.  Other¬ 
wise  I  should  enucleate  the  third  lobe,  leave  the  abdominal 
fistula  open  temporarily,  and  expect  that  the  patient  would 


[N.  Y.  Med.  Jook., 


pass  his  urine  by  the  normal  route  a  few  weeks  later  It 
will  be  safer  here  to  make  a  permanent  suprapubic  urethra. 
Hunter  McGuire  opens  the  bladder  at  the  lowest  available 
median  ventrad  point,  and  leaves  open  the  ceplialad  extrem¬ 
ity  of  the  abdominal  incision.  The  abdominal  wound  then 
Jin*  sutured  elsewhere,  we  have  left  a  fistula  two  or  three 
inches  in  length,  the  walls  of  which  are  kept  m  apposition 
by  the  abdominal  wall  caudad  to  the  external  opening  o 
the  fistula,  so  that  the  patient  can  retain  his  urine  or  pass  it 
at  will.  The  suprapubic  urethra  in  McGuire’s  operation  is 
composed  of  cicatricial  tissues,  and  it  is  difficult  to  tell  just 
how  far  contraction  will  proceed,  and  I  suppose  that  the 
region  of  the  tract  is  apt  to  remain  in  a  sensitive  condition. 

In  order  to  overcome  these  objections,  I  shall  now  resort  to 
apian  which  has  not  been  tried  before,  so  far  as  I  know 
and  which  may  never  be  tried  again.  My  original  abdominal 
incision  through  the  skin  is  lengthened  two  inches.  A  rib¬ 
bon  of  skin  and  subcutaneous  fat  about  three  inches  long  and 
one  third  of  an  inch  broad  is  dissected  away  from  either  side 
of  the  abdominal  incision,  leaving  the  caudad  extremities  of 
the  ribbons  attached.  The  free  ends  of  the  ribbons  are  now 
sutured  with  fine  catgut  to  the  mucous  membrane  of  the 
bladder  wound,  each  on  its  respective  side.  The  temporary 
sutures  which  held  the  bladder  up  are  now  cut,  and  as  the 
bladder  drops  down,  it  takes  with  it  the  two  ribbons  of 
skin  which  lie  prettily  face  to  face,  and  which  are  to  form 
a  soft  urethra  of  skin.  Iodoform  is  now  rubbed  gently  into 
the  deep  portions  of  the  wound,  because  it  will  make  a  thin, 
firm  protective  coagulum  with  lymph,  and  turn  aside  urine 
that  mi  edit  otherwise  infiltrate  the  tissues.  The  wounds  of 
the  abdominal  wall  are  now  closed  with  catgut,  leaving 
room  for  drainage  about  the  fistula.  A  short  rubber  drain- 
acre-tube  is  introduced  into  the  bladder,  and  this  will  be  left 
in  place  for  forty-eight  hours,  the  patient  lying  upon  his 
side  or  abdomen  during  this  time,  or.  until  plastic  lymp 
has  sealed  the  woimd  securely  against  infiltration  of  urine. 

The  patient  will  be  given  ten  grains  each  of  boric  and 
benzoic  acids  internally  for  several  days,  and  the  urine  wi 
by  this  means  be  converted  into  a  “  healing  ”  flui  . 


#rt0utnl  Communications. 


THE  GROSS  ANATOMY  OF 
CHRONIC  PULMONARY  CONSUMPTION 


Note  —Four  weeks  after  the  operation  the  patient  had  made  an  un¬ 
eventful  ’  recovery,  and  all  of  the  sutured  abdominal  wounds  healed  by 

primary  union.  The  ribbons  of  skin  now  form  a  soft,  round  urethra. 
The  patient  can  retain  his  urine  or  pass  it  at  will,  and  he  substitutes  a 
<dass  drainage-tube  for  the  penis,  pressing  one  end  of  the  tube  against 
the  suprapubic  meatus  and  passing  urine  through  it.  In  order  to  do 
this,  he  makes  an  ordinary  expulsive  effort,  and  no  urine  passes  by  way 

of  the  penis.  — 


Bismuth  Salts  and  the  Odor  of  Garlic.-“The  cause  of  the  odor  of 
garlic  occasionally  communicated  to  the  breath  of  patients  who  are  tak- 
ing  preparations  of  bismuth  is  said  to  be  the  presence  of  the  metal  el- 
lurium  as  an  impurity.  The  fact  that  tellurium  gives  this  odor  to  the 
breath  was  first  noticed  by  Sir  James  Simpson,  who  when  inakin 
trials  of  the  salts  of  cerium,  also  experimented  upon  tellurium.  He  - 
ports  a  case  of  a  divinity  student  who  inadvertently  got  a  dose  of  te  - 
Limn  which  was  followed  by  the  evolution  of  such  a  persistent  odo 
of  garlic  that  for  the  remainder  of  the  session  the  patient  had  to  sit 
apart  from  his  fellows.  That  specimens  of  bismuth  preparations, 
which  caused  this  peculiar  odor  of  breath,  contained  tellurium  was  es¬ 
tablished  in  1875.  The  British  Pharmacopoeia  guards  against  this  im¬ 
purity  by  giving  a  special  test  for  its  detection  in  bismuthum  punfica- 
tum.” — British  Medical  Journal. 


IN  RELATION  TO  DIAGNOSIS  AND  PROGNOSIS* 

By  J.  WEST  ROOSEVELT,  M.  D., 

VISITING  PHYSICIAN  TO  BELLEVUE  AND  THE  BOOSEVELT  HOSPITALS,  NEW  YORK. 

The  great  importance  of  making  an  early  diagnosis  and 
correct  prognosis  in  consumption  will,  I  hope,  excuse  me 
or  adding  to  an  already  voluminous  literature. 

During  this  century  two  great  observers  have  done  hu¬ 
manity  incalculable  good;  the  one,  Laennec,  by  enlarging 
greatly  the  possibility  of  diagnosis,  the  other,  Koch,  by 
demonstrating  the  essential  causal  factor  of  consumption— 
the  bacillus.  The  evidence  of  the  existence  of  consumption 
afforded  by  the  discovery  of  this  bacillus  in  the  sputa  is  nat¬ 
urally  absolutely  unassailable.  The  absence  of  the  bacteria, 
however,  even  when  the  examinations  are  made  by  an  ex, 
pert,  must  always  leave  a  doubt  in  the  mind  as  to  whether 
tubercular  disease  may  be  excluded  or  not.  There  are  so 
many  important  precautions  to  be  observed  before  the  ab¬ 
sence  of  bacilli  can  fairly  be  held  to  exclude  consumption 
that  one  must  be  very  careful  in  estimating  the  value  of 
negative  observations;  moreover,  one  must  not  waste  too 
much  valuable  time  in  examining  sputa,  for  it  must  always 
be  remembered  that  not  the  bacilli  in  the  sputa  are  to  be 
feared,  but  those  remaining  in  the  lungs.  Therefore,  one 
should  not  give  the  latter  a  good  chance  to  increase  while 

looking  for  the  former.  . 

To  exclude  consumption  by  negative  results  obtained  m 

searching  for  bacilli,  it  is  necessary,  first,  that  the  examina¬ 
tion  be  made  by  an  expert  with  a  good  microscope  and 
good  dyes  ;  second,  that  a  sufficient  quantity  of  sputum  be 
obtained  ;  third,  that  a  very  large  number  of  observations 
extending  over  a  considerable  time  be  made.  Some  patients 
do  not  expectorate,  and  in  these  no  examination  is  possible. 
In  some  the  sputa  are  very  scanty.  In  all,  time  is  very 
valuable.  Frequently  it  happens  that  no  expert  is  at  hand. 
By  “  expert  ”  I  mean  a  person  trained  by  long  practice  to 
make  the  observations.  If  any  one  of  the  conditions  enumer¬ 
ated  be  unfulfilled,  the  result  is  of  no  practical  value.  One 
must  be  able  to  rely  upon  the  observer’s  skill.  Any  one  not 
frequently  making  examinations  of  sputa  is  not  fit  to  make 
any.  The  aniline  dyes  used  must  be  known  to  be  capable 
of' staining.  The  lens  employed  must  be  sufficiently  pow¬ 
erful  and  must  be  optically  very  perfect.  The  sputum  must 
be  that  coughed  up,  not  merely,  as  often  happens,  saliva  and 
mucus  from  the  naso-pharynx  and  mouth.  It  must  also 
be  as  fresh  as  possible.  Cover  glasses  must  be  thinly  and 
evenly  spread,  the  number  examined  must  be  very  great,  an 
each  must  be  systematically  examined  so  that  every  part  is 

SGGD. 

The  importance  of  thoroughly  appreciating  these  points 
is  my  excuse  for  dwelling  upon  them.  That  they  are  not 


*  Read  before  the  Section  in  Practice  of  the  New  York  Academy 
of  Medicine,  May  20,  1890. 


July  19,  1890.] 


ROOSEVELT:  TEE  GROSS  ANATOMY  OF  CONSUMPTION. 


59 


always  known  to  medical  men  almost  any  one  who  has 
had  much  experience  will  admit,  since  he  probably  has,  at 
different  times,  received  saliva,  vomit,  and  miscellaneous 
dirt  (such  as  orange-pits  and  many  other  things),  all  of 
which  are  called  “  sputa,”  and  has  been  asked  to  pass  judg¬ 
ment  upon  them.  If  he  objects,  quite  often  both  he  and 
pathologists  in  general  are  severely  censured  as  useless 
dreamers  by  “  the  busy  practitioner  ”  who  has  perpetrated 
the  outrage.  It  rarely  occurs  to  the  said  practitioner  that 
he  may  himself  be  at  fault.  It  is  much  the  same  with  the 
practical  man,  physician  or  surgeon,  when  he  sends  small 
fragments  of  something  in  various  peculiar  fluids — often  most 
ingeniously  devised,  if  the  absolute  destruction  of  all  recog¬ 
nizable  histological  elements  is  desired — without  any  his¬ 
tory,  or  with  a  most  imperfect  one,  to  a  pathologist  with  a 
request  for  a  diagnosis  at  once.  He 'is  personally  aggrieved 
if  the  pathologist  demurs,  and  he  feels  that  pathology  is  not 
worth  much  after  all  !  It  would  be  well  if  the  information 
was  more  widely- spread  that,  in  general,  alcohol  is  the  best 
preservative  for  tumors,  etc.,  and  that  a  history  must  ac¬ 
company  the  specimen,  and  that,  for  sputum,  clean  bottles  | 
are  advisable.  Then  physicians  would  not  (as  has  occurred 
m  the  author’s  experience)  send  tumors  in  blood,  brine, 
glycerin,  or  carbolic  acid,  or  send  sputum  in  a  dirty  piece 
of  toilet  paper,  twisted  up  at  the  ends,  or  an  old  pill  box  ! 

It  was  natural  that  the  results  of  the  labors  both  of  Koch 
and  Laennec  should  have  been  misjudged,  especially  in  re¬ 
spect  to  their  value  as  negative  evidence.  In  each  case  their 
value  as  positive  evidence  was  enormous,  the  bacillus  indeed 
affording,  so  far  as  we  know,  absolute  proof.  Positive  evi¬ 
dence  is  that  naturally  first  sought.  The  history  of  most 
important  additions  to  scientific  knowledge  is  much  the 
same.  First  the  facts  are  made  public  by  the  discoverer. 
Next  the  truth  of  his  statements  is  denied  by  many.  Then, 
after  a  longer  or  shorter  time,  scientific  public  opinion  ad¬ 
mits  the  facts,  and  usually  tries  to  fit  them  to  all  sorts  of 
preposterous  theoretical  notions.  Almost  always  the  first 
general  idea  after  accepting  the  facts  is  to  see  what  they 
positively  prove  to  exist.  Long  after  this  comes  the  ques¬ 
tion  ot  what  they  do  not  demonstrate. 

In  medicine,  where  so  much  is  vague,  resting  upon  per¬ 
sonal  observation,  the  absence  of  anything  which  is  positive 
evidence  is  peculiarly  apt  to  be  regarded  as  far  too  valuable 
negative  evidence.  The  question,  for  example,  presented 
inmost  cases  is,  “//as this  person  consumption ?”  not  “Can 
you  say  that  this  person  has  not  consumption  ?”  Too  often 
the  absence  of  facts  enabling  us  to  answer  “Yes”  to  the  first 
question  is  regarded  as  justifying  us  in  replying  to  the  sec¬ 
ond,  “  He  has  not !  ”  Nothing  can  be  more  irrational  than 
such  reasoning,  vet  it  is  not  uncommon. 

Of  both  Laennec’s  and  Koch’s  discoveries  it  may  be  said 
that  their  value  as  positive  evidence  is  so  great  that  their  I 
importance  in  excluding  disease  has  been  overestimated.  I 
Ihe  work  of  both  has  also  another  point  of  resemblance 
since  each,  in  his  sphere,  seems  to  have  presented  it  com¬ 
pleted  to  the  world.  No  important  fact  has  yet  been  added 
to  the  observations  of  either,  although  the  theoretical  ex¬ 
planation  of  these  observations  may  be  disputed.  It  may 
1  >e  added  that  the  practical  value  of  the  work  of  both  is  not  I 


even  yet  widely  understood.  I  desire  to  present  certain 
anatomical  facts  bearing  upon  it. 

I  « 

Clinical  Classification  of  Cases  based  upon  the  Gross  Anato¬ 
my  of  the  Lesions. 

In  this  paper  we  have  nothing  to  do  with  the  finer  de¬ 
tails  of  pathological  anatomy.  The  reader  is  perfectly  free 
to  regard  the  tubercle  bacillus  as  the  cause  of  the  disease, 
or  the  result,  if  he  prefer.  He  may,  if  he  wishes,  think  that 
the  «  cussedness  ”  of  the  disorder  is  such  that  it  would  be 
just  like  it  to  create  a  new  organism  to  deceive  men.  He 
may  speak  of  “  catarrhal  ”  or  “  pneumonic  ”  or  any  other 
sort  of  phthisis  ;  and,  if  he  so  wills,  may  think  that  the 
“  catarrh  ”  or  “  pneumonia,”  or  what  not,  is  sufficiently  pe¬ 
culiar  to  make  (in  a  sort  of  wanton  pathological  playful¬ 
ness)  things  looking  and  acting  like  tubercles,  and  then  add 
tubercle  bacilli  to  these,  for  the  further  mystification  of  sci¬ 
entists.  He  is  at  liberty  to  believe  all  these  or  to  adopt  al¬ 
most  any  other  theorj7  ;  but  he  must  admit  certain  things 
if  he  wishes  to  understand  the  point  of  view  of  the  writer. 
These  are — 

1.  The  discovery  of  tubercle  bacilli  in  sputum  furnishes 
positive  evidence  of  consumption  or  of  tuberculosis  some¬ 
where  in  the  air  passages  or  mouth. 

2.  Chronic  consumption  of  the  lungs  occurs  sometimes 
in  a  form  in  which  the  lesions  consist  of  more  or  less  dis¬ 
tantly  separated  small  nodules,  and  sometimes  in  a  form  in 
which  there  is  a  more  or  less  widespread  diffuse  solidifica¬ 
tion  of  the  lung.  In  either  of  these  forms  cavities  may  be 
found.  In  both,  tbe  lesion  first  invades,  in  a  large  majority 
of  cases,  the  apices  of  the  lungs. 

The  anatomical  classification  is  adopted  for  diagnostic 
and  prognostic  purposes.  It  does  not  pretend  to  be  of 
value  to  the  pathologist,  nor  does  it  in  the  least  regard  the 
question  of  how  the  lesions  are  produced.  It  looks  only  at 
physical  conditions,  and  the  relation  of  these  to  examina¬ 
tion  by  physical  means.  The  class  characterized  by  the 
formation  of  nodules  I  shall  call  “the  discrete  form.”  The 
class  in  which  solidification  of  considerable  portions  of 
the  lungs  occurs  will  be  called  “the  diffuse  form.”  The 
first  embraces  those  cases  which  Professor  Delafield  puts 
in  the  first  division  of  the  class  which  he  calls  chronic 
miliary  tuberculosis*  in  his  admirable  study  of  the  anato¬ 
my  of  consumption.  It  also  embraces  certain  cases  which 
are  contained  in  Delafield’s  second  subdivision  of  chronic 
miliary  tuberculosis,  in  which,  besides  tubercles,  there  is 
new  fibrous  tissue.  It  is  intended  to  mean  any  form  of 
consumption  in  which  the  lesion  produces  hut  little  solidi¬ 
fication  of  the  parts  invaded.  The  “  diffuse  form,”  for  the 
purposes  of  this  paper,  includes  all  cases  in  which  the  lesion 
is  such  as  to  solidify  considerable  portions  of  the  lung  in 
mass.  Certain  cases  of  Delafield’s  second  division  of  chronic 
miliary  tuberculosis  are  included  for  convenience  iD  it  just 
as  certain  lesions  much  more  complex  than  miliary  tuber¬ 
cular  inflammation  are  included  in  the  “  discrete  form.”  I 
repeat  that  my  classification  does  not  pretend  to  histologi- 

*  Delafield,  Studies  in  Path.  Anat.,  p.  87.  William  Wood  k  Co., 
New  York. 


60 


ROOSEVELT :  THE  GROSS  ANATOMY  OF  CONSUMPTION.  [N.  Y.  Med.  Jopr., 


cal  accuracy ;  it  is  convenient,  I  think,  tor  diagnostic  pur¬ 
poses. 

The  Discrete  Form  presents  itself,  in  New  \ork'at  least, 
very  often  to  the  observer.  In  it  we  find  scattered  nodules 
varying  in  size  from  that  of  the  conventional  millet-seed 
to  that  of  a  pea.  These  nodules  are  separated  by  lung  tis¬ 
sue,  which  is  physically  normal  or  emphysematous  i.  e., 
capable  of  expansion  and  contraction  and  of  causing  air- 
currents  in  the  same  way  and  under  the  same  physical  cii- 
cumstances  as  healthy  or  as  emphysematous  lung.  In  ad 
vauced  cases  the  nodules  may  break  down  and  form  cavities, 
usually  of  small  size.  When  the  nodules  become  sufficiently 
numerous  the  lung  is  practically  solidified ;  but  this  occurs 

only  late  in  the  course  of  the  disease. 

With  the  formation  of  discrete  nodules  there  is  usually 
more  or  less  bronchitis  and  pleurisy.  There  is  also  com¬ 
monly  some  emphysema,  generally  of  the  kind  called  “  com 
pensatory.”  This  emphysema  is,  it  seems  to  the  writer,  an 
example  of  wliat  he  believes  to  be  rare  in  most  other  con¬ 
ditions— dilatation  of  the  air-vesicles  and  passages  caused 
by  mechanical  over-distension.  It  seems  very  probable  that 
as  the  elasticity  of  a  larger  or  smaller  part  ot  the  pulmo¬ 
nary  parenchyma  is  destroyed  by  the  growth  of  new  tissue, 
the  thoracic  expansion  causes  a  negative  pressure  in  the  parts 
not  affected,  which  is  much  greater  than  normal.  Let  us 
suppose  that  one  third  of  the  parenchyma  of  a  lung  is,  by 
reason  of  this  solidification  in  discrete  nodules,  rendered 
non-elastic  and  impermeable  to  air.  Let  us  disregard  the 
other  lung  or  suppose  that  one  third  of  it  is  similarly 
affected.  If  the  expansion  of  the  chest  is  the  same  as  in 
health,  then  the  permeable  vesicles  must  during  inspiration 
dilate  one  third  more  than  in  health.  The  fact  that  em¬ 
physema  is  frequently  limited  to  those  portions  of  the  lung 
near  the  nodules  is  explained  by  the  pleural  adhesions,  which 
eause  that  part  to  follow  closely  the  movement  of  the  near¬ 
est  ribs.  If  there  were  no  such  adhesions  the  emphysema 
would  be  more  evenly  distributed  throughout  the  whole 
lung.  The  chest  movement  is  actually,  of  course,  more  or 
less  restricted  in  these  cases.  The  assumption  that  it  is 
normal  is  only  made  for  the  sake  of  simplicity. 

Besides  this  mechanical  cause  of  the  emphysema,  it  is 
possible  that  some  obstruction  to  the  circulation  is  pm 
duced  by  the  nodules  and  that  atrophy  from  lack  of  nutii 
tion  results.  In  certain  cases,  of  course,  the  tubercular  pro¬ 
cess  takes  place  in  lungs  already  emphysematous,  for  em¬ 
physema  does  not  protect  from  consumption. 

The  Diffuse  Form.— In  this  class  the  important  clinical 
fact  is  that  consolidation  of  the  lung  tissue  occurs  and  pro¬ 
duces,  at  a  much  earlier  stage  than  in  the  discrete  form, 
recognizable  physical  signs.  It  has  another  important  clin¬ 
ical  distinction  in  a  large  number  of  cases ;  the  physical 
signs  correspond  pretty  closely  to  the  patient’s  actual  con¬ 
dition  and  give  a  much  more  accurate  idea  of  the  severity 
and  progress  of  the  disease. 

The  consolidated  tissue  consists  sometimes  entirely  of 
dense  connective  tissue.  Sometimes  patches  of  coagulation 
necrosis,  diffuse  tubercle,  interstitial  pneumonia,  broncho¬ 
pneumonia,  and  peribronchitis  are  mixed  in  varying  propor¬ 
tions  in  it.  In  advanced  cases  cavities  form.  With  this,  as 


with  the  “  discrete  form,”  there  is  usually  bronchitis  and 
pleurisy,  the  latter  causing  adhesions  between  the  pleural 

surfaces.  . 

The  Discrete  and  Diffuse  Forms  contrasted.— The  clinic¬ 
al  value  of  the  classification,  temporarily  adopted,  is  that  it 
recognizes  the  existence  of  cases  in  which  the  physical  signs 
bear  no  relation  to  the  extent  of  the  lesion— cases,  more¬ 
over,  in  which  the  bacillus  is  very  likely  not  to  be  found, 

at  an  early  period,  in  the  sputa. 

In  some  of  these  there  is  at  first  no  expectoration,  and 
therefore  the  bacillus  is  not  to  be  discovered.  In  some  the 
expectoration  is  scanty.  As  the  nodules  in  which  the 
bacilli  grow  are  scattered  (and  frequently  not  in  direct  com¬ 
munication  with  the  air  passages),  it  may  easily  happen  that 
for  a  long  time  no  bacilli  are  expectorated.  The  discrete 
form  furnishes  cases  fondly  believed  by  many  laryngolo¬ 
gists  to  be  examples  of  primary  tubercular  disease  of  the 
larynx.  It  has  also  furnished  to  the  writer  some  cases 
which  he  thought  to  be  broncho-pneumonia,  and  some 
which  he  supposed  were  substantive  emphysema.  It  has 
also  caused  much  doubt  in  regard  to  diagnosis,  both  in  its 
earlier  and  later  stages.  At  the  present  time  the  bacillus 
(unfortunately  often  too  late)  may  give  evidence  unimpeach¬ 
able  of  the  disease.  So  far  as  the  writer  has  observed, 
bacilli  are  found  sooner  or  later  in  every  case  properly  ex¬ 
amined.  . 

The  “  diffuse  form  ”  not  only  is  apt  to  give  fairly 

marked  physical  signs  at  an  early  date,  but  also  (as  the  con¬ 
solidation  is  accompanied  by  considerable  liquid  exudation, 
which  soon  enters  the  bronchi)  at  an  earlier  date  are  the 
bacilli  apt  to  appear  in  the  sputa.  They  are  also  apt  to  be 

more  abundant  from  the  first. 

To  illustrate,  let  us  suppose  that  there  is  in  the  right  up¬ 
per  lobe  a  lesion  of  the  “  discrete  form.”  The  lesion  we  will 
say  consists  of  nodules  scattered  throughout  the  upper  third 
of  the  lobe,  each  nodule  not  ^more  than  an  eighth  of  an 
inch  in  diameter,  and  the  average  distance  between  them 
about  half  an  inch.  Let  us  also  say  that  the  nodules  are 
closer  together  at  the  extreme  apex  and  more  widely  sepa¬ 
rated  lower  down,  and  that  there  is  enough  pleurisy  to  have 
caused  adhesion  of  the  pleural  surfaces  at  the  extreme  apex. 
Let  us  suppose  that  there  is  as  yet  little  softening  of  the 
nodules  and  but  slight  bronchitis,  though  there  is  some  em¬ 
physema  between  the  nodules. 

The  anatomical  form  of  this  lesion  is  such  that  the  only 
physical  signs  in  very  many  instances  would  be  very  slight 
dullness,  with  some  prolongation  of  the  expiration,  and 
usually  some  exaggeration  of  the  intensity  of  both  respira¬ 
tory  murmur  and  voice,  or  perhaps  diminished  percussion 
resonance  or  slightly  tympanitic  resonance.  The  pleural 
adhesions  might  or  might  not  give  audible  evidence  of  their 
existence.  If  they  did,  when  one  thinks  of  the  numerous 
cases  of  non-phthisical  people  who  are  found,  post  mortem, 
to  have  such  adhesions,  this  evidence  becomes  of  little 

value. 

As  there  is  normally  over  the  right  apex  of  many  people 
slight  relative  dullness,  and  all  the  other  peculiarities  noted, 
it  Is  very  hard  positively  to  estimate  the  value  of  any  of 
them. 


July  19,  1890.J 


ROOSEVELT:  THE  GROSS  ANATOMY  OF  CONSUMPTION. 


61 


The  bacillus  may  help  us  in  such  a  case,  if  found ;  but 
it  is  precisely  in  such  a  case  that  it  is  most  difficult  to  find. 
The  sputum  is  scanty  or  absent.  The  bacillus  is  discharged 
in  small  numbers,  if  at  all. 

These  cases  are  not  rare,  and  the  recognition  of  this 
serves  to  emphasize  what  is  probably  the  most  important  fact 
in  connection  with  early  diagnosis — namely,  that  physical 
examination  and  negative  microscopical  examination  are  to 
be  regarded  only  after  careful,  study  of  the  clinical  history. 
Percussion  and  auscultation  and  the  microscopic  examina 
tion  may  reveal  nothing,  yet  commencing  consumption 
may  be  safely  assumed  to  exist  from  the  evidence  of  the  pa 
tient’s  history  and  general  appearance.  Much  that  was 
written  by  Walshe  so  many  years  ago  in  regard  to  early 
diagnosis  is  as  true  to-day  as  ever,  in  spite  of  the  great  ad¬ 
vances  of  the  last  few  years.* 

I  have  said  that  the  disease  “  may  be  safely  assumed  to 
exist.  This  sentence  hardly  expresses  my  meaning,  though 
it  does  state  the  exact  facts.  My  meaning  is  that  cases  oc 
cur  not  infrequently  in  which  tubercle  bacilli  can  not  be 
discovered,  and  in  which  physical  examination  of  the  chest 
gives  none  or  very  vague  abnormal  signs  ;  yet  it  is  the  duty 
of  a  physician  to  make  a  diagnosis  of  consumption ,  and  to 
take  proper  measures  for  treatment,  no  matter  at  what  cost. 
The  chances  of  consumption  being  the  trouble  are  so  strong 
that  the  physician  should  risk  his  own  reputation,  and  per¬ 
haps  cause  much  inconvenience  and  pecuniary  loss  to  the 
patient.  Just  as  it  is  the  duty  of  a  physician  to  conceal  his 
fears,  possibly  at  the  risk  of  his  reputation,  in  many  cases 
where  symptoms  are  present  which  may  indicate  disease  (as 
in  glycosuria  in  pregnancy,  for  example),  but  where  the 
chances  are  very  great  that  these  symptoms  are  merely 
transitory  and  unimportant,  so  is  it  his  duty,  when  the 
chances  are  very  great  that  serious  disease  exists,  to  state 
the  facts  plainly  and  truthfully,  and,  in  the  case  of  con¬ 
sumption,  even  to  alarm  a  patient  needlessly,  rather  than  to 
let  him  die  (equally  needlessly)  while  waiting  for  positive 
evidence. 

The  Discrete  Form  in  Relation  to  Physical  Signs. — In 
its  earliest  stages  the  changes  produced  by  this  form  are 
such  as  to  cause  but  little  variation  from  the  normal  phys¬ 
ical  condition  of  the  lungs.  The  nodules  are  not  large 
enough,  nor  are  they  near  enough  together,  to  produce  a 
change  in  the  percussion  note  sufficiently  marked  to  be  recog¬ 
nized.  Sometimes  they  cause  slight  dullness.  Often  their 
presence  is  indicated  only  by  a  note  which  is  more  tvm 
panitic  than  pulmonary  in  quality,  but  not  always,  as  far  as 
the  writer  can  judge,  higher  pitched.  This  note  resembles 
closely  the  sound  produced  by  percussion  over  the  patient’s 
trachea.  The  tympanitic  quality  of  tone  heard  in  some 
cases  over  a  consolidated  and  compressed  lung  is,  in  the 
writer’s  experience,  the  same  as  the  tracheal  note.  It  is 
fair  to  assume  that  in  many  instances  this  type  of  note  is 
real ly  produced  in  the  trachea,  and  that  the  physical  changes 
in  the  lung  are  such  as  either  directly  to  transmit  the  force 
of  the  blow  struck  to  the  trachea,  or  perhaps  the  scattered 


xeq. 


See  Walshe,  Diseases  of  the  Lungs,  4th  edition,  1871,  p.  475  et 


nodules,  with  the  altered  lung  elasticity  and  altered  air 
capacity  together,  form  a  body  which  resounds  in  unison 
with  the  air  in  the  trachea  and  large  bronchi  without  modi¬ 
fying  very  much  the  note  of  the  latter. 

V*  hatever  be  the  explanation  of  the  phenomena,  we  find 
in  the  early  stages  of  this  form  of  the  disease  sometimes  one 
sometimes  another  of  the  following  percussion  signs  :  Dull¬ 
ness,  normal  or  exaggerated  pulmonary  resonance,  or  ve- 
siculo-tympanitic  or  tympanitic  resonance,  or  the  cracked- 
pot  sound.  The  pitch  over  the  affected  area  may,  when  the 
resonance  is  pulmonary  in  quality,  be  higher  or  lower  or 
the  same  as  that  over  the  corresponding  part  of  the  unaf¬ 
fected  lung.  Later  in  the  disease  the  increasing  number  of 
nodules  usually  gives  rise  to  dullness  more  or  less  marked. 

Both  vocal  resonance  and  fremitus  bear  little  relation  to 
the  percussion  note,  or  indeed  to  each  other.  The  voice  is 
a  poor  help  in  diagnosis  in  such  cases,  and  should  be  re¬ 
ceived  only  as  evidence  which  gives  some  weight  to  other 
signs. 

The  respiration  is,  when  bronchitis  or  pleurisy  are  very 
slight  or  absent,  quite  often  normal.  Probably  prolonga¬ 
tion  of  the  expiratory  sound  with  slight  rise  in  pitch  is  the 
earliest  recognizable  sign.  Sometimes  there  is  simply  an 
exaggeration  of  both  inspiratory  and  expiratory  sounds. 
Sometimes  both  are  feeble  and  sometimes  both  are  normal. 
With  sufficiently  closely  grouped  nodules  the  breathing  is 
apt  to  become  somewhat  bronchial  in  quality,  and,  when  the 
nodules  are  numerous  enough  practically  to  solidify  a  con¬ 
siderable  part  of  a  lobe,  the  type  is  often  purely  bronchial. 
In  certain  cases  the  breathing  is  cavernous  or  amphoric, 
and  yet  no  cavities  exist.  The  latter,  when  present,  may,  of 
course,  give  bronchial,  cavernous,  or  amphoric  breathing. 

The  presence  of  pleural  adhesions  sometimes  gives  rise 
to  special  signs  and  sometimes  does  not.  In  certain  cases 
it  seems  quite  possible  that  such  adhesions  cause  the  so- 
called  “  cog-wheel  ”  or  “  wavy  ”  respiration.  In  others  they 
may  produce — they  certainly  are  coexistent  with — fine  dry 
or  moist  rales.  Sometimes,  also,  they  seem  to  produce 
“  friction,”  or  “  stretching,”  or  “  tearing  ”  sounds.  So  often 
in  early  cases  are  the  adhesions  near  the  summit  of  the  lung 
(where  relatively  little  gliding  motion  of  the  pleura  takes 
place)  that  it  is  easy  to  understand  how  frequently  their  ex¬ 
istence  is  not  possible  to  demonstrate  during  life. 

To  the  writer  the  absence  of  signs  due  to  pleural  ad¬ 
hesions,  especially  near  the  apices,  is  perfectly  comprehen¬ 
sible.  Not  so  clear,  in  spite  of  the  positive  statements  of 
many  observers,  are  the  reasons  why  many  signs,  supposed 
to  be  produced  by  these  adhesions,  should  really  be  caused 
by  them.  Why  the  type  of  subcrepitant  rale,  for  example, 
which  sounds  like  the  bursting  of  fine  bubbles,  should  ever 
be  produced  by  the  stretching  of  tissue,  moist  or  dry,  which 
not  only  contains  no  air  but  is  not  in  contact  with  any,  is  not 
easy  to  explain.  True,  there  is  no  positive  evidence  that  the 
bubbling  sound  is  really  produced  in  the  substance  of  the 
adhesions.  It  may  be,  as  some  think,  in  the  neighboring 
lung;  but  this  also  is  not  positively  demonstrated.  The 
sound  of  this  type  of  subcrepitant  rale  is  fairly  closely  imi¬ 
tated  if  one  listens  to  the  noise  caused  by  rubbing  together 
two  pieces  of  glass  moistened  with  saliva  containing  air- 


62 


BROWN:  SUPPURATION  OF  THE  ANTRUM  OF  HIGHMORE.  [N.  Y.  Med.  Joub., 


bubbles.  If  the  bubbles  be  carefully  excluded  there  is  uo 
rale  heard.  It  has  not  been  demonstrated,  as  far  as  I  know, 
that  any  bubbling  sound  is  actually  produced  by  stretching 
any  elastic  substance,  whether  dry  or  soaked  in  fluid,  while 
this  substance  is  placed  under  conditions  which  absolutely 
prevent  the  aspiration  into  its  tissue  of  bubbles  of  air  or 
other  gases.  There  is  room  for  much  study  upon  this  sub¬ 
ject.  °It  sounds  at  first  plausible  that  an  increase  of  serum 
in  the  pleural  adhesions  will  produce  this  sound.  1  et,  we 
hardly  know  that  it  ever  does.  Neither  can  we  say  posi¬ 
tively  that  it  does  not. 

The  mechanical  results  of  pleural  adhesions,  so  far  as 
the  lung  and  chest  movements  are  concerned,  are,  first,  that 
the  gliding  of  the  pleural  surfaces  is  more  or  less  restricted 
over  a  larger  or  smaller  area;  second,  that  this  restriction 
probably  modifies  somewhat  the  direction  of  expansion  of 
the  entire  lung  as  well  as  those  parts  of  it  near  the  adhe¬ 
sions  ;  third,  that  in  some  cases  the  new  tissue  forming  the 
adhesions  by  its  contraction  tends  more  or  less  to  deform 
the  chest  and  restrict  its  motion,  and  also  to  deform  the 
lung. 

In  spite  of  very  widely  distributed  and  .firm  adhesions, 
however,  it  is  possible  for  the  lung  seemingly  to  do  its  work 
as  well  as  usual,  and  no  symptoms  whatever  indicate  firm, 
even  complete,  union  between  the  pleural  sui  faces.  Com¬ 
plete  obliteration  of  the  pleural  or  of  the  pericardial  cavities 
is  perfectly  compatible  with  apparently  undisturbed  func¬ 
tion  of  lung  or  heart.  It  seems  as  though  the  mechanical 
advantage  of  these  lubricated  surfaces,  permitting  freer 
movement  of  the  contained  organs,  is  .sufficiently  great  to 
cause  them  to  remain  in  the  evolution  of  the  race,  but  not 
great  enough  to  make  them  necessary  to  each  individual. 
In  the  wonderfully  balanced  collection  of  what  are,  after  all, 
but  makeshifts  called  the  human  body,  the  heart  or  lung- 
crippled  by  adhesions,  is  still  often  able  to  work  well  enough 
to  keep  the  rest  of  the  organs  going. 

If,  in  addition  to  the  nodules,  there  is  enough  bronchitis, 
signs  of  this  alone  may  be  found.  Signs  of  bronchitis,  with 
or  without  emphysema,  upon  one  side  of  the  chest  are 
valuable  evidence  of  consumption.  Bronchitis  upon  one 
side  probably  never  occurs  unless  there  be  some  local  cause. 
Especially  suspicious  are  such  signs  in  a  young  adult  who 
gives  a  history  of  cough  lasting  for  some  time,  with  other 
rational  symptoms  of  consumption. 

When  the  nodules  become  sufficiently  numerous  to  crowd 
one  another  pretty  closely,  the  lung  is  practically  solidified, 
and  the  signs  become  those  of  solidification.  In  such  in¬ 
stances,  however,  the  disease  is  far  advanced. 

It  is  evident  that  in  this  form  the  physical  signs  bear 
but  little  relation  to  the  extent  of  the  lesion.  The  diagno¬ 
sis  in  early  cases  must  be  made  without  too  much  regard 
for  the  signs.  Of  the  prognosis  the  same  is  true.  The  ba¬ 
cillus  also  is  frequently  hard  to  find.  In  the  patient  s  gen¬ 
eral  condition  and  history  we  have  the  indications  upon 
which  both  diagnosis  and  prognosis  must  rest. 

The  Diffuse  Form  and  its  Physical  Signs. — In  this  form 
the  solidification  of  considerable  parts  of  the  lung  makes  the 
recognition  of  the  disorder  in  very  many  cases  quite  easy. 
The  signs  of  consolidation  become  marked  quite  early. 


These  are  well  known,  and  it  is  not  worth  while  to  repeat 
them  in  detail.  The  consolidation  gives  signs  which  fairly 
indicate  the  progress  of  the  lesion.  The  bacillus  is  gener¬ 
ally  easy  to  find  in  the  expectoration. 

Summary  and  Conclusions. — 1.  For  clinical  purposes 
we  may  describe  a  discrete  and  a  diffuse  form  of  consump¬ 


tion. 


2.  The  discrete  form  is  not  at  first  easy  to  recognize, 
since  abnormal  signs  often  are  absent  and  the  bacillus  ab¬ 
sent  or  hard  to  find.  The  physical  signs  in  this  form  are 
not  to  be  regarded  as  of  value  in  prognosis,  while  in  the  dif¬ 
fuse  form  they  are  fairly  trustworthy. 

3.  The  diagnosis  of  commencing  consumption  must  be 
made  from  the  patient’s  history,  quite  as  much  as  from 
physical  examination  of  the  chest  or  sputa.  If  we  wait  too 
long  in  order  to  become  certain  in  diagnosis,  we  also  quite 
often  permit  our  patient  to  become  certain  to  die.  It  is 
better  far  to  run  the  risk  of  making  an  incorrect  diagnosis 
by  concluding  that  the  disease  exists  when  it  does  not  than 
to  run  the  risk  of  jeopardizing,  or  possibly  needlessly  sacri¬ 
ficing,  a  life  for  fear  of  a  diagnostic  error. 

32  East  Thirty-first  Street. 


SUPPURATION  OF  THE  ANTRUM  OF  HIGHMORE.* 


By  MOREAU  R.  BROWN,  M.  D., 

PROFESSOR  OF  LARYNGOLOGY  AND  RHINOLOGY  AT  THE  CHICAGO  POLYCLINIC. 


Although  a  complete  description  of  the  maxillary  an¬ 
trum  was  given  by  Nathaniel  Highmore  as  early  as  1601,  it 
was  not  until  two  centuries  had  elapsed  that  the  diseases 
occurring  within  the  cavity  began  to  attract  the  attention  of 
surgical  writers. 

In  1846  there  appeared  in  the  published  report  of  the 
clinical  lectures  in  surgery,  delivered  at  St.  George’s  Hos¬ 
pital  by  Sir  Benjamin  Brodie,  the  first  clear  and  detailed 
description  of  diseases  of  the  antrum  of  which  we  can  find 
authentic  record.  In  this  report  the  description  of  “ inflam¬ 
mation  dependent  on  local  causes,  inflammation  independent 
of  local  causes,  collection  of  transparent  fluid  in  the  antrum, 
polypi  of  the  antrum,  and  malignant  tumors  of  the  antrum, 
is  given  in  a  manner  which  shows  familiarity  with  the  dis¬ 
eases  based  upon  personal  experience. 

The  situation  of  the  antrum  of  Highmore  or  the  maxil¬ 
lary  antrum  is  found  to  vary  even  on  different  sides  of  the 
same  face.  In  general  terms,  its  floor  is  said  to  extend 
above  the  alveolar  process  from  the  second  bicuspid  tooth 
backward.  Projecting  into  it  are  several  conical  processes 
corresponding  to  the  first  and  second  molar  teeth,  and  in 
some  cases  it  is  perforated  by  the  roots  of  these  teeth.  The 
antrum  is  occasionally  subdivided  by  incomplete  bony  la¬ 
mella,  and  it  is  lined  with  mucous  membrane  continued 
i  from  that  of  the  nasal  cavities.  Its  bony  walls  are  thin, 
particularly  the  orbital  plate,  the  nasal  wall,  and  the  facial 
wall,  above  and  between  the  first  and  second  molars  and 
immediately  above  the  canine  fossae.  Located  in  the  upper 
and  anterior  part  of  the  middle  meatus  of  the  nose,  and  con- 


*  Read  before  the  Illinois  State  Medical  Association,  May  9,  1890. 


8WH;  SOPPUKATION  Ob'  THE  ANTRUM  OF  mOBUORB 


cealed  from  view  by  the  middle  turbinated  body,  is  the 
hiatus  semilunaris  which  communicates  with  the  frontal 
cells  and  the  ostium  maxillare. 

Ihe  term  suppuration  or  empyema  of  the  antrum  is  used 
to  designate  a  condition  characterized  by  the  formation  of 
pus  on  the  surface  of  the  mucous  membrane  lining  the 
maxillary  sinus.  The  pathological  changes  which  take  place 
in  the  mucous  membrane  of  this*cavity  during  the  continu¬ 
ance  of  the  morbid  process  do  not  differ  from  those  which 
occur  in  similar  membranes  under  like  conditions. 

Causes.  The  proportion  of  cases  from  dental  complica¬ 
tions  to  those  from  other  sources  is  as  yet  an  undetermined 
question.  A  large  percentage  of  those  which  fall  under  the 
observation  of  the  dentist  owe  their  origin  to  diseases  of 
the  dental  arch,  whereas  these  disturbances  play  a  more 
secondary  part  in  the  cases  which  are  met  with  by  the 
rhinologist.  Bosworth  contends,  and  with  apparent  cause, 
that  hypertrophy  of  the  middle  turbinated  body  and  other 
obstructions  to  the  ostium  maxillare  will  interfere  with  the 
outflow  of  the  secretion,  the  accumulation  of  which,  in  a 
closed  cavity,  results  in  a  purulent  discharge.  Among  other 
causes  are  tumors  within  the  antrum,  blows  upon  the  cheek, 
injury  to  the  teeth,  and  division  of  the  infra-orbital  nerve. 
Observation  on  the  subject  has  led  me  to  ascribe  to  the  dis¬ 
turbance  to  health  which  we  call  “  taking  cold  ”  a  more 

prominent  position  in  the  list  of  causes  than  is  generally 
allowed  to  it.  ^  J 

A  tabulated  statement  shows  that  out  of  twenty-one 
antra  which  were  involved,  nine  were  considered  to  have 
been  o t  this  origin.  These  cases  were  under  observation 
from  their  commencement  until  relieved  by  treatment,  A 
majority  of  the  patients  had  been  under  my  professional 
care  prior  to  the  antral  disorder,  and  hence  I  am  able  to 
state  positively  that  there  was  no  evidence  of  a  former  sup¬ 
puration.  There  was  one  point,  however,  which  may  be 
worth  mentioning  as  possibly  having  exerted  some  influence 
over  the  production  of  the  inflammation — namely,  the  preva¬ 
lence  of  the  epidemic  of  la  grippe.  In  two  of  the  cases  sup¬ 
puration  followed  directly  upon  an  attack  of  this  disease. 

The  lining  membrane  of  the  antrum  participates  in  the 
inflammatory  process  resulting  from  catching  cold  in  a 
similar  manner  to  that  of  the  Eustachian  tube.  After  the 
cold  has  passed,  the  inflammation  and  suppuration,  should 
it  have  reached  that  stage  of  purulency,  may  disappear, 
and  the  membrane  return  to  its  former  condition,  minus  a 
certain  amount  of  its  normal  ability  to  withstand  such  dis¬ 
turbances.  Repeated  attacks  of  this  nature  soon  lead  to  the 
chronic  form  of  the  disorder. 

Symptoms. — Should  the  inflammation  be  acute,  there 
will  be  pain  and  tenderness  with  a  sense  of  weight  and  full¬ 
ness  over  the  antrum  and  with  pressure  up  against  the  eye, 
hyperiemia  of  the  ocular  conjunctiva,  and  sensitiveness  of 
the  teeth,  especially  noticed  on  masticating.  The  pain  is 
increased  by  stooping  over,  aud  is  worse  in  the  morning. 

If  the  inflammation  owes  its  origin  to  dental  complica¬ 
tions,  the  symptoms  indicative  of  these  disorders  are  added 
to  the  above;  or  if  it  be  the  nasal  mucous  membrane  that 
is  affected,  those  of  the  coryza  are  also  present.  Should 
the  natural  outlet  of  the  sinus  become  closed,  as  it  fre- 


63 


quently  does  from  swelling  of  its  lining  membrane,  the  pain 
increases  and  the  face  is  more  tender. 

The  formation  of  pus,  which  is  announced  by  a  chill 
causes  distension  of  the  walls,  which  may  produce  disturb¬ 
ance  of  vision  by  pressing  on  the  orbital  plate,  and  a  tumor¬ 
like  projection  forms  over  the  thinnest  walls.  Unless  sur¬ 
gically  relieved,  spontaneous  evacuation  takes  place.  If  the 
natural  opening  of  the  antrum  into  the  nose  remains  free, 
the  pus  finds  a  ready  outlet  through  this  channel,  and  the’ 
irritation  caused  thereby  to  the  delicate  mucous  membrane 
may  produce  an  obstinate  turgescence  of  the  turbinated 
bodies  and  occlusion  of  the  nasal  passage.  The  purulent 
discharge  will  either  gradually  diminish  and  finally,  in  the 
course  of  a  few  days,  cease  altogether,  as  is  witnessed  some¬ 
times  in  coryza,  or  it  may  continue  in  diminished  quantity, 
and  all  symptoms  of  a  painful  nature  disappear.  The  lat¬ 
ter  is  more  apt  to  occur  in  cases  from  dental  complications 
The  discharge  now  takes  place  into  the  nose  at  intervals 
during  the  day,  particularly  shortly  after  arising  from  bed 
m  the  morning,  or  on  stooping  over ;  also  when  lying  down 
it  the  position  of  the  head  be  changed,  as  on  turning  from 
the  affected  to  the  sound  side.  In  this  (now  chronic)  form 
of  the  disease,  although  turgescence  of  the  turbinated  bodies 
seldom  occurs  from  the  irritation  produced  by  the  pus,  yet 
it  has  been  observed  to  exist  in  a  very  persistent  form 
And  that  hypertrophy  may  thus  be  brought  on,  or  an  exist¬ 
ing  hypertrophy  aggravated,  I  can  bear  personal  witness 
to.  I  therefore  believe  that  the  hypertrophy  of  the  middle 
turbinated  body,  and  possibly  the  polypoid  growths  so  often 

seen  in  connection  with  chronic  empyema,  are  rather  a  result 
than  a  cause. 

When  the  dental  arch  has  been  the  cause  of  the  puru- 
lency,  the  pus  is  of  a  very  offensive  odor,  the  opposite  of 
what  prevailed  in  several  of  the  acute  cases  reported  in  my 
table  from  catching  cold.  Extension  of  the  disease  into 
the  neighboring  cavities,  and  even  death,  has  been  noted 
among  the  rarer  events. 

Diagnosis.— In  acute  suppuration  we  are  so  aided  in  the 
diagnosis  by  the  history  of  the  case  that,  with  ordinary 
care,  the  disorder  can  readily  be  recognized.  In  chronic 
empyema  a  discharge  which  is  influenced  by  position  is  ob¬ 
served  by  the  patient  to  come  from  the  nose.  By  carefully 
inspecting  the  nasal  cavity  we  shall  often  find  pus ;  it  may¬ 
be  but  a  thin  film  on  the  anterior  and  inferior  part  of  the 
middle  turbinated  body,  or  between  it  and  the  outer  and 
inner  wall.  When  wiped  away,  fresh  pus  can  occasionally 
be  made  to  appear  by  changing  the  position  of  the  head  or 
pressing  upon  the  thin  walls  of  the  antrum. 

Voltolini’s  method,  as  described  and  brought  to  greater 
perfection  by  Heryng,  is  of  undoubted  value.  It°is  em¬ 
ployed  as  follows  :  The  patient  is  placed  in  a  room  made 
absolutely  dark  and  a  small  Edison  incandescent  lamp  of 
about  four  candle  power,  which  has  been  connected  with  a 
battery  and  fastened  on  the  upper  surface  of  a  tongue  de¬ 
pressor,  is  put  in  the  mouth.  The  lips  are  now  clos’ed  and 
the  current  of  electricity  turned  on,  so  that  the  lamp  may 
g  ow  to  its  full  intensity,  whereupon  the  bones  of  the  face 
will  become  beautifully  illuminated,  a  darker  shade  marking 
the  situation  of  the  antrum.  Should  there  be  fluid  or  ° 


a 


64 


BROWN:  SUPPURATION  OF  THE  ANTRUM  OF  HIGHMORE.  [N.  Y.  Med.  Jock., 


;  ,VlT1  thp  -flvitv  the  fact  will  become  apparent  by  I  among  both  dentists  and  surgeons,  and  which  I  shall  pre- 

XXnce  of  the  oo,  and  the  marked  contra,  |  "  "i- 


WitThheewate'rtrhcitaet  made  by  McIntosh  &  Co.,  of  this  city,  1  ris'es'th'e  opening  to  be  made  through  the  alveolus  and  com 


theyEdison  current,  has  enabled  me  to  carry  on  my  |  ^worthf  advTses”  that' artificti 


experiments  satisfa  which  full  reliance  I  opening  be  made  in  the  same  situation. 

A  more  sunple  test,  and  one  upon  which  run  I  *  New  York,  says:  “I  should  never  hesi. 

can  be  placed,  is  made  with  the  perox.de  of  hydrogen in  ed  . .  •  >t  .  ’  e  alve0|us  even  at  the 


as  follows:  cltoe  Cing  hePen  freely  a/plied  to  the  rate  to  make  the  opening  through  the  alveolus  even  at  the 

middle  turbinated  body  and  the  mucous  membrane  of  the  sacrifice  of  a  sound  tooth. 


nasal ^avitv "untidhoroughly  anesthetized  and  contracted,  a  I  Dr.  J.  H.  Bryan  »  is  equally  explicit :  “  The  operation 

.-rrszr:  := 

^  a  .  .  ,r  - ;i„r.on;c  onrl  u  solution  of  per-  tooth  is  present,  it  should  be  extracted  anc 


aU.einhiatus  ZSZLZT-  Xion  ol  pe,  Loth  -  present,  it  should  be  extracted  and  the  opening  e„- 

*■  ...  i  _ i-  _  ~ +  -la  in.  I  lornforl 


M  (loco  vA  1  Ll  vv  .  a  I  .  j  ^ 

oxide  of  hydrogen  (one  part  to  twelve  parts  of  water)  is  in-  larged. 


iected  into  the  antrum.  If  pus  be  present,  it  is  driven  out  Garretson  ||  says 

•  a  .  n  mi  .  x  j.1.  _  ~  /-.Vi  Vine?  I  tnn/itorl  OT1  f]  TA  Pfl P.tTH 


“The  second  molar  tooth  is  to  be  ex- 


'and  fills  the  nose  as  a  white  foam.  That  ’the  solution  has  traded  and  penetration  of  the  cavity  effected  through  the 
entered  the  antrum  will  be  made  evident  by  the  patient  alveolus  of  the  palatine  fang. 


entered  the  “  ft.  teeth^and  a  After  such  evidence  in  favor  of  the  operation  through 

X  rSness  in*.  cheek.  I  know  of  no  test  so  simple,  the  alveolus  and  without  referenee  ,0  other  authority,  we 


failing  as  this  ^  ~  ^"on  symptom  w  s  before  we  condemn  that  which  has  the  support  of  men  of 

rw  Xg  pustThl  nasal  passa  e/  In  one  in-  experience  and  which  has  endured  the  test  of  time  and  o 

a  slight  aiscnarg  P  v  .  ,  ODeration  which,  to  say  the  most  of  it, 


sdtTng  surgeon,  a  subsequent  operation  confirmed  the  opin-  has  but  the  result  of  a  few  cases  in  evidence  of  its  claims 


auiuiug  — -  i  i.  .  • . 

ion  of  suppuration  I  had  been  induced  to  hold  after  the  ap-  for  superiority 

I  TKn  nnmP 


plication  of  this  test 

By  the  proper  use  of  the  peroxide  of  hydrogen  one  can 

satisfactorily  differentiate  between  purulency  of  the  max¬ 
illary  sinus  and  the  other  hidden  sources  of  pus  which  is 
discharged  into  the  nose.  Should  the  ostium  maxillare  be 
occluded  and  we  be  unable  to  inject  the  antrum,  the  symp- 


The  prime  object  of  opening  the  antrum  is  to  give  it 
free  drainage  and  to  enable  us  to  medicate  its  diseased  mu¬ 
cous  membrane.  The  latter  of  these  indications  is  easy  to 
accomplish,  and  the  former  only  requires  that  the  aperture 
be  made  in  the  most  dependent  portion  of  the  sinus ;  but 
does  drilling  through  the  alveolus  from  below  upward  al- 


rs  rx: = = =  x  — ^ 


evidence  of  that  condition. 

If  it  be  deemed  necessary  to  make  an  exploratory  punct¬ 
ure,  the  difficulties  which  may  arise  from  the  plugging  of 
the  cannula,  the  thick  bone,  the  abnormal  conditions  of 
the  inferior  turbinated  body,  the  different  positions  of  the 
antrum,  and  the  danger  of  breaking  the  instrument,  will 
cause  one  to  hesitate  before  attempting  it  in  the  inferior 
meatus  through  the  nasal  wall,  and  to  give  preference  to 
perforating  the  facial  wall  above  the  alveolus  with  a  small 

drill. 

Treatment  can  occasionally,  particularly  in  acute  cases 
from  cor.yza,  be  advantageously  carried  out  through  the 
natural  nasal  opening  by  means  of  the  cannula  spoken  of 
under  the  head  of  diagnosis,  using  diluted  peroxide  of 
hydrogen  in  preference  to  other  remedies.  But  a  majority 
of  the  cases  will  require  surgical  treatment  in  order  to  evacu¬ 
ate  the  antrum  and  give  it  free  drainage.  Much  has  been 
written  in  late  years  as  to  the  best  method  of  accomplishing 

this. 

Mickulitz  recently  revived  the  practice  of  entering 
the  antrum  through  the  nasal  wall,  but  the  operation, 
for  obvious  reasons,  seems  destined  to  again  become  ob¬ 
solete. 

The  operation  which  to-day  stands  in  greatest  favor 


conical  processes  projecting  into  the  antrum  corresponding 
to  the  first  and  second  molar  teeth,  one  of  which  is  generally 
sacrificed  in  the  operation.  When  the  tooth  is  removed 
the  projection  remains  in  the  floor  ot  the  antrum,  and  if  we 
penetrate  the  thin  plate  forming  it  and  enlarge  the  opening, 
as  is  advised  by  writers  on  the  subject,  the  base  of  the  ele¬ 
vation  remains  and  offers  an  obstruction  equal  to  its  height 
to  the  complete  and  thorough  drainage  of  the  antrum.  This 
objection  may  be  considered  chimerical,  yet  we  are  justified 
in  assuming  it  to  be  one  which  may  exist  if  we  hold  the 
statements  and  drawings  of  anatomists  correct,  and  as  yet 

we  have  no  reason  to  doubt  them. 

This  may  possibly  have  been  the  cause  of  failure  to 
check  the  formation  of  pus  in  some  cases  reported  in  medi¬ 
cal  literature.  _  . 

A  plug  retained  in  the  artificial  opening  will  maintain 

its  patulency  and  exclude  foreign  matter,  but  it  will  also 


*  See  Voltolini,  Krankheiten  der  Nose. 

f  See  Diseases  of  the  Throat  and  Nose,  Bosworth,  p.  478. 

X  Diseases  of  the  Antrum.  Journal  of  the  Am.  Medical  Association, 

December  21,  1689. 

#  Diagnosis  and  Treatment  of  Abscess  of  the  Antrum.  Journal  of 
the  Am.  Medical  Association ,  October  5,  1889. 

||  A  System  of  Oral  Surgery,  p.  757. 


July  19,  1890.] 


VANCE:  ABSORPTION  OF  THE  NECK  OF  THE  FEMUR. 


65 


interfere  with  complete  drainage.  It,  however,  will  serve 
to  bring  about  good  results  if  the  case  has  not  been  one  of 


long  duration.  A  tube  of  metal  will  be  required  in  the 
more  chronic  cases,  but  the  use  of  this  when  placed 
through  the  alveolus  from  below  is  an  annoyance  to  the 
patient,  and  he  may  fail  in  his  endeavors  to  keep  foreign 
matter  from  entering  it. 

Modern  dental  surgery  has  taught  us  to  value  a  dead 
tooth,  and  even  a  root,  provided  it  is  not  causing  irrita¬ 
tion,  and  hence  it  appears  to  be  our  duty  not  to  lightly 
sacrifice  them  for  any  purpose  when  the  same  end  can  be 
accomplished  by  other  means. 

The  operation  which  I  prefer  is  that  of  opening  the  an¬ 
trum  in  its  most  dependent  portion,  but  through  the  upper 
part  of  or  immediately  above  the  alveolus,  as  follows:  The 
mucous  membrane  having  been  locally  anesthetized,  an  in¬ 
cision  is  made  into  it  or  a  small  piece  is  cut  out  with  a 
tubular  knife  just  below  the  gingivo-labial  fold  between 
the  upper  portions  of  the  roots  of  the  second  bicuspid  and 
first  molar  teeth.  A  drill,  preferably  driven  by  an  electric 
motor,  is  entered  at  the  point  of  incision  into  the  soft  tis¬ 
sues  and  directed  upward,  inward,  and  slightly  backward, 
forming  an  angle  of  about  forty-five  degrees  with  the  plane 
of  the  alveolus.  A  few  revolutions  will  send  the  drill  into 
the  antrum  at  its  most  dependent  portion.  The  opening 
thus  made  must  be  of  sufficient  diameter  to  admit  of  thor¬ 
ough  cleansing  and  draining.  A  gold  tube  is  to  be  well 
fitted  so  that  the  distal  end  will  enter  just  within  the 
antrum,  and  to  the  other  end  projecting  beyond  the 
mucous  membrane  a  small  strip  of  gold  is  attached  and 
fastened  to  a  collar  around  the  tooth.  By  this  method 
we  have  free  drainage  without  the  danger  of  foreign 
substances  entering  the  antrum,  and  plugging  the  tube  is 
not  necessary.  I  find  that  cases  so  treated  have  invaria¬ 
bly  done  better  than  those  where  the  opening  had  been 
made  through  the  alveolus  from  below,  and,  as  the  opera¬ 
tion  is  free  from  any  of  the  objections  made  to  the  latter, 
I  urge  its  trial  and  condemn  the  extraction  of  a  sound  or 
even  of  a  diseased  tooth  for  the  purpose  of  entering  the 
antrum. 

The  after-treatment  consists  in  daily  or  twice  a  day 
washing  the  cavity  with  a  saturated  solution  of  boric  acid 
and  occasionally  injecting  iodine,  sulphate  of  zinc,  or  sub¬ 
nitrate  of  bismuth. 

A  summary  of  the  nineteen  cases  which  have  come 
under  my  observation  during  the  past  eighteen  months 
shows,  of  twenty-one  suppurating  antra,  that  nine  were  due 
to  “catching  cold,”  eight  were  due  to  dental  complications, 
one  was  due  to  polypi  of  the  antrum  ;  two,  cause  doubtful, 
and  one,  unknown  cause.  Fifteen  were  diagnosticated  by 
the  assistance  of  peroxide  of  hydrogen.  Three  were  cured, 
and  one  is  now  under  treatment  by  medication  through  the 
natural  nasal  opening.  In  ten  the  antra  were  opened  through 
the  upper  part  of  the  alveolus  below  the  gingivo-labial  fold. 
In  two  a  tooth  was  first  extracted,  and  in  four  a  tooth  had 
been  extracted  at  a  prior  date  and  the  opening  made  through 
the  alveolus  from  below.  One  patient  refused  treatment; 
one  is  now  under  treatment. 

126  State  Street. 


INJURIES  OF  TIIE  HIP  AND 
ABSORPTION  OF  TIIE  NECK  OF  THE  FEMUR.* 
By  REUBEN  A.  VANCE,  M.  D., 

CONSULTING  SURGEON,  SAINT  ALEXIS  HOSPITAL,  CLEVELAND,  OHIO. 

I  he  injuries  of  the  hip  that  result  in  fracture  are  well 
known  ;  the  fractures  thus  produced  in  their  various  aspects 
have  been  so  much  discussed  and  written  about  that  their 
literature  is  one  of  the  most  voluminous  in  the  history  of 
practical  surgery.  On  the  present  occasion  I  wish  to  call 
your  attention  to  one  of  the  consequences  of  injuries  of  the 
hip  that  has  been  but  little  discussed  or  written  about,  and 
which  is  nevertheless  one  that  has  exercised  an  unrecog¬ 
nized  but  potent  influence  over  the  progress  of  all  lesions 
about  the  head  and  neck  of  the  femur.  I  refer  to  absorp¬ 
tion  of  the  bony  tissues  of  the  femoral  cervix,  the  result  of 
injuries  a  lesion  not  necessarily  preceded  by  fracture,  but 

one  that  may  occur  as  a  consequence  of  contusions  of  the 
hip. 

lhat  this  lesion  has  been  recognized  is  well  known  to 
all  familiar  with  the  writings  of  Benjamin  Bell  and  George 
Gulliver.  Within  recent  years  Richard  Quain,  in  his  Clin¬ 
ical  Lectures ,  has  set  forth  this  peculiar  consequence  of  in¬ 
juries  of  the  hip  in  a  lucid  manner,  and  illustrated  its  mor¬ 
bid  anatomy  with  great  success. 

A  brief  review  of  two  of  the  earlier  cases  will  fitly  intro¬ 
duce  what  I  shall  have  to  say  on  the  subject.  The  first  case 
is  from  the  Edinburgh  Medical  and  Surgical  Journal ,  No. 
128,  for  July,  1836  ;  the  second  from  the  same  periodical, 
No.  129,  for  October,  1836  ;  both  are  contributed  by  Mr. 
George  Gulliver,  and,  in  the  number  last  named,  the  morbid 
appearances  are  illustrated  in  excellent  style. 

J.  Fox,  aged  thirty-two,  after  a  service  of  eight  years  in 
the  West  Indies,  died  of  phthisis,  for  which  disease  he  had  been 
two  years  under  treatment  in  hospital.  A  long  time  after  his 
confinement  it  was  noticed  that  his  right  inferior  extremity  was 
emaciated,  but  there  was  no  note  of  any  affection  of  the  limb 
previous  to  his  admission  into  hospital.  At  the  post-mortem 
the  right  inferior  extremity  was  found  by  measurement  to  be  at 
least  an  inch  and  a  half  shorter  than  the  other,  and  the  extent 
between  the  pubis  and  trochanter  of  the  affected  side  was  dimin¬ 
ished  in  a  corresponding  manner.  The  limb  was  much  ema¬ 
ciated,  but  its  position  was  natural,  and  the  motions  of  the 
coxofemoral  articulation  were  not  impaired.  Having  removed 
the  upper  part  of  the  femur,  I  found  the  neck  absent.  The 
head  was  flattened  and  expanded  considerably;  it  was  approxi¬ 
mated  to  the  shaft,  so  as  to  be  situated  much  below  the  great 
trochanter.  A  section  of  the  part  was  made,  when  the  upper 
and  lower  shell  of  what  remained  of  the  neck  was  seen  to  be 
foi  med  of  compact  bone,  quite  equal  to  the  ordinary  thickness 
in  this  situation,  and  the  reticular  texture  of  the  bone  wTas  more 
dense  for  some  distance  from  the  edges,  so  as  to  form  an  indis¬ 
tinct  line  on  either  side  of  the  most  contracted  part  toward  the 
center.  The  cancelli  were  filled  with  caseous  matter,  in  some 
places  nearly  colorless,  in  others  tinged  with  dark  grumous 
blood.  The  acetabulum  was  diminished  in  depth,  but  enlargtd 
Literally,  so  as  to  correspond  with  the  altered  shape  of  the  head 
<»t  the  thigh  bone.  The  cartilage  of  the  articulation  presented 
throughout  its  usual  thickness  and  consistency,  and  was  gener- 

Read  before  the  Society  of  the  Alumni  of  Bellevue  Hospital  at  its 
first  annual  reunion. 


66 


VANCE:  ABSORPTION  OF  THE  NECK  OF  THE  FEMUR.  [«■  Med.  Jocb., 


ally  smooth  and  lubricated  with  synovia.  I  examined  the  other 
'thiKh  hone  and  found  its  form  and  condition  in  ever;  respect 
natural  I  now  sought  information  concerning  the  history  ot 
the  case  from  some  of  Fox’s  comrades,  who  had  served  and  come 
home  with  him.  From  them  it  appeared  that  Fox  had  received 
a  fall  about  three  years  before  in  the  Island  of  Nevis,  in  conse 
mience  of  which  he  often  complained  of  pain  about  the  hip,  but 
continued  to  do  his  military  duty  many  months  after,  never 
having  been  confined  on  account  of  the  accident.  The  morbid 
parts  described  in  this  case  are  preserved  in  the  Museum  of  the 
Army  Medical  Department.” 

»  j0hn  Lyun,  aged  nineteen,  a  stout,  active  recruit  ot  the 
Thirty-eighth  Regiment,  fell  into  the  hold  of  the  ship  in  which 
he  was  proceeding  to  join  his  corps  in  India,  and  injured  the 
right  hip  in  consequence  of  which  he  was  confined  to  his  berth. 
On  his  arrival  in  India,  about  three  months  after  the  accident, 
being  perfectly  well,  he  was  attached  to  the  light  company  ot 
his  regiment.  He  continued  to  perform  the  active  duties  re¬ 
quired  of  him  in  this  company  for  about  three  years  after  the 
accident  when  he  became  very  gradually  lame  in  the  injured 
limb  and  was  accordingly  admitted  into  the  hospital.  When  he 
had  been  about  eighteen  months  under  treatment,  the  infirmity 
increasing,  he  was  considered  to  be  unfit  for  service.  His  gen¬ 
eral  health  had  been  throughout  good,  and  he  was  accustomed 
to  move  about  with  the  assistance  of  a  crutch,  but  he  was  so 
much  addicted  to  the  drinking  of  ardent  spirits  that  it  was 
deemed  expedient  to  retain  him  in  hospital  until  he  could  be 
brought  before  the  annual  invaliding  committee.  While  de¬ 
tained  for  this  purpose  he  was  bit  during  the  night  by  a  snake 
(. Bumgarus  lineatus),  from  the  effects  of  which  he  died  in  a  few 
hours,  being  then  twenty-four  years  of  age. 

“The  hip  joint  presented  to  the  Museum  of  the  Army  Medi¬ 
cal  Department,  by  Dr.  Dempster,  exhibits  remarkable  shorten¬ 
ing  of  the  neck  and  enlargement  of  the  head  of  the  thigh  bone, 
with  suttable  change  of  form  in  the  acetabulum.  The  head  of 
the  bone  is  enlarged  principally  around  its  inferior  border  as  if 
from  expansion,  its  upper  and  front  part  being  flattened,  so  that 
the  articular  surface  extends  anteriorly  close  to  the  shaft,  while 
the  neck  presents  a  greater  extent  posteriorly.  The  acetabulum 
is  much  widened  and  remarkably  shallow,  corresponding  to  the 
alteration  of  shape  in  the  head  of  the  bone.  A  section  made  in 
the  usual  direction  through  the  upper  part  of  the  thigh  bone 
exhibits  the  center  of  its  neck  hardly  half  an  inch  long.  There 
is  no  appreciable  diminution  in  the  density  or  strength  of  the 
bone;  and  the  compact  shell  of  the  neck,  as  well  as  the  can¬ 
cellous  structure,  appears  throughout  perfectly  natural.  The 
articular  cartilages,  as  far  as  can  be  ascertained  from  a  dry  but 
imperfectly  macerated  preparation,  appear  of  the  usual  thick¬ 
ness,  without  a  trace  of  ulceration. 


an  hour  from  business  on  account  of  pain  in  or  defect  of  the 
limb.  In  May,  1887,  he  noticed  that  he  was  wearing  off  the 
back  of  the  right  pantaloon  leg,  and  became  conscious  ot  a  slight 
halt  in  his  gait.  He  then  fell  under  my  observation.  In  answer 
to  my  inquiry,  he  said  that  every  night  the  leg  was  weak  and  a 
trifle  painful,  that  before  the  injury  there  was  never  the  slight¬ 
est  defect  in  his  limbs.  In  May,  1887,  careful  measurements 
revealed  between  half  an  inch  and  an  inch  shortening;  the 
right  thigh  was  three  quarters  of  an  inch  less  in  circumference 
than  the  left.  No  difference  was  perceptible  in  measurements 
between  the  top  of  the  trochanter  major  and  the  lower  end  of 
the  femur  on  the  right  and  left  side;  or,  with  the  limbs  extend¬ 
ed,  between  the  trochanter  major  and  the  malleolus  of  the  fibula 
on  either  side.  But  there  was  a  decided  difference  on  the  two 
sides  when  measurement  was  made  between  the  crest  of  the 
ilium  and  the  trochanter — and  the  whole  of  the  shortening  on 
the  right  side  could  be  accounted  for  by  the  approximation  of 
the  right  trochanter  to  the  iliac  crest.  At  this  time  the  motions 
of  the  hip  joint  were  unimpaired,  and  no  tenderness  was  appar¬ 
ent  when  the  joint  surfaces  were  forcibly  approximated  in  dif¬ 
ferent  positions  of  the  limb.  The  range  of  motion  ot  the  thigh 
was  limited  in  but  one  direction— the  limb  could  not  be  abduct¬ 
ed  to  the  same  extent  as  the  left.  There  was  no  eversion  ot  the 
right  foot.  He  called  for  an  opinion  as  to  the  nature  of  bis  in¬ 
jury  and  its  future  progress,  he  then  contemplating  a  suit  for 
damages  against  the  property  owner  in  front  of  whose  prem¬ 
ises  he  fell— a  suit  that  was  never  brought,  owing  to  advice  re¬ 
ceived  from  counsel. 


I  will  now  recite  certain  facts  in  the  history  of  a  case 
that  has  long  been  under  my  observation  ; 


A  gentleman,  forty-seven  years  of  age,  a  native  of  Ohio  and 
a  life-long  resident  of  Cleveland,  while  on  his  way  to  his  place 
of  business  in  December,  1886,  slipped  and  fell,  striking  on  the 
right  hip  with  sufficient  violence  to  make  a  decided  ecchymosis 
over  the  trochanter  major.  Although  suffering  much  pain,  he 
continued  his  journey  and  attended  to  his  usual  vocations.  The 
only  change  he  felt  compelled  to  make  was  to  ride  to  and  trom 
his  place  of  business  during  the  ensuing  week.  The  limb  was 
sore  and  weak  during  this  interval,  and  over  the  bruised  region 
felt  very  tender.  At  the  end  of  that  time  he  was  awakened 
one  night  by  violent  pain  in  the  knee ;  this  was  so  severe  that 
he  remained  in  bed  the  following  day.  The  next  morning  he 
was  able  to  go  to  his  store  as  usual,  and  since  then  has  not  lost 


This  gentleman  has  been  under  my  observation  ever 
since.  I  have  recently  repeated  my  examination,  and  his 
present  condition  is  as  follows  :  There  is  an  inch  and  a 
quarter  difference  in  the  circumference  of  the  two  thighs ; 
an  inch  and  a  half  in  the  length  of  the  two  limbs,  located 
in  the  upper  end  of  the  right  femur.  The  motions  ot  the 
thigh  are  now  restricted  in  every  direction,  particularl)  so 
in  abduction.  Within  a  circumscribed  limit,  however,  he 
can  ilex,  extend,  abduct,  adduct,  and  circumduct  the  limb 
as  well  as  ever.  With  the  limb  straight  he  can  neither  in¬ 
vert  nor  evert  it  to  the  same  extent  as  its  fellow,  and  when 
lying  on  his  back  the  right  foot  seems  somewhat  everted. 
After  exertion  there  is  a  sense  of  weakness  in  the  limb,  and 
at  all  times  a  decided  halt  in  his  gait,  but  he  is  free  from 
pain  and  can  walk  to  and  from  his  place  of  business  with¬ 
out  distress.  In  short,  he  is  weak  and  lame  in  the  right 
lower  extremity,  but  otherwise  well. 

Quain  admirably  summarizes  the  morbid  anatomy  of 
this  lesion.  The  changes  involve  the  neck  and  head  of  the 
femur  and  acetabulum  of  the  pelvic  hone,  and  are  indicated 
by  comparison  with  the  bones  of  the  opposite  side  in  their 
natural  state.  The  head  of  the  femur  is  expanded  and  flat¬ 
tened,  and  shortened  as  if  thrust  down.  The  regular  ar¬ 
rangement  of  the  arches  of  the  cancellated  structure  is  no 
longer  apparent,  the  joint  surfaces  are  not  inflamed,  the 
cartilaginous  investments  are  intact,  and  the  peculiai  lesions 
of  chronic  rheumatic  arthritis  are  absent. 

In  the  American  Journal  of  the  Medical  Sciences  for 
October,  1867,  will  be  found  an  extremely  interesting  arti¬ 
cle  by  Dr.  John  H.  Packard,  of  Philadelphia— On  Some 
Points  relating  to  Fractures  of  the  Neck  of  the  Femur — in 
which  are  adduced  many  considerations  that  bear  foicibly 
on  any  conclusions  that  may  be  drawn  from  the  clinical 


July  19,  1890.] 


HOLT:  ACUTE  PRIMARY  BRONCIIO-PNEUMOFJA. 


67 


and  pathological  facts  above  set  forth.  But  my  object  at 
present  is  not  so  much  to  dwell  upon  those  aspects  of  the 
case  as  to  emphasize  certain  medico-legal  features  that  are 
liable  at  any  moment  to  assume  prominence.  These  are  of 
especial  interest  to  the  medical  profession.  Some  years 
since  a  prominent  surgeon  in  Cincinnati  was  hailed  while 
driving  along  the  street  by  a  young  physician,  who  re¬ 
quested  him  to  stop  and  glance  at  a  painter,  who,  in  falling 
from  a  ladder,  had  dislocated  his  thigh,  which  dislocation 
the  }ouug  man  assured  him  he  had  reduced.  The  surgeon 
complied,  saw  the  patient,  examined  the  limb,  and  assured 
the  injured  man  that  the  thigh  bone  was  back  in  its  proper 
position.  This  was  all  the  professional  connection  the  sur¬ 
geon  had  with  the  case.  It  seems  that  in  a  couple  of 
months  the  painter  was  back  at  his  business  apparently  all 
right,  but  in  a  few  weeks  he  began  to  walk  lame,  and  at  the 
expiration  of  another  month  or  so  his  legal  representative 
called  on  the  surgeon  with  a  demand  for  compensation, 
alleging  that,  through  want  of  skill  on  his  part,  a  fracture 
of  the  neck  of  the  thigh  bone  had  been  overlooked,  and 
that  his  client  was  lame  as  a  result  of  such  malpractice.  In 
this  position,  the  lawyer  went  on  to  say,  he  was  sustained 
by  the  opinion  of  a  local  professor  of  surgery  and  practi¬ 
tioner  of  high  repute,  who  had  assured  him  that  the  lame¬ 
ness  of  his  client  was  wholly  due  to  failure  on  the  part  of 
his  surgical  advisers  to  resort  to  measures  calculated  to 
keep  the  parts  at  rest  until  the  fracture  of  the  neck  of  the 
femur  had  united ;  that,  by  permitting  him  to  get  up  too 
soon,  either  the  callus  had  yielded  or  the  hitherto  untorn 
portion  of  the  cervical  ligament  had  ruptured ;  and  that 
the  shortening  of  the  limb  of  late  development  was  due  to 
one  or  other  of  these  causes,  and  could  be  due  to  nothing 
else.  This  case,  vexatious  and  expensive  as  all  such  cases 
are,  finally  came  to  naught  from  inability  on  the  part  of  the 
painter  to  stand  the  expense  of  litigation,  and  not  because 
of  the  injustice  of  his  claim  or  the  bad  character  of  the 
surgical  advice  on  wrhich  it  was  based. 

In  the  interpretation  of  these  cases  during  life  a  history 
of  the  patient  is  of  the  utmost  importance.  Absorption  of 
the  neck  of  the  femur  may  follow  the  most  diverse  injuries. 
If  there  has  been  fracture  or  dislocation,  the  surgeon  will 
always  guard  his  prognosis;  it  is  in  the  slighter  cases,  and 
those  where  a  simple  contusion  alone  is  apparent,  that 
trouble  is  apt  to  arise;  conversely,  in  patients  where  an  in¬ 
jury  of  the  hip  is  not  attended  by  inability  to  walk  that 
lasts  for  weeks;  where  no  shortening  occurs  at  first,  but  is 
of  late  development  and  gradual  onset ;  where  the  defect 
in  length  is  shown  not  to  be  located  in  any  other  part  of 
the  limb  than  the  region  around  the  joint,  and  where  other 
parts  of  the  body  are  free  from  evidences  of  chronic  rheu¬ 
matic  arthritis,  the  morbid  anatomical  condition  is  absorp¬ 
tion  of  the  neck  of  the  femur. 


The  late  Dr.  W.  T.  O’Donnell. — Dr.  O’Donnell,  of  Devil’s  Lake, 
North  Dakota,  died  on  the  2d  of  May,  at  the  age  of  forty-seven.  He 
was  a  native  of  New  Hampshire  and  a  graduate  of  Dartmouth  College. 
Dr.  0  Donnell  was  an  excellent  classical  scholar  and  a  devoted  student 
of  Hippocrates  and  other  ancient  medical  writers,  and  several  com¬ 
munications  of  his  relating  to  their  writings  have  appeared  in  this 
Journal. 


ACUTE  PRIMARY  BROJSf CHO-PNEUMONIA, 

WITH  LOW  TEMPERATURE  AND  OTHER  OBSCURE  SYMPTOMS.* 

By  L.  EMMETT  IIOLT,  M.  I)., 

PROFESSOR  OF  DISEASES  OF  CHILDREN  IN  THE  NEW  YORK  POLYCLINIC. 

The  diagnosis  of  acute  disease  among  infants  of  the  first 
few  months  of  life  is  attended  by  peculiar  difficulties.  This 
difficulty  depends  not  so  much  upon  the  fact  that  a  wide 
range  of  diseases  is  likely  to  be  met  with  as  it  does  upon 
the  masking  of  the  ordinary  diseases  by  very  unusual  symp¬ 
toms.  If  one  has  the  opportunity  to  see  the  autopsies  in 
his  cases,  he  is  continually  surprised  at  the  want  of  corre¬ 
spondence  existing  between  the  symptoms  and  the  lesions. 

The  following  two  cases  of  broncho-pneumonia  illus¬ 
trate  this  point ;  in  both  cases  almost  all  the  usual  symp¬ 
toms  of  pneumonia  were  wanting,  and  vet  the  lesions  were 
typical. 

Case  I.  Extensive  Broncho-pneumonia  in  the  Upper  and 
Lower  Lobes  of  the  Right  Lung  ;  Mild  Oastro-enteric  Symptoms 
for  Four  or  Five  Days ;  Pulmonary  Symptoms  only  Twenty  - 
four  hours ,  and  these  Obscure  Ones. — A  fairly  nourished  female 
infant,  five  weeks  old,  was  admitted  to  the  Babies’  Hospital, 
February  11,  1890.  It  was  sent  from  one  of  the  day  nurseries, 
where  the  child  had  been  under  the  daily  observation  of  a  phy¬ 
sician.  For  four  or  five  days  the  movements  from  the  bowels 
had  been  green  but  not  very  frequent,  and  there  had  been  occa¬ 
sional  vomiting.  The  symptoms  were  attributed  to  improper 
feeding. 

When  admitted,  the  child  seemed  bright;  cough  was  not  no¬ 
ticeable  ;  there  was  no  vomiting;  the  passages  were  very  green 
and  contained  undigested  food,  but  were  not  frequent  or  offen¬ 
sive.  The  evening  temperature  was  101°  F.  A  teaspoonful  of 
castor-oil  was  given  and  a  comfortable  night  passed.  Four  green 
movements  in  the  first  twenty-four  hours.  On  the  following 
morning  three  drops  of  paregoric  were  given.  Within  a  few 
hours  after  this  dose  the  appearance  of  the  child  changed  com¬ 
pletely.  The  pulse  became  weak  and  thready;  there  was  con¬ 
siderable  dyspnoea,  the  respirations  being  rapid  and  superficial, 
with  a  peculiar  catch  in  the  middle  of  each  inspiration,  so  that 
this  appeared  double,  while  expiration  was  natural.  There  was 
slight  general  cyanosis;  the  pupils  were  tightly  contracted,  the 
eyes  a  little  sunken,  the  fontanel  depressed,  the  face  drawn 
and  anxious;  there  was  general  relaxation,  and  the  whole  aspect 
of  the  case  was  alarming  in  the  extreme.  A  careful  examination 
of  the  chest  was  made,  but  only  rude  breathing  sounds  could  be 
heard  anywhere,  of  about  equal  intensity  upon  the  two  sides. 
The  rectal  temperature  was  99°  F.  throughout  the  entire  day. 

Mustard  packs  and  hot  baths  were  used  at  short  intervals 
and  stimulants  by  the  mouth  freely  given,  and,  though  at  first 
some  reaction  was  produced,  the  child  lost  ground  steadily  dur¬ 
ing  the  day.  By  evening  there  was  marked  cyanosis,  cold  ex¬ 
tremities,  pulse  too  rapid  to  be  counted.  Death  occurred  dur¬ 
ing  the  night  in  a  condition  of  collapse,  the  infant  having  had 
severe  symptoms  less  than  twenty-four  hours. 

Autopsy. — Thirty  hours  after  death.  Brain  not  examined. 
Lungs  show  no  fluid  in  either  pleural  cavity.  The  left  lung  nor¬ 
mal,  slightly  congested  behind.  One  third  of  the  right  upper 
lobe  and  about  three  quarters  of  the  lower  lobe  behind  were 
consolidated,  dark-colored,  slightly  mottled  with  gray ;  no  crepi¬ 
tation,  the  condition  shading  over  gradually  into  the  healthy 
lung.  On  section,  fairly  typical  broncho-pneumonia.  Slight 

*  Read  before  the  Section  in  Paediatrics  of  the  New  York  Academy 
of  Medicine,  April  10,  1890. 


HOLT:  ACUTE  PRIMARY  BRONCHO-PNEUMONIA. 


[N.  Y.  Med.  Jour., 


68 


swelling  of  the  bronchial  glands.  Eight  auricle  and  ventricle 
contained  dark  fluid ;  a  small,  partly  decolorized  thrombus  in 
the  right  ventricle  extending  into  the  pulmonary  artery.  Fora¬ 
men  ovale  closed  excepting  a  pin-hole  opening;  the  kidneys 
were  pale,  but  the  organs  essentially  normal,  including  the  in¬ 
testines. 

I  made  a  microscopical  examination  of  the  lungs  in  this 
case  to  clear  up  any  lurking  suspicion  in  the  mind  of  any 
one  that  this  was  not  a  case  of  pneumonia  at  all,  but  only 
collapse. 

There  was,  as  in  the  next  case,  in  all  the  consolidated 
areas,  a  very  extensive  exudation  of  round  cells  filling  the 
alveoli,  especially  about  the  larger  blood-vesse"ls  and  the 
bronchi,  and,  in  addition,  in  many  places  quite  large  capil¬ 
lary  haemorrhages. 

Case  II.  Acute  Broncho-pneumonia ,  Cardiac  and  Pulmo¬ 
nary  Thrombi ,  and  Areas  of  Pulmonary  Gangrene;  Severe 
Symptoms  only  Two  Days;  Low  Temperature.  A  well-noui- 
ished  male  infant,  six  months  old,  was  admitted  to  the  Babies’ 
Hospital  on  the  evening  of  Monday,  February  17th,  with  gen¬ 
eral  symptoms  of  great  prostration.  The  pulse  was  120,  but 
weak  and  intermittent ;  respirations,  32  and  quite  labored  ; 
temperature,  101’4°.  The  child  was  drowsy  and  swallowed 
with  difficulty  ;  slight  cervical  opisthotonus  ;  pupils  normal ;  no 
bulging  of  fontanel. 

This  child  was  also  sent  from  a  day  nursery,  and  the  follow¬ 
ing  history  was  obtained  :  Well  till  one  week  ago  ;  since  then  a 
slight  cough  ;  two  days  ago  bowels  loose,  but  no  passage  for  past 
twenty-four  hours ;  right  ear  discharging  for  two  days.  The 
infant  had  been  at  the  day  nursery  on  the  Saturday  previous ; 
was  seen  at  that  time  by  the  physician  in  attendance,  and  did 
not  seem  at  all  sick.  On  Monday  for  the  first  time  did  the  child 
appear  ill,  and  when  it  was  brought  back  to  the  nursery  the 
mother  was  directed  to  the  hospital.  A  hot  mustard  bath  and 
free  stimulation  ordered. 

On  the  following  morning  the  temperature  was  99°  ;  pulse, 
132;  respirations,  44.  The  prostration  had  increased,  there 
was  no  stupor,  but  the  infant  was  very  drowsy  and  quite  re¬ 
laxed  ;  there  was  pallor,  but  no  cyanosis  ;  fontanel  depressed  ; 
marked  recession  of  epigastrium  and  suprasternal  and  supra¬ 
clavicular  spaces  on  inspiration  ;  no  dullness  ;  very  rude  respira¬ 
tory  murmur  over  the  whole  chest,  with  only  a  few  coarse  rales 
at  the  bases  of  the  lungs.  The  respirations  were  so  shallow 
and  superficial  that  the  examination  was  not  very  satisfactory. 
Throat  negative;  opisthotonus  still  present.  As  there  seemed 
no  evident  cause  for  the  prostration  and  drowsiness,  the  intes¬ 
tines  were  irrigated  and  the  stomach  washed  out  without  any 
apparent  improvement  in  the  condition.  No  urine  was  passed 
during  the  day.  By  evening  there  was  a  very  decided  increase 
in  all  the  severe  symptoms,  the  prostration  extreme,  bordering 
on  collapse  in  spite  of  stimulants  both  to  the  skin  and  internally. 

At  7  p.  m.  the  temperature  was  96°;  pulse,  140  and  very 
weak;  respirations,  48,  with  great  dyspnoea;  slight  cyanosis. 

He  now  passed  into  collapse  and  died  at  3  a.  m.  the  follow¬ 
ing  morning,  thirty  hours  after  admission  and  forty- eight  after 
the  onset  of  severe  symptoms. 

Autopsy . — Eleven  hours  after  death.  Slight  congestion  of 
the  brain  ;  otherwise  normal. 

Lungs. — No  fluid  in  the  pleural  cavity.  Slight  fibrinous  exu¬ 
dation  of  recent  origin  upon  the  posterior  surface  of  both  lower 
lobes.  The  right  lung  showed  partial  consolidation  of  the  pos¬ 
terior  and  upper  portion  of  the  upper  lobe,  very  extensive  con¬ 
solidation  of  the  lower  lobe,  the  anterior  portions  of  both  being 
congested  and  oedematous.  On  section,  these  portions  gave  the 


typical  appearances  of  broncho-pneumonia.  Near  the  center  of 
the  lower  lobe  was  a  grayish  area,  in  which  the  lung  tissue  was 
almost  completely  disintegrated.  It  was  gangrenous,  but  with¬ 
out  any  odor.  The  gangrenous  area  was  about  the  size  of  a 
walnut ;  in  the  artery  leading  to  this  area  a  firm  thrombus,  com¬ 
pletely  filling  it,  was  found.  In  the  central  part  of  the  right 
middle  lobe  there  was  a  similar  gangrenous  area  and  a  similar 
thrombus.  These  thrombi  extended  to  the  large  branches  of 
the  pulmonary  artery  at  the  root  of  the  luug.  The  left  lung 
showed  typical  broncho-pneumonia  in  the  posterior  portion  of 
both  lobes,  the  lesion  not  quite  so  far  advanced  as  upon  the 
right  side.  At  the  root  of  the  left  lung  a  cheesy  bronchial 
gland  was  discovered,  and  quite  near  it  a  very  small  area,  in 
which  were  scattered  recent  miliary  tubercles.  On  section  of 
this,  a  small,  cheesy  nodule  the  size  of  a  pea  was  found.  The 
bronchial  glaDds  at  the  root  of  the  right  lung  were  swollen  but 
not  cheesy.  No  tubercles  were  found  in  any  other  part  of  the 
body. 

The  heart  contained  a  small  thrombus  in  the  left  ventricle, 
which  extended  slightly  into  the  aorta  and  also  into  the  left 
auricle,  being  closely  adherent  to  the  mitral  valve.  In  the  right 
ventricle  there  was  a  much  larger  thrombus,  extending  some 
distance  in  the  pulmonary  artery.  This  also  extended  into  the 
right  auricle,  to  the  walls  in  which  it  was  very  closely  adherent. 
There  was  quite  marked  cloudy  swelling  of  the  kidney,  but  the 
other  organs  were  essentially  normal.  The  appearance  of  the 
tubercles  in  the  lung  is  evidently  only  an  incident  in  the  case, 
as  this  certainly  had  nothing  to  do  with  the  symptoms  and  was 
entirely  distinct  from  the  pathological  process  in  the  luDgs  else¬ 
where.  It  is,  however,  of  interest  as  showing  a  tubercular 
affection  of  the  lung  from  a  bronchial  gland  pretty  clearly  oc¬ 
curring  in  the  child  under  circumstances  when  it  would  be 
scarcely  expected  and  evidently  having  caused  no  symptoms, 
although  the  process  must  have  existed  for  some  time. 

Microscopical  examinations  were  made  of  several  parts  of 
the  lungs  and  of  the  kidney  by  Dr.  R.  G.  Freeman.  Ordinary 
typical  broncho-pneumonia  was  found  with  very  abundant  exu¬ 
dation  of  cells  into  the  alveoli,  but  little  fibrin.  The  epithelium 
of  the  convoluted  tubes  was  quite  granular,  and  in  a  few  places 
cast  matter  was  found  in  the  tubes. 

Remarks.—  In  both  these  cases  the  lesions  were  very 
ordinary  ones,  with  the  exception  of  the  thrombi  and  gan¬ 
grenous  areas  in  the  second  child,  and  yet  the  history,  the 
symptoms,  and  the  course  are  as  far  as  possible  from  those 
seen  in  typical  cases  of  pneumonia. 

In  both  cases  the  lesion  was  evidently  very  recent,  but 
certainly  in  the  second  child  considerably  longer  than  the 
two  days  of  acute  symptoms.  There  was  then  in  both 
cases  acute  pneumonia  with  early  latent  symptoms. 

The  low  range  of  temperature  is  a  point  of  especial  in¬ 
terest.  While  it  is  very  common  for  secondary  pneumonia 
to  develop  with  little  or  no  elevation  of  temperature,  it  is 
very  exceptional  to  see  so  little  fever  in  cases  of  acute  pri¬ 
mary  pneumonia.  On  the  contrary,  high  temperature  in  a 
case  of  acute  illness  is  generally  the  thing  which  makes  us 
scrutinize  the  lungs  for  evidence  of  disease. 

In  Case  I  a  singular  feature  is  the  fact  that  severe  symp¬ 
toms  first  developed  shortly  after  a  dose  of  opium,  although 
this  was  a  small  one — only  three  drops  of  paregoric.  The 
embarrassed  respiration,  slight  cyanosis,  and  contracted 
pupils  suggested  strongly  opium  poisoning.  W  ithout  the 
autopsy  there  would  have  been  certainly  some  good  reasons 
for  believing  that  the  opium  had  had  something  to  do  with 


July  19,  1890.*] 


REETT:  AN  INTR  ALIO  AMENTARY  OVARIAN  CYST. 


69 


the  infant’s  death.  In  the  light  of  the  lesions  found,  the 
connection  can  not  be  regarded  as  anything  more  than  a 
coincidence. 

,  In  Case  II  the  pathological  conditions  considered  in  re¬ 
lation  to  the  symptoms  were:  (1)  Cerebral  congestion  or 
possibly  meningitis  associated  with  the  otitis;  (2)  toxic 
symptoms  from  gastro-enteric  catarrh;  (3)  acute  nephritis 
and  uraemia;  (4)  acute  pulmonary  congestion  with  areas  of 
collapse;  (5)  pneumonia. 

Pneumonia  was  strongly  suspected  in  this  case  from  its 
resemblance  to  Case  I,  the  autopsy  upon  which  had  been 
but  a  few  days  before. 

We  are,  then,  to  suspect  pneumonia  in  infancy  if  dysp¬ 
noea,  rapid  breathing,  great  prostration,  and  slight  cyanosis 
exist,  even  though  the  temperature  be  scarcely  above  the 
normal  and  though  the  examination  of  the  chest  may  give 
no  positive  evidence  that  the  lungs  are  diseased. 

The  great  frequency  of  pneumonia  in  young  children 
should  put  us  always  on  our  guard  to  watch  for  its  many 
masked  forms. 

15  East  Fifty-fourth  Street. 


AN  INTRALIGAMENTARY  OYARIAN  CYST 

SUCCESSFULLY  TREATED  WITH  IODINE  INJECTIONS.* 
By  R.  B.  RHETT,  Jh.,  M.  D., 

CHARLESTON,  8.  C. 

On  April  7,  1889,  I  was  called  to  Mrs.  H.,  white,  aged  twen¬ 
ty-eight,  who  gave  the  following  history  :  She  had  always  suf¬ 
fered  some  dysmenorrhoea,  except  from  August,  1886,  when  she 
had  an  attack  of  typhoid  fever,  to  October  10,  1887,  when  she 
married.  During  that  interval  there  was  no  pain  or  difficulty. 
For  years  she  has  suffered  slightly  from  incontinence  of  urine. 
Immediately  subsequent  to  marriage  the  dysmenorrhoea  re¬ 
turned  and  increased  in  severity;  the  pains,  dragging  weights, 
etc.,  continued  also  between  the  periods.  She  felt  sick  and 
badly  all  the  time,  but  believed  this  to  be  the  normal  condition 
of  women  during  early  married  life.  In  January,  1889,  she 
missed  her  periods.  In  February  for  the  first  time  she  noticed 
in  dressing  that  her  abdomen  had  become  enlarged,  as  her  clothes 
were  too  tight,  and  thought  she  had  conceived.  On  February 
20th  her  menses  returned  and  continued  almost  constantly  untij 
April  1st,  when  her  physician  prescribed  medicine  which  stopped 
them.  On  March  8th  she  was  seized  suddenly  with  most  violent 
cramps  and  retching.  The  agony  was  so  intense  that  she  fainted 
four  or  five  times.  She  was  also  unable  to  void  her  urine,  though 
constantly  attempting  to.  Her  family  physician  drew  off  her 
urine  repeatedly  and  administered  anodynes.  On  the  18th,  while 
she  was  still  confined  to  her  chamber,  another  attack  occurred 
similar  in  every  particular,  though  slightly  less  in  intensity. 
For  some  months  she  had  suffered  from  constipation  and  there 
seemed  to  be  some  obstruction  in  the  passage. 

In  1886  she  fell  down  a  flight  of  stairs.  For  some  time  pre¬ 
vious  to  March  8th  she  was  in  the  daily  habit  of  lifting  buckets 
of  water  through  a  window.  In  raising  the  buckets  from  the 
outside  piazza  floor  the  abdomen  was  strained  against  the  win¬ 
dow-sill  and  often  caused  sharp  pains.  This  fall  or  the  forcible 
compression  of  the  abdomen  against  the  sharp  edge  of  the  sill 
may  account,  by  having  caused  hasmorrhage,  for  the  color  of 
the  fluid  in  the  tumor,  which  at  the  operation  was  found  to  be 
brown. 


Physical  examination  revealed  the  presence  of  a  tumor  ex¬ 
tending  across  and  occupying  the  lower  part  of  the  abdomen 
from  the  right  inguinal  region  just  below  the  anterior  superior 
spine  of  the  ilium  to  just  under  the  left  twelfth  rib.  The  tumor 
was  hard  and  tense  and  felt  like  a  fibro-cyst.  It  could  be  felt 
plainly  pressing  down  on  the  anterior  wall  of  the  vagina,  and 
there  gave  the  sensation  of  a  solid  growth. 

The  womb  was  fixed  and  deflected  to  the  right,  and  meas¬ 
ured  four  inches  and  a  half  in  diameter.  The  bladder  was  elon¬ 
gated. 

An  effort,  with  partial  success,  was  made  to  improve  the  pa¬ 
tient’s  general  condition  before  operating,  by  means  of  baths, 
tonics,  etc. 

About  the  middle  of  April  Dr.  J.  J.  Edwards  was  called  into 
consultation  and  agreed  with  me  as  to  the  propriety  of  operat¬ 
ing  for  the  removal  of  the  growth. 

The  diagnosis  of  an  intraligamentary  ovarian  cyst  was  made, 
and  measures  for  operating  were  taken  accordingly. 

On  May  1,  1889,  the  operation  was  performed.  An  incision 
about  four  inches  in  length  was  made  in  the  median  line,  reach¬ 
ing  to  about  two  inches  below  the  umbilicus  and  just  below  the 
upper  margin  of  the  tumor.  The  incision  was  very  cautiously 
deepened  until  the  cyst-wall  was  reached  and  recognized.  A 
trocar  resembling  Dunster’s  was  thrust  in  near  the  upper  extrem¬ 
ity  of  the  incision  and  the  sac  partly  evacuated  of  a  brown  fluid. 
The  opening  was  then  carefully  prolonged  through  the  cyst-wall 
downward.  The  patient  was  then  turned  on  her  side  and  the 
fluid  and  solid  contents  of  the  sac  were  scooped  out  with  the  hand 
and  the  cavity  was  thoroughly  washed.  She  was  then  turned 
back  and  the  incision  carried  up  into  the  peritoneal  cavity.  A 
short  coil  of  intestines  was  found  adherent  to  the  peritoneal 
surface  of  the  tumor  and  was  released.  Later  during  the  op¬ 
eration  this  raw  oozing  surface  of  the  coil  bulged  up  into  the 
opening  and,  in  checking  haemorrhage,  was  grasped  with  press¬ 
ure-forceps  by  an  assistant  and  so  bruised  by  the  forceps  as  to 
necessitate  the  sewing  up  of  about  an  inch  of  its  surface. 

An  attempt  was  made  to  peel  out  the  tumor;  but  the 
haemorrhage  was  so  terribly  profuse  and  the  constant  necessity 
of  stopping  to  control  it  so  great,  that  very  little  progress  was 
made.  The  patient  was  several  times  during  the  operation  in¬ 
jected  hypodermically  with  ammonia  and  hot  bottles  were  kept 
in  constant  contact  with  her  person.  She  became  so  weak  that 
death  on  the  table  was  imminent,  and  I  decided  to  abandon 
:’urther  efforts  to  enucleate.  The  abdominal  aud  tumor  cavi¬ 
ties  were  thoroughly  cleansed  with  hot  water.  The  edges  of 
the  incised  peritonaeum  were  sewed  together,  closing  off  the 
peritoneal  cavity  completely  from  that  of  the  tumor.  The 
freed  portion  of  the  sac,  which  in  proportion  to  what  remained 
was  very  little  indeed,  was  cut  off  and  the  edges  wrere  drawn  in 
apposition  with  sutures.  The  wound  of  the  abdominal  walls 
was  closed  by  deep  stitches  with  two  drainage-tubes  in  the 
lower  angle — one  glass,  bent  at  an  angle,  passing  into  the  pelvic 
cavity  and  the  other,  of  rubber,  seven  inches  long,  pushed  into 
the  upper  portion  of  the  sac. 

The  cavity  after  the  first  twenty-four  hours,  for  two  weeks, 
was  injected  every  four  hours  with  bichloride-of-mercury  solu¬ 
tion,  1  to  10,000  of  boiled  water,  and  once  daily  with  about 
half  an  ounce  of  tincture  of  iodine,  containing  a  small  quantity 
of  saturated  solution  of  iodide  of  potassium  to  prevent  the 
iodine  from  being  precipitated  when  coming  in  contact  with 
any  water  remaining  in  the  cavity  that  had  just  previously 
been  washed  out.  The  iodine  was  thrown  through  a  long- 
nozzled  syringe  against  the  upper 'surfaces  and  into  the  two 
sulci — one  of  which  was  under  the  left  twelfth  rib  and  the 
other  in  the  right  inguinal  region.  Three  hours  after  each  of 
these  injections  the  sac  was  washed  out.  The  syringe  used 


*  Read  before  the  Medical  Society  of  South  Carolina,  April  23,  1890. 


70 


B  UCKMA  S  TER :  PE  RSIS  TENT  VOMITING. 


[N.  Y.  Mkl».  Jour., 


while  the  tracts  were  large  enough  was  one  with  a  bent  nozzle, 
which  Emmet  recommends  for  withdrawing  mucous  discharges 
from  the  uterine  canal. 

When  the  tracts  became  too  small  a  malleable  silver  cannula 
attached  to  a  small  aspirating  syringe  was  used.  For  the  first 
two  days  a  few  drops  of  carbolic  acid  were  added  to  the  tinct¬ 
ure  of  iodine,  with  the  idea  of  producing  a  slight  caustic  action. 

I  now,  however,  believe  that  the  quantity  was  so  small  that  it 
had  no  effect.  At  no  time  did  the  patient  complain  of  much 
pain  deep  in  the  abdomen.  The  opening  and  the  surface  around 
it  were  greased  with  vaseline.  As  the  cavities  contracted  the 
tubes  were  removed,  one  at  the  end  of  three  weeks  and  the 
other  at  the  end  of  five.  The  injections  of  iodine  after  the 
second  week  were  for  a  short  time  given  every  second  day,  and 
then  every  third  until  the  tenth  week,  when  the  cavities  had  en¬ 
tirely  closed.  After  the  third  week  the  iodine  was  immediately 
withdrawn  with  the  injecting  syringe,  as  it  was  believed  that 
the  surfaces  were  all  thoroughly  reached,  and  the  tracts  were 
not  washed  out  in  three  hours.  After  the  eighteenth  day  the 
discharge  changed  and  became  a  transparent  amber-colored 
fluid.  At  the  end  of  six  weeks  the  patient  was  up,  and  has 
since  enjoyed  excellent  health,  and  there  is  at  present  no  evi¬ 
dence  whatsoever  of  any  return  of  the  growth. 

I  have  searched  the  limited  literature  within  my  reach 
and  fiud  no  reference  to  a  similar  line  of  treatment.  The 
old  treatment  of  injecting;  any  ovarian  cyst  cavity  after  tap¬ 
ping,  where  the  products  of  inflammation  were  locked  up 
in  the  cavity,  I  regard  as  different  in  material  points.  The 
theory  upon  which  this  treatment  was  based  was,  that, 
because  of  the  low  vitality  and  non-malignancy  of  the 
structures,  besides  its  antiseptic  and  haemostatic  effects, 
the  pure  tincture  of  iodine  might,  as  it  does  in  some  path¬ 
ological  conditions  of  the  endometrium,  produce  disin¬ 
tegration,  resolution,  and  complete  absorption  of  the  growth. 
This  effect  followed  in  this  instance,  but  there  may  have 
been  other  factors  which  accomplished  the  result.  The 
test  of  experience  alone  can  prove  it.  But  if  time  should 
establish  it  to  be  the  best  and  safest  treatment,  then  should 
we  have  a  simple  and  easy  process  substituted  for  one  from 
which  even  the  boldest  and  most  skillful  gynaecologists 
shrink. 

The  appalling  haemorrhage,  the  dangers  of  tearing  the 
ureters,  the  rectum,  the  bladder,  etc.,  would  be  entirely  re¬ 
moved,  and  in  many  cases  it  would  be  unnecessary  to  even 
open  the  peritoneal  cavity. 


A  CASE  OF  PERSISTENT  VOMITING, 
WITH  A  HISTORY  OF  CHYLOUS  (?)  VOMITING, 
RELIEYED  BY  LAPAROTOMY.* 


By  A.  H.  BUCKMASTER,  M.  D. 

Mrs.  0.,  aged  thirty-five,  married  fourteen  years,  and  the 
mother  of  one  child,  sought  my  aid  for  the  relief  of  persistent 
vomiting.  She  had  had  no  miscarriages,  and  her  only  labor 
was  a  severe  one.  The  membranes  ruptured  at  2  o’clock  a.  m., 
and  the  child’s  head  appeared  at  the  vulval  cleft  at  2  o’clock 
r.  m.,  where  it  remained  tfntil  6  o’clock,  when  delivery  took 

*  Read  before  the  Alumni  Association  of  the  Woman’s  Hospital, 
January  16,  1890. 


place  spontaneously.  There  was  a  complete  rupture  through 
the  recto-vaginal  septum.  Seven  days  after  labor,  while  nurs¬ 
ing  the  child,  as  the  patient  felt  the  distention  in  the  breasts, 
she  regurgitated  a  milky-white  fluid  through  the  mouth.  Ibis 
happened  every  time  she  nursed  the  child,  and  finally  led  the 
medical  attendant  to  advise  the  weaning  of  the  infant,  which 
was  done.  She  drank  no  milk  after  the  birth  of  the  child,  tak¬ 
ing  cocoa,  gruel,  etc.  As  the  milk  decreased,  pari  passu  the 
amount  of  regurgitation  of  milky  fluid  also  diminished. 

Seven  months  later  Dr.  W.  G.  Hoyt,  of  this  city,  restored 
the  recto-vaginal  septum. 

A  year  and  a  half  after  the  labor  the  patient  began  to  vomit 
I  daily.  She  consulted  Dr.  Stern,  of  Leicester,  Mass.,  who  treated 
her  during  the  summer,  with  slight  improvement  of  the  symp¬ 
tom.  The  vomiting  occurred  immediately  after  eating,  and  at 
other  times  irrespective  of  the  taking  of  food. 

The  patient  then  came  to  New  York  and  saw  Dr.  Weinberg, 
and  was  by  him  referred  to  the  late  Dr.  James  B.  Hunter.  Dr. 
Hunter  placed  her  in  the  Woman’s  Hospital,  and  thought  the 
trouble  was  due  to  enlarged  and  cystic  ovaries,  and  recom¬ 
mended  oophorectomy.  The  patient  was  so  weak  at  the  time 
that  her  friends  decided  not  to  have  her  undergo  the  operation. 
She  went  to  Brooklyn  and  entered  the  Long  Island  College 
Hospital.  She  remained  a  short  time,  and  finally  consulted  me, 
by  the  advice  of  Dr.  Thomas  B.  Watkins,  now  of  Chicago.  I 
found  her  much  emaciated  and  so  weak  that  she  could  scarcely 
walk.  On  either  side  of  the  uterus  were  two  large,  movable 
masses,  of  about  the  size  of  small  lemons.  She  complained  that 
she  could  not  drink  part  of  a  glass  of  water  without  vomiting. 
Examination  of  the  urine  revealed  nothing,  and  I  sent  the  pa¬ 
tient  to  Dr.  B.  F.  Westbrook,  of  Brooklyn,  asking  him  to  go  over 
the  case  carefully  for  any  organic  disease  that  might  account 
for  the  vomiting,  and  to  state  whether  he  considered  the  vomit¬ 
ing  of  a  reflex  character,  and  if  the  patient  could  stand  the 
etherization.  Dr.  Westbrook  returned  a  written  report,  advis¬ 
ing  the  removal  of  the  masses  in  the  pelvis,  as  he  could  find  no 
other  cause  for  the  vomiting,  and  stating  that  he  considered  the 
patient’s  condition  critical.  In  January,  1889,  I  removed  the 
masses  spoken  of,  which  were  very  much  enlarged  ovaries. 
There  were  no  adhesions,  and  the  patient  made  an  uninterrupted 
recovery.  She  did  not  vomit  after  the  operation,  except  when 
coming  out  of  the  anaesthesia,  for  four  months,  and  gained  in 
flesh  during  this  time  thirty-six  pounds.  At  the  end  of  this 
period  vomiting  began  again  and  soon  was  as  bad  as  eve/.  After 
drifting  from  physician  to  physician,  she  sought  my  care  in  the 
following  September.  I  again  used  all  the  means  I  could  think 
of  to  help  the  trouble,  but  without  avail.  Lavage  and  strict 
diet  of  various  kinds  proved  futile.  The  cervix  contained  a 
|  slight  amount  of  hard  tissue.  This  was  removed  with  no  favor¬ 
able  result. 

On  December  7th  I  made  an  explorative  incision,  thinking 
perhaps  that  Loreta’s  operation  might  be  indicated.  I  removed 
the  small  intestines  from  the  abdominal  cavity  and  carefully  ex¬ 
amined  them  coil  by  coil  for  adhesions  or  other  abnormities. 
The  pyloric  orifice  was  palpated,  as  were  the  kidneys.  1  he 
only  thing  noticed  was  that  the  right  kidney  appeared  some¬ 
what  enlarged,  and  just  above  it  was  what  I  took  to  be  an  en¬ 
larged  suprarenal  capsule.  The  abdomen  was  closed,  and  the 
patient  did  not  vomit  for  several  months.  It  is  now  five  months 
since  the  last  operation,  and  the  patient  states  that  vomiting  has 
begun  again,  and  she  fears  that  she  will  be  as  bad  as  ever. 


The  two  interesting  points  in  the  above-given  history 
are  the  temporary  cessation  of  the  vomiting  after  laparoto¬ 
my  and  the  milk-like  vomiting  after  the  birth  of  the  child. 

;  The  latter  symptom,  which  I  had  on  the  statement  of  the 


July  19,  1890.] 


DOUGLAS:  HYSTERECTOMY  FOR  (EDEMATOUS  FIBROID. 


71 


patient,  I  treated  as  an  idle  story  until  by  repeated  cross- 
examination  ot  the  patient’s  mother  and  husband  I  was  un¬ 
able  to  make  them  contradict  the  assertion.  Dr.  Busey’s 
interesting  article  on  The  Effusion  of  Chyle  and  Chyle-like, 
Milky,  batty,  and  Oily  Fluids  into  the  Serous  Cavities*  has 
induced  me  to  present  this  case  for  your  attention,  and  in 
closing  I  will  take  the  liberty  of  quoting  two  of  his  foot¬ 
notes  : 

“  Practices  observed  saliva  evidently  milky.  For  a  woman, 
he  says,  nursing  a  child,  again  became  pregnant,  and  therefore 
weaned  the  child.  The  right  breast,  from  neglect,  became  like 
a  large  tumor,  and  on  a  certain  night  subsequently,  while  suf¬ 
fering  much  pain,  she  had  an  abundant  discharge  of  milk  from 
the  mouth,  with  a  corresponding  decrease  of  the  swelling  in  her 
breast.  She  swallowed  the  milk  as  it  came  into  her  mouth 
(without  any  inconvenience),  which  continued  for  four  months. 

“  But  it  may  be  asked,  How  came  the  decrease  in  the  breast  ? 
In  my  judgment,  in  no  other  way  than  this:  that  the  masses  of 
the  blood  were  laden  witli  chyle,  the  particles  of  which  could 
not  permeate  the  lactiferous  tubules  of  the  mammal  on  account 
of  their  collapsed  condition,  but  formed  a  tumor  in  those  near¬ 
est  the  mammary  gland,  especially  since  their  arteries  were 
filled  and  were  not  capable  of  removing  any  more.  Indeed,  the 
chylous  and  milky  particles  were  abundantly  distributed  through 
the  blood  mass,  and  permeated  the  glandular  structures,  espe¬ 
cially  the  salivary,  which  offered  the  least  resistance.  In  the 
mean  time  the  blood,  on  account  of  its  freer  and  quieter  motion, 
propelled  the  chylous  particles  remaining  in  the  breast  toward 
the  veins,  and  thus  to  the  heart ;  hence  it  followed  the  breast 
was  emptied.”  Sialographia ,  etc.,  Ductuum  Aquosorum  Anat. 
Nova.  Lugduni  Batavorum,  1695,  p.  49. 

‘‘A  woman  who  was  nursing  twins  began  to  complain,  a 
few  days  after  the  death  of  one  of  them,  of  a  sense  of  dull  pain 
and  tension  beneath  the  ribs  of  the  right  side  of  the  abdomen 
and  over  the  umbilicus.  This  feeling  was  succeeded  by  stretch¬ 
ing,  the  stretching  by  itching,  and  the  itching  by  an  exudation 
of  fluid  from  the  skin,  the  color,  taste,  and  consistence  of  which 
were  identical  with  milk,  and  which  yielded  a  true  butter  on 
agitation.”  Ephemerides  Germania ?,  decur.  ii,  ann.  viii. 


HYSTERECTOMY  FOR  (EDEMATOUS  FIBROID. 

RECOVERY. 

By  RICHARD  DOUGLAS,  M.  D., 

PROFESSOR  OF  GYNECOLOGY,  MEDICAL  DEPARTMENT,  VANDERBILT  UNIVERSITY 

NASHVILLE,  TENN. 

Jane  V.,  colored,  aged  forty,  widow,  of  short  and  thick 
stature,  the  mother  of  three  children,  youngest  eighteen  years 
old.  Five  years  ago  she  discovered  a  hard,  round,  painless  tu¬ 
mor,  about  the  size  of  a  small  orange,  in  the  left  inguinal  region. 
There  was  but  little  change  in  the  growth  during  the  first  two 
years  of  its  recognized  existence;  during  the  last  three,  how¬ 
ever,  its  growth  has  been  quite  active.  Her  menstrual  history 
normal ;  slight  vesical  and  rectal  irritation,  with  a  sense  of 
weight  and  heaviness  in  pelvis,  were  the  only  symptoms  indi¬ 
cating  its  presence,  she  being  able  to  discharge  her  duties  as 
cook  in  a  private  family  up  to  January  1,  1889,  since  which  time 
the  growth  has  been  rapid,  the  tumor  attaining  such  dimensions 
as  to  give  rise  to  serious  symptoms,  attributable  to  size  and 
weight.  When  first  seen  by  me  in  July  last  she  was  confined 
to  her  bed  ;  the  abdomen  was  greatly  distended  by  a  large, 


*  Amer.  Jour,  of  the  Med.  Sciences,  1889. 


smooth,  symmetrical,  and  decidedly  elastic  tumor.  The  poor 
woman  was  in  great  distress,  unable  to  walk  or  stand  with  com¬ 
fort ;  confined  to  her  bed,  finding  rest  only  upon  her  side;  in 
changing  her  position  it  was  necessary  for  some  one  to  assist  in 
lifting  the  tumor  over ;  at  times  there  was  alarming  dyspnoea, 
obstinate  constipation,  and  decided  tenderness  all  over  the  tu¬ 
mor.  Vaginal  examination  was  negative,  the  uterus  being  al¬ 
most  out  of  reach  high  up  in  the  pelvis.  Operation  was  advised 
but  refused. 

On  September  20th  was  recalled,  and  found  her  general  con¬ 
dition  much  worse.  The  tumor  was  now  hard,  yet  in  parts  there 
w  as  a  deceptive  w ave  appreciable.  The  diagnosis  was  extremely 
difficult,  but,  from  race,  clinical  history,  and  physical  signs,  it 
pointed  to  oedematous  fibroid. 

After  due  preparation  she  was  submitted  to  operation  on 
September  28th.  The  usual  short  incision  was  made,  the  char¬ 
acter  of  the  growth  found  to  be  soft  fibroid,  and  its  removal  de¬ 
termined  upon.  The  incision  was  extended  as  necessary  to  a 
point  one  inch  below  the  ensiform  cartilage;  the  growth  almost 
filled  the  abdominal  cavity  ;  the  greater  omentum  was  spread 
out  and  attached  over  its  entire  anterior  portion,  and  immense 
veins  larger  than  a  lead-pencil,  a  dozen  or  more  in  number, 
coursed  over  its  surface;  strong  and  vascular  adhesions  attached 
the  tumor  to  the  ascending  and  transverse  colon,  and  a  coil  of 
small  intestine  was  adherent  to  the  left  side.  The  adhesions 
were  grasped  with  forceps  and  ligatured  on  the  proximal  side 
with  No.  4  carbolized  silk,  and  divided  between  forceps  and 
ligature,  the  forceps  being  left  in  situ  on  the  tumor  side  in  pref¬ 
ence  to  double  ligature,  simply  as  a  matter  of  expediency.  All 
the  adhesions  were  carefully  treated  in  this  manner,  and  the 
tumor,  freed  of  all  save  its  deep  pelvic  attachments,  was  deliv¬ 
ered  from  the  cavity  and  held  well  up  by  the  assistants.  The 
appendages  were  so  much  elongated  by  the  growth  that  they 
were  with  ease  brought  up  alongside  of  the  body  of  the  uterus, 
and  the  wire,  ofBantock’s  modification  of  Koeberl6’s  serre-nceud, 
was  made  to  embrace  the  uterus  and  appendages  just  above  the 
vaginal  attachment.  The  clamp  was  now  tightened  by  several 
turns  of  the  screw,  and,  when  deemed  sufficiently  constricted,  the 
pedicle-pins  were  introduced  just  above  the  wire,  and  the  uterus 
with  its  growth  cut  away  half  an  inch  above  the  pins,  the  stump 
appearing  perfectly  white  and  bloodless.  Immediately  after  the 
amputation  the  wire  was  tightened  by  two  turns  of  the  screw, 
a  point  to  which  Bantock  attaches  much  importance.  The  little 
blood  that  had  escaped  into  the  cavity  was  sponged  out,  and  the 
abdominal  incision  closed  down  to  the  stump,  some  care  being 
taken  to  stitch  the  parietal  peritonaeum  to  the  stump  immedi¬ 
ately  below  the  grasp  of  the  wire,  thus  completely  closing  and 
protecting  the  cavity  from  such  discharge  as  might  take  place 
from  the  pedicle.  The  excess  of  tissue  was  then  trimmed  off  of 
the  stump  and  its  peritoneal  covering  drawn  over  its  surface  by 
stitches,  the  object  being  not  only  to  limit  the  exposed  portion, 
but  also  to  compress  it  by  the  tightly  drawn  silk  sutures.  A 
few  superficial  stitches  were  now  introduced  to  draw  the  skin 
more  closely  about  the  pedicle,  and  gauze  carefully  packed  under 
the  pins  and  about  the  stump.  Iodoform  was  dusted  over  the 
wound  and  the  usual  dressings  were  applied.  The  operation 
was  completed  in  about  two  hours  and  twenty  minutes.  The 
tumor  weighed  twenty-three  pounds  and  a  half.  Patient  showed 
but  little  shock,  reacting  promptly. 

There  is  nothing  in  the  progress  of  the  case  worthy  of  note 
except  that  the  temperature  remained  under  100°  F.  The  bowels 
moved  on  the  fourth  day  without  a  laxative  ;  the  wound  healed 
primarily  throughout;  the  clamp  was  tightened  from  day  today 
by  a  few  turns  of  the  screw  ;  there  was  never  any  suppuration 
at  the  pedicle.  The  stump  mummified  and  dropped  off  on  the 
twenty  second  day,  leaving  a  small  cupped  granulating  depres- 


72  HUBER:  EMPYEMA  COMPLICATED  WITH  PULMONARY  (EDEMA.  [N.  Y.  Med. 

eion  this  healing  in  a  short  time.  It  is  now  seven  months  since  I  must  be  given  and  the  chest  aspirated  without  delay.  The 

theoperation,  and  my  patient  has  regained  her  former  health  and  quantity  to  be  drawn  off.  must  necessarily  vary  wi 

vigor.  This  case  may  be  reported  not  only  as  one  of  recovery  circumstances  of  the  individual  case.  Even  in  a  simp  e 
from  operation,  but  as  one  of  absolute  restoration  to  health.  case  0f  effusion  there  is  ordinarily  greater  or  less  danger  of 

producing  fresh  congestion  and  hyperaemia  of  the  lungs  in 
removing  a  large  quantity.  It  must  not  be  lost  sight  of 
that  our  purpose  is  to  relieve  the  intrathoracic  pressure,  to 
free  the  overburdened  heart,  and  to  remove  the  symptoms 
of  oppression.  As  has  been  well  said,  “slowness  in  the 
withdrawal  of  the  fluid,  as  well  as  the  small  quantity  drawn, 
lessens  the  probability  of  any  unpleasant  effect.”  Bowditch 
says:  “I  always  draw  with  great  deliberation;  I  pull  so 
lightly  upon  the  handle  of  the  piston  that  it  seems  as  if  the 


CASE  OF  EMPYEMA 

COMPLICATED  WITH  PULMONARY  (EDEMA. 

REMARKS* 

By  F.  HUBER,  M.  D. 


Though  the  subject  of  empyema  has  but  recently  been 

discussed  before  this  Section,  I  have  taken  the  liberty  to  llgllu;y  ut,uu  ^  - — -  r - 

present  the  following  case,  in  order  to  direct  attention  to  a  fluid  itse]f  were  pressing  out  from  the  chest  and  pushed  the 
not  infrequent  complication  and  to  lay  stress  upon  a  prac-  piston  upward,  my  hand  simply  following  the  impulse.” 

..  i  •  j.  •  il.  — rvf  f»r>mnlif».at,ftd  with  t £  +  ,.,-,0  on  nncmrmlieated  case,  the  lesso 


tical  point  in  the  management  of  cases  complicated  with 
pulmonary  oedema  of  the  other  side. 

The  little  patient,  Jessie  W.,  aged  twenty  months,  was  re¬ 
ferred  to  me  through  the  courtesy  of  Dr.  D.  Cook,  December 
5,  1889.  Unfortunately,  I  was  not  able  to  see  the  child  until 
midnight,  though  notified  earlier  in  the  evening  that  effusion 
was  present,  with  oedema  of  the  other  lung.  I  found  the  pa¬ 
tient,  who  had  been  ill  sixteen  days,  in  a  very  precarious  con¬ 
dition,  extremely  restless,  tossing  about  wildly,  and  ciying  in¬ 
cessantly.  Marked  orthopnoea  present  for  several  hours.  Face 


If  this  be  true  of  an  uncomplicated  case,  the  lesson  ap¬ 
plies  with  far  greater  force  to  a  case  in  which  the  danger 
to  be  avoided  already  exists  and  presents  itself  to  us,  face 
to  face.  Some  years  ago,  after  reading  of  a  number  of 
cases  of  empyema  cured  by  aspiration,  I  was  in  the  habit 
of  withdrawing  large  quantities,  and  did  not  meet  with  an) 
bad  effects  in  simple  cases  of  purulent  effusion.  In  several 
instances  in  which  oedema  was  present  upon  the  other  side, 
though  the  aspiration  was  slowly  performed  with  a  Dieula- 


_  -  .  , ,  ‘  fov  instrument  and  the  patient  stimulated,  the  oedema  pro- 

and  extremities  cyanosed,  pulse  feeble,  limbs  cold,  eyes  sunken  -  and  the  cases  resulted  fatally  within  thirty-six 

and  heavy.  Several  drachms  of  brandy  were  given  and  the  g  ’  ^  ^  cages  were  UTlfavorable,  the  oedema  of 

child,  seated  in  the  mother’s  lap,  was  aspirated  and  about  six  1  o  ..  of  subsequent 

ounces  of  purulent  fluid  were  drawn  off  very  slowly.  Though  the  the  lung  being  well  marked,  but  in  the  light  o  s  q 
breathing  became  easier,  the  general  condition  was  bad  and  the  experience,  1  am  forced  to  concede  that,  q  • 

child  wTas  at  once  placed  in  bed  with  the  head  low,  hot  bottles  drawn  off  been  less,  the  circulatory  changes  wou  no  iave 
being  applied  to  the  extremities  and  warm  applications  over  the  been  so  extreme  within  a  comparatively  short  time  and  the 
prsecordial  region.  Very  soon  the  little  patient  rallied  and  filing  heart  might  have  regained  its  tone  and  the  termina- 
grew  quiet,  soon  after  fell  asleep,  and  passed  a  fairly  comfoita-  jqeen  rnore  favorable.  Since  then  three  additional 

ble  night.  The  next  day,  as  the  child  had  gained  ground  and  g  of  a  with  pulm0nary  oedema  hare  come  under 

looked  considerably  better,  it  was  determined  to  operate,  the  v  ation>  From  four  to  six  ounces  only  were  drawn 

oedema  of  the  other  lung  having  subsided.  Accordingly,  assist-  and  the  heart  allowed  to  regain 

ed  by  Dr.  Cook,  the  child  was  placed  on  the  healthy  side  and,  off,  the  patients  stimulated  and  the 
without  an  anaesthetic,  the  chest  was  incised  posteriorly  below  its  force ;  the  pulmonary  oedema  graduc  y 
the  ano-le  of  the  scapula  and  a  drainage-tube  inserted.  The  six  hours,  and,  as  in  the  case  reported  above,  subsequen  .  in¬ 
cavity  was  now  irrigated  with  hot  water  and  an  antiseptic  1  •  •  J— 1 - —  — fnllnwnd  bv  recovery. 

dressing  applied.  Irrigation  was  only  resorted  to  once  or  twice 
subsequently,  to  wash  out  the  fibrinous  masses.  A  sheet  of  rub¬ 
ber  several  inches  square  was  placed  over  the  opening  to  act  as 
a  valve.  This  innovation,  however,  did  not  impress  Dr.  Cook 
or  myself  very  favorably,  and  was  discarded  after  a  few  days. 

The  subsequent  course  was  favorable,  and  in  less  than  four 


1  lie  SU  USC4UCUU  wuiov  "  - - - 1  I  ,  1 

weeks  not  only  had  the  lung  expanded  fully,  but  even  the  in-  first  or  second  week. 


cision  with  drainage  was  practiced,  followed  by  recovery. 

The  complication,  in  my  experience,  occurs  rather  in 
the  acute  suppurative  pleurisies,  in  which  class,  as  a  rule, 
the  constitutional  symptoms  are  severe,  the  effusion  of  fluid 
rapid,  and  the  heart’s  action  greatly  enfeebled.  It  occurs 
early,  too,  in  the  history  of  the  case — about  the  end  of  the 

I  have  not  met  with  it  in  the  sub- 


tegumental  wound  had  healed.  1  avu.^.  -  „  ■  ,  ,  T, 

,  ,  .  .  I  accustom  itself  gradually  to  the  extra  work  demanded.  Its 

Hyperaemia  or  congestion  of  the  lungs  is  a  veiy  g  ai  ^  o  ^  may  be  rather  suddco.  A  child  aged 

complication,  which  may  result  in  cedema  and  even  c  »  was  ,eft  fairiy  comfortahle  on  the  morning  of 

free  albuminoid  and  frothy  expectoration,  often  ter imna  mg  y  unforeseen  circumstances  pre¬ 
in  asphyxia  and  death  by  suffocation-mdema,  pneumonia  the  —  day  ^  ^  ^  ,  „as  called 

serosa  of  Traube,  acute  albuminoid  expectoration  of  the  ™  „atient  suffering  from  orthopnoea,  cya- 


acute  or  chronic  variety,  where  the  heart  has  a  chance  to 


French  authors. 

When  pulmonary  oedema  occurs  as  a  complication  of 
purulent  pleurisy  it  always  adds  to  the  gravity  of  the  case, 
and  may  be  the  immediate  cause  of  death.  The  treatment 
should  be  prompt  and  bold.  Stimulants  of  various  kinds 


*  Read  before  the  Section  in  Paediatrics  of  the  New  York  Academy 
of  Medicine,  April  10,  1890. 


out  and  found  the  patient  suffering  from  orthopnoea,  cya¬ 
nosed,  with  the  usual  symptoms  of  extreme  air-hunger,  and 
with  a  marked  pulmonary  oedema  of  the  other  lung.  I  was 
compelled  to  aspirate  at  3  a.  m.,  and  drew  off  about  four 
ounces,  sufficient  to  relieve  the  urgent  symptoms.  The 
same  afternoon,  when  Professor  Jacobi  saw  the  case,  the 
danger  was  over.  A  few  days  later  the  child  was  operated 
on  and  recovered. 


July  19,  1890.] 


LEADING  ARTICLES. 


F3 


THE 


NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 


Published  by 
D.  Appleton  &  Co. 


Edited  by 
Frank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  JULY  19,  1890. 


NEW  YORK’S  NEW  WATER  SUPPLY. 


At  the  time  of  writing,  the  Croton  water  is  flowing  for  the 
first  time  through  the  new  aqueduct.  It  is  given  out  that  for 
the  present  the  flow  is  to  be  allowed  to  continue  only  long 
enough  to  fill  the  Central  Park  reservoir,  which  is  said  not  to 
have  been  full  at  any  time  during  the  last  fifteen  years ;  and 
that  then  the  new  aqueduct  is  to  be  emptied  for  a  period  of 
about  six  weeks  to  give  an  opportunity  for  finishing  certain, 
work  on  it  considered  essential  to  its  enduring  efficiency. 

When  the  old  aqueduct  was  built,  in  the  first  half  of  the 
century,  it  was  commonly  thought  to  be  quite  sufficient  for  a 
town  of  any  size  that  the  imagination  of  the  wildest  optimist 
could  picture  New  York  as  likely  to  attain,  but  within  forty 
years  it  showed  its  incapacity,  and  it  may  take  its  place  by  the 
side  of  the  brownstone  rear  wall  of  the  City  Hall  as  a  monu 
ment  to  the  defective  foresight  of  the  citizens  of  New  York, 
and  by  the  side  of  the  old  lady’s  declaration,  in  colonial  times, 
that  she  could  foresee  the  time  when  New  York  would  contain 
“fifty  thousand  inhabitants,”  wherein  the  old  lady  was  a  trifle 
behind  her  predecessor  who  had  foretold  the  stretching  of 
London  to  Greenwich.  Water  has  been  going  to  Waste  over 
the  Croton  dam  for  years;  there  has  been  “  water  all  around, 
but  none  to  drink.”  If  it  is  beyond  all  practicable  expedients 
to  bring  the  whole  of  this  water  to  town — and  we  do  not  un¬ 
derstand  that  even  the  two  aqueducts  will  do  it — it  seems  to 
us,  as  we  have  stated  before,  that  other  sources  of  supply 
should  be  drawn  upon,  especially  the  one  involved  in  Mr.  Bart¬ 
lett  s  scheme.  It  will  not  do  to  put  off  further  undertakings  of 
the  kind  until  another  water  famine  is  upon  us. 

The  temporary  relief  alluded  to  will  come  none  too  soon. 
The  supply  of  water  available  in  most  New  York  houses  has 
dwindled  year  by  year  until  it  reached  its  minimum  this  sum¬ 
mer,  when  it  would  not  run  in  the  second  stories  of  most 
houses  during  the  greater  part  of  the  day,  Sundays  and  holidays 
excepted,  and  often  failed  on  the  first  floor,  or  came  only  in  a 
fitful  dribble ;  so  that  the  illustration  employed  by  one  of  the 
comic  newspapers,  in  which  it  puts  into  the  mouth  of  a  matron 
the  query,  addressed  to  her  husband,  whether  it  would  be 
better  to  wash  the  child’s  face  or  have  boiled  potatoes  for  din¬ 
ner,  is  hardly  strained.  A  water  supply  of  good  quality  and 
adequate  quantity  is  a  sanitary  necessity  of  the  first  magnitude, 
to  say  nothing  of  its  importance  to  comfort.  When  the  quan 
tity  falls  oft  seriously  the  quality  is  almost  sure  to  deteriorate 
Organic  impurities  necessarily  find  their  way  into  open  reser¬ 
voirs.  When  they  are  copiously  diluted  they  are  relatively  or 
altogether  harmless;  when  they  gain  access  to  small  bodies  of 


water  they  may  be  potent  for  evil.  Fortunately,  during  our 
water  famine  there  has  been  no  widespread  prevalence  of  dis¬ 
ease  attributable  to  drinking  contaminated  water,  but  in  hun¬ 
dreds  of  ways  our  restriction  has  doubtless  contributed  in¬ 
directly  to  grave  attacks  of  sickness,  and  all  the  more  this 
summer,  seeing  that  the  supply  of  ice  in  the  market  is  reduced 
almost  beyond  precedent,  and  its  quality  correspondingly  ques¬ 
tionable.  Our  impression  is  that  it  would  be  wise  to  allow 
the  preliminary  flow  through  the  new  aqueduct  to  continue 
through  the  few  remaining  weeks  of  warm  weather,  provided 
the  nature  of  the  work  of  perfecting  the  conduit  admits  of  such 
a  course. 


ACROMEGALY. 


Within  the  last  few  years  this  disease  has  been  brought 
before  the  notice  of  the  profession,  and  now  cases  are  being 
found  in  all  the  large  centers  of  clinical  research.  The  credit 
of  first  having  described  this  very  strange  affection  is  undoubt¬ 
edly  due  to  Marie,  who  made  a  study  of  certain  cases  at  Char¬ 
cot’s  clinic  in  Paris.  His  records  have  been  published  in  the 
numbers  of  tbe  Revue  de  medecine  for  the  current  year,  and 
have  attracted  a  great  deal  of  attention. 

Quite  recently  the  description  of  a  case  was  given  at  the 
meeting  of  the  Association  of  American  Physicians  at  Wash¬ 
ington.  In  addition  to  the  work  done  by  Marie,  M.  Suza-Leite, 
another  of  Charcot’s  pupils,  has  collected  all  that  is  known  of 
this  strange  disease,  and,  having  added  some  original  observa¬ 
tions  made  at  Charcot’s  clinic,  has  published  a  comprehensive 
treatise  which  embodies  all  our  present  knowledge  of  the  sub¬ 
ject. 

The  disease  begins  by  a  gradual  thickening  of  the  hands, 
which  become  uniformly  enlarged,  the  other  members  not 
altering  their  form.  But  after  the  hands  become  enlarged  a 
change  comes  over  the  face  in  that  it  becomes  longer  by  a  well- 
marked  prognathism.  The  lower  lip  grows  thick  and  pendu¬ 
lous,  the  nose  becomes  hypertrophied,  the  orbital  arches  become 
prominent,  the  lids  thicken,  and  the  skin  generally  undergoes 
pigmentation.  Deformity  extends  to  the  trunk,  lateral  curva¬ 
ture  of  the  spiue  takes  place  in  the  cervico-dorsal  region,  the 
ends  of  the  ribs  become  prominent,  and  the  patient  comes  to 
present  a  humpbacked  appearance.  In  addition  to  these  changes, 
the  patient  complains  of  headache,  of  pains  in  various  parts  of 
the  body,  of  increased  thirst  and  hunger,  and  of  disturbances 
of  vision,  and  in  women  amenorrhoea  is  wont  to  occur.  These 
are  the  principal  characteristics  of  tbe  disease.  But  there  are 
other  less  striking  ones  which  are  important  from  a  diagnostic 
point  of  view. 

For  the  first  two  years  of  its  course  the  progress  of  the  dis¬ 
ease  may  be  rapid,  but  at  the  end  of  that  time  a  stationary 
period  is  reached,  with  occasional  exacerbations  of  the  symp¬ 
toms  already  present,  the  patients  eventually  dying  either  by 
the  cachexy  induced  or  by  reason  of  some  cerebral  lesion. 
They  are  lesions  which  belong  especially  to  acromegaly,  and  it 
is  doubtless  a  distinct  disease.  The  lesion  most  constantly 
present  is  a  considerable  enlargement  of  the  pituitary  body, 


MINOR  PA  RAG  RAPUS.— ITEMS. 


(N.  Y.  Mki>.  Joor., 


74 


which  acts  in  all  respects  like  a  tumor  at  the  base  of  the  brain, 
and  lias  all  the  accompaniments  of  such  a  structure— viz.,  com¬ 
pression  of  all  cerebral  structures,  but  especially  those  con¬ 
cerned  with  vision.  The  ganglia  and  the  nervous  cords  of  the 
sympathetic  afford  evidence  of  having  undergone  hypertrophy, 


be  followed  by  pulmonary  complications.  IvunckeVs  experi¬ 
ments  ( Bulletin  medical)  show  that  the  chloroform  is  decom¬ 
posed  into  hydrochloric  acid,  and  he  believes  that  it  is  that 
which  does  the  mischief.  He  thinks  that  the  effect  might  be 
counteracted  by  inhalation  through  linen  soaked  in  an  alkaline 

solution. 


the  thymus  is  persistent,  and  lesions  are  found  in  the  thyreoid 
body,  the  heart,  and  the  vessels.  After  the  changes  in  the 
pituitary  body  have  occurred  similar  processes  begin  to  take 
place  in  the  bony  parts,  the  sella  turcica  becomes  enlarged,  and 
other  bony  changes  have  been  found. 

The  cause  of  this  strange  malady  is  obscure.  It  begins  in 
adolescence  or  in  mature  age,  and  some  of  the  patients  give  his¬ 
tories  of  antecedent  mental  shock,  exposure  to  cold,  rheuma¬ 
tism,  or  syphilis,  but  nothing  is  really  known  of  its  aetiology. 


SUPPURATION  AFTER  CATARACT  EXTRACTION. 

In  the  Klinisches  Monatsblatt  fur  Augenheilkunde,  accord¬ 
ing  to  the  Deutsche  Medizinal-Zeitung,  Professor  Adamtlk  has 
brought  together  a  large  amount  of  statistical  material  from 
which  he  deduces  that  suppuration  following  a  cataract  extrac¬ 
tion  does  not  depend  upon  the  traumatism  inflicted  during  the 
operation,  but  upon  infection.  To  prove  this  he  quotes  cases 
in  which  the  greatest  possible  amount  of  traumatism  was  in¬ 
flicted  without  any  resulting  suppuration,  and  contends  that  a 
clumsily  performed  operation  is  no  more  likely  to  be  followed 
by  this  complication  than  one  very  skillfully  performed. 


MINOR  PARAGRAPHS. 

AN  INJUSTICE  TO  AN  HONORABLE  HOUSE. 

Under  the  heading  “  Messrs  Hazard,  Hazard,  &  Co.  sail 
under  False  Colors,”  the  Virginia  Medical  Monthly  says: 
“We  have  had  occasion  for  some  time  to  doubt  the  honesty  of 
this  firm,  but  were  hoping  that  before  this  they  would  have 
relieved  themselves  of  occasion  for  our  suspicion.  We  have 
afforded  them  abundant  opportunities  to  straighten  themselves 
out  in  our  estimation,  but,  as  they  seem  entirely  lost  to  those 
principles  which  regulate  dealings  with  honest  houses,  we  are 
painfully  forced  to  recall  any  commendation  we  may  have  given 
this  house  in  the  past.”  The  Monthly  then  appends  a  letter  from 
Mr.  W.  F.  Ford,  which  appeared  in  our  issue  for  June  21st,  as 
confirmatory  of  its  unfavorable  inference.  The  statements  em¬ 
bodied  in  Mr.  Ford’s  letter  are  true,  but  they  are  not  the  whole 
truth,  and  they  do  not  warrant  our  Virginia  contemporary’s 
deduction.  Mr.  Ford  says  that  he  has  “  been  manufacturing  for 
the  surgical  profession  continuously  for  over  forty  years,”  but 
he  omits  to  state  that  for  about  half  that  period  he  was  manu¬ 
facturing  under  the  firm  now  styled  Hazard,  Hazard,  &  Co. 
and  that  his  connection  with  that  firm  ceased  only  very  re- 
cently — so  recently,  in  fact,  that  the  statement  in  their  adver¬ 
tisement  to  which  he  objects  was  simply  the  result  of  their 
failure  to  remove  a  standing  notice  instantly.  We  happen  to 
know  that  they  ordered  its  removal  as  soon  as  their  attention 
was  called  to  it.  We  regret  exceedingly  that  our  contemporary 
should  have  drawn  from  anything  published  in  this  Journal  an 
inference  in  any  way  unfavorable  to  a  house  which  for  more 
than  a  century  has  deserved  and  received — and,  we  believe, 
still  deserves  and  receives— the  confidence  of  the  medical  pro¬ 
fession. 


-  THE  ANIMAL  PARASITES  OF  SHEEP. 

The  Bureau  of  Animal  Industry  of  the  Department  of  Agri¬ 
culture  has  lately  brought  out  a  volume  with  this  title,  by 
Cooper  Curtice,  D.  V.  S.,  M.  D.,  illustrated  with  thirty-six 
ithographs  of  the  various  parasites,  mostly  from  original  draw¬ 
ings.  The  diseases  to  which  the  parasites  give  rise  are  de¬ 
scribed,  and  their  prevention  and  treatment  are  dealt  with. 
The  value  of  such  a  publication  to  those  who  are  engaged  in 
sheep-raising  must  prove  very  great. 


THE  MEDICAL  REGISTER  OF  NEW  YORK,  NEW  JERSEY, 
AND  CONNECTICUT. 

The  twenty-eighth  volume  of  this  annual  has  just  been  re¬ 
ceived,  being  overdue  a  fortnight  or  more.  The  editor,  in  his 
preface,  adverts  to  the  fact  that,  in  regard  to  the  physicians  of 
the  city,  the  chauges  and  removals  have  been  unprecedentedly 
numerous,  a  fact  which,  while  it  has  occasioned  delay,  makes 
the  volume  all  the  more  important  for  reference  purposes.  Over 
7,600  physicians  find  registration  from  the  three  States  intended 
to  be  covered  by  this  publication  for  1890-  91. 


THE  UNIVERSITY  OF  THE  CITY  OF  NEW  YORK. 

The  fiftieth  anniversary  of  the  establishment  of  the  Medical 
Department  is  close  at  hand,  and  that- fact  is  made  the  occasion 
of  a  more  than  usually  elaborate  annual  announcement,  em¬ 
bellished  with  views  of  some  of  the  lecture-rooms  and  students’ 
laboratories.  The  announcement  is  made  that  during  the  half- 
century  of  its  existence  the  institution  has  conferred  the  degree 
of  M.  D.  on  5,832  matriculates. 


THE  ADMINISTRATION  OF  CHLOROFORM  BY  GASLIGHT. 

Considerable  attention  has  been  given  of  late  to  the  chem¬ 
ical  composition  of  the  compounds  formed  by  chloroform 
vapor,  air,  and  the  products  of  the  decomposition  of  coal  gas. 
It  appears  from  the  investigations  of  several  chemists  (Stob- 
wasser,  von  Iterson,  Zweifel,  and  others)  that  chloroform 
vapor  may  be  decomposed  by  gas  flame  and  give  rise  to  a  com¬ 
pound  of  carbon  and  chlorine  which  is  very  irritating  to  the 
respiratory  organs.  This  substance,  along  with  others,  forms  a 
vapor  in  the  neighborhood  of  the  gas  jet  or  of  the  petroleum 
flame.  The  operators  sometimes  experience  pains  in  the  head, 
nausea,  and  dizziness,  while  the  subjects  of  operation  suffer 
afterward  from  dyspnoea,  cough,  and  lacrymation.  Asphyxia 
in  the  course  of  the  anaesthesia  may  develop  at  any  moment  and 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  July  15,  1890  : 


— - - - - 

Week  ending  July  8. 

Week  ending  July  15. 

_L)  1 5S  A  5^  It*  S . 

Cases. 

Deaths. 

Cases. 

Deaths. 

TvnhniH  fp.VP.t* . 

8 

0 

26 

6 

43 

2 

44 

5 

Cerebro-spinal  meningitis . 

2 

271 

2 

23 

1 

240 

1 

19 

74 

23 

54 

15 

Varicella . . 

4 

0 

3 

0 

The  Astley  Cooper  Prize.— The  British  Medical  Journal  states 
that  Mr.  William  Watson  Cheyne,  M.  B.,  has  received  the  award  of 


July  19,  1890.J 


ITEMS— PROCEEDINGS  OF  SOCIETIES. 


75 


the  triennial  prize  of  three  hundred  pounds  for  the  best  essay  on  The 
Origin,  Anatomy,  Results,  and  Treatment  of  Tubercular  Diseases  of  the 
Hones  and  Joints. 

The  American  Public  Health  Association  will  hold  its  eighteenth 
annual  meeting  in  Charleston,  S.  C.,  on  the  16th,  17th,  18th,  and  19th 
of  December,  under  the  presidency  of  Dr.  Henrv  B.  Baker,  of  Lansing 

Mich. 

The  Ontario  Medical  Association. — At  the  June  meeting,  we  learn 
from  the  Montreal  Medical  Journal,  Dr.  T.  Addis  Emmet,  of  New  York, 
and  Dr.  E.  M.  Moore,  of  Rochester,  were  elected  honorary  members. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army,  for  the  week  ending  July  12,  1890  : 

Robinson,  Samuel  Q.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
temporary  duty  at  the  U.  S.  Military  Academy,  West  Point,  N.  Y.,  to 
take  effect  upon  the  arrival  there  of  Carter,  W.  Fitzhcgh,  Captain 
and  Assistant  Surgeon,  and  will  report  in  person  to  the  commanding 
officer,  Fort  Du  Chesne,  Utah  Territory,  for  duty,  relieving  Price, 
Curtis  E.,  Captain  and  Assistant  Surgeon.  Captain  Price,  on  being 
relieved  by  Captain  Robinson,  will  proceed  to  Fort  Wadsworth, 
New  York  Harbor,  and  report  in  person  to  the  commanding  officer  of 
that  post  for  duty,  relieving  Benham,  Robert  B.,  Captain  and  Assist¬ 
ant  burgeon.  Captain  Benham,  on  being  thus  relieved  from  tem¬ 
porary  duty  at  Fort  Wadsworth,  will  report  in  person  without  delay 
to  the  commanding  officer,  Fort  Hamilton,  New  York  Harbor,  for 
duty.  Par.  12,  S.  0.  163,  A.  G.  0.,  July  2,  1890,  Washington,  D.  C. 
Gardiner,  John  de  B.  W.,  Captain  and  Assistant  Surgeon,  having  been 
found  incapacitated  for  active  service  by  an  army  retiring  board, 
and  having  complied  with  Par.  12,  S.  0.  135,  June  10,  1890,  from 
this  office,  is,  by  direction  of  the  Acting  Secretary  of  War,  granted 
leave  of  absence  until  further  orders  on  account  of  disability.  Par. 
3,  S.  0.  163,  A.  G.  0.,  July  2,  1890,  Washington,  D.  C. 

Taylor,  Marcus  E.,  Captain  and  Assistant  Surgeon.  By  direction  of 
the  Secretary  of  War,  the  leave  of  absence  on  surgeon’s  certificate 
granted  in  S.  0.  45,  June  13,  1890,  Division  of  the  Pacific,  is  ex¬ 
tended  five  months  on  surgeon’s  certificate  of  disability,  with  per¬ 
mission  to  go  beyond  sea.  Par.  6,  S.  0.  159,  A.  G.  0.,  July  10 
1890. 

Naval  Intelligence.  Official  List  of  Changes  hi  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  July  12,  1890: 

Rixey,  P.  H.,  Surgeon.  Leave  of  absence  granted  for  fifteen  days. 
Ogden,  F.  N.,  Assistant  Surgeon.  Promoted  to  be  a  Passed  Assistant 
Surgeon. 

White,  S.  Stuart,  Assistant  Surgeon.  Promoted  to  be  a  Passed  As¬ 
sistant  Surgeon. 

Atlee,  L.  W.,  Assistant  Surgeon.  Granted  three  months’  leave  of  ab¬ 
sence. 

Woolverton,  T.,  Medical  Inspector.  To  await  orders  to  the  U.  S. 
Steamer  Philadelphia. 

Lovering,  P.  A.,  Passed  Assistant  Surgeon.  To  await  orders  to  the 
U.  S.  Steamer  Philadelphia. 

McMurtrie,  D.,  Medical  Inspector.  Granted  leave  of  absence  for  — 
days. 


|)roeettrin0s  of  So  rictus. 


RICHMOND,  YA.,  ACADEMY  OF  MEDICINE  AND 

SURGERY. 

Meeting  of  May  27 ,  1890. 

The  President,  Dr.  W.  W.  Parker,  in  the  Chair. 

A  Nasal  Concretion. — The  President  exhibited  a  specimen 
resembling  wood  coated  with  calcareous  matter — the  whole  of 


about  the  size  of  a  bicuspid  tooth.  A  child  of  ten  had  expelled 
it  from  the  nose  in  the  act  of  sneezing;  its  presence  there  had 
been  known  for  seven  years. 

Unusual  Relation  of  Pulse  and  Temperature  in  Ma¬ 
larial  Fever. — Dr.  R.  D.  Garoin  reported  having  observed  in 
a  case  of  malarial  fever  (in  a  girl  of  eighteen  years),  one  even¬ 
ing,  a  temperature  of  101°  F.,  the  pulse  being  normal.  lie  had 
given  no  heart  sedatives. 

Salol  in  Dysentery. — Dr.  Aaron  Jeffery,  having  used  salol 
in  several  cases  of  dysentery,  reported  very  flattering  results. 
Having  failed  with  the  ordinary  treatment  of  the  disease,  he 
had  ordered  salol  in  powder,  ten  grains  every  three  hours,  with 
the  result  of  disappearance  of  blood  and  mucus  in  about  twenty- 
four  hours. 

Dr.  Landon  B.  Edwards  had  been  using  salol  in  dysentery 
since  attention  had  been  called  to  its  virtue  by  Dr.  W.  P.  Nicol- 
son,  of  Atlanta.  He  now  preferred  it  to  calomel  and  opium. 
He  stated  that  the  condition  of  pulse  and  temperature  referred 
to  by  Dr.  Garcin  was  common  in  malarial  and  typbo-malarial 
fevers.  He  had  observed  in  typho-malarial  fever  a  pulse  of  60 
or  65  while  the  temperature  ranged  from  101°  to  103°,  probably 
being  no  higher  from  the  effect  of  antifebriles.  The  condition  of 
the  pulse  was  so  peculiar  as  to  suggest  idiosyncrasy,  but  an  ex¬ 
amination  after  recovery  had  discovered  a  normal  rate. 

Salines  in  Peritonitis  and  Typho-malarial  Fever.— Dr. 

Edwards  also  called  attention  to  the  use  of  salines  in  peritonitis 
and  typho-malarial  fever.  There  bad  been  hesitation  and  fear  in 
regard  to  using  the  suggestion  from  lack  of  accuracy  in  differ¬ 
entiating  typhoid  and  typho-malarial  affections.  He  was  confi¬ 
dent  that  if  this  treatment  was  adopted  a  decided  inroad  would 
be  made  in  the  direction  of  shortening  the  duration  of  typho- 
malarial  fever.  This  idea  was  sustained  by  eminent  authorities. 
He  had  learned,  since  a  correspondence  with  Dr.  Joseph  Price, 
that  in  peritonitis  and  typho-malarial  fever  the  use  of  salines 
had  become  comparatively  general  in  the  North.  He  did  not 
positively  advocate  this  plan,  but  suggested  it.  Whereas  a  doctor 
would  do  well  ordinarily  to  bring  a  case  of  typho-malarial  fever 
to  a  close  in  fifteen  or  twenty  days,  he  had  completed  two  cases 
in  about  eight  days  with  the  use  of  salines  and  such  antipyretics 
as  acetanilide,  antipyrine,  and  quinine.  Fluid  diet  was  as  essen¬ 
tial  as  medicines.  In  using  the  antipyretics  he  had  guarded 
them  with  heart  tonics,  preferably  strophanthus. 

The  President  had  observed,  in  reference  to  the  abnormal 
relation  of  pulse  and  temperature,  the  pulse  as  low  as  30  in 
some  cases  of  typho-malarial  fever. 

Dr.  O.  A.  Crenshaw  stated,  in  reference  to  Dr.  Edwards’s 
remarks,  that  the  treatment  in  1845  had  been  with  purgatives 
and  venesection. 

Dr.  Edwards  stated  that  salines  were  used  not  for  their  pur¬ 
gative  but  for  their  derivative  effect. 

Dr.  Crenshaw"  believed  that  typho-malarial  fever,  so  called, 
was  nothing  but  typhoid  fever  modified  by  malarial  poison  as  a 
result  of  the  unfortunate  hygienic  conditions  in  our  cities.  In 
typhoid  fever  no  purgatives  should  be  used.  In  typho-malarial 
i:ever  he  followed  the  plan  of  purgatives  in  the  beginning,  and 
quinine. 

Antipyrine  in  Malarial  Fever. — Dr.  Garoin  asked  the  ex¬ 
perience  of  any  present  in  the  use  of  antipyrine  in  malarial 
fever.  He  had  found  that  it  only  controlled  temperature  while 
it  was  administered. 

Antipyrine  in  Typhoid  Fever. — Dr.  Jeffery  had  found 
that  in  typhoid  fever  antipyrine  reduced  the  temperature  for 
the  first  few  days,  but  afterward  had  no  effect.  He  thought 
the  drug  too  depressing  to  be  safe,  and  that  it  did  great  harm 
in  suddenly  reducing  high  temperature,  thus  obscuring  the  true 
nature  of  the  disease. 


76 


proceedings  of  societies. 


[N.  Y.  Med.  Jour., 


Dr  T  J.  Moore,  in  reference  to  tlie  saline  treatment  sug¬ 
gested  by  Dr.  Edwards,  asked  if  the  natural  history  of.  these 
diseases  had  not  been  overlooked.  The  history  of  typhoid  am 
typbo-malarial  fevers  showed  that  they  would  run  their  course. 

He  would  therefore  suggest  palliative  treatment.  e  c  1  no 
like  to  tamper  with  new  remedies  until  they  had  been  proved  ot 
value  Where  there  was  a  tendency  to  ulceratiou  of  the  bowe 
in  typho-malarial  fever  the  use  of  salines  might  set  up  a  diar¬ 
rhoea  which  it  would  be  difficult  to  control.  Quiet  had  been 
found  very  necessary  in  such  conditions.  In  reference  to  peri¬ 
tonitis,  salines  might  be  resorted  to  where  there  was  a  pouring 
out  of  serum  but  not  genuine  pus.  Wegner  and  one  or  two 
others  had  recommended,  where  there  was  an  exudation  ot 
bloody  serum  but  no  true  peritonitis,  the  use  of  salines  to  stimu¬ 
late  absorption.  . 

Dr.  Edwards  feared  that  he  might  have  been  misunder¬ 
stood.  Where  there  was  decided  typhoid  fever  or  ulceration 
present  he  would  not  advise  salines  nor  had  he  ever  seen  them 
recommended.  But  in  typho-malarial  or  bilious  typhoid  tever— 
the  fever  in  which  the  leading  element,  bilious  or  malarial,  as 
the  case  might  be,  was  modified  by  a  typhoid  element  (a  furred 
tongue  and  constipated  bowels  distinguishing  true  typhous- 
salines  might  be  used. 

Sulphonal  as  a  Hypnotic. -Dr.  Jeffery  reported  the  his¬ 
tory  of  a  case  of  a  lady  who,  after  taking  thirty  grains  of 
sulphonal,  slept  from  6  p.  m.  on  Saturday  until  10  a.  m.  on  Sun¬ 
day  ;  then,  after  an  hour  or  two  for  breakfast,  again  slept  until 
4  p.  m.,  and  again  from  supper  until  the  following  morning. 
This  was  the  only  case  in  which  he  had  observed  such  pro¬ 
longed  effect,  although  he  had  used  the  drug  with  success  in 

various  classes  of  wakefulness. 

Dr.  Crenshaw  thought  that  sulphonal  was  an  unreliable 

hypnotic.  ....  ,  , 

The  President  had  seen  one  case  in  which  it  seemed  de¬ 
pressing. 

Diabetes  was  the  subject  for  the  evening. 

Dr.  T.  J.  Moore  opened  the  discussion.  He  snid  that  there 
were  two  conditions  under  which  sugar  existed  in  the  urine, 
known  as  diabetes  mellitus  and  glycosuria.  The  first  was  char¬ 
acterized  by  the  constant  and  persistent  presence  of  sugar  in 
greater  or  less  quantity  ;  the  second  was  a  transitory  condition, 
where  sugar  made  its  appearance  for  the  time  being,  but  ulti¬ 
mately  disappeared.  In  the  former  condition  diet  of  a  proper 
nature,  and  diet  alone,  would  either  greatly  reduce  the  amount 
of  sugar  passed  per  diem ,  or  would  cause  it  to  disappear  during 
the  time  the  diet  was  continued,  to  return,  however,  when 
it  was  left  off.  As  to  causes  in  diabetes  mellitus,  heredity 
played  a  conspicuous  part,  and  it  was  liable  to  continue  in  the 
family  for  three  or  four  generations.  Mental  emotions,  nervous 
disturbances  of  all  kinds— such  as  want,  deprivation,  exposure 
to  cold,  etc.— might  give  rise  to  it.  Any  irritation  affecting  the 
floor  of  the  fourth  ventricle— central  lesions  and  pathological 
changes  in  the  vicinity  of  this  region  frequently  caused  it— such 
as  tumors,  serous  effusion,  haemorrhage,  red  and  white  soften¬ 
ing,  gummata,  and  interstitial  changes  of  nervous  matter. 
Gout,°  rheumatism,  rheumatoid  arthritis,  pneumonia,  typhoid 
and  scarlet  fevers,  were  all  said  to  at  times  predispose  to  if 
not  directly  to  induce  it.  Abstinence  from  animal  and  confine¬ 
ment  to  starchy  foods  was  asserted  by  a  certain  class  of  authors 
to  give  genesis  to  it.  The  statistics  would  not  sustain  this  dec¬ 
laration.  Vegetarians  and  the  residents  of  hot  climates  who 
subsisted  chiefly  upon  vegetable  diet  were  not  specially  prone 
to  it.  It  was  generally  a  disease  of  adult  life,  a  limited  pei- 
centage,  however,  occurring  in  children  from  five  years  upward. 
To  enumerate  the  causes  of  glycosuria  would  necessitate  repe¬ 
tition.  Carbonic  oxide,  chloroform,  ether,  alcohol,  strychnine, 


morphine,  and  the  ingestion  of  large  quantities  of  mineral  acids, 
phosphoric  especially,  had  been  known  to  give  rise  to  it.  Uric 
acid  in  the  gouty  would  likewise  produce  it.  Anaemia  following 
malarial  poisoning,  rheumatism,  cholera,  or  prolonged  lactation 
had  been  known  to  cause  it.  Abnormal  conditions  of  the  digestive 
tract  and  congestion  of  the  pancreas  sometimes  caused  glycosuria. 
Overwork,  anxiety,  and  morbid  mental  disturbances  occasion¬ 
ally  produced  it.  Women  undergoing  the  change  of  life,  and 
broken-down  aged  people  were  liable  to  it.  It  was  difficult  to 
determine  at  first  which  of  these  conditions  existed.  In  time 
the  frequent  examination  of  urine  would  alone  solve  the  prob¬ 
lem.  Several  of  the  conditions  above  enumerated  as  producing 
glycosuria  would  likewise  produce  diabetes  mellitus.  In  the 
latter  disease  the  range  of  the  thermometer  was  peculiarly  in¬ 
teresting.  It  was  quite  often  as  low  as  93°,  more  often  97  and 
97*5°.  The  specific  gravity  of  the  urine  was  high,  frequently 
ranging  from  1-028  to  1*046.  The  diurnal  quantity  of  urine 
ranged  from  six  to  thirty  pints,  with  a  general  average  of  six  to 
twelve  pints,  and  of  sugar  from  three  ounces  to  half  a  pound. 
Uric  acid,  bippuric  and  phosphoric,  the  lime  and  potash  salts 
(oxalate  of  calcium  in  particular),  and  albumin— had  all  been 
found  as  accompaniments.  The  disease  was  an  insidious  one, 
often  accidentally  discovered  in  a  general  examination  of 

urine.  • 

The  impression  was  prevalent  that  in  true  diabetes  the 

career  of  one  so  affected  was  necessarily  short.  Severe  cases, 
occurring  in  the  weak,  aged,  or  generally  broken  down,  would 
average  about  two  years.  Under  more  favorable  conditions 
patients  would  live  from  ten  to  twenty  years.  The  appetite  was 
voracious  and  difficult  to  satisfy.  Thirst  was  continuous.  As 
to  morbid  anatomy,  the  liver  was  most  frequently  congested 
without  structural  change;  the  kidney  congested,  punctated, 
and  its  epithelial  cells  fatty.  The  anatomical  changes  were  con¬ 
fined  to  the  convoluted  portions  of  the  tubules.  The  sacculated 
condition  of  the  kidney  was  an  occasional  accompaniment. 
The  heart  was  usually  feeble,  and  there  was  an  increase  of  the 
watery  element  of  the  blood,  with  decrease  and  disintegration 

of  the  red  corpuscles.  '  . 

Reflex  disturbances  were  prominent.  Neuralgia  m  brachial, 

femoral,  dorsal,  epigastric,  and  other  regions  was  common.  The 
skin  was  dry,  harsh,  and  rough,  with  a  yellowish  tint.  The 
mucous  membranes  were  congested.  1  he  tongue  was  often  red, 
streaked,  and  covered  with  thick,  tenacious  mucus.  Sweating 
was  common,  with  certain  anatomical  peculiarities.  Often  one 
side,  a  limb,  the  soles  of  the  feet,  or  the  palms  of  the  hands, 
would  alone  be  affected.  (Edema  of  the  extremities  toward  the 

termination  was  quite  common. 

Death  was  produced  in  various  ways.  Exhaustion  and  sec¬ 
ondary  lung  complication  were  some  of  them,  chronic  pneumo¬ 
nia,  without  tubercular  deposit,  being  a  fertile  source.  Patients 
occasionally  fell  into  coma  and  thus  passed  away.  During  the 
course  of  the  disease  various  skin  eruptions  made  their  appear¬ 
ance,  often  in  groups.  Lichen,  impetigo,  eczema,  furuucles, 
carbuncles,  and  gangrene  were  all  found  at  times.  Where  the 
latter  appeared,  speedy  death  was  almost  inevitable.  Gangrene 
of  the  lung  occasionally  carried  off  the  patient.  No  satisfac¬ 
tory  treatment  had  been  discovered.  The  best  results  had  been 
obtained  from  the  treatment  recommended  by  Dr.  Banting  for 
the  reduction  of  obesity,  with  the  addition  of  gluten  biscuit,  or 
those  made  from  almond  flour.  It  required  from  twenty-four 
to  forty-eight  hours  first  to  find  out  by  tests  the  quantity  of 
sugar  in  the  urine.  Then,  having  put  the  patient  upon  the 
above  diet,  the  urine  should  be  examined  in  two  weeks  to  ob¬ 
serve  progress.  If  the  sugar  was  reduced  one  half  at  the  end 
of  three  or  four  months,  moderate  success  was  being  obtained. 
As  to  medicines,  opium  seemed  beneficial.  Its  principle,  codeia, 


July  19,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


had  been  suggested.  Mr.  Ralph  recommended  the  bimecolate 
of  morphine.  It  was  best  to  use  the  drug  tentatively.  In¬ 
stead  of  several  times  a  day,  administer  a  fair  dose  at  night, 
afterward  increased  if  necessary.  The  opium  habit  was  ap¬ 
parently  not  so  liable  to  be  contracted  by  these  patients. 
Bromides  and  salicylates  had  also  been  used,  and  phosphorus 
when  there  was  a  nervous  element;  acids  and  pepsin  when 
there  was  indigestion  present.  Steam  baths  and  hot  douches 
were  beneficial  for  their  effect  upon  the  skin.  Whatever  the 
plan  of  treatment  adopted,  it  would  be  likely  to  disappoint  in 
most  cases.  Those  improving  rapidly  and  readily  most  proba¬ 
bly  had  glycosuria,  which  would  be  relieved  any  way. 

As  to  physiology,  it  was  supposed  that  some  congestion  or 
irritation  of  the  liver  either  interfered  with  the  action  of  the 
cells,  thus  allowing  the  sugar  to  pass  through  unchanged,  or 
else  caused  an  overstimulation  of  said  cells,  resulting  in  over¬ 
action  of  the  sugar-producing  function. 

Dr.  Crenshaw  recommended  Waukesha  Springs  for  diabetes. 
The  Bishop  of  Canada  had  been  apparently  cured  and  many 
others  greatly  benefited  by  this  water.  Siluria  and  Bethesda 
waters  were  also  used.  The  speaker  cited  the  case  of  a  man  in 
this  city  who,  though  rejected  twenty-five  years  ago  by  an  in¬ 
surance  company  on  account  of  diabetes,  was  now  living,  thanks 
to  Wahkesha  water.  He  had  dieted  himself  very  little  in  the 
mean  time.  Carlsbad  water  would  probably  benefit  dyspeptic 
cases;  opium  those  in  which  brain  symptoms  were  manifested. 
He  did  not  believe,  however,  that  true  diabetes  mellitus  could 
be  cured. 

Dr.  Edwards  mentioned  that  Balmanno  Squire,  of  London, 
had  recommended  phosphorus  as  a  specific  cure  for  diabetes. 
Squire  had  prescribed  phosphorus  for  a  skin  eruption  upon  a 
patient  who  also  had  glycosuria.  The  effect  had  been  a  cure  of 
both.  If  there  was  any  one  remedy  in  the  form  of  a  drug,  it 
would  seem  to  be  phosphorus.  He  thought  the  benefit  from 
the  various  springs  was  transient.  Some  years  ago  he  had  pre¬ 
scribed  Buffalo  Lithia  Water  for  a  clergyman  afflicted  with 
glycosuria.  He  had  been  apparently  cured,  but  the  trouble 
returned,  and,  in  order  to  gain  benefit,  he  had  been  compelled 
to  alternate  between  Buffalo  Lithia,  Allegheny,  Blue  Ridge,  and 
Raleigh. 

Mr.  Blair  believed,  as  to  the  waters,  that  pure  water  was  the 
secret  of  benefit ;  therefore  he  suggested  distilled  water.  He 
thought  that  phosphorus  would  prove  as  ineffectual  as  all  other 
drugs.  He  believed  a  young  subject  affected  with  diabetes  mel¬ 
litus  would  certainly  die;  an  old  one  would  probably  prolong 
life  by  diet  and  other  means  until  killed  by  some  other  disease. 
He  related  the  case  of  a  hospital  patient  who,  not  improving 
much,  went  to  his  work  and,  though  he  was  not  cured,  he  grew 
better  from  that  time.  The  speaker  would  recommend  em¬ 
ployment.  He  would  suggest  in  the  way  of  food  wheaten  bread, 
cut  very  thin  and  toasted.  Dextrin  would  not  be  so  readily 
converted  into  sugar  as  starch.  All  the  remedies  that  had  been 
used  appealed  to  the  nervous  system.  Sugar  in  the  urine  was 
no  proof  of  diseased  kidney;  but  that  organ  would  be  injured 
by  the  long-continued  passing  of  such  quantities  of  water 
through  it.  He  had  known  of  a  woman  (diabetic  all  her  life) 
passing  as  much  as  a  pound  and  a  half  of  sugar  per  diem.  He 
referred  to  a  man  in  this  city  who  for  twelve  years  had  been 
afflicted  with  diabetes.  Six  months  ago  he  had  been  dieted, 
with  the  result  of  the  disappearance  of  sugar.  He  was  now 
dying  from  the  effects  of  contracted  kidney.  Twelve  years  ago 
he  had  received  a  great  mental  shock,  which  was  probably  the 
cause  of  the  diabetic  trouble.  Though  he  now  passed  large 
quantities  of  urine,  the  specific  gravity  was  low.  This  was  one 
of  the  symptoms  of  contracted  kidney,  due  directly,  however, 
to  the  hypertrophied  heart. 


77 


AMERICAN  NEUROLOGICAL  SOCIETY. 

Sixteenth  Annual  Meeting ,  held  at  Philadelphia ,  June  4,  5,  and 

6 ,  1890. 

The  President,  Dr.  E.  C.  Spitzka,  of  New  York,  in  the  Chair. 

Unusual  Forms  of  Chorea,  possibly  of  Spinal  Origin.— 

This  was  the  title  of  a  joint  communication  by  Dr.  S.  Weir 
Mitohell  and  Dr.  C.  W.  Burr.  The  first  case  described  was 
one  of  inherited  congenital  chorea,  possibly  involving  the  spinal 
cord.  The  patient,  a  young  man  eighteen  years  of  age,  had  pre¬ 
sented  himself  at  Dr.  Mitchell’s  clinic  in  1889  complaining  of  con¬ 
stant  involuntary  movements  of  the  legs,  arms,  and  head.  The 
history  of  the  patient’s  family  was  of  special  interest  in  this 
case.  His  maternal  grandmother  had  suffered  from  chorea  for 
many  years,  not  from  birth,  but  she  had  while  so  affected  given 
birth  to  the  patient’s  mother,  who  was  choreic  from  birth  till 
death.  Both  the  patient’s  parents  had  died  of  phthisis.  There 
was  no  history  of  other  cases  of  chorea  or  any  nervous  disease 
in  the  family.  The  patient’s  choreic  movements  began  in  early 
infancy,  probably  from  birth.  As  a  child  he  was  puny  and  of 
tardy  development.  His  present  condition  was  that  of  a  fairly 
built  young  man  of  good  strength,  weighing  one  hundred  and 
thirty  pounds.  Other  than  the  condition  immediately  asso¬ 
ciated  with  the  chorea  there  was  no  physiological  disturbance. 
The  knee-jerk  was  increased  on  both  sides,  and  the  cremasteric, 
plantar,  and  abdominal  reflexes  were  marked.  Ankle  clonus  was 
occasionally  present,  and  at  times  rigidity  at  the  knee,  the  feet 
being  then  turned  toward  inward  at  the  ankle.  All  the  condi¬ 
tions  were  increased  by  emotion  and  the  administration  of 
moderate  doses  of  strychnine.  Sensation  to  touch,  pain,  and 
temperature  were  normal,  and  so  was  station.  While  awake, 
the  patient’s  entire  voluntary  muscular  system  was  more  or  less 
in  action.  The  sudden  presence  of  a  stranger  emphasized  the 
trouble.  During  sleep  there  was  perfect  quiet.  No  spinal  ten¬ 
derness  had  existed,  urine  was  normal,  and  so,  with  some  slight 
muscular  insufficiency  excepted,  was  vision. 

Dr.  Mitchell  then  read  in  detail  the  histories  of  two  other 
cases  in  which  the  patients  were  brothers,  their  father  having, 
at  forty-five  years  of  age,  developed  alleged  choreic  symptoms. 
The  first  of  these  two  cases  had  resembled  in  general  aspect 
canine  chorea. 

The  authors  of  the  paper  thought  the  first  of  the  series  of 
three  cases,  in  which  the  disease  had  run  through  three  genera¬ 
tions,  extremely  rare.  That  organic  changes  were  present  some¬ 
where  in  the  motor  tract  of  the  patient  might,  they  thought,  be 
admitted,  because  of  the  extreme  chronicity  of  the  affection, 
its  resistance  to  all  treatment,  and  the  presence  of  very  dis¬ 
tinct  ankle  clonus  and  rigidity,  these  latter  symptoms  pointing 
to  involvement  of  the  cord.  Whether  the  changes  were  con¬ 
fined  to  the  cord  it  was  more  difficult  to  say.  It  was  not  wished 
to  do  more  than  indicate  the  spine  as  possibly  implicated  in  all 
the  cases. 

Double  Consciousness.— Dr.  Mitchell  then  alluded  to  the 
notorious  case  of  Ansell  Brown,  who  had  left  his  home, 
assumed  another  name,  and,  as  asserted,  had  lived  some  time 
without  knowledge  of  his  previous  existence.  On  regaining 
control  of  his  proper  identity  he  had  returned.  Hypnotism  had 
been  recently  tried  upon  him.  While  under  its  influence  the 
man’s  mind  could  be  made  to  revert  to  incidents  in  his  fictitious 
existence,  while  of  his  real  identity  he  would  then  know  noth¬ 
ing. 

The  Weather  in  Relation  to  Neuralgic  Pain. —  Dr. 

Mitohell  related  the  history  of  a  patient  of  his  who  had  made 
elaborate  studies  and  observations  of  the  effect  of  variations  of 
the  weather  upon  neuralgia,  from  which  he  was  a  great  suf- 


proceedings  of  societies. 


[N.  Y.  Mkl>.  Jouk., 


7* 


ferer.  The  scientific  findings,  briefly  stated,  were  that  the 
maximum  of  pain  bore  direct  proportion  to  the  prevalence  of 
storms,  and  that  the  aurora  was  a  certain  precursor  of  neuralgic 
exacerbation. 

Chronic  Softening  of  the  Spinal  Cord ;  Senile  Paraplegia. 

_ Dr.  o.  L.  Dana  read  a  paper  on  this  subject,  narrating  a  case 

which  he  said  established  upon  a  firm  foundation,  for  the  first 
time,  the  fact  that  in  the  gray  matter  of  the  cord  there  might 
exist  progressive  softening  from  obliterating  arteritis,  just  as  was 
found  in  the  brain.  It  also  established  the  pathology  of  senile 
paraplegia,  no  convincing  evidence  as  to  the  nature  of  which 
had,  until  recently,  been  adduced.  The  question  of  non-inflam- 
matory  softening  of  the  cord  had  been  but  obscurely  dealt  with, 
or  let  entirely  alone.  Acute  softening  bad  been  described,  usu¬ 
ally  as  synonymous  with  acute  myelitis,  but  the  term  was 
wrongly  used  and  should  not  be  applied  to  inflammatory  pro¬ 
cesses  at  all.  It  had  of  late  been  suggested  that  some  of  the 
cases  of  acute  myelitis  were  in  fact  primarily  necrotic  processes, 
but  evidence  was  lacking  in  substantiation.  The  case  be  would 
describe  did  not  belong  to  the  acute  type,  but  was  a  chronic 
myelo-malacia. 

The  patient,  an  old  man  of  seventy  years  ot  age,  of  whose 
early  life  little  could  be  elicited  except  that  he  had  been  gen¬ 
erally  healthy,  had  about  four  years  ago  noticed  some  weak¬ 
ness  of  the  legs.  There  was  no  pain.  This  condition  had  pro¬ 
gressed  until  one  year  ago.  There  was  complete  disability  to 
walk,  incontinence  of  urine,  and  trouble  with  the  rectal  sphinc 
ters.  When  seen  in  1889  the  man  had  presented  the  character 
istic  appearance  of  senility.  The  symptoms  of  the  disease  were 
limited  to  the  lower  extremities,  which  were  wasted  and  con- 
tractured.  The  knee-jerks  were  gone;  there  was  also  no  clonus 
or  trepidation.  Sensation  was  everywhere  normal— indeed,  the 
condition  was  rather  that  of  hypereesthesia.  No  pains  in  the 

leg9 _ girdle  pains  or  bedsores.  Up  to  the  time  of  the  patient’s 

death,  which  had  resulted  immediately  from  exhaustion,  the 
general  symptoms  had  changed  but  little.  The  mind  was  clear, 
though  senile.  The  only  gross  changes  in  the  cord  or  mem¬ 
branes  was  noticed  in  the.  anterior  horns  in  the  sections  taken 
low  down.  The  more  minute  examination  of  microscopical 
sections  had  demonstrated  the  case  as  one  of  degenerative  en¬ 
darteritis  with  sclerosis,  obliteration  of  the  vessels  causing  the 
softening  of  the  anterior  horns  and  intermediate  gray  matter 
This  process  was  accompanied  by  secondary  congestion,  dilata¬ 
tion  of  small  vessels  and  capillaries,  but  no  haemonhages.  Ihe 
condition  was  one  of  softening  of  the  cord,  precisely  analogous 
to  the  so-called  softening  of  the  brain.  It  was  not  inflammatory 
and  could  not  be  termed  an  anterior  polio-myelitis.  It  was  not 
a  cell  atrophy,  and  did  not  belong  to  the  spinal  forms  of  pro¬ 
gressive  muscular  atrophy.  While  the  change  was,  without 
doubt,  largely  a  senile  one,  the  cord  did  not  correspond  to  the 
description  of  such  conditions  given  by  Leyden.  The  disease 
might,  the  speaker  thought,  be  called  a  senile  paraplegia  from 
softening  of  the  anterior  horns  due  to  obliterating  arteritis. 

Traumatic  Neuro-psychoses.— Dr.  G.  L.  Walton  read  a 
contribution  to  this  subject  in  which  he  dealt  exhaustively  with 
the  questions  of  pathology  and  prognosis  in  injuries  inflicted 
upon  the  nervous  system  by  railway  collisions  and  similar  acci¬ 
dents.  Under  the  influence  of  Eric.hsen’s  views,  functional  and 
organic  injuries  were  for  a  long  time  indiscriminately  classed 
together  under  the  ambiguous  and  misleading  term  spinal  con¬ 
cussion,  while  a  common  prognosis  was  given  to  all,  leaving  the 
student  in  doubt  as  to  whether  the  worst  or  best  results  might 
be  anticipated.  To  H.  W.  Page  was  due  the  credit  of  having 
elaborately  corrected  this  inaccuracy  and  of  sifting  out  the 
comparatively  rare  cases  of  organic  spinal  disease,  whose  sad 
course  and  prognosis  had  been  so  long  allowed  to  overshadow 


and  include  the  more  common  cases  in  which  no  demonstrable 
lesion  existed.  To  the  latter  class  he  had  first  applied  the  term 
traumatic  neurasthenia.  Dr.  Putnam,  in  1883,  after  reporting 
several  cases  of  traumatic  hemianesthesia,  had  called  attention 
to  the  importance  of  looking  for  evidences  of  typical  hysteria, 
in  the  chronic  as  well  as  in  the  acute  stages  of  so-called  spinal 
concussion.  Among  those  who  had  early  inclined  toward  the 
modified  views  regarding  the  effects  of  trauma  on  the  nervous 
system  might  be  mentioned  Dr.  Dana,  who,  writing  in  1883, 
had  very  appropriately  added  hypochondriasis  to  the  two  terms 
already  applied.  Spitzka  had  considered  that  spinal  concussion 
could  produce  spinal  irritation.  These  theories  were  in  direct 
opposition  to  the  idea  advanced  by  Westphal— that  a  diffuse 
sclerosis  was  set  up  by  the  jar.  This  view  had  many  followers, 
both  in  Germany  and  America.  In  a  recent  work  by  Clevenger, 
of  Chicago,  it  was  proposed  to  give  to  these  cases  the  name 
“Erichsen’s  disease.”  This  writer  regarded  the  spinal  sympa¬ 
thetic  system  as  the  starting  point  of  the  pathological  process. 
Seguin,  in  Sajous’s  Annual  for  1889,  considered  organic  injury  to 
the  nervous  system  a  rarity  as  resulting  from  the  forms  of 
trauma  under  consideration.  Without  exhausting  the  litera¬ 
ture  of  the  subject,  it  might  fairly  be  concluded  that  there  was 
at  present  a  very  general,  though  not  unanimous,  tendency  to 
abandon  the  theory  of  spinal  concussion,  and  to  regard  the 
majority  of  the  genuine  cases  as  identical  with  already  recog¬ 
nized  functional  forms  of  disease  rather  than  cases  of  organic 
spinal  injury.  Dr.  Walton’s  experience  had  lead  him  from  the 
first  to  regard  disease  of  the  spinal  cord  resulting  from  trauma 
as  of  comparative  rarity,  when  no  dislocation  or  fracture  had  oc¬ 
curred,  while  Seguin’s  conclusions  regarding  the  preponderance 
of  the  subjective  symptoms,  and  the  degree  in  which  we  were 
generally  dependent  on  the  patients,  were  fully  justified  by  the 
majority  of  the  cases  which  had  come  under  that  writer’s  ob¬ 
servation.  In  examining  such  cases  for  legal  purposes,  we 
should  avoid  the  tendency  of  accepting  the  statements  regard¬ 
ing  previous  health  for  fear  of  coincident  trouble.  Analysis  of 
one  hundred  successive  cases,  where  nervous  symptoms  were 
complained  of  and  where  the  question  of  damages  had  arisen 
or  was  likely  to  arise,  gave  the  following  result:  Two  were 
cases  of  vertebral  fracture,  one  of  vertebral  dislocation,  one  of 
injury  to  cervical  nerve  roots,  two  of  neuritis,  one  ot  long¬ 
standing  spinal  sclerosis,  one  of  old  infantile  paralysis,  one  of 
extensive  atheroma,  one  ot  choroiditis,  four  of  heart  disease, 
one  of  cystitis  of  local  origin,  and  two  of  severe  constitutional 
disease;  four  of  these  seventeen  had  died.  The  remaining 
eighty-two  cases,  with  the  exception  of  the  simulants,  would 
come  under  the  class  designated  as  neuro-psvchoses. 

A  Case  of  Complete  Paraplegia  cured  by  Operation.— 

Dr.  F.  X.  Dercum  presented  a  middle-aged  man  with  the  fol¬ 
lowing  history :  This  patient  had  in  1887  suffered  severe  pain 
in  the  arms  and  shoulders.  The  pain  was  referred  to  the  prin¬ 
cipal  nerve  tracts  in  the  arms.  Some  time  after  this  he  had  lost 
power  in  his  legs.  Then  about  October  of  1888,  in  addition  to 
complete  paraplegia,  there  was  loss  of  sensibility,  but  with  con¬ 
striction  pain  about  the  upper  portion  of  the  chest.  There  was 
complete  paralysis  of  both  sphincters.  Examination  had  re¬ 
vealed  the  fact  that  the  man’s  back  was  very  painful  over  the 
third,  fourth,  and  fifth  dorsal  vertebrae.  Thinking  there  might 
be  some  local  cause  for  the  paralysis,  trephining  was  decided 
upon.  The  spines  and  arches  of  the  first  to  the  fifth  dorsal  ver¬ 
tebra,  inclusive,  were  accordingly  removed.  The  dura  was 
found  somewhat  abnormally  resistant  to  the  touch,  and  was 
opened.  Adhesions  existed  between  the  dura  and  the  pia. 
After  the  operation,  which  the  man  had  borne  well,  he  at  once 
said  that  his  pain  was  absent.  A  few  days  afterward  he  was 
able  to  feel  his  foot  when  touched.  Then  he  was  sensible  that 


July  19,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


79 


his  hands  were  cold,  and  was  able  in  a  few  days  more  to  move 
his  toes.  There  had  been  a  very  gradual  but  steady  progress 
toward  complete  recovery.  He  had  also  regained  control  of 
the  sphincters.  Whether  the  result  was  to  be  ascribed  to  relief 
from  pressure  or  to  reaction  from  the  shock  of  the  surgical  op¬ 
eration,  the  speaker  did  not  venture  to  suggest.  The  paraplegia 
was  probably  the  result  partly  of  pressure  and  partly  of  mye¬ 
litis. 

Pathological  Findings  in  a  Case  of  Athetosis. — Dr.  G.  M. 

Hammond  presented  a  report  on  the  pathological  findings  in  the 
original  case  of  athetosis,  on  which  Dr.  W.  A.  Hammond’s  de¬ 
scription  of  athetosis  had  been  based.  After  briefly  referring  to 
the  case,  Dr.  Hammond  stated  that  the  portion  involved  in  the 
lesion  consisted  of  fibrous  connective  tissue.  Topographically 
the  lesion  was  a  lengthy  one  in  the  antero-posterior  direction, 
parallel  in  its  short  axis  with  the  internal  capsule.  Its  posterior 
end  invaded  the  stratum  zonule  of  the  thalamus  in  its  posterior 
third,  and  the  posterior  third  of  the  posterior  half  of  the  inter¬ 
nal  capsule.  In  its  anterior  extension  it  crossed  the  capsule,  in 
vading  the  posterior  third  of  the  outer  articulus  of  the  lenticular 
nucleus.  The  author  called  attention  to  the  fact  that  the  motor 
tract  was  not  implicated  in  the  lesion,  and  claimed  that  this  case 
was  further  evidence  of  his  theory  that  athetosis  was  caused  by 
irritation  of  the  thalamus,  the  striatum,  or  the  cortex,  and  not 
by  a  lesion  of  the  motor  tract. 

The  President  reported  a  case  of  hemi-athetosis  in  which 
the  lesion  was  found  to  be  in  the  same  situation  as  the  one  in 
Dr.  Hammond’s  case. 

A  Case  of  Locomotor  Ataxia  associated  with  Nuclear 
Cranial-nerve  Palsies  and  with  Muscular  Atrophies. _ Dr. 

Frederick  Peterson  reported  the  history  of  the  above-named 
case.  The  patient  had  been  under  the  writer’s  observation  since 
March,  1890,  but  the  features  of  the  case  had  been  previously 
described  by  Dr.  Seguin  in  the  Journal  of  Nervous  and  Mental 
Disease  for  May,  1888.  It  was  the  first  of  five  cases  of  oph¬ 
thalmoplegia  reported  by  that  author.  As  there  had  been  so 
many  new  developments  in  the  patient’s  condition  during  the 
past  four  years,  it  was  thought  best  to  briefly  outline  the  history 
from  the  first  observations  made  up  to  the  time  when  he  had 
come  under  the  writer’s  notice.  M.  J.  T.,  now  thirty-seven 
years  of  age,  had  had  a  chancre  and  secondary  symptoms  fifteen 
years  before.  In  1882  he  discovered  one  morning  dimness  of 
vision  and  external  strabismus  of  the  left  eye,  with  diplopia. 
Subsequently  shooting  pains  in  the  legs  and  arms  had  developed. 

In  1883  he  had  a  momentary  loss  of  consciousness.  During  this 
year  he  had  been  under  specific  treatment  at  Hot  Springs  for 
some  time.  In  1884  there  was  partial  double  ptosis.  In  1886, 
when  lost  sight  of  by  Dr.  Seguin,  the  ptosis  was  a  little  greater 
and  the  bladder  was  paretic.  There  was  mild  paresis  of  the 
right  hand.  Dr.  Seguin,  writing  in  1888,  said  of  this  case  that 
some  of  the  symptoms  seemed  to  justify  a  suspicion  of  incipient 
“  Posterior  spinal  sclerosis.”  Since  1886  until  the  present  time 
there  had  been  gradual  progress  in  the  disease.  The  main  feat 
nres  of  the  case  might  be  summarized  as  follows  :  The  patient 
had  had  a  number  of  bilateral  motor  cranial  palsies — namely,  of 
the  third,  fourth,  fifth,  and  sixth  nerves.  He  had  also  exhibited 
slight  traces  of  crossed  paralysis  for  more  than  four  years.  Lo¬ 
comotor  ataxia  had  developed,  as  was  shown  by  the  occurrence 
at  one  time  ot  lightning  pains  and  by  the  presence  now  of  ataxia, 
widely  distributed  amesthesias,  failure  of  knee-jerks,  ocular, 
vesical,  and  anal  symptoms.  Finally  he  presented  marked  tro¬ 
phic  changes  in  numerous  muscles.  As  to  the  morbid  processes 
underlying  these  various  manifestations,  there  was,  in  the  first 
place,  undoubtedly  a  sclerosis  of  the  posterior  columns  of  the 
spinal  cord.  The  ophthalmoplegia  was  of  course  nuclear.  Read 
in  one  way,  the  symptoms  on  the  side  of  the  cranial  nerves,  taken 


in  conjunction  with  the  muscular  atrophies  and  paralyses  else¬ 
where,  certainly  very  closely  resembled  the  syndrome  so  well 
described  by  Dr.  Sachs  in  a  paper  last  year  under  the  title  of 
Polioencephalitis  Superior  and  Poliomyelitis.  The  most  impor¬ 
tant  matter  to  be  settled  in  this  case  was  whether  the  muscular 
atrophies  were  due  to  peripheral  or  central  lesions.  Speculation 
upon  the  question  would  seem  to  be  of  very  little  utility,  and  its 
solution  must  be  left  to  the  hoped-for  autopsy.  It  had  been 
assumed  by  a  number  of  authors  that  total  paralysis  of  all  of  the 
muscles  supplied  by  the  third  nerve  implied  not  a  nuclear  but 
a  nerve-trunk  palsy.  In  the  writer’s  case  all  of  the  muscles  of 
both  third  nerves  were  totally  paralyzed,  including  both  irides, 
and  yet  there  was  every  reason  to  believe  that  the  palsies  were 
nuclear.  It  would  at  least  be  difficult  to  conceive  of  a  lesion  at 
the  base  of  the  brain  so  widely  affecting  the  trunks  of  both 
third,  fourth,  and  sixth  nerves,  and  the  motor  portions  of  both 
trigemini,  yet  permitting  the  escape  of  the  sensory  portions  of 
the  latter. 

Multiple  Neuritis,  or  Beri-beri,  among  Seamen.— Dr.  J. 

J.  Putnam  reported  about  twenty  cases  of  a  disease  resembling 
beri-beri,  but  possibly  another  form  of  multiple  neuritis,  occur¬ 
ring  among  fishermen  in  northern  latitudes,  and  referred  to  a 
similar  series  of  cases  reported  by  Dr.  F.  0.  Shattuck  in  1881. 
By  correspondence  with  physicians  in  the  seaport  towns,  Dr. 
Putnam  had  ascertained  that,  besides  the  larger  epidemics,  spo¬ 
radic  cases  had  occurred  from  time  to  time.  One  physician  had 
reported  frequent  cases  of  swelling  and  numbness  of  the  hands, 
attributed  to  handling  fish.  The  influence  of  alcohol  and  the 
metallic  poisons  could  be  excluded ;  and,  since  the  outbreak  had 
occurred  only  now  and  then,  the  influences  to  which  the  sea¬ 
men  were  habitually  exposed  could  hardly  be  considered  as  the 
whole  cause,  though  insufficient  food  had  seemed  to  play  apart 
in  some  instances.  Most  of  the  patients  had  recovered,  but 
some  had  died. 

On  Cases  of  Postero-lateral  Sclerosis,  with  Special  Ref¬ 
erence  to  the  Pathology  of  the  Disease.— Dr.  Putnam  re¬ 
ferred  to  a  series  of  eight  cases  of  similar  character,  presenting 
the  symptoms  of  “combined  sclerosis”  of  the  spinal  cord, 
which  he  had  seen  during  the  past  few  years,  and  reported  four 
of  them,  in  which  he  had  examined  the  cord  microscopically. 
All  the  cases  of  the  series,  though  differing  in  some  respects, 
resembled  each  other  as  follows :  All  the  patients  were  past  mid¬ 
dle  life,  and  all  were  either  anaemic  or  in  a  state  of  poor  nutri¬ 
tion.  The  symptoms  in  all  consisted  in  both  motor  and  sensory 
disorders  in  all  four  limbs,  sometimes  associated  with  inco-ordi¬ 
nation,  sometimes  not.  The  upper  knee-jerk  was  exaggerated 
in  all  but  two  or  three  ;  in  those  it  was  absent.  Tabetic  pains 
were  present  in  one  case  only.  Anatomically,  sclerosis  was 
found  in  the  posterior  and  lateral  columns,  varying  in  exact 
position.  In  almost  every  case  the  posterior  change  seemed  the 
older  and  most  intense.  Besides  the  “typical”  sclerosis,  there 
was  evidence  of  a  more  recent  process,  characterized  by  granule¬ 
cell  formation  and  the  breaking  down  of  the  nerve  tubes  so  as 
to  form  circular  or  oval  spaces.  This  new  process  was  devel¬ 
oped  on  the  borders  of  the  older  change.  The  gray  matter  of 
the  cord  was  more  or  less  affected,  and  the  nerve  roots  in  about 
the  same  degree.  The  cases  had  all  run  a  rapid  course,  termi¬ 
nating,  after  one  to  four  years,  in  death,  preceded  by  paraple¬ 
gia  due  to  non-inflammatory  softening.  Next  to  inherent  struct¬ 
ural  weakness,  as  an  mtiological  factor,  came  impaired  nutri¬ 
tion  and  toxic  influences.  The  importance  was  pointed  out  of 
recognizing  and  attempting  to  meet  the  partial  courses  of  the 
disease,  of  which  several  might  be  present  at  once.  As  special 
stigmata  of  degeneracy  in  these  four  cases,  the  writer  referred 
to  the  mental  condition  and  family  history  of  several  of  the  pa¬ 
tients,  to  the  remarkably  abnormal  shape  of  the  cord  in  one, 


[N.  Y.  Mrd.  Jour., 


the  small  size  of  the  dorsal  gray  matter  in  another,  and  t  >e 

presence  of  a  second  central  canal  in  a  third. 

On  Ingravescent  Apoplexy.— Dr.  C.  L.  Dana  read  a  pa¬ 
per  with  this  title.  He  said  that  there  were  three  sets  of  intra¬ 
cranial  blood-vessels— those  in  the  dura,  those  in  the  pia  mater, 
and  those  in  the  substance  of  the  brain.  We  had,  corresponding¬ 
ly,  three  types  of  intracranial  hemorrhage.  The  central  hemor¬ 
rhages  were  far  the  most  common,  and  presented  a  tolerably  uni¬ 
form  clinical  type.  There  was  one  form,  however,  which  seemed 
to  have  escaped  critical  attention,  though  it  could  not  be  ex¬ 
cessively  rare.  In  1876  Dr.  Broadbent  had  reported  six  cases  of 
what  he  termed  “  ingravescent  apoplexy/’  In  1889  M.  P.  Puesch, 
of  Montpellier,  had  also  reported  a  case  of  the  same  character. 

The  writer  had  met  two  cases  presenting  the  general  clinical 
characters  of  ingravescent  apoplexy,  but  was  able  to  make  an 
autopsy  upon  only  one,  of  which  the  history  was  as  follows: 

A  woman  was  brought  to  the  hospital  on  May  1st  without  any 
history.  She  was  in  a  stupid  condition,  but  not  unconscious, 
and  she  was  at  first  thought  to  be  intoxicated.  Examination 
showed,  however,  some  hemianalgesiaof  the  leftside  and  slight 
hemiplegia  of  the  same  side.  The  right  pupil  was  slightly  con¬ 
tracted,  temperature  normal,  pulse  tense.  Next  day  the  pa¬ 
tient’s  mind  was  clearer;  she  answered  questions,  and  recog¬ 
nized  those  about  her.  But  the  hemiplegia  was  very  much 
worse,  and  the  analgesia  no  better.  Toward  night  she  became 
more  stupid,  and  finally  comatose;  cederna  of  the  lungs  devel¬ 
oped.  No  contractures  of  the  paralyzed  side  were  noted.  The 
temperature  rose,  and  the  patient  died  next  day,  May  3d.  At 
the  autopsy  the  brain  was  found  congested.  Pressure  over  the 
supramarginal  gyrus  showed  that  there  was  a  softened  place 
beneath  it.  The  brain  was  placed  in  boroglycerin  and  alcohol, 
and  opened  later  by  vertical  sections.  These  showed  a  clot  in 
the  lateral  ventricle,  and  some  blood  in  the  third  ventricle. 
Beneath  the  supramarginal  gyrus  was  a  large  haemorrhagic  focus 
about  an  inch  and  a  half  in  diameter.  This  extended  forward 
and  downward,  cleaving  the  external  capsule.  The  haemorrhage 
had  finally  extended  downward  and  inward  and  broken  into  the 
lateral  ventricle.  Puesch  had  attempted,  on  the  slender  basis 
of  seven  cases,  to  erect  “ingravescent’’  or,  as  he  called  it, 
“progressive”  apoplexy  into  a  distinct  type.  This  seemed  to 
the  author  to  he  somewhat  premature.  The  history  of  his  case 
was  not  exactly  like  those  of  Broadbent’s  in  respect  to  reten¬ 
tion  of  consciousness,  and  the  hemiplegia  was  relatively  less 
marked.  Yet,  anatomically,  it  was  one  of  the  “  cleaving 
hemorrhages  due  to  rupture  of  a  posterior  branch  of  a  lenticu¬ 
lar  artery,  and  running  the  same  course  as  was  described  by 
Broadbent.  The  hemianesthesia  seemed  to  the  author  to  he  a 
very  distinctive  point.  Practically,  the  question  came  up  as  to 
whether,  in  such  cases,  trephining  would  be  justifiable.  In  gen¬ 
eral,  the  idea  of  trephining  for  non-traumatic  hemorrhage  was 
not ’to  be  entertained  at  all.  Butin  ingravescent  apoplexy  it 
deserved  consideration,  because  here  the  hemorrhage  was  ac¬ 
cessible,  and  because,  unless  some  relief  was  given,  it  would 
surely  break  into  the  lateral  ventricle  and  kill  the  patient.  In 
all  the  reported  cases,  also,  the  patients  were  not  old,  were  not 
syphilitic,  and  presumably  had  not  extensively  diseased  arteries. 
In  reaching  haemorrhages  in  these  cases,  the  best  place  to  tre¬ 
phine  would  be  a  little  below  and  in  front  of  the  parietal  emi¬ 
nence.  The  surgeon  should  then  explore  downward  and  for¬ 
ward,  care  being  taken  not  to  injure  the  terminal  branches  of  the 
Sylvian  artery,  which  were  in  this  neighborhood.  In  cases  of 
“ingravescent”  apoplexy,  surgical  interference,  if  undertaken, 
should  be  before  the  blood  broke  into  the  ventricles.  This  could 
be  told  by  the  sudden  increase  in  the  severity  of  the  symptoms, 
and,  if  the  blood  was  poured  in  rapidly,  by  contractures  on  the 
paralyzed  side.  The  temperature  changes  were  believed  to  be 


the  same  in  the  ingravescent  as  in  ordinary  apoplexy.  The  au 
thor  trusted  that  the  report  of  his  case  might  excite  tbeinteres 
of  others,  and  call  attention  to  this  apparently  distinctive  and 

fatal  form  of  cerebral  haemorrhage.  -  -fll 

Tumor  of  the  Quadrigeminal  Region,  with  Special 
Reference  to  Ocular  Symptoms.— Dr.  B.  Sachs  read  a  paper 
with  this  title.  He  had  been  fortunate  enough  to  obtain  two 
autopsies  during  the  past  year  which  bore  upon  this s  question, 
and  had  also  seen  several  other  cases  which  were  subjected  to 
careful  clinical  examination.  His  first  case  was  °*e  of  "usu¬ 
ally  severe  tuberculosis  cerebri.  The  mam  points  of  the  history 
he  had  been  able  to  complete  through  the  kindness  of  several 
colleagues.  E.  L.,  aged  three  years.  The  mother  had  noticed 
a  change  in  the  child’s  disposition  for  several  months  follow  ing 
an  attack  of  measles.  Examination  had  disclosed  double  and 
almost  complete  ptosis.  There  was  no  upward  or  downward 
movement  of  either  eye.  Both  external  recti  muscles  were 
thrown  into  clonic  spastic  condition  when  the  attempt  was  made 
to  use  them.  The  interni  were  capable  of  very  slight  motion, 
but  all  the  other  ocular  muscles  were  completely  paralyzed. 
There  was  distinct  accommodative  power,  with  but  slight  reac¬ 
tion  to  light.  Although  in  a  semi-stupor,  the  child  could  be 
made  to  walk,  exhibiting  most  distinct  cerebellar  staggering. 
Autopsy  had  revealed  adhesions  of  the  dura  to  the  skull,  with  a 
slight  increase  of  subdural  fluid.  A  solitary  tubercle  was  at 
once  discovered  near  the  right  lateral  sinus,  pressing  into  he 
lateral  edge  of  the  cerebellum,  and  producing  thrombosis  of  the 
lateral  sinus.  The  cerebellum  was  the  seat  of  the  most  pro¬ 
found  changes.  The  base  presented  several  unusual  conditions. 
There  was  great  thickening  of  the  pia,  with  small  tubercular 
deposits  between  the  corpora  mamillaria  and  the  optic  chiasm 
and  in  the  interpeduncular  space.  The  thickening  at  this  pom 
was  so  great  that  both  third  nerves,  instead  of  lying  across  the 
crura,  after  removal  of  the  brain,  pointed  backward,  and  the 
ri-ht  sixth  was  twisted  out  of  its  position.  Section  of  the  brain 
showed  the  tumor  to  occupy  almost  the  center  of  the  tegmen  a 
division  of  the  crus,  and  that  it  had  left  a  very  small  portion  of 
the  corpora  quadrigemina  and  the  brachia  intact. 

Mrs.  L.,  aged  forty  years,  bad  always  enjoyed  good  health 
until  four  years  ago,  when  she  began  to  be  troubled  with  hea  -  I 
1  aches,  vomiting,  cerebral  in  character,  and  a  peculiar  sensation 
in  the  head  on  looking  upward,  with  diplopia.  These  symp¬ 
toms  had  increased  until  there  was  paresis  of  both  internal  recti. 
The  extend  acted  fairly  well,  but  nystagmus  supervened  if  at¬ 
tempts  were  made  to  turn  the  eyes  out.  Upward  movements 
of  the  eyes  were  barely  possible ;  downward  vision  was  limited. 
Knee-jerks  and  sensations  normal.  Tbe  diagnosis  of  opthal- 
moplegia  nuclearis,  probably  polio-encephalitis  chronica,  was 
made  at  that  time,  but  later  abandoned,  and  the  alternative  of 
tremor  accepted,  for  the  patient  had  developed  inco-ordination, 
with  characteristic  staggering,  and  was  found  to  have  doub  e 
optic  neuritis.  No  autopsy  was  obtained,  but  the  idea  of  tremor 

in  this  case  could  hardly  be  rejected. 

A  young  man,  thirty-tbree  years  of  age,  had  been  under  ob¬ 
servation  for  several  months.  The  patient  had  had  chancre 
fourteen  vears  ago,  was  thoroughly  treated  at  that  time,  and 
had  no  symptoms  since.  The  author  found  the  patient  with 
left  ptosis,  covering  almost  three  quarters  of  the  pupil,  but 
could  be  raised  slightly  with  great  effort.  Reflexes  to  light  and 
accommodation  were  nearly  normal ;  the  left  pupil  was  possi¬ 
bly  a  little  sluggish  to  light.  There  were  swelling  and  redness 
of  the  left  optic  disc.  Tbe  left  adducens  was  completely  para¬ 
lyzed;  all  other  movements  of  the  eyes  were  perfect.  The  pa¬ 
tient  was  at  once  put  on  vigorous  specific  treatment,  and  kept 
on  it  for  months,  with  no  change  in  the  condition,  the  general 
health  remaining  good.  Was  the  lesion  central  or  peripheral? 


July  19,  1890.] 


SPECIAL  ARTICLES , 


81 


The  author  could  not  conceive  of  a  lesion  at  the  base  of  such  a 
character  that  only  the  sixth-nerve  fibers  and  a  few  of  the  third- 
nerve  fibers  were  affected.  Such  a  selective  disorder  was  with¬ 
in  the  range  of  possibility,  but,  until  this  was  proved,  the  fear  of 
a  nuclear  lesion  could  not  be  lost  sight  of  in  such  a  case  as  that 
just  described. 

Crus  Lesion. — This  was  the  title  of  a  second  paper  by  Dr. 
Sachs.  Crus  lesions,  he  said,  were  rarer  than  many  other  cere¬ 
bral  lesions,  but  their  symptoms  were  well  marked.  The  case 
under  consideration  had  some  special  interest,  however,  in  con¬ 
nection  with  post-hemiplegic  disturbances  of  motion,  and  from 
this  point  of  view  the  results  of  the  post-mortem  examination 
were  worthy  of  consideration.  Seven  years  ago  the  patient,  a 
,  woman  about  fifty  years  of  age,  had  had  a  dizzy  attack  one 
morning,  and  had  found  her  vision  rather  blurred.  There  was 
a  recurrence  of  the  attack  in  fifteen  minutes.  There  was  no 
unconsciousness  or  difficulty  with  speech ;  but  when  the  pa¬ 
tient  attempted  to  walk  she  found  she  could  not  with  ease;  by 
morning  she  had  almost  complete  left  hemiplegia ;  she  could  not 
open  either  eye.  At  that  time  speech  was  heavy  and  indistinct, 
but  from  this  she  had  recovered  in  three  weeks.  Hearing, 
taste,  and  smell  were  altogether  normal.  The  hemiplegia  was 
never  recovered  from.  The  patient  became  somewhat  unruly  and 
demented,  and  was  finally  taken  to  the  Montefiore  Horne,  where 
she  had  remained  for  many  years.  A  few  further  details  of  the  | 
patient’s  chronic  condition  were  elicited  in  examination.  There 
had  been  no  history  of  syphilis,  but  there  was  very  marked 
atheroma  of  the  peripheral  arteries.  In  addition  to  the  left 
hemiplegia,  the  patient  had  suffered  amputation  of  the  right  leg 
above  the  ankle,  for  old  necrosis  of  the  tibia,  fully  six  years  be¬ 
fore.  There  was  rigidity  of  the  left  leg,  and  increased  knee- 
jerks  of  both  sides.  The  wrist  reflex  was  decidedly  increased 
on  the  paralyzed  side,  but  the  left  upper  extremity  was  subject 
to  the  wildest  ataxic  movements.  This  would  go  on  until  the 
arm  dropped  from  exhaustion,  when  it  would  remain  quiet  until 
aroused  again  by  an  effort  to  use  the  hand.  She  had  become 
extremely  emotional,  took  very  little  nourishment,  and  had 
finally  died.  The  diagnosis  of  crus  lesion  of  the  right  side, 
probably  softening  from  thrombosis,  was  made,  and  confirmed 
by  the  autopsy. 

Remarks  on  Therapeutics  as  applied  to  Nervous  Disor¬ 
ders. — Dr.  W.  R.  Bikdsall  read  a  paper  with  this  title.  While 
admitting  that  many  of  the  diseases  which  the  neurologist  was 
called  upon  to  investigate  were  practically  incurable,  the  author 
maintained  that  those  who  saw  no  advance  in  the  therapeutics 
of  nervous  diseases  were  probably  looking  in  the  wrong  direc¬ 
tion  for  progress,  the  advance  being  in  great  part  the  outcome 
of  those  very  investigations  considered  by  many  as  unpractical 
scientific  refinements.  The  early  diagnosis  of  disease  he  re¬ 
garded  as  the  most  important  factor  for  therapeutic  success  in 
diseases  of  the  nervous  system,  as  it  frequently  enabled  the 
physician  to  check  the  course  of  the  disease  where  marked 
disability  had  not  yet  resulted.  Hygienic  measures  were  con¬ 
sidered  of  prime  importance,  and  pharmaceutical  remedies  as 
valuable  accessories,  in  the  treatment  of  these  diseases.  All 
relation  between  storage  and  expenditure  must  be  readjusted 
to  the  disturbance  in  equilibrium,  and  the  therapeutics  con¬ 
sisted  in  bringing  about  such  a  readjustment  by  any  means  in 
our  power.  The  modern  craze  for  so-called  physical  culture, 
the  author  believed,  was  bringing  forth  dangers  as  great  as  those 
it  was  sought  to  remedy,  through  over- training,  improper  train¬ 
ing,  training  for  brain  workers  which  fatigued  rather  than 
rested  the  brain,  together  with  other  faulty  methods.  Hydro¬ 
therapy  he  considered  was  much  neglected,  and  electro¬ 
therapy  overestimated.  Next  to  hygiene,  cutaneous  irritation 
was  decidedly  the  most  important  therapeutic  measure  pos-  I 


sessed  by  the  neurologist.  Surgical  interference  and  the  drugs 
usually  employed  by  the  neurologist  were  briefly  referred  to. 

Diffuse  Cortical  Sclerosis  of  the  Brain  in  Children.— Dr. 
William  N.  Bullard  read  a  paper  with  this  title.  He  thought 
it  was  rather  doubtful  whether  cases  of  cortical  sclerosis  could 
always  be  distinguished  from  forms  of  diffuse  sclerosis  in  which 
the  cortical  layers  were  not  specially  affected.  The  history  of 
a  boy,  aged  twelve  years,  was  given,  in  which,  after  an  accident 
— a  fall,  striking  the  head  on  the  curbstone — there  had  been 
gradual  loss  of  mind  with  total  paralysis  of  the  left  extremities, 
and  death  fifteen  months  after  the  accident.  The  autopsy  had 
revealed  oedema  of  the  pia,  chronic  leptomeningitis,  atrophy  of 
the  brain,  with  secondary  chronic  internal  hydrocephalus,  and 
chronic  ependymitis  of  the  fourth  ventricle.  Microscopical 
|  examination  of  the  brain  showed  the  first  layer  of  the  cortex, 
the  fibrous  network,  to  contain  a  few  spider  cells  in  the  mesh 
due  to  atrophy  of  the  nerve  fibers,  and  an  increase  in  the 
neuroglia.  There  was  a  slight  degree  of  nerve-cell  infiltration 
of  the  adventitial  sheaths  of  the  blood-vessels  in  the  cortex. 
Beyond  this  there  was  nothing  else  abnormal.  Provisional 
conclusions  were  that  there  existed  in  children  a  non-congenital 
form  of  diffuse  cerebral  sclerosis  in  which  the  cortical  layers  of 
the  brain  were  more  specially  affected,  and  which  was  distin¬ 
guished  from  the  other  forms  by  its  appearance  in  healthy  chil¬ 
dren,  either  without  known  cause  or  after  traumata,  by  the 
steadily  progressive  character  of  its  symptoms,  and  by  the  espe¬ 
cial  prominence  of  the  gradually  increasing  dementia,  which 
finally  reached  an  extreme  degree  without  a  corresponding  loss 
of  motor  power  and  while  the  sensation  was  comparatively  un¬ 
affected. 

Officers  for  the  ensuing  Year  were  elected  as  follows: 
President,  Dr.  Wharton  Sinkler,  of  Philadelphia;  vice-presi¬ 
dents,  Dr.  0.  L.  Dana,  of  New  York,  and  Dr.  S.  G.  Webber, 
of  Boston  ;  secretary  and  treasurer,  Dr.  Graeme  M.  Hammond, 
of  New  York;  councilors,  Dr.  J.  A.  Walton,  of  Boston,  and 
Dr.  L.  0.  Gray,  of  New  York. 


Serial  gtritdes. 

LETTERS  TO  MY  HOUSE  PHYSICIANS. 

By  WILLIAM  OSLER,  M.  D., 

BALTIMORE. 

Letter  I. 

Freiburg,  May  17,  1890. 

Dear  L. :  This  is  a  charming  town,  beautifully  situated  at  the  south¬ 
western  end  of  the  Black  Forest,  and  with  a  medical  faculty  which  at¬ 
tracts  students  from  all  parts  of  Germany  and  not  a  few  from  abroad. 
During  the  past  few  years  the  number  of  men  in  attendance  has  risen 
rapidly  and  the  semester  has  reached  six  hundred.  I  met  here  my 
friend  Ramsay  Wright,  of  Toronto  University,  and  together  we  saw 
much  of  interest. 

Baumler,  who  has  charge  of  the  medical  clinic,  is  a  man  of  about 
forty-five,  and  we  are  very  much  indebted  to  him  for  making  our  short 
stay  here  agreeable  and  profitable.  He  was  in  London  at  the  German 
Hospital,  and  subsequently  practiced  there  as  a  consultant  for  nine  years, 
when  he  was  called  to  the  chair  of  medicine.  The  medical  wards,  con¬ 
taining  about  one  hundred  and  twenty  beds,  are  very  conveniently  ar¬ 
ranged,  and  the  plan  of  having  a  separate  lecture-room  for  each  depart¬ 
ment,  w'hich  is  almost  universal  at  German  universities,  is  very  advan¬ 
tageous.  There  are  three  assistants,  the  first  of  whom,  Dr.  Reinhold, 
has  been  here  three  years,  and,  as  is  customary,  is  appointed  for  an  in¬ 
definite  term.  The  second  and  third  assistants  remain  for  one  or  two 
years.  In  addition,  four  men  are  named  for  periods  of  three  months  to 
act  as  clinical  clerks  in  the  wards. 


SPECIAL  ARTICLES. 


[N.  Y.  Mkd.  Jouk., 


82 


To-day’s  routine  was  as  follows  :  At  7  a.  m.  the  professor  gave  a 
didactic  lecture  (of  which  five  are  delivered  weekly)  to  about  a  dozen 
students,  the  small  number  being  due  to  a  holiday  yesterday  and  in  part, 
no  doubt,  to  the  fact  that  attendance  upon  these  systematic  lectures  is 
not  compulsory.  The  subject  was  Diseases  of  the  (Esophagus,  and 
spontaneous  rupture,  perforation,  and  haemorrhage  were  discussed  in  a 
most  exhaustive  manner.  Afterward,  in  his  private  room,  Dr.  Baumler 
raised  the  question  of  the  value  of  such  teaching  to  the  medical  student 
and  suggested  that  the  same  might  be  got  in  a  shorter  time  from  books. 
Possibly ;  and,  though  I  am  strongly  opposed  to  our  present  system  of 
over-lecturing,  I  could  not  but  feel  that  the  men  who  had  listened  and 
taken  notes  had  got  their  information  in  a  much  more  interesting  and 
instructive  manner  than  if  they  had  read  the  subjects  in  any  text-book. 
Indeed,  I  do  not  know  of  any  one  Practice  which  contained  all  the  in¬ 
formation  given  in  the  three  quarters  of  an  hour.  The  question  must 
be  discussed  temperately,  as  it  has  two  sides,  one  of  which  is  ably  pre¬ 
sented  in  the  May  number  of  the  New  Review  in  a  Lecture  against  Lec¬ 
turing,  by  Professor  Sedgwick. 

One  thing  in  the  lecture-room  pleased  me  greatly  :  around  the  walls 
were  inscribed  on  each  side— above  the  names  of  Hippocrates,  Galen, 
Yesalius,  and  Harvey,  and  beneath  these  in  groups— those  of  the  great 
clinicians  of  all  countries  ;  and  it  warmed  my  heart  to  see,  as  the  rep¬ 
resentatives  of  America,  the  names  of  Flint  and  of  dear  old  Dr.  Bow 
ditch.  At  8  o’clock  the  visit  to  the  wards  was  made  and  new  or  spe¬ 
cially  interesting  cases  examined.  In  commenting  upon  a  case  of  typh 
litis,  Baumler  spoke  of  the  great  frequency  of  recovery  in  this  disease, 
which  he  thought,  as  is  now  almost  universally  accepted,  was  always  at 
first  an  affection  of  the  appendix.  The  tendency  toward  early  opera¬ 
tion  was,  in  his  opinion,  at  present  too  strong.  I  mentioned  the  case 
which  we  had  in  the  wards  a  few  months  ago,  and  which  was  certainly 
a  most  encouraging  one  in  support  of  early  interference  ;  but  who  can 
say  whether  the  small  localized  abscess  found  by  Dr.  Halsted  at  the 
point  of  the  appendix  might  not  have  healed,  or  at  any  rate  subsided, 
as  the  inflammation  had  done  in  a  previous  attack  ?  Still,  no  one  will 
deny  that  the  lad  is  not  better  without  his  rudimentary  appendage. 

At  nine  o’clock  the  students  assembled  in  the  large  ward,  in  the 
center  of  which  chairs  were  arranged  on  either  side  of  a  bed,  a  method 
which  is  followed  in  the  case  of  fever  patients,  and  other  cases  too  ill 
to  take  to  the  auditorium.  A  Practicant,  as  a  final  student  is  called, 
was  then  asked  to  examine  the  patient  before  the  class,  and  an  hour 
was  occupied  in  the  thorough  investigation  of  the  case— one  of  typhoid 
fever.  Comments  were  made  on  each  interesting  feature,  and  the 
symptoms  summed  up  in  a  clear  and  orderly  fashion,  most  instructive 
to  the  class,  the  members  of  which  had  an  opportunity  of  afterward 
looking  at  the  case.  Typhoid  patients  are  uniformly  bathed  whenever 
the  temperature  rises  to  103°  F.,  and  no  internal  antipyretics  are  used. 
The  good  effects  are  not,  it  is  thought,  confined  to  the  lowering  of  the 
fever.  The  mortality  is  here  only  about  eight  per  cent,  lower  than  in 
the  ordinary  symptomatic  method ;  but  you  shall  hear  much  more  on 
this  subject.  A  convenience  which  we  do  not  always  see  in  American 
hospitals  is  the  stand  in  each  ward  for  the  examination  of  the  urine, 
and  a  microscope  with  the  necessary  reagents.  A  clinic  is  held  daily, 
and  on  Wednesday  it  lasts  two  hours  ;  so  we  concluded  that  the  Frei¬ 
burg  professor  did  a  very  full  day’s  work  before  ten  o’clock  in  the 
morning.  In  another  ward  we  found  waiting  four  candidates  tor  the 
Staats-Examen — the  test  demanded  by  the  State  and  which  is  a  very 
formidable  affair,  lasting  for  several  days  in  each  subject.  We  then 
went  to  the  post-mortem  room  to  see  a  case  of  bullet-wound  of  the 
brain.  Ziegler,  the  professor  of  pathology,  came  here  last  year  from 
Tubingen,  and  lends  additional  strength  to  the  faculty,  as  he  is  one  of 
the  most  progressive  of  the  younger  generation  of  workers  in  his  de¬ 
partment.  To  English  and  American  students  he  has  become  well 
known  through  McAlister’s  translation  of  his  work  on  pathological 
anatomy,  which  has  had  an  extraordinary  success  here,  a  sixth  edition 


in  the  post-mortem  room,  for  he  bungled  the  inspection  of  the  abdomen 
and  thorax  in  a  shocking  manner.  The  examination  of  the  heart— the 
pons  asinorum  of  dissection— loosened  his  sweat  centers,  but  Ziegler 
dealt  with  him  most  gently,  considering  the  repeated  aggravations.  W  e 
could  not  wait  to  see  the  end,  as  it  was  a  matter  of  several  hours.  In 
addition  to  this  searching  examination,  there  are  others  in  pathological 
histology  and  general  pathology.  Von  Kalilden,  the  Docent  in  patholo¬ 
gy,  showed  us  the  laboratory,  which  is  not  large  but  very  well  equip¬ 
ped,  particularly  for  histological  work.  We  afterward  spent  a  very 
pleasant  evening  with  Ziegler  and  von  Kalilden,  both  of  whom  are 
genial,  sociable  men.  Ziegler  must  be  most  industrious,  as,  in  addition 
to  the  teaching,  which  occupies,  he  said,  at  least  three  hours  a  day,  the 
revision  of  his  text-book  has  been  continuously  in  hand,  the  editions 
having  followed  each  other  so  rapidly ;  then  he  edits  his  Beitrdge,  which 
has  become  a  most  important  pathological  journal,  and  recently,  in 
conjunction  with  von  Kahlden,  he  has  established  the  Centralblatt  fur 
Pathologie.  By  the  way,  I  have  sent  out  von  Kahlden’s  new  book  on 
histological  methods.  Call  the  attention  of  S.  to  the  section  on  Ehr- 
lich’s  blood  methods,  which  seems  fuller  than  is  usually  given.  To¬ 
day  we  saw  Ziegler  perform  a  most  interesting  autopsy  before  the  class 
in  a  case  of  bullet-wound  of  the  brain.  Early  in  April  the  young  lad 
had  attempted  suicide,  and  had  discharged  a  revolver  twice  at  his  head. 
One  bullet  flattened  against  the  frontal  sinus,  where  it  was  found  post 
mortem  ;  the  second  passed  through  the  left  hemisphere  to  the  occipital 
lobe,  where  it  lay  on  the  median  surface  close  to  the  cuneus.  There 
was  a  firm -walled  tract  in  the  course  of  the  bullet.  An  operation  for 
abscess  had  been  performed  yesterday,  apparently  only  by  enlargement 
of  the  original  orifice  and  the  insertion  of  a  drainage-tube.  There  w a^ 
extensive  basic  meningitis.  The  boy  was  hemiplegic  and  aphasic,  but 
we  did  not  learn  whether  an  examination  of  his  visual  fields  had  been 
made,  which  would  have  been  of  great  interest  considering  the  posi¬ 
tion  of  the  bullet  in  the  occipital  lobe.  _  .  . 

One  of  the  assistants  showed  us  through  the  new  surgical  clinic, 
which  is  not  yet  completed.  The  operating  theatre  is  very  well  ar¬ 
ranged,  with  a  composition  stone  floor  and  iron  frames  for  the  seats,  so 
that  the  whole  room  can  be  flushed  with  the  hose  and  thoroughly 
cleansed.  Carbolic  acid  is  the  chief  disinfectant,  bichloride  being 
rarely  used,  and  the  gauze  for  dressings  is  simply  sterilized. 

The  Anatomical  Institute  is  a  fine  new  building,  of  about  the  size  ot 
one  of  the  pay-wards,  with  a  large  lecture-room  in  the  rear.  Professor 
Wiedersheim  is  in  charge,  and,  as  is  customary  in  German  universities 
is  an  anatomist  in  the  wide  and  proper  sense  of  the  term,  having  to  teach 
human  and  comparative  anatomy  and  histology.  One  of  his  assistants 
takes  the  surgical  anatomy,  and  this  really  meets  the  objection  one 
often  hears  urged  in  America  against  a  pure  anatomist  teaching  medi¬ 
cal  students.  In  a  well-equipped  anatomical  department  how  easy  it, 
would  be  to  have  one  of  the  surgical  assistants  teach  the  senior  stu¬ 
dents  the  surgical  relations  of  the  subject  in  special  courses  !  The  ana¬ 
tomical  lecture-room  is  one  of  the  best  1  have  seen-high  and  spacious, 
with  splendid  light  from  the  roof  and  sides.  In  the  center  of  the  arena 
is  a  trap-door  with  hydraulic  arrangement,  by  which,  on  turning  a  key  in 
the  floor,  a  table  ascends  from  the  preparation-room  below.  Wieders¬ 
heim  is  a  beautiful  draughtsman,  and  the  blackboards  were  covered 
with  elaborate  diagrams,  in  colored  chalks,  of  the  origin  of  the  cranial 
nerves.  In  the  schemata  which  he  thus  makes  of  the  nervous  system 
from  day  to  day  he  always  uses  the  same  colored  chalk  to  indicate  the 
same  structure  at  different  levels. 

A  man  who  has  brought  much  renown  to  the  university  is  Weis- 
mann,  the  professor  of  zoology,  whose  writings  on  heredity  and  Dar¬ 
winism  have  attracted  so  much  attention.  In  a  recent  pamphlet, 
Ueber  die  Hypothese  einer  Vererbung  von  Verletzungen,  he  makes  a 
strong  criticism  of  the  recorded  instances  of  the  inheritance  of  pecul¬ 
iarities  of  structure  acquired  by  accident  or  disease.  His  collected  es¬ 
says  have  been  issued  in  English  by  the  Clarendon  Press,  at  Oxford, 


being  in  course  of  publication.  He  is  a  young-looking  man,  with  a 
pleasing,  frank  manner,  and  he  gave  us  a  hearty  welcome  and  asked  us 
to  come  to  the  post-mortem  room  to  see  an  examination  of  three  stu¬ 
dents  for  the  license  (/ Staats-Examen ),  and  a  most  practical  test  it  was. 
The  men  drew  lots  for  trunk,  head,  and  position  of  scribe.  The  poor 
fellow  who  began  the  work  had  evidently  not  been  a  diligent  attendant 


and  form,  perhaps,  the  most  notable  contributions  to  the  theory  of  evo¬ 
lution  which  have  been  made  during  the  past  decade. 

We  came  to  the  conclusion  that  Freiburg  had  a  most  progressive 
university,  and  certainly,  so  far  as  medicine,  pathology,  and  anatomy 
are  concerned,  the  post-graduate  student  will  find  everything  that  he 

could  desire. 


.July  19,  1890.] 


BOOK  NOTICES. 


83 


|Soah  plotters. 


A  Text-book  of  Obstetrics ,  including  the  Pathology  and  Thera¬ 
peutics  of  the  Puerperal  State.  Designed  for  Practitioners 
and  Students  of  Medicine.  By  F.  Winckel,  Professor  of 
Gymecology  and  Director  of  the  Royal  Hospital  for  Wom¬ 
en,  etc.,  Munich.  Translated  from  the  First  German  Edi¬ 
tion,  with  Permission  of  the  Author,  under  the  Supervision 
of  J.  Clifton  Edgar,  A.  M.,  M.  D.,  Adjunct  Professor  of 
Obstetrics  in  the  Medical  Department  of  the  University  of 
the  City  of  New  York.  One  Hundred  and  Ninety  Illustra¬ 
tions.  Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1890.  Pp. 
xxiii-17  to  927.  [Price,  $6.] 

No  one  is  better  known  for  painstaking  work  than  the  au¬ 
thor  of  this  treatise,  which  is  rather  more  voluminous  than  the 
average  work  upon  obstetrics.  Perhaps  this  may  have  resulted, 
in  part  at  least,  from  the  extensive  opportunities  which  he  has 
had  for  observation.  Not  only  was  he  conversant  with  the  ex¬ 
perience  of  his  father  and  grandfather  in  this  field,  but  he  also 
tells  us  that  since  1864  the  enormous  number  of  17,200  ob¬ 
stetric  cases  have  been  under  his  direction.  We  have  a  right 
to  expect  ripeness  of  opinion  after  such  an  experience.  A  note¬ 
worthy  peculiarity  in  this,  as  well  as  in  all  other  works  on  ob¬ 
stetrics,  as  a  rule,  is  the  painfully  minute  attention  which  is 
given  to  directions  concerning  the  care  of  the  pregnant  and 
parturient  woman.  Perhaps  it  is  a  pardonable  fault,  if  indeed 
it  is  a  fault,  to  exceed  in  giving  directions  to  an  embryo  ac¬ 
coucheur  as  to  the  simplest  and  most  obvious  requirements,  but 
such  a  plan  allows  little  scope  for  the  quality  which  we  Ameri¬ 
cans  know  as  common  sense,  which  ought  to  be  an  indispensable 
prerequisite  to  the  practice  of  obstetrics. 

With  the  arrangement  of  the  various  subjects  in  this  book 
no  fault  can  be  found.  It  is  progressive  and  judicious,  and 
suited  to  the  requirements  of  learners.  The  subject  of  extra- 
uterine  pregnancy  is  unsatisfactorily  treated  of.  Every  one 
knows  Winckel’s  preference  for  treating  this  condition  with 
hypodermic  injections  of  morphine,  which  seems,  to  us  at  least, 
a  haphazard  way  of  treating  a  most  serious  condition.  There 
is  no  apparent  change  in  his  views  of  the  pathology  of  this  con¬ 
dition,  notwithstanding  the  wonderful  contributions  of  the  past 
few  years.  Tait’s  name  is  not  mentioned  in  this  connection. 
This  is  bad  for  the  book  and  does  not  hurt  Mr.  Tait.  We  do 
not  know  what  the  author’s  opinion  of  Mr.  Tait  personally  is, 
and  again  Mr.  Tait  may  not  be  right  in  his  rather  narrow  view 
of  the  pathology  of  this  subject,  but  no  one  who  is  writing  a 
book  or  a  chapter  on  extra-uterine  pregnancy  can  afford  to 
ignore  Tait’s  contributions  to  this  subject. 

The  author  is  generally  inclined  to  be  fair  and  generous  in 
his  treatment  of  Americans,  but  we  do  not  agree  to  his  state¬ 
ment  that  “  clinical  observation  of  normal  and  abnormal  labors 
is  at  a  very  low  ebb  in  North  America,  with  the  exception  of 
^ew  \  ork,  Boston,  and  Philadelphia.”  If  this  were  strictly 
true  it  would  be  a  sad  commentary  on  the  obstetric  instruction 
which  many  hundreds  of  Americans  have  received  in  Germany 
and  elsewhere  in  Europe.  Again,  he  is  in  error  when  he  says 
that  the  disproof  of  the  statement  that  there  are  but  few  in¬ 
stances  of  contracted  pelvis  in  the  United  States  is  seen  in  the 
great  number  of  urinary  fistulse  among  parous  women  here.  As 
a  matter  of  fact,  urinary  fistula  resulting  from  parturition  is  a 
rare  accident  with  us  nowadays.  It  would  hardly  be  rash  to 
say  it  was  rarer  than  in  Germany,  and  Emmet  showed  long 
ago,  in  collating  his  enormous  experience  upon  this  subject,  that 
very  many  of  his  cases  were  imported  from  Europe.  Such 
cases  are  usually  sent  to  city  hospitals  for  operation,  and  perhaps 


the  great  diminution  in  their  number  during  recent  years  argues 
better  obstetrics  in  Europe  as  well  as  in  America.  Winckel 
thinks  the  statement  that  there  are  few  contracted  pelves  here 
is  unjustifiable  until  thousands  upon  thousands  of  pelvic  meas¬ 
urements  have  been  made.  In  our  opinion,  a  short  cut  to  a 
conclusion  which  is  equally  valid  is  furnished  by  the  fact  that 
there  are  so  few  cases  of  lesion  which  results  from  contracted 
pelvis.  This  is  not  intended  as  any  disparagement  to  the  study 
of  the  anatomy  of  the  bony  pelvis,  which  has  no  doubt  been 
too  much  neglected  with  us.  The  subject  is  here  treated  of  by 
a  master  in  a  way  which  is  both  comprehensive  and  entirely  in¬ 
telligible. 

The  impression  which  one  gets  of  Winckel  the  teacher  and 
the  obstetrician  from  the  perusal  of  his  book  is  one  of  great  re¬ 
spect  for  his  learning  and  for  his  conservatism.  His  idea  seems 
to  us  the  true  one,  that  pregnancy  and  parturition  are  simply 
physiological  processes,  which,  as  a  rule,  require  slight  inter¬ 
ference,  and  should  not  be  interfered  with  or  disturbed  for 
slight  causes.  As  to  the  work  of  the  translator,  it  has  been  ad¬ 
mirably  done,  and  we  congratulate  him  on  so  faithfully  render¬ 
ing  into  English  the  work  of  his  teacher,  from  whom  we  doubt 
not  he  derived  much  healthful  inspiration. 


The  Surgery  of  the  Kidneys:  being  the  Harveian  Lectures, 
1889.  By  J.  Knowsley  Thornton,  M.  C.,  Surgeon  to  the 
Samaritan  Free  Hospital,  etc.  Nineteen  Illustrations.  Lon¬ 
don  :  Charles  Griflfin  &  Company,  1890.  Pp.  vii-102. 

Mr.  Thornton  has  very  happily  arranged  these  lectures  and 
has  included  most  of  what  is  at  present  known  regarding  the 
surgery  of  the  kidneys.  They  form  very  entertaining  as  well  as 
instructive  reading,  and  are  particularly  valuable  to  the  prac¬ 
titioner  who  can  not  devote  much  time  to  this  subject. 


Food  m  Health  and  Disease.  By  I.  Burney  Yeo,  M  D 
F.  R.  C.  P.,  Professor  of  Clinical  Therapeutics  in  King’s  Col- 
lege,  London,  etc.  Philadelphia  :  Lea  Brothers  &  Co.,  1890. 
Pp.  x-583.  [Price,  $2.] 

The  authoi  has  aimed  to  make  this  work  one  of  practical 
utility  and  to  render  it  as  far  as  possible  representative  of  the 
subject  that  it  treats  of.  It  is  concise,  suggestive,  and  available 
for  emergencies  as  well  as  for  conditions  requiring  careful  study. 
Diet  in  gastrio  disorders,  diabetes,  gout,  anaemia,  consumption, 
etc.,  receives  careful  attention  according  to  the  dictates  of  mod¬ 
ern  research. 


May's  Diseases  of  Women,  being  a  Concise  and  Systematic  Ex¬ 
position  of  the  Theory  and  Practice  of  Gynaecology.  For 
the  Use  of  Students  and  Practitioners.  Second  Edition,  re¬ 
vised  by  Leonard  S.  Rau,  M.  D.,  Attending  Gynaecologist 
to  Harlem  Hospital,  Outdoor  Department,  New  York,  etc. 
With  Thirty-one  Illustrations  on  Wood.  Philadelphia :  Lea 
Brothers  &  Co.,  1890.  Pp.  xii-25  to  373.  [Price,  $1.75.] 
That  such  works  as  this  are  necessary  is  shown  by  the  call 
for  a  second  edition.  The  author  disavows  any  originality  in 
the  woik,  and  states  plainly  that  it  is  only  a  compilation  from 
standard  authors.  As  a  quiz  book  or  a  book  of  reference  for 
one  who  is  too  much  occupied  to  consult  the  sources  from  which 
this  is  drawn,  it  will  play  a  useful  part. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

Mineral  Springs  and  Health  Resorts  of  California,  with  a  Complete 
Chemical  Analysis  of  every  Important  Mineral  Water  in  the  World 
Illustrated.  A  Prize  Essay.  Annual  Prize  of  the  Medical  Society  of 
the  State  of  California,  awarded  April  20,  1889.  By  Winslow  An¬ 
derson,  M.  D.,  Assistant,  Chair  Medical  Chemistry  and  Materia  Medica, 


miscellany. 


[N.  Y.  Mkd.  Jouh. 


84 


and  Teacher  of  Chemistry  in  the  Laboratories  of  the  University  of  Cali¬ 
fornia  in  the  Medical  and  Dental  Departments,  etc.  San  Francisco: 

The  Bancroft  Company,  1890.  Pp.  xxx-3  to  384.  [Price,  $1.50.] 
Rheumatism  and  Gout.  By  F.  Leroy  Satterlee,  M.  D.,  Ph.  D.,  1  ro- 
fessorof  Chemistry,  Materia  Medica,  and  Therapeutics  in  the  New  F  or  i 
College  of  Dentistry,  etc.  Detroit:  George  S.  Davis,  1890.  Pp.  83. 

[The  Physician’s  Leisure  Library.] 

Philosophy  in  Homoeopathy.  Addressed  to  the  Medical  Profession 
and  to  the  General  Reader.  By  Charles  S.  Mack,  M.  D.,  Professor  of 
Materia  Medica  and  Therapeutics  in  the  Homoeopathic  Medical  College 
of  the  University  of  Michigan  at  Ann  Arbor.  Chicago  :  Gross  &  Del- 
bridge,  1890.  Pp.  V  to  174. 

Le<;ons  sur  les  maladies  du  larynx.  Faites  h  la  Faculte  de  m^decine 
de  Bordeaux  (cours  libre).  Par  le  Dr.  E.  J.  Moure,  Professeur  libre  de 
laryngologie,  otologie  et  rhinologie,  etc.  Recueillies  et  redigees  par  le 
Dr!  M.  Natier,  Ancien  chef  de  clinique  du  DocteurE.  J.  Moure,  et  revues 
par  l’auteur.  Avec  des  figures  en  noir  dans  le  texte.  Paris  :  Octave 

Doin,  1890.  Pp.  iv-599. 

Die  Protozoen  als  Kranklieitserreger.  Von  Dr.  L.  Pfeiffer,  Geh. 
Med  Rath  und  Vorstand  des  Grossh.  Sachs.  Impfinstituts  in  Weimar. 

Mit  34  Abbildunden  im  Text  und  1  Tafel.  Jena:  Gustav  Fischer,  1890 

Pp.  iv— 100. 

Die  Untersuchung  der  hiuteren'Larynxwand.  Von  Dr.  Gustav  Kil¬ 
lian,  Privatdocent  fiir  Laryngologie  und  Rhinologie  in  Freiburg  i.  Breis- 
gau.  Mit  40  Abbildungen  in  Texte.  Jena:  Gustav  Fischer,  1890. 

Pp.  11. 

Transactions  of  the  Southern  Surgical  and  Gynaecological  Associa¬ 
tion.  Volume  II.  Second  Session,  held  at  Nashville,  Tenn.,  November 
12  13,  and  14,  1889. 

Transactions  of  the  Medical  Society  of  the  State  of  New  York,  for 
the  Year  1890. 

A  Digest  of  Current  Orders  and  Decisions,  with  Extracts  from  Army 
Regulations  relating  to  the  Medical  Corps  of  the  U.  S.  Army.  Compiled 
under  Direction  of  the  Surgeon-General  by  Charles  R.  Greenleaf,  Major 
and  Surgeon,  U.  S.  A. 

International  Atlas  of  Rare  Skin  Diseases.  Editors  :  Malcolm  Mor¬ 
ris  London;  P.  G.  Unna,  Hamburg;  L.  A.  Duhring,  Philadelphia;  H. 
Leloir,  Lille.  I  and  II.  Philadelphia:  J.  B.  Lippincott  Company, 

1 889 

The  Operative  Treatment  of  Hip  Disease.  By  De  lorrest  Willard, 
M.  D.  [Reprinted  from  the  Medical  News .] 

The  Treatment  of  Local  and  General  Peritonitis.  By  W.  E.  B 

Davis,  M.  D.,  Birmingham,  Ala. 

Report  of  the  Ladies’  Health  Protective  Association  of  New  York, 

1888  and  1889. 

Primary  Cancer  of  the  Gall-bladder  and  Bile-ducts.  By  J.  H.  Mus- 
ser  M.  D.  [Reprinted  from  the  Transactions  of  the  Association  of 

American  Physicians.] 

Case  of  Tubercular  Pericarditis ;  Unusual  Amount  of  Effusion;  Ac¬ 
cidental  Paracentesis  Pericardii.  Notes  of  the  Treatment  of  Peritonitis. 
By  J.  H.  Musser,  M.  D. 

The  Prophylaxis  of  Tuberculosis.  By  Karl  von  Ruck,  B.  S.,  M.  D 
[Reprinted  from  the  Therapeutic  Gazette .] 

A  Study  of  Metastatic  Carcinoma  of  the  Stomach.  Report  of  a 
Case  of  Primary  Carcinoma  of  the  Testicle ;  Secondary  Involvement  of 
the  Vena  Cava  Inferior  ;  Metastases  in  the  Lungs,  Stomach,  and  Falx 
Cerebri.  By  John  S.  Ely,  M.  D.  [Reprinted  from  the  American  Jour¬ 
nal  of  the  Medical  Sciences.] 

Chips  from  a  Surgeon’s  Workshop.  Five  Consecutive  Cases  of 
Gunshot  Wounds  of  the  Abdominal  Viscera  treated  by  Abdominal  Sec¬ 
tion.  Two  Deaths,  Three  Recoveries.  By  A.  C.  Bernays,  M.  D.,  St 
Louis.  [Reprinted  from  the  St.  Louis  Medical  and  Surgical  Journal .] 
Aus  der  gynakologischen  Abtheilung  des  St.  Francis  Hospitals  in 
New  York.  Die  Laparotomien  des  Jahres  1889.  Von  Dr.  George  M. 
Edebohls,  New  York.  [Aus  der  New  Yorker  Medidnischen  Monats- 

schrift .] 

Sifilide  congenita  tardira.  Nota  clinica  del  dott.  Umberto  Dieci 
[Estratto  dalla  Rassegna  di  scienze  mediche .J 

Nefrectomia  transperitoneal.  Por  el  Dr.  Raimundo  Menocal.  [Pub- 
licado  en  la  Revista  de  Ciencias  Medicos .] 


Ueber  das  mechanische  Latenzstadium  des  Gesammtmuskels.  ’V  on 
Dr.  Med.  W.  Cowl.  [Separat-Abdruck  aus  den  Verhandlungen  der 

physiologisch en  Gesellschaft  zu  Berlin .] 


jgtsrellattjj. 


Coca  and  its  Therapeutic  Applications. — M.  Angelo  Mariam’s  mono¬ 
graph  on  this  subject  has  already  been  mentioned  in  this  journal.  Dr. 
Henry  Schweig  speaks  of  the  author’s  researches  as  having  extended 
over  a  period  of  more  than  twenty-five  years,  not  only  in  the  prepara¬ 
tion  of  laboratory  products,  but  in  matters  pertaining  to  the  cultiva¬ 
tion  of  the  plant  with  special  reference  to  the  higher  development  of 
its  active  principles.  _ _ 

ANSWERS  TO  CORRESPONDENTS. 

No.  326. — If  your  diploma  was  not  issued  by  a  college  situated  in 
the  State  of  New  York,  it  will  have  to  be  certified  to  before  you  can 
register  here.  _ ___ 

To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  mch  arti¬ 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
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Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
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dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  July  26,  1890. 


(SBrtjgmal  Communications. 

THE  DOSAGE  AND  ADMINISTRATION 
OF  CREASOTE  IN  PHTHISIS* 

By  WILLIAM  H.  FLINT,  M.  D., 

ATTENDING  PHYSICIAN  AT  THE  PRESBYTERIAN  HOSPITAL. 

Medical  opinion  is  at  present  almost  unanimously  fa- 
orable  to  the  use  of  pure  beech-wood  creasote  in  phthisis, 
nd  convincing  proofs  of  the  efficacy  of  this  remedy  have 
>een  furnished  by  many  authors  on  both  sides  of  the  At- 
antic.  Among  the  most  valuable  contributions  of  our  own 
ountrymen  to  the  earlier  demonstrative  literature  of  this 
abject,  the  papers  of  Dr.  Beverley  Robinson  deserve  par- 
icular  mention  and  are  widely  quoted.  Our  journals  are, 
loreover,  constantly  heralding  new  and  striking  successes 
ttained  by  the  use  of  creasote,  so  that  it  no  longer  seems 
ecessary  to  cite  cases  in  proof  of  the  value  of  this  medica- 
lent. 

In  view,  however,  of  the  divergent  opinions  expressed 
y  competent  observers  regarding  the  dosage  and  the  ad- 
linistration  of  creasote,  the  writer  hopes  that  the  society 
dll  consider  as  opportune  a  discussion  regarding  the  quan- 
ity  of  the  drug  to  be  employed  and  the  best  methods  of 
:s  exhibition. 

With  a  view  to  the  inauguration  of  such  a  discussion, 
tie  writer  begs  to  present  the  recommendations  of  some  of 
fie  authors  whose  articles  have  come  to  his  notice,  as  well 
s  the  results  of  his  own  observation  and  study. 

Bouchard  and  Gimbert  ( Gazette  hebdomadaire,  1877, 
p.  486,  504,  522,  and  620),  to  whom  belongs  the  credit  of 
iscuing  the  creasote  treatment  of  phthisis  from  the  oblivion 
i  which  it  had  been  consigned  after  its  discovery  by  Reich- 
nbach,  in  the  early  part  of  the  nineteenth  century,  suggest- 
d  six  or  seven  drops  as  the  average  daily  dose  of  creasote, 
ut  recommended  that  this  quantity  be  increased  in  the 
vent  of  its  being  easily  tolerated.  Their  favorite  formula 


as  the  following  : 

Ijl  Creasote .  rrixxxj  ; 

Tincture  of  gentian .  uilxxij ; 

Alcohol .  3  x  ; 

Tokay  or  Malaga  wine .  3  v. 

>ose,  from  3  j  to  §  ss. 


Dr.  Beverley  Robinson  ( Medical  Record ,  Sept.  2,  1878, 
.  223),  who  may  be  called  the  apostle  of  the  creasote  treat¬ 
ment  in  this  country,  at  first  used  the  creasote  mixture  of 
me  IT.  S.  Pharmacopoeia  in  dessertspoonful  doses.  This 
uxture  is  composed  of  creasote  and  glacial  acetic  acid,  each, 
lxvj ;  spirit  of  juniper,  fi  3  ss. ;  syrup,  fl  §  j ;  distilled  wa- 

A  §  xv,  and  each  ounce  contains  one  minim  of  creasote. 

A  few  years  later  Dr.  Robinson  (TV.  Y.  Medical  Journal, 
ov.  14,  1886,  p.  535)  adopted  the  method  of  antiseptic  in- 
dations  in  his  treatment  of  phthisis,  using,  by  preference, 
mixture  composed  of  equal  parts  of  creasote  and  of  alco- 
al,  or  of  creasote,  alcohol,  and  chloroform. 

In  the  American  Journal  of  the  Medical  Sciences,  Janu¬ 

*  Read  before  the  New  York  Clinical  Society,  May  23,  1890. 


ary,  1889,  Dr.  Robinson  published  a  comprehensive  and  mas¬ 
terly  article  on  the  whole  subject  of  the  use  of  creasote  in 
phthisis,  to  the  results  of  which  later  researches  have  cer¬ 
tainly  added  but  little.  In  the  course  of  this  article  Dr. 
Robinson  again  described  his  method  of  using  creasote  in¬ 
halations,  recommending  the  inhaler  now  generally  known 
by  his  name  and  several  solutions  well  adapted  for  use  in 
this  inhaler.  The  solutions  employed  by  Dr.  Robinson  are 
three  in  number,  and  their  composition  is  as  follows  : 

First,  one  recommended  by  Dr.  Brunton  and  modified 
by  Dr.  Robinson  : 

B  Iodoform .  gr.  xxiv  ; 

Creasote .  Tq,iv  ; 

Oil  of  eucalyptus .  rrt  viij  ; 

Chloroform .  mxlviij  ; 

Alcohol, 


Ether, 


aa  q.  s.  ad  fl  §  ss.  M. 


Second,  the  formula  of  Dr.  Coghill  (Brit.  Med.  Jour. 
1881,  vol.  i,  p.  84)  : 

Tr.  iodi  setherealis,  ) 

Acid,  carbolici,  j  ’  ’ '  &a  ^  ’ 

Creasot .  3  j  ; 

Spts.  vin.  rect .  ad  §j.  M. 

Third,  Dr.  Robinson’s  own  prescription  : 

$  Creasote .  3  j ; 

Alcohol .  ad  ?  ss.  M. 

The  inhaler  was  worn  by  Dr.  Robinson’s  patients  at  first 
for  fifteen  or  twenty  minutes  every  three  hours,  and  from 
ten  to  twenty  drops  of  the  mixture  were  placed  upon  the 
sponge  at  least  three  times  in  twenty-four  hours. 

For  internal  administration  Dr.  Robinson  employed  the 
following  formula,  which  he  adapted  from  Jaccoud  and 
which  has,  I  think,  come  into  pretty  general  use  : 

R  Creasoti .  lUvj  ; 

Glycerini .  |  j  ; 

Spts.  frumenti .  3  ij. 

M.  Sig. :  As  directed. 

The  dose  of  this  preparation  generally  used  was  one  tea¬ 
spoonful,  and  this  was  given  every  three  hours,  diluted  with 


two  parts  of  water  to  prevent  irritation  of  the  throat  and 
stomach.  Dr.  Robinson  contended  that  creasote  should  be 
taken,  at  first  at  least,  in  small  or  moderate  doses,  continued 
a  long  time,  and  increased  very  gradually.  His  average 
daily  dose  was  from  three  to  six  minims,  and  this  quantity 
le  administered,  uninterruptedly,  for  many  months. 

Dr.  Austin  Flint  (A'.  Y.  Medical  Journal,  Dec.  8,  1888, 
o.  617)  used  doses  of  three  or  four  drops  thrice  daily,  and 
inhalations  of  the  creasote,  chloroform,  and  alcohol  solution 
already  described,  at  first  for  a  few  minutes,  three  times  a 


day,  and  then  for  increasing  periods  even  up  to  four  or  eight 
lours  a  day. 

Professor  Sommerbrodt,  of  Breslau  (Therapeut.  Monats- 
hefte ,  July,  1889;  JY.  Y.  Medical  Journal ,  Oct.  5,  1889, 
1.  373),  strongly  advocates  the  use  of  creasote  in  heroic 
doses,  acting  upon  the  assumption  that  enough  creasote  may 
ie  give'n  to  so  charge  the  blood  with  the  remedy  as  to  an¬ 
tagonize  the  development  of  tubercle  bacilli. 

Professor  Sommerbrodt  bases  his  method  upon  the  re- 


86 


FLINT:  CREASOTE  IN  PHTHISIS. 


[N.  Y.  Med.  Jodb., 


searches  of  Dr.  P.  Guttman,  whose  experiments  showed 
that  tubercle  bacilli  could  hardly  be  cultivated  in  sterilized 
serum  containing  ^  volume  of  creasote,  and  that  the 
culture  could  not  be  carried  on  if  the  solution  were  a  little 
stronger  than  1  in  4,000. 

Professor  Sommerbrodt  has  tested  his  method  in  hun 
dreds  of  cases,  using  capsules  each  containing  one  minim 
of  creasote.  He  usually  begins  the  treatment  with  three 
capsules  the  first  day,  and  adds  one  capsule  on  each  suc¬ 
ceeding  day  until  the  eighteenth  day,  after  which  the  maxi¬ 
mum  quantity,  from  twenty  to  twenty-five  minims  per  diem , 
is  administered  for  many  consecutive  months. 

Professor  Sommerbrodt  reports  most  gratifying  results 
from  this  method  and  states  that,  in  his  experience,  his  suc¬ 
cess  in  any  given  case  was  in  direct  ratio  with  the  amount 
of  creasote  taken.  One  of  his  patients  took  nearly  nine 
ounces  of  creasote  and  thirty-five  ounces  of  Peruvian  balsam 
between  September  1,  1888,  and  June,  1889,  with  very  good 
results. 

Dr.  P.  Bogdanovitch  ( Meditzinskoe  Obozrenoe  ;  British 
Med.  Journal ,  March  10,  1888,  p.  548)  published  the  re¬ 
sults  of  his  experience  in  his  own  case  of  pulmonary  and 
laryngeal  phthisis.  For  two  years  he  took  doses  of  half  a 
grain,  four  or  five  times  daily,  without  effect.  He  then 
augmented  the  dose,  commencing  with  four  grams  daily 
and  increasing  the  quantity  within  two  months  to  forty -four 
grains  in  twenty-four  hours.  The  results  were  speedy 
amelioration,  as  regarded  the  cough  and  dyspnoea,  diminu 
tion  of  scutum,  and  disappearance  of  fever  and  laryngeal 
spasm.  The  bacilli  remained  just  as  numerous  as  at  the 
beginning  of  the  treatment.  Dr.  Bogdanovitch  infers  from 
his  experience  that -five  grains  should  be  taken  four  times  a 
day  in  capsules,  after  food.  This  heroic  Russian  method 
may  do  well  in  the  iron-bound  realms  of  the  Czar,  but  would 
hardly  be  adapted  to  the  average  invalid’s  stomach  in  these 
latitudes. 

Even  Dr.  Bogdanovitch  experienced  epigastric  discom¬ 
fort  after  taking  small  doses  on  an  empty  stomach.  This 
symptom  did  not  present  itself  when  even  twelve  grains 
were  taken  after  meals.  If,  however,  twelve  grains  were 
taken  at  a  single  dose,  or  twenty  grains  within  an  hour,  Dr 
Bogdanovitch  suffered  from  giddiness,  cardiac  palpitation, 
weak  pulse,  asthenia,  pallor,  and  anxiety.  All  of  these  toxic 
symptoms  disappeared  within  half  an  hour  or  an  hour,  and 
did  not  return.  The  condition  of  the  urine  was  not  re 
ported. 

Dr.  Lanisniee  (  Union  medicate ,  quoted  by  Brit.  Med, 
Jour.,  1888,  i,  p.  1360)  claimed  that  nausea  and  vomiting 
from  creasote  might  be  avoided  by  the  use  of  the  following 
formula : 

B  Creasote .  5  centigrammes ; 

Balsam  of  Peru . : .  H  decigrammes  ; 

Norway  pitch .  7£ 

Sig.  Make  one  capsule. 

Four  of  these  capsules  are  taken  with  the  meals,  morn 
ing  and  evening,  and  the  dose  gradually  increased  to  twelve 
daily. 

Dr.  Rosenbusch  ( Przeglad  Lekarski,  Feb.  4  and  11, 
1888,  and  Wien.  med.  Presse,  June  10,  1889;  see  Thera¬ 


peutic  Gazette ,  May  15,  1888,  p.  359,  and  London  Lancet , 
1888,  i,  p.  643)  reported  good  results  from  pulmonary  in¬ 
jections  of  creasote  in  phthisis.  He  injected  eight  minims 
of  a  three-per-cent,  solution  of  creasote  in  almond-oil  into 
each  of  two  spots  in  the  diseased  lung  at  intervals  of  two  or 
three  days.  The  points  selected  for  the  injections  were 
either  the  second  intercostal  space  or  the  supraspinous 
fossae.  Dr.  Rosenbusch  alleged  all  the  good  results  for  this 
method  obtained  by  other  modes  of  administering  creasote. 
The  only  unpleasant  symptom  following  the  injections  was 
pleuritic  pain,  when  the  injections  were  too  near  the  pleural 
surface.  No  haemorrhages  occurred  after  the  injections,  but 
the  sputum  of  one  patient  who  had  already  suffered  from 
haemoptysis  was  slightly  colored  for  a  short  time. 

Other  observers  have  not  been  able  to  attain  the  good 
results  alleged  by  Dr.  Rosenbusch  for  intrapulmonary  in¬ 
jections  of  creasote. 

Dr.  T.  Stachiewicz  ( Year-Book  of  Treatment ,  1890,  p. 
34)  carefully  employed  Rosenbusch’s  method  and  found 
that  cough  and  expectoration  notably  increased  after  each 
injection  of  creasote.  Dr.  Stachiewicz  concludes  that,  if 
cavities  have  formed,  creasote  injections  may  cause  rapid 
destruction  of  pulmonary  tissue  by  engendering  inflamma¬ 
tion.  Dr.  Stachiewicz  also  believes  that  haemoptysis  is 
likely  to  follow  intrapulmonary  injections. 

Dr.  Mackey  {Brit.  Med.  Jour.,  1888,  No.  ii,  p.  765) 
used  intrapulmonary  injections  of  a  three-per-cent,  solution 
of  creasote  in  olive-oil.  The  seventh  injection,  however, 
caused  haemoptysis  and  increased  the  inflammatory  symp¬ 
toms  so  that  the  treatment  was  abandoned. 

Dr.  J.  Rosenthal  {Berlin,  klin.  Wochenschrift ,  1888,  32, 
pp.  640,  666)  advocated  the  use  of  carbonic-acid  water  as 
a  menstruum  for  creasote.  This  suggestion  was  based  upon 
the  result  of  many  experiments  conducted  by  Dr.  Rosenthal 
regarding  the  effect  of  solutions  of  creasote  in  carbonated 
water  upon  cultures  of  thirty-two  varieties  of  micro-organ¬ 
isms.  Rosenthal  found  that  the  growth  of  the  micro-organ¬ 
isms  was  almost  or  quite  arrested  by  carbonic-acid  water  con¬ 
taining  1  part  in  2,000  of  creasote.  Other  experiments  made 
by  Rosenthal  showed  that  creasote,  even  in  weak  solutions, 
will  not  only  hinder  the  growth  of  the  micro-organisms,  but 
will  actually  kill  the  latter.  Rosenthal’s  experiments  also 
demonstrated  that  a  sufficient  quantity  of  creasoted  water! 
can  be  given  hypodermically  to  a  rabbit  to  make  a  dilution 
of  one  to  four  thousand  in  its  blood  without  causing  appre¬ 
ciable  morbid  symptoms.  Creasote  solutions  of  this  strength 
were  shown  by  Koch  to  greatly  retard  the  growth  of  tuber¬ 
cle  bacilli  in  various  culture  media.  Thus,  by  inference, 
Dr.  Rosenthal  assumes,  as  did  Sommerbrodt,  that  a  suffi¬ 
ciently  concentrated  solution  of  creasote  may  be  made  in 
the  blood  to  directly  antagonize  the  growth  of  the  bacilli 
tuberculosis. 

Rosenthal  recommended  that  the  carbonated  creasote- 
water  be  prepared  of  such  strength  that  each  litre  should 
contain  from  0-6  to  1*2  of  creasote  and  30  grammes  ol 
cognac.  The  doses  of  this  solution  are  so  arranged  that  0’1 
of  creasote  is  taken  on  the  first  day,  and  the  remedy  gtadu 
ally  increased  until  the  daily  dose  is  0*8. 

Von  Driver  {Berlin,  klin.  Wochenschrift ,  1888,  No.  35 


roly  26,  1890.] 


FLINT:  CREASOTE  IN  PHTHISIS. 


87 


iee  New  York  Medical  Journal ,  June  1,  1889,  p.  615) 
ised  creasote  mixed  with  alcohol  and  sherry  wine,  accord- 
ng  to  the  formula  of  Frantzel,  which  is  as  follows  : 

$  Creasoti .  Tffxv; 

Tr.  gent .  rrivj ; 

Spts.  vin.  rect .  fl  3  vj ; 

Vini  xerici . q.  s.  ad  fl  3  iv. 

Sig.  §  ss.  t.  i.  d.,  with  water. 

Dr.  von  Driver  believed  in  the  heroic  method,  and  in¬ 
creased  his  doses  as  rapidly  as  possible  until  the  maximum 
vas  reached.  This  maximum  was  0‘75  gramme  (i.  e.,  Ill 


jrs.). 

Groh  (  Wien.  med.  Blatter ,  No.  27,  1889)  administered 
reasote  in  wafers  intimately  mixed  with  powdered  cacao. 

Dr.  James  E.  Newcomb  ( Medical  Record ,  August  10, 
.889,  p.  145)  reported  favorably  concerning  the  effect  of 
reasote  in  his  service  at  the  Roosevelt  Out-patient  De- 
tartment.  He  administered  the  creasote  by  mouth  only, 
md  used  the  following  formula  : 

I£  Creasoti, 


Tr.  capsici 


: .  [ 
1C1,  ) 


,aa 


3  1J-  3  ii] ; 

Mucilag.  acac .  §  ss. ; 

Aquae . ad  f  iv. 

M.  Sig.  :  3  j,  well  diluted  with  water,  after  meals. 

Dr.  Ruetimeyer  {Brit.  Med.  Jour.,  1889,  i,  p.  102)  uses 
reasote  in  emulsion  with  olive-oil,  almond-oil,  or  cod-liver 


>il,  in  which  form  it  is  fairly  palatable  and  causes  hardly 
ny  indigestion. 

Dr.  Dor  {Revue  de  med.,  February,  1890;  Am.  Jour,  of 
he  Med.  Sci.,  May,  1890,  p.  521)  advocates  the  use  of  intra- 
racheal  injections  of  sterilized  olive-oil  containing  creasote 
n  the  proportion  of  one  part  of  creasote  to  twenty  of  oil, 
ontinued  for  many  months.  Dr.  Dor  injects  31  minims  of 
his  mixture,  containing  3T  grains  of  creasote,  twice  daily, 
nd  reports  that  he  never  observed  untoward  results — such 
s  haemoptysis,  fever,  or  pleuritic  pain — to  follow  the  injec- 
10ns.  After  the  injections  the  patients  are  made  to  assume 
'ositions  adapted  to  facilitate  the  gravitation  of  the  creasote 
0  the  diseased  part  of  the  lung.  The  fact  of  its  penetra- 
lon  is  evidenced,  according  to  Dor,  by  the  production  of 
uberepitant  rales.  Dr.  Dor  maintains  that  the  digestive 
disturbances  often  resulting  from  the  internal  administration 
1  creasote  were  entirely  absent  in  his  cases. 

This  observer’s  experiments  with  animals  showed  that 
he  oil  reached  the  alveoli  and  remained  there  for  fifteen 
ays  in  some  cases  before  undergoing  complete  absorption. 

The  writer’s  experience  with  creasote  in  phthisis  em- 
races  seventy-three  cases,  among  which  there  have  been 
xamples  of  all  stages  of  the  disease. 

The  cases  were  divided  into  three  classes,  according  to 
he  methods  of  treatment  adopted — 

1.  Those  in  which  creasote  inhalations  were  alone  em- 
'loyed. 

2.  Those  in  which  creasote  was  administered  both  by 
nhalation  and  by  the  stomach  or  the  rectum. 

3.  Those  in  which  the  drug  was  given  only  by  the 
tomach  or  the  rectum. 

This  subdivision  of  the  material  was  made  with  a  view 
0  ascertaining  which  mode  of  administration  yielded  the 


best  results,  or  whether  a  combination  of  both  modes  was 
most  advantageous. 

There  are  so  many  variables  in  a  clinical  problem  of 
this  sort  that  statistics  upon  a  large  scale  are,  of  course, 
necessary  to  definitely  settle  the  question.  So  far,  how¬ 
ever,  as  the  limited  experience  of  the  writer  goes,  it  tends 
to  show  that  neither  of  the  above-mentioned  methods  inva¬ 
riably  furnishes  the  best  results.  The  inhalation  method 
was,  naturally,  most  successful  for  patients  whose  gastro¬ 
intestinal  tracts  were  diseased,  while  the  other  methods  were 
more  satisfactory,  producing  more  immediate  and  even  phe¬ 
nomenal  results,  in  cases  whose  digestive  organs  were  in  a 
fairly  healthy  condition. 

The  solution  used  for  inhalation  was  always  that  con¬ 
taining  equal  parts  of  creasote,  alcohol,  and  chloroform. 
This  combination  was  very  acceptable  to  the  patients,  save 
in  a  few  cases  in  which  it  caused  nausea  and  gastric  distress 
whenever  employed.  The  inhalers  used  were  Dr.  Robin¬ 
son’s  and  that  of  the  Brompton  Hospital.  In  mild  cases 
the  inhalations  were  administered  for  fifteen  minutes,  every 
two  or  three  hours  ;  and  in  severe  ones,  every  hour  during 
the  day-time  and  every  three  hours  at  night.  From  ten  to 
fifteen  drops  of  the  solution  were  placed  upon  the  sponge 
about  every  five  hours  during  the  day,  and  twice  during  the 
night.  The  writer  employed  several  preparations  for  the 
administration  of  creasote  by  the  mouth  and  the  rectum. 
At  first  he  relied  upon  the  solution  recommended  by  Jac- 
coud,  and  composed  of  creasote,  ntvj ;  glycerin,  f  j;  and 
whisky,  §  ij.  This  was  well  borne  by  strong  stomachs,  but 
presented  the  disadvantage  that  the  dose  could  not  be 
greatly  increased  without  the  exhibition  of  an  undesirably 
large  amount  of  glycerin  and  whisky.  The  former  of  these 
medicaments  in  large  quantities  perhaps  engendered  gastric 
distress  quite  as  much  as  the  creasote,  and  produced  too 
free  peristole  of  the  stomach.  The  use  of  whisky  in  the 
early  stages  seemed  contra-indicated  when  there  was  little 
need  of  stimulants,  and  also  exposed  patients  to  the  risk  of 
contracting  an  undue  fondness  for  alcohol,  which  might 
outlast  their  disease.  For  these  reasons  the  writer  early 
adopted  the  use  of  an  emulsion  composed  of  cod-liver  oil, 
40  parts,  and  mucilage  of  acacia,  60  parts — each  drachm  con¬ 
taining  two  minims  of  creasote.  This  was  generally  better 
tolerated  than  the  glycerin  and  whisky,  particularly  when 
given  after  food.  In  suitable  cases  the  emulsion  was  given 
every  two  hours,  and  the  dose  increased  up  to  the  point  of 
toleration,  which,  in  the  majority  of  the  cases,  was  about 
ten  or  twelve  minims  per  diem. 

In  many  instances,  when  the  patients  could  be  persuaded 
to  temporarily  adopt  an  exclusively  milk  diet,  the  creasote 
emulsion  was  administered  in  the  milk,  being  thoroughly 
mixed  with  the  latter  by  means  of  energetic  shaking.  The 
succussion  may  be  well  performed  in  an  ordinary  bottle  or 
by  means  of  a  lemonade  shaker,  such  as  is  habitually  em¬ 
ployed  by  bar-tenders  in  preparing  various  beverages.  The 
writer  succeeded  in  administering  more  creasote  in  this 
manner,  without  exciting  gastric  symptoms,  than  by  any 
other  methodj  and  can  heartily  recommend  it  for  cases  re¬ 
quiring  large  doses  of  creasote,  frequently  repeated.  In  a 
few  cases  twenty-four  minims  of  creasote  were  daily  given 


88 


ELIOT:  TENORRHAPHY. 


[N.  Y.  Med.  Jour., 


in  this  way  for  several  consecutive  days  before  the  growing 
gastric  distress  necessitated  a  diminution  of  the  dose.  The 
figurative  thorn  upon  this  therapeutic  rose  is  the  bad  taste 
imparted  to  the  milk  by  the  creasote.  Some  patients  do 
not,  however,  object  to  the  flavor,  and  some  get  on  very 
well  by  mixing  the  creasote  with  only  a  part  of  the  milk  to 
be  taken,  reserving  the  remainder  of  the  milk  for  the  final 
swallows.  In  this  way  the  after-taste  is  greatly  diminished, 
and  it  may  be  quite  removed  by  any  good  mouth-wash. 

Rectal  injections  of  milk  containing  the  creasote  emul¬ 
sion,  and  which  the  writer  has  not  seen  referred  to  in  medical 
literature,  have  also  proved  very  valuable  in  his  experience. 
This  channel  for  the  introduction  of  creasote  may  be  ad¬ 
vantageously  employed  when  the  stomach  or  the  palate  re¬ 
bels  against  the  administration  of  the  remedy  per  os.  One 
or  two  drachms  of  the  emulsion,  containing,  respectively, 
two  and  four  minims  of  creasote,  may  be  shaken  up  with 
four  ounces  of  milk,  and  such  an  enema  may  be  given  every 
five  or  six  hours.  When  the  rectum  becomes  intolerant  of 
this  treatment,  a  small  amount  of  laudanum  may  be  added 
to  the  enema  to  obtund  the  sensibility  of  the  bowel,  and  from 
two  to  four  drachms  of  whisky  may  be  added  where  stimu¬ 
lation  is  indicated. 

Another  mode  of  administration  which  promises  much, 
but  which  awaits  development,  is  by  means  of  keratin-coated 
or  other  so-called  enteric  pills.  The  writer  has  been  thus 
far  disappointed  in  his  efforts  at  securing  pills  which  would 
not  dissolve  in  the  stomach.  The  solubility  in  the  gastric 
juice  of  those  keratin-coated  pills  which  he  has  employed 
was  proved  by  eructations  of  creasote  and  by  the  rapid  de¬ 
velopment  of  gastric  irritability.  It  is,  however,  quite  rea¬ 
sonable  to  suppose  that  the  pharmacist’s  art  will  eventually 
provide  pills  or  capsules  which  will  resist  the  action  of  the 
gastric  juice  and  liberate  the  creasote  in  the  intestinal  canal, 
being  dissolved  by  the  pancreatic  juice  and  the  bile.  This 
part  of  the  digestive  tract  may  thus  be  made  to  absorb  the 
creasote  when  the  stomach  or  the  rectum  is  incapable  of  its 
appropriation. 

The  conclusions  reached  by  the  writer,  as  the  result  of 
his  reading  and  of  his  own  experience,  are: 

1.  That  intrapulmonary  and  intratracheal  injections  of 
creasote  are  of  doubtful  utility,  and  may  be  positively  in¬ 
jurious. 

2.  That,  for  administration  by  mouth  or  rectum,  solu¬ 
tions  and  emulsions  of  creasote  are  preferable  in  most  cases 
to  capsules,  pills,  or  wafers. 

3.  That  milk  is  an  excellent  vehicle  for  the  administra¬ 
tion  of  creasote  in  solution  or  in  emulsion. 

4.  That  each  method  of  administering  creasote  used  by 
the  writer — viz.,  by  inhalation,  by  mouth  or  rectum  alone, 
and  by  both  these  channels  simultaneously — is  useful,  and 
may  each  be  particularly  adapted  to  individual  cases.  In 
suitable  cases  the  most  rapid  progress  seems  to  be  made 
when  all  these  ports  of  entry  are  utilized. 

5.  That  the  best  results  for  each  individual  attend  the 
administration  of  the  maximum  quantity  of  creasote  which 
this  patient  will  bear. 

6.  That  the  average  patient  will  not  easily  tolerate  more 
than  ten  or  fifteen  minims  of  creasote  per  diem  for  any  great 


length  of  time,  and  that  many  will  only  bear  two  or  three 
drops  per  diem  continuously  administered. 

1.  That  it  is  very  important  that  the  treatment  be  uni¬ 
form  and  uninterrupted. 

8.  That,  consequently,  an  effort  should  always  be  made, 
if  intolerance  of  creasote  is  shown  by  any  one  mucous  sur¬ 
face,  to  employ  some  other  channel  of  introduction,  in 
order  that  the  continuity  of  the  treatment  be  not  inter¬ 
rupted. 

37  East  Thirty-third  Street. 


TENORRHAPHY. 

By  ELLSWORTH  ELIOT,  Jr.,  M.  D., 

ASSISTANT  SURGEON  TO  THE  VANDERBILT  CLINIC  AND  THE 
NEW  YORK  HOSPITAL,  OUT-PATIENT  DEPARTMENT. 

Probably  among  minor  operations  few  have  received 
the  attention  that  has  been  given  to  tenorrhaphy.  As  a  re¬ 
sult  of  this  attention,  one  would  naturally  infer  that  the 
diagnosis  and  treatment,  both  operative  and  subsequent, 
had  reached  such  a  degree  of  perfection  as  to  demand  no 
further  consideration. 

But  that  this  is  not  the  actual  truth  is  often  brought 
to  our  notice  by  patients  who  present  themselves  for  treat¬ 
ment  of  complete  or  partial  loss  of  function  of  a  member, 
where  a  several  weeks’-old  cicatrix  over  the  course  of  an  im¬ 
portant  tendon  tells  too  clearly  the  history  of  its  previous 
division,  as  well  as  the  lack,  at  the  same  time,  of  a  correct 
knowledge  of  the  nature  of  the  lesion  on  the  part  of  the 
practitioner.  But,  even  with  a  correct  diagnosis,  it  is  not 
at  all  infrequent  to  meet  with  patients  who  have  submitted 
to  operative  treatment  in  whom  the  return  of  the  function  of 
the  divided  tendon  can  be  said  to  have  only  partially  taken 
place.  Therefore  it  seems  hardly  superfluous,  even  at  the 
risk  of  repetition,  to  state  and  emphasize  such  principles  as 
should  guide  us  in  the  diagnosis  and  treatment  of  these 
cases — all  the  more  so,  in  fact,  since  frequently  the  ques¬ 
tion  of  the  ability  of  the  patients  to  obtain  their  livelihood 
is  dependent  upon  the  surgeon’s  skill  in  obtaining  a  good 
result. 

In  reaching  a  positive  diagnosis  in  cases  of  divided 
tendon  or  tendons  we  are  often  assisted  by  considering  the 
character  of  the  weapon  that  inflicted  the  injury.  From 
the  firm  and  tough  structure  of  these  organs  it  is  evident 
that  blunt  instruments  or  missiles,  which  produce  contused 
or  lacerated  wounds  of  the  soft  parts,  are  usually  incapable 
of  severing  a  tendon.  In  fact,  such  injuries  may  tear  away 
the  softer  tissues  that  surround  a  tendon  without  injuring 
this  structure,  or,  what  is  perhaps  more  usual,  may  tear 
away  a  longitudinal  slip  from  the  tendon  itself  without  di¬ 
viding  it. 

On  the  other  hand,  wounds  inflicted  by  glass  or  sharp 
cutting  instruments,  although  apparently  “  superficial,” 
should  always  lead  to  a  careful  examination  on  the  part  of 
the  surgeon.  Deficient  movement  of  an  injured  member 
by  the  patient  himself  is  usually  a  valuable  indicator  of  loss 
of  function  of  that  member.  Under  certain  circumstances 
it  is  the  only  necessary  symptom  to  be  elicited.  But  it  is 
important  to  remember  that,  valuable  as  it  is,  it  is  still 


July  26,  1890.] 


ELIOT:  TENORRHAPHY. 


89 


capable  of  misleading  one,  and  that  this  is  especially  the 
case  when  in  the  hand,  for  example,  considerable  swelling 
prevents  the  patient  from  fully  flexing  his  fingers.  Here, 
even  if  the  long  flexor  tendon  of  one  of  the  fingers  was 
divided,  the  patient  would  still  be  able  to  flex  that  finger 
by  means  of  the  sublimis  digitorum  until  the  large  amount 
of  general  swelling  checked  simultaneously  the  flexion  of 
all  the  fingers  and  before  the  long  flexor  tendons  of  those 
fingers,  not  the  seat  of  injury,  could  complete  their  action 
in  producing  full  flexion  of  the  third  phalanges  into  the 
palm  of  the  hand.  But,  although  this  swelling  prevents 
the  patient  from  fully  bending  his  normal  fingers,  yet  by 
the  examiner  this  obstacle  may  be  overcome,  with  perhaps 
some  pain  to  the  patient,  and  by  him  the  finger  may 
be  fully  flexed.  With  the  finger  once  in  this  position 
the  patient  experiences  no  difficulty  in  retaining  it  there, 
provided  his  long  flexor  tendon  is  uninjured.  If  this, 
however,  has  been  previously  divided,  the  finger,  after  be¬ 
ing  forced  by  the  examiner  into  the  fully  flexed  position, 
returns  with  the  removal  of  the  examiner’s  finger  into  the 
semi-flexed  position,  and  at  the  same  time  the  third  phalanx 
becomes  fully  extended  upon  the  second.  But,  when  more 
than  one  tendon  is  divided,  in  situations  where  a  consid¬ 
erable  number  are  closely  aggregated  together,  the  exact 
diagnosis  becomes  more  difficult,  and  usually  requires  an 
exploratory  incision. 

Before  resorting  to  this  step,  however,  we  may  try 
another  method  of  diagnosis,  especially  applicable  to  those 
cases  in  which  a  number  of  tendons  have  been  divided — 
namely,  that  of  electiicity.  By  means  of  this  agent,  either 
with  the  constant  or  faradaic  current,  one  pole  being  placed 
over  some  indifferent  part  of  the  body,  the  other  over  the 
known  point  of  entrance  of  the  nerve  to  the  muscle,  the 
usual  normal  reaction  will  ensue  on  the  passage  of  the  cur¬ 
rent  through  the  muscle,  should  the  tendon  be  intact,  but 
would  naturally  be  absent  were  that  structure  divided.  But 
this  method  is  open  to  the  objection  that  a  battery  is  not 
always  at  hand,  as  well  as  the  fact  that  the  exact  relations 
of  the  so-called  “points  of  nerve  stimulation  ”  to  the  sur¬ 
face  of  the  body  vary  in  different  people,  and  can  therefore 
not  be  fully  relied  upon  in  making  an  accurate  diagnosis. 

We  come  now  to  the  consideration  of  the  most  im¬ 
portant  point  of  the  subject — namely,  the  treatment  of  a 
divided  tendon.  Tenorrhaphy,  like  all  operations,  is  one  in 
which  the  strictest  antiseptic  precautions  should  be  ob¬ 
served.  Billroth  says  that,  in  his  experience,  before  the 
days  of  antisepsis  it  was  an  operation  in  which  septicaemia 
was  not  an  infrequent  sequela.  Such  an  unfavorable  ter¬ 
mination  to-day  could  only  be  the  result  of  gross  neglect 
of  antiseptic  rules. 

If  possible,  the  operation  should  be  done  with  cocaine, 
because  the  pain  after  the  primary  incision  is  very  slight, 
and  because  the  patient  himself  can  usually  be  of  assistance 
in  making  certain  movements  of  the  injured  part,  and 
thereby  enable  the  surgeon  to  detect  more  readily  the  ten¬ 
don  for  which  he  is  searching.  Provided  but  one  tendon 
is  divided,  the  line  of  incision  should  be  directly  parallel 
to  the  line  of  the  tendon,  its  center  being  over  the  point 
of  its  division,  and  the  dissection  carried  to  such  a  point 


until  its  sheath  is  exposed.  If,  however,  several  tendons 
are  divided,  for  example,  by  a  transverse  wound  in  the 
neighborhood  of  the  wrist,  an  incision  should  be  made  at 
right  angles  to  the  wound,  and  the  crucial  flaps  so  formed 
should  be  reflected  from  the  deep  fascia,  or,  in  other  situa¬ 
tions,  from  that  fascia  or  structure  that  forms  the  sheath  of 
the  divided  tendons,  and  never  through  it,  for  this  sheath 
contains  a  large  number  of  the  vessels  that  nourish  the  ten¬ 
don,  and  these  would  be  materially  damaged  by  any 
manipulation  resulting  in  the  separation  of  the  sheath  from 
its  contents.  Also,  this  same  structure  sometimes  serves 
the  double  purpose  of  sheath  and  pulley,  and  in  the  latter 
capacity  binds  the  tendon  firmly  in  place  and  gives  it  in¬ 
creased  leverage  in  the  performance  of  its  function. 

Thus  the  aponeurotic  canal  which  contains  the  peronseus 
longns  behind  the  external  malleolus  not  only  binds  the 
tendon  firmly  to  the  bone,  but  also  helps  to  serve  as  a  pul¬ 
ley,  for  here  the  tendon  changes  its  course  and  no  longer 
lies  in  the  same  vertical  line  with  the  fleshy  portion  of  the 
muscle.  Consequently,  wherever  possible,  remove  all  over- 
lying  structures  as  far  as  the  sheath,  through  which  the  di¬ 
vided  ends  of  one  or  more  tendons  are  easily  recognized. 
The  distal  end  of  the  tendon  is  but  very  slightly  retracted; 
the  proximal  end,  from  its  being  connected  to  the  contract¬ 
ing  portion  of  the  muscle,  may  have  retracted  a  distance  of 
one  to  even  four  or  five  inches,  the  average  being  one  to  two 
inches.  If  the  distance  exceeds  this,  it  will  be  impossible 
to  draw  the  divided  ends  together  without  opening  the 
sheath  of  the  tendon  ;  but  this  should  always  be  avoided,  if 
possible,  by  inserting  a  very  narrow-toothed  thumb-forceps 
within  the  sheath  at  the  point  of  division  of  the  tendon? 
and,  after  seizing  the  proximal  end,  gently  drawing  it  down 
to  the  site  of  suture,  where  it  should  be  temporarily  held 
by  a  ligature  until  the  distal  end  is  similarly  secured. 

Such  an  extensive  incision  is  also  of  advantage  in  mak¬ 
ing  a  correct  diagnosis.  It  is  not  always  easy  without  this 
assistance,  in  places  where  tendons  are  numerous,  to  match 
their  divided  ends ;  but  if  the  incision  is  sufficiently  ex¬ 
tended  toward  the  origin  of  the  muscle  to  discover  the 
identity  of  the  proximal  stump,  that  of  the  distal  end  may 
readily  be  detected  by  traction,  thereby  discovering  the 
action  of  the  muscle  to  which  it  belongs,  and  consequently 
the  muscle  itself. 

It  is  scarcely  necessary  to  state  the  great  importance  of 
a  correct  anatomical  knowledge  of  the  relation  of  groups  of 
tendons  to  one  another  and  to  the  surrounding  parts  in  en¬ 
abling  one  to  carry  out  this  step  of  the  operation  satisfac¬ 
torily. 

It  now  remains  to  consider  the  different  substances  by 
which  the  tendons  which  have  thus  been  found  divided  and 
the  ends  of  which  have  been  approximated  may  be  held  in 
contact  until  complete  union  between  them  has  taken 
place.  Silk,  silk-worm  gut,  and  catgut  have  all  been  used 
for  this  purpose,  as  well  as  other  material.  The  first-men¬ 
tioned  substance,  however,  although  known  to  have  become 
encapsulated  in  the  body,  is  open  to  the  objection  that  its 
subsequent  removal  from  the  parts  it  is  made  to  include 
takes  place  by  a  process  of  ulceration,  and  it  is  reasonable  to 
infer  that  this  cutting  through  a  portion  of  the  tendon  must 


90 


THAYER:  OBSERVATIONS  ON  RHEUMATISM. 


[N.  Y.  Med.  Jour., 


weaken  it,  although  the  divided  ends  may  in  the  mean  time 
have  become  healed. 

Silk-worm  gut,  some  observers  say,  has  the  durability  of 
silk  and  the  capacity  for  being  absorbed  that  catgut  pos¬ 
sesses;  but  that  this  is  not  always  the  case  has  been  the  ex¬ 
perience  of  the  writer,  who  has  removed  stitches  of  this 
material  from  an  abdominal  wall,  after  being  in  place  six 
weeks,  when  the  buried  portions  were  as  strong  as  at  the 
time  of  their  insertion.  Catgut,  from  its  undoubted  after¬ 
absorption,  leaves  no  breach,  and  therefore  does  not  ulti¬ 
mately  weaken  the  tendon,  and  also,  in  virtue  of  this  same 
characteristic,  interferes  to  the  slightest  degree  with  the 
subsequent  healing  of  the  wound  by  primary  intention — a 
factor  upon  which  ultimate  success  is  greatly  dependent. 
Its  durability  also  is  sufficiently  lasting  for  it  to  accomplish 
its  intended  purpose,  and,  when  it  eventually  softens,  the 
divided  ends  of  a  tendon  are  bound  firmly  together  by  the 
process  of  union. 

With  the  incisions  all  ready  for  suture,  one  point  alone 
remains  to  be  mentioned.  As  has  already  been  said,  the 
ultimate  success  of  the  operation  depends  in  a  measure  on 
securing  primary  union.  In  order  to  render  this  more  cer¬ 
tain,  the  catgut  sutures  between  the  tendons  may  be  cut 
sufficiently  long  to  protrude  between  the  edges  of  the  sutured 
wound.  In  this  way  they  serve  the  purpose  of  small  drains, 
which  carry  away  all  discharge  from  the  neighborhood  of 
the  sutured  tendons — a  region  where  tension  is  the  highest 
and,  consequently,  the  risk  of  suppuration  the  greatest.  By 
this  means  the  primary  dressing  may  be  undisturbed  for  at 
least  ten  days,  when,  on  its  removal,  all  traces  of  these  small 
drains  will  have  disappeared  and,  in  a  good  result,  primary 
union  will  have  taken  place. 

In  the  application  of  the  dressing  it  is  of  paramount 
importance  to  fix  the  limb  securely  in  such  a  position  that 
the  divided  tendons  will  be  relaxed  and  completely  at  rest. 
If  one  or  more  flexors  have  been  involved,  the  joint  or 
joints  over  which  the  tendons  play  should  be  superflexed, 
and  a  splint  should  hold  it  securely  in  this  position.  If  the 
extensors  have  been  involved,  the  limb  should  be  immobil¬ 
ized,  superextended.  If  two  antagonistic  groups  of  mus¬ 
cles  have  been  divided,  the  limb  should  be  immobilized  in 
that  position  which  represents  the  resultant  action  of  both 
groups  of  tendons. 

In  the  after-treatment  the  question  arises,  How  soon 
may  the  patient  begin  to  use  the  affected  member  ?  a  ques¬ 
tion  upon  which  all  are  not  agreed.  In  its  consideration, 
however,  it  is  essential  to  remember  that,  in  the  expe¬ 
rience  of  some,  tendons  which  have  been  sutured  have 
suddenly  and  without  apparent  cause  ruptured  at  the  point 
of  suture  and  retracted  after  an  interval  of  from  two  to 
five  weeks  from  the  operation.  That  this  accident  may  oc¬ 
cur  should  tend  to  make  one  conservative  in  the  after- 
treatment  of  these  cases.  Too  early  motion  of  any  kind 
may  be  accompanied  by  this  complication.  Its  delay,  on 
the  other  hand,  does  not  at  all  imply  loss  of  function  of  the 
member;  for  it  is  an  every-day  matter  to  immobilize  joints 
for  six  weeks,  or  even  longer,  for  fracture  or  disease,  with 
subsequent  full  return  of  function  in  the  part  so  treated. 
It  simply  means  an  inconvenience  to  the  patient,  which 


had,  however,  much  better  be  endured  than  the  patient  to 
be  troubled  during  the  remainder  of  his  life  by  a  weakness 
or  even  a  crippling  of  one  of  the  important  parts  of  the 
body. 

The  following  case  is  subjoined  to  illustrate  the  method 
of  treatment  under  discussion,  as  well  as  the  result  obtained 
thereby  : 

T.  R.,  nineteen  months  ago,  was  admitted  into  the  New 
York  Hospital,  suffering  from  an  incised  wound  just  above  the 
left  wrist,  the  result  of  an  explosion  of  a  glass  siphon  bottle. 
Examination  revealed  division  of  all  the  tendons  on  the  anterior 
aspect  of  the  wrist,  except  those  of  the  flexor  profundus  digi- 
torum,  two  of  which,  however,  were  nicked  ;  the  ulnar  artery 
was  divided ;  the  ulnar  and  median  nerves,  with  the  radial 
artery,  were  found  intact. 

Cocaine  was  injected,  and  an  incision  was  made  at  right  an¬ 
gles  to  the  incised  wound,  from  its  center  upward,  two  inches 
toward  the  elbow  joint,  and  the  integument  and  superficial 
fascia  alone  reflected,  leaving  the  deep  fascia  exposed,  through 
which  the  glistening  tendons  could  be  seen.  Each  one  of  these 
was  in  turn  drawn  down  with  a  thumb-forceps  inserted  in  the 
sheath  of  the  tendon  to  that  point  at  which  this  structure  had 
previously  been  divided,  and  there  sutured  to  its  distal  portion 
with  catgut,  each  being  joined  by  one  central  and  two  lateral 
sutures,  drawn  sufficiently  tight  to  approximate,  hut  not  to 
compress,  the  ends  of  the  tendon.  These  sutures  were  then  left 
hanging  from  the  radial  extremity  of  the  wound,  the  edges  of 
which  were  brought  together  by  interrupted  catgut  stitches. 
An  iodoform-bichloride  dressing  was  applied,  and  the  wrist  im¬ 
mobilized  in  the  flexed  and  adducted  position.  No  reaction  fol¬ 
lowed  the  operation.  The  dressing  was  removed  in  ten  days. 
There  was  primary  union  throughout.  On  the  fourteenth  day 
slight  passive  motion  was  performed.  On  the  twenty-first  day 
active  motion  was  allowed,  and  up  to  the  present  day  the  func¬ 
tions  of  wrist  and  fingers  equal  those  of  the  uninjured  side. 


OBSERVATIONS  ON  RHEUMATISM, 
ESPECIALLY  AS  INVOLVING  THE  TONSILS.* 
By  WILLIAM  HENRY  THAYER,  M.  D. 

Within  a  very  few  years  different  observers  have  noted 
the  occurrence  of  rheumatic  inflammation  in  tissues  and  or¬ 
gans  not  previously  recognized  as  liable  to  its  invasion. 

If  we  examine  all  the  authorities  earlier  than  1850,  we 
shall  find  that  acute  rheumatism  is  supposed  to  affect  only 
the  fibrous  tissues  about  the  articulations,  the  voluntary  mus¬ 
cles,  and  the  heart,  especially  its  lining  and  investing  mem¬ 
branes. 

A  little  later,  some  few  have  recognized  its  implication 
of  the  lungs  as  a  rheumatic  bronchitis  or  pneumonia,  its 
character  being  revealed  by  being  preceded  or  followed  by 
articular  rheumatism,  and  yielding  to  remedies  suitable  to 
that  disease.  Thus  Fuller  (1852)  says  that  during  his  ser¬ 
vice  in  St.  George’s  Hospital  some  pulmonary  inflammation 
(bronchitis,  pneumonia,  or  pleurisy)  was  observed  in  one  in 
every  eighteen  cases  of  acute  rheumatism,  uncomplicated 
with  recent  cardiac  mischief.  Trousseau  in  his  Clinical 
Medicine  says :  “  There  is  rheumatic  pneumonia,”  and  no- 

*  Read  before  the  Fifth  District  Branch  of  the  New  York  State 
Medical  Association  at  its  sixth  annual  meeting,  May  27,  1 890. 


July  26,  1890.] 


TEA  YER :  OBSER  YA  TIONS 


where  alludes  to  inflammation  of  the  tonsils.  He  says,  how¬ 
ever  (vol.  i,  pi  331)  :  “There  is  another  kind  of  painful 
sore  throat — the  rheumatic  sore  throat,”  which  he  describes 
as  general  redness  of  the  pharynx  with  oedematous  uvula, 
disappearing  entirely  in  a  day  or  two,  with  metastasis  to  the 
articulations.  Flint  (1879)  says:  “Bronchitis, pleurisy, and 
pneumonia  are  rarely  associated  with  rheumatism.”  In  his 
Diseases  of  the  Pharynx  he  makes  no  allusion  to  any  rheu¬ 
matic  inflammation.  Garrod  (1880)  describes  rheumatic 
inflammation  of  the  heart,  pleura,  and  peritonaeum,  but  not 
of  the  throat.  Watson  (1840)  and  Bennett  (1860)  make 
no  mention  of  any  pulmonary  complication  of  rheumatism. 

The  relation  of  amygdalitis  to  rheumatism  in  any  case 
has  never  been  noticed  until  within  a  very  recent  period  ; 
no  text-book  on  practice  twenty  years  old  has  any  mention 
of  it.  Senator,  in  von  Ziemssen’s  Cyclopaedia  (1877),  says: 
“  Inflammation  of  various  mucous  surfaces  is  by  no  means 
unusual.  Foremost  among  these  is  bronchitis,  then  pharyn¬ 
gitis,  noticed  by  Lebert  and  Meyer.”  Rheumatic  inflam¬ 
mation  of  the  tonsils,  such  as  I  shall  presently  describe 
as  occurring  in  a  number  of  cases  under  my  observation 
in  the  winter  of  1888— ’89,  is  either  a  new  manifestation 
or — which  is  hard  to  believe — has  entirely  escaped  notice 
hitherto.  The  only  experience  that  has  been  published 
is  that  of  Dr.  C.  W.  Haig-Brown,  who,  in  the  British 
Medical  Journal  for  September  14,  1889,  has  a  valuable 
paper  entitled  Follicular  Tonsillitis  and  its  Relations  to 
Rheumatism,  in  which  he  relates  the  frequency  of  amygda¬ 
litis  and  of  rheumatism  in  a  public  institution,  due,  as  he 
thought,  to  sewer  exhalations.  Improvement  of  the  sewer¬ 
age  reduced  the  cases  of  amygdalitis  from  twenty-one  per 
cent,  of  all  the  sick  to  five  per  cent.,  and  rheumatism  from 
four  to  one  per  cent.  He  gives  a  considerable  experience  of 
the  sequence  of  one  disease  to  the  other,  or  their  concur¬ 
rence.  He  says :  “  Having  so  far  established  a  causative  and 
clinical  relationship  between  rheumatism  and  amygdalitis, 
we  are  led  to  one  of  certain  conclusions  :  That  rheumatism 
is  a  general  disease,  which  as  frequently  finds  expression  in 
the  throat  as  in  the  fibrous  and  serous  membranes  ;  or  that 
the  inflamed  tonsil  is  the  receptacle  for  the  rheumatic  poi¬ 
son,  and  the  medium  for  its  conduction  to  the  general  cir¬ 
culation  ;  or,  finally,  that  specific  germs  find  their  way  into 
the  body  under  circumstances  favorable  to  their  entry,  and 
then  evidence  their  presence  in  inflammation  of  the  tonsils 
and  the  fibrous  and  fibro-serous  membranes.” 

Garrod  says  (1880)  :  “  The  pathology  of  articular  rheu¬ 
matism  must  be  allowed  to  be  in  a  very  unsettled  state,  and 
further  observations  and  experiments  are  required  before  we 
can  arrive  at  any  satisfactory  conclusion  with  regard  to  it. 

.  .  .  The  name  implies  that  the  disease  has  been  considered 
to  be  dependent  upon  some  altered  condition  of  the  blood.” 
This  altered  condition  was  believed  to  be  the  presence  of 
lactic  acid  in  the  blood,  the  result  of  imperfect  digestion — 
a  belief  that  originated  with  Prout.  “  But,”  says  Garrod, 
“  no  abnormal  principle  has  yet  been  found  in  the  blood  ; 
lactic  acid  has  been  assumed  to  exist  in  it,  but  no  proof  has 
been  given  of  its  presence.” 

The  adoption  of  Prout’s  view  led  to  the  treatment  with 
alkalies,  which  was  eminently  successful  and  considerably 


ON  RHEUMATISM.  9i 

shortened  the  attacks  5  and  it  is  noticeable  that  under  this 
treatment  the  urine  after  a  few  days  became  alkaline,  and 
simultaneously  with  this  change  in  the  urine  convalescence 
began.  Acidity  somewhere  is  apparently  an  element  in  the 
pathology  of  rheumatism,  although  no  acid  is  found  in  the 
blood. 

And,  says  Fuller  (1852)  :  “When  the  rheumatic  poison 
is  present  in  the  system,  any  disturbing  circumstance,  even 
of  temporary  duration,  such  as  over-fatigue,  anxiety,  grief, 
or  anger,  by  rendering  the  system  more  susceptible  of  its 
influence,  may  prove  the  accidental  or  exciting  cause  of  the 
disease ;  and  exposure  to  cold  or  to  atmospheric  vicissitudes 
is  almost  certain  to  induce  an  attack.  .  .  .  Thus  it  appears 
that  cold  and  other  external  agencies  are  only  predisposing 
or  exciting  causes  of  rheumatism,  and  that  the  primary, 
proximate,  or  essential  cause  of  the  disease  is  the  presence 
of  a  morbid  matter  in  the  blood,  generated  in  the  system  as 
the  product  of  a  peculiar  malassimilation — ofi  vicious  meta. 
phoric  action.”  But  what  this  morbid  product  is,  is  thus 
far  only  matter  of  conjecture  ;  neither  chemist  nor  micros- 
copist  has  been  able  to  discover  it. 

In  the  winter  of  1888—  89  I  saw  six  cases  of  rheumatic 
amygdalitis,  some  of  which  are  offered  in  detail : 

Case  I. — Wilber  T.,  aged  twelve,  previously  well,  had  an 
attack  of  follicular  amygdalitis  in  December,  1888,  and  on  Janu¬ 
ary  14,  1889.  On  the  24th  of  January  a  third  attack,  with  sub¬ 
acute  rheumatism,  which  lasted  only  four  days. 

February  10th.— Cough,  without  physical  signs.  Pain  and 
tenderness  in  right  groin  and  along  right  iliacus  internus  mus¬ 
cle,  and  in  front  of  left  ear;  and  on  the  12th  in  the  left  ankle. 
Temperature,  100  5°  F. ;  pulse,  102.  The  dry  cough  continued 
till  February  17th,  the  pains  having  nearly  abated,  but  on  the 
22d  there  was  still  some  stiffness  of  left  wrist. 

He  was  then  out  and  going  to  school  until  May  23d,  when 
he  had  an  acute  amygdalitis,  the  tonsils  being  so  much  swollen 
as  nearly  to  close  the  isthmus  faucium,  with  fever.  He  got  an 
active  cathartic,  and  the  next  day  the  tonsils  were  nearly  nor¬ 
mal  and  fever  gone.  He  continued  well  after  this  until  Febru¬ 
ary  3,  1890,  when  he  had  an  acute  inflammation  of  the  tonsils, 
with  rheumatism,  from  all  of  which  he  recovered  in  six  days. 

February  16 ,  1890.— In  bed  with  subacute  rheumatism  in 
toes,  ankles,  and  right  hip,  which  disappeared  in  two  days. 

March  12th. — Subacute  rheumatism  since  9th,  now  chiefly 
in  left  wrist.  Slight  icterus.  Was  given  dilute  nitrohydro- 
chloric  acid  and  strychnine. 

llfth.— Some  pain  in  cardiac  region.  Pulse  60,  somewhat 
Unequal,  with  a  slight  thrill  in  radial  artery. 

April  12th. — No  pain  and  no  thrill  in  pulse  since  March 
16th.  Out  daily  and  feels  well. 

Was  treated  with  salicylate  of  sodium  during  the  several 
attacks,  followed  by  tincture  of  chloride  of  iron  and  dilute 
phosphoric  acid  after  convalescence.  But  the  latest  attack  was 
treated  by  nitrohydrochloric  acid  and  strychnine,  in  addition  to 
the  salicylate. 

Thus  in  five  consecutive  months  he  had  five  attacks,  and, 
after  nine  months’  freedom  from  illness,  three  more  attacks, 
in  the  course  of  two  months,  of  amygdalitis  or  rheumatism, 
or  both  combined.  In  the  intervals  he  was  out  and  gen¬ 
erally  at  school.  Since  the  latest  attack  in  March  he  has 
been  well ;  has  been  on  a  plainer  diet  than  usual,  with  care 
to  avoid  anything  likely  to  produce  indigestion. 


Til  A  TER :  0  BSER  VA  TI  ON'S  ON  RHE  UMATISM. 


[N.  Y.  Med.  Jocr., 


March  1st.— Cough  less.  Pain  in  neck  and  right  side  of 


92 

Case  II.— A.  W.  A.,  commercial  traveler,  aged  forty,  mar¬ 
ried.  Has  had  an  attack  of  alcoholism  about  every  two  years; 
one  in  October  and  November,  1888,  for  which  he  had  been 
under  treatment.  Then  went  to  Indiana,  whence  he  returned 
December  4th  with  acute  rheumatism  of  arms  and  neck,  amyg¬ 
dalitis  and  gonorrhoea,  dating  from  December  1st. 

December  5th.- In  bed.  Pulse,  84.  Tongue  thickly  coated. 
Redness  and  swelling  of  tonsils  and  pharynx,  without  exuda¬ 
tion.  Deglutition  painful.  Neck  and  shoulders  paintul  and  im¬ 
movable. 

1th. _ Right  knee  invaded  ;  neck  same.  Tonsils  pale  and  less 

swollen. 

In  a  day  or  two  began  to  have  headache,  at  first  every  other 
afternoon,  with  fever  and  delirium.  The  pain  was  in  the  right 
frontal  region.  By  January  1,  1889,  it  continued  daily,  and 
there  was  spasm  of  the  left  arm  and  leg  when  he  attempted  to 
rise.  The  fever  recurred  every  afternoon,  and  the  pain  was 
then  most  severe.  His  morning  temperature  was  normal.  His 
knee  continued  inflamed,  but  there  was  no  rheumatism  else¬ 
where.  The  record  of  January  23d  is:  “10  a.  m.,  daily  head¬ 
ache,  generally  in  the  afternoon,  with  much  fever,  followed  by 
sweating.  Spasm  of  left  side  once  every  day  when  attempt¬ 
ing  to  sit  up,  but  less  severe  than  it  has  been.  Temperature, 

98-4°.” 

There  was  gradual  improvement  from  this  time  until  Febru¬ 
ary  1st,  when,  after  the  excitment  attending  an  interview  about 
business,  he  had  headache  and  delirium  all  day,  and  in  the 
evening  was  violent  and  noisy,  until  quieted  by  a  hypodermic 
injection  of  morphine  and  atropine.  Next  morning  his  pulse 
was  68;  temperature,  98°.  The  sulphate  of  quinine,  which  he 
had  taken  since  January  23d,  was  increased  January  30th  to 
twenty  grains  every  morning,  and  ten  grains,  if  fever,  every 
evening.  He  had  uo  fever  or  headache  after  February  2d,  and 
steadily  gained  strength  and  flesh.  His  lame  knee  was  the  only 
remnant  of  rheumatism,  which  was  gradually  relieved  under  the 
application  of  compound  tincture  of  iodine.  The  quinine  was 
steadily  reduced,  so  that  on  the  8th  of  February  he  was  taking 
six  grains  a  day.  On  the  9th  he  was  dressed,  and  began  to  go 
to  business  March  6th.  The  gonorrhoea  never  received  atten¬ 
tion  and  disappeared  in  a  few  days. 

The  treatment  was  first  with  salicylate  of  sodium,  for  which 
acetate  of  potash  was  substituted  December  9th,  and  sulphate 
of  morphine  and  atropine  given  at  night.  Quinine  was  begun 

December  24th— six  grains  daily. 

January  1st.— Iodide  of  potassium  was  given  in  place  of  the 
acetate,  and  continued  till  January  23d,  when  it  was  omitted, 
and  quinine  increased  to  eighteen  grains  daily,  and  bromide  of 
potassium  was  given  with  every  dose. 

30th. _ The  quinine  was  increased  to  thirty  grains  a  day,  but 

reduced  after  February  2d  on  the  disappearance  of  the  fever. 

Case  III.— F.  B.,  a  girl,  seventeen  years  old,  who,  March 
23,  1889,  had  an  acute  catarrh,  with  cough. 

March  27th.— Follicular  amygdalitis. 

April  5th. — Cough  nearly  gone.  Large  swelling,  with  ten¬ 
derness  of  left  submaxillary  gland,  which  subsided  in  a  few 
days. 

23ft. _ Amygdalitis.  Rheumatism  in  shoulders  and  insteps. 

Got  salicylate  of  sodium. 

28th. — Rheumatism  has  gone  from  joint  to  joint,  with  little 
swelling.  Now  in  left  wrist  only.  It  soon  entirely  disappeared. 

Case  IY.— Miss  E.  B.,  aged  thirty. 

February  13 ,  1889.  —  Painful  deglutition  last  two  days. 
Moderate  follicular  amygdalitis. 

mh.— Pain  in  left  arm  and  in  one  spot  in  abdomen. 

26th. — Catarrhal  laryngitis  for  two  days;  still  has  pain  in 
neck,  left  chest,  and  leg. 


oead. 

j^th. — Hoarseness  and  cough  much  less.  Never  any  expecto¬ 
ration.  Pulse,  66  ;  small.  No  impulse  of  heart  felt.  Rhythm 
normal,  except  that  the  first  sound  is  duplicated.  Pain  at  times 

under  right  knee  ;  none  elsewhere. 

6th. — Pain  in  both  ankles  and  right  elbow.  Got  out  about 
March  12th,  and  lameness  of  joints  gradually  disappeared. 

Case  V.  June  3 ,  1889.— Grace  W.,  aged  sixteen.  In  bed 
with  acute  articular  rheumatism,  involving  now  left  knee  and 
ankle  and  lumbar  region.  Has  had  this  for  several  days,  follow¬ 
ing  quinsy  with  purulent  discharge.  Reports  that  she  had 
quinsy  in  1886  and  1888,  the  second  attack  being  followed  by 
articular  rheumatism,  continuing  nine  weeks. 

3th. — Right  hand  swollen  and  very  painful ;  no  rheumatism 
elsewhere,  except  at  times  pain  in  the  left  chest,  with  dyspnma. 
Pulse  regular.  Impulse  of  heart  normal. 

1th. _ After  visit  on  5th,  the  left  hand  became  inflamed. 

Yesterday  both  hands  were  well.  Last  night  and  now,  some 
pain  in  chest,  due  to  indigestion.  Relieved  by  a  mustard  emetic, 
and  had  no  return  of  rheumatism. 

Case  VI.— Mrs.  0.,  aged  thirty. 

February  3 ,  1889. — Follicular  amygdalitis,  with  subacute 
rheumatism. 

Case  YII  is  of  especial  interest,  as  an  instance  of  rheuma¬ 
tism  involving  a  derangement  of  the  lymphatics.  E.  K.,  a  gener¬ 
ally  healthy  boy,  twelve  years  of  age,  began  late  in  November, 
1889,  to  have  occasional  pain  in  the  left  side  of  the  abdomen, 
overa  limited  region,  without  fever  or  other  symptom.  Then 
headache  for  several  days.  But  by  December  4th  his  pains 
were  gone  and  he  went  to  school. 

December  12th. — Pain  in  the  right  side  of  abdomen  between 
the  crest  of  the  ilium  and  the  ribs  when  he  moves,  and  some¬ 
what  aggravated  by  pressure.  None  on  the  left  side,  none  in 
head,  some  pain  in  left  tonsil.  Is  generally  well. 

16th. — Slight  pain  on  both  sides  of  abdomen.  The  left  sub¬ 
maxillary  lymphatic  gland  has  been  swollen  and  tender  for  th( 
last  two  days. 

He  had  slight  fever  December  21st  and  22d.  Temperature. 
100-8°.  From  that  time  through  January  he  had  daily  moder 
ate  headache  from  rising  until  noon,  and  every  day  slight  pair 
in  abdomen,  but  he  was  not  far  from  well  in  general,  did  not 
lose  flesh,  and  went  to  school  daily. 

January  25th—  Pulse,  84,  regular.  Temperature,  98-8° 
Slight  pain  on  both  sides  of  abdomen  and  lower  right  chest 
without  tenderness.  Bowels  moving  daily.  Swelling  of  lym 
phatic  submaxillary  gland  nearly  gone.  From  this  time  he  wa 
taken  out  of  school,  but  was  out  of  doors  daily.  He  eontinuei 
to  have  slight  pains  a  part  of  every  day— sometimes  on  one  side 
sometimes  on  the  other  of  abdomen  and  chest;  but  by  th< 
middle  of  March  they  were  much  less  frequent.  He  had  a  goo< 

appetite  and  slept  well.  i 

March  21st. — Yesterday  began  to  have  some  sore  throat,  bu 
so  slight  that  he  did  not  speak  of  it.  Was  feverish  and  restles 
all  night.  This  morning  great  swelling  of  the  left  (salivary 
submaxillary  and  sublingual  glands  and  surrounding  tissue 
above  and  below  lower  jaw,  so  that  he  can  only  separate  jaw 
half  an  inch.  Face  flushed.  Swallowing  painful.  Pulse,  120. 

5  p.  m .—Opened  mouth  with  difficulty  widely  enough  t 
show  swelling  of  entire  soft  palate  and  tongue ;  not  very  red. 

22 d. — Raises  some  mucus,  streaked  with  blood.  Pulse,  ID 

less  full. 

5  P.  M.— Pulse,  100.  Temperature  in  axilla,  100'8°.  Som 
headache. 

He  improved  rapidly,  but  on  March  30th  was  still  sonn 
what  restricted  in  opening  his  mouth,  by  the  relics  of  the  celh 


July  26,  1890.] 


THAYER:  OBSERVATIONS  ON  RHEUMATISM. 


93 


litis  around  the  muscles  of  the  jaw.  He  had  no  abdominal  pain 
during  this  attack,  and  has  had  non  eanywhere  since  his  recov¬ 
ery,  eight  weeks  before  the  date  of  the  present  report.  About 
the  first  of  May  he  had  an  indigestion,  entirely  relieved  by  a 

mustard  emetic. 

Seen  May  7th.  Feels  very  well.  Left  lymphatic  submaxil¬ 
lary  gland  still  visible  and  palpable,  but  not  tender. 

His  treatment  was  first  with  a  cathartic,  then  salol  for  a  fort¬ 
night.  Then  iron,  quinine,  and  phosphoric  acid.  The  attack 
of  cellulitis  was  treated  with  a  cathartic  dose  of  calomel,  aconite 
during  the  continuance  of  the  fever,  with  a  mouth-wash  of  car¬ 
bolic-acid  solution,  and  soap  liniment  and  aconite  liniment  to 
the  cheek,  with  whisky  after  the  first  day.  And  when  conva¬ 
lescence  was  fairly  established  he  was  put  upon  dilute  nitro- 
hydrochloric  acid  after  meals,  which  was  continued  four 
weeks. 

May  M-Two  months  from  the  attack  of  cellulitis.  Dur¬ 
ing  this  interval  he  has  been  entirely  free  from  pain  or  other 
symptom,  except  the  attack  of  indigestion  mentioned  at  the  be¬ 
ginning  of  the  month.  To-day  there  is  slight  swelling  and  ten¬ 
derness  ot  the  left  parotid  gland,  with  some  pain  in  chewing. 
Throat  normal.  No  pain  in  swallowing.  Tongue  clean.  No 
fever. 

Directed  decolorized  tincture  of  iodine  to  the  surface  three 
times  a  day,  and  an  aloetic  laxative. 

23d. — Swelling  less;  hardly  any  tenderness.  No  pain  in 
chewing.  Reports  slight  pain  on  right  side  in  swallowing. 
Tonsils  nearly  normal  size.  Tongue  clean.  Temperature, 
98-8°.  Pulse  has  a  slight  thrill ;  impulse  of  heart  strong,  regu¬ 
lar.  Feels  well.  Goes  out. 

Solution  of  carbolic  acid  and  glycerin  for  gargle. 

25th. — No  pain  in  swallowing.  Parotid  swelling  has  nearly 
disappeared,  but  there  is  a  slight  swelling  and  tenderness  of  in¬ 
teguments  around  zygomatic  arch. 

Resume  dilute  nitrohydrochloric  acid. 

There  has  been  through  this  case  evidence  of  the  endo¬ 
cardium  sharing  in  the  rheumatic  affection,  indicated  by  a 
somewhat  rasping  systolic  sound  and  a  thrill  in  the  radial 
pulse  at  the  time  of  the  acute  attacks.  He  had  never  pre¬ 
viously  to  this  illness  had  any  cardiac  affection. 

Some  of  the  cases  just  related  may  be  a  desirable  contri¬ 
bution  to  the  study  of  the  physiology  of  the  tonsils  which  has 
enlisted  the  attention  of  various  physicians  within  the  last 
few  years.  Without  venturing  to  express  any  opinion  upon 
the  subject,  I  offer  them  as  possibly  available  items  of  evi¬ 
dence  when  the  physiological  inquiry  is  in  progress.  It 
was  begun,  I  believe,  by  Dr.  R.  Kingston  Fox,  and  has  been 
pursued  by  Dr.  S.  Spicer  and  several  others,  but  never 
experimentally.  Dr.  Fox  says  of  the  functions  of  the  ton¬ 
sils  in  health  ( Lancet ,  1888)  :  “These  organs  consist  of  a 
mass  of  closed  sacs  or  nodules,  identical  in  structure  with 
those  of  the  solitary  and  Peyer’s  glands,  and,  indeed,  of  the 
ordinary  lymphatic  glands  of  the  body.  Some  small  mu¬ 
cous  glands  open  into  the  crypts  on  the  surface,  but  these 
are  quite  insignificant.  .  .  .  Their  functions  must  be  of  the 
absorbent  kind.  ...  In  health,  food  matter,  perhaps  a  fer¬ 
ment,  would  be  absorbed  from  the  saliva,  and  stimulate  the 
tonsils  to  healthy  activity.  In  disease  a  poison,  perhaps 
also  a  ferment,  is  absorbed  from  the  saliva  and  overstimulates 
the  tonsil ;  there  is  overactivity,  multiplication  of  ill-formed 
cells,  and  other  phenomena  of  inflammation.” 

Dr.  Spicer  ( Lancet ,  1888),  quoting  Dr.  Fox,  says  the 


tonsils  are  absorbents  of  the  excess  of  buccal  secretions 
and  liquids  from  the  food,  and  form  part  of  the  blood¬ 
manufacturing  system— “  nurseries  for  young  leucocytes, 
planted  by  the  waterside,  and  drawing  their  sustenance  from 
the  nutrient  stream.  .  .  .  The  anatomical  facts  on  which 
these  views  are  based  are  the  following :  The  tonsils  are 
like  sponges  in  texture,  consistence,  and  structure,  being- 
riddled  with  lacunae  or  crypts.  In  the  intervals  of  degluti- 
tion  these  spongy  organs  lie  in  the  glosso-epiglottic  fosste, 
soaking  in  the  buccal  secretions,  which  fill  up  all  their 
pores.  Further,  the  tonsils  are  constructed  on  the  type  of 
ane,  corrugated  so  as  to  expose  a  large  sur¬ 
face,  and  on  these  corrugations  are  thickly  studded  lymph 
follicles,  as  well  as  in  these  organs  a  very  rich  plexus  of 
lymphatic  vessels,  which  must  have  some  function  ;  and 
what  more  probable  than  the  relation  suggested,  of  which 
we  have  so  much  confirmatory  evidence.  Also  these  fol¬ 
licle  aggregations  are  situated  at  places  just  below  the  out¬ 
put  of  the  buccal  secretions,  and  in  the  course  which  these 
must  take.” 

It  will  be  observed  that  the  views  just  quoted  of  the 
physiology  of  the  tonsils  are  purely  theoretical.  They  are 
plausible  theories,  but  careful  experiments  which  have  been 
made  lately  do  not  confirm  them.  Dr.  Eugene  Hodenpyl, 
of  Brooklyn,  has  been  devoting  much  time  and  care  to  ex¬ 
periments  upon  living  animals  and  microscopic  examination 
of  the  faucial  tonsils,  with  results  not  yet  published,  but 
which  he  has  kindly  permitted  me  to  use.  Some  of  his 
conclusions  from  an  exhaustive  study  of  the  tonsils  are  as 
follows :  “  None  of  the  theories  thus  far  advanced  to  explain 
the  functions  ot  the  tonsils  are  conclusive.  The  tonsils  are 
not  absorbing  organs.  They  neither  absorb  fluids  nor  solid 
particles  from  the  mouth,  under  ordinary  conditions,  nor  do 
they  take  up  foreign  materials  from  the  tissues  in  their  im¬ 
mediate  neighborhood.” 

The  question  as  to  the  office  of  the  tonsils  in  health,  and 
what  relation  they  bear  to  the  general  physical  organization 
in  the  diseases  in  which  they  suffer,  may  be  considered  to 
be  still  open  for  investigation  and  discussion. 


Antiseptic  Solutions  for  Midwives. — “  The  Academie  de  medecine, 
of  Paris,  having  recommended  that  midwives  should  be  advised  to  em¬ 
ploy  a  solution  of  bichloride  of  mercury  in  all  obstetric  cases,  and  that 
to  avoid  accidents  it  should  be  colored,  a  committee,  including  MM. 
Brouardel  and  Tarnier,  and  of  which  Dr.  Baden  is  the  reporter,  recom¬ 
mends  that  the  packets  of  disinfectant  should  be  made  up  according  to 
the  following  formula :  ‘  Corrosive  sublimate,  26  centigrammes  ;  tartaric 
acid,  1  gramme;  alcoholic  solution  of  dry  carmin  of  indigo  (6  per 
cent.),  1  drop  ;  reduce  to  an  impalpable  powder.’  This  quantity  suffices 
for  a  quart  of  water.” — British  Medical  Journal. 

Death  after  the  Inhalation  of  Bromide  of  Ethyl. — “  A  somewhat 
important  case  is  now  before  the  Berlin  courts,  in  which  a  dentist  is 
charged  with  having  caused  the  death  of  a  patient  by  means  of  an 
anaesthetic.  The  patient  was  a  lady,  and  the  dentist  intrusted  his 
pupil,  whose  age  was  under  seventeen,  with  the  administration  of  bro¬ 
mide  of  ethyl.  Of  this  about  an  ounce  was  administered,  together 
with  four  or  live  drops  of  chloroform.  The  patient  is  stated  to  have 
recovered  completely  from  the  effects  of  the  anaesthetic,  and  to  have 
felt  quite  well  during  the  remainder  of  the  day.  The  next  day,  how¬ 
ever,  she  died,  and  a  commission  of  medical  experts  has  been  directed 
to  report  upon  the  matter.” — Lancet. 


SOME  POINTS  IN  THE  DIAGNOSIS  OF 
CERTAIN!  SIMULATED  MENTAL  AND 
NERVOUS  DISEASES.* 


By  J.  T.  ESKRIDGE,  M.  D., 


DENVER,  COL., 

FORMERLT  post-graduate  instructor  in  nervous  diseases  in  the 

JEFFERSON  MEDICAL  COLLEGE,  AND  PHYSICIAN  TO  THE 

hospital  of  the  college,  etc. 


The  symptoms  exhibited  by  a  shrewd  malingerer  or  a 
clever  hysterical  patient  may  so  closely  simulate  organic 
disease  of  the  nervous  system  that  the  best  diagnostician 
will  at  times  hesitate  in  some  cases  before  giving  an  opin¬ 
ion.  In  some  instances  persons  suffering  from  actual  disease 
of  the  nervous  system  may  feign,  for  reasons  best  known 
to  themselves,  a 'different  trouble,  or  the  hysterical  may 
simulate  a  certain  organic  nervous  affection  and  at  the  same 
time  be  suffering  from  some  other  organic  disease;  and,  on 
the  other  hand,  we  not  infrequently  find  an  array  of  so- 
called  hysterical  phenomena  in  patients  who  are  afflicted 
with  some  serious  organic  brain  lesions.  The  hysterical 
should  not  be  confounded  with  the  malingerer,  but  it  is 
rarely  we  see  a  case  of  hysteria  without  some  elements  of 
malingering.  The  causes  for  the  latter  are  different  from 

those  that  result  in  hysteria. 

Malingering.— In  civil  life  the  causes  for  malingering 
are  found  among  the  mercenary,  who  feign  injury  for  the 
hope  of  gaining  remuneration,  from  a  corporation  most 
commonly  ;  among  the  criminal  class,  who  hope  to  escape 
their  deserved  punishment;  and  among  the  tramp  class,  who 
are  trying  to  “dead-beat”  their  way,  in  order  to  gain  sus¬ 
tenance  in  hospitals,  or  to  eke  out  a  miserable  existence  by 
imposing  upon  the  charitably  inclined.  Among  the  crimi¬ 
nals  and  tramps  epilepsy  and  insanity,  according  to  the 
writer’s  experience,  are  the  most  common  affections  of  the 
nervous  system  feigned;  but  among  the  mercenary  feigners 
organic  diseases  of  the  spinal  cord,  and  sometimes  of  the 
brain,  are  more  or  less  imperfectly  simulated. 

The  object  of  this  paper  is  not  to  go  into  a  lengthy 
discussion  on  the  points  in  the  differential  diagnosis  be¬ 
tween  real  and  feigned  disease,  but  to  call  the  attention  ot 
the  members  of  the  society  to  the  subject  of  the  paper  in 
the  hope  of  eliciting  discussion  and  the  narration  of  similar 
cases.  I  will  illustrate  the  tramp,  criminal,  and  mercenary 
malingerers  by  the  following : 


Tramp  Class.  Case  I.  Feigned  Epilepsy. — A  boy,  eighteen 
years  old,  gave  a  history  of  convulsions  dating  over  a  period  of 
three  or  four  years.  He  professed  to  be  a  telegraph  operator. 
He  was  found  on  the  streets  of  Denver  in  a  convulsion,  and 
taken  to  a  police  station  in  an  apparently  unconscious  condition. 
He  was  taken  to  the  County  Hospital  the  next  day.  He  was 
having,  on  an  average,  two  or  three  convulsions  daily,  but  none 
of  the  attacks  since  his  admission  into  the  hospital  had  been 
witnessed  by  a  physician.  He  was  given  large  doses  of  sodium 
bromide,  but  his  attacks  continued  and  seemed  to  increase  in 
frequency.  This  fact  was  reported  to  me  and  at  once  aroused 
my  suspicion  of  their  genuineness.  On  further  inquiry,  I  found 
lie  did  not  bite  his  tongue,  and  that  the  attacks  usually  only 


*  Read  before  the  Colorado  State  Medical  Society  at  its  annual 
meeting. 


occurred  in  the  presence  of  certain  persons  whose  sympathies 
he  had  enlisted  in  his  favor.  On  getting  a  detailed  history 
from  him  of  his  attacks,  I  found  his  mental  condition  at  the 
time  of  their  occurrence  and  the  seizures  themselves  did  not 
correspond  with  the  phenomena  of  epilepsy.  I  requested  Dr. 
Baker,  the  resident  physician,  to  have  the  nurses  or  attendants 
notify'him  of  the  attacks,  and  for  him  to  study  them.  At  my 
next  visit  the  doctor  reported  that  he  had  seen  an  attack  in 
which  the  patient  assumed  grotesque  positions,  and  that  the  eyes 
turned  upward  when  he  raised  the  lids  to  examine  the  pupils. 

I  immediately  had  his  bromide  discontinued,  and  gave  him,  in¬ 
stead,  large  doses  of  milk  of  asafcetida  by  the  mouth.  He  protest¬ 
ed  that  he  had  no  control  over  his  seizures.  Not  long  after  this 
I  witnessed  one  of  his  attacks.  He  frothed  at  the  mouth,  threw 
his  limbs  in  every  conceivable  direction,  and  assumed  an  opis- 
thotonic  position.  At  this  stage  I  made  firm  pressure  over  each 
supra- orbital  nerve  with  the  ball  of  each  of  my  thumbs,  and,  as 
the  pressure  increased,  it  caused  him  so  much  pain  that  he 
struggled  to  free  himself  from  my  grasp,  and  caught  hold  of 
my  hands  and  pulled  them  away  from  his  face.  On  my  again 
renewing  the  pressure,  and  this  time  with  redoubled  energy,  he 
jumped  up,  and  the  spasm  (?)  was  over.  From  this  time  he 
took  the  precaution  to  have  no  more  convulsions  when  a  physi¬ 
cian  was  around.  Only  a  few  attacks  occurred  during  the  re¬ 
maining  weeks  of  his  stay  in  the  hospital,  and  these  were 
always  in  the  presence  of  persons  whose  sympathy  he  had  en¬ 
listed  in  his  favor.  A  few  days  after  he  was  dismissed  from 
the  hospital  he  was  again  found  by  the  police  lying  on  the  street 
in  an  apparently  unconscious  condition.  He  was  returned  to 
us  for  treatment.  This  time,  from  the  first,  he  was  treated  as 
“a  suspect,”  and  denied  many  privileges  of  the  hospital  which 
the  other  patients  enjoyed.  No  bromide  was  given  him.  He 
had  a  few  attacks  at  chosen  intervals,  but  these  always  oc¬ 
curred  in  the  presence  of  certain  persons,  and  away  from  the 
presence  of  the  attending  physician.  After  remaining  at  the 
hospital  for  a  few  days,  he  suddenly  left  to  escape  arrest  foi 
theft. 

Case  II.— An  inmate  of  the  hospital  for  one  or  two  years 
about  forty  years  old,  says  that  he  has  been  subject  to  epileptic 
convulsions  for  three  or  four  years,  the  attacks  dating  from  the 
time  when  his  left  knee,  which  is  now  ank'ylosed,  first  became 
affected.  The  patient  is  addicted  to  drunkenness,  is  disagrees 
ble,  quarrelsome,  repulsive,  and  believed  to  be  a  masturbator 
I  first  began  to  study  his  case  in  November,  1889.  At  that  timj 
he  was  taking  large  doses  of  potassium  bromide,  and  was  re 
ported  to  be  having  one  or  two  attacks  during  the  day,  and  a 
times  as  many  as  three  during  the  night.  The  night  in  Novem 
ber  immediately  preceding  my  seeing  him  he  had  had  severs 
seizures,  and  had  kept  the  patients  in  his  ward  awake  most  o 
the  time.  Two  or  three  persons  had  been  engaged  in  holdin 
him.  I  saw  him  about  4  p.  m.  He  was  then  in  an  attack,  an 
the  nurse  stated  that  he  had  had  them  almost  continuously  fo 
hours.  His  face  was  flushed,  and  his  movements  were  an  ac 
mirable  imitation  of  an  epileptic  attack.  I  had  never  suspecte 
the  genuineness  of  his  malady,  and  now  supposed  he  was  in 
condition  of  status  epilepticus.  On  inquiry,  however,  I  learne 
that  he  would  sometimes  throw  himself  from  the  bed  in  a 
attack  and  thrash  himself  around  the  room  at  a  furious  rate  ui 
less  restrained.  On  raising  the  eyelids  the  eyes  turned  upwai 
and  the  pupils  reacted  to  light.  The  pulse  was  not  much  acce 
erated  above  the  normal.  I  immediately  made  firm  pressui 
over  each  supra-orbital  nerve;  the  convulsive  movements  stoi 
ped,  and  the  patient  expressed  his  surprise  by  a  silly  laugh.  F 
then  admitted  that  he  had  been  feigning  “  fits,”  but  contend* 
that  he  wras  subject  to  regular  epileptic  paroxysms.  I  had  ti 
bromide  discontinued,  and  no  convulsions  occurred  for  sever 


uly  26,  1890.] 


ESKRIDGE:  SIMULATED  MENTAL  AND  NERVOUS  DISEASES. 


95 


ays.  In  a  short  time  the  nurse  reported  that  he  was  again 
ccasionally  having  a  convulsion,  but  I  did  not  have  the  good 
>rtune  to  witness  any  more  attacks,  and  Dr.  Baker,  the  resi- 
ent  physician,  said  he  had  not  seen  any  of  them.  He  was  ur- 
ent  for  medicine  for  his  epilepsy.  I  ordered  twenty  grains  of 
odium  chloride  to  be  given  him  three  time9  daily.  As  the 
medicine  tasted  salty,  but  different  from  his  usual  bromide 
fixture,  he  thought  it  was  composed  of  potassium  bromide  and 
odide,  and  again  his  paroxysms  ceased,  and  have  recurred  only 
comparatively  few  times  since.  At  the  present  writing  he  has 
ot  had  a  convulsion  for  nearly  ten  weeks.  I  have  a  suspicion 
hat  this  man  may  have  true  epilepsy,  with  a  large  element  of 
pure  cussednes9.”  On  one  occasion,  Dr.  Baker  informed  me,  he 
cted  strangely  in  a  dazed  kind  of  manner,  and  afterward  seemed 
o  have  no  recollection  of  what  he  had  done  during  this  time. 

Criminal  Class.  Cask  I. — In  the  spring  of  last  year  a  man 
y  the  name  of  T.,  whose  paramour,  with  whom  he  had  lived 
ar  ten  years,  claiming  her  as  his  wife,  left  him  and  became 
atimate  with  a  man  by  the  name  of  K.  T.  threatened 
o  kill  K.  and  the  so  -  called  Mrs.  T.,  and  purchased  ten 
rains  of  strychnine  at  a  drug-store  in  the  name  of  K.  T. 
oon  left  Denver  and  went  to  Omaha.  A  few  w'eeks  later  T. 
rrived  in  Denver  about  four  o’clock,  p.  m.,  and  secreted  him- 
elf  until  dark,  when  he  went  to  the  rear  of  the  house  in 
rhich  K.  and  Mrs.  T.  were  staying.  He  $iere  met  K.  and 
itally  shot  him.  He  remained  in  the  city  twenty-four  hours 
nd  escaped  to  Kansas  City.  He  was  arrested  and  brought 
ack  to  Denver.  At  the  trial,  at  which  he  was  convicted  of 
mrder  in  the  first  degree  and  sentenced  to  be  hanged,  he  gave 
le  the  details  of  the  killing,  the  causes  that  led  to  it,  and  many 
f  the  particulars  quite  connectedly.  He  is  a  man  below  the 
verage  intelligence,  but  cunning,  and  shows  an  infatuation  for 
is  unworthy  paramour.  There  certainly  was  no  evidence  of 
isanity,  and  I  so  testified.  A  short  time  after  T.  was  removed 
o  the  State  Penitentiary  at  Cafion  City  he  was  alleged  to  be 
asane.  He  was  brought  to  Denver  early  in  the  fall  of  1889 — 
his  time  in  order  to  have  the  question  of  his  insanity  tested, 
le  then  professed  to  have  forgotten  almost  everything ;  he 
ad  never  heard  of  a  man  by  the  name  of  K. ;  never  heard  of 
place  called  Denver;  never  knew  that  he  had  been  tried  for 
filing  any  one;  did  not  know  where  he  had  been  staging.  He 
ave  expressions  to  delusions  of  depression  and  expansion  at 
ne  and  the  same  time.  He  at  times  very  feebly  and  imperfect¬ 
s''  imitated  the  paretic  dement,  but  usually  best  played  the  r61e 
fa  dement.  This  was  done  so  poorly  as  to  expose  the  decep- 
ion  to  any  one  at  all  conversant  with  mental  diseases.  He 
eigned  to  have  forgotten  everything  connected  with  the  past — 
specially  everything  connected  with  his  crime,  things  that 
tamp  themselves  almost  indelibly  upon  a  mind  capable  of  re- 
lembering  anything.  But,  at  the  same  time,  he  could  relate 
rhat  was  given  him  to  eat,  how  he  was  treated,  and  little  occur¬ 
ences  in  prison  life.  This  man  is  still  in  the  State  Penitentiary, 
nd  is  alleged  by  some  to  be  insane. 

The  diagnostic  points  in  this  case  are :  First,  the  cbar- 
cter  of  the  delusions.  No  one,  sane  or  insane,  can  be  de¬ 
ceased  and  animated  at  one  and  the  same  time.  An  insane 
>erson  can  not  have  delusions  of  expansion  (mania)  and 
iepression  (melancholia)  at  one  and  the  same  time.  Such 
[elusions  may  alternate,  but  there  is  always  a  change  in  the 
>erson’s  actions  while  possessed  of  an  expansive  or  de- 
>ressed  delusion. 

Second,  as  regards  memory  :  In  dementia,  memory  of 
)ast  events  is  always  retained  after  memory  of  recent  events 

iave  faded  away. 


Case  II. — A  male  criminal,  about  thirty  years  old,  was  con¬ 
fined  in  the  Arapahoe  County  jail,  accused  of  obtaining  money 
under  false  pretenses.  He  had  been  incarcerated  for  several 
months,  and  seemed  to  be  in  fair  health.  About  four  weeks 
before  the  time  set  for  his  trial  he  began  to  have  convulsive 
paroxysms.  These  continued  for  three  weeks,  although  he  was 
taking  large  doses  of  potassium  bromide.  The  attendants  at 
the  jail  were  up  with  him  night  and  day,  two  or  three  being  re¬ 
quired,  they  thought,  to  prevent  his  injuring  himself  against  the 
iron  bars,  as  he  threw  himself  about  at  a  violent  rate.  Dr.  Mc- 
Lauthlin,  the  county  physician,  had  seen  him  a  number  of 
times  and  pronounced  the  attacks  hysterical  or  feigned.  He  re¬ 
quested  me  to  see  him.  I  visited  him  early  one  morning,  found 
him  strapped  down  and  three  attendants  by  him.  They  stated 
that  he  had  been  having  convulsions  every  few  minutes  all  night, 
and  that  it  was  with  great  difficulty  that  they  could  prevent 
him  from  injuring  himself.  His  pulse  was  110;  breathing 
rapid ;  temperature  normal.  His  face  was  pale  and  haggard. 
While  I  was  talking  with  him  he  said:  “Now  it  is  coming 
again,”  and  began  to  roll  his  eyes  upward.  His  face  was  twisted 
from  side  to  side,  not  spasmodically  jerked  by  individual  mus¬ 
cles.  Soon  his  arms  and  legs  were  involved  and  he  assumed  an 
opisthotonic  position.  I  spoke  to  him  ;  he  neither  answered  nor 
gave  the  least  sign  of  hearing.  I  opened  the  eyes  and  found 
the  pupils  reacted  to  light.  Without  further  examination  I 
placed  the  balls  of  my  thumbs  over  the  supra-orbital  nerves  at  the 
point  of  their  emergence  from  their  foramina,  and  pressed  with 
considerable  force.  The  result  was  marked  and  almost  instan¬ 
taneous.  He  at  once  endeavored  to  turn  his  head  from  me,  but, 
failing  in  this,  he  clinched  my  hands  with  both  of  his  and  pulled, 
and  at  the  same  time  freed  his  head  from  my  grasp  by  a  volun¬ 
tary  rotation  of  his  head.  I  requested  the  attendants  to  leave 
the  cell.  I  then  told  the  prisoner  that  I  had  caught  him  feign¬ 
ing,  and  that  if  he  had  another  such  spell  while  he  was  in  jail 
I  would  go  into  Court,  if  called  upon  to  testify  in  his  case,  and 
swear  that  he  was  feigning,  which  would  prejudice  the  jury’s 
mind  against  him.  He  promised  to  desist  from  another  attempt. 
I  had  him  unstrapped  and  dismissed  his  attendants,  assuring 
them  that  he  had  no  further  need  of  their  services.  His  epi¬ 
lepsy  was  cured.  His  object  in  feigning  epilepsy  was  to  be 
transferred  to  the  County  Hospital  for  treatment,  from  which 
he  knew  he  could  effect  his  escape. 

Mercenary  Class.  Case  I. — Miss  O.  fell,  in  stepping  from  the 
car  of  the  Denver  Tramway  Company  in  January,  1889,  striking 
the  back  of  her  head  against  the  ground.  She  seemed  to  be  dazed 
or  semi-unconscious,  and  was  taken  into  a  house  a  few  yards 
distant,  where  she  remained  in  about  the  same  condition  until 
transferred  to  Saint  Luke’s  Hospital  the  next  morning.  She 
was  in  the  hospital  two  to  three  weeks,  and  about  one  week  of 
this  time  she  seemed  to  be  semi-unconscious,  but  irritable  and 
cranky  all  of  the  time.  It  was  learned  that  there  was  some 
bruising  of  the  soft  tissues  over  the  occipital  bone  just  to  the 
left  of  the  prominence  of  this  bone.  It  was  thought  by  the  sur¬ 
geon  under  whose  care  she  was  at  the  time  she  remained  at  the 
hospital  that  there  was  a  fracture  of  the  occipital  bone,  with 
depression  of  the  fracture. 

By  order  of  the  Court,  Dr.  H.  A.  Lemen,  Dr.  H.  A.  Baker, 
and  the  writer  were  appointed  to  examine  into  her  condition, 
The  examination  took  place  October  17,  1889.  Her  history,  as 
she  gave  it  to  us,  wa9  as  follows :  She  said  she  had  always  enjoyed 
good  health  up  to  the  time  of  the  accident,  but  since  that  time 
she  had  lost  just  forty  pounds  by  actual  weight ;  she  had  grown 
nervous;  suffered  much  from  pains  in  the  back  and  head,  espe¬ 
cially  in  the  occipital  region;  was  sleepless;  could  not  see  the 
largest  letters  on  the  street  signs,  and  it  was  with  great  diffi¬ 
culty  that  she  could  walk.  We  found  her  tempei*ature,  includ- 


96 


ESKRIDGE:  SIMULATED  MENTAL  AND  NERVOUS  DISEASES. 


[N.  Y.  Med.  Joub., 


ing  that  of  the  surface  of  the  head,  normal.  The  motorial  and 
sensory  phenomena  showed  no  deviation  from  health.  The  elec¬ 
trical  reactions  and  reflexes,  deep  and  superficial,  were  good  and 
equal  on  both  sides.  Touch,  taste,  smell,  and  hearing  were  well 
preserved  and  about  equal  on  both  sides.  We  now  came  to  the 
eyes.  She  contended  that  before  the  accident  she  could  read 
fine  print  and  signs  at  a  distance,  as  well  as  the  ordinary  per¬ 
son,  without  the  use  of  glasses.  We  found  the  pupils  equal,  re¬ 
acting  well  to  light  and  accommodation,  and  about  normal  in 
size.  The  ophthalmoscope  showed  healthy  fundi.  The  fields 
seemed  contracted,  but,  on  repeating  the  examination  several 
times,  the  size  of  the  fields  varied  very  considerably.  She  was 
shown  a  book  and  professed  to  be  unable  to  see  whether  or  not 
there  was  any  print  in  it.  Of  large  letters,  which  the  normal  eye 
will  read  at  a  hundred  feet  distance,  she  said  she  could  not  see 
what  they  were  when  held  only  a  few  feet  from  her  eyes. 
Glasses,  plus  36,  about  one  dioptre,  were  placed  before  each  eye. 
She  then  read  fine  print  at  the  ordinary  distance.  The  fields  of 
vision  were  enlarged,  and  she  read  at  a  distance  as  well  as  the 
majority  of  persons.  This  was  positive  proof  that  she  was 
feigning  poor  vision.  As  we  had  found  no  evidence  of  any  or¬ 
ganic  disease,  we  felt  justified  in  excluding  any,  especially  after 
detecting  her  in  feigning  imperfect  vision.  She  was  nervous, 
irritable,  and  not  very  well  nourished.  After  excluding  every¬ 
thing  except  spinal  irritation,  we  next  proceeded  to  test  the 
truthfulness  of  her  statements  regarding  her  health  before  the 
accident.  We  weighed  her  and  found  that  she  was  nearly  ten 
pounds  heavier  than  she  professed  to  have  been  two  days  before 
her  examination.  Upon  inquiry  of  her  employer  at  the  time  ot 
and  before  the  accident,  we  learned  that  she  had  not  been  well. 
He  said  that  she  looked  as  well  in  October  as  she  did  in  Janu¬ 
ary  before  the  accident,  and  that  while  she  was  living  in  his 
family  she  had  been  nervous,  irritable,  and  poorly  nourished, 
and  required  to  rest  in  bed  one  day  every  week  or  two  on  ac¬ 
count  of  pain  in  the  lower  portion  of  the  body.  The  physicians 
who  had  treated  her  before  she  came  to  Colorado  stated  that 
she  was  irritable  and  nervous,  and  suffered  from  uterine  trouble 
while  under  their  care.  Since  our  official  report  we  have  seen 
her  on  the  streets  of  Denver  walking  as  briskly  and  nimbly  as 
one  in  perfect  health. 

Case  II. — Mrs.  H.,  aged  thirty-three,  was  a  passenger  on  the 
Santa  F6  train  at  the  time  of  the  Fountain  explosion  from  giant 
powder  in  May,  1888.  Her  face  and  hands  were  cut  with  glass, 
and  she  was  shaken  up  considerably.  The  explosion  took  place 
about  4  o’clock,  a.  m.,  while  the  passengers  were  all  asleep.  She 
stated  that  before  the  accident  she  had  enjoyed  perfect  health, 
but  since  that  time  she  has  been  nervous  and  sleepless,  and  has 
suffered  from  pain  in  the  head  and  spine.  She  has  brought  suit 
against  the  railroad,  and,  as  with  most  persons  who  are  waiting 
the  award  for  damages,  every  symptom  is  exaggerated.  The 
first  examination,  in  August,  1889,  was  highly  unsatisfactory,  as 
she  complained  of  the  slightest  contact  of  substances  with  any 
portion  of  the  body.  After  a  prolonged  examination  I  could 
find  no  evidence  of  any  organic  trouble,  and  so  informed  her. 
She  presented  herself  a  few  months  ago,  and  still  no  symptoms 
of  any  organic  lesion  were  found.  On  May  16,  1890,  she  again 
presented  herself  for  examination,  with  the  following  account  of 
her  symptoms  :  She  says  she  has  constant  pain  from  the  middle 
of  the  back,  running  through  to  the  stomach ;  has  great  difficulty 
in  rising  from  the  sitting  to  the  erect  posture  on  account  of  pain 
in  the  back.  The  pain  in  the  back  runs  from  below  upward. 
Complains  of  pain  and  a  drawing  sensation  in  the  legs  and  feet 
at  night.  She  is  exceedingly  nervous  and  feels  as  if  something 
was  going  to  happen.  Says  she  is  unable  to  read  fine  print,  and 
a  bright  light  is  painful ;  is  deaf  in  the  left  ear,  and  can  hear 
only  imperfectly  with  the  right..  Says  that  conversation  carried 


on  in  an  ordinary  tone  of  voice  she  does  not  hear ;  complains 
of  buzzing  in  the  head  and  a  dizzy  sensation,  a  feeling  likened 
to  lumps  in  the  back  of  the  neck,  and  a  drawing  sensation  of  the 
oost-cervical  muscles,  causing  her  to  bend  her  head  backward. 

Examination. — Gait  good ;  no  ataxic  symptoms ;  knee-jerks 
equal,  but  slightly  exaggerated.  All  the  other  deep  reflexes 
normal,  as  are  the  superficial  reflexes.  A  thorough  and  pro¬ 
longed  electric  test,  both  with  galvanism  and  faradism,  showed 
normal  reactions.  The  results  of  testing  the  sense  of  touch 
were  curious  and  significant.  Some  time  was  spent  in  trying 
to  ascertain  the  condition  of  this  sense.  At  one  time  it  was 
normal ;  the  next  minute  it  would  vary  greatly  from  the  nor¬ 
mal,  or  she  would  profess  not  to  be  able  to  feel  anything.  There 
was  no  paresis,  paralysis,  or  wasting  of  any  muscles.  She  was 
able  to  bend  the  back  in  various  positions  without  complaint  if 
her  attention  was  kept  engaged,  but  her  movements  became 
limited  and  painful  when  her  attention  was  directed  to  what 
she  was  doing. 

The  dynamometer  registered  R.  80  ;  L.  80.  On  requesting 
her  to  try  the  instrument  again,  it  registered,  only  a  few  minutes 
after  the  first  trial,  R.  110  ;  L.  104. 

The  examination  of  the  special  senses  was  not  completed 
when  I  had  to  postpone  it  until  the  next  day.  As  yet,  two 
weeks  having  elapsed,  she  has  not  presented  herself.* 

Whatever  real  trouble  the  outcome  of  this  case  may  result 
in,  it  is  now  evident  that  she  is  hysterical  and  feigning,  and  thus, 
by  her  over-anxiety  to  appear  injured,  she  may  be  preventing 
the  detection  of  some  organic  lesion. 

Case  III. — Mr.  M.,  a  nervous,  slenderly  built  man,  about 
forty-five  years  old,  was  injured  on  the  Denver  Tramway  Road 
by  being  struck  on  the  back  by  a  wagon  while  in  the  act  of 
getting  on  a  car.  He  was  knocked  down  and  rendered  uncon¬ 
scious  for  some  hours.  He  remained  in  bed  about  a  week. 
About  six  months  after  the  accident  Dr.  Parkhill  and  I  exam¬ 
ined  him  at  his  request,  for  the  purpose  of  testifying  in  court. 
He  professed  to  have  considerable  pain  in  the  back  throughout 
the  entire  length  of  the  spine.  He  complained  of  the  slightest 
touch  on  most  of  the  spinous  processes.  He  had  a  limping,  halt¬ 
ing  gait,  walked  with  a  cane,  and  said  he  had  most  pain  in  the 
lower  portion  of  the  back  and  in  the  left  leg.  After  two  pro¬ 
longed  and  thorough  examinations  we  found  movement  much 
more  free  and  extensive  than  he  had  stated.  Sensation  in  every 
portion  of  the  body  was  normal.  The  reflexes  and  electrical 
reactions  showed  no  deviation  from  health.  We  could  find  no 
positive  evidence  of  any  organic  lesion,  and  one  of  us,  the  other 
not  being  called,  so  testified  in  court. 

In  conclusion,  I  will  discuss  only'a  few  of  the  points 
suggested  by  the  case  histories  that  form  the  foundation  of 
this  communication  to  the  society  : 

First,  the  detection  of  feigned  epileptic  convulsions. 
Under  ordinary  circumstances,  the  dilatation  and  immobile 
state  of  the  pupils,  the  insensibility  of  the  corneae,  the  char¬ 
acter  of  the  muscular  contractions,  the  onset  of  the  attack, 
the  stages  of  the  seizure,  and  the  subsequent  sequelae  will 
serve  to  distinguish  the  true  epileptoid  or  epileptic  fit 
from  the  feigned.  But  we  must  remember,  as  Romberg 
long  ago  pointed  out,  that  there  may  be  some  reflex  irrita¬ 
bility  in  true  epilepsy,  such  as  to  produce  winking  when  the 
cornea  is  touched.  During  the  past  year  I  saw  an  account 
of  the  observations  of  a  German  physician,  whose  name  1 
have  forgotten,  on  the  detection  of  feigned  epilepsy  in  crimi 

*  Her  suit  has  since  been  decided  in  the  U.  S.  District  Court.  Sh( 
sued  for  $26,000,  and  was  awarded  $760  damages. 


July  26,  1890.] 


ESKRIDGE:  SIMULATED  MENTAL  AND  NERVOUS  DISEASES . 


97 


nals.  This  observer  had  detected  simulated  epilepsy  in  sev¬ 
eral  hundred  criminals  simply  by  pressing  with  the  ball  of 
each  thumb  over  the  supra-orbital  nerves.  His  position  is 
behind  or  at  the  head  of  the  “  suspect,”  with  his  face  looking 
toward  the  simulator’s  feet.  In  this  position  one  can  exert 
considerable  pressure  on  the  supraorbital  nerves,  and  if  the 
patient  is  not  unconscious  he  is  unable  to  bear  the  pain,  and 
soon  endeavors  to  free  himself  from  the  operator’s  grasp. 
I  have  not  had  the  opportunity  to  try  this  test  in  attacks  of 
true  epilepsy,  but  here  a  corrugation  of  the  forehead  would 
not  be  sufficient  to  pronounce  the  case  feigned,  because 
there  may  be  some  reflex  action  of  the  muscles  even  when 
a  person  is  unconscious.  I  have  had  the  opportunity  of 
employing  this  method  in  detecting  feigned  epilepsy  in 
four  malingerers,  and  in  each  the  attack  was  cut  short,  and 
the  simulator  exerted  himself  voluntarily  in  order  to  get 
relief  from  the  pressure. 

Before  leaving  the  subject  of  feigned  epilepsy  I  wish  to 
utter  a  caution — viz.,  that  because  a  person  is  caught  feign¬ 
ing  epilepsy  we  must  not  at  once  conclude  that  he  does  not 
sutler  from  real  epilepsy.  Real  and  feigned  epilepsy,  I 
think,  were  exhibited  by  at  least  one  of  the  persons  whose 
cases  have  just  been  narrated. 

Feigned  Insanity. — In  the  majority  of  cases  of  simulated 
insanity  the  deception  is  comparatively  easy  to  expose.  It 
is  self-evident  that  the  task  is  made  easy  in  proportion  to 
the  familiarity  of  the  examiner  with  the  different  types  of 
insanity  and  their  differential  diagnosis,  and  in  proportion 
to  the  amount  of  clinical  study  he  has  given  to  the  insane. 
It  sometimes  happens  that  an  asylum  superintendent  is  a 
poor  diagnostician  of  insanity,  because,  in  many  instances, 
of  the  large  amount  of  executive  work  devolving  upon  him, 
thus  leaving  him  insufficient  time  to  devote  to  the  intelli¬ 
gent  and  systematic  study  of  minute  peculiarities  of  indi¬ 
vidual  cases  and  groups  of  cases.  It  is  rarely  that  a  simu¬ 
lator  of  insanity  is  sufficiently  informed  in  regard  to  the 
diagnostic  symptoms  of  the  different  varieties  of  the  disease 
to  prevent  his  confounding  them.  His  task  is  especially 
difficult  when  he  attempts  to  simulate  mania,  melancholia, 
or  dementia.  In  mania  or  melancholia  the  patient  may  be 
boisterous  or  quiet,  but  in  the  former  the  delusions  are 
always  of  an  expansive  character,  while  in  the  latter  they 
always  take  a  depressive  form.  In  dementia,  a  form  of  in¬ 
sanity  probably  one  of  the  most  difficult  to  feign,  the  fail¬ 
ure  of  memory  is  just  the  opposite  to  what  the  ordiuary 
layman,  when  he  attempts  to  simulate,  will  assume.  In  this 
form  of  insanity  memory  for  recent  events  is  first  lost  or 
affected,  while  that  for  occurrence's  which  took  place  before 
the  mind  became  impaired  is  often  retained  with  great 
minuteness  for  details;  and  this  holds  good  until  the  mind 
becomes  almost  a  total  blank.  The  patient  is  usually  quite 
talkative  unless  harassed  by  depressive  delusions.  Recent 
events,  unless  of  an  extraordinary  character,  make  no  or 
but  little  impression.  He  is  unable  to  tell  what  occurred 
the  day  before,  or  what  he  ate  the  previous  or  probably 
the  same  day.  Any  one  who  has  studied  the  diagnostic 
symptoms  of  dementia  and  is  at  all  conversant  with  the 
symptoms  exhibited  by  T.  must  realize  that  by  deception 
this  criminal  has  thus  far  cheated  justice. 


In  stuporous  insanity  malingering  is  sometimes  hard  to 
detect.  A  case  of  feigned  stupor  reported  by  Field  in  the  New 
York  Medical  Journal  for  May  3,  1890,  will  illustrate  this: 

“  Since  his  admission  he  had  not  spoken  or  made  any 
voluntary  movement ;  would  follow  where  he  was  led ;  if 
put  in  a  chair,  would  remain  there;  would  not  partake  of 
any  food  or  water  unless  they  were  put  in  his  mouth  ;  would 
swallow  mechanically.  Sometimes  he  would  wet  his  cloth¬ 
ing  or  the  bed.  He  had  a  fixed,  staring  expression,  only 
occasionally  winking.  He  was  not  cataleptic,  although  two 
physicians  had  so  certified  to  the  District  Attorney.  Noth¬ 
ing  would  startle  him  out  of  his  condition — neither  prick¬ 
ing,  nor  dashes  of  cold  water,  nor  pressure  on  the  supra¬ 
orbital  nerves.  He  lost  thirty  to  forty  pounds  of  weight. 
Subsequently  he  was  sent  to  the  Jefferson  Market  prison, 
from  which  he  escaped  by  sawing  out  a  bar  in  conjunction 
with  another  prisoner.  His  associate  was  recaptured  and 
told  how  he  had  aided  the  malingerer  in  his  deception. 
The  feigning  of  the  prisoner  had  been  carried  on  for  three 
or  four  months.” 

Real  or  Pretended  Traumatic  Cerebro  spinal  Affections, 
especially  such  as  follow  Railroad  Accidents. — That  cases 
of  severe  and  permanently  disabling  nervous  injuries  follow 
upon  and  are  caused  by  the  physical  and  mental  strain  in¬ 
cident  to  severe  railroad  collisions  are  as  well  attested  as 
that  cases  claiming  such  injuries  have  been  suddenly  and 
permanently  cured  after  damages  for  the  same  have  been 
settled  by  the  company  sued.  In  the  few  remaining  min¬ 
utes  for  which  I  crave  the  society’s  indulgence  I  shall  not 
attempt  to  discuss  the  positions  taken  by  three  classes  of 
writers  on  the  so-called  “  cerebro-spinal  shock.”  One  class, 
represented  by  the  railroad  surgeon,  who  often  becomes 
in  these  suits  for  damages  railroad  advocates,  contend  that 
most  of  the  symptoms  are  simulated.  The  second  class  is 
formed  by  Charcot  and  his  disciples,  who  at  one  time 
maintained  that  all  of  the  symptoms  might  be  accounted 
for  on  the  theory  of  hysteria,  especially  the  class  which  he 
designates  traumatic  hysteria.  And  the  third  and  last 
class  is  composed  of  the  over-enthusiastic  so-called  medical 
expert,  who  is  too  apt  to  accept  the  statements  of  the  pa¬ 
tient  implicitly  and  attribute  all  of  the  symptoms  to  some 
obscure  organic  disease  of  the  nervous  system.  Practically 
we  meet  with  applicants  for  remuneration  the  symptoms  of 
whose  injuries  are  mostly,  if  not  entirely,  feigned ;  and 
others  whose  ailments  are  purely  of  an  hysterical  nature, 
and  yet  others  whose  symptoms  are  due  to  organic  disease 
of  the  nervous  system.  On  the  other  hand,  it  is  not  infre¬ 
quently  that  we  may  find  the  simulated,  the  hysterical,  and 
the  organic  symptoms  combined  in  the  same  patient  at  the 
same  time. 

We  may  ask,  What  should  be  the  testimony  of  the 
medical  witness  when  called  upon  to  testify  in  regard  to 
nervous  injuries,  real  or  feigned,  alleged  by  parties  suing 
for  damages  ?  He  should  be  unbiased,  and  base  his  testi¬ 
mony  on  demonstrable  tacts  and  not  upon  possibilities.  It 
is  well  to  bear  in  mind  that  the  central  nervous  system  may 
have  sustained  permanent  injuries  and  no  objective  symp¬ 
toms  be  manifest  to  the  most  careful  examiner  until  several 
months,  or  perhaps  one  or  more  years,  after  the  accident. 


9S 


PARKE:  AMYGDALITIS  AND  TEE  CEREBROSPINAL  CENTERS.  [N.  Y.  Mkd.  Jour., 


AN  INQUIRY  INTO 


This  should  teach  the  claimant  caution.  In  such  cases,  if 
the  patient’s  health  is  not  being  injured  by  delay  of  legal 
proceedings,  the  suit  should  be  deferred  as  long  as  possible.  THE  RELATIONSHIP  OF  AMY  GDALITIS  TO 


The  examinations  should  be  made  jointly  by  at  least  two 
physicians — one  for  the  plaintiff  and  the  other  for  the  de¬ 
fendant — and  these  should  consult  together  simply  to  arrive 
at  the  truth.  The  examinations  should  be  thorough,  and 
repeated  sufficiently  often  to  prevent  erroneous  conclusions. 
The  patient’s  body  should  be  bared,  the  spines  of  the  ver¬ 
tebrae  and  the  muscles  of  the  back  carefully  examined — the 


THE  CEREBRO-SPINAL  CENTERS. 

By  J.  RICHARDSON  PARKE,  Ph.  G.,  M.D. 

Lesions  of  the  buccal  and  guttural  mucous  membrane 
and  its  underlying  structures,  especially  acute  suppurative 
amygdalitis,  by  reason  both  of  their  frequency  and  extremely 
painful  character,  challenge  to-day  no  insignificant  share  of 


former  for  tenderness  and  deformity,  and  the  latter  for  the  practitioner’s  attention,  and  warrant,  I  trust,  the  public 


tenseness  or  rigidity.  We  should  look  for  wasting  of  mus-  expression  of  whatever  opinions  experience  or  observation 


cles.  Next,  the  patient  should  be  required  to  bend  the  may  dictate  in  reference  both  to  cause  and  treatment, 
back  in  different  positions,  and  the  freedom  or  restraint  of  When  we  remember  the  anatomy  and  physiology  of  the 

I  .  i  i  .1  i*  1*1  .  1  ' -  1.  1 1  r  ^  ...  i-  l .  .  n  ♦  L  /%  I  n-n  A  or 


motions  observed  and  carefully  noted.  The  gait  of  the  tonsils, both  of  which  are  admirably  set  forth  in  the  Lancet 
patient  should  be  scrutinized,  and  all  of  the  tests  for  ataxic  for  1888,  ii,  805-807,  by  Spicer,  the  tenuity  of  the  follicles 


symptoms  carefully  employed.  The  reflexes,  deep  and  su-  which  comprise  the  gland,  the  character  of  secretion,  and 


perficial,  should  be  thoroughly  investigated,  after  which  a 
careful  electrical  test  for  the  condition  of  the  nerves  and 
muscles  should  be  used.  The  tactile,  muscular,  temperature, 
weight,  and  pain  senses  should  be  carefully  examined  and 
compared  on  the  two  sides  of  the  body.  This  is  sometimes 
of  the  greatest  importance,  especially  when  hysteria  or  feign¬ 
ing  is  suspected.  I  have  some  cases  of  organic  lesion  of  the 
cord  under  my  care  at  present  in  which,  in  certain  portions  of 


the  intimate  manner  in  which  it  stands  related  to  both  great 
divisions  of  the  nervous  system,  comparing  their  somewhat 
unique  physiology  with  the  remarks  which  every  physician 
must  sometimes  hear  in  reference  to  certain  peculiar  phe¬ 
nomena  attending  the  onset  of  the  disease,  I  can  not  but 
wonder  that  the  attention  of  pathologists  has  not  been  di¬ 
rected  more  specifically  to  the  question  of  idiopathic  neu¬ 
rotic  influence  in  the  causation  of  this  exceedingly  prevalent 


the  body  where  the  senses  of  touch  and  pain  are  present,  the  and  painful  complaint 


sense  of  temperature  is  abolished.  There  should  never  be  Most  common  in  young  strumous  constitutions,  v\hich  it 


less  than  two  thorough  examinations,  and  the  results  of  the  is  well  known  are  usually  of  high-strung  nervous  tempera 


second  examination  should  be  compared  with  the  first,  ments,  it  has  hitherto  been  supposed,  even  by  such  close 


The  condition  of  the  special  senses  should  never  be  neg-  observers  as  Ringer,  Cornil  and  Ranvier,  and  the  late  Pro 
lected.  The  patient’s  own  story  of  his  sufferings  should  be  fessor  Gross,  to  be  dependent  upon  such  trivial  causes  as 


duly  considered,  but  only  in  connection  with  the  results  of 
the  examination.  In  other  words,  we  should  never  be  led 
into  the  error  in  these  cases,  where  heavy  damages  are 
claimed,  of  making  a  diagnosis  on  subjective  symptoms 
only,  as  has  occurred  in  a  recent  case  in  this  city.  The 
health  of  the  patient  prior  to  the  accident  should  be  ascer¬ 
tained,  if  possible.  If,  after  careful  and  repeated  examina¬ 
tions,  we  find  no  objective  evidence  of  disease  of  the  nerv¬ 
ous  system,  it  seems  to  me  that  the  only  thing  left  for  the 
medical  witness  to  do  is  to  so  testify ;  for,  if  we  have  to 
base  the  diagnosis  entirely  on  subjective  symptoms,  unaided 
by  physical  signs,  we  are  placing  the  companies  sued,  so 
far  as  our  testimony  is  concerned,  on  the  honesty  of  the 
claimant  for  damages.  Some  of  our  courts  of  this  city  have 
decided,  and  it  seems  to  me  properly,  that  if  the  medical 
man  has  to  base  his  opinion  of  the  case  entirely  upon  what 
the  patient  tells  him,  such  testimony  in  those  cases  is  inad¬ 
missible,  and  the  claimant’s  statements  must  go  direct 
to  the  jury  without  being  interpreted  for  them  by  a  physi¬ 
cian. 

I  wish  to  say,  in  conclusion,  that  the  physician  who  has 
carefully  studied  these  cases  and  compared  the  results  of 
different  examinations  will  soon  be  able  to  sift  the  truth 
from  the  feigned  symptoms  of  disease.  Especially  is  this 
true  when  the  physiognomy  of  the  patient  is  studied  dur¬ 
ing  the  examination  and  compared  with  its  appearance  when 
his  attention  is  not  absorbed  by  the  examiner’s  method  of 
procedure. 


cold,  exposure,  etc.,  without  even  an  inquiry  into  the  re¬ 
markable  fact  that  similar  exposure  will  invariably  produce 
in  one  amygdalitis,  and  in  another  always  pharyngitis  and 
never  amygdalitis ;  in  one  the  slow,  deliberate  changes  of  a 
typical  membranous  inflammation,  in  the  other  a  rapidly 
developing  suppurative  cellulitis. 

That  the  disease  is  not  induced  primarily  in  insusceptible 
subjects  by  either  cold  or  exposure  is  proved  by  a  thousand 
facts  within  our  knowledge.  Some  of  our  old  army  sur¬ 
geons  who  witnessed  the  horrible  exposure  of  our  soldiers 
on  some  of  the  Southern  battle-fields,  as  well  as  the  Surgeon- 
General’s  Reports,  speak  of  comparatively  few  cases  of  ton¬ 
sillitis,  while  tetanus,  sciatica,  and  other  neuroses  were  ex¬ 
ceedingly  prevalent. 

After  the  battle  of  Ticonderoga  in  1758  the  wounded 
were  exposed  all  night  in  open  boats  on  Lake  George.  Yine 
died  of  traumatic  tetanus ;  no  cases  of  amygdalitis.  On  board 
the  frigate  Amazon  before  Charleston,  in  our  war  with  the 
British,  similar  reports  are  recorded.  The  battles  of  Baut¬ 
zen  and  Dresden  in  Napoleon’s  third  campaign,  and  a  thou¬ 
sand  others  in  history,  furnish  similar  instances  (Gross). 
Amygdalitis  is  uncommon  to  the  higher  types  of  virility,  but 
occurs  chiefly  in  anaemic,  delicate  girls,  and  in  men  some¬ 
times  when  the  nervous  system  is  unstrung  by  excesses, 
either  sexual  or  alcoholic.  A  patient  of  mine,  a  mill  girl 
having  no  exposure  to  cold,  developed  acute  amygdalitis 
four  hours  after  being  struck  in  the  back  by  a  loose  belt: 
and  while  practicing  in  Philadelphia  I  treated  a  case  of  sup- 


July  26,  1890.] 


PARKE:  AMYGDALITIS  AND  THE  GEREBRO-SPINAL  CENTERS. 


99 


purated  tonsils  palpably  induced  by  reading  the  newspaper 
details  of  a  fire  on  Pine  Street,  where  two  people  were 
roasted  to  death.  The  lady  had  never  left  her  comfortable 
room,  yet  the  onset  of  the  disease  occurred  within  three 
hours  after  reading  the  horrible  details. 

The  glosso-pharyngeal  nerve  rising  from  the  gray  nuclei 
in  the  floor  of  the  fourth  ventricle  is  very  closely  connected 
with  the  pneumogastric,  sympathetic,  and  facial  nerves,  and 
at  the  superior  cervical  ganglion  it  touches  like  the  key  of 
a  battery  the  whole  sympathetic  system,  both  giving  and 
receiving  impressions,  and,  being  a  branch  of  the  eighth 
pair,  it  also  stands  intimately  related  to  the  spinal  acces¬ 
sory,  which  receives  filaments  from  the  lateral  tract  as  far 
down  as  the  sixth  cervical,  while  its  connection  with  the 
vagus  renders  the  circuit  complete  and  gives  ground  for 
the  peculiar  pathological  phenomena  referred  to. 

In  support  of  the  theory  of  neurotic  influence  in  the 
causation  of  amygdalitis,  it  may  be  observed  that  the  lym¬ 
phatics  of  the  submaxillary  base,  as  well  as  the  buccal  and 
salivary  glands,  are  always  more  or  less  involved.  That  sen¬ 
sation  popularly  known  as  “  creeping  of  the  flesh,”  super¬ 
vening  upon  certain  conditions  of  mental  horror,  and  the 
quivering  of  the  subcutaneous  areolar  tissue  in  bodies  re¬ 
cently  dead  exemplify  this  peculiar  nervous  condition,  which 
is  somewhat  difficult  to  describe.  The  irritation  of  the 
spinal  accessory  within  the  cranium  induces  convulsive 
movements  in  such  muscles  of  the  larynx  as  are  supplied 
by  branches  of  the  vagus,  showing  its  accessory  relationship 
to  that  nerve,  as  also  the  mixed  quality  of  its  filaments, 
while  the  glosso-pharyngeal,  being  a  nerve  of  common  sen¬ 
sation,  acts  centripetallv  to  reflect  stimuli  to  adjacent  con¬ 
tractile  surfaces,  chief  among  which  are  the  pharyngeal 
constrictors,  tonsils,  and  fauces,  as  well  as  the  tongue  itself 
as  far  forward  as  the  foramen  caecum  (Gray),  all  of  which 
are  intimately  involved  in  acute  forms  of  the  disease. 

It  was  a  matter  of  early  observation,  recorded  by  Luys, 
Neftel,  and  others,  that  severe  mental  as  well  as  physical 
impressions  were  potent  in  inaugurating  pathological  pro¬ 
cesses  in  such  structures  as  hereditary  or  fortuitous  circum¬ 
stances  had  sufficiently  debilitated,  and  it  is  now  admitted 
by  all  neurologists  that  when  the  mind  is  intensely  occu¬ 
pied,  very  slight  neurotic  stimuli  will  produce  involuntary 
and  reflex  movements  of  corresponding  intensity.  Mr.  Dar¬ 
win  records  it  as  a  fact  of  his  observation  that  an  instinct¬ 
ive  reflex  act  may  override  even  the  strongest  efforts  of 
volition,  and  Mr.  Kirke  assumes,  as  the  result  of  experi¬ 
ment  upon  frogs,  that  both  optic  lobes  and  optic  thalami 
are  distinctly  concerned  in  the  government  of  these  reflexes, 
although  it  is  the  opinion  of  most  physiologists,  Mr.  Foster 
among  the  number,  that,  as  reflex  acts  are  performed  after 
division  of  every  segment  of  the  cord,  the  reflecting  power 
of  the  latter  is  almost,  if  not  wholly,  distinct  from  that  of 
the  encephalon. 

As  the  existence  and  locality  of  the  ano-spinal  and  vesi- 
co-spinal  centers  have  long  ago  been  demonstrated,  it  is  not 
improbable  that  adeno-spinal  centers  also  exist,  any  strong- 
mental  emotion  acting  upon  which  might  readily  affect  the 
circulus  tonsillaris,  as  it  is  well  known  to  affect  the  vesical 
sphincters,  and  produce  amygdalitis  without  any  exposure. 


Indeed,  both  Virchow  and  Carswell,  as  well  as  the  late  Pro¬ 
fessor  Vanzetti,  of  the  University  of  Padua,  in  treating  of 
lymphangeiectasis,  definitively  teach  that  the  lesion  may  be 
produced  by  any  cause,  either  mental  ox  physical,  affecting 
the  general  health,  and  Professor  Willard  Parker  as  long 
ago  as  1856,  speaking  of  concussion  of  the  nerves,  makes 
significant  statements  bearing  in  the  same  direction. 

In  relation  to  the  selective  seats  of  morbid  action  result¬ 
ing  from  neurotic  impressions,  it  must  be  apparent  that  im¬ 
pulses  affecting  the  spinal  structures  must  of  necessity  be  of 
spinal  origin,  since  the  tonicity  of  all  muscles  is  only  de¬ 
stroyed  by  section  of  the  cord.  While  we  have  in  the  or¬ 
dinary  muscles  of  contraction  the  tabular  membrane  blend¬ 
ing  with  the  sarcolemma  and  the  motorial  end  plates  inti¬ 
mately  interwoven  with  the  substance  of  the  fiber,  we  find 
in  the  structures  under  consideration  the  sensitive  end  bulbs 
of  Krause,  any  irritation  of  which  may,  of  course,  produce 
tonsillitis;  but  that  it  may  supervene  even  without  this  irri¬ 
tation  I  am  radically  convinced. 

What,  then,  is  our  morbid  anatomy  and  rationale  of  treat¬ 
ment  ?  First  we  should  have  sudden  occlusion  of  the  fol¬ 
licles  induced  by  a  mental  impulse,  transmitted  to  the  motor 
nerves  with  consequent  retention,  and  at  the  same  time 
stimulation  of  secretion,  which  accounts,  in  my  opinion,  for 
the  sudden  onset  of  quinsy  ;  followed  by  rapid  inflammatory 
action,  tumefaction,  and  suppuration  of  the  tonsils,  the 
glands  of  the  mouth  generally  sympathizing  and  discharg¬ 
ing  excessive  quantities  of  thick,  ropy,  and  tenacious  mucus. 

Now,  as  to  treatment,  the  first  indication  prior,  of  course, 
to  the  suppurative  stage,  would  be  a  powerful  solvent  of 
animal  membrane,  such  as  papaine,  which  Wurtz  and  Bou- 
chut  pronounce  the  most  rapid  solvent  of  albuminous  sub¬ 
stances  (Bartholow,  Chapman,  Potter),  bicarbonate  of  so¬ 
dium,  or  lactic  acid  by  spray.  Systemically,  agents  which 
depress  the  motorial  function  of  the  spinal  cord — aconite, 
veratrum,  and  pulsatilla.  The  use  of  belladonna  I  have  not 
been  fortunate  in,  notwithstanding  the  apotheosis  accorded 
it  by  the  savants  of  the  homoeopathic  school,  and  many 
regular  practitioners  besides.  It  dries  the  mucous  mem¬ 
brane,  and  consequently  antagonizes  the  action  of  the  reme¬ 
dies  already  spoken  of.  Granted  that  it  momentarily  para¬ 
lyzes  the  function  of  secretion,  yet  the  testimony  of  Brun- 
ton.  Wood,  Gundry,  and  many  others  clearly  shows  that  an 
enormously  augmented  secretion  quickly  follows. 

I  have  found,  acting  upon  my  own  theory  in  the  matter, 
almost  uniform  success  in  a  gentle  but  sustained  opium 
narcosis,  fortified,  to  prevent  nausea  and  depression,  with 
spirit  of  ether  or  one  of  the  bromides,  and  accompanied,  as 
spoken  of,  by  the  solvent  spray. 

If  the  barest  chance  of  abortion  exists,  the  course  laid 
down  will,  I  am  convinced,  afford  the  best  hope  of  success, 
while  after  the  inauguration  of  the  suppurative  stage  the 
case  becomes  one  for  the  nurse  rather  than  the  physician,  if 
the  knife  be  not  called  into  use. 

The  astringent  lotions  or  gargles  so  commonly  used, 
while  highly  beneficial  in  staphylitis,  pharyngitis,  and  other 
purely  membranous  inflammations  of  the  mouth  and  throat, 
will  be  found  worse  than  useless  in  this  affection,  although 
antiphlogistics  are  indicated  in  all. 


100 


CRANDALL:  IMPACTED  URETHRAL  CALCULUS. 


[N.  Y.  Med.  Joub., 


IMPACTED  URETHRAL  CALCULUS  IN 
A  BOY  OF  THREE  YEARS.* 

By  F.  M.  CRANDALL,  M.  D. 


THE 


NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 


The  patient,  a  boy  aged  three  years,  was  brought  to  the  dis¬ 
pensary  February  5tb.  Three  days  before  he  had  been  seized 
with  fever  and  vomiting,  accompanied  by  soreness  of  the  mouth. 
Examination  revealed  an  ordinary  follicular  stomatitis,  to  which 
the  symptoms  were  evidently  due.  Castor-oil  had  been  given 
on  the  first  day.  It  acted  normally,  but  had  been  followed  by 
persistent  bearing-down  pains  and  tenesmus.  The  rectum  had 
been  forced  down  almost  into  a  condition  of  prolapse.  But  lit¬ 
tle  urine  had  been  passed  since  the  onset  of  the  disease,  seventy- 
two  hours  before.  Free  doses  of  sweet  spirits  of  niter  had  not 
increased  the  amount. 

Examination  showed  a  hard  mass  lying  in  the  urethra  about 
one  fourth  of  an  inch  from  the  meatus.  The  glans  was  some¬ 
what  swollen,  the  meatus  reddened,  and  the  rectum  was  in  a 
state  of  partial  prolapse.  The  mass  was  reached  with  dressing 
forceps,  and  after  some  difficulty,  due  to  slipping  of  the  forceps 
and  scaling  off  of  the  outer  portions,  it  was  removed.  There 
was  some  laceration  and  bleeding,  but  it  was  not  serious  and 
gave  no  after-trouble.  The  child  at  once  passed  a  large  quantity 
of  normal  urine,  and  from  a  condition  of  restlessness,  moaning, 
and  crying,  lay  quietly  back  in  the  mother’s  lap  and  was  soon 
asleep. 

Two  weeks  before  there  had  been  a  similar  but  milder  attack, 
lasting  two  days.  The  child  was  fretful,  passed  urine  in  drops, 
and  had  the  same  straining  at  the  rectum.  During  the  previous 
months  there  had  been  occasional  attacks  of  screaming  and  cry¬ 
ing,  for  which  no  cause  had  been  discovered.  Retention  of  urine 
had  not  been  noticed.  Otherwise  the  child  had  been  exception¬ 
ally  healthy  and  had  never  had  any  severe  illness.  He  had  never 
passed  milky  urine,  nor  had  any  sediment  been  noticed.  There 
had  been  no  enuresis. 

The  mother  is  healthy  and  has  had  ten  children — all  living  and 
healthy.  The  father  has  had  two  attacks  of  acute  articular 
rheumatism— one  last  winter  and  one  sixteen  years  ago.  No 
history  of  rheumatism  or  growing  pains  could  be  obtained  among 
any  of  the  children. 

The  child  was  perfectly  free  from  symptoms  until  March  Bd, 
when  he  contracted  diphtheria,  from  which  he  died.  The  mother 
failed  to  visit  the  surgeon  to  whom  she  had  been  directed  for 
examination.  It  is  impossible  to  say,  therefore,  whether  there 
were  other  stones  in  the  bladder.  The  urine  examined  one  week 
after  the  removal  of  the  stone  was  normal.  The  calculus  weighed 
four  grains  and  three  quarters  and  consists  of  auric-acid  nucleus 
with  a  phosphatic  crust.  It  was  five  lines  in  length,  the  trans¬ 
verse  diameters  being  four  lines  and  two  lines  and  a  half,  re¬ 
spectively. 

Though  the  onset  of  the  stomatitis  and  symptoms  due  to  the 
stone  were  thought  to  be  simultaneous,  there  would  seem  to  be 
no  further  connection  than  that  of  coincidence.  The  symptom 
of  chief  interest  was  the  marked  forcing  down  of  the  rectum, 
which  to  the  mother’s  mind  was  the  chief  trouble.  This  was 
not  continuous,  however,  as  in  the  cases  recently  reported  by 
Dr.  Caille  and  Dr.  Fruitnight,  but  only  during  the  period  of 
impaction  in  the  urethra. 

Aside  from  these  two  attacks  and  possibly  what  the  mother 
called  the  “  screaming  spells,”  no  symptom  could  be  discovered 
which  could  in  any  way  be  referred  to  a  calculus. 


Published  by 
D.  Appleton  &  Co. 


Edited  by 

Frank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  JULY  26,  1890. 


THE  JOHNS  HOPKINS  HOSPITAL. 


*  Read  before  the  Section  in  Paediatrics  of  the  New  York  Academy 
of  Medicine,  April  10,  1890. 


It  would  not  be  easy  to  overrate  the  importance  of  this 
institution,  which  was  opened  in  Baltimore  a  little  more  than  a 
year  ago.  Much  has  been  published  about  it,  referring  chiefly 
to  its  prospective  features,  and  that  has  made  a  decided  im¬ 
pression  on  members  of  the  medical  profession  and  on  philan¬ 
thropists  in  general;  but  a  record  of  what  has  been  done  is 
likely  to  make  a  still  deeper  impression.  This  seems  to  have 
been  the  trustees’  conviction,  and  accordingly  they  asked  Dr. 
John  S.  Billings,  whose  efficient  aid  in  planning  the  institution 
they  cordially  acknowledge,  to  prepare  a  description  of  the 
grounds  and  buildings.  This  he  has  done,  and  his  description, 
together  with  certain  introductory  matter,  including  his  own 
address  at  the  opening  of  the  hospital,  makes  a  quarto  volume 
of  more  than  a  hundred  pages  of  letter-press,  followed  by  fifty- 
six  full-page  plates.  Most  of  the  plates  are  architectural  plans 
and  sections,  but  many  of  them  show  views  of  the  buildings, 
including  a  number  of  interiors.  The  views  are  excellent  re¬ 
productions  of  well-made  photographs.  They  are  very  artistic 
pictures,  but  it  is  apparent  that  in  their  preparation  there  has 
been  no  straining  after  striking  effects.  The  letter-press  of  the 
volume  is  correspondingly  creditable  as  a  piece  of  mechanical 

work. 

From  a  study  of  the  description  and  the  illustrations  it  is 
abundantly  evident  that  in  the  hospital,  as  in  the  volume,  the 
adaptation  of  means  to  ends  has  been  held  paramount  to  mere 
pleasantness  of  aspect.  The  buildings  are  plain,  but  well  pro¬ 
portioned,  conveniently  distributed  over  the  grounds,  and  of 
an  attractive  general  appearance.  The  same  may  be  said  of 
such  of  the  appliances  as  are  described  and  figured.  In  all  this 
Dr.  Billings’s  guidance  has  been  apparent  from  the  outset,  and 
the  handsome  way  in  which  this  is  acknowledged  by  the  trus¬ 
tees  is  most  gratifying,  for.  it  is  seldom  that  a  medical  man’s 
work  is  so  appreciated. 

It  may  be  remembered  that,  when  the  trustees  began  their 
task  of  carrying  out  Hopkins’s  instruction  to  provide  for  a 
hospital  that  should,  “  in  structure  and  arrangement,  compare 
favorably  with  any  other  institution  of  like  character  in  this 
country  or  in  Europe,”  they  first,  also  in  accordance  with  his 
injunction,  sought  advice.  They  procured  plans  anu  descrip¬ 
tions  of  what  such  a  hospital  ought  to  be  from  a  number  of 
men  familiar  with  the  workings  of  great  general  hospitals. 
Each  of  these  men  wrote  an  essay,  and  the  essays  were  studied 
by  the  trustees  and  published  in  the  form  of  a  volume.  The 
trustees  thus  incurred  a  debt  which  they  now  repay  by  the 
publication  of  the  volume  before  us — one  that  will  go  far  to 


July  26,  1890.] 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


101 


assist  the  designers  of  hospitals  yet  to  come  in  doing  their  work 
satisfactorily  and  without  undue  loss  of  time. 


THE  MIDWIFERY  DISPENSARY. 

The  task  of  teaching  obstetrics  practically  to  medical  stu¬ 
dents  is  one  that,  for  its  full  and  satisfactory  accomplishment, 
calls  for  agencies  and  appliances  that  can  not  be  put  into  opera¬ 
tion  without  much  good  management  on  the  part  of  the 
teachers,  to  say  nothing  of  their  self-sacrificing  devotion  to  the 
work.  To  make  the  student  a  mere  spectator  in  a  lying-in 
hospital  is  not  enough ;  being  relieved  of  all  responsibility,  he 
is  apt  not  to  draw  upon  his  own  capability  to  the  extent  neces¬ 
sary  to  train  it  for  the  demands  that  he  will  eventually  have  to 
make  on  it  in  his  practice.  He  who  would  study  the  art  of 
obstetrics  to  the  greatest  advantage  must  exchange  the  com¬ 
parative  ease  of  hospital  life  for  hard  work  in  the  tenement- 
houses.  Lying-in  hospitals  are  very  useful  institutions  un¬ 
doubtedly,  serving  as  a  refuge  for  the  homeless  and  the  de¬ 
serted;  but  their  maintenance  is  expensive  and  the  number  of 
their  inmates  is  necessarily  limited.  In  any  degree  to  which  it 
is  practicable  to  multiply  them,  they  can  not  afford  all  the  aid, 
or  even  a  tithe  of  it,  that  the  community  wishes  to  furnish  to 
poor  women  in  their  time  of  need  ;  hence  it  is  most  desirable 
that  their  work  should  be  supplemented  to  the  utmost  by  or¬ 
ganized  medical  attendance  on  poor  women  in  their  own 
homes. 

Organizations  for  that  purpose  have  been  at  work  success¬ 
fully  in  New  York  for  many  years,  but  they  have  never  been 
adequate  to  the  amount  of  work  to  be  done,  and  in  some  re¬ 
spects  they  have  been  defective  in  what  might  reasonably  have 
been  expected  of  them.  We  are  very  glad  therefore  to  be  able 
to  announce  the  recent  establishment  of  an  obstetrical  institu¬ 
tion  which,  after  close  observation  of  its  methods,  we  look 
upon  as  not  only  an  important  addition  to  our  agencies  for 
ameliorating  the  condition  of  the  poor,  but  also  as  an  educa¬ 
tional  resource  of  the  most  promising  kind.  This  is  the  Mid¬ 
wifery  Dispensary,  which  has  been  in  operation  since  last 
December.  It  is  situated  in  a  dense  tenement-house  district,  at 
No.  312  Broome  Street,  a  short  distance  east  of  the  Bowery. 
No  medical  treatment  is  carried  out  in  the  house;  the  premises 
occupied  by  the  dispensary  consist  only  of  offices  in  which  suf¬ 
ficiently  minute  and  very  carefully  arranged  records  are  kept, 
of  sleeping-rooms  for  the  resident  physician  and  the  students, 
and  of  store-rooms.  There  are  three  attending  physicians,  all 
of  whom  are  men  of  experience  in  obstetrics  and  have  been 
engaged  in  teaching  it  for  a  number  of  years.  One  of  the 
physicians  is  in  attendance  at  the  house  daily  for  a  certain 
number  of  hours,  and  is  always,  when  it  is  practicable,  present 
at  a  confinement.  The  material  appliances  in  the  way  of  in¬ 
struments,  dressings,  medicaments,  etc.,  are  ample,  and  the 
establishment  is  perfectly  in  readiness  to  afford  its  full  re¬ 
sources  at  short  notice  and  to  meet  any  sort  of  obstetrical  or 
puerperal  complication. 

Most  praiseworthy  discretion  has  been  shown  in  settling  the 
extent  to  which  students  are  allowed  to  take  part  in  the  obser¬ 


vation  and  conduct  of  cases.  The  details  of  the  plan  are  too 
many  to  be  mentioned  in  this  article;  it  is  enough  if  we  say 
that  they  allow  the  student  the  fullest  scope  compatible  with 
safety,  and  that  they  secure  to  the  patient  the  presence  of  a 
licensed  physician  invariably.  In  return  for  a  very  small  fee* 
a  student  resides  in  the  house  for  a  specified  term,  and  takes 
part  in  the  management  of  a  definite  number  of  cases.  Stu¬ 
dents  are  allowed  to  renew  their  terms  of  residence  when  it 
can  be  done  without  excluding  other  applicants,  so  that  a  con¬ 
tinuous  residence  of  considerable  duration  is  often  practicable. 
They  are  provided  with  the  means  of  pursuing  their  studies, 
and  their  personal  comfort  is  well  looked  after. 

Many  an  established  physician,  looking  back  upon  the  dis¬ 
advantages  under  which  he  slowly  and  laboriously  and  timidly 
acquired  his  knowledge  of  obstetrics,  will  be  glad  to  learn  of 
the  facility  with  which  a  practical  familiarity  with  the  art  may 
now  be  gained  ;  if  he  will  also  commend  this  and  kindred  in¬ 
stitutions  to  his  benevolent  friends  and  patients,  he  will  aid 
materially  in  furthering  the  work  of  medical  education  as  well 
as  in  promoting  the  alleviation  of  distress.  In  advancing  both 
these  purposes  the  medical  profession  has  always  been  earnest 
and  active. 

MINOR  PARAGRAPHS. 

OXYGEN  INHALATIONS  IN  PNEUMONIA. 

TnE  Lancet  remarks  that  the  action  of  oxygen  inhalation  is 
very  often  disappointing.  It  seems  in  practice  far  more  inert 
than  one  might  reasonably  expect  from  its  life-supporting 
properties.  Various  explanations  have  from  time  to  time  been 
offered,  but  its  efficiency  still  remains  rather  circumscribed. 
One  of  the  diseased  conditions  in  which  its  inhalatiou  has  been 
most  beneficial  is  the  dyspnoea  of  uraemic  intoxication.  An¬ 
other  disease  has  lately  been  pointed  out  anew  by  Dr.  John 
Chambers  as  suitable  for  oxygen  inhalation.  This  is  pneumo¬ 
nia,  and  the  time  for  using  oxygen  with  benefit  has  been  found 
by  him  to  be  that  very  critical  stage  when  lividity  and  cyanosis 
testify  to  the  difficulty  with  which  the  circulation  is  being  car¬ 
ried  on.  Since  the  direct  result  of  an  impeded  circulation  is  a 
deficient  aeration  of  the  blood,  it  is  not  surprising  that  oxygen 
inhalation  affords  a  certain  promise  of  relief.  Under  its  use  the 
lips  recover  their  redness,  the  breathing  becomes  easier,  and  the 
enfeebled  heart’s  action  is  re-enforced.  Dr.  Chambers  is  satis¬ 
fied  that  he  has  saved  life  in  cases  in  which,  from  all  the  indica¬ 
tions  present,  a  fatal  result  was  inevitable. 


EXHIBITIONISM;  A  SEXUAL  PERVERSION. 

M.  Magnan  has  recently  presented  to  the  Soci6t6  de  mede- 
cine  16gale  the  history  of  two  cases  showing  that  variety  of  sex¬ 
ual  perversion  not  infrequently  observed  among  men  living  in 
cities,  known  as  “  exhibitionists,”  or  those  having  the  propensity 
to  expose  their  genitals  in  public  places  or  to  individuals,  usually 
women  whom  they  meet  in  unfrequented  places.  According  to 
the  report  of  these  cases  in  Progres  medical ,  one  of  the  subjects 
presented  unmistakable  hereditary  defect,  and  both  showed 
present  typical  degeneracy.  The  author  classes  these  persons 
with  the  kleptomaniacs,  the  pyromaniacs,  and  the  suicidal  and 
homicidal  insane.  These  degenerate  beings  are  ordinarily  a 
great  trial  to  the  police  and  are  exceedingly  shrewd  in  the 
avoidance  of  arrest ;  but  imprisonment  has  little  deterrent  or 
reformatory  influence  upon  them.  They  are  seldom  persons 


who  have  a  steady  form  of  employment.  It  is  probable  that 
they  are  psychically  incapable  of  acquiring  a  regular  trade  or 
business  or  of  applying  themselves  to  its  pursuit. 


THE  ROOSEVELT  HOSPITAL. 

Last  year  Mr.  William  J.  Symsdied  after  having  bequeathed 
the  sum  of  $350,000  to  the  hospital  for  the  purpose  of.  building 
an  operating  theatre.  In  expectation  of  receiving  the  legacy, 
the  trustees  set  about  excavating  for  the  foundation  of  the  build¬ 
ing,  but  the  validity  of  the  will  was  contested,  and  they  sus¬ 
pended  the  work.  Now  it  is  announced  that  the  contest  has 
been  discontinued,  and  it  is  expected  that  the  theatre  will  be 
built.  _ 

“  INFANT  INDUSTRIES.” 

A  clerk  in  the  employ  of  the  Brooklyn  Board  of  Health 
was  recently  detected  in  furnishing  information  regarding  re¬ 
turns  of  births  to  certain  selected  manufacturers.  The  World 
remarks  that  he  “  is  doubtless  one  of  those  kind-hearted  per¬ 
sons  who  are  in  favor  of  protecting  and  helping  along  our  in¬ 
fant  industries.” 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  July  22,  1890 : 


DISEASES. 

Week  ending  July  15. 

Week  ending  July  22. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

26 

6 

24 

7 

Scarlet  fever . 

44 

5 

43 

7 

Cerebro-spinal  meningitis . 

1 

1 

1 

0 

Measles . 

240 

19 

215 

10 

Diphtheria . 

54 

15 

72 

21 

Varicella . 

3 

0 

7 

0 

The  Mississippi  Valley  Medical  Association. — At  the  meeting  to  be 
held  in  Louisville  on  the  10th  of  October,  Dr.  John  A.  Wyeth,  of  New 
York,  will  deliver  an  address,  and  Dr.  Frank  Woodbury,  of  Philadel¬ 
phia,  will  read  a  paper. 

The  Red  Cross  Society  of  Munich. — Mr.  Henry  Villard,  of  New 
York,  is  reported  to  have  given  the  Red  Cross  Society  of  Munich  the 
sum  of  $12,500  as  a  contribution  toward  the  construction  of  a  hospital 
for  the  society. 

The  American  Chemical  Society  will  hold  a  meeting  at  Newport, 
R.  I.,  on  Wednesday  and  Thursday,  August  6th  and  Yth. 

The  Luzerne  County  (Pa.)  Medical  Society  will  hold  a  meeting  at 
Glen  Summit  on  Wednesday,  August  6th,  under  the  presidency  of  Dr. 
G.  W.  Guthrie,  of  Wilkesbarre. 

The  Medico-chirurgical  College  of  Philadelphia. — Dr.  W.  C.  Hollo- 
peter  has  been  elected  Lecturer  on  Diseases  of  Children,  and  Dr.  Ernest 
B.  Sangree  Director  of  the  Histological  Laboratory. 

Change  of  Address. — Dr.  Walter  Lester  Carr,  to  No.  8  East  Fifty- 
eighth  Street. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army,  for  the  week  ending  July  19,  1890 : 

Arthur,  William  H.,  Captain  and  Assistant  Surgeon,  is,  by  direction 
of  the  Secretary  of  War,  granted  leave  of  absence  for  three  months, 
to  take  effect  September  15,  1890,  or  as  soon  thereafter  as  his  ser¬ 
vices  can  be  spared.  Par.  1,  S.  O.  160,  A.  G.  O.,  Washington,  D.  C., 
July  11,  1890. 

Maus,  Louis  M.,  Captain  and  Assistant  Surgeon.  By  direction  of  the 
Secretary  of  War,  the  leave  of  absence  on  surgeon’s  certificate  of 
disability  granted  in  S.  O.  4,  January  6, 1890,  from  this  office,  is  ex- 


A.  G.  O.,  Washington,  D.  C.,  July  11,  1890.  ( 

Corbusier,  William  H.,  Captain  and  Assistant  Surgeon,  is,  by  diitc- 
tion  of  the  Secretary  of  War,  granted  leave  of  absence  for  four 
months  on  surgeon’s  certificate  of  disability,  with  permission  to  leave 
the  Division  of  the  Missouri.  Par.  4,  S.  O.  162,  A.  G.  O.,  Washing¬ 
ton,  D.  C.,  July  14,  1890. 

Page,  Charles,  Colonel  and  Assistant  Surgeon-General,  Medical  Di¬ 
rector  of  the  Department,  is  granted  leave  of  absence  for  one 
month,  to  take  effect  the  30th  instant.  Par.  3,  S.  O.  91,  Depart¬ 
ment  of  the  Missouri,  St.  Louis,  Mo.,  July  14,  1890. 

Phillips,  John  L.,  Captain  and  Assistant  Surgeon,  is,  by  direction  of 
the  Secretary  of  War,  granted  leave  of  absence  for  two  months. 
Par.  4,  S.  O.  164,  Headquarters  of  the  Army,  A.  G.  O.,  Washington, 
D.  C.,  July  16,  1890. 

Naval  Intelligence. — Official  List  of  Changes  in  the  Medical  Corps 

of  the  United  States  Navy  for  the  week  ending  July  19,  1890: 

Anzall,  E.  W.,  Assistant  Surgeon.  Detached  from  U.  S.  Steamer  Ga¬ 
lena  and  to  wait  orders. 

Eckstein,  A.  C.,  Surgeon.  Granted  leave  of  absence  for  the  month  of 
August. 

Penrose,  T.  N.,  Medical  Inspector.  Granted  leave  of  absence  for  two 
weeks. 

Cabell,  A.  G.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  the  month  of  August. 

Ashbridge,  Richard,  Passed  Assistant  Surgeon.  Granted  one  month’s 
sick  leave. 

Heyl,  T.  C.,  Surgeon.  Granted  leave  of  absence  for  the  month  of  Au¬ 
gust. 

Cooke,  George  H.,  Medical  Inspector.  Detached  from  Navy  Yard, 
League  Island,  and  ordered  to  the  Pensacola. 

White,  C.  H.,  Medical  Inspector.  Detached  from  the  Pensacola  and  to 
proceed  home  and  wait  orders. 

Hoehling,  A.  A.,  Medical  Inspector.  Detached  from  Naval  Hospital, 
Washington,  and  ordered  to  League  Island  Navy  Yard. 

Wells,  H.  M.,  Medical  Inspector.  Detached  from  Museum  of  Hygiene 
and  ordered  to  Naval  Hospital,  Washington,  D.  C. 

Whitfield,  James  M.,  Assistant  Surgeon.  Ordered  to  U.  S.  Steamer 
Ajax  and  other  Monitors. 

Woolverton,  Thkoron,  Medical  Inspector.  Ordered  to  the  U.  S.  Steam¬ 
er  Philadelphia. 

Lovering,  P.  A.,  Passed  Assistant  Surgeon.  Detached  from  the  U. 
S.  Revenue  Steamer  Wabash  and  ordered  to  the  U.  S.  Steamer 
Philadelphia. 

Bailey,  T.  B.,  Assistant  Surgeon.  Detached  from  the  U.  S.  Revenue 
Steamer  St.  Louis  and  ordered  to  the  U.  S.  Steamer  Philadelphia. 

White,  S.  S.,  Passed  Assistant  Surgeon.  Ordered  to  the  Marine  Ren¬ 
dezvous,  San  Francisco,  Cal. 

Society  Meetings  for  the  Coming  Week: 

Wednesday,  July  30th :  Gloucester,  N.  J.,  County  Medical  Society  (quar¬ 
terly)  ;  Middlesex,  Mass.,  North  District  Medical  Society  (Lowell). 


% ctters  to  %  (Bfciior. 


THE  MANAGEMENT  OF  THE  MENSTRUAL  EPOCH. 

4  King  Street,  New  York,  June  26,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  In  your  June  14th  issue  there  occurs  a  letter  entitled 
“The  Management  of  the  Menstrual  Epoch,”  which  refers  to 
and  recommends  the  use  of  tampons  during  menstruation,  and 
claiming  for  such  use,  if  adopted,  the  marking  of  “  a  new  era  in 
the  alleviation  of  human  suffering.”  The  idea  is  a  very  old  one 
among  Eastern  nations,  and  the  use  of  paper-ball  tampons 
(wood  pulp  and  silk  fiber)  is  universal  among  Japanese  women. 


102 


MINOR  PARAGRAPHS.— ITEMS.— LETTERS  TO  TEE  EDITOR.  [N.  Y.  Mkd.  Jour., 


tended  six  months  on  account  of  sickness.  Par.  16,  S.  O.  160, 


July  26,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


103 


I  quote  from  Professor  Wernich,  late  gynaecologist  to  the 
Medico-surgical  Academy,  Tokio,  Japan,*  as  follows: 

“The  first  rule  which  a  menstruating  woman  observes  in 
Japan  is  rest.  Absolute  abstinence  from  sexual  enjoyment  is 
strict  law;  there  are  distinct  prescriptions  against  locomotion 
in  the  house,  and  especially  in  the  street;  cleanliness  during 
that  period,  as  washing  is  considered  as  very  injurious,  is  taken 
care  of  in  a  quite  peculiar  way.  To  let  menstrual  blood  touch 
the  body  or  the  linen,  which  is  to  be  still  used,  would  pass 
for  the  neplus  ultra  of  uncleanness.  Therefore  the  menstruat¬ 
ing  woman  kneads  or  rolls,  with  one  of  the  sheets  of  white 
papers — of  which  she  carries  always  a  large  provision,  for  that 
very  purpose,  in  her  right  sleeve — a  ball  from  the  size  of  an  al¬ 
mond  to  that  of  a  large  walnut,  and  inserts  it  into  the  vagina, 
replacing  it  by  another  when  it  is  soaked  in  blood.  In  cases  of 
fluor  albus  I  have  also  frequently  found  such  paper  balls  in  the 
vagina.  From  the  number  of  the  balls  used  in  the  menstrua¬ 
tion,  conclusions  are  drawn  as  to  its  abundance  and  favorable 
course.”  Albekt  S.  Ashmead,  M.  D. 


IProcettrmp  ai  Somites. 


ROYAL  ACADEMY  OF  MEDICINE  IN  IRELAND. 

SECTION  IN  SURGERY. 

Meeting  of  Friday ,  February  21,  1890. 

Mr.  Edward  Hamilton  in  the  Chair. 

Erasion  of  the  Knee  Joint.— Mr.  Lentaigne,  at  the  request 
of  the  chairman,  described  the  operation  of  erasion  of  the  knee 
joint  which  he  had  performed  upon  a  young  man  whom  he  ex¬ 
hibited.  The  patient  had  been  two  years  and  four  months  suf¬ 
fering  from  white  swelling  of  the  knee  joint  previous  to  the 
operation,  but  no  external  sinuses  had  appeared.  The  case 
seemed  to  be  suitable  for  erasion,  and  he  had  performed  the 
operation,  which  was  his  first  of  the  kind,  by  making  the  usual 
horseshoe  incision.  After  denuding  the  patella  he  had  sawed 
clear  through  the  middle  of  it.  Turning  down  the  lower  and 
turning  up  the  upper  fragments,  respectively,  he  had  removed 
all  the  synovial  membrane,  cleaning  away  a  mass  of  tubercular 
tissue  in  the  crucial  ligaments.  Then  he  had  stitched  with  cat¬ 
gut  the  lateral  ligaments,  which  were  both  cut,  and  the  patella. 
The  condition  of  the  joint  was  that  of  pretty  advanced  tuber¬ 
cular  disease.  In  parts,  the  synovial  membrane  was  about  an 
inch  thick,  with  a  caseous  mass  in  the  center.  Inside  the  joint 
there  was  apparently  an  abscess,  due  to  the  breaking  down  of  a 
caseous  mass.  As  regarded  after-treatment,  he  had  applied 
permanent  dressing,  using  plenty  of  iodoform  and  large  rubber 
drainage-tubes,  which  remained  for  a  month,  when  the  knee 
was  again  dressed.  The  patient  had  worn  Thomas’s  splint, 
which  tended  to  the  success  attained.  It  was  intended  that  he 
should  return  after  a  year  to  get  the  knee  flexed,  but  the  speaker 
feared  that  in  trying  to  restore  full  functional  value  by  forcible 
flexion  harm  might  be  done. 

On  a  Series  of  One  Hundred  Cataract  Extractions.— Mr. 

Swanzy  read  a  paper  on  a  series  of  one  hundred  cataract  ex¬ 
tractions.  He  employed  the  three-millimetre  flap  operation, 
with  a  very  narrow  iridectoiny  in  the  upper  quadrant  of  the  iris. 
He  instilled  eserine  prior  to  the  operation  to  facilitate  the  ob¬ 


*  Geoyraphico-medical  Studies  after  the  Experience  of  a  Journey 
Around  the  World.  Chapter  on  Adult  Men  and  Women  of  Japan. 

Berlin,  1878. 


taining  of  a  neat  coloboma,  which  it  was  difficult  to  procure  if 
the  iris  prolapsed,  and  the  reduction,  after  delivery  of  the  lens, 
of  all  the  rest  of  the  iris  into  the  anterior  chamber.  Quite  a 
narrow  coloboma  was  required,  and  was  sufficient  to  efficiently 
protect  the  eye  against  the  danger  of  secondary  iris  prolapse  in 
the  course  of  the  healing — a  danger  to  which  eyes  operated  on 
by  the  simple  method  were  so  liable,  as  it  provided  a  gateway 
by  which  the  aqueous  humor  contained  in  the  posterior  chamber 
might  escape  through  the  wound,  without  carrying  with  it  a 
portion  of  iris.  Mr.  Swanzy  considered  that  such  an  iridectomy 
was  no  “mutilation  of  the  iris,”  but  rather  a  measure  which 
rested  upon  a  sound  scientific  basis,  and  which  was  calculated 
to  protect  the  eye  against  a  serious  danger.  In  this  series  the  iris 
was  incarcerated  in  the  cicatrix  in  one  eye  only.  After  the  lens 
was  extracted  the  woimd  was  carefully  searched  with  an  iris  for¬ 
ceps  for  any  tag  of  capsule  which  might  have  prolapsed  into  it, 
and  if  any  was  found,  it  was  drawn  gently  forward  and  snipped  off 
with  the  scissors.  A  tag  of  capsule  was  found  in  the  wound  in 
nine  of  the  one  hundred  eyes  operated  on.  He  strongly  recom¬ 
mended  this  proceeding.  The  antiseptic  measures  consisted  in 
the  washing  of  the  patient’s  face  with  hot  water  and  soap,  and 
the  washing  and  wiping  out  of  the  conjunctival  sac  with  a  1-to- 
5,000  solution  of  sublimate  lotion  just  before  the  operation, 
while  all  through  the  latter  the  same  lotion  was  used  for  wiping 
and  irrigating  the  wound  and  surface  of  the  eyeball.  No 
sponges  were  used,  but  small  bits  of  lint  which  had  been  boiled 
in  the  sublimate  solution,  and  which  were  kept  stored  in  it. 
The  solutions  of  eserine,  cocaine,  and  atropine  were  all  made 
with  sublimate  solution,  1  to  5,000.  Prior  to  the  operation  the 
instruments  were  boiled,  washed  in  absolute  alcohol,  and  laid 
ready  for  use  in  a  bath  of  a  one-per-cent,  solution  of  carbolic 
acid.  After  the  operation  they  were  again  washed  in  absolute 
alcohol.  The  dressing  consisted  in  a  layer  of  lint  previously 
boiled  in  sublimate  lotion,  and  wet  with  it;  over  this  absorbent 
wool  similarly  boiled  and  wet,  then  a  layer  of  oiled-silk  protect¬ 
ive,  and  then  the  bandage.  This  was  not  disturbed  for  forty- 
eight  hours.  The  results  obtained  consisted  in  ninety-three  per 
cent,  good  vision,  five  per  cent,  moderate  vision,  and  two  per 
cent,  losses.  The  two  losses  were  due  to  suppuration,  and  were 
the  only  cases  of  suppuration  which  occurred.  In  each  of  them 
the  operation  had  been  normal. 

The  Chairman  noted  with  interest  the  careful  manner  in 
which  the  antiseptic  system  of  surgery  was  apparently  carried 
out  in  the  operations;  and  he  suggested  a  discussion  upon  the 
value  of  iridectomy  as  part  of,  or  an  element  in,  the  operation 
of  cataract  extraction. 

Mr.  Story  asked  whether  the  series  represented  the  last,  one 
hundred  cases  in  which  Mr.  Swanzy  performed  the  extraction 
of  cataract  by  the  three-millimetre  flap,  with  iridectomy,  and  so 
included  cases  complicated  and  uncomplicated — i.  e.,  with  dis¬ 
location  of  the  lens,  synechia  anterior,  and  synechia  posterior, 
the  result  of  old  iritis.  But  even  if  the  series  consisted  of  one 
hundred  selected  cases,  the  results  attained  were  admirable,  as 
showing  a  total  loss  of  only  two  percent.,  while  achieving  mod¬ 
erately  fair  sight  in  five  per  cent.,  and  good  in  ninety-three  per 
cent,  (taking  it  as  “  good  ”  when  the  patient  bad  a  vision  of  six 
sixtieths).  In  the  Dublin  Medical  Journal ,  1880,  he  himself  had 
published  a  series  of  his  first  forty-seven  cataract  extractions, 
showing  a  loss  of  seven  or  eight  per  cent.,  recording  as  loss  or 
failure  where  the  patient  could  not  count  figures  at  a  yard  or 
two  yards  off,  and  he  found  that  the  records  of  eleven  thousand 
or  twelve  thousand  extractions  disclosed  a  similar  percentage  of 
failures.  Hence  the  question  which  he  asked.  He  agreed  with 
Mr.  Swanzy  as  to  iridectomy  forming  part  of  the  operation,  be¬ 
ing  of  opinion  that  it  facilitated  the  removal  of  the  lens  and 
prevented  the  danger  of  prolapse  of  the  iris.  He  also  agreed 


104 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


with  Mr.  Swanzy  as  to  the  importance  of  antiseptic  precautions 
In  St.  Mark’s  Hospital  a  different  plan  was  followed.  The  eye 
was  washed  with  a  solution  of  hydronaphthol,  and  the  instru¬ 
ments  were  boiled  in  the  same,  while  the  operation  was  done 
under  cocaine.  He  did  not,  however,  take  the  tiouble  Mi. 
Swanzy  advocated,  of  inserting  an  iris  forceps  afterward  to 
search  for  pieces  of  capsule.  He  dusted  over  the  surface  of  the 
wound  and  eyeball  with  finely  powdered  iodoform.  As  regarded 
irrigation  proposed  by  Dr.  McKeown,  of  Belfast,  for  washing 
out  the  cortex,  be  had  not  found  it  useful.  The  cortex  was  in¬ 
jured  by  nearly  all  the  substances  employed  to  wash  out  the  an¬ 
terior  chamber,  even  by  pure  water.  In  his  paper  he  had  advo¬ 
cated  the  three-millimetre  flap  extraction  in  opposition  to  the 
linear  extraction  of  von  Graefe,  which  was  then  in  vogue.  It 
was  a  mistake  to  call  the  operation  von  Graefe’s,  for  the  oper¬ 
ation  owed  its  existence  to  De  Wecker,  one  of  the  great  oph¬ 
thalmologists  of  Paris.  Shortly  after  De  Wecker  had  described 
it  he  had  read  the  paper,  and  had  been  struck  with  the  sim¬ 
plicity  of  the  operation,  which  he  had  been  the  first  to  perform 
in  this  country.  He  had  advocated  the  operation,  but  it  had 
met  with  Mr.  Swanzy’s  disapproval  at  the  time.  Therefore  it 
was  a  pleasure  to  find  that  Mr.  Swanzy  now  considered  it  the 
best  operation  for  cataract  extraction. 

Mr.  Fitzgerald  said  that  Mr.  Swanzy  had  distinctly  stated 
that,  strictly  speaking,  the  operation  was  not  Graefe’s,  but  was 
Graefe’s  modified.  The  operation  which  he  himself  had  been  in 
the  habit  of  doing  was  identical  with  Mr.  Swanzy’s  up  to  a  short 
time  ago,  when  he  had  determined  to  try  the  simple  operation 
— the  extraction  without  iridectomy.  He  did  not  make  his  in¬ 
cision  quite  the  same  as  Mr.  Swanzy’s  ;  he  made  his  puncture  a 
little  outside  the  clear  cornea,  and  he  brought  the  upper  part  of 
the  flap  well  into  the  clear  cornea.  For  comparison  he  was 
anxious  to  give  statistics— twenty-six  cases  of  extraction  with¬ 
out  the  iridectomy  in  hospital  practice,  and  also  fifty-six  in  pri¬ 
vate  practice,  and  then  going  back  and  taking  twenty-six  with 
iridectomy  in  private  practice ;  but  the  twenty-six  hospital  cases 
with  iridectomy  he  had  been  unable  to  procure.  He  judged  his 
results  more  hardly  than  Mr.  Swanzy,  who  seemed  content  to 
take  as  “  good  ”  if  he  could  procure  the  counting  fingers  at  a  few 
metres  off.  Up  to  the  present  he  had  himself  no  case  to  deplore, 
and  he  recollected  no  case  of  suppuration.  Therefore,  as  far  as 
he  had  gone,  the  results  from  the  simple  operation  proved  im 
mensely  superior  to  those  obtained  with  iridectomy.  The  rea¬ 
sons  which  induced  him  to  undertake  the  operation  were  those 
urged  by  De  Wecker,  and,  so  far,  he  had  had  no  cause  to  regret 
it.  Although  he  had  had  two  cases  of  prolapse  of  the  iris,  he 
thought  there  was  needless  alarm,  and  that  by  using  the  eserine 
after  the  operation,  by  careful  bandaging  and  keeping  the  patient 
quiet  for  twenty-four  hours,  there  need  be  no  apprehension  of 
it.  Of  secondary  operations  he  had  had  a  good  number,  but 
not  more  than  Mr.  Swanzy.  The  difficulty  of  giving  statistics 
of  hospital  cases  arose  from  the  fact  that  the  hospital  patients 
seldom  returned  unless  compelled  when  they  had  got  a  cataract 
in  the  other  eye ;  but  in  private  practice  the  patients  came  to 
get  further  improvement  of  vision.  As  regarded  antiseptic  treat¬ 
ment,  he  carried  it  out  more  in  the  way  Mr.  Story  described 
than  in  Mr.  Swanzy’s.  He  could  not  rise  to  the  point  of  boiling 
the  instruments,  which  was  very  destructive  of  them,  at  least 
of  the  handles.  He  used  hydronaphthol,  but  he  did  not  use 
atropine  or  eserine  before  the  operation.  In  the  dressings,  band¬ 
age  was  the  same  as  Mr.  Swanzy’s. 

Mr.  Maxwell  would  perform  iridectomy  where  the  cataract 
was  large  and  hard,  but  would  dispense  with  it  vhere  the 
cataract  was  soft  and  small.  He  would  not  select  lenses  till  at 
least  two  weeks  after  the  operation. 

Mr.  Swanzy  replied.  His  one  hundred  cases  were  not  se 


lected,  but  related  to  all  those  in  which  he  had  operated  to  the 
end  of  1888,  excluding,  of  course,  such  a  case  as  that  of  a  man 
having  a  bad  injury  of  the  eye  and  among  them  a  traumatic 
cataract,  or  of  a  young  person  with  a  cataract  coming  on.  His 
classification  of  results  was  in  accordance  with  the  handy  con¬ 
ventional  method  of  recording  them  as  adopted  by  Professor 
Knapp  and  others— viz. :  “  no  improvement,”  2  ;  “  moderate,” 
5;  and  “good,”  93  per  cent.  But  he  would  not  set  down  as 
“good”  the  ability  to  count  fingers  merely  at  three  or  four 
metres.  Where  the  vision  reached  the  standard  of  six  sixtieths 
he  regarded  that  as  good  already,  with  every  probability  of 
getting  better.  With  regard  to  antiseptics,  he  had  found  more 
satisfaction  from  the  use  of  a  l-to-5,000  solution  of  sublimate 
than  any  other.  He  had  no  idea  about  hydronaphthol,  but  he 
abominated  iodoform  in  every  respect.  As  regarded  the  intro¬ 
duction  of  the  three-millimetre  flap  operation  into  Dublin,  he 
did  not  know  of  anybody  having  done  it  before  himself.  He 
had  been  performing  it  for  some  years,  and  whether  or  not  Mr. 
Story  began  it  two  or  three  months  before  him  did  not  matter. 
He  did  not  call  it  von  Graefe’s  operation.  What  he  said  was 
that  it  was  known  as  von  Graefe’s  operation,  of  which  it  was 
the  lineal  descendant;  not  as  von  Graefe  left  it  when  he  died, 
but  von  Graefe’s  improved  upon,  and  so  properly  called  his. 
As  to  Mr.  Fitzgerald’s  operation  being  or  having  been  identical 
with  his  own,  perhaps  it  was,  so  far  as  the  position  of  the  in¬ 
cision  in  the  margin  of  the  cornea  went ;  but  he  was  not  quite 
sure  that  it  was  in  respect  of  the  minute  coloboma  or  the  par¬ 
ticular  care  taken  in  respect  of  the  capsule  in  the  wound  which 
he  regarded  as  a  vital  matter.  Prolapse  of  the  iris  with  subse 
quent  incarceration  in  the  cicatrix  was  a  danger,  and  in  his 
series  of  one  hundred  cases  it  occurred  once;  but  in  Mr.  Fitz¬ 
gerald’s  fifty-two  it  occurred  twice,  being  nearly  four  per  cent. 

a  result  nearly  as  good  as  Professor  Knapp’s.  Mr.  Fitzgerald’s 
cases  of  full  vision  were  due  to  his  performing  discission  of  the 
capsule,  and  not  because  he  left  out  the  iridectomy.  As  legaided 


- 7 - 

iridectomy,  its  performance  did  not,  as  Mr.  Maxwell  had  sug¬ 
gested,  depend  on  whether  the  cataract  was  soft  or  hard,  whether 
the  patient  was  going  to  get  a  prolapse  of  the  iris  or  not,  but 
whether  the  wound  would  properly  heal  and  remain  healed  by 
primary  union  and  without  rupture.  He  had  yesterday  re¬ 
ceived  a  letter  from  one  of  the  most  distinguished  ophthalmic 
surgeons  in  the  United  States,  who  stated  that  in  thirty  per 
cent,  of  his  cases  he  had  had  prolapse,  sometimes  coming  on 
some  days  after  the  operation  without  apparent  cause,  and  that 
when  men  recorded  cases  without  prolapse  he  simply  doubted 
their  statistics.  With  regard  to  Mr.  Maxwell’s  point  of  order¬ 
ing  lenses  two  weeks  or  so  after  the  operation,  they  should  not 
be  ordered  until  the  eyes  were  white,  not  watering. 

SECTION  IN  MEDICINE. 

Meeting  of  Friday ,  February  28,  1890. 

The  President,  Dr.  Atthill,  in  the  Chair. 

The  Influenza  Epidemic  of  1889-90,  as  observed  in 
Dublin.— Dr.  J.  W.  Moore  read  a  paper,  in  which  he  consid¬ 
ered  the  effect  produced  on  the  public  health  and  on  the  bills 
of  mortality  in  Dublin  by.  the  epidemic,  and  described  his  im¬ 
pressions  as  to  the  origin,  nature,  and  course  of  the  disease. 

The  lessons  to  be  learned  from  the  epidemic  might  be  stated 
in  the  form  of  propositions,  as  follows: 

1.  Influenza  was  an  acute  specific  infective  disease  of  the 
miasmatic  rather  than  the  miasmatic-coDtagious  class.  Its 
virus  or  contagium,  when  once  introduced  into  the  body,  acted 
primarily  and  quickly  on  the  nervous  system,  producing  the 
phenomena  of  an  acute  pyrexia,  with  singularly  rapid  pulse. 

2.  The  disease  appeared  to  be  pandemic  rather  than  epi- 


July  26,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


105 


demic,  affecting  multitudes  at  one  and  the  same  moment,  both 
by  sea  and  land — a  known  fact,  which  suggested  to  Dr.  Hilton 
Fagge  the  view  that  the  organisms  which  gave  rise  to  influenza, 
if  organisms  there  be,  could  not  undergo  multiplication  and  de¬ 
velopment  anywhere  except  in  the  air  itself.  The  virus  of 
influenza  was  then  a  miasma,  or  what  the  physicians  of  the  six¬ 
teenth  and  seventeenth  centuries  called  a  “fouling  of  the  air.”* 
In  this  connection,  Ilirsch,  of  Berlin,  pointed  out  that  influenza 
had  not  spread  more  quickly  in  our  own  times,  with  their  mul¬ 
tiplied  and  perfected  ways  and  means  of  communication,  than 
in  former  decades  or  centuries.!  The  prevalence  of  the  disease 
was  absolutely  independent  of  season  and  weather — a  fact 
which  distinguished  influenza  from  epidemic  bronchial  catarrh.]; 

3.  If  this  miasmatic  or  pandemic  view  of  the  origin  of  in¬ 
fluenza  was  correct,  there  was  no  need  to  seek  for  a  period  of 
incubation,  the  virus  being  already  “  hatched  ”  at  the  time  of  its 
reception  into  the  human  system — that  was,  at  the  time  of  in¬ 
fection.  In  several,  if  not  in  most,  cases  there  was  an  interval 
between  the  reception  of  the  poison  and  the  development  of 
the  symptoms.  The  most  common  duration  of  this  interval 
seemed  to  be  one  or  two  days.  But  this  pseudo-incubation 
period  might  be  explained  on  the  supposition  that  in  certain 
individuals  an  intact  condition  of  the  mucous  membranes  might 
present  an  obstacle  to  the  entrance  of  the  virus  into  the  blood, 
and  so  delay  the  development  of  the  disease. 

Of  course,  it  was  not  denied  that  the  morbific  agent  or  virus 
was  capable  of  adhering  to  the  human  body,  or  to  clothes,  or 
luggage,  or  letters,  so  as  to  be  conveyed  from  one  place  to 
another  (Hilton  Fagge).  “But,”  adds  that  writer,  “its  subse¬ 
quent  growth  and  development  is,  doubtless,  altogether  inde¬ 
pendent  of  this  kind  of  assistance.” 

4.  Very  young  children  seemed  to  enjoy  a  certain  immunity 
from  influenza,  or  to  have  the  disease  in  a  mild  form. 

5.  Adults  suffered  severely  in  many  cases,  the  symptoms  be¬ 
ing  chills,  headache,  often  sleeplessness,  sometimes  delirium, 
pains  in  the  eyeballs,  nape  of  the  neck,  small  of  the  back,  knees, 
and  along  the  margins  of  the  ribs;  loss  of  the  special  senses  of 
smell,  taste,  and  sometimes  hearing;  smarting  of  the  eyes,  pho¬ 
tophobia,  lacrymation,  otalgia,  complete  loss  of  appetite,  bad 
taste  in  the  mouth,  nausea,  and  perhaps  vomiting  ;  constipation, 
but  occasionally  diarrhoea;  cough,  frequent  sweating,  loss  of 
strength,  fainting.  Of  course,  it  was  only  a  selection  from  these 
symptoms  that  was  present  in  a  given  case. 

6.  Influenza,  while  infrequently  directly  fatal,  caused  an  in¬ 
direct  loss  of  life  which  was  appalling,  chiefly  through  compli¬ 
cations  affecting  the  respiratory  and,  in  advanced  life,  the  circu¬ 
latory  systems. 

7.  Influenza  was  a  perilous  complication  of  pulmonary  con¬ 
sumption. 

8.  Other  complications  of  which  the  author  had  had  expe¬ 
rience  were  epistaxis  (one  case),  facial  neuralgia  (several  cases), 
profuse  sweatings  (several  cases),  skin  rashes  (four  cases — three 
were  examples  of  papular  sweat  rashes,  with  sudamina ;  one  was 
an  erythema  fugax),  herpetic  eruptions  (several  cases),  cystitis, 
followed  by  mild  orchitis  (one  case). 

In  contrast  to  dengue  fever,  the  speaker  believed  that  influ¬ 
enza  was  a  nou-eruptive  fever.  When  rashes  did  appear  they 
were  accidental  rather  than  essential  or  specific,  and  they  re¬ 
sulted  from  hyperpyrexia,  or  profuse  sweating,  or  from  the 
ingestion  of  such  drugs  as  quinine,  or  antipyrine,  or  salicylate 
of  sodium. 


*  Hirsch,  Handbook  of  Geographical  and  Historical  Pathology ,  vol 

i,  p.  34,  New  Syd.  Soc.,  1883. 
f  Op.  cit.,  p.  36. 

!  Cf.  Hirsch,  op.  cit.,  p.  26. 


9.  Influenza  seemed  to  have  the  property  of  picking  out  the 
weak  point  in  an  individual’s  constitution.  If  the  patient  was 
neurotic,  nervous  and  neuralgic  symptoms  were  likely.  Any 
old  tendency  to  catarrh  of  either  the  respiratory  or  the  digestive 
mucous  membranes  was  at  once  intensified  in  the  presence  or  in 
the  wake  of  this  strange  malady. 

10.  The  febrile  movement  in  even  uncomplicated  influenza 
was,  as  Wunderlich  would  say,  “polytypical,”  or  “atypical.” 

11.  Influenza  showed  a  marked  tendency  to  relapse,  and  to 
this  was  largely  due  the  indirect  fatality  of  the  malady. 

12.  The  treatment  of  the  affection  turned  upon  common- 
sense  principles.  It  was  expectant,  palliative,  and  symptomatic. 
There  was  no  specific  for  influenza,  but  the  most  useful  drugs  to 
employ  in  its  treatment  were  (1)  quinine,  (2)  antipyrine  (except 
in  young  children  and  the  weakly),  (3)  salicylate  of  sodium, 
especially  in  effervescence,  (4)  phenacetine,  and  (5)  effervescing 
citrate  of  caffeine. 

Influenza,  or  Dengue,  as  observed  at  Kells.— Dr.  Ring- 
wood  read  a  paper  on  dengue  fever,  which,  he  stated,  had  been 
endemic  in  the  neighborhood  of  Kells  for  the  last  five  years, 
the  disease  having  appeared  soon  after  the  return  of  our  troops 
from  Egypt.  The  character  of  the  disease  for  the  first  six 
months  was  that  of  bilious  relapsing  fever  of  so  virulent  a  type 
that  six  of  the  cases  observed  by  him  were  exactly  similar  to 
the  cases  of  yellow  fever  which  occurred  in  Dublin  in  1826,  and 
were  then  described  by  Dr.  Stokes  and  Dr.  Graves. 

He  held  that  the  present  form  of  influenza  was  a  very  mild 
form  of  dengue,  generally  free  from  eruption.  The  limits  of 
his  paper  prevented  his  referring  to  treatment,  except  to  say 
that  he  had  found  the  best  results  were  obtained  by  the  free  use 
of  pure  salicine. 

The  President  suggested,  as  questions  for  discussion,  whether 
the  disease  which  had  been  described  by  Dr.  J.  W.  Moore  was 
a  specific  and  contagious  disease,  or,  as  was  held  by  some, 
merely  an  ordinary  inflammatory  cold,  very  common  at  the 
present  time;  and  also  whether  the  cases  described  by  Dr. 
Ringwood  were  of  the  same  disease  which  prevailed  in  Dublin 
or  of  an  entirely  different  and  specific  disease. 

Dr.  Finny  did  not  think  that  Dr.  Ringwood  had  thoroughly 
proved  his  point  as  to  the  identity  of  the  disease  in  Kells  with 
that  in  Dublin.  Having  seen  the  lady  referred  to,  in  consultation 
with  Dr.  Ringwood,  he  had  to  acknowledge  that  he  had  never 
met  with  a  similar  case.  The  variations  of  the  fever  presented 
remarkable  phenomena,  the  temperature  in  the  sqme  day  run¬ 
ning  from  99°  in  two  hours  up  to  105°  F.,  which  was  reached 
between  eleven  and  twelve  o’clock  noon,  and  in  the  evening  it 
was  down  to  normal.  The  lungs  were  largely  affected  with 
patches  of  pneumonic  complication.  It  was  noteworthy  that 
the  lap-dog  suffered  too,  having  a  discharge  from  the  Dose,  as 
showing  that  the  influenza  affected  the  lower  animals. 

Dr.  McSwiney  had  met  with  cases  characterized  by  frequent 
desire  to  urinate  in  large  quantity,  somewhat  as  in  hysteria ; 
also  by  fainting,  epistaxis,  pain  in  the  frontal  sinuses,  followed 
by  a  discharge  of  pus;  and,  in  the  recovery  stage,  by  diapho¬ 
resis. 

Dr.  A.  W.  Foot  said  the  term  “influenza,”  whatever  it 
meant,  had  been  dragged  in  by  the  neck  and  shoulders  as  a 
dens  ex  machina  to  explain,  in  the  case  of  the  first  paper,  dis¬ 
eases  with  the  old-fashioned  names  of  “feverish  cold,”  “heavy 
cold,”  as  distinguished  from  “light,”  “rheumatic  cold,”  or 
other  forms  of  ordinary  catarrh;  and,  in  the  case  of  Dr.  Ring- 
wood’s  paper,  anomalous  forms  of  eruptive  fever.  He  had  entered 
the  room  with  but  slight  respect  for  influenza;  yet  when  he 
heard  cholera  and  yellow  fever  mentioned  in  the  same  breath 
all  that  was  requisite  to  make  him  a  perfect  convert  to  its  im¬ 
portance  was  to  give  it  a  spice  of  hydrophobia.  But  then 


106 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mud.  Joor., 


there  was  the  high  death-rate  from  influenza  recorded  by  the 
Registrar-General.  Man,  woman,  and  child,  horse,  dog,  and 
cat  had  suffered,  and  the  weary,  over- worked  dispensary  doctor 
made  the  shortest  diagnosis  and  put  down  “influenza.  ’  Hence 
the  alarming  statistics.  He  preferred  to  rely  on  observations 
in  hospital  practice  rather  than  on  those  in  private.  Fagge  was 
entirely  against  the  miasmatic  origin  of  influenza,  using  the 
word  “  miasmatic  ”  as  telluric.  The  prevalence  of  influenza  in 
every  climate,  torrid  and  temperate,  in  every  soil,  dry  and 
moist,  in  high  elevations  and  lowlands,  and  in  fleets  on  the 
ocean’  showed  that  it  had  no  miasmatic  or  telluric  origin.  As 
regarded  treatment,  he  had  not  heard  any  recommendation  of 
rum  punch,  which  he  had  known  to  cure  many  cases. 

Dr.  0.  J.  Nixon  said  Dr.  Foot’s  remarks  implied  a  complete 
disbelief  in  the  existence  of  influenza  as  an  epidemic,  especially 
occurring  at  the  present  time.  He  required  proof  where  proba¬ 
bility  only  was  to  be  had.  But  there  was  one  important  fact 
that  according  to  the  returns  of  the  Registrar-General,  in 
Paris  the  deaths  for  the  last  week  of  December,  1888,  amounted 
to  955,  while  for  the  last  week  of  last  December  the  deaths 
were  2,874;  and  again,  taking  the  first  week  of  January,  1889, 
the  deaths  were  970,  while  in  the  first  week  of  January  of  the 
present  year  the  deaths  were  2,683.  There  must  surely  be 
some  very  unusual  conditions  to  produce  such  a  striking  in¬ 
crease  in  the  death-rate. 

Dr.  J.  Bellew  Kelly  (Drogheda)  felt  disappointed  at  not 
having  heard  more  as  regarded  treatment.  He  had  learned  noth¬ 
ing  that  had  not  been  on  record  for  centuries,  especially  in  con¬ 
nection  with  the  epidemics  of  1510  and  1743,  whatever  the  name 
of  the  disease,  whether  la  grippe ,  influenza,  or  dengue.  Every 
form  of  disease  of  a  febrile  type  was  liable  to  all  sorts  of  com¬ 
plications.  He  had  had  three  hundred  cases,  and  in  all  these  he 

had  not  treated  one  pregnant  woman. 

Dr.  J.  W.  Moore,  in  reply,  said  Dr.  Foot  had  not  correctly 

stated  Dr.  Hilton  Fagge’s  view,  which  was  that  the  organisms  of 
influenza  could  not  undergo  multiplication  and  development 
anywhere  except  in  the  air  itself;  and  that  constituted  the  dis¬ 
tinct  theory  of  miasma ;  while  Hirsch  considered  the  virus  of 
influenza  was  a  miasma  or  fouling  of  the  air.  If  influenza  was 
not  an  epidemic,  Dr.  Foot  had  given  no  explanation  of  the  ex¬ 
cessive  death-rate  of  January,  1890,  which  was  certainly  not 
due  to  the  weather.  The  death-rate  was  opposed  to  all  accepted 
theories  of  the  influence  of  the  weather.  Indeed,  in  spite  of  the 
mild  weather,  the  death-rate  exceeded  that  which  was  incidental 
to  the  intense  cold  of  January,  1881.  His  classification  was 
nearly  the  same  as  Dr.  Nixon’s.  He  gave  five  classes— cardiac, 
pulmonary,  gastric,  febrile,  rheumatoid,  yet  all  of  afebrile  type. 
Dengue  and  influenza  were  absolutely  and  positively  distinct. 
There  was  not  a  single  case  of  dengue  in  Dublin  or,  he  believed, 
elsewhere  in  Ireland.  It  was  an  accepted  doctrine  that  dengue 
was  a  tropical  or  subtropical  disease.  No  true  case  of  yellow 
fever  could  possibly  occur  in  Ireland,  for  under  70°  F.  was  fatal 
to  the  disease.  His  theory  of  pseudo-incubation  was,  that  the 
virus  of  the  disease  seemed  to  be  hatched  and  multiplied  in  the 
open  air,  and  then  lodged  on  the  persons  of  individuals,  who 
acted  as  fomites  of  the  disease.  There  was  no  evidence  to  show 
that  the  virus  was  multiplied  and  developed  within  the  system. 


NEW  YORK  CLINICAL  SOCIETY. 

Meeting  of  May  23,  1890. 

The  President,  Dr.  L.  B.  Bangs,  in  the  Chair. 

The  Dosa-g©  and  Administration  of  Creasote  in  Phthisis. 

—A  paper  on  this  subject  was  read  by  Dr.  W.  H.  Flint.  (See 

page  85.) 


Dr.  Beverley  Robinson  said  that  he  was  much  gratified  at 

the  very  complimentary  manner  in  which  Dr.  Flint  had  referred 

to  his  paper  on  creasote  as  a  remedy  in  phthisis  pulmonahs. 

He  was  particularly  glad  to  take  part  in  this  discussion,  as  he 
believed  in  creasote  as  a  very  useful  remedy  in  this  disease. 
Prior  to  using  it  in  an  accurate  and  extensive  way,  he  had  tried 
all  the  vaunted  methods  in  treating  phthisis.  For  some  time 
lavage  and  gavage  had  inspired  him  with  much  confidence,  and 
he  had  hoped  that  we  might  thus  so  improve  the  nutrition  of 
phthisical  patients  that  the  Bacillus  tuberculosis  would  ulti¬ 
mately  be  compelled  to  relinquish  its  hold.  Certainly,  patients 
often  did  gain  considerably  in  weight,  but  the  physical  signs  in 
the  lungs  remained  stationary.  He  had  also  believed,  during 
quite  a  period  of  time,  in  the  marked  beneficial  effects  resulting 
from  intrapulmonary  injections  of  different  kinds.  He  had 
I  now  practically  abandoned  them,  as  he  had  lost  faith  in  them, 
except  in  a’very  limited  number  of  cases.  After  reading  Bou¬ 
chard’s  paper  when  it  was  first  published,  he  had  commenced 
using  creasote  ;  but  in  the  beginning  he  had  only  had  faith  in  it 
as  a  good  anticatarrhal  agent,  to  be  ranked  in  the  same  category 
with  many  similar  drugs  that  were  said  to  have  a  special  effect 

in  lessening  bronchial  inflammation. 

Later  on,  and  very  soon  after  the  first  publications  in  regard 
to  the  useful  effect  of  the  drug  appeared  in  Germany,  he  had  taken 
up  his  observations  on  creasote  with  considerably  more  accu¬ 
racy  and  attention  to  the  smallest  changes  in  signs  and  symp- 
|  toms  brought  on  by  its  use.  The  result  had  been  to  convince 
him  of  its  great  utility.  Prior  to  using  it  he  had  become  very 
skeptical  as  to  the  curative  influence  of  drugs  in  this  disease, 
and  he  had  given  cod-liver  oil  and  the  hypophosphites  par¬ 
ticularly  to  hospital  and  dispensary  patients — with  great  incre¬ 
dulity  as  to  their  beneficial  effects.  Now  and  for  some  time 
past  his  faith  had  returned  in  a  measure.  In  his  experience, 
creasote  must  be  given  in  small  doses  and  continued  a  long 
time  if  we  wished  to  obtain  really  good  effects  from  its  use. 
It  was  possible  that  some  patients  might  bear  large  doses  well, 
but  it  was  always  a  risk  to  insist  upon  them.  He  had  always 
used  creasote  by  the  mouth  or  in  inhalation,  and  had  had  no 
experience  with  the  method  of  giving  it  by  the  rectum.  He 
was  not  favorably  disposed  toward  this  other  way  of  giving 
the  drug.  Creasote  should  be  pure,  well  diluted,  and  per¬ 
fectly  dissolved,  in  order  to  prevent  any  possible  danger  of 
stomachal  intolerance.  The  dose  of  a  half  to  a  minim  should 
be  given  five  or  six  times  in  twenty-four  hours,  and  increased  in 
amount  very  slowly.  It  should  be  continued  for  months  at  a 
time,  and  indeed  so  long  as  there  was  any  indication  for  its  use. 
Taken  in  this  way,  it  would  usually  produce  good,  and  at  times 
remarkably  good,  effects.  Sputa  would  diminish  and  disappear, 
nutrition  was  benefited,  strength  increased,  and  cough  arrested. 
The  local  signs  were  sometimes  much  improved.  He  had  known, 
in  at  least  two  cases,  the  bacilli  to  disappear  entirely  from  the 
sputa,  where  they  had  previously  been  recognized.  In  several 
cases  he  believed  he  had  seen  his  patients  recover.  Now,  be 
could  not  say  this  of  any  hospital  or  dispensary  patients  thus 
affected  whom  he  had  formerly  treated  with  cod-liver  oil  and 
the  hypophosphites.  Altogether,  in 'his  judgment,  creasote 
was  the  best  remedy  we  now  were  in  possession  of  for  the 
amelioration  and  possible  cure  of  pulmonary  phthisis.  W e  must 
not,  however,  run  risks  of  disgusting  our  patients  with  it  by 
increasing  the  doses  too  rapidly.  Above  everything,  we  must 
preserve  the  digestive  organs  intact,  and  must  not  interfere  with 
the  assimilative  process.  If  we  did  this,  we  lost  immediately 
all  the  possible  good  effects  from  creasote,  and  took  away  fion 
the  patient  one  of  his  reliable  chances  of  living.  Whenever  i 
could  be  carried  out,  he  liked  the  combined  method  best— o 
inhalation  and  administration  by  the  stomach.  In  this  manne 


July  26,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


107 


he  was  sure  we  should  obtain  our  most  welcome  results.  He 


would  be  glad  if  these  expressed  opinions  should  carry  convic¬ 
tion,  and  make  it  almost  obligatory  for  any  one  treating  a  case 
of  phthisis  to  give  creasote. 

Dr.  W  .  H.  Katzenbaoh  remarked  that,  for  the  last  year  or  so, 
he  had  employed  creasote  in  the  treatment  of  phthisis  in  private 
practice,  with  results  corresponding  with  those  mentioned  by 
Dr.  Flint  and  Dr.  Robinson.  Under  its  administration,  in  a  good 
proportion  of  cases,  appetite  and  digestion  had  improved,  cough 
and  expectoration  had  subsided,  fever  abated,  nutrition  in¬ 
creased,  and  the  patient  gained  in  weight.  A  recent  case  would 
illustrate  this.  A  young  woman,  aged  twenty-three  years,  had 
consulted  him  early  in  March  of  the  present  year  with  signs  of 
phthisis  in  the  second  stage,  involving  a  considerable  portion 
of  the  upper  lobe  of  the  right  lung  anteriorly.  The  physical 
signs  were  dullness,  broncho-vesicular  respiration,  increased 
vocal  resonance,  and  subcrepitant  rales.  Her  temperature  was 
lOO-o0  F.,  pulse  120,  and  respiration  32.  Weight,  one  hundred 
and  seven  pounds.  She  was  given  creasote  in  conjunction  with 
cod-liver  oil  and  extract  of  malt.  By  the  middle  of  March  her 
appetite  had  improved  and  her  cough  had  diminished.  Men¬ 
struation,  which  had  been  suppressed,  reappeared,  and  she  felt 
stronger  in  every  respect.  By  the  latter  part  of  April  her  tem¬ 
perature  was  98'5°  F.,  pulse  80,  and  respiration  24.  The  respi¬ 
ration  over  the  affected  lung  was  still  broncho-vesicular,  but  the 
rales  had  disappeared.  Her  weight  was  one  hundred  and  eleven 
pounds  and  five  eighths. 

In  medicinal  doses,  Headland  had  said  that  creasote  had  “  a 
double  action,  being  anodyne,  like  hydrocyanic  acid,  and  a  mu¬ 
cous  stimulant,  like  turpentine  ”  (quoted  by  Still6). 


When  its  use  was  begun,  creasote  might  increase  cough  and 
expectoration  from  its  liquefying  action  on  the  sputa,  but  sub¬ 
sequently  the  secretion  diminished  or  was  arrested,  and  cough 
was  relieved.  In  the  late  stages  of  phthisis,  with  cavities,  high 
fever,  copious  expectoration,  loss  of  appetite,  and  impaired 


The  following 


digestion,  the  results  had  not  been  favorable, 
formula  was  the  one  commonly  used  : 

R  Creasoti  (beech  wood) .  3  j  • 

Glycerin . ad  §  iij. 

M.  Sig. :  Take  half  a  teaspoonful  after  meals  and  at  bed¬ 
time,  with  whisky,  a  half  to  a  tablespoonful,  and  water  two 
ounces. 


to  the  mode  of  action  of  the  drug  in  phthisis.  In  man  there 
were,  some  fourteen  pounds  of  blood,  in  which  any  so-called 
“antiseptic”  remedy  must  inevitably  be  diluted  when  absorbed, 
and  it  was  easier  for  him  to  believe  that  creasote  might  act  by 
altering  in  some  manner  the  tissues  or  “soil  ”  in  which  the  tu¬ 
bercle  bacilli  grew,  or  by  improving  bodily  nutrition,  than 
to  admit  that  its  influence  was  in  any  way  germicidal,  even 
when  inhaled.  In  the  latter  case  it  was  difficult  to  prove  bow 
deeply  it  diffused  into  the  lungs,  or  that  it  ever  came  in  direct 
contact  with  many  foci  of  bacilli. 


Ihjorts  on  tljf  froguss  erf  ®ebkiiw. 


GYNAECOLOGY. 

By  ANDREW  F.  CURRIER,  M.  D. 

Contribution  to  the  Subject  of  Fibromata  of  the  Uterus  (Walton, 
Arch,  de  tocol.,  December,  1889).— The  object  of  this  paper  is  princi¬ 
pally  to  indicate  the  line  of  conduct  which  is  proper  for  the  general 
practitioner  in  meeting  the  ordinary  difficulties  which  are  associated 
with  uterine  fibromata.  Radical  treatment  is  not  believed  in  for  such 
conditions  so  long  as  conservative  treatment  is  suitable.  The  following 
propositions  are  submitted : 

1.  With  fibromata  which  completely  fill  the  uterine  cavity,  rapid 
dilatation  will  enable  one  to  make  a  diagnosis,  and  facilitate  an  opera¬ 
tion  if  the  latter  is  indicated. 

2.  Ablation  of  the  neoplasm  will  check  the  haemorrhage,  even 
though  a  second  growth  is  developing  in  the  uterine  wall. 

3.  Forced  dilatation  may,  of  itself,  rupture  the  capsule  of  a  submu¬ 
cous  fibro-myoma,  the  spontaneous  enucleation  of  which  may  follow. 

4.  Forced  dilatation  combined  with  curetting  will  always  arrest 
haemorrhage  from  fibromata  which  are  not  attackable  per  vaginam. 

5.  Forced  dilatation  by  facilitating  the  return  circulation  may  lead 
to  involution,  to  diminution,  and  to  clinical  disappearance  of  the  tumor. 

6.  The  suppression  of  haemorrhage  and  of  compression  symptoms, 
the  absence  of  pain  and  of  all  disturbance,  constitute  a  cure  clinically. 

7.  The  best  means  for  overcoming  the  foetid  condition  of  the  leu- 
corrhceal  discharge  attending  these  tumors,  and  so  of  avoiding  auto¬ 
infection,  is  to  dilate  freely  the  uterine  cavity  and  disinfect  it. 


Dr.  W.  G.  Thompson  said  that  it  had  been  his  fortune  to  suc¬ 
ceed  Dr.  Flint  several  times  in  his  hospital  service,  and  he  wished 
to  add  his  testimony  to  the  value  of  the  results  of  the  creasote 
treatment  in  many  of  Dr.  Flint’s  cases  of  phthisis.  He  had 
used  the  drug  extensively  for  a  number  of  years,  and  was  con¬ 
vinced  that  it  was,  upon  the  whole,  the  most  useful  remedy  that 
we  possessed  for  controlling  many  of  the  more  urgent  symp¬ 
toms  of  phthisis,  notably  diminishing  cough,  expectoration,  and 
dyspnoea,  and  favoring  gain  in  nutrition.  In  cases  fairly  ad¬ 
vanced,  he  believed  in  pushing  the  administration  of  the  drug 
to  the  limit  of  toleration.  This  limit  was  considerably  extended 
by  taking  great  pains  to  secure  a  pure  wood  creasote,  and  to 
administer  it  in  the  careful  manner  described  by  Dr.  Flint. 
The  drug  was  of  special  value  in  that  it  might  be  given  in  sev¬ 
eral  ways— by  the  mouth,  by  inhalation,  or  by  the  rectum. 
When  the  stomach  showed  signs  of  irritation  from  large  doses 
of  creasote,  he  had  found  it  to  be  still  very  well  borne  when  ad¬ 
ministered  by  the  rectum  in  five-minim  doses,  in  emulsion,  or  by 
inhalation.  If  the  inhalers  worn  were  not  deep  enough,  ex¬ 
coriation  might  result,  and  he  mentioned  three  cases  in  which 
lie  had  seen  severe  ulceration  of  the  nose  and  chin  from  the 
careless  use  of  inhalers  with  creasote.  Notwithstanding  the 
results  of  experiments  upon  animals,  alluded  to  by  Dr.  Flint, 
the  speaker  thought  that  we  were  still  completely  in  doubt  as 


Concerning  Gastric  Affections  in  Connection  with  Diseases  of  the 
Female  Genital  Organs  (Rosenthal,  Ctrlbl.  f.  Gyn.,  Nov.  30,  1889).— 
The  author  disagrees  with  Hegar,  Engelhardt,  and  others  who  look 
upon  the  nervous  disorders  connected  with  gastric  affections  as  spinal- 
cord  symptoms,  and  seeks  to  find  their  explanation  in  an  irritation  of 
certain  roots. and  plexuses,  including  the  ischiadic  and  crural  and  also 
the  root  areas  of  the  cauda  equina.  Neuritis  of  the  nerve-roots  with 
severe  symptoms  is  a  rare  occurrence.  Those  forms  of  digestive  dis¬ 
order  which  have  a  reflex  relation  with  disease  of  the  uterus  and  its 
annexa  usually  appear  as  dyspepsia,  cardialgia,  and  vomiting.  Two 
different  types  of  digestive  disorder  may  be  distinguished.  In  that 
form  which  is  characterized  by  cardialgia,  vomiting,  and  pneumatosis, 
there  is  superacidity  as  the  result  of  the  gastric  irritation  ;  in  the  other 
form  there  is  insufficiency  of  hydrochloric  acid,  indicating  gastric  ex¬ 
haustion.  In  the  first  form  the  condition  of  the  urine  is  of  especial 
importance.  To  be  rational  in  one’s  treatment  of  these  cases  they 
should  be  carefully  distinguished  from  those  in  which  there  is  a  de¬ 
ficiency  of  acid.  In  the  first  the  author  prescribes  Carlsbad  water, 
borax,  or  a  mixture  of  carbonate  of  potassium  and  bismuth  ;  also  large 
doses  of  bromide  of  potassium  morning  and  evening,  and  in  some  cases 
hydrotherapy.  In  the  second  form  large  doses  of  hydrochloric  acid  are 
indicated,  perhaps  with  the  addition  of  pepsin. 

The  Electrical  Treatment  of  Uterine  Fibromata  (Apostoli,  Con- 
cours,  Nov.  9,  1889). — The  electrical  treatment  of  fibroid  tumors  of  the 
uterus  which  was  devised  by  Apostoli  in  1882  was  recently  discussed 
before  the  Paris  Society  of  Surgery  in  connection  with  a  method  which 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


|N.  Y.  Med.  Jock., 


108 


purports  to  have  superiority  over  all  others  in  that  it  is  new,  and  that 
it  rests  upon  the  use  of  currents  of  moderate  intensity,  upon  intra¬ 
uterine  action,  and  upon  frequent  changes  of  the  current. 

Apostoli  opposes  these  pretensions  as  follows : 

1.  This  method,  devised  by  Championnifcre  and  Danion,  is  not  new, 
and  is  only  the  reproduction  of  old  methods  which  have  been  tried 
and,  in  part,  abandoned. 

Apostoli  claims  priority  and  originality  in  the  use  of  all  medical 
electric  currents  exceeding  fifty  milliamperes.  For  two  years  he  used 
no  current  exceeding  seventy  milliamperes,  but  subsequently  he  found 
it  safe  and  advisable  to  use  stronger  ones,  the  intensity  being  moder¬ 
ated  according  to  the  uterine  or  circumuterine  intolerance,  and  in¬ 
creased  in  complicated  forms  of  endometritis  or  in  severe  haemorrhage. 

Aim6  Martin  and  Cheron  discovered  in  1879  the  extra-uterine  action 
of  the  current,  and  defined  its  action  upon  the  cervix  and  the  vagina ; 
they  were  also  the  first  to  use  interruptions  and  reversions  of  the  gal¬ 
vanic  current.  Benedikt  also  used  reversions  of  the  current  prior  to 
Championniere  and  Danion. 

2.  This  method  is  inferior  to  that  of  Apostoli,  because  its  authors 
still  continue  as  surgeons  to  substitute  for  it,  in  certain  cases,  castra¬ 
tion  and  hysterectomy ;  because  they  use  it  upon  old  or  slightly  sick 
women,  and  operate  upon  the  younger  ones ;  because  the  method  is 
only  vaginal  and  extra-uterine,  thus  omitting  to  cure  a  concomitant  en¬ 
dometritis  ;  because  recurrences  constantly  occur  unless  they  continue 
to  use  the  treatment ;  because  they  do  not  profess  that  peripheral  in¬ 
flammatory  exudates  disappear ;  because  their  use  of  sodium-chloride 
solutions  shows  that  they  do  not  regard  their  method  as  reliable ;  be¬ 
cause  they  have  not  demonstrated  anatomical  reductions  in  the  tumors 
treated. 

The  experience  of  Championniere  and  Danion  rests  upon  seven 
months’  trial  in  eleven  cases,  while  Apostoli  has  tried  his  seven  years, 
many  thousands  of  cases  having  been  treated. 

Apostoli  asserts  that  his  method  is  inoffensive  and  supportable  if 
one  confines  himself  to  the  rules  which  he  (Apostoli)  has  prescribed. 
His  method  is  the  most  efficient : 

1.  Because  it  is  a  sufficient  method,  and  in  most  cases  can  supplant 
surgery  in  the  treatment  of  fibromata. 

2.  Because  it  does  not  select  its  cases,  and  benefits  young  and  old. 

3.  Because  it  makes  use  of  vaginal  galvano-puncture,  either  by 
itself  or  in  connection  with  the  intra-uterine  action  which  relieves 
lesions  of  the  endometrium. 

4.  Because  failure  with  it  is  exceptional  with  simple  fibroid  tumors 
that  is,  with  those  which  are  not  fibro-cystic,  which  are  not  complicated 
with  ascites,  and  which  have  no  peripheral  lesions  of  the  annexa. 

5.  Because  with  this  method  recurrence  is  exceptional,  most  of  the 
results  being  permanent  after  treatment  has  been  sufficiently  prolonged. 

6.  Because  it  includes  in  its  sphere  of  action  under  formulae  of 
different  intensity  and  localization  the  treatment  of  fibromata,  endome¬ 
tritis,  metritis,  and  many  cases  of  oophoro-salpingitis. 

7.  Because  it  can  dispense  with  the  use  of  all  additional  methods 

of  treatment. 

8.  Because  it  produces  anatomical  reduction  of  the  tumor  to  a 
greater  or  less  extent. 

At  a  meeting  of  the  Paris  Surgical  Society  (Concours,  Mar.  15, 
1890),  Lucas-Championniere  spoke  concerning  the  electrical  treatment 
of  fibroid  tumors.  He  uses  a  method  to  which  Apostoli’s  name  is  at¬ 
tached,  but  in  a  different  manner  from  Apostoli,  inasmuch  as  he  pene¬ 
trates  neither  the  uterine  tissue  nor  the  uterine  cavity  with  the  electrode. 
An  electrical  tampon  is  placed  against  the  vaginal  portion  of  the  cervix, 
and  the  current  is  reversed  from  time  to  time.  The  intensity  of  the 
current  used  does  not  exceed  80  to  120  milliamperes.  In  all  cases  this 
treatment  has  been  well  tolerated,  and  causes  a  disappearance  of  the 
feeling  of  heaviness,  the  htemorrhage,  and  the  pain ;  it  also  causes 
diminution  in  the  volume  of  the  tumor.  Such  results  have  often  been 
seen  in  women  forty  to  forty-five  years  old,  but  in  some  cases  the  dis¬ 
ease  has  been  very  rebellious  to  treatment. 

Le  Dentu  called  attention  to  a  rare  form  of  fibroma  in  the  abdomi¬ 
nal  wall  of  a  woman  upon  whom  he  performed  ovariotomy  in  1 888. 
The  following  year  an  enlargement  appeared  at  the  site  of  the  cicatrix, 
and  this  proved  to  be  a  tumor  as  large  as  a  good-sized  nut  which  was 


adherent  to  the  deeper  portions  of  the  skin  and  abdominal  wall.  It  was 
easily  removed,  and  the  author  thinks  it  was  not  a  keloid  growth  but  a 
neoplasm  of  a  fibrous  character  which  started  from  the  cicatricial  tissue. 

Alexander’s  Operation. — At  the  same  meeting  (ibid.)  Lagrange  called 
attention  to  a  patient  upon  whom  he  had  performed  Alexander’s  opera- 
tion  for  backward  displacement  of  the  uterus.  The  operation  was  done 
in  May,  1889,  and  had  resulted  in  the  disappearance  of  the  symptoms 
which  were  present  prior  to  the  operation.  No  pessary  had  been  used 
since  the  performance  of  the  operation,  and  the  uterus  remained  in  good 
position. 

Terrillon  said  that  the  fixation  of  the  ligaments  to  the  pillars  ot  the 
inguinal  ring  was  sometimes  inconstant,  and  that  it  was  better  to  use  a 
pessary  for  several  months  after  the  performance  of  the  operation. 

Trelat  thought  that  one  could  say  within  a  month  after  the  per¬ 
formance  of  Alexander’s  operation  whether  the  success  would  be  perma¬ 
nent  or  not.  Failure  is  sometimes  due  to  rupture  of  the  thin  and  tense 
fibers  of  the  shortened  ligament.  In  performing  the  operation,  he 
thinks  that  sections  10  or  12  centimetres  long  should  be  removed  from 
each  ligament. 

Bouilly  believed  that  success  or  failure  in  Alexander’s  operation  de¬ 
pended  largely  upon  the  condition  of  the  pelvic  floor,  which  under  cer¬ 
tain  circumstances  played  a  very  important  role  in  the  reproduction  of 
retroflexion.  In  some  women  one  can  succeed  in  maintaining  t  e 
uterus  in  its  proper  position  after  Alexander’s  operation  only  by  sup¬ 
plementing  that  operation  by  the  performance  of  perineorrhaphy  or 
colporrhaphy. 

Electrotherapy  in  Slavjansky’s  Clinic  (Massen,  An.  de  Obst., 

Ginecop.  y  Ped.,  February,  1890).— The  battery  which  was  used  by  the 
author  was  one  of  Gaiffe’s  with  thirty-six  cells,  the  latter  being  the 
modified  Leclanclie  containing  a  solution  of  peroxide  of  manganese 
and  chloride  of  zinc.  He  also  used  a  smaller  battery  containing 
twenty-four  cells  containing  the  bisulphate-of-mercury  solution.  All 
antiseptic  precautions  were  used  in  administering  the  treatment,  not 
only  the  instruments  being  disinfected,  but  also  the  genitals  of  the  pa¬ 
tient.  The  uterine  sound  was  introduced  through  a  vaginal  speculum, 
this  being  contrary  to  the  custom  of  Apostoli.  At  the  beginning  of  a 
course  of  treatment  the  current  should  not  be  passed  for  more  than 
five  or  six  minutes ;  subsequently  it  may  be  used  eight  or  ten  minutes. 
Ten  minutes  should  be  the  maximum  time  for  the  treatment  of  inter¬ 
stitial  fibro-mvomata.  The  intensity  of  the  current  should  not  exceed 
50  milliamperes  at  first,  and  this  may  be  gradually  increased  in  subse¬ 
quent  seances  to  120  milliamperes  for  inflammatory  conditions,  and  250 
or  more  for  fibro-myomata.  To  measure  the  intensity  of  the  current, 
Gaiffe’s  horizontal  galvanometer  is  recommended,  while  the  resistance 
should  be  regulated  by  a  rheostat,  200  ohms  being  a  suitable  resistance 
with  currents  of  moderate  intensity,  while  with  those  currents  of  250 
milliamperes  or  more  the  resistance  should  not  exceed  7  ohms.  Inflam¬ 
matory  products  do  not  perceptibly  increase  the  resistance,  but  with 
fibro-myomata  the  resistance  is  decidedly  augmented.  The  author 
agrees  with  Apostoli  in  affirming  the  hasmostatic  action  of  the  positive 
pole.  Ordinarily  the  treatment  may  be  given  once  in  five  days,  but 
with  fibro-myomata  which  are  not  very  sensitive  it  may  be  given  more 
frequently.  If  the  treatment  is  external  the  patient  should  rest  for  an 
hour  after  receiving  it  and  then  attend  to  her  ordinary  duties,  but  in 
the  treatment  of  fibro-myomata  it  is  better  that  she  should  rest  for  the 
remainder  of  the  day.  The  passage  of  the  current  does  not  usually 
produce  much  pain,  and  anesthesia  is  therefore  unnecessary.  There 
may  be  smarting  upon  the  abdomen  similar  to  that  which  is  produced 
by  a  sinapism  ;  there  may  also  be  a  feeling  of  compression  in  the  uterus, 
and  at  times  a  dragging  sensation  about  the  waist.  The  feeling  ma>  be 
more  intense  if  there  is  a  focus  of  recent  inflammation.  If  the  negative 
pole  has  been  used,  there  may  be  contractile  pains  like  those  of  parturi 
tion  two  or  three  hours  after  the  seance  is  concluded.  Usually  there  if 
no  pain  at  night  and  the  patients  can  sleep  quietly.  At  the  beginning 
of  a  course  of  treatment  there  may  be  a  moderate  leucorrhoeal  dischargi 
mingled  with  blood.  All  other  treatment  should  be  suspended  whil* 
electrotherapy  is  being  used,  except  the  use  of  vaginal  douches.  Durinj 
a  period  of  five  months  and  a  half  the  author  treated  twenty  cases  o 
fibro-myoma,  twenty -two  of  metritis  and  endometritis,  and  seventy  o 
disease  of  the  uterine  appendages  and  the  broad  ligaments.  There  wer 


July  26,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


109 


also  three  cases  of  ainenorrhoea  and  one  of  hystero-epilepsy.  In  thirty- 
four  cases  a  cure  was  effected,  in  eight  there  was  no  change  percepti¬ 
ble,  and  in  three  the  patients  became  worse.  The  author  lias  formu¬ 
lated  his  conclusions  as  follows  : 

1.  Apostoli’s  method  merits  the  attention  and  sympathy  of  gynae¬ 
cologists. 

2.  It  represents  one  of  the  bases  of  conservative  gynaecology,  and 
has  an  assured  future. 

3.  It  is  still  in  its  initial  period,  and,  like  all  electrotherapy,  rests 
upon  experimentation. 

4.  In  the  treatment  of  fibroid  tumors  it  relieves  pain  and  haemor¬ 
rhage,  and  restores  the  normal  function  of  the  uterus.  Subsequently 
the  tumor  becomes  movable  as  the  result  of  absorption  of  inflammatory, 
matter,  and  finally  there  is  reduction  of  the  neoplasm. 

5.  It  offers  perfect  results  for  haemorrhagic  endometritis,  and  is  a 
successful  rival  to  the  operation  of  curetting  the  uterine  mucous  mem¬ 
brane. 

6.  Before  castration  is  performed  the  electrical  treatment  should 
receive  a  trial. 

Irrigation  of  the  Peritonaeum  (Delbet,  Ann.  de  gyn .,  September, 
1889). — The  author  has  made  experiments  with  the  view  of  ascertain¬ 
ing  whether  irrigation  is  really  a  good  way  of  cleansing  the  peritonaeum, 
and  whether  it  may  not  cause,  in  a  reflex  manner,  cardiac  or  respiratory 
syncope.  The  liquid  which  is  poured  into  the  peritoneal  cavity  is  dif¬ 
fused  throughout  it,  and  this  is  an  advantage  if  one  is  operating  for 
general  peritonitis,  or  in  cases  in  which  the  contents  of  a  ruptured  in¬ 
testine  or  an  abscess  have  been  poured  upon  the  peritonaeum  ;  but  if 
the  object  is  simply  to  remove  pus  which  has  leaked  into  Douglas’s  cul- 
de-sac  from  a  tube  which  has  been  torn  in  the  course  of  its  removal, 
irrigation  may  force  the  pus  into  or  upon  parts  which  were  not  previ¬ 
ously  soiled.  Hence  the  body  of  the  patient  should  be  elevated  during 
the  process  of  irrigation  and  the  intestines  retained  in  situ  by  means  of 
sponges.  In  many  cases  it  will  be  almost  impossible  to  remove  all 
matter  from  the  peritoneal  cavity  which  enters  it,  and  it  will  usually 
suffice  to  remove  the  greater  portion  of  it.  Irrigation  of  the  cavity 
with  fluid  at  a  temperature  of  48°  to  50°  C.  will  usually  have  no  influ¬ 
ence  upon  the  temperature  and  respiration.  It  is  usually  better  to  have 
the  temperature  at  38°  or  39°  C.,  which  is  about  the  temperature  of  the 
body.  The  haemostatic  action  of  fluids  at  very  high  temperatures  is 
doubtful.  The  quantity  of  liquid  absorbed  during  the  first  few  minutes 
of  irrigation  is  considerable.  If  a  7-to-l,000  solution  of  chloride  of 
sodium  is  used,  the  effect  is  that  of  indirect  transfusion.  A  prolonged 
operation  or  excessive  loss  of  blood  would  be  an  indication  for  irriga¬ 
tion  with  such  a  solution,  even  if  the  peritonaeum  did  not  require  cleans¬ 
ing.  This  facility  of  absorption  may  constitute  a  source  of  danger  if 
the  cavity  contains  pus  or  faecal  matter,  for  they  may  contain  soluble 
poisons  which  might  be  absorbed  to  the  disadvantage  of  the  patient. 
Pus  or  faecal  matter  should  be  removed  as  far  as  possible  with  sponges 
before  beginning  the  irrigation.  The  peritonaeum  may  be  irrigated  with 
toxic  solutions  without  danger  of  intoxication  if  a  preliminary  irriga¬ 
tion  of  the  weak  saline  solution  be  used  for  ten  minutes,  and  the  irri¬ 
gation  with  the  toxic  fluid  be  followed  by  another  irrigation  with  the 
saline  solution  to  wash  away  the  excess  of  the  former.  The  following 
are  the  indications  for  antiseptic  irrigation  of  the  peritonaeum : 

1.  The  diffusion  of  septic  matter  in  the  cavity  in  the  course  of  a 
laparotomy. 

2.  Penetration  of  pus  or  faecal  matter  into  the  peritoneal  cavity 
prior  to  an  operation. 

3.  Septic  peritonitis. 

4.  Possibly  peritoneal  tuberculosis. 

Ligature  of  the  Uterine  Arteries  (Gubaroff,  Prog.  Gin.,  Aug.  10, 
1889). — The  author  has  tried  upon  the  cadaver  a  new  method  for  ligat¬ 
ing  the  uterine  arteries,  and  Sneguireff  has  successfully  performed  the 
same  operation  upon  the  living  subject.  It  consists  in  the  intraperito- 
neal  ligation  of  the  nutrient  vessels  of  the  uterus,  the  uterine,  the 
utero-ovarian,  and  the  artery  of  the  round  ligament,  the  anastomoses 
which  these  vessels  make  with  their  vaginal  branches  being  preserved 
to  prevent  necrosis  of  the  uterus.  The  operation  consists  in  a  cutane¬ 
ous  incision,  the  same  as  for  the  ligation  of  the  common  iliac  or  the  ex¬ 
ternal  iliac,  the  tendinous  portion  of  the  transversalis  abdominis  muscle 


being  avoided.  The  lower  extremity  of  the  incision  should  reach  the 
external  inguinal  ring.  After  dividing  the  three  muscular  layers  of  the 
abdominal  wall  and  the  transverse  aponeurosis,  the  peritoneal  sac  of 
the  iliac  fossa  is  reached,  and  then,  following  the  internal  border  of  the 
psoas  major,  the  point  of  division  of  the  common  iliac  artery.  Then 
the  tissues  may  be  retracted  with  a  Sims  speculum  and  the  iliac  artery 
followed  until  one  reaches  the  emergence  of  the  uterine  artery,  in  front 
of  which  the  ureter  may  be  seen  passing.  The  utero-ovarian  or  sper¬ 
matic  artery  may  also  be  readily  seen  at  the  bottom  of  the  cavity  and 
ligated.  The  latter  vessel  is  accompanied  by  its  veins  and  should  be 
separated  from  them  before  ligation.  The  artery  of  the  round  ligament 
may  either  be  ligated  alone  or  in  conjunction  with  the  structure  which 
it  nourishes.  The  latter  vessel  proceeds  from  the  inferior  epigastric, 
and,  as  it  is  not  always  easy  to  separate  it  from  the  round  ligament, 
it  may  be  preferable  to  ligate  the  inferior  epigastric.  The  ligation  of  the 
nutrient  arteries  of  the  uterus  is  indicated — 

1.  In  inoperable  cases  of  cancer  of  the  uterus  with  profuse  metror¬ 
rhagia. 

2.  In  intraligamentous  tumors  and  subserous  myomata,  in  which 
cases  ligature  of  the  uterine  arteries  should  precede  intraperitoneal 
operations. 

3.  In  cases  of  metrorrhagia,  independent  of  appreciable  anatomical 
lesion,  which  have  resisted  the  use  of  the  ordinary  haemostatics. 

New  Operative  Procedure  for  reaching  the  Organs  of  the  Pelvis 
by  way  of  the  Perinaeum  (Zuckerkandl,  ibid.,  Aug.  10,  1889).— The 
author  has  devised  a  method  of  procedure  which  enables  one  with 
more  ease  than  any  other,  it  is  claimed,  to  expose  the  pelvic  organs — 
namely,  the  rectum,  sigmoid  flexure,  uterus  and  annexa,  prostate  gland, 
vesiculae  seminales,  and  posterior  wall  of  the  bladder — through  the  soft 
parts  which  constitute  the  perinaeum.  The  principle  upon  which  this 
new  procedure  is  based  is  the  following:  If  in  the  perineal  region  a  flap 
is  cut  with  three  sides  ('  '),  the  horizontal  portion  of  which  is  situated 
three  centimetres  anterior  to  the  anus  with  the  lateral  incisions  diverg¬ 
ing  toward  the  sacral  region,  and  if,  after  separating  the  external 
sphincter,  the  recto-prostatic  cellular  tissue  is  penetrated,  and  then  the 
recto-vesical  tissue  in  the  male  or  the  recto-vaginal  tissue  in  the  female, 
the  insertion  of  the  levator  ani  muscle  in  the  rectum  is  released,  the 
anterior  wall  of  the  rectum  will  appear,  and  then  the  fold  of  perito¬ 
naeum  which  lies  at  the  bottom  of  the  excavation.  The  rectum  being 
drawn  downward,  the  peritoneal  fold  may  also  be  drawn  down  toward 
the  skin.  The  latter  being  opened,  one  has  ready  access,  in  the  female; 
to  the  uterus,  the  tubes,  the  ovaries,  and  the  broad  ligaments.  The 
application  of  this  procedure  to  the  operations  which  are  performed 
upon  the  uterus  offers  the  following  advantages  :  First  of  all,  the  uterus 
is  more  accessible  by  this  procedure.  By  the  division  of  the  fibers  of 
the  levator  ani,  the  rectum  may  be  displaced  and  access  to  the  uterus 
obtained  which  exceeds  in  facility  for  execution  that  which  is  obtained 
by  way  of  the  vagina.  Both  the  uterus  and  its  annexa  are  made  readily 
accessible  by  this  step.  The  broad  ligaments  with  the  uterine  arteries 
are  readily  ligated,  which  is  not  always  the  case  when  one  operates 
through  the  vagina.  There  need  be  no  fear  of  ligating  the  ureters. 
The  entire  genital  tract  can  be  readily  inspected,  and  one  can  proceed 
to  a  more  radical  extirpation  of  the  internal  genitals  than  by  other 
methods.  Asepsis  of  the  entire  operative  field  can  also  be  more  readily 
accomplished. 

Results  obtained  by  the  Total  Extirpation  of  the  Uterus  (Kalten- 
bach,  Jour,  de  med.,  Jan.  12,  1890). — Kaltenbach  reports  fifty-seven 
cases  in  which  he  has  removed  the  entire  uterus,  the  indication  being 
carcinoma  in  fifty-three,  sarcoma  in  two,  and  prolapse  in  two.  He  finds 
that  the  operation  is  always  indicated  for  carcinoma  when  it  can  be 
easily  performed,  and  he  hopes  in  suitable  cases  to  obtain  complete 
cure.  Theoretically,  partial  extirpation  may  be  excellent  and  sufficient; 
but  practically  it  is  rarely  indicated.  In  one  of  his  cases  a  partial  ex¬ 
tirpation  was  performed  upon  a  woman  who  was  seven  months  preg¬ 
nant,  a  carcinomatous  node  as  large  as  a  nut  being  found  upon  the  an¬ 
terior  lip  of  the  cervix.  A  wedge-shaped  excision  was  made  and  the 
pregnancy  pursued  its  normal  course.  In  general,  the  author  thinks 
that  all  operations  for  cancer  should  be  extended  beyond  the  vaginal 
insertion,  total  extirpation  being  preferable  apart  from  its  offering 
greater  chance  of  immunity  from  recurrence  of  the  disease.  Only  two 


110 


REPORTS  ON  TEE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jodk., 


of  Kaltenbach’s  patients  died  from  the  operation,  one  being  from  uraemia 
after  ligation  of  the  left  ureter  and  wounding  of  the  bladder.  In  two 
cases  it  was  subsequently  necessary  to  perform  kolpokleisis  on  ac¬ 
count  of  vesico-vaginal  fistula.  In  three  of  the  cases  the  patients  were 
more  than  sixty  years  of  age.  Great  stress  is  laid  upon  the  importance 
of  suturing  the  peritonaeum  and  disinfection  with  salicylic  and  boric 
acids.  In  twenty-five  of  the  cases  of  carcinoma  a  year  passed  without 
recurrence  of  the  disease.  Recovery  from  the  operation  was  rapid.  If 
the  disease  recurred, .the  thermo-cautery  and  chloride  of  zinc  were  used. 

In  no  operation  was  there  severe  haemorrhage.  In  one  case  a  cancer¬ 
ous  fistula  of  the  bladder  was  cured. 

Curetting  for  Endometritis  (Bouilly,  Jour,  de  rued.,  March  9,  1890). 

_ The  author  gives  the  results  of  seventy-five  cases  in  which  he  has 

performed  curetting  since  1887.  He  refers  particularly  to  simple 
cases — that  is,  those  which  are  not  complicated  by  the  presence  of 
polypi  or  myomata ;  but  he  also  refers  to  cases  in  which  there  may 
be  a  certain  amount  of  disease  of  the  annexa.  In  all  of  these  cases 
curetting  had  been  preceded  by  other  treatment.  The  principal  indi¬ 
cations  for  the  operation  were  haemorrhage,  leucorrhcea,  and  pelvic 
or  sacral  pain  before  or  during  menstruation.  Pain  alone,  however, 
is  not  to  be  considered  a  sufficient  indication.  In  twelve  cases  the 
operation  was  done  without  an  anaesthetic,  but  such  a  plan  is  not 
to  be  recommended,  on  account  of  the  pain  which  accompanies  it. 
The  operation  should  be  preceded  by  dilatation,  and  the  author  used 
laminaria  tents  for  this  purpose,  using  at  first  a  small  one  for  twenty- 
four  hours,  and  then  a  large  one  for  twenty-four  hours  longer.  There 
is  little  pain  attending  such  dilatation.  Next,  the  vagina  should  be 
irrigated,  the  uterus  drawn  down,  and  the  endometrium  curetted. 
The  curetting  is  followed  by  an  injection  of  tincture  of  iodine,  or  of 
carbolized  glycerin,  if  the  metritis  is  muco-purulent  in  character,  and 
by  a  chloride-of-zinc  application  if  it  is  haemorrhagic.  For  the  first 
few  subsequent  days  the  vagina  is  closed  with  a  tampon  of  antiseptic 
material.  The  immediate  results  of  these  operations  were :  No  acci¬ 
dents  ;  absolute  freedom  from  bad  conditions.  In  many  cases  the  pel¬ 
vic  or  abdominal  pain  disappeared  at  once.  In  many  other  cases  the 
best  results  were  not  obtained  at  once.  In  sixty-nine  of  the  author  s 
cases  the  histories  were  followed  up  for  some  time,  and  these  cases 
were  classified  as  cures  thirty-nine,  improvement  fifteen,  failure  fifteen. 
In  haemorrhagic  metritis  the  cures  were  especially  frequent,  and  in¬ 
cluded  nineteen  cases.  There  were  twenty  cases  of  muco-purulent  en¬ 
dometritis  which  were  cured,  the  annexa  in  three  of  the  cases  being 
rather  painful  prior  to  the  operation.  With  such  a  complication,  it  was 
found  that  the  abdominal  pain  disappeared  very  slowly.  The  author 
has  concluded  that,  if  tubal  disease  really  exists,  no  benefit  need  be 
expected  from  curetting.  The  cases  which  were  tabulated  as  im¬ 
proved  included  those  in  which  one  or  several  of  the  symptoms  disap¬ 
peared.  Of  the  fifteen  unsuccessful  cases,  four  were  cases  of  haemor¬ 
rhagic  and  eleven  of  muco-purulent  metritis.  Curetting  is  indicated  in 
chronic  simple  endometritis,  and  in  the  haemorrhagic  form  it  is  a  most 
valuable  resource.  It  is  less  valuable  in  cases  of  cervical  glandular 
disease,  and  is  entirely  uncertain  if  there  is  any  disease  of  the  annexa. 

The  Surgical  Treatment  of  Backward  Uterine  Deviations  (Riche- 
lot,  Jour,  de  med.,  Dec.  8,  1889).— In  the  treatment  one  must  take 
into  consideration  the  faulty  attitude  of  the  organ,  the  accompanying 
lesion  of  the  uterus  (metritis)  and  the  lesion  of  the  annexa  (salpingo- 
oophoritis),  and  pelvic  adhesions.  In  retroversion  with  adhesions  the 
prognosis  is  that  of  salpingo-oophoritis.  Slow  or  rapid  rupture  of 
the  adhesions,  uterine  massage,  and  Alexander’s  operation  should  be 
considered  out  of  the  question.  The  only  suitable  treatment  is  that 
which  takes  cognizance  of  the  diseased  annexa,  the  faulty  position 
of  the  uterus  being  of  secondary  consideration.  Palliative  means  may 
be  used  for  the  accompanying  perimetritis  at  its  beginning,  but,  if 
the  lesions  are  rebellious  and  progressive,  laparotomy  should  be  per¬ 
formed  and  the  tubes  and  ovaries  removed.  Removal  of  the  diseased 
annexa  and  rupture  of  the  adhesions  will  suffice  for  a  cure  without  re¬ 
sorting  to  hysteropexia.  In  other  words,  the  therapeutics  of  compli¬ 
cated  retroversion  is  that  of  the  diseases  of  the  annexa  and  of  the  pel¬ 
vic  peritonaeum.  If  the  retroverted  uterus  is  mobile,  it  will  sometimes 
suffice  to  relieve  the  pain  which  is  caused  by  the  metritis.  In  other 
cases  pessaries  may  be  used,  the  round  ligaments  shortened,  or  hystero¬ 


pexy  performed.  Neither  of  these  methods  is  certain  to  produce  a 
cure.  Nicoletis  has  suggested  for  this  condition  subvaginal  amputation 
of  the  cervix,  circular  incision  through  the  lornices,  disengaging  the 
cellular  tissue  around  the  inferior  segment  of  the  organ,  laying  bare  the 
posterior  cul-de-sac  of  the  peritoneum,  and  securing  it  by  sutures  to  the 
straightened  uterus.  The  stump  is  then  secured  to  the  posterior  i  aginal 
wall  in  such  a  way  that  the  fundus  is  thrown  forward. 

The  Castration  of  Women  (Tissier,  Jour,  de  med.,  Feb.  9,  1890). — 
This  operation  was  suggested  by  both  Hegar  and  Battey  at  about  the 
same  time,  the  object  being  to  produce  the  menopause  prematurely  in 
certain  pathological  conditions.  Thus  defined,  the  operation  has  an 
entirely  different  field  from  those  which  are  performed  for  the  removal 
of  extensively  diseased  ovaries  and  tubes.  As  is  well  known,  castra¬ 
tion  of  women  was  practiced  ages  ago,  but  not  until  1872  did  it  become 
an  operation  of  election  in  and  for  pathological  states.  Some  of  the 
indications  for  the  operation  are  troublesome  uterine  myomata,  uncon¬ 
trollable  uterine  haemorrhage,  certain  conditions  of  atresia  of  the  geni¬ 
tals,  and  certain  forms  of  contraction  of  the  pelvis.  It  is  justifiable  in 
certain  cases  of  dysmenorrhoea  in  which  all  other  forms  of  treatment 
have  failed  to  make  life  less  of  a  burden.  The  operation  is  indefensible 
for  neuropathic  or  disturbed  mental  conditions,  dangerous  and  inexcusa¬ 
ble  for  the  relief  of  pelvic  peritonitis,  and  criminal  for  nymphomania* 
Formerly  the  incision  into  the  abdominal  cavity  was  made  through  the 
vagina,  but  now  the  median  line  of  the  abdominal  wall  is  universally 
chosen.  Practiced  with  careful  antiseptic  precautions,  this  operation  has 
the  minimum  of  gravity,  and  Tait  has  been  able  to  do  almost  a  thou¬ 
sand  cases  without  accident.  The  menopause  results  if  the  ovaries  are 
completely  removed,  and  this  result  may  take  place  at  once  or  after  a 
few  months.  In  order  that  there  may  be  an  indication  for  the  opera¬ 
tion,  it  is  necessary  that  the  trouble  to  be  relieved  should  have  definite 
relations  to  the  menstrual  function,  that  the  age  for  the  natural  meno¬ 
pause  should  not  have  been  passed  nor  be  imminent.  It  is  also  neces¬ 
sary  that  one  should  first  make  fair  trial  of  other  and  less  dangerous 
methods  of  treatment,  and  be  fairly  satisfied  of  their  inutility  before 
proposing  castration.  This  should  include  in  the  case  of  uterine  myo¬ 
mata  the  use  of  the  positive  intra-uterine  galvanic  current,  but  not  the 
galvano-puncture,  which  is  not  useful  and  is  dangerous.  For  cases  in 
which  the  haemorrhage  is  severe  this  treatment  should  be  preferred  to 
castration,  being  fully  as  effective  and  less  dangerous.  Castration  is 
indicated  for  those  tumors  in  which  very  rapid  growth  produces  con¬ 
ditions  which  are  constantly  and  increasingly  dangerous. 

The  Treatment  of  Endometritis  with  Chloride  of  Zinc  (Moret,  Jour, 
de  med.,  Feb.  9,  1890).— 1.  The  vaginal  and  uterine  canal  should  be 

cleansed  with  a  solution  of  sublimate. 

2.  The  cervico-uterine  canal  should  be  sounded  with  a  smooth,  flexi¬ 
ble  bougie,  which  is  better  for  this  purpose  than  the  uterine  sound,  for 
it  is  likely  to  wound  the  mucous  membrane. 

3.  The  bougie  having  been  withdrawn,  its  curve  is  to  be  noted,  and 
then  one  should  introduce  a  pencil  composed  of  three  parts  of  rye  flour 
and  one  of  chloride  of  zinc.  The  pencil  should  be  four  to  six  millime¬ 
tres  in  thickness,  and  should  penetrate  as  far  as  the  fundus. 

4.  The  posterior  vaginal  cul-de-sac  should  be  tamponed  with  absorb¬ 
ent  cotton  impregnated  with  iodoform,  and  the  remainder  of  the  vagina 
with  ordinary  non-absorbent  cotton. 

This  treatment  may  be  followed  by  pain,  slight  fever,  and  possibly 
by  transient  retention  of  the  urine.  In  ten  or  twelve  days  the  slough 
produced  by  the  caustic  will  be  discharged.  After  its  expulsion  the 
uterine  cavity  should  be  dilated  with  a  No.  16  bougie,  and  the  size 
should  gradually  be  increased  to  21  to  avoid  contraction  and  dysmenor- 
rhoeal  pain.  During  the  following  month  irrigation  should  be  prac¬ 
ticed  daily  with  sublimate  solution. 

A  Comparative  Estimate  of  Tait’s  Method  for  Perineal  Repair 
(Ott,  Ann.  de  Obst.,  Ginecop.  y  Red.,  February,  1890).— The  Simon- 
Hegar  method  for  restoring  the  perimeum  is  based  upon  the  anatomi¬ 
cal  conditions  of  the  parts  and  may  be  termed  the  normal  method.  All 
the  modifications  of  this  method  proposed  by  different  authors  consist 
mainly  in  two  particulars :  1st,  modification  of  the  shape  of  the  denuded 
surface ;  2d,  the  manner  of  maintaining  the  denuded  portions  in  con¬ 
tact  until  cicatrization  is  effected.  As  to  the  shape  of  the  denuded 
surface,  the  author  thinks  it  should  be  in  each  case  to  the  form  of  the 


July  26,  1890.] 


MISCELLANY. 


lesion  and  the  direction  of  the  tear ;  in  other  words,  that  it  is  impossi¬ 
ble  to  lay  down  a  general  rule  for  operation  which  would  apply  in  all 
cases.  As  to  the  suturing,  he  prefers  an  interrupted  suture  of  silk, 
using  a  double  row  of  them.  Silk  is  preferred  to  catgut,  as  it  is  light, 
easily  disinfected,  and  more  durable  than  catgut.  Interrupted  sutures 
enable  one  to  avoid  the  propagation  of  infection  should  suppuration 
appear  at  one  point,  and  they  are  more  favorable  to  union  of  the  tis¬ 
sues,  which  is  a  matter  of  great  importance,  especially  if  there  is  rupt¬ 
ure  of  the  intestine.  In  the  complete  ruptures  the  author  does  not 
include  the  intestinal  mucous  membrane  in  his  suture,  and  takes  up 
only  a  relatively  small  portion  of  tissue.  Successive  rows  of  sutures 
are  passed,  and  in  this  way  a  perinaeum  is  built  up  which  is  difficult  to 
distinguish  from  the  normal  body. 

Tait’s  method  is  believed  to  be  contrary  to  normal  anatomical  con¬ 
ditions,  and  hence  the  advantages  claimed  for  it  of  simplicity  and  rapid¬ 
ity  of  execution  have  no  real  value. 


®  x  b  c  tl  I a  it 


Native  Midwifery  in  Canton. — Dr.  Mary  W.  Niles  writes  as  follows 
in  the  China  Medical  Missionary  Journal  for  June  : 

During  a  seven  years’  residence  in  Canton  I  have  gained  an  insight 
into  the  customs  and  practices  of  the  Cantonese  at  childbirth — experi¬ 
ences  not  confined  to  any  one  class,  but  acquired  in  the  houses  of  the 
learned  and  wealthy  as  well  as  in  sampans  and  hovels.  Supersti¬ 
tion  reigns  supreme.  The  woman  is  placed  in  a  sitting  posture  over  a 
tub,  and  constantly  urged  from  the  first  to  bear  down.  In  the  case  of 
a  primipara,  she  may  thus  be  deprived  of  rest  and  food  for  several  days. 
Often  exhaustion  and  uterine  inertia  arise  from  no  other  cause.  The 
midwife  is  constantly  shouting  that  the  child  is  just  ready  to  be  born. 
She  spends  her  time  stretching  the  vulvar  orifice.  This  may  be  advan¬ 
tageous  when  her  statements  are  true,  but  when  maintained  for  hours 
by  relays  of  midwives,  it  causes,  to  say  the  least,  excessive  swelling. 
If  there  is  any  delay,  the  patient  is  kept  in  an  excited  state  of  mind  by 
neighbors  calling  and  advising  this  and  that,  by  constant  invocations  to 
Kun  Yam  to  save,  by  burning  incense,  and  drinking  tea  sent  by  the 
idols.  A  sword  and  fish-net  are  laid  upon  the  bed,  to  drive  away  the 
evil  spirits.  There  are  also  many  other  idolatrous  practices. 

The  fee  to  the  common  classes  is  $1  for  a  girl  and  $2  for  a  boy;  to 
the  poorest  class  50  cents  for  a  girl  and  $1  for  a  boy. 

The  midwrife  has  some  nice  tricks  of  her  own  to  increase  her  fee. 

She  works  upon  the  overwrought  mind  of  the  patient  by  causing 
her  to  believe  there  is  some  difficulty  in  the  birth  that  she  can  only 
overcome,  and,  unless  she  has  more  money,  will  not  stay.  The  more 
terror  she  can  inspire,  the  more  gain  she  expects.  I  must,  however, 
say  that  all  midwives  are  not  so  unscrupulous.  I  am  acquainted  with 
at  least  four  who,  with  all  their  faults,  have  gained  great  favor  in  my 
eyes  by  always  sending  for  me  when  they  get  into  difficulty.  It  there¬ 
fore  does  not  behoove  me  to  speak  ill  of  those  who  sound  my  praises 
to  their  patients  and  enjoin  a  strict  observance  of  my  orders — to  my 
face,  at  least.  To  proceed,  immediately  after  the  placenta  is  delivered 
the  patient  is  placed  upon  the  bed  and  compelled  to  sit  erect.  If  she 
can  bear  it,  this  is  very  favorable  to  the  expulsion  of  clots,  etc. ;  if  she 
can  not,  some  one  must  assist  her.  Again,  if  she  becomes  faint,  it  is 
all  the  more  important  she  should  be  held  upright.  A  few  months  ago 
I  witnessed  the  efforts  made  to  revive  a  woman  in  a  condition  of  syn¬ 
cope  after  childbirth.  I  had  been  called  to  the  case,  as  one  of  difficult 
labor.  But  when  I  arrived,  the  child  and  placenta  were  already  deliv¬ 
ered.  The  woman  was  in  the  usual  position.  Perceiving  that  fffie  was 
not  in  a  condition  to  endure  very  much,  I  requested  her  to  lie  down. 

^  hen  I  myself  have  assisted  at  labors,  my  instructions  are  gener¬ 
ally  carried  out — at  least  while  I  am  present. 

There  seems  to  be  a  superstition  that  if  there  has  been  foreign  in¬ 
terference  some  dire  results  may  follow  disobedience  to  orders.  Once, 
when  I  had  but  left  a  few  moments,  a  messenger  ran  after  me  beseech- 


m 

*ng  me  to  return,  as  the  patient  had  fainted.  I  hastened  back  and  be¬ 
held  a  scene.  The  very  small  room  occupied  by  the  patient  was  filled 
with  people.  The  one  window  and  the  two  doors  were  shut.  The  room 
was  filled  with  smoke  from  fire-crackers  and  the  burning  of  a  var¬ 
nished  umbrella.  A  lighted  furnace  was  also  in  the  room.  Besides 
the  noise  made  by  the  crackers,  all  were  screaming  at  the  top  of  their 
voices,  calling  to  the  woman’s  spirit  to  return.  She  was  supported  by 
the  husband  and  midwife — one  behind,  the  other  before.  They  had 
their  arms  tightly  around  her,  excluding  almost  every  breath  of  air. 
A  third  assisted  in  holding  her  head  up  by  keeping  a  tight  grip  upon 
her  hair.  Finding  my  voice  could  not  be  heard  in  this  tumult,  I  struck 
out  right  and  left,  and  soon  made  the  attendants  aware  of  my  firm  in¬ 
tention  to  make  them  let  go  their  hold,  even  if  it  had  to  be  done  bv 
force.  As  soon  as  she  was  in  a  horizontal  position  she  revived.  But, 
before  I  was  aware  of  it,  my  efforts  were  seconded  by  holding  over  her 
face  a  large  Chinese  iron  cooking  vessel,  heated  for  the  purpose.  Of 
course  this  was  instantly  removed.  Immediately  after  a  patient  has 
been  placed  upon  the  bed  the  custom  is  to  give  a  large  bolus  contain¬ 
ing  some  very  acrid  substances,  mixed  with  the  juice  of  fresh  ginger, 
followed  by  a  bowl  of  rice  and  salted  duck-eggs.  The  pill  and  ginger 
is  continued  to  the  second  and  third  day,  and  afterward  “  ginger  vine¬ 
gar  ”  is  given  with  the  rice  throughout  the  whole  of  the  puerperal 
month,  a  large  jar  of  this  being  always  prepared  before  the  birth  of  the 
child. 

Much  importance  is  attached  to  the  “  ginger  vinegar,”  and  it  is  the 
gravest  question  as  to  whether  the  patient  will  be  allowed  to  take  it. 
If  at  the  time  permission  is  not  given,  a  day  must  be  set  apart  when  it 
can  be  taken.  Friends  come  to  me  a  number  of  times  during  the  month 
to  know  if  the  “  ginger  vinegar  ”  may  now  be  given.  Some  drink  a  cup 
of  child’s  urine  every  day  for  three  days.  Having  witnessed  these  per¬ 
nicious  practices,  I  was  surprised,  while  reading  a  Chinese  book  on  mid¬ 
wifery,  to  see  how  many  of  them  were  condemned,  and  what  sensible 
advice  it  contained,  and  given  by  people,  too,  who  are  ignorant  of  the 
very  mechanism  of  parturition.  I  understand  the  pamphlet  in  question 
to  be  considered  an  authority.  I  know  not  why  the  educated  forego  its 
advice,  to  follow  the  superstitious  practices  of  ignorant  old  women. 
The  book  ...  is  probably  the  treatise  on  midwifery  translated  by  Dr. 
Lochart.  It  was  fully  translated  by  Dr.  Kerr  thirty  years  ago.  The 
Practice  of  Obstetrics  among  the  Chinese,  written  by  Robert  P.  Harris, 
M.  D.,  of  Philadelphia,  and  published  in  the  American  Journal  of  Ob¬ 
stetrics  and  Diseases  of  Women  and  Children ,  July,  1881,  drew  its  in¬ 
formation  and  made  extensive  quotations  from  Dr.  Kerr’s  translation. 
The  book  evinces  the  greatest  ignorance  of  the  facts  of  gestation,  the 
mechanism  of  labor,  and  the  causes  of  difficulty  in  the  delivery  of  the 
foetus  and  secundines  ;  yet  its  mission  “  to  restrain  the  activity  of  the 
midwife,  and  to  educate  the  people,  that  she  is  not  in  any  manner  to 
assist  in  the  delivery  of  the  foetus,”  is  most  laudable. 

I  will  make  some  extracts,  which  would  be  really  helpful  if  native 
midwives  would  follow  their  advice  : 

“  There  are  three  important  principles  to  be  borne  in  mind  :  1.  Lie 
down.  2.  Endure  the  pain.  3.  Be  slow  about  the  delivery.  If  these 
rules  were  obeyed,  at  least  three  fourths  of  the  difficulties  I  have  met 
would  have  been  avoided.  The  first  pains  are  in  the  abdomen.  The 
woman  should  have  her  mind  made  up  to  this  as  necessary,  and  not  to 
be  feared.  If  the  pains  do  not  increase  in  severity,  she  need  not  inform 
any  one  of  them,  but  lie  still  and  be  at  peace.  The  foundation  of  all  dif¬ 
ficulty  lies  in  sitting  over  the  tub  .  .  .  when  the  pains  are  but  slight.” 

“  When  the  pains  are  beginning,  the  woman  should  eat  and  sleep  as 
usual.” 

“  The  rapidity  of  the  pains  will  show  the  course  of  the  labor.  It  is 
most  important  not  to  consider  the  tub  and  the  straw  very  early,  and 
hence  bear  down  and  put  pressure  upon  the  abdomen.  The  body  should 
be  kept  straight,  neither  in  lying  or  standing  should  it  deviate  to  one 
side.” 

“  The  woman  should  take  matters  into  her  own  hands,  and  not  al¬ 
low  herself  to  be  governed  by  others,  such  as  midwives  or  meddlesome 
neighbors.  This  matter  is  of  the  greatest  importance  to  herself.  She 
must  nourish,  and  not  waste,  her  strength.” 

“  It  is  the  best  plan  to  go  to  bed  and  lie  there  with  eyes  closed.  If 
wearied  with  lying,  rise  and  walk  about  with  the  support  of  friends,  and 


112 


MISCELLANY. 


[N.  Y.  Mkd.  Joiir. 


then  return  to  the  bed.  The  woman  should  lie  upon  her  back.  After 
prolonged  efforts  at  expulsion,  the  strength  of  the  foetus  is  exhausted, 
and  when  the  proper  time  for  birth  arrives  there  is  no  strength  ior  de¬ 
livery.”  (Write  “  mother  ”  instead  of  “  foetus  ”  and  the  remark  is  cor¬ 
rect.)  “  In  a  case  in  which  the  arm  or  foot  presents,  direct  the  woman 
to  lie  down.  Gently  push  up  the  arm  or  foot.  Have  her  remain  quiet 
for  one  night,  and  delivery  will  be  accomplished  nonmally.  ’  1  he  au¬ 

thor  gives  a  case  of  shoulder  presentation,  where  he  replaced  the  arm, 
and  the  child  was  born  normally  the  next  day.  We  know  that  spon¬ 
taneous  evolution  or  spontaneous  version  might  take  place.  Last  year 
Dr.  Kerr  replaced  the  arm,  when  spontaneous  version  took  place  and 
the  vertex  became  the  presenting  part.  Certainly  the  recumbent  posi¬ 
tion  and  quietness  would  be  most  favorable  to  spontaneous  version, 
and  would  tend  to  delay  impaction  and  exhaustion. 

“  The  doubter  says,  1  Shall  we  not  have  a  midwife  ?  ’  Yes,  but  re¬ 
member  the  midwife  is  your  servant,  and  you  not  hers.  Midwives  are 
stupid,  not  acquainted  with  the  doctrines.” 

a  Late,  or  early,  they  call  upon  the  patient  to  exert  her  stiength. 
They  rub  the  back,  and  push  down  upon  the  abdomen,  and  call  out, 

*  The  head  is  here.’  They  pass  the  hand  into  the  vagina  and  do  injury. 
All  this  as  though  they,  and  they  only,  were  responsible  for  the  whole 
matter.  Her  duty  is  simply  to  pick  up  the  baby.” 

“  After  the  birth  it  is  not  necessary  to  take  any  medicine.  The  pill 
of  (rats’  kidneys  and  rabbits’  brains)  injures  the  spirits  and  de 

stroys  the  blood  when  the  patient  is  in  the  weakest  condition  and  least 
able  to  bear  it.  The  ...  is  very  unwise  to  take,  as  it  impoverishes 
the  blood  and  gives  puerperal  fever.” 

u  The  diet  should  be  good,  but  not  fat ;  chicken  or  duck  broth, 
from  which  the  fat  has  been  removed.  No  one  should  be  allowed  to 
visit  the  room.  All  should  be  very  quiet.  Do  not  pray  to  the  idols  in 
presence  of  the  patient.  Let  only  one  midwife  be  present,  and  let  her 
sit  at  one  side,  not  allowing  her  to  interfere  with  the  course  of  events. 
If  cold,  have  a  fire  in  the  room.  If  hot,  have  a  pail  of  cold  water  to 
absorb  the  hot  air.” 

These  extracts  indicate  common  sense  in  the  management  of  labor, 
and  would,  no  doubt,  have  greater  influence  if  it  were  not  for  the  super¬ 
stitions  which  are  so  universally  prevalent. 

Mortality  in  Cities  in  the  United  States.— The  following  table  rep- 
esents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub- 
ished  in  the  Abstract  of  Sanitary  Reports  for  July  18th: 


CITIES. 


NewYork,N.Y .  July  12. 

Chicago,  111 .  July  12. 

Philadelphia.  Pa .  July  5. 

Baltimore,  Md .  July  12. 

St.  Louis,  Mo .  July  5. 

Boston,  Mass .  July  12. 


Washington.  D.  C 

Detroit,  Mich. . 

Milwaukee,  Wis . 

Minneapolis,  Minn... 

Kansas  City,  Mo . 

Providence,  R.  1 . 

Indianapolis,  Ind.... 

Richmond.  Va . 

Toledo,  Ohio . 

Fall  River,  Mass . 

Nashville,  Tenn . 

Charleston,  S.  C . 

Portland,  Me . 

Galveston,  Texas  . . . . 

Auburn,  N.  Y . 

Auburn,  N.  Y . 

Newton,  Mass . 

Rock  Island,  Ill 


July  12. 
July  5. 
July  12. 
July  5. 
July  5. 
July  12. 
July  11. 
July  5. 
July  11. 
July  12. 
July  12. 
July  12. 
July  12. 
June  27. 
July  5. 
Julv  12. 
July  12. 
July  6. 

Pensacola,  Fla . I  July  5. 


Cm  C 

ll 


500,343 


3 

o 

DEATHS  FROM- 

Total  deaths  f 
all  causes, 

|  Cholera. 

|  Yellow  fever. 

|  Small-pox. 

|  Varioloid. 

|  Varicella. 

|  Typhus  fever,  j 

|  Enteric  fever,  i 

|  Scarlet  fever.  ; 

1  Diphtheria. 

CO 

01 

1 

s 

Whooping- 

cough. 

1,157 

443 

6 

51 

21 

25 

14 

19 

l! 

6 

6 

623 

13 

l 

8 

4 

260 

10 

2 

3 

2 

2 

312 

4 

3 

1 

194 

1 

6 

i 

3 

101 

:: 

1 

82 

2 

5 

2 

4 

i 

55 

1 

61 

1 

55 

47 

1 

56 

0 

O 

33 

56 

•  • 

•  • 

•  • 

:: 

1 

2 

1 

•• 

i’ 

34 

1 

2 

35 

1 

1 

10 

1 

’  * 

15 

5 

12 

4 

" 

i  4 

| 

)  3 

.. 

...... 

A  Check  upon  Early  Marriages.— “  A  variety  of  arguments,  based 
on  science,  prudence,  and  economy,  have  often  been  urged  against  the 
headlong  folly  of  very  early  marriage.  Reasoning  of  this  kind,  how¬ 
ever,  has  unfortunately  but  little  influence  with  such  as  those  who 
commit  the  folly  in  question,  for,  indeed,  it  is  not  reason  in  any  recog¬ 


nizable  degree  which  guides  their  crude  calculations.  If  it  were,  the 
probability  of  overstrain  in  childbirth,  which  is  the  natural  counteipart 
of  early  functional  activity,  of  domestic  discord  and  beggary,  and  their 
too  common  social  accompaniments,  would  not  be  so  freely  and  fre¬ 
quently  encountered.  These  matters  are  part  of  the  tribute  \v  hich  will 
always  be  paid  while,  for  the  want  of  native  sense  and  sound  home¬ 
training,  fancy  is  allowed  to  guide  one  of  the  most  important  concerns 
of  life.  The  one  available  means  of  cure  for  this  prevalent  evil  con¬ 
sists  in  a  just  exercise  of  parental  control,  but  this,  we  need  hardly  le- 
mind  ourselves,  is  onlv  too  easy  of  evasion.  In  a  case  lately  reported 
to  the  Holborn  Board  of  Guardians,  a  juvenile  couple  and  their  infant, 
already  dependent  on  the  rates,  were  said  to  have  been  married  by  the 
Superintendent  Registrar  on  receipt  of  a  forged  notice  of  consent  pur¬ 
porting  to  come  from  the  girl’s  father.  The  lesson  thus  conveyed  was 
not  lost  on  the  board,  which  decided  to  notify  the  Registrar-General  as 
to  the  wisdom  of  instructing  an  official  to  make  personal  inquiry  in  all 
such  cases  respecting  the  wishes  of  the  parents  in  regard  to  the  matri¬ 
monial  ventures  of  their  children  under  adult  age.  The  proposal  is 
certainly  a  sound  one,  and  represents  the  minimum  of  justifiable  inter¬ 
ference  on  the  part  of  a  society  which  regards  its  own  most  natural 
interests.” — Lancet.  _ 

To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing :  .  .  . 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti¬ 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us;  (3)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of— we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  oj  interest 
to  <fur  readers  will  be  considered  as  doing  them  and  us  a  favor,  and , 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers.  j 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  August  2,  1890. 


futures  an  t>  b  b  r  f  s  s  c  s  . 


A  HISTORICAL  SKETCH  OF  SURGERY, 
ANCIENT,  MEDUEVAL,  AND  MODERN.* 


By  B.  A.  WATSON,  A.  M.,  M.  D., 

SURGEON  TO  JERSET  CITY  AND  CHRIST  HOSPITALS. 


It  is  with  us  the  midday  of  science.  The  grandeur  of 
the  present  completely  overshadows  the  past.  Those  mighty 
agents  electricity  and  steam  have  become  the  servants  of 
man  and  readily  obey  his  mandates.  The  transatlantic 
cable  annihilates  space.  The  modern  steamship  brings  us 
to  our  American  homes  from  a  city  on  the  Emerald  Isle 
within  the  short  space  of  six  days.  The  ponderous  loco¬ 
motive  engine,  breathing  and  pulsating  like  a  thing  of  life, 
drawing  a  long  train  of  cars  freighted  with  human  beings, 
traverses  our  broad  continent  from  New  York  to  San  Fran¬ 
cisco  within  about  the  same  brief  period  of  time.  Are  these 
the  noblest  achievements  of  science  in  our  own  age?  The 
answer  to  this  question  must  certainly  be  given  in  the  nega¬ 
tive,  since  we  are  fully  prepared  to  show  that  surgery  has 
kept  pace  witb,  if  it  has  not  actually  led,  every  other  depart¬ 
ment  of  science  ;  but  the  historical  treatment  of  our  subject 
requires  us  to  say  adieu  for  the  present  to  this  land  of  mid 
day  brightness,  in  order  to  visit  that  of  Egyptian  darkness. 

It  was  in  this  far-off  Eastern  country,  in  the  northeast¬ 
ern  part  of  the  dark  continent,  that  surgery  and  nearly  every 
other  art  and  science  had  their  birth. 

The  brightness  of  this  scientific  day  has  passed  away 
and  we  are  now  compelled  to  search  for  the  evidences  of 
her  earliest  grandeur  in  a  dim  light,  which  confines  our  re¬ 
searches  to  the  pyramids,  temples,  tombs,  and  works  of 
sculpture.  But  thanks  to  the  Egyptologists  who  have  de¬ 
ciphered  the  ancient  hieroglyphics  found  on  these  works  of 
art,  and  thus  afforded  us  an  indistinct  and  imperfect  view 
of  the  old  pagan  civilization.  In  prehistoric  times  the  prac¬ 
tice  of  surgery  at  first  was  unquestionably  patriarchal,  but, 
as  the  inhabitants  of  the  earth  increased,  the  skill  of  cer¬ 
tain  individuals  in  this  department  became  known  ;  and 
bus  they  may  have  established  the  first  monopolies. 

Herodotus  visited  Egypt  about  the  middle  of  the  fifth 
century  before  Christ,  and  was  informed  by  an  Egyptian 
priest  that  Athothis,  the  first  successor  of  Menes,  founded 
die  palace  at  Memphis,  and,  being  a  physician,  was  the  au- 
hor  of  books  on  surgery. 

A  medical  papyrus  in  the  museum  at  Berlin,  composed 
inder  Ramses  II  (Dynasty  XIX),  confirms  the  latter  state¬ 
ment.  The  era  of  Menes,  according  to  Bunsen,  was  3643 
me.;  according  to  Lepsius,  3893;  according  to  Brugsch, 
D55  ;  and  according  to  Mariette,  5004. 

Priority  in  surgical  authorship  therefore  comes  down 
o  us  bearing  an  ancient  and  regal  stamp. 

The  great  school  of  anatomy,  surgery,  and  medicine  was 
ounded  at  Alexandria  300  years  before  Christ.  This  famous 
chool  of  medicine  continued  to  supply  the  world  with  sur- 


*  The  president’s  address  delivered  before  the  Medical  Society  of 

Sew  Jersey,  June  10,  1890. 


geons  for  many  centuries.  The  most  eminent  among  the 
earlier  of  the  surgeons  of  this  university  were  Herophilus 
and  Erasistratus.  They  dissected  the  human  body,  and  like¬ 
wise  made  vivisections  on  criminals  who  were  placed  in 
their  hands  by  Ptolemy  I  for  this  purpose. 

Erasistratus  was  a  bold  surgeon,  who  opened  the  ab¬ 
dominal  cavity  for  the  purpose  of  performing  surgical  op¬ 
erations  on  the  liver,  and  also  for  the  extirpation  of  the 
spleen.  The  invention  and  application  of  the  catheter  in 
cases  of  retention  of  urine  likewise  belongs  to  him.  Heroph- 
ilus  gained  the  king’s  favor  and  secured  a  position  in  the 
Alexandrian  school  by  the  reduction  of  a  dislocated  shoul¬ 
der.  Here  he  devoted  himself  earnestly  to  the  study  of 
anatomy,  which  to  this  day  bears  the  impress  of  bis  name. 
Both  Erasistratus  and  Herophilus  are  enumerated  among 
the  most  distinguished  teachers  and  authors  of  their  day. 
The  pupils  of  these  eminent  surgeons  greatly  enriched  sur- 
gery  by  the  introduction  of  the  tourniquet  and  appliances 
for  the  reduction  of  dislocations  of  the  femur.  A  pupil  of 
theirs  likewise  employed  an  instrument  for  crushing  stones 
within  the  bladder. 

The  ancient  status  of  surgery  in  Egypt  can  not  be  fully 
shown  by  historical  data,  but  that  it  attained  a  very  high 
standard  under  pagan  rule  can  n.ot  be  doubted.  Herodotus 
has  informed  us  that  the  ophthalmic  surgeons  were  cele¬ 
brated  and  practiced  at  the  Court  of  Cyrus.  Ebers  inter¬ 
prets  a  passage  in  the  papyrus  which  he  discovered  as  re¬ 
lating  to  the  operation  for  cataract.  Surgical  instruments 
for  the  ear  are  figured,  and  artificial  teeth  have  been  found 
in  mummies.  The  further  examination  of  these  bodies, 
which  have  been  preserved  from  putrefaction  for  thousands 
of  years  in  their  Egyptian  tombs,  reveals  the  fact  that  band- 
agmg  in  those  ancient  times  was  a  fine  art,  and  the  well-set 
fractures  certify  to  a  high  degree  of  skill  in  surgery.  In 
the  museum  collections  of  Egyptian  antiquities  are  found 
lancets,  forceps,  knives,  probes,  scissors,  cupping-vessels,  etc. 
The  walls  of  temples  and  monuments  are  figured  with  pa¬ 
tients  undergoing  surgical  operations.  It  may.be  confi¬ 
dently  asserted,  on  the  basis  of  established  facts,  that  Egyp¬ 
tian  surgery  under  the  old  pagan  civilization  did  not  lag 
behind  the  other  arts  and  sciences  cultivated  in  that  Oriental 
jand.  Therefore  let  us  glance  hastily  at  the  progress  which 
had  already  been  made  in  architecture  and  sculpture.  Archi¬ 
tecture  here  attained  in  this  early  age  a  degree  of  perfec¬ 
tion  which  has  not  yet  been  excelled,  and  in  some  respects 
not  even  equaled,  in  our  own  favored  times. 

In  proof  of  the  correctness  of  this  assertion,  let  us  care¬ 
fully  examine  the  ancient  temples,  obelisks,  and  pyramids. 
Sculpture  was  here  molded  with  a  high  degree  of  accuracy 
more  than  two  thousand  years  before  the  birth  of  Christ. 
The  sciences  of  geometry,  music,  and  astronomy  are  known 
to  have  reached  a  very  high  standard  in  the  early  history  of 
^c?ypb  The  most  brilliant  era  of  learning  under  pagan 
rule  existed  about  one  hundred  years  before  the  birth  of 
Christ.  The  Alexandrian  school  had  then  reached  the  acme 
of  its  glory,  medicine  had  been  divorced  from  the  priestly 
rule,  and  likewise  was  freed  from  mysticisms  and  supersti¬ 
tions.  The  teachers  had  been  selected  because  of  their 


114 


WATSON:  SURGERY,  ANCIENT,  MEDIMYAL,  AND  MODERN  [N.  Y.  Mbd.  Jock.. 


well-known  scientific  attainments,  and  represented  not  Egypt 
alone,  bat  the  scientific  lore  of  the  Orient.  These  professors 
were  amply  pensioned  by  the  Government,  and  given  free 
access  to  the  largest  library  in  the  world;  while,  for  the 
further  stimulation  to  action  of  these  scientific  gladiators, 
they  were  required  to  engage  in  open  debates  and  other 
literary  trials.  Is  it  therefore  strange  that  this  university 
should  have  produced  a  Euclid,  whose  name  is  still  famil¬ 
iar  in  every  school  where  mathematics  is  studied?  The 
advent  of  Christ  produced  a  struggle  between  paganism 
and  His  followers.  The  miraculous  cures  effected  by  the 
Son  of  God  and  His  disciples  were  death-blows  to  scientific 
or  rational  surgery.  The  early  Christians  were  a  band  of 
fanatical  “  Faith  Curists.”  This  new  development  produced 
its  natural  effect  on  the  Alexandrian  University,  but  still  it 
continued  its  existence  more  than  six  hundred  years  after 
the  birth  of  Christ.  Consequently  the  life  of  this  institu¬ 
tion  was  about  one  thousand  years.  During  this  time  there 
had  been  gathered  into  its  library  about  seven  hundred 
thousand  volumes.  In  the  year  of  our  Lord  640  the  city 
was  captured  by  the  Arabians,  and  the  professors  fled  to 
various  parts  of  the  world  to  escape  death  at  the  hands  of 

their  enemies.  . 

Many  of  the  physicians  and  surgeons  went  into  Italy, 

which  became  their  future  home.  This  school  was  the  most 
brilliant  gem  in  the  pagan  civilization.  The  surgeons  who 
were  trained  within  her  walls  while  she  was  at  the  height 
of  her  glory  became  the  peers  of  kings,  and  even  those 
educated  there  after  she  had  entered  on  her  decline  were 
always  respected  and  honored  where  science  could  be  ap¬ 
preciated.  The  destruction  of  this  famous  school  of  science 
was  the  prelude  to  the  present  Egyptian  darkness.  There 
is  no  mention  made  in  the  Old  Testament  of  the  perform¬ 
ance  of  any  surgical  operation  by  the  Jews  before  the  chil¬ 
dren  of  Israel  went  into  Egypt,  where  they  sojourned  four 
hundred  and  thirty  years;  and,  consequently,  it  may  be 
rationally  inferred  that  they  learned  this  art  from  the  Egyp¬ 
tian  surgeons.  The  first  reference  made  to  the  performance 
of  any  operation  on  the  dead  or  living  human  body  after 
this  Egyptian  residence  occurred  seventeen  hundred  years 
before°the  birth  of  Christ,  when  “Joseph  commanded  his 
servants,  the  physicians,  to  embalm  his  father,  and  the 
physicians  embalmed  Israel.”  Circumcision  was  an  opera¬ 
tion  which  was  practiced  by  the  Israelites  during  their  so¬ 
journ  in  Egypt,  This  operation  was  first  performed  on 
Abraham  when  he  was  ninety  years  of  age,  which  was  about 

1897  before  the  advent  of  Christ. 

The  operation  of  circumcision  was  done  with  sharp 
Ethiopian  stones.  In  addition  to  these  surgical  operations 
performed  by  the  Israelites,  there  are  also  references  made 
in  the  Scriptures  to  the  following  surgical  dressings,  appli¬ 
ances,  and  instruments:  “An  eye  salve,”  “a  lump  of  figs 
laid  for  a  plaster  upon  the  boil,”  “an  awl  for  boring  the 
ears,”  “a  roller  to  bind,”  as  applied  to  a  broken  limb,  lan¬ 
cets’  etc.  There  are  no  means  known  by  which  it  can  be 
determined  whether  the  Jews  had  made  much  or  little 
progress  in  the  art  and  science  of  surgery  after  their  de¬ 
parture  from  Egypt ;  but,  after  Christ  came,  the  scientific 
study  of  medicine  was  entirely  abandoned.  The  miracles  of 


our  Lord,  shown  in  the  healing  of  the  sick  and  the  cure  of 
bodily  infirmities,  led  to  the  belief  that  the  physicians  in 
these  difficult  and  disagreeable  processes  were  all  wrong,  and 
that  the  true  remedial  mode  was  by  prayer,  fasting,  and  faith. 

The  earliest  history  of  Greek  surgery,  like  the  Egyptian, 
has  its  origin  in  mythological  legendry,  and  one  of  these 
legends  may  possess  sufficient  interest  for  my  readers  to 
justify  me  in  repeating  it  here.  This  interest  depends  on 
the  fact  that  representations  of  the  serpent  have  been  for 
ages  and  are  still  variously  employed  in  connection  with 
medical  literature.  Thus  Hygeia,  the  daughter  of  ^Escula- 
pius  and  the  goddess  of  health,  is  represented  by  an  an¬ 
cient  statue  in  the  British  Museum  as  feeding  a  serpent..  I 
saw  when  at  Pompeii  in  1889,  a  similar  statue  standing 
before  the  ruins  of  an  old  drug-store  *  “  The  mythical 

origin  of  Greek  medicine  selects  Melampus  as  the  first  who 
practiced  the  medical  art  in  Greece,  and  he  is  believed  to 
have  acquired  his  skill  by  a  divine  revelation.  Near  his 
house  stood  an  oak-tree,  in  whose  trunk  a  serpent  made  its 
nest.  The  servants  of  Melampus  killed  the  old  serpent, 
but  their  master  would  not  suffer  the  young  ones  to  be  mo¬ 
lested,  and  he  fed  them  daily  with  his  own  hands.  One 
day  he  slept  beneath  the  shade  of  the  oak,  and  the  young 
serpents,  creeping  about  him,  licked  his  ears.  When  he 
awoke  he  found  to  his  astonishment  that  he  could  discern 
the  uses  of  inanimate  things — herbs,  minerals,  and  all  dumb 
animals.  He  began  at  once  to  apply  this  knowledge  to  the 
service  of  his  fellow-creatures,  and  kings  and  princes  be¬ 
came  his  patients.”  ij 

The  parentage  of  ^Esculapius,  the  grandest  of  all  the 

Grecian  deities,  is  a  subject  on  which  all  the  ancient  histo¬ 
rians  are  in  perfect  accord.  They  have  told  us  that  Apollo 
was  his  father,  and  Coronis  his  mother.  Furthermore,  that 
HCsculapius,  like  most  of  the  other  young,  heroes  of  his 
time,  was  instructed  by  the  Centaur  Chiron  in  all  the  aits, 
especially  those  pertaining  to  the  practice  of  surgery. 
Plato  has  informed  us  that  the  skill  of  JEsculapius  was 
merely  confined  to  the  dressing  and  healing  of  wounds  with 
herbs  proper  for  arresting  haemorrhage  and  assuaging  pain. 
“Plutarch  asserts  that  such  comprised  the  whole  of  ancient 
Grecian  medicine.” 

The  mythical  story  of  iEsculapius  possesses  for  every 
medical  student  a  high  degree  of  interest,  since  his  name 
was  for  ages  closely  associated  with  the  medical  practice  in 
Greece.  He  was  revered  by  the  Greeks  as  a  physician,  and 
at  the  same  time  worshiped  as  a  god.  The  temples  of  ,Escu- 
lapius  were  erected  in  every  part  of  Greece,  and  no  other 
deity  in  Grecian  mythology  shared  with  him  his  medical 
attributes.  These  temples  served  at  tbe  same  time  as  hos¬ 
pitals  for  the  sick  and  places  for  the  worship  of  this  deity. 

Among  the  most  magnificent  of  these  temples  were 
those  at  Epidaurus,  Trikka,  Cos,  Rhodes,  and  Cnidos.  The 
temple  at  Epidaurus  is  supposed  to  have  been  erected  twelve 
hundred  years  before  Christ,  and  was  surrounded  by  an 
extensive  grove  of  trees,  abounding  in  serpents.  These 
serpents— emblems  of  health  and  life— were  also  kept  in 
all  the  HEscnlapian  temples. 

There  were  hung  on  the  walls  of  these  temples  tablets 


*  A  Chronology  of  Medicine,  edited  by  John  Morgan  Richards,  p.  30. 


August  2,  1890.] 


WATSON:  SURGERY ,  ANCIENT \  MEDIAE V A L,  AND  MODERN 


115 


on  which  were  recorded  the  name  and  age  of  the  patient, 
the  disease  and  its  symptoms,  and  the  treatment  by  which 
the  cure  had  been  accomplished. 

These  records  were  the  principal  source  from  which 
medical  knowledge  was  obtained  when  the  Greeks  com¬ 
menced  the  study  of  medicine  as  a  science.  These  temples 
were  at  first  devoted  entirely  to  the  treatment  of  the  sick 
and  the  worship  of^Esculapius;  afterward,  in  some  instances, 
became  the  chief  medical  schools  of  Greece.  The  most 
ancient  of  these  schools  were  situated  at  Cos,  Cnidos,  and 
Rhodes.  The  temples  were  always  presided  over  by  the 
./Esculapiadae,  a  sect  of  priests,  the  reputed  descendants  of 
JDsculapius.  The  teaching  of  surgery  was  not  long  con¬ 
fined  to  the  descendants  of  HSsculapius,  since  Pythagoras, 
in  the  sixth  century  before  Christ,  established  at  Crotona  a 
school  of  medicine,  in  which  Democedes,  an  eminent  sur¬ 
geon,  was  trained.  It  is  also  thought  that  some  surgical 
training  was  given  to  students  in  the  Grecian  gymnasiums. 
These  priests,  the  HSsculapiadae,  in  the  selection  of  sites  for 
the  ^Esculapian  temples  and  the  preparation  of  the  sick  for 
admission,  showed  a  degree  of  knowledge  worthy  of  an 
honest  surgeon’s  highest  admiration,  while,  by  their  con¬ 
stant  exhibition  of  -greed  and  their  cunningly  devised  plans 
for  the  deception  of  their  patients,  they  set  an  example 
which  could  be  advantageously  imitated  by  the  most  un¬ 
scrupulous  quacks  of  any  age. 

The  temples  commonly  occupied  some  elevated  and 
healthy  locality,  in  close  proximity  to  cities,  surrounded  by 
pleasant  groves,  and  in  the  neighborhood  of  thermal  springs 
or  fountains  of  medicated  waters.  The  sick,  prior  to  their 
admission,  were  required  to  submit  to  a  thorough  purifica¬ 
tion  by  fasting,  ablution,  and  inunction,  while  all  other  per¬ 
sons  were  rigorously  excluded  from  these  temples.  Homer 
added  other  gems  to  the  crown  of  the  already  deified  H5scu- 
lapius  by  rendering  immortal  the  names  of  his  sons,  Ma- 
chaon  and  Podalirius,  whom  he  praised  as  the  grandest  of 
heroes  and  the  wisest  of  surgeons.  The  two  brothers  were 
at  the  siege  of  Troy,  which  occurred  twelve  hundred  years 
before  the  birth  of  Christ,  and  participated  in  this  action  in 
their  dual  capacity. 

In  Homeric  poems  their  virtues  are  thus  portrayed  : 

“  Of  two  great  surgeons ,  Podalirius  stands 
This  hour  surrounded  by  the  Trojan  bands, 

And  great  Machaon,  wounded  in  bis  tent, 

Now  wants  the  succor  which  so  oft  he  lent.” 

The  treatment  of  wounds  at  this  early  period  (about 
1200  b.  c.)  is  thus  described  by  Homer,  who  wrote  in  the 
ninth  century  before  Christ : 

“Patroclus  cut  the  forky  steel  away, 

And  in  his  hand  a  bitter  root  he  pressed, 

The  wound  he  washed  and  styptic  juice  infused. 

The  closing  flesh  that  instant  ceased  to  glow, 

The  wound  to  torture  and  the  blood  to  flow.” 

Iliad ,  Book  XI. 

We  learn  from  ancient  history  that  skillful  physicians 
were  highly  appreciated  under  pagan  rule  ;  when  captured 
as  prisoners  of  war  they  were  sold  into  bondage  for  fabu¬ 
lous  prices.  In  some  cases  they  were  admitted  as  residents 


to  the  royal  palaces  of  their  captors  and  rewarded  for  spe¬ 
cial  services  by  receiving  in  marriage  the  daughter  of  the 
ruling  sovereign  and  a  portion  of  his  kingdom. 

Homer,  speaking  for  the  wise  and  august  Nestor,  says : 

“A  wise  physician,  skilled  our  wounds  to  heal, 

Is  more  than  armies  to  the  public  weal.” 

It  must  be  admitted  that  nothing  like  a  clear  and  com¬ 
prehensive  history  of  Grecian  surgery  can  now  be  obtained 
until  we  come  down  to  the  Hippocratic  period  in  the  fifth 
century  before  Christ.  Homer  probably  possessed  some 
definite  knowledge  of  the  surgery  of  the  Trojan  period, 
but  his  writings,  unfortunately,  afford  us  but  little  of  the 
desired  light,  and,  in  fact,  they  may  be  fitly  compared  to 
the  vivid  flashes  of  lightning  in  a  dark  night.  Here  fol¬ 
lows  a  long  period — about  seven  hundred  years— Tof  which 
nothing  is  known  of  the  surgical  progress  of  Greece.  How¬ 
ever,  it  is  quite  evident  that  surgical  progress  during  this 
period  was  severely  embarrassed  by  the  want  of*  an  accu¬ 
rate  anatomical  knowledge.  The  laws  of  Greece  strictly 
prohibited  the  dissection  of  the  human  body,  and  this 
condition  must  have  been  a  great  obstacle  in  the  way  of 
surgical  advancement.  Hippocrates  (450-351  b.  c.)  was 
born  on  the  island  of  Cos,  a  famous  seat  of  learning  at 
that  time,  and  he  availed  himself  of  all  its  advantages.  In 
later  years,  prior  to  commencing  his  life’s  work,  he  traveled 
over  every  part  of  Greece,  spent  much  time  in  study  at 
Athens  and  other  seats  of  learning,  and  was  everywhere 
assisted  by  the  ablest  masters  in  science  and  philosophy. 
In  this  manner  his  mind  was  well  stored  with  knowledge  by 
a  long  and  faithful  course  of  study,  while  the  variety  of 
these  studies,  aided  by  the  advantages  of  travel  and  contact 
with  the  brightest  minds  of  earth,  had  broadened  his  views 
and  developed  his  reasoning  faculties  far  beyond  those  ordi¬ 
narily  found  in  professional  men  of  his  or  any  other  age. 
Still,  there  was  something  wanting  to  enable  genius  to  rise  to 
an  undying  fame.  He  must  know  his  own  power. 

This  knowledge  was  soon  revealed  to  him.  A  pestilence 
had  seized  hold  of  Athens.  He  hastened  to  this  city  thus 
threatened  with  destruction,  and  succeeded  in  delivering 
her  from  the  terrible  scourge.  The  people  were  grateful 
for  the  deliverance,  and  promptly  rewarded  him  for  these 
valuable  services.  A  golden  crown  was  placed  upon  his 
head,  and  all  the  rights  of  citizenship  were  conferred  upon 
him.  These  honors  and  marks  of  distinction  were  promptly 
followed  by  others  from  various  sources,  some  of  which  he 
accepted  and  others  he  declined;  but  nothing  was  now 
wanting  to  enable  him  to  fulfill  man’s  highest  mission,  to 
win  for  himself  undying  fame,  and  at  the  same  time  become 
the  world’s  greatest  benefactor.  His  writings  mark  in  Gre¬ 
cian  history  a  new  era — the  brightest  the  world  has  ever 
known — and  well  may  he  be  styled  the  “  Father  of  Medi¬ 
cine.”  He  died  in  the  ninety-ninth  year  of  his  age,  free 
from  all  disorders  of  the  mind  and  body,  and  after  death  he 
was  designated  “  The  Great  ” — the  same  honor  which  was 
conferred,  on  Hercules.  He  was  the  Homer  of  his  profes¬ 
sion.  The  works  of  Hippocrates  were  long  preserved  in 
the  Alexandrian  library,  and  have  been  handed  down  to  us 
in  such  a  form  that  every  one  who  will  may  read  them,  and 


116 


WATSON:  SURGERY ,  ANCIENT ,  MEDIJEVAL ,  AND  MODERN.  [N.  Y.  Mud.  Jocr., 


they  prove  to  us  that  he  was  a  general  practitioner  and  not 
a  specialist. 

“  Mo  less  than  eight  of  his  seventeen  treatises  now  ad¬ 
mitted  to  be  genuine  works  are  strictly  surgical,  .  .  .  and 
furnish  us  a  very  clear  insight  of  the  principles  and  practice 
of  this  science  and  art  as  it  was  understood  twenty-three  cent¬ 
uries  ao-o.  .  .  .  A  hen  we  reflect  upon  the  character  and  im¬ 
portance  of  the  numerous  operations  which  were  then  per¬ 
formed,  we  certainly  find  more  occasion  for  admiration 
than  we  do  for  adverse  criticism,  thus  we  find  that,  in 
the  ancient  days  of  surgery,  fractures  and  dislocations  were 
carefully  adjusted  and  reduced ;  extension  and  counter¬ 
extension  were  made  by  ingenious  apparatus;  the  most  ex 
act  coaptation  of  fractured  bones  was  insisted  upon,  as  it 
was  considered  disgraceful  to  allow  the  patient  to  be 
maimed  with  a  crooked  or  a  shortened  limb.  Splints,  and 
even  waxed  bandages,  giving  as  much  fixity,  support,  and 
immobility  to  the  parts  as  is  now  done  by  starch  and  plaster 
of  Parisr  were  then  in  use.  Hippocrates  also  gives  direc¬ 
tions  for  the  suspension  of  fractured  limbs  in  gutters  and 
slings.  The  projecting  ends  of  bones  in  compound  fract¬ 
ures  were  carefully  resected.  The  bones  of  the  cranium 
were  trepanned  for  fracture  with  depression  of  bone,  or 
for  the  evacuation  of  accumulations  of  blood  or  pus.  Ab¬ 
scesses  of  the  liver,  and  even  of  the  kidneys,  were  opened 
with  boldness  and  freedom.  The  thoracic  cavity  was  ex¬ 
plored  by  rude  percussion  and  auscultation  for  the  detec¬ 
tion  of  fluids,  and,  when  found,  paracentesis  was  performed, 
as  was  also  done  in  abdominal  dropsies.  The  rectum  was 
explored  by  an  appropriate  speculum  ;  fistula  in  ano  and 
haemorrhoids  were  operated  upon  ;  club-feet  were  adjusted 
by  bandaging  and  the  use  of  stiff  leather  and  leaden  shoes; 
the  bladder  was  explored  by  sounds  for  the  detection  of 
calculi ;  lithotomy  was  performed  by  specialists  ;  gangre¬ 
nous  and  mangled  limbs  were  amputated  ;  the  dead  foetus 
was  extracted  with  instruments  from  the  uterus;  venesec¬ 
tion,  scarification,  and  cupping  were  also  practiced  in  the 
days  of  Hippocrates.”  * 

Hippocrates  failed  to  leave  behind  any  distinguished 
sons  or  pupils  whose  names  have  been  handed  down  in  the 
history  of  surgery.  Aristotle  (384-322  b.  c.),  who  lived  at 
a  somewhat  later  period  than  Hippocrates,  added  some¬ 
thing  to  the  existing  knowledge  of  anatomy.  Praxagoras,  a 
distinguished  surgeon  of  Cos — a  contemporary  of  Aristotle 

_ contributed  to  both  anatomy  and  surgery.  He  was  the 

first  to  establish  a  distinction  between  the  arteries  and 
veins,  while’  in  his  surgical  practice  he  was  bolder  than 
most  of  his  predecessors,  since  he  removed  the  uvula  in  in¬ 
flammatory  sore  throat,  opened  the  abdominal  cavity  in 
those  affected  with  the  iliac  passion,  and  replaced  the  in 
testines  in  their  normal  position.  Asclepiades  was  born  at 
Prussa,  in  Bithynia,  was  educated  at  Alexandria  under 
Cleophantus,  and  commenced  life  as  a  teacher  of  elocution 
He  taught  in  Athens  and  other  parts  of  Greece,  but,  having 
failed  in  this  attempt,  he  turned  his  attention  to  surgery, 
which  he  began  to  practice  at  Rome,  where  he  flourished 
as  a  surgeon  and  the  friend  of  Cicero  about  ninety  years 


before  the  birth  of  Christ.  Here  he  gained,  by  the  ostenta¬ 
tious  display  of  a  little  wisdom  and  much  tact,  both  popu¬ 
larity  and  wealth.  He  cultivated  most  assiduously  the 
friendship  of  politicians  and  others  having  power.  As¬ 
clepiades  was  the  successor  of  Archagathus,  a  Peloponesian, 
who  settled  at  Rome  as  a  practitioner  of  surgery  about 
two  hundred  years  before  the  birth  of  Christ,  and  is  sup¬ 
posed  to  have  been  the  first  to  practice  medicine  as  a  pro¬ 
fession  in  that  aucient  city  ;  but,  having  given  offense  to 
some  of  its  ignorant  and  superstitious  inhabitants,  was 
nicknamed  the  “  executioner ,”  and  finally  banished. 

Asclepiades  shrewdly  avoided  the  errors  into  which 
Archagathus  had  fallen,  studied  carefully  the  foibles  and 
whims  of  the  Romans,  and  thus  enriched  himself  by  appeal' 
ing  to  their  pride  and  vanity.  He  practically  discarded  the 
use  of  all  internal  medicines,  under  the  pretext  that  they 
offended  the  stomach,  and  confined  himself  principally  to 
hygienic  measures  and  the  regulation  of  the  diet.  Ihe  chief 
remedial  agents  employed  by  him  consisted  in  the  internal 
use  of  wine  and  a  free  application  of  friction  to  the  skin. 
His  comparative  ignorance  of  medicine  was  in  a  measure 
compensated  for  by  his  superior  knowledge  of  elocution, 
which  he  now  turned  to  a  good  account  by  establishing  a 
medical  school,  in  which  he  became  a  teacher.  He  was  the 
first  to  announce  the  doctrine  of  the  self-limitation  of  dis¬ 
ease,  and  declared  that  the  principal  cure  for  fevers  was  the 
disease  itself.  He  wrote  on  ulcers,  acute  and  chronic  dis¬ 
eases,  and  likewise  recommended  tracheotomy  in  cases  of 
impending  suffocation.  In  perfect  harmony  with  the  many 
other  acts  of  his  life,  we  are  told  that  he  made  a  wager  that 
he  would  never  be  sick,  and,  if  we  can  believe  his  biog¬ 
rapher,  he  won  even  this  bet,  since  he  died  from  the  effects 
of  a  fall  in  old  age. 

The  writings  of  the  earliest  historians  make  it  apparent 
that  Greece,  like  every  other  portion  of  the  inhabited  world, 
had  her  own  charlatans  many  centuries  before  the  birth  of 
Christ.  The  Greeks  had  also  in  their  pay  military  sur¬ 
geons;  but,  according  to  Xenophon,  they  were  only  called 
after  sanguinary  battles  to  dress  the  wounded.  1  he  aleipti, 
or  physicians,  sold  also  secret  remedies  at  the  public  baths, 
and  were  frequently  consulted  in  cases  of  wounds,  etc. 

It  is  self-evident  that  attempts  were  made  to  practice 
surgery  among  all  the  nations  of  the  earth  at  a  very  early 
day  ;  in  fact,  such  efforts  were  contemporaneous  with  man’s 
wants.  It  is  equally  certain  that  the  knowledge  of  this  art 
did  not  make  any  decided  progress  among  any  of  the  na¬ 
tions  until  the  other  arts  and  sciences  were  cultivated.  It 
may  therefore  be  confidently  asserted  that  those  nations  in 
which  the  light  of  general  science  was  first  diffused  were 
the  first  to  elevate  the  standard  of  surgery.  In  perfect  har¬ 
mony  with  this  opinion  is  the  fact  that  in  Egypt  and 
Greece  the  science  and  art  of  surgery,  as  shown  by  an 
cient  history,  soon  attained  a  comparatively  high  standard 
while  Persia  was  dependent  on  these  countries  for  her  sur 


o-eons. 

O 


*  International  Encyclopcedia  of  Surgery,  vol.  vi,  pp.  114  et  seq. 


The  story  of  King  Darius  andDemocedes  (fifth  centun 
before  Christ)  shows  that  the  surgical  representatives  o 
these  countries  sometimes  came  in  conflict  with  each  other 
“  It  happened  that  King  Darius  as  he  leaped  from  hi 


August  2,  1890.] 


WATSON :  SURGERY, ,  ANCIENT \  MEDIAEVAL,  AND  MODERN. 


117 


horse  sprained  his  foot.  The  sprain  was  of  no  common 
severity,  for  the  ankle  bones  were  forced  out  of  their 
sockets.”*  In  fact,  it  was  a  dislocation.  Now  Darius  had 
already  at  his  court  certain  Egyptians,  whom  he  reckoned 
the  best  skilled  physicians  in  all  the  world ;  to  their 
aid  therefore  he  had  recourse;  but  they  twisted  the 
foot  so  clumsily  and  used  such  violence  that  they  only 
made  the  mischief  greater.  For  seven  days  and  seven 
nights  the  king  lay  without  sleep,  so  grievous  was  the  pain 
he  suffered.  On  the  eighth  day  of  his  indisposition,  one 
who  had  heard,  before  leaving  Sardis,  of  the  skill  of  Demo- 
cedes,  the  Crotonian,  told  Darius,  who  commanded  that  he 
should  be  brought  with  all  speed  into  his  presence. 

When,  therefore,  they  found  him  among  the  slaves  of 
Crates,  quite  uncared  for  by  any  one,  they  brought  him 
just  as  he  was,  clanking  his  fetters  and  clothed  in  rags,  be¬ 
fore  the  king.  As  soon  as  he  was  entered  into  the  presence, 
Darius  asked  him  if  he  knew  medicine,  to  which  he  an¬ 
swered  “  No,”  for  he  feared  if  he  made  himself  known  he 
would  lose  all  chance  of  again  beholding  Greece.  Darius, 
however,  perceiving  that  he  dealt  deceitfully  with  him  and 
really  understood  the  art,  bade  those  who  had  brought  him 
ioto  his  presence  go  fetch  the  scourges  and  the  pricking 
irons  (or  blinding  irons  to  put  out  his  eyes).  Upon  this 
Democedes  made  confession,  but  at  the  same  time  said  he 
had  no  thorough  knowledge  of  medicine;  he  had  but  lived 
some  time  with  a  physician,  and  in  this  way  had  gained  a 
slight  smattering  of  the  art.  However,  Darius  put  himself 
under  his  care,  and  Democedes,  by  using  the  remedies  cus¬ 
tomary  among  the  Greeks,  and  exchanging  the  violent 
treatment  of  the  Egyptians  for  milder  means,  first  enabled 
him  to  get  some  sleep,  and  then  in  a  very  little  time  restored 
him  altogether,  after  he  had  quite  lost  the  hope  of  ever 
having  the  use  of  his  foot.  Democedes,  subsequently, 
while  still  residing  at  the  Persian  court,  added  another 
triumph  to  that  already  gained  by  the  successful  treat¬ 
ment  of  a  tumor  of  the  breast,  under  which  Atossa,  the 
daughter  of  Cyrus  and  wife  of  Darius,  had  labored  for  a 
considerable  period. 

There  were  no  medical  schools  established  in  Persia 
prior  to  the  birth  of  Christ ;  but  the  Nestorians,  a  sect  of 
Christians  fleeing  the  persecutions  of  orthodoxy,  some  time 
in  the  fifteenth  century  of  the  Christian  era  settled  at  Edes- 
sa,  in  Mesopotamia,  and  founded  a  medical  college.  This 
school  gained  some  celebrity.  Another  body  of  Nestorians 
settled  in  the  city  of  Dschondisabour  and  established  an¬ 
other  medical  college.  It  was  in  this  school  that  the  Per¬ 
sians  and  Arabians  studied  the  healing  art  during  a  portion 
of  the  Dark  Ages.  The  Hindoo  mythology  assigns  to 
Brahma  the  powers  of  deity  and  likewise  those  of  a  physi¬ 
cian,  but  has  most  generously  attributed  to  six  other  minor 
divinities  the  power  of  healing  the  sick. 

It  is  unquestionably  true  that  surgery  in  the  early  part 
of  the  Christian  era  had  already  attained  to  a  high  standard 
in  India,  the  real  question  being  whether  the  Greeks  got 
their  knowledge  of  surgery  from  the  Hindoos,  through  the 
Egyptian  priesthood,  or  the  Hindoos  obtained  it  from  con¬ 


*  History  of  the  Heroes  of  Medicine ,  by  Russel,  pp.  2  et  seq. 


tact  with  the  western  civilization  after  the  campaigns  of 
Alexander. 

It  seems  to  me  highly  probable  that  this  knowledge 
came  to  the  Hindoos  from  contact  with  the  western  civili¬ 
zation.  The  oldest  existing  book  relating  in  any  way  to 
surgery  is  the  Charaka  Samhita ,  a  bulky  encyclopaedia, 
probably  composed  some  centuries  after  Christ.  Another 
work  of  at  least  equal  authority,  but  probably  somewhat 
more  modern,  is  the  Susrata.  The  Susrata  speaks  of  a  sin¬ 
gle  class  of  practitioners  who  treated  both  medical  and  sur¬ 
gical  cases. 

The  only  distinction  recognized  between  medicine  and 
surgery  was  the  inferior  order  of  barbers,  nail-trimmers,  ear- 
borers,  tooth-drawers,  and  phlebotomists,  who  were  outside 
of  the  Brahmanical  caste.  The  same  author  describes  more 
than  one  hundred  surgical  instruments  made  of  steel,  which 
include  the  most  important  of  those  now  in  common  use  by 
surgeons.  The  Chinese  seem  to  have  been  far  behind  the 
Hindoos.  Their  knowledge  of  surgery  is  still  of  a  very 
primitive  character.  Their  distinctive  surgical  invention  is 
acupuncture,  or  the  insertion  of  fine  needles  into  the  seats 
of  pain  or  inflammation.  The  present  ignorance  of  the 
Chinese,  as  well  as  the  ancient,  in  surgical  matters  is  proba¬ 
bly  due  to  their  prejudices  and  superstitions.  They  are  op¬ 
posed  to  drawing  blood  or  dissecting  the  human  body,  al¬ 
though  they  are  credited  with  opening  boils.  The  moxa  is 
a  great  favorite  with  them,  but  is  employed  more  frequently 
as  a  prophylactic  than  as  a  curative  agent.  The  Chinese 
policy  was  for  ages  opposed  to  any  association  with  the  civ¬ 
ilized  nations  of  earth  ;  and  consequently  they  debarred 
themselves  from  learning  much  of  that  which  would  have 
otherwise  come  to  them  through  contact.  They  are,  or 
have  been  until  very  recently,  entirely  without  medical 
schools. 

History  fails  to  show  that  there  has  been  in  any  age 
any  attempt  to  teach  medicine.  The  Japanese  did  nothing 
for  the  advancement  of  surgery  during  ancient  times;  in 
fact,  all  that  has  been  said  of  the  Chinese  is  equally  applica¬ 
ble  to  them.  Rome  was  settled  about  seven  hundred  and 
fifty  years  before  the  birth  of  Christ,  and  remained  about 
six  hundred  years  without  either  physicians  or  surgeons, 
trusting  entirely  during  this  long  period,  for  the  cure  of 
diseases  and  wounds,  to  spells  and  incantations.  Public 
edicts  were  issued  against  the  professional  practice  of  medi¬ 
cine  and  surgery  during  this  period,  while  the  public  were 
encouraged  to  put  their  faith  in  traditional  prescriptions 
and  religious  rites. 

Cato,  the  first  Censor,  gravely  wrote  down  the  mystic 
words  of  incantation  for  curing  dislocations  and  fractures 
of  bones.  Rome  produced  a  surgical  author,  who  lived  dur¬ 
ing  the  Augustan  period  (30  b.  C.-14  a.  d.),  whose  writ¬ 
ings  have  been  handed  down  to  us,  and  constitute  the  most 
perfect  record  in  our  possession  of  ancient  surgery.  The 
era  in  which  he  lived  was  the  grandest  period  of  the  Roman 
Empire  and  gives  us  in  literature  the  immortal  names  of 
Virgil,  Horace,  Ovid,  and  Celsus.  The  writings  of  Aure¬ 
lius  Cornelius  Celsus  likewise  serve  as  a  connecting  link  be¬ 
tween  the  Hippocratic  period  and  the  early  part  of  the 
Christian  era,  showing  the  marked  progress  which  had  been 


118 


WATSON:  SURGERY, ,  ANCIENT ,  MEDIAEVAL,  AND  MODERN. 


[N.  Y.  Med.  Joub., 


made  during  the  preceding  four  hundred  years.  In  these 
writings  we  behold  the  mighty  influence  wielded  by  the 
Alexandrian  school  on  the  science  and  art  of  surgery.  In 
fact,  the  author  shows  perfect  familiarity  with  both  Greek 
and  Egyptian  surgery.  Celsus  has  carefully  described  the 
operation  for  cataract,  plastic  operations  on  the  ears,  lips, 
nose,  etc.  Likewise  the  removal  of  nasal  polypi  and  the 
plugging  of  the  nostrils  for  the  control  of  haemorrhage.  In 
addition  to  these  operations,  he  described  the  method  em¬ 
ployed  for  the  extirpation  of  bronchocele,  the  dilferential 
diagnosis  of  umbilical  tumors  and  omental  and  intestinal 

O 

hernia,  and  the  treatment  of  the  latter  with  pads  and  ban¬ 
dages.  He  also  mentions  the  suturing  of  the  intestines, 
treatment  of  hydrocele,  varicocele,  phimosis,  stone  in  the 
bladder — operative  method  employed,  etc. 

These  writings  by  Celsus  show  a  marked  advance  in  the 
performance  of  amputations  of  the  extremities  since  the 
Hippocratic  age.  Hippocrates  informs  us  that  these  ampu¬ 
tations  were  only  made  through  the  dead  parts  lest  the  pa¬ 
tient  should  die  from  loss  of  blood.  Celsus  gives  directions 
for  the  performance  of  these  operations  through  the  living 
tissues,  and  describes  ligation  of  the  arteries  as  the  most  po¬ 
tent  means  known  for  the  control  of  arterial  haemorrhage. 

It  should  be  here  understood  that  I  have  enumerated 
only  a  limited  number  of  the  surgical  operations  which  Cel¬ 
sus  has  described  so  lucidly,  and  the  modern  surgeon  may 
be  confidently  assured  that  these  surgical  writings  are  still 
worthy  of  a  careful  perusal. 

Soranus,  surnamed  the  younger,  a  native  of  Ephesus,  a 
distinguished  pupil  of  the  Alexandrian  school,  located  at 
Rome,  under  the  reign  of  Trajan  and  Hadrian  (98-138 
A.  d.).  The  works  of  this  distinguished  author  have  per¬ 
ished  with  the  exception  of  some  fragments  which  have  been 
handed  down  to  us.  In  his  treatise  De  utero  et  pudendo 
muliebrie  he  gives  a  lucid  description  of  the  differential  di¬ 
agnosis  of  pregnancy,  ascites,  and  solid  tumors  by  the  aid 
of  percussion,  palpation,  and  succussion  ;  and  likewise  men¬ 
tions  the  use  of  the  vaginal  speculum  and  the  uterine  sound. 
He  also  wrote  a  treatise  on  fractures,  a  portion  of  which  is 
still  extant. 

Antyllus,  a  distinguished  Italian  surgeon  and  author, 
flourished  in  the  latter  part  of  the  first  or  in  the  early  part 
of  the  second  century.  The  greater  portion  of  his  works 
have  perished,  but  fragments  have  been  preserved  in  the 
quotations  of  subsequent  writers.  He  was  the  first  to  rec¬ 
ommend  bronchotomy  in  cynanche,  arteriotomy  instead  of 
venesection,  etc. 

Galen,  whose  writings  were  regarded  as  the  highest  au¬ 
thority  for  more  than  thirteen  hundred  years  on  medical 
topics,  was  a  physician  rather  than  a  surgeon.  He  was  born 
at  Pergamus,  in  Asia  Minor,  about  one  hundred  and  thirty 
years  after  the  birth  of  Christ,  settled  in  Rome,  where  he 
won  the  highest  fame,  in  the  year  one  hundred  and  sixty- 
four,  but  remained  there  about  five  years,  when  he  returnee 
to  the  land  of  his  birth,  where  he  died  about  200  a.  d. 

The  most  worthy  surgeons  who  graced  the  decline  of 
the  Roman  Empire  were  Oribasius  (350  a.  d.),  Aetius  (400 
a.  d.),  and  Paulus  H^gineta  (420  a.  d.).  These  were  al 
compilers  rather  than  original  authors. 


The  surgery  of  Oribasius  is  characterized  by  timidity 
and  shows  no  progress  since  the  Hippocratic  period.  AYe 
have  reached  a  period  when  amulets,  charms,  and  incan¬ 
tations  were  employed  in  the  place  of  rational  means  for 
the  relief  of  surgical  cases.  Thus  Aetius,  in  composing 
a  certain  ointment,  required  that  there  should  be  repeated 
in  a  loud  voice,  “  May  the  God  of  Abraham ,  the  God  of 
Isaac,  and  the  God  of  Jacob  deign  to  accord  virtues  to  this 
medicine and,  when  a  foreign  body  had  lodged  in  the 
gullet,  recommended  that  the  neck  of  the  patient  should  be 
touched  by  the  surgeon,  who  at  the  same  time  exclaims: 

“  Get  thee  out  or  descend ,  the  martyr  Blaise,  Servant  of  Jesus 
Christ,  commands  thee." 

The  writings  of  Aetius,  like  those  of  Oribasius,  contained 
only  extracts  from  the  older  surgical  authors ;  and  these 
were  interwoven  with  the  grossest  bigotry  and  superstition 
—  products  offered  by  Aetius  in  the  place  of  scientific 
knowledge  and  rational  conclusions. 

There  is  much  difference  of  opinion  among  the  old 
historians  in  regard  to  the  age  in  which  Paulus  JEgineta 
lived  and  wrote ;  and  at  this  day  it  is  probably  im¬ 
possible  to  fix  it  with  any  degree  of  certainty.  Some 
authorities  believe  it  was  as  late  as  the  seventh  century 
of  the  Christian  era,  while  others  think  it  was  as  early  as 
the  fifth. 

His  writings  are  similar  in  most  respects  to  those  of 
Oribasius  and  Aetius,  but  possess  some  original  and  valuable 
information.  He  was  educated  at  Alexandria,  and  is  sup¬ 
posed  to  have  been  a  professor  in  that  city.  His  work  pre¬ 
sents  an  able  and  orderly  summary  of  Greek  medicine  from 
Hippocrates  downward.  This  author,  in  his  published 
work,  draws  from  many  sources,  and  much  from  his  own 
personal  experience. 

We  have  now  traced  the  history  of  surgery  from  its 
mythological  origin  in  Egypt,  and  from  the  cloud-capped 
Olympus,  the  habitation  of  the  gods  in  Greece ;  we 
have  watched  it  loitering  in  primitive  purity  about  the 
temples  of  JEsculapius,  till  it  found  its  onward  way  to 
Rome,  where,  polluted  by  the  filth  of  that  vicious  metropo¬ 
lis,  we  have  seen  it  converted  into  a  diabolical  system  of 
charlatanism — reason  and  experience  banished,  ignorance 
and  superstition  re-established — where  charms,  amulets,  and 
sacrilegious  incantations  take  the  place  of  scientific  knowl¬ 
edge  ;  in  this  degraded  state  it  falls  into  the  bands  of  the  so- 
called  Christian  priest  physicians,  after  it  had  been  rescued 
from  the  pagan  priesthood  by  the  efforts  of  Hippocrates 
and  the  Alexandrian  school  of  medicine. 

The  dark  age  of  surgery  is  thus  ushered  in,  but  the 
darkness  steadily  increases  during  the  next  eight  or  nine 
hundred  years.  During  this  period  there  were  no  distin¬ 
guished  surgeons,  and  nearly  all  which  had  been  previously 
learned  of  this  science  and  art  was  forgotten.  It  was  prin¬ 
cipally  in  the  school  of  Salernum  that  even  a  flickering  light 
was  maintained.  The  University  of  Salerno  was  founded 
in  1150,  and  was  long  one  of  the  greatest  seats  of  learning 
in  Italy.  It  appears  from  history,  however,  that  Salerno, 
even  prior  to  this  date,  was  entitled  to  some  consideration 
as  a  city  of  medical  learning,  since  at  the  end  of  the  seventh 
century  it  was  the  seat  of  a  Benedictine  monastery,  and  that 


for  their  medical  acquirements.  But  it  has  been,  by  recent 
researches,  clearly  established  that  the  celebrated  “  Scliola 
salernitana ”  was  purely  a  secular  institution.  It  is  there¬ 
fore  certain  that  the  school  of  medicine  gradually  grew  up, 
since,  at  the  end  of  the  ninth  century,  Salernian  physicians 
were  already  spoken  of  and  the  city  was  known  as  “  Civitas 
Hippocratica .” 

At  a  later  period  we  find  great  and  royal  personages  re¬ 
sorting  to  Salerno  for  the  restoration  of  their  health,  among 
whom  was  William  of  Normandy,  afterward  the  Conqueror. 
The  Jewish  element  appears  to  have  been  important  among 
the  students,  and  possibly  among  the  professors.  The  repu¬ 
tation  of  the  school  was  great  until  the  twelfth  or  thirteenth 
century,  when  the  introduction  of  Arab  medicine  was  gradu¬ 
al  lv  fatal  to  it. 

v 

The  foundation  of  the  University  of  Naples  and  the 
rise  of  Montpellier  also  contributed  to  its  decline.  About 
the  middle  of  the  eleventh  century  the  Arabian  medical 
writers  began  to  be  known  by  Latin  translations  in  the 
western  world. 

Constantinus  Africanus,  a  monk,  was  the  author  of 
the  earliest  of  such  versions  (1050  a.  d.).  His  labors  were 
directed  chiefly  to  the  less  important  and  bulky  Arabian 
authors,  of  whom  Haly  was  the  most  noted.  During  this 
period  the  translation  of  the  works  of  the  old  masters  in 
medicine  was  pushed  forward,  compendiums  from  the  same 
source  were  prepared,  but  none  of  the  books  contained  any 
original  matter,  nor  were  the  selections  always  well  chosen. 
In  surgery  this  period  was  much  more  productive  than  in 
medicine,  especially  in  Italy  and  France ;  but  the  limits  of 
our  subject  only  permit  us  to  mention  Gulielmus  de  Sali- 
ceto,  of  Piacenza  (about  1275),  Lanfranc,  of  Milan  (died 
about  1306),  Guy  de  Chauliac  (about  1350),  and  the  Eng¬ 
lishman,  John  Ardern  (about  1350). 

The  above-named  authors  contributed  somewhat  to  the 
advancement  of  surgery,  or  at  least  helped  to  stay  the  tide 
which  was  so  surely  bearing  it  away.  They  possessed  suffi. 
cient  independence  to  oppose  the  charlatanism  of  the  greedy 
“baith  Curists  ”  in  the  Roman  priesthood,  and  taught  the 
importance  of  clinical  observations  and  rationalism  in  the 
practice  of  surgery.  The  science  and  art  of  surgery  had  at 
this  time  reached  its  lowest  degradation.  The  priests  had 
entirely  abandoned  the  precepts  of  the  old  masters  in  sur¬ 
gery,  and  professed  to  cure  all  sorts  of  injuries  by  use  of 
the  so-called  sacred  relics,  charms,  amulets,  etc.  The  most 
absurd  reports  were  made  of  miraculous  cures,  attested  by 
monks,  abbots,  bishops,  popes,  and  consecrated  saints.  They 
alleged  that  they  had  restored  the  blind,  the  epileptic,  the 
insane,  etc.  “The  Saints  of  the  Romanists  have  usurped  the 
place  ot  the  Zodiacal  constellations  in  the  government  of 
the  parts  of  man’s  body;  for  every  limb  they  have  a  Saint. 
Thus  St.  Otilia  keepes  the  head  instead  of  Aries ;  St.  Bla- 
sius  is  appointed  to  governe  the  neck  instead  of  Taurus”  ; 
and  so  old  Melton  goes  on  to  the  end  of  the  list.  Petti¬ 
grew  gives  the  names  of  nearly  fifty  Roman  Catholic  saints 
who  were  believed  to  have  special  control  over  certain  in¬ 
dividual  diseases,  both  medical  and  surgical.  The  priest¬ 
hood  also  assigned  saints  to  wells  and  springs  to  give  heal- 


119 

and  instituted  health-seeking  pil- 

This  evil  had  become  so  firmly  rooted  that  it  required 
the  best  efforts  of  the  Popes  and  Holy  Councils  for  nearly 
one  hundred  years  to  remove  surgery  from  the  vile  hands 
into  which  it  had  fallen.  The  first  mandate  against  this 
practice  was  issued  by  the  Lateran  Council,  under  Pope 
Callestus  II,  a.  d.  1123,  while,  “in  1215,  Innocent  III  ful¬ 
minated  an  anathema  specially  directed  against  surgery,  by 
ordaining  that,  as  the  Church  abhorred  all  cruel  or  sangui¬ 
nary  practices,  no  priest  should  be  permitted  to  follow  sur¬ 
gery,  or  to  perform  any  operations  in  which  either  instru¬ 
ments  of  steel  or  fire  were  employed,  and  that  they  should 
refuse  their  benediction  to  all  those  who  professed  and  pur¬ 
sued  it.”  f 

It  is  unquestionably  true  that  the  priest  surgeons,  on 
account  of  the  opposition  in  the  Roman  Church,  were  at 
first  influenced  to  employ  barbers  to  perform  surgical  oper¬ 
ations  under  their  directions,  although  the  practice  had  its 
origin  in  the  early  part  of  the  tenth  century,  while  the 
final  edict  which  compelled  this  course  was  not  promulgated 
until  the  first  part  of  the  thirteenth.  The  barber  surgeons, 
having  learned  something  of  the  art  of  surgery  from  the 
priests,  finally  usurped  the  entire  practice. 

Well  may  the  surgeon  of  the  present  day  thank  God 
that  his  lot  has  been  cast  with  intelligent  confreres  rather 
than  with  the  barber  surgeons,  of  whom  Thomas  Gale,  an 
English  military  surgeon,  said  in  1544  :  “  I  remember  when 
I  was  at  the  wars  of  Muttrel,  in  the  time  of  that  famous 
prince  King  Henry  VIII,  there  was  a  great  rabblement 
there  that  took  upon  them  to  be  surgeons.  Some  were 
sow-gelders  and  horse-gelders,  with  tinkers  and  cobblers. 
This  noble  set  did  such  great  cures  that  they  got  themselves 
a  perpetual  name,  for,  like  as  Thessalus’s  sect  were  called 
Thessalanians,  so  was  this  rabblement  for  these  notorious 
cases  called  dog  leeches;  for  in  two  dressings  they  did 
commonly  make  these  cures  whole  and  sound  for  ever 
after.”  \ 

History  informs  us  in  the  following  language  that  Kino- 
Henry  VIII  and  his  Parliament,  in  the  third  year  of  his 
reign,  restrained,  the  practice  of  both  (medicine  and  surgerv) 
by  the  following  act :  “  To  the  King  our  Sovereign  Lord, 
and  to  all  the  Lords  spiritual  and  temporal,  and  Commons 
in  this  present  Parliament  assembled :  For-as-mucb  as  the 
science  and  cunning  of  physick  and  surgery  (to  the  perfect 
knowledge  whereof  be  requisite  both  great  learning  and  ripe 
experience)  is  daily,  within  this  realm,  exercised  by  a  great 
multitude  of  ignorant  persons,  of  whom  the  greater  part 
have  no  manner  of  insight  in  the  same,  nor  in  any  other 
kind  of  learning ;  Some  also  can  no  letters  on  the  book  so 
far  forth  that  common  artificers,  as  smiths,  weavers,  and 
women,  boldly  and  accustomably  take  upon  themselves 
great  cures,  and  thing  of  great  difficulty,  in  the  which  they 
partly  use  sorcery  and  witchcraft,  partly  apply  such  medi¬ 
cines  unto  the  disease,  as  be  very  noious,  and  nothing  meet 
Eerefore,  to  the  high  displeasure  of  God,  great  infamy  of 


*  International  Encyclopedia  of  Suryery,  vol.  vi,  p.  1181. 
t  Ibid.  \  Ibid.,  p.  1189. 


August  2,  1890.]  WATSON:  SURGERY ,  ANCIENT ,  MEDIEVAL,  AND  MODERN. 

ing  virtues  to  these  waters, 
grimages  to  these  places.* 


120 


WATSON:  SUROBR7\  ANCIENT ,  MEMJjVA^ ,  a  AW  [K-  ?•  Mlm-  Jorlt-' 


the  faculty,  and  the  grievous  hurt,  damage  and  destruction 
of  many  of  the  king’s  liege  people,  most  especially  them 
that  can  not  discern  the  uncunning  from  the  cunning  :  Beit 
therefore  to  the  surety  and  comfort  of  all  manner  of  people , 
by  the  authority  of  this  present  parliament  enacted,  that  no 
person  within  the  city  of  London,  nor  within  seven  miles 
of  the  same,  take  upon  him  to  exercise  or  occupy  as  a 
physician  or  surgeon,  except  he  be  first  examined,  approved 
and  admitted  by  the  bishop  of  London,  or  by  the  dean  of 
St  Paul’s  for  the  time  being,  calling  to  him  or  them  four 
doctors  of  physick,  and  for  surgery,  other  expert  persons 
in  that  faculty  ;  and  for  the  first  examination  such  as  they 
shall  think  conveniant,  and  afterwards  always  four  of  them 
that  have  been  so  approved,  upon  the  pam  of  forfeiture, 
for  every  month  that  they  do  occupy  as  physicians  or  sur¬ 
geons  not  admitted  or  examined  after  the  tenour  of  this 

act,  of  five  pound,  etc.”*  > 

These  extracts  present  a  faithful  picture  of  the  de¬ 
graded  condition  of  surgery  in  the  hands  of  the  barber  sur¬ 
geons,  to  whom  it  was  principally  confided  until  about  the 
middle  of  the  seventeenth  century,  while  the  use  of  the 
sympathetic  powder  of  Sir  Kenelm  Bigby  affords  us  a 
glimpse  of  the  irrational  methods  employed  in  the  treat¬ 
ment  of  wounds.  “  Whenever  any  wound  had  been  in¬ 
flicted,  this  powder  was  applied  to  the  weapon  that  had  in¬ 
flicted  it,  which  was,  moreover,  covered  with  ointment  and 
dressed  two  or  three  times  a  day.”  Fortunately  for  the 
science  of  surgery  and  humanity,  during  the  whole  period 
in  which  the  practice  of  surgery  was  monopolized  by  the 
barber  surgeons  there  were  a  few  scientific  and  bold  spirits, 
who  kept  alive  the  flickering  sparks  of  an  almost  forgotten 
science.  Among  this  number  must  be  mentioned  Mondim 
de  Luzzi,  a  professor  of  anatomy  at  Bologna,  who  dissected 
the  human  subject  before  his  class  in  1315— a  feat  which 
had  not  been  previously  performed  during  the  Christian 
era.  He  likewise  composed  a  work  on  anatomy,  which 
continued  to  be  used  in  all  the  medical  schools  of  Europe 
for  about  two  centuries. 

This  bold  and  successful  example  was  imitated  by  othei 
teachers.  The  dissection  of  the  human  body  once  more 
placed  surgery  on  a  firm  basis,  and  it  has  continued  to  pro¬ 
gress  both  as  a  science  and  an  art  to  the  present  time.  It 
was  not,  however,  until  the  first  half  of  the  sixteenth  cen¬ 
tury  that  there  appeared  one  greater  than  himself,  and 
whose  labors  far  excelled  those  of  this  noble  pioneer. 

Andreas  Vesalius  was  horn  in  1514  and  died  in  1564 
He  became,  when  twenty-two  years  of  age,  a  professor  of 
anatomy  in  the  renowned  University  at  Padua,  where  he 
lectured  to  large  classes  of  students.  He  published  in  1543 
by  far  the  most  splendid  work  on  anatomy  the  world  had 
ever  seen.  Thus  it  was  that  he  surprised  the  world  and  im¬ 
mortalized  his  name.  There  was  born  at  Laval,  m  the 
province  of  Mayenne,  France,  about  1509,  the  most  famous 
surgeon  of  his  age,  Ambroise  Pare,  who  did  more  for  the 
advancement  of  surgery  than  any  other  that  lived  during 
the  sixteenth  century.  He  inherited  from  his  parents  pov¬ 
erty,  a  strong  constitution,  lofty  ambition,  and  a  strong  will¬ 


power.  This  inheritance  secured  for  him  in  after  life  a 
royal  recognition  among  men  of  science  and  the  rulers  of 

his  country. 

In  boyhood  he  was  apprenticed  to  a  barber  surgeon, 
from  whom  he  learned  the  rudiments  of  minor  surgery. 
Having  come  in  contact  with  Germain  Colot,  a  distinguished 
lithotomist,  whom  he  greatly  admired  for  his  skill  and  dex¬ 
terity,  the  young  barber  surgeon  determined  to  go  to  Pans 
in  order  to  further  perfect  himself  in  surgery.  He  served 
three  years  at  the  H6tel  Dieu  as  a  house  surgeon,  and  was 
appointed  a  military  surgeon  at  the  age  of  twenty-seven,  in 
which  capacity  he  rapidly  rose  to  the  highest  rank  in  the 
French  army.  It  was  in  this  service  that  he  so  greatly  dis¬ 
tinguished  himself  as  a  close  observer  and  rational  practi¬ 
tioner.  He  rendered  special  service  to  the  profession  by 
the  re-introduction  and  popularization  of  the  ligature,  by 
discarding  the  senseless  and  barbarous  treatment  of  wounds 
with  boiling-hot  oil,  by  improving  the  hygienic  surround¬ 
ings  of  the  wounded — which  action  was,  at  this  early  day, 
based  on  the  discovery  that  the  atmosphere  of  hospitals, 
camps,  etc.,  contained  some  septic  agent  which  exerted  a 

deleterious  effect  on  open  wounds. 

He  likewise  rendered  great  and  permanent  service  to 
surgery  as  an  author,  and  these  books  still  remain  and  speak 
to  the  profession,  although  the  hand  which  penned  them 
has  long  since  returned  to  dust.  This  distinguished  sur¬ 
geon  died  in  1590,  full  of  years  and  crowned  with  honors, 
"he  grandeur  of  his  labors  has  immortalized  his  name. 
Humanity  owes  him  a  debt  which  it  can  never  repay,  and 
may  the  rising  generation  of  surgeons  imitate  his  noble  ex¬ 
ample,  and  thus  erect  a  monument  to  their  names  which  can 

never  be  destroyed  by  vandalism. 

It  may  be  observed,  in  rapidly  passing  over  the  history 
of  the  sixteenth  century,  that  certain  events  which  had  oc¬ 
curred  during  the  fifteenth  century  served  to  awaken 
thought  and  pave  the  way  for  the  rapid  progress  made  in 
the  arts  and  sciences  during  Pare’s  time.  Thus  the  dis¬ 
covery  of  printing  became  the  hand-maiden  for  the  diffusion 
of  knowledge.  The  dissection  of  the  human  subject  sup¬ 
plied  the  requisite  anatomical  knowledge  for  the  intelligent 
performance  of  surgical  operations.  The  establishment  of 
medical  schools  in  various  parts  of  Italy— particularly  those 
of  Padua  and  Bologna — afforded  an  opportunity  for  stu¬ 
dents  to  congregate  together  for  the  purpose  of  receiving  in¬ 
struction  and  stimulated  the  professors  to  greater  activity 
in  their  teachings. 

Thus  we  find  that  Montagnana,  a  professor  at  Padua,  in 
1460,  who  cultivated  anatomy,  boasted  of  having  opened 
fourteen  subjects,  a  thing  quite  remarkable  for  his  time, 
while  Leonard  Bertapaglia,  a  professor  of  surgery  at  Padua, 
published  a  commentary  on  the  fourth  book  of  Avicenna, 
which  is  characterized  for  its  classical  lore,  but  not  other¬ 
wise  above  the  barber  surgery  of  the  times,  since  his  sur¬ 
gical  theories  are  filled  with  absurdities.  Another  profes¬ 
sor  at  Padua,  Alexander  Beneditti,  is  said  to  have  contrib¬ 
uted  greatly  to  the  improvement  of  anatomy  and  surgery  in 
Italy  toward  the  end  of  the  fifteenth  centur). 

It  was  likewise  during  this  century  that  the  operation 
was  devised  for  the  replacing  of  the  nose  when  lost  by  ac- 


*  The  Unity  of  Medicine.  By  F.  Davis,  London.  Pp.  48  et  seq. 


August  2,  1890.] 


WATSON:  SURGERY, ,  ANCIENT \  MEDIEVAL,  AND  MODERN. 


121 


cident  or  disease.  This  operation  was  first  performed  by 
three  Italians — Vincent  Vianoe,  Branca,  and  Bojani.  It  was 
afterward  improved  by  Tagliacozzi.  The  treatment  of  gun¬ 
shot  wounds  in  the  sixteenth  century  was  greatly  improved 
by  Maggi  Leone,  a  professor  at  Pavia ;  Botal,  a  celebrated 
anatomist ;  Felix  Wurz,  a  German  surgeon ;  Guillemeau,  a 
pupil  of  Pare  ;  and  others.  Besides  the  anatomists  and  sur¬ 
geons  already  mentioned,  among  the  distinguished  in  the 
profession  in  this  century  there  should  be  added  the  fol¬ 
lowing  names:  Fabricius  Hildanus;  Berenger  de Carpi,  who 
dissected  more  than  one  hundred  subjects;  James  Dubois, 
who  Latinized  his  name  Sylvius,  and  was  the  master  of 
the  great  Vesalius  and  the  true  founder  of  anatomy  in 
France,  and  also  the  first  who  injected  the  blood-vessels. 
Likewise  Eustachius,  who  discovered  the  Eustachian  tube  ; 
Gabriel  Falloppius,  who  first  described  the  Falloppian  tube  ; 
Fabricius  ab  Acquapendente,  who  first  described  the  valves 
of  the  veins ;  and,  lastly,  Michael  Servetus,  who  compre¬ 
hended  the  circulation  of  the  blood  through  the  lungs ;  but 
it  was  reserved  for  Harvey  at  a  later  date  to  discover  the 
general  circulation. 

The  seventeenth  century  was  not  marked  by  any  grand 
advance  in  surgery ;  but  several  discoveries  were  made 
which  have  since  contributed  to  the  material  progress  of 
this  art  and  science.  Thus  the  discovery  of  the  general 
circulation  of  the  blood  by  William  Harvey  in  1619  has 
brought  forth  valuable  results.  Malpighi,  of  Bologna,  soon 
afterward  supplemented  Harvey’s  discovery  by  microscopic¬ 
ally  demonstrating  the  course  of  the  blood-corpuscles  in  the 
minute  blood-vessels,  and  the  communication  between  the 
veins  and  arteries.  History  informs  us  that  “  burning 
spheres,”  as  they  are  termed  by  Aristophanes,  were  sold  in 
the  shops  of  Athens  in  his  day — about  400  b.  c. 

There  is  no  evidence  that  lenses  were  employed  at  this 
early  date  for  magnifying,  at  least  otherwise  than  as  read¬ 
ing-glasses.  It  is  not  until  the  seventeenth  century  that  we 
find  powerful  magnifiers  of  glass  actually  employed  for  sci¬ 
entific  investigation.  The  names  of  Malpighi,  Lieberkuhn, 
Hooke,  Leeuwenhoek,  Swammerdam,  Lyonnet,  and  Ellis  are 
closely  connected  with  the  history  of  the  simple  micro¬ 
scope. 

The  use  of  this  instrument  has  proved  to  be  a  most  pow¬ 
erful  adjuvant  for  the  advancement  of  surgery,  since  it  en¬ 
ables  us  to  study  the  minute  tissues  of  the  body,  and  thus 

understand  the  nature  and  difference  between  histological 

© 

and  pathological  elements.  During  this  century  there  was 
considerable  progress  made  in  the  study  of  anatomy,  and 
among  the  names  which  were  made  illustrious  by  these  re¬ 
searches  in  the  anatomical  field  may  be  mentioned  that  of 
Schneider,  a  German  anatomist  and  writer,  whose  name  is 
associated  with  the  mucous  lining  of  the  nose;  Francis  Glis- 
son,  memorable  for  his  researches  on  the  anatomy  of  the 
liver;  Peyer,  who  studied  carefully  the  glands  of  the  intes¬ 
tines  ;  Meibomius,  who  studied  the  anatomy  of  the  eyelids  ; 
Thomas  Willis,  who  studied  the  anatomy  of  the  brain  ; 
while  Stenson  and  Wharton  studied  the  anatomy  of  the 
glandular  system. 

Surgery  made  little  progress  during  this  century,  owing 
principally  to  the  fact  that  it  had  not  yet  been  taken  from 


the  hands  of  the  barber  surgeons  and  elevated  to  the  stand¬ 
ard  which  it  now  holds  among  the  professions.  England, 
however,  produced  during  this  period  some  surgeons  whose 
names  are  worthy  of  mention,  although  they  are  scarcely 
entitled  to  be  considered  illustrious.  Among  these  were  Rich¬ 
ard  W  iseman,  author  of  a  book  on  surgery,  and  James 
Young,  an  English  surgeon  of  Plymouth,  a  contemporary 
of  Wiseman,  who  published  a  treatise  on  several  surgical 
subjects  at  London  in  the  year  1679. 

The  eighteenth  century  was  not  characterized  by  any  re¬ 
markable  progress  in  surgery,  although  the  tendency  was  in 
the  right  direction.  There  was,  in  fact,  some  marked  im¬ 
provement  made  in  the  treatment  of  gunshot  wounds.  (The 
discovery  of  gunpowder  and  the  use  of  firearms  in  war 
marked  a  new  period  in  military  surgery  ;  but  the  date  of 
this  innovation  has  never  been  satisfactorily  settled.  It  is, 
however,  fully  established  that  it  was  employed  in  the  early 
part  of  the  Christian  era.  The  soldiers  were  horrified  at 
the  enormous  increase  in  the  mortality  attending  a  battle, 
while  the  surgeons  were  unable,  in  their  ignorance  of  scien¬ 
tific  wound  treatment,  to  render  any  important  service. 
Under  these  circumstances  the  wounds  were  soon  declared 
to  be  poisoned  with  the  gunpowder  and  ball,  and  the  sur¬ 
geons  and  soldiers  united  in  thinking  that  this  mighty 
agent  was  the  power  of  hell  and  had  been  invented  by  the 
devil.)  The  old  and  cruel  treatment  which  had  been-dn- 
troduced  by  John  de  Vigo  and  others,  based  on  the  sup¬ 
position  that  every  gunshot  wound  contained  a  poisonous 
substance,  even  in  its  primary  condition,  and  therefore  must 
be  treated  by  pouring  boiling  hot  oil  into  it,  was  entirely 
abandoned. 

The  cumbrous  dressings  which  had  been  previously  in 
vogue  were  entirely  superseded  and  more  rational  means 
were  employed  in  the  treatment  of  wounds.  The  numerous 
European  wars  of  this  century  gave  an  abundant  oppor¬ 
tunity  for  the  study  of  gunshot  wounds.  “  The  degrading 
association  of  the  barbers  and  surgeons  was  abolished  in 
1743  at  Paris  by  an  edict  breaking  the  legal  fetters  which 
had  for  so  many  years  bound  together  the  surgeons  of  St. 
Cosine  and  the  barbers,  and  the  example  was  speedily  fol¬ 
lowed  in  1745  by  a  similar  act  of  the  English  Parliament. 
Freed  from  this  galling  servitude,  surgery  became  a  sepa¬ 
rate  and  distinct  branch,  to  be  ever  afterward  studied  and 
cultivated  by  educated  members  of  the  profession.”  Prior 
to  this  date  surgery  had  not  been  taught  in  the  medical 
schools  during  the  Christian  era ;  but  in  this  century  sur¬ 
gical  professors  were  appointed  in  Holland  and  Germany. 
The  study  of  anatomy,  which  had  made  very  rapid  progress 
during  the  two  preceding  centuries,  still  continued  to  en¬ 
gage  the  attention  of  anatomists  in  every  part  of  Europe. 
Duverney,  during  the  latter  part  of  the  seventeenth  century, 
had  established  the  identity  of  the  chyliferous  and  lym¬ 
phatic  vessels,  Pacchioni  had  discovered  the  lymphatic  glands 
of  the  dura  mater,  and  Cowper  the  two  glands  which  have 
since  borne  his  name. 

It  was  during  this  century  that  anatomists  studied  care¬ 
fully  the  anatomy  of  the  brain,  nerves,  eye,  and  ear.  Pac¬ 
chioni  and  Baglivi  gave  their  attention  to  the  brain,  but  the 
result  was  entirely  negative.  Turin  Le  Cat  and  Meckel 


122 


WATSON:  SURGERY,  ANCIENT,  MEDIEVAL,  ANN  MODERN. 


[N.  Y.  Med.  Jour., 


studied  the  cranial  nerves  with  satisfactory  results*  “  It 
had  already  been  established  in  the  seventeenth  century 
that  the  seat  of  cataract  was  the  crystalline  lens,  and  Mor¬ 
gagni  now  described  the  humor  in  the  midst  of  which  it  was 
nourished.  Experiments  were  also  made  by  Petit  in  regard 
to  the  nerves  of  the  eye,  the  effect  of  age  in  producing 
changes  in  the  organ,  etc. ;  and  Albinus  and  Haller  each 
professed  to  have  discovered  the  pupillary  membrane.  The 
two  anatomists,  however,  who  accomplished  most  at  this 
time  in  perfecting  the  study  of  the  anatomy  of  the  eye  were 
Porterfield,  of  Edinburgh,  and  Zinn,  of  Gottingen,  each  of 
whom  ascribed  important  functions  to  the  ciliary  process. 
The  structure  of  the  membrana  tympani  and  the  distribu¬ 
tion  of  the  auditory  nerve  had  been  accurately  studied  a 
few  years  before  the  commencement  of  the  eighteenth  cent¬ 
ury  ;  but  Valsalva  now  described  much  more  precisely  the 
minute  portions  of  the  ear,  and  of  the  labyrinth  especially, 
the  use  of  the  fluid  of  which  was  afterward  discovered  by 
Cotunnius  and  Meckel.”  f 

Important  results  were  obtained  during  this  century,  by 
the  study  of  the  lymphatics,  by  Cruikshank,  Hewsen,  Paul 
Mascagni,  and  William  and  John  Hunter.  The  study  of 
pathological  anatomy  now  commenced  in  all  the  European 
countries,  with  which  the  name  of  John  Baptiste  Morgagni 
is  still  intimately  connected,  having  been  perpetuated  by  the 
woik  which  he  prepared  on  this  subject.  The  surgeons 
of  the  eighteenth  century  whose  names  have  been  handed 
down  to  "us  were  the  following:  John  Hunter,  Jean  Louis 
Petit,  Laurence  Heister,  Percival  Pott,  Pierre  Joseph  De¬ 
sault,  William  Cheselden,  Sir  James  Earle,  Henry  Francis 
Le  Dran,  and  Chopart.  The  first  named  in  this  distin¬ 
guished  galaxy  of  illustrious  men  was  unquestionably  the 
most  distinguished  anatomist  and  surgical  pathologist  of 
his  era.  He  was  born  of  Scotch  parents  in  1728,  and  died 
in  1793.  Poverty,  ignorance,  energy,  an  indomitable  will¬ 
power,  and  a  robust  constitution  were  his  inheritance.  His 
father  had  died  when  young  Hunter  was  only  two  years  old, 
and  his  mother,  although  a  strong-minded  woman,  had 
failed  to  exercise  much  influence  over  him.  lie  went  to 
London  when  about  twenty  years  of  age,  where  his  elder 
brother,  William,  had  been  living  some  time.  At  that  time 
Dr.  William  was  doing  a  large  and  lucrative  practice  and 
rapidly  gaining  in  reputation.  The  meeting  between  the 
brothers  was  cordial,  and  John  was  given  the  position  of 
assistant  in  William’s  anatomical  rooms,  which  were  then 
in  their  infancy,  but  rapidly  growing  in  favor  on  account  ot 
the  educational  advantages  which  they  offered  to  students. 
The  high  position  which  Dr.  W  illiam  Hunter  had  already 
attained  in  the  great  metropolis  stimulated  his  brother  John 
to  put  forth  all  his  latent  or  undeveloped  energies,  in  order 
that  he  too  might  at  some  future  time  become  a  power 
among  men.  Ignorant  and  poor  as  he  was  at  that  time, 
the  indomitable  will-power,  supported  by  energy  and  a 
robust  constitution,  absolutely  settled  the  question  in  favor 
of  success,  since  with  such  persons  “  to  will  ”  is  to  do.  He 
pressed  forward,  soon  acquired  a  thorough  knowledge  of 


anatomy,  and  acted  as  his  brother’s  prosector  for  his  ana¬ 
tomical  lectures.  He  spent  the  summer  of  1749  at  the 
Chelsea  Hospital,  under  the  instruction  of  the  celebrated 
Cheselden,  who  was  then  nearing  his  grave;  and  m  1751 
be  became  a  pupil  at  St.  Bartholomew’s,  where  he  received 
instruction  from  the  renowned  Percival  Pott,  another  lumi¬ 
nary  of  British  surgery. 

It  was  at  this  time  the  desire  of  his  brother  W  illiam 
that  John  should  become  a  physician  rather  than  a  surgeon. 
With  this  objective  view,  John  was  persuaded  by  William 
and  other  friends  to  enter  as  a  student  St.  Mary’s  Hall,  Ox¬ 
ford,  in  1753.  He  remained  there  but  a  short  time,  having 
now  full v  determined  that  he  would  spend  no  more  time  in 
the  study  of  Latin  and  Greek*  He  looked  upon  such  stud¬ 
ies  as  a  waste  of  time  ;  and,  in  referring  to  the  subject  some 
years  afterward,  he  thus  feelingly  expressed  himself:  “  They 
wanted,”  he  said,  “to  make  an  old  woman  of  me,  or  that  I 
should  stuff  Latin  and  Greek  at  the  university  ;  but,”  added 
he,  significantly  pressing  his  thumb-nail  on  the  table,  “these 
schemes  I  cracked  like  so  many  vermin  as  they  came  before 
me.”  One  can  not  but  regret  that  Hunter  did  not  carry 
out  the  wishes  of  his  friends.  A  little  “  stuffing  ”  of  Latin 
and  Greek  would  have  been  of  vast  benefit  to  him  in  pre¬ 
venting  those  errors  of  style  and  literary  composition  which 
so  greatly  disfigure  and  obscure  his  writings. 

Hunter  once  more  returned  to  his  surgical  studies,  and 
we  find  him  at  St.  George’s  Hospital  in  1754,  where  two 
years  later  he  was  appointed  a  house  surgeon.  He,  how¬ 
ever,  occupied  this  position  only  for  a  brief  period,  when, 
having  received  an  appointment  as  staff  surgeon,  he  went 
with  the  army  to  Belleisle,  an  island  off  the  western  coast 
of  France,  while  the  following  year  he  participated  with 
the  English  army  in  the  Peninsular  war.  He  returned 
in  1763  to  London  and  resumed  the  practice  of  sur¬ 
gery,  having  profited  greatly  by  his  extensive  military  ex¬ 
perience. 

He  added  steadily  from  this  date  new  laurels  to  those 
which  he  already  possessed,  gained  in  reputation  and  power, 
and  soon  after  became  recognized  as  the  greatest  surgeon 
of  his  age.  His  surgical  writings  show  him  to  have  been 
possessed  of  considerable  originality  and  most  excellent 
powers  of  observation.  He  wrote  a  Treatise  on  Venereal 
Disease,  and  likewise  a  Treatise  on  the  Blood,  Inflamma¬ 
tion,  and  Gunshot  Wounds.  The  former  work  contains 
such  a  clear  and  accurate  description  of  the  primary  lesion 
of  syphilis  that  it  has  since  continued  to  be  known  as  the 
true  or  Hunterian  chancre. 

The  most  distinguished  surgeon  of  France  in  the  eight¬ 
eenth  century  was  Jean  Louis  Petit,  the  inventor  of  the 
screw  tourniquet,  still  in  common  use.  He  wrote  the  first 
Treatise  on  Diseases  of  the  Bones ,  which  was  soon  translated 
into  several  languages.  Another  French  surgeon,  Pierre 
Joseph  Desault,  who  lived  during  the  latter  part  of  this 
century,  did  much  for  surgery.  He  invented  many  surgical 
instruments  and  appliances,  some  of  which  are  still  used 
and  continue  to  bear  his  name.  It  is  likewise  claimed  that 

*  John  Hunter  and  his  Pupils.  By  S.  D.  Gross.  M.  D.,  LL.  D.,  D.  C.  L. 


*  History  of  Medicine ,  by  Dunglison,  p.  262. 
f  Ibid.,  p.  262. 


Oxon.,  LL.  D.  Cantab.,  pp.  14  et  seq.  Philadelphia  :  Presley  Blakiston, 
1881. 


August  2,  1890.] 


WATSON:  SURGERY, \  ANCIENT \  MEDIAEVAL,  AND  MODERN. 


123 


he  was  the  first  to  give  a  systematic  course  of  lectures  on 
surgical  anatomy,  and  clinical  lectures  on  general  surgery. 

A  General  System  of  Surgery,  written  by  Laurence 
Heister,  who  was  born  at  Frankfort-on-the-Main  in  1683 
and  died  in  1758,  has  rendered  his  name  illustrious  and  kept 
it  from  perishing  to  the  present  time.  He  gained  the  repu¬ 
tation  of  being  an  accomplished  army  surgeon  during  the 
war  between  the  French  and  the  Dutch  in  Flanders,  which 
lasted  from  1707  to  1709.  This  work  on  general  surgery 
was  handsomely  illustrated  and  published  in  several  lan¬ 
guages. 

The  distinguished  English  surgeon  and  author,  Percival 
Pott,  who  was  born  in  1713  and  died  in  1788,  gave  us 
some  of  the  most  valuable  contributions  ever  made  to  sur¬ 
gical  pathology  and  practice. 

His  Chirurgical  Works  are  contained  in  three  handsome 
octavos.  His  classical  and  vivid  description  of  caries  of 
the  vertebrae  and  spinal  curvature  caused  his  name  to  be 
affixed  to  this  morbid  condition.  Pott’s  disease  <5f  the  spine 
can  never  be  forgotten  while  the  English  language  is  spoken 
or  read. 

We  have  traced  our  noble  profession  from  the  dim 
mythological  ages,  when  the  gods  alone  were  supposed  to 
possess  the  power  of  healing  the  wounded,  down  through 
the  pagan  civilization  to  the  formation  of  the  Alexandrian 
school,  which,  one  hundred  years  before  the  birth  of  Christ, 
shed  a  grand  meteoric  light  over  the  world,  the  true  efful¬ 
gence  of  a  grand  science ;  have  followed  it  through  the 
dark  ages,  when  it  struggled  fiercely  against  the  igno¬ 
rance,  greed,  and  fanaticism  of  the  “  Faith  Curists,”  and 
likewise  against  the  wicked  superstitions  of  a  belligerent 
and  benighted  populace  ;  have  pointed  out  the  beacon  lights 
which  were  erected  by  our  confreres  in  mediaeval  times,  and 
have  now  reached  the  commencement  of  the  nineteenth 
century,  the  brightest  period  which  has  ever  had  an  ex¬ 
istence  since  the  world  was  created.  We  stand  in  the  posi¬ 
tion  of  a  traveler  who  has  wandered  through  the  virgin 
forests,  beheld  the  grandeur  of  an  ancient  Oriental  city, 
traversed  the  quagmires  of  a  dark  and  dismal  swamp, 
emerged  into  a  rural  and  sparsely  settled  district,  where  he 
beheld  an  occasional  flickering  light ;  but,  pressing  forward, 
he  now  stands  within  the  suburbs  of  a  great  metropolis, 
where  he  beholds,  by  the  aid  of  the  brilliant  electric 
lights,  the  grandest  structures  erected  by  modern  civiliza¬ 
tion. 

Would  that  I  possessed  the  power  of  a  Homer,  Virgil, 
or  Milton,  that  I  might  immortalize  these  men  who  have 
made  surgery  wrhat  it  is  in  1890 ;  but,  alas  !  I  have  neither 
the  power  or  space  in  which  to  do  justice  to  the  many 
grand  heroes  of  the  present  age,  and  must  therefore  content 
myself  by  merely  mentioning  the  names  of  a  few  who  have 
been  the  pioneers  in  the  grandest  work  the  world  has  ever 
known.  The  names  Dupuytren,  Roux,  Lisfranc,  Velpeau, 
and  Nelaton,  of  France;  Abernethy,  Cooper,  Brodie,  Fer- 
gusson,  and  Laurence,  of  England  ;  Colles  and  Hamilton,  of 
Ireland;  Bell,  Syme,  Liston,  and  Simpson,  of  Scotland; 
Graefe  and  Rust,  of  Germany  ;  Scarpa  and  Porta,  of  Italy  ; 
Pbysick,  Mutter,  Pancoast,  S.  D.  and  S.  M.  Gross,  of  Phila¬ 
delphia ;  Wright  Post,  Kissam,  Rodgers,  Watson,  Stevens, 


Mott,  Van  Buren,  Parker,  Sands,  Wood,  Little,  Carnochan, 
A.  C.  Post,  and  Sims,  of  New  York ;  Nathan  Smith,  of  New 
Haven ;  the  Warrens  and  Hayward,  of  Boston  ;  N.  R. 
Smith,  of  Baltimore;  Warren  Stone,  of  New  Orleans;  Dud¬ 
ley,  of  Lexington;  Brainard,  of  Chicago;  Eve,  of  Nashville; 
Hodgen,  of  St.  Louis;  and  James  Cabell,  of  Virginia,  are 
now  numbered  with  the  noble  dead,  while  there  yet  remain 
with  us  some  of  the  grandest,  noblest  pioneers,  and  most 
distinguished  surgeons  the  world  has  ever  known.  I  can 
not,  therefore,  do  justice  to  the  surgical  progress  of  this 
century  without  mentioning  these  names.  Among  this  long 
list  of  distinguished  names  I  can  not  refrain  from  mention¬ 
ing  some  of  our  European  confreres,  although  I  shall  enter 
more  fully  on  the  work  done  by  Americans,  since  we  all 
naturally  feel  an  especial  interest  in  our  countrymen.  Ger¬ 
many  has  produced  during  this  century  some  of  the  most 
distinguished  surgeons  the  world  has  ever  known,  and  among 
those  names  already  immortal  are  Virchow',  who  has  given 
us  the  best  work  on  Cellular  Pathology  ;  Billroth,  the  best 
on  Surgical  Pathology  ;  and  Esmarch,  the  best  Hand-book 
on  Military  Surgery.  However,  the  fame  of  Billroth  and 
Esmarch  does  not  by  any  means  entirely  rest  on  these  valua¬ 
ble  publications,  since  the  boldness  and  originality  of  their 
surgical  procedures  have  likewise  electrified  the  world. 

The  commencement  of  this  century  found  America 
without  any  really  distinguished  surgeon,  without  a  surgical 
literature  of  her  own,  and  without  colleges  in  which  to  edu¬ 
cate  her  own  students.  She  was  at  this  period  almost  en¬ 
tirely  dependent  on  Great  Britain  for  the  education  of  her 
sons  in  medicine,  and  our  medical  literature  was  likewise 
principally  obtained  from  the  same  source.  It  is  likewise 
true  that  in  no  part  of  the  civilized  world  had  surgery 
reached  a  high  degree  of  perfection,  but  America  had  just 
emerged  from  a  long  revolutionary  struggle  and  started 
forth  among  the  independent  nations — she  was  now  com¬ 
pelled  to  provide  for  her  own  wants.  This  fact  undoubtedly 
prompted  her  to  put  forth  her  best  efforts.  The  trying  or¬ 
deals  through  which  the  colonies  had  passed  in  their  long 
and  murderous  wars  with  the  Indians,  followed  by  the  revo¬ 
lutionary  struggle  of  seven  years  war  with  England,  had 
produced  a  bold  and  hardy  race  of  pioneers,  who  were  pre¬ 
pared  to  attempt  anything  which  offered  even  the  slightest 
chance  of  success.  The  women  possessed  fortitude  and 
courage,  and  were  prepared  to  suffer  pain,  if  it  only  offered 
an  adequate  reward.  It  is  not  therefore  surprising  that  in 
the  autumn  of  1809  Mrs.  Crawford,  who  was  suffering  from 
an  ovarian  tumor,  approached  the  unpretentious  house  of 
Dr.  Ephraim  McDowell,  at  Danville,  Ky.,  and  there  sub¬ 
mitted  to  an  ovariotomy — the  first  operation  of  this  kind 
ever  performed ,  but  an  operative  procedure  which  lias  al¬ 
ready  been  repeated  many  thousand  times  with  the  most 
happy  results.  Mrs.  Crawford  recovered  and  lived  many 
years  in  the  full  enjoyment  of  health  and  with  entire  free¬ 
dom  from  pain.  This  operation  was  subsequently  repeated 
several  times  by  Dr.  McDowell,  who,  we  are  informed,  saved 
the  lives  of  eleven  patients  out  of  thirteen.  Thus  began  an 
operation  which  has  added  thousands  of  years  to  the  lives  of 
civilized  women,  and  saved  them  from  untold  misery.  Mc¬ 
Dowell,  however,  did  not  escape  the  sad  fate  which  awaits 


124  WATSON:  SURGERY ,  AAC7AAT,  MEDIAEVAL,  AND  MODERN.  [N.  Y.  Med.  Jodr., 

every  bold  innovator  in  science.  His  fate  in  this  respect  was  |  the  use  of  this  agent.  It  enabled  the  scientific  investigator 

no  better  than  that  of  the  immortal  Jenner,  who  was  assailed  I  to  go  forward  with  his  vivisections  without  giving  pain. 

by  his  own  professional  brethren,  the  ministers  of  the  gos-  It  likewise  in  this  case  greatly  increased  the  field  of  labor, 
pel,  and  the  public  press.  Poor  McDowell  carefully  pre-  and  added  at  least  fourfold  to  the  previous  value  of  these 
pared  a  report  of  this  operation  for  publication  in  a  medical  investigations.  Brain  surgery,  abdominal  surgery,  and  gy- 
iournal  which  was  edited  by  a  personal  friend  and  pro-  naecology,  which  are  essentially  new  departments  in  the 
fessional  brother,  carried  it  to  him  with  his  own  hands,  and  surgical  field,  could  have  never  had  an  existence  without 
requested  this  now  unknown  distinguished  functionary  to  modern  anaesthetics.  The  experimental  work  required  in 
publish  the  same.  The  manuscript  was  in  due  time  re-  these  departments  could  not  have  been  done  without  their 
turned  to  the  immortal  McDowell,  to  whom  it  was  sug-  use. 

gested  in  a  very  friendly  way  that  he  ought  never  again  to  Most  of  these  operative  procedures  are  also  absolutely 
attempt  the  performance  of  this  barbarous  operation,  the  impracticable  without  the  same.  The  most  brilliant  prog- 
which  had  not  even  been  recommended  by  the  most  distin-  ress  in  surgery  the  world  has  ever  known  has  been  made 
guished  surgeons  of  the  world.  It  was  likewise  added  by  since  the  discovery  of  modern  anaesthetics.  This  wonder- 
this  friend  and  distinguished  editor  that  the  “publication  of  ful  progress  has  been  so  marked  ns  to  attract  the  attention 
your  report  of  this  case  would  endanger  the  safety  of  my  of  the  laity.  Says  Dr.  W.  W.  Keen :  “  This  progress  is 
journal  and  be  ridiculed  by  the  entire  profession.”  This  due  chiefly  to  two  things— the  introduction  of  antiseptic 
rebuff  probably  deterred  him  for  a  time  from  making  any  methods,  and  to  what  we  have  learned  from  laboratory  wor 
further  attempts  at  publication,  since  the  earliest  publica-  and  experiments  on  animals.” 

tion  made  by  him  on  this  subject  was  in  1817.  The  per-  It  therefore  appears  that,  at  the  beginning  of  this  cent- 
formance  of  this  operation  was  at  first  ridiculed  in  England,  ury,  only  two  things  were  required  to  bring  surgery  to  the 
but  soon  afterward  he  was  given  full  credit  for  the  same,  highest  possible  standard.  An  anaesthetic  was  needed  t  at 
Thus  time  rights  these  grievous  wrongs  and  genius  re-  the  necessary  experimental  studies  might  be  made  on  ani- 
ceives  its  just  reward.  "  ^  mals;  furthermore,  that  all  surgical  operations  might  be 

It  was  not  until  near  the  middle  of  the  nineteenth  cent-  carefully  and  properly  performed  ;  while  the  antiseptic 

ury  that  the  grandest  achievement  recorded  in  all  history  method  of  wound  treatment  was  required  for  the  banish- 

was  consummated  by  the  discovery  of  a  potent  and,  at  the  ment  of  all  septic  complications.  It  must  be  now  umver- 

same  time,  comparatively  safe  anaesthetic,  which  enabled  sally  admitted  by  every  careful  student  of  surgery  that  the 
surgeons  to  say  to  the  most  horrible  agonies  attendant  on  introduction  of  the  aseptic  method  of  wound  treatment 

the  performance  of  surgical  operations  “  Begone !  ”  when  marks  an  era  in  surgical  progress  only  second  to  that  de- 

his  words  were  promptly  followed  by  a  deep  sleep,  as  if  pendent  on  the  use  of  anaesthesia. 

uttered  by  Jehovah  himself,  and  the  same  condition  con-  The  world  is  indebted  to  Sir  Joseph  Lister,  of  London, 
tinued  at  the  will  of  the  operator  until  the  operation  was  who  primarily  perfected  and  popularized  this  method  of 
completed.  wound  treatment.  He  has  been  far  more  successful  than 

The  patient  is  then  called  back  to  life — a  performance  the  majority  of  innovators,  since  he  has  lived  to  see  the 
which  approximates  even,  in  the  grandeur  of  its  power,  the  value  of  his  labors  universally  acknowledged  by  the  pnn- 
miraculous  raising  of  the  dead.  No  discovery  ever  made  cipal  surgeons  in  every  part  of  the  world.  The  marvelous 

in  the  arts  or  sciences  possesses  a  value  which  can  in  any  feats  performed  in  brain  surgery,  relating  to  the  removal  of 

way  be  compared  with  that  of  chloroform  and  ether.  It  is  tumors  alone,  is  thus  stated  by  Dr.  Keen:  “Now,  there 
the  priceless  gem  to  suffering  humanity.  What  would  not  have  been  twenty  tumors  removed  from  the  brain,  of  which 
a  rational  man  pay  for  the  relief  which  these  agents  afford  seventeen  have  been  removed  from  the  cerebrum,  with  thir- 
during  the  performance  of  a  painful  surgical  operation  ?  teen  recoveries,  and  three  from  the  more  dangerous  part  of 
The  king  would  surrender  his  realm  if  this  priceless  boon  the  cerebellum,  all  of  which  proved  fatal.  Until  this  re- 
could  not  be  obtained  for  a  less  consideration  under  such  cent  innovation  every  case  of  tumor  of  the  brain  was  abso- 
circumstances,  and  the  miser  would  give  up  his  life-long  lutely  hopeless.” 

hoardings  for  it.  Let,  therefore,  the  names  of  Morton  and  These  successes  in  brain  surgery  have  been  made  pos- 
Simpson  go  down  to  future  generations  as  the  greatest  dis-  sible  principally  by  the  experimental  studies  of  Ferner  and 
coverers  known  in  the  world’s  history.  Their  services  to  Horsley,  of  England;  Fntsch,  Hertzig,  and  Goltz,  of  Ger- 
humanity  are  far  more  valuable  than  those  of  any  other  many.  In  another  part  of  this  paper  we  have  mentioned 
discoverers,  inventors,  or  heroes  who  have  lived  in  any  age.  the  fact  that  the  first  ovariotomy  was  performed  in  1809; 

Priority  in  this  grand  work  belongs  to  America,  since  but  only  thirty -five  years  ago  the  abdomen  was  really  a 
Morton  discovered  and  popularized  the  use  of  sulphuric  ether  closed  cavity,  and  the  entrance  of  the  same  was  even  then 
as  an  anaesthetic  in  1846,  while  Dr.  Simpson  did  the  same  practically  tabooed  by  every  prudent  surgeon.  Accidental 
for  chloroform  in  1847.  The  use  of  these  agents  during  wounds  of  this  cavity,  with  very  few  exceptions,  terminated 
the  performance  of  surgical  operations  marks  the  commence-  fatally.  Dr.  Keen,  in  speaking  of  the  success  of  operative 
ment  of  the  grandest  epoch  in  surgery.  The  anaesthetic  |  procedures  on  this  cavity,  says:*  “Mr.  Tait  has  completed 
enabled  the  surgeon  to  perfect  and  make  successful  the  old  - - - - 

operations,  while  it  opened  the  field  for  the  performance  of  *  pr.  Keen  in  Harper's  New  Monthly  Magazine ,  October,  1889,  pp. 
•  new  ones,  which  could  never  have  been  undertaken  without  |  703  et  seq. 


August  2,  1890.] 


WATSON:  SURGERY,  ANCIENT,  MEDIAEVAL,  AND  MODERN. 


125 


a  second  series  of  one  thousand  cases  in  which  he  opened 
the  abdomen  for  the  removal  of  tumors,  for  abscesses,  for 
explorations,  etc.  In  his  first  thousand  cases  only  ninety- 
two  patients  died  (9‘2  per  cent.),  and  in  the  second  thou¬ 
sand  only  fifty-three  died  (5-3  per  cent..). 

“In  ovariotomy  alone  the  percentage  fell  from  8T  in 
the  first  thousand  to  3‘3  in  the  second.  Only  a  quarter  of 
a  century  ago  the  mortality  of  ovariotomy  was  but  little  if 
at  all  under  50  per  centum.  .  .  . 

“Spencer  Wells,  even  with  the  far  larger  mortality  of 
his  earlier  days,  added  twenty  thousand  years  to  human  life 
as  the  net  result  of  one  thousand  ovariotomies.” 

How  changed  the  condition  to-day  in  regard  to  this 
cavity,  since  not  a  single  organ  within  it  is  any  longer  ex¬ 
empt  from  the  work  performed  by  the  surgeon’s  knife  !  The 
uterus  is  now  frequently  successfully  extirpated,  gunshot 
and  stab  wounds  of  the  intestines  are  sutured,  etc.  In  this 
cavity  American  surgery  has  led  the  way,  and  to  Americans 
surely  belong  the  highest  honors.  The  first  case  of  abdomi¬ 
nal  section  for  traumatism  was  that  of  Dr.  Walters,  of  Pitts¬ 
burgh,  Pa.,  for  ruptured  bladder,  in  1862.  The  first  case  for 
gunshot  wound  of  the  intestine  was  that  of  Dr.  R.  A.  Kin- 
loch,  of  Charleston,  S.  C.,  in  1863.  “  The  elder  Gross  long 

since  led  the  way  by  his  experiments  on  dogs,  but  we  owe 
our  present  boldness  and  success  chiefly  to  the  experiments 
of  Parkes,  Bull,  and  Senn — all  Americans — who  have  first 
shown  in  animals  that  it  was  safe  and  right,  with  antiseptic 
methods,  to  interfere  actively  for  the  health  and  healing  or 
our  patients.” 

In  the  department  of  gynaecology  the  highest  honors  ever 
won  justly  belong  to  Dr.  J.  Marion  Sims,  of  New  York,  who 
finally  succeeded,  after  many  years  of  patient  and  industrious 
experimentation,  in  discovering  a  method  by  which  he  was 
enabled  to  certainly  and  effectually  cure  both  vesico-vaginal 
and  recto-vaginal  fistulae.  Dr.  George  J.  Fisher  says  of  this 
great  surgeon,  who  has  certainly  immortalized  his  name  by 
his  labors,*  that  “  every  now  and  then  the  world  is  amazed 
by  the  appearance  of  a  genius  who,  in  a  few  short  years, 
does  the  work  which  all  previous  centuries  had  failed  to  do, 
teaches  his  lessons  well,  becomes  immortal,  and  flits  away. 
It  is  impossible  to  speak  too  highly  of  such  a  one  who  has 
just  departed.  Gynaecology  scarcely  had  an  existence  previ¬ 
ous  to  the  commencement  of  J.  Marion  Sims’s  brilliant  and 
successful  operations  for  vesico-vaginal  fistulae.  There  is 
nothing  in  the  whole  domain  of  surgery  at  all  comparable 
with  this  man’s  contributions  to  gynaecology.  He  taught 
how  to  effect  the  absolute  and  permanent  cure  of  the  most 
distressing  and  loathsome  condition  of  woman  which  it  is 
possible  to  imagine,  resulting  from  the  injuries  and  lacera¬ 
tions  incident  to  difficult  childbirth,  a  condition  which  the 
most  skillful  surgeons  had  up  to  that  time  utterly  failed 
even  to  ameliorate.  Frankly  and  freely,  and  without  remu¬ 
neration,  to  go  forth  to  all  the  principal  civilized  nations  of 
the  earth,  personally  and  unreservedly  to  teach  the  surgeons 
of  the  world  all  his  methods,  and  to  establish  model  hos¬ 
pitals  for  the  benefit  of  multitudes  of  afflicted  women,  fur¬ 
nished  an  example  of  broad  and  generous  humanity,  and  of 

*  International  Encyclopaedia  of  Surgery,  vol.  vi,  p.  1201. 


unselfishness,  to  which  the  world  had  been  before  a 
stranger. 

“Dr.  Sims  well  merited  all  the  appreciation,  admiration, 
and  glory  which  were  rather  tardily  bestowed  upon  him. 
In  future  the  civilized  world  will  never  cease  to  express  its 
unlimited  gratitude  for  his  eminent  services,  and  this  will 
be  repeated  age  after  age  as  long  as  the  primaeval  curse  shall 
rest  upon  woman,  artd  until  she  shall  enter  upon  a  millennium 
when  sickness  and  disease  shall  be  no  more.” 

The  present  high  standard  of  orthopaedic  surgery  is  due 
very  largely  to  the  efforts  of  an  American  surgeon,  who,  by 
his  energy  and  mechanical  skill,  brought  about  a  reforma¬ 
tion  in  the  treatment  of  these  morbid  conditions  which  has 
yielded  the  most  satisfactory  results  in  these  cases.  Pro¬ 
fessor  Lewis  A.  Sayre,  of  New  York,  has  won  the  highest 
laurels  in  this  department  of  surgery,  and  may  be  properly 
regarded  as  the  father  of  the  present  method  of  treatment 
of  these  cases.  Dr.  Bigelow,  of  Boston,  Mass.,  has  intro¬ 
duced  and  popularized  a  method  of  rapid  lithotrity  which 
has  attracted  much  attention  in  professional  circles,  and 
been  accepted  as  a  marked  improvement  over  the  other 
mode  of  treatment. 

The  limits  of  this  paper  forbid  that  more  time  should  be 
occupied  in  bringing  forward  the  grand  achievements  of  a 
noble  profession.  Let  the  aspirant  for  honors  in  this  field 
remember  that  he  who  enters  here,  with  the  full  determina¬ 
tion  of  gaining  honest  laurels,  must  possess  all  the  qualities 
of  mind  and  body  which  would  secure  fame  for  him  on  the 
field  of  battle.  The  battle  for  honest  fame  is  always  a  des¬ 
perate  struggle  ;  many  must  fall  by  the  wayside  and  be  car¬ 
ried  to  the  rear  fainting  and  disappointed ;  some  of  these 
will  so  far  recover  that  they  may,  after  a  while,  return  to 
the  front  to  again  renew  their  struggle,  while  others  will  be 
buried  in  unknown  graves,  unhonored  and  unwept. 

The  moment  an  aspirant  enters  a  gladiatorial  contest  for 
fame  he  will  hear  the  jeers  of  the  populace,  will  be  con¬ 
fronted  by  his  foe,  and  will  require  the  courage  of  a  lion. 
Having  already  gained  the  victory,  he  will  then  find  that 
his  confreres ,  still  fearing  that  a  full  acknowledgment  of  the 
dearly  earned  laurels,  so  recently  won,  may  possibly  have 
an  injurious  influence  on  their  own  reputation  or  business, 
contrive  that  to  the  hero  only  fair  words  and  no  substantial 
aid  will  be  given.  Dr.  J.  Marion  Sims  must  have  fully  real¬ 
ized  the  force  of  all  these  facts  when  he  came  to  New  York, 
after  having  patiently  studied  gynaecology  for  years,  when 
he  demonstrated  to  Dr.  Valentine  Mott  and  others  the 
methods  by  which  he  was  enabled  to  heal  vesico-vaginal 
fistulae,  and  performed  several  operations  in  their  presence 
which  resulted  in  perfect  cures,  since  still  they  would  not 
consent  to  join  with  him  in  the  establishment  of  a  female 
hospital  where  he  could  have  an  opportunity  of  carrying 
forward  his  humane  work.  Poor  Sims,  in  this  moment  of 
despondency,  came  in  contact  with  a  true  friend,  a  news¬ 
paper  man,  who  said  to  him,  uYou  shall  succeed  ;  your  mis¬ 
sion  is  a  noble  one,  and  you  are  worthy  of  success.”  The 
good  Samaritan  called  a  public  meeting,  which  was  attended 
by  the  best  people  in  New  York  city,  except  physicians, 
who  were  especially  conspicuous  by  their  absence.  The 
charitable  designs  of  Sims  were  fairly  presented,  as  well  as  . 


126 


WOOD:  THE  AFTER-TREATMENT  OF  OBSTETIO  OASES. 


[N.  Y.  Med.  Jock., 


the  great  value  of  his  recent  discoveries  to  suffering  human¬ 
ity.  This  meeting  resolved  that  Dr.  Sims  should  have  an 
opportunity  to  go  forward  .with  his  noble  work.  The  fol¬ 
lowing  morning  the  newspapers  gave  a  full  report  of  the 
doings  at  this  gathering.  The  effect  of  this  report  on  the 
distinguished  surgeons  was  magical.  They  promptly  drove 
to  Dr.  Sims’s  residence  and  congratulated  him  on  his  pros¬ 
pects,  magnified  the  value  of  his  discoveries,  and  proffered 
their  assistance.  Mis  laurels  were  won  and  his  worth  was 
duly  acknowledged.  These  points  have  been  brought  forward 
to  illustrate  the  difficulties  with  which  all  great  advances 
have  to  contend.  Dr.  Sims’s  trials  and  difficulties  were  no 
greater  than  those  which  have  obstructed  progress  in  all 
former  times.  The  following  question  now  presents  itself 
for  our  consideration:  Is  fame  worth  the  effort?  We  all 
recognize  the  fact  that  Dr.  Sims  has  erected  over  his  bones 
an  imperishable  monument;  but  this  is  no  reward  for  the 
great  effort  which  he  put  forth.  However,  there  is  another 
and  far  nobler  result  which  he  has  accomplished.  His 
labors  will,  for  ages  yet  to  come,  prevent  thousands  from 
suffering  untold  agony. 

In  this  light  we  behold  him  as  the  benefactor  of  the 

<D 

whole  human  race,  entitled  to  their  sincere  homage,  and 
one  who  should  be  glorified  on  earth.  Labor  in  such  a 
field  is  the  grandest  in  which  any  human  being  can  ever  en 
gage,  while  death  in  such  a  cause  raises  a  man  almost  to  the 
level  of  the  gods.  The  old  pagan  civilization  fully  recog¬ 
nized  this  right,  and  he  who  became  distinguished  as  a 
mighty  healer  of  the  sick  was  henceforth  classed  among 
the  gods.  Let  us  so  far  imitate  this  worthy  example  as  to 
dedicate  the  temples  erected  for  the  healing  of  the  sick  and 
wounded  to  the  men  in  our  own  noble  profession  who  have 
immortalized  their  names  on  earth  by  their  untiring  efforts 
in  behalf  of  suffering  humanity.  Let  honor  be  given  to 
whom  honor  is  due.  Then  we  shall  see  hospitals  bearing 
the  names  Pare,  Hunter,  Morton,  Simpson,  McDowell,  Lis¬ 
ter,  Sims,  Gross,  etc.,  instead  of  those  of  “  faith-curing  ” 
monks  and  questionable  saints,  who  lived  in  the  dark  ages 
when  ignorance  and  superstition  won  all  the  prizes. 


#  right  a  l  Commmwatiotts. 


THE  AFTER-TREATMENT  OF  OBSTETRIC  CASES.* 
By  WILLIAM  B.  WOOD,  M.  D. 

From  series  of  observations  and  tests  which  need  not 
now  be  detailed  I  some  years  ago  became  convinced  that 
the  number  of  cases  of  confinement  in  which  the  cervix  was 
torn  was  really  much  greater  than  any  published  average. 
I  now  believe  that  slight  lacerations  at  least  occur  in  every 
confinement.  The  cases  upon  which  this  conclusion  is  based 
include  many  that  have  been  handled  by  the  best  obste¬ 
tricians  in  New  York,  than  whom,  as  a  class,  there  are  no 
better  in  the  world. 


*  Read  before  the  Section  in  Practice  of  Medicine  of  the  New  York 
Academy  of  Medicine,  May  20,  1890. 


The  reason  why  many  of  these  lacerations  are  unnoticed 
and  unrecorded  is  because  nature  so  rapidly  repairs  such 
damage  that  the  lesser  tears  are  already  healed  before  the 
usual  time  for  making  an  examination.  Even  more  con¬ 
siderable  lacerations  often  escape  detection  until  serious 
secondary  symptoms  undermine  the  woman’s  general  health 
and  send  her  to  the  specialist  to  undergo  heroic  methods 
of  repair. 

For  five  years  I  have  worked  upon  the  theory  that  if  the 
minor  lacerations,  which  are  to  be  found  immediately  after 
labor,  are  so  kindly  and  rapidly  healed,  the  more  serious 
ones  would  also  heal  if  the  wounds  could  be  kept  long 
enough  in  conditions  favorable  to  such  repair. 

Under  a  proper  system  of  treatment  not  only  will  there 
be  healing  of  fresh  lacerations,  but  long-standing  and  trou¬ 
blesome  tears  may  in  a  later  confinement  be  encouraged  to 
heal,  and  will,  as  effectively  as  if  by  an  operation,  disappear. 
The  history  of  several  of  the  many  cases  in  which  such  late 
union  has  been  successfully  accomplished  will  be  published 
later.  I  need  now  say  only  that,  under  the  system  of  treat¬ 
ment  pursued,  not  only  in  no  case  has  a  fresh  laceration 
remained  ununited,  but  lacerations  that  were  extensive  and 
of  long  standing  have,  after  being  stretched  and  freshened 
by  a  second  confinement,  come  together  in  such  healthy 
union  that  it  would  require  an  expert  to  detect  that  the 
woman  had  ever  been  pregnant. 

If  I  am  right  in  my  conclusion  as  to  the  great  number 
of  cases  in  which  lacerations  occur,  then  the  importance  of 
any  method  that  shall  obviate  permanent  injury  is  manifest. 
That  lacerations -are  more  frequent  than  w,s  once  thought 
possible  is  now  accepted  by  all  authorities  in  gynaecological 
science.  The  physician  who  declares  that  no  patient  of  his 
ever  had  a  laceration,  and  he  who  proclaims  his  thousand 
women  confined  without  a  torn  uterus,  now  receives  only 
ridicule  for  his  boasting,  while  the  rest  of  the  profession 
struggle  to  heal  the  rents  in  the  uteri  that  were  so  loudly 
declared  unlacerated. 

The  old-fashioned  argument  was  that  nature  never  would 
make  such  bungling  work  of  a  normal  function,  and  there¬ 
fore  if  the  uterus  was  torn  it  must  necessarily  be  the  fault 
of  the  accoucheur.  The  case  of  the  savage  was  also  fre¬ 
quently  brought  into  the  question,  and  her  easy  delivery 
given  as  an  evidence  of  what  nature  could  do  if  there  were 
no  medical  interference.  Now,  however,  we  know  that  the 
best  skill  can  not  prevent,  but  only  moderate  and  control, 
the  extent  of  lacerations,  and  that  the  labor  of  the  savage, 
who  steps  aside  from  the  line  of  march,  drops  her  infant, 
and  then  walks  on  with  it  in  her  arms,  has  little  more  rela¬ 
tion  to  the  labor  of  civilized  woman  than  the  dropping  of 
a  calf  or  colt.  The  fact  that  is  pertinent  to  the  present 
question,  and  which  is  quite  sufficient  to  explain  why  civil¬ 
ized  have  more  difficult  labor  than  savage  women,  is  the 
well-known  law  in  comparative  anatomy  that  as  races  ad¬ 
vance  into  higher  development  the  cranium  increases  in  size, 
while  the  pelvic  frame  as  steadily  diminishes.  With  in¬ 
creased  circumference  of  the  infant’s  head  and  diminished 
aperture  of  the  mother’s  pelvis  difficult  labor  is  the  penalty 
race  and  individual  pay  for  their  civilization. 

Any  consideration  of  the  final  outcome  of  this  state  of 


WOOD:  TIDE  AFTER-TREATMENT  OF  OBSTETRIC  CASES. 


ugust  2,  1890.] 


lings,  or  discussion  of  its  remedy,  is  apart  from  the  branch 
f  the  subject  which  we  now  have  to  consider ;  but  the  fact 
mains  as  an  indisputable  law  in  development,  and  entails 
-esent  injuries  to  child-bearing  women  which  demand  pres¬ 
et  remedies  that  shall  make  severe  surgical  operations  un- 
icessary,  or  at  least  infrequent,  and  shall  lessen  the  sum 
accumulated  evils  that  afflict  so  large  a  proportion  of 
e  women  who  have  been  mothers. 

Outside  of  lacerated  cervix,  no  other  one  cause  of  dis- 
unfort  consequent  upon  confinement  is  so  universal  ant 
istinate  as  arrested  involution.  Both  these  evils  can  be 
ade  to  yield  to  the  one  system  of  treatment  which  I  have 
lopted  as  a  regular  routine  in  all  puerperal  cases,  and 
hich  five  years  of  trial  have  convinced  me  will  give  brill- 
nt  results  in  the  hands  of  any  careful  practitioner. 

Under  favorable  and  in  uncomplicated  conditions  the 
erus  returns  to  its  normal  size  and  weight  not  sooner 
an  in  from  six  to  ten  weeks.  Dr.  Lusk  says  that  at  the 
id  of  the  second  week  after  confinement  the  average 
eight  is  three  quarters  of  a  pound,  the  length  is  five 
ches,  and  the  walls  are  barely  half  an  inch  in  thickness, 
ae  vagina  is  still  much  relaxed,  as  it  requires  three  or 
ur  weeks  for  it  to  regain  its  normal  dimensions. 

The  increased  size  and  weight  of  the  uterus,  the  re- 
xed  condition  of  the  uterine  supports,  the  flaccidity,  in- 
isticity,  and  engorgement  of  the  deeper  portions  of  the 
gina  and  the  pelvis,  according  to  the  best  authority,  exist 
the  majority  of  cases  from  six  to  twelve  weeks,  and  even 
nger  in  women  in  whom  the  intellectual  powers  have  been 
veloped  at  the  expense  of  the  physical. 

Yet  it  is  in  the  second  week,  while  the  uterus  is  of  five 
six  times  its  usual  weight,  with  the  deeper  lacerations 
11  unhealed,  that  most  women  assume  the  upright  position 
d  resume  their  active  occupations.  As  a  result,  the  uterus 
ops  low  down  or  tips  out  of  its  normal  position,  thus  by 
essure  retarding  the  return  circulation  and  putting  the 
axed  uterine  appendages  upon  a  dangerous  stretch.  The 
healed  surfaces  at  the  mouth  of  the  uterus  are  forced 
art  by  the  downward  traction,  and  the  ununited  edges  of 
3  laceration  heal  wide  apart,  leaving  the  woman  with  a 
rmanent  tear,  which  a  greater  degree  of  caution  could 
ve  prevented.  In  this  condition,  with  uterus  perma- 
ntly  over-heavy  and  over-large,  lying  crowded  low  down 
displaced,  the  tubes  swollen  and  sensitive,  sagging  down 
hind  the  uterus,  between  it  and  the  rectum,  the  woman 
i  hope  for  neither  good  health  nor  average  usefulness. 
ie  evils  that  follow  from  this  condition,  which  is  classic, 

I'  universally  recognized  by  the  profession.  They  have 
en  most  vividly  and  accurately  summed  up  by  Dr.  Em¬ 
it  in  his  work  on  Gynaecology.  I  believe  they  can  be 
aided  by  increased  care  and  prolonged  treatment  during 
d  after  the  puerperal  period. 

The  patient  should  before  confinement  be  educated  up 
a  conception  of  the  importance  of  submitting  implicitly 
the  directions  given.  Even  in  normal  conditions  of  the 
irus  the  supports  are  too  frequently  inadequate  to  hold 
it  organ  in  place.  The  human  race  has  not  yet,  in  the 
>eess  of  evolution,  perfectly  adapted  itself  to  the  upright 
itude ;  only  in  the  genu-pectoral  or  quadruped  position  | 


127 

does  the  human  uterus  have  perfect  support;  when,  there¬ 
fore,  the  puerperal  condition  overtaxes  these  already  inade¬ 
quate  supports,  they  almost  invariably  fail  to  perform  their 
natural  function. 

The  first  requisite,  therefore,  of  a  successful  treatment 
is  to  keep  the  uterus  well  up  until  involution  and  healing 
are  complete ;  otherwise  both  are  arrested 

After  confinement  the  mother  should  be  kept  in  bed  for 
four  weeks.  The  recumbent  position  should  be  strictly 
maintained  for  from  fourteen  to  twenty-one  days,  the  pa¬ 
tient  being  allowed  to  lie  upon  the  back,  faee,  or  side,  but 
never  to  assume  the  upright  posture.  At  the  end  of  twenty- 
one  days  an  examination  should  be  made  with  the  patient  in 
either  the  Sims  or  genu-pectoral  position,  great  care  being 
taken  not  to  stretch  the  perinseum. 

After  twenty-one  days,  hot  injections,  given  after  Dr. 
Emmet’s  method,  may  often  be  used  to  advantage,  but 
should  not,  in  my  opinion,  be  employed  where  there  have 
been  extensive  lacerations  which  are  still  unhealed,  as  the 
hot  water,  given  in  long  injections,  renders  more  difficult 
the  union  of  the  surfaces,  which  will  sometimes  unite,  pro¬ 
vided  the  recumbent  position  be  so  long  maintained,  as  late 
as  the  fifth  week.  If  at  the  end  of  the  fourth  week  the 
condition  of  the  cervix  is  satisfactory,  the  patient  may  safely 
be  allowed  to  get  up;  but  never  on  any  condition  without 
first  having  the  still  over-heavy  uterus  supported  by  well- 
adjusted  pads.  The  patient  is  placed  in  the  genu-pectoral 
position,  prepared  pads  of  surgeon’s  wool  dipped  in  boro- 
glycerin  are  packed  in  under  and  behind  the  uterus  to  hold 
it  in  normal  position  and  to  relieve  the  relaxed  appendages 
of  the  extra  weight.  In  from  five  to  eight  weeks  after  con¬ 
finement  the  uterus  will,  in  favorable  cases,  with  this  as¬ 
sistance,  have  returned  to  its  normal  condition,  and  will  re¬ 
main  in  natural  position  without  artificial  support. 

The  physician  should,  however,  examine  the  patient  once 
a  month  for  a  year  after  confinement,  to  assure  himself  that 
no  displacement  has  been  brought  about  by  accidental 
causes.  Many  maintain  that  women  will  not  be  at  so  much 
trouble,  and  will  not  afford  the  physician  an  opportunity  to 
follow  cases  such  a  length  of  time;  in  hospital  and  charity 
work  they  usually  will  not  and  can  not,  but  the  class  of 
women  met  with  in  private  practice  will,  if  their  physician 
educates  them  to  a  realization  of  the  importance  of  such 
caution  in  its  bearing  upon  their  whole  future  state  of 
health.  In  my  experience  there  are  few  women  who  will 
not  cheerfully  submit  to  any  course  of  treatment  that  ob¬ 
viates  the  necessity  for  an  operation. 

Let  a  woman  who  has  serious  laceration  of  the  cervix 
and  who  contemplates  submission  to  the  surgeon’s  knife 
come  to  learn  that  there  is  a  possible  and  simpler  remedy 
after  and  through  a  second  confinement,  the  success  of 
which  remedy  depends  upon  her  strict  obedience  to  direc¬ 
tions,  and  there  is  small  danger  of  any  rebellion  on  her  part, 
even  though  you  prolong  the  four  weeks  in  bed  to  eight,  as 
is  occasionally  necessary.  The  greater  part  of  a  physician’s 
duty  is  to  educate  his  patients  to  an  intelligent  comprehen¬ 
sion  of  and  rational  co-operation  in  his  methods  of  treat¬ 
ment.  The  day  for  dogmatic  dicta  is  past. 

The  favorable  reflex  influence  that  nursing  has  upon  the 


RAKE:  THE  TREATMENT  OF  LEPROSY. 


[N.  Y.  Med.  Jotjb., 


128 


pelvic  organs  is  an  important  element  in  stimulating  them 
to  return  to  normal  conditions.  When,  however,  lactation 
becomes  a  drain  upon  the  general  vitality  of  the  mother, 
this  unfavorable  condition  more  than  counterbalances  the 
favorable  stimulation  which  the  uterus  thus  receives.  There 
is  a  large  class  of  women  with  highly  developed  ner\ous 
systems  who  begin  to  show  the  drain  of  lactation  as  early 
as  from  the  third  to  the  twelfth  week  after  confinement. 
In  such  cases  the  whole  surplus  vital  energy  is  absorbed  by 
the  lactative  function  and  the  all-important  reparative  pro¬ 
cess  in  the  uterus  and  its  appendages  is  checked,  and,  unless 
the  nursing  is  promptly  discontinued,  is  permanently  ar¬ 
rested. 

With  the  improved  methods  of  sterilized  feeding  there 
is  little  risk  to  the  child  in  weaning  it  from  the  breast,  while 
there  is,  in  certain  conditions,  great  risk  to  the  mother  in 

continuing  to  nurse  the  babe. 

When  all  is  said  about  confinement,  its  complications 
and  evil  sequences,  the  increase  of  the  difficulties  caused  by 
advancing  civilization  and  the  artificiality  of  town  life  are 
really  more  than  counterbalanced  by  the  remarkable  im¬ 
provement  in  gynaecology  which  has  been  made  during  the 
last  decade;  so  that  the  death-rate  both  for  women  in  child¬ 
birth  and  for  new-born  children  is  actually  decreasing  rather 
than  increasing. 

Antisepsis  has  eliminated  the  most  dreaded  elements  of 
childbirth  ;  surgical  skill  is  now  able  successfully  to  repair, 
immediately  after  the  termination  of  labor,  injuries  to  the 
vaginal  outlet,  and  it  only  requires  that  we  should  adopt  a 
system  of  after-treatment  that  will  prevent  arrested  involu¬ 
tion  and  permanently  lacerated  cervix  to  do  away  with  all 
the  most  common  undesirable  results  of  confinement,  and 
remove  to  a  great  degree  the  dread  of  childbed,  which  with 
some  otherwise  reasonable  women  amounts  to  a  mania. 

22  East  Forty-first  Street. 


TWO  CASES 

SHOWING  THE  TREATMENT  OF  LEPROSY: 

(1)  BY  EXCISION  OF  TUBERCLES; 

(2)  WITH  OINTMENT  OF  RED  IODIDE  OF  MERCURY. 

By  BEAVEN  RAKE,  M.  D.  Lond., 

MEDICAL  SUPERINTENDENT  OF  THE  TRINIDAD  LEPER  ASYLUM. 

The  Treatment  of  Early  Leprosy  by  Excision  of 

Tubercles. 

The  treatment  of  tubercular  leprosy  by  excision  has 
been  somewhat  fully  discussed  in  the  Asylum  Report  for 
1885,  and  also  in  an  article  in  the  British  Medical  Journal 
(June  9,  1888,  p.  1214).  I  do  not  propose,  therefore,  to 
add  very  much  here  to  what  I  have  already  written,  but 
simply  to  describe  a  very  early  case  in  which  I  had  the  op¬ 
portunity  of  trying  excision. 

Ernest  Berrington,  negro,  aged  eight,  was  admitted  to  the 
asylum  on  June  3,  1889.  I  had  previously  seen  him  as  a  pri¬ 
vate  patient,  and  urged  his  coming  in  for  operative  treatment. 

His  condition  on  admission  was  described  as  follows:  On 
the  left  cheek  is  an  isolated  circular  mass  of  tubercles  about  an 


inch  and  a  quarter  in  diameter.  Round  it  are  small  tubercles  of 
about  the  size  of  peas.  On  the  nose  and  right  cheek  are  several 
solitary  tubercles  the  size  of  small  shot. 

There  is  a  solitary  tubercle  of  the  size  of  a  pea  above  the 
right  elbow.  The  fingers  are  rather  swollen. 

The  skin  over  the  shins  is  tense  and  copper-colored.  There 
are  several  small  tubercles  on  the  left  calf  and  above  the  left 
knee.  Soles  are  anaesthetic ;  femoral  glands  on  both  sides  and 
axillary  on  right  side  are  enlarged.  The  disease  began  with  an 
eruption  of  tubercles  on  the  left  cheek  about  eighteen  months 

ago.  '  1 

June  10th. — Was  given  chloroform,  and  with  a  very  sharp 

knife  the  mass  of  tubercles  was  shaved  off  the  left  cheek.  Then 
fuming  nitric  acid  was  rubbed  in,  and  afterward  tannin  applied. 
The  small  isolated  tubercles  on  both  cheeks,  forehead,  chin, 
both  legs,  and  above  right  elbow  were  similarly  treated. 

12th.— Sites  of  isolated  tubercles  covered  with  scabs  which 
have  sunk  in.  On  left  cheek  is  a  large  scab  and  some  dis 
charge.  The  sores  are  being  dressed  with  pure  creolin.  Patient 
was  ordered  liquor  hydrarg.  perchlor.,  3j  ;  inf.  quassias,  ad  3  j 
t.  i.  d. 

July  10th.— Face  nearly  healed,  but  fresh  tubercle  has  ap¬ 
peared  under  right  eye  and  also  under  left  eye. 

From  this  date  the  tubercles  have  gradually  increased  botl 
in  the  sites  of  excision  and  elsewhere.  On  two  occasions  they 
have  been  inoculated  with  leprous  cultures,  with  the  result  0 
setting  up  a  certain  amount  of  ulceration  in  the  tubercles,  no 
materially  checking  their  progress.  At  the  present  time  th« 
mass  of  tubercles  below  the  left  eye  is  ulcerating,  and  the  tu 
bercle  above  the  right  elbow  is  scabbed  over,  but  still  increas 
ing. 

I  am  always  on  the  lookout  for  early  cases  of  leprosy 
for  it  is  to  them  that  we  must  look  for  any  success  in  treal 
ment.  I  hoped  that  free  removal  with  a  sharp  knife,  fo 
lowed  by  the  thorough  rubbing  in  of  fuming  nitric  aci 
and  the  use  of  large  doses  of  mercury  internally,  might  ai 
rest  the  disease.  Leloir  has  taken  up  the  same  idea  tin 
leprosy  may  be  a  purely  local  growth  at  first,  and  so  con 
plete  destruction  of  tubercles  may  prevent  a  general  invasio 
of  the  economy.  In  favor  of  this  I  may  cite  my  failure  ev< 
to  find  bacilli  in  the  blood  of  lepers  at  any  stage  of  the  di 
ease,  or  to  cultivate  them  from  leprous  blood.  The  trea 
ment  by  excision  will  certainly  be  worth  trying  again,  in 
still  earlier  subject  if  possible. 

The  Treatment  of  Tuberculated  Leprosy  by  Red- 
Iodide-of-Mercury  Ointment. 

Raymond  H.,  negro,  aged  eight,  was  admitted  to  the  asylu 
on  September  16,  1889.  He  had  been  suffering  from  tuberc 
lated  leprosy  for  some  years. 

His  state  on  admission  was  as  follows:  Numerous  tubercl 
of  the  size  of  small  shot  on  forehead,  cheeks,  chin,  and  ea 
Few  small  pale-brown  patches  on  back. 

General  swelling  of  forearms,  hands,  and  fingers,  also  of  le; 
feet,  and  toes.  Pale-brown,  raised,  shining  masses  near  elbo 
and  knees.  Sensation  perhaps  slightly  lessened  in  fingers  a 
toes,  but  this  appears  to  be  due  to  thickening  of  tissues.  0 
vical,  axillary,  and  femoral  glands  enlarged. 

September  18th.— Ordered  ung.  hydrarg.  iodid.  rubr— £ 
application  to  be  made  to  the  whole  body  and  extremities. 

25th. — Desquamating  freely  after  one  application.  Nnml 
of  separate  tubercles  on  face  and  ears  seems  less.  To  have 
other  application  to-night. 


129 


igust  2,  1890.]  KRAUS8 :  TRAUMATIC  ANEURYSM 

27th. — Face  swollen,  puffy  below  eyes.  Not  salivated. 
October  2d. — Not  much  change  in  tubercles  of  face  since  last 
ae.  Repeat  ointment  to-night. 

16th. — Small  tubercles  of  face  about  the  same,  also  swelling 
extremities.  Repeat  ointment  to-night. 

23d. — Skin  peeling  from  face  and  neck.  Tubercles  about 
3  same.  Hands  and  feet  swollen.  Not  much  evidence  of 
ltment  on  extremities. 

28th. — Was  rubbed  with  ointment  again  last  night.  Face 
ittle  swollen,  but  less  effect  than  at  first. 

November  8th. — Tubercles  increasing  on  ears,  cheek,  fore- 
ad,  and  chin.  Repeat  ointment  to-night. 

11th. — Blisters  on  back  from  ointment.  Face  swollen.  Some 
ivation.  Tubercles  have  increased  on  face.  Large  lumps 
er  angles  of  jaws. 

As  in  this  case  the  disease  took  the  form  of  a  general 
filtration  of  the  extremities,  with  a  few  small  tubercles  on 
e  face,  it  was  thought  that  a  strong  germicide  ointment, 
:e  red  iodide  of  mercury,  might  succeed  in  killing  the 
cilli  and  reducing  the  infiltration  and  tubercles.  At  first 
ere  seemed  to  be  slight  improvement,  but  after  a  few  ap- 
ications  the  ointment  lost  its  caustic  effect  on  the  skin, 
ough  in  the  end  salivation  was  set  up  and  the  remedy 
^continued.  Tuberculation  is  now  progressing  in  the 
tient. 


TRAUMATIC  ANEURYSM  OF 
THE  INTERNAL  MAXILLARY  ARTERY. 

COMPRESSION ;  RE  CO  VER  T. 

By  WILLIAM  0.  KRAUSS,  B.  S.,  M.  D., 

LECTURER  ON  PATHOLOGY,  AND  ASSISTANT  TO 
E  CHArR  OP  CLINICAL  MEDICINE,  NIAGARA  UNIVERSITY  MEDICAL  COLLEGE, 

BUFFALO,  N.  Y. 

J.  McH.,  aged  thirty -four  years  and  one  month;  single; 
fight,  one  hundred  and  seventy  pounds;  height,  five  feet 
/en  inches  ;  occupation,  painter ;  constitution,  strong,  robust ; 
tecedents — parents  both  living  and  healthy,  offering  no  he- 
litary  taint  of  any  kind;  no  history  of  syphilis,  tuberculosis, 
■obolism,  or  rheumatism. 

Early  History. — No  infantile  diseases.  Patient  has  always 
en  a  healthy  man  with  the  exception  of  an  attack  of  lead 
lie  which  occurred  three  years  ago.  Was  obliged  to  sus- 
nd  work  for  three  months.  No  palsy  or  cerebral  symptoms 
;ervened,  and  the  attack  passed  off  without  any  apparent 
}uels. 

Present  History. — In  the  afternoon  of  August  23,  1889,  as 
}  patient  was  at  work  on  a  staging  sixteen  feet  high,  it  sud- 
aly  gave  way  and  he  was  precipitated  to  the  ground.  His 
upanions  say  he  fell  backward,  striking  upon  the  left  side  of 
i  head.  He  was  picked  up  unconscious,  having  received  sev- 
d  contusions,  the  largest  being  over  the  left  temporal  fossa; 
fractures  or  dislocations  were  recognizable.  After  a  lapse  of 
'eral  hours  he  regained  consciousness,  and  complained  of 
asea,  vertigo,  and  syncope,  which  continued  for  some  time, 
i  noticed  no  peculiar  sensation  about  the  head  except  a  dull, 
avy  ache,  and  some  pain  over  the  left  temporal  fossa,  which 
is  swollen  and  quite  sensitive  to  touch.  He  retired  early  that 
ening,  his  sleep  being  much  disturbed  owing  to  pain  and  ex- 
etnent.  The  following  morning  he  was  awakened  from  a 
Jft  sleep  by  a  hissing  noise  which  seemed  to  come  from  the 
low,  and  which  the  patient  thought  was  produced  by  a  snake, 
s  search  through  the  pillow  and  bedding  revealing  nothing, 
concluded  that  the  noise  was  in  his  head,  and  more  especially 


OF  INTERNAL  MAXILLARY  ARTERY. 

in  the  ears.  Being  unable  to  stop  the  hissing  sound  by  plugging 
the  ears,  he  consulted  a  physician,  who  applied  blisters  behind 
the  ears  and  ordered  aural  douches. 

The  patient,  experimenting  upon  himself,  found  that  by  sev¬ 
eral  manipulations  he  was  able  to  control  the  sound  tempo¬ 
rarily  :  by  holding  the  breath  for  a  time,  the  bruit  would 
grow  fainter  and  disappear  entirely,  but  on  respiring  would 
reappear ;  pressure  over  the  left  temporal  fossa  and  on 
the  neck  (carotid)  would  intercept  the  noise;  biting  the 
teeth  firmly  together  would  also  stop  the  sound  for  the  time 
being. 

The  sound  is  described  as  a  hissing,  at  times  squeaking  noise, 
continuous  by  night  and  day.  Exercise  increases  its  intensity 
and  rhythm  ;  rest,  on  the  other  hand,  diminishes  the  same.  At 
night  it  seems  to  grow  more  impetuous,  owing  no  doubt  to  the 
stillness  of  the  surroundings.  No  other  subjective  symptoms 
are  noticed  except  a  dull,  heavy  feeling  on  the  left  side  of  the 
head,  and  at  times  a  slight  vertigo. 

The  patient  consulted  me  for  the  first  time  August  30,  1889, 
and  gave  in  substance  the  foregoing  history.  On  subjecting 
him  to  a  careful  examination,  the  following  objective  symptoms 
were  obtained  :  There  is  present  a  slight  swelling  at  the  junc¬ 
tion  of  the  malar  and  zygomatic  process  of  the  frontal  bone, 
with  some  discoloration.  An  impulse  is  perceptible  under  the 
finger,  diffused  and  feeble,  simultaneous  with  the  radial  pulse. 
The  anterior  and  posterior  temporal  arteries  can  be  distinctly 
traced  from  their  points  of  origin  to  some  distance  mesad,  and 
show  no  irregularity.  Percussion  of  the  cranium  gives  a  nega¬ 
tive  result,  save  a  dull,  heavy  pain  over  the  left  temporal  fossa 
and  malar  bone. 

Auscultation. — A  stethoscope  applied  over  this  region  elicits 
an  interrupted,  sharp,  hissing  bruit,  synchronous  with  the  apex 
beat,  having  its  point  of  greatest  intensity  about  an  inch  dorsad 
of  the  external  canthus  of  the  left  orbit.  The  bruif  is  less  in¬ 
tense  over  the  temporal  fossa,  and  less  distinct  over  the  left 
upper  side  of  the  head.  On  the  right  side  the  bruit  is  also  audi¬ 
ble,  but  much  less  distinctly. 

Digital  pressure  over  the  external  carotid  artery  at  the  in¬ 
ferior  posterior  angle  of  the  inferior  maxillary  bone  produces  a 
complete  and  sudden  cessation  of  the  bruit ;  pressure  over  the 
common  temporal  artery  over  the  malar  bone  does  not  alter  the 
bruit  in  character  or  intensity.  The  stethoscope,  when  applied 
with  some  force  over  the  left  temporal  fossa,  intercepts  the  bruit. 
An  examination  of  the  ears  shows  congestion  of  the  membrana 
tympani  on  the  left  side  ;  examination  of  the  eyes  and  mouth 
gives  a  negative  result. 

The  diagnosis,  based  upon  the  objective  symptoms,  is  that  of 
a  deep-seated  aneurysm  situated  in  the  left  temporal  fossa,  which 
by  exclusion  is  shown  to  be  of  the  internal  maxillary  artery  or 
one  of  its  branches.  The  patient  was  presented  before  the  Buf¬ 
falo  Pathological  Society,  November,  1889  {Buffalo  Med.  and 
Surg.  Journal ,  December,  1889,  p.  292),  and  the  diagnosis  con¬ 
firmed. 

The  treatment  of  the  case  has  been  with  ergot,  iodides,  and 
light  cathartics.  The  bruit  seeming  to  grow  more  intense,  it  was 
proposed,  if  pressure  proved  of  no  avail,  to  resort  to  a  surgical 
operation — that  of  tying  the  left  external  carotid  artery.  The 
patient  being  averse  to  operative  procedure,  a  U-shaped  spring 
with  pads  at  both  ends  was  applied  to  the  head,  so  that  one 
pad  rested  in  the  left  temporal  fossa.  This  spring  was  applied 
every  night  for  a  period  of  ten  weeks,  and  resulted  in  the  com¬ 
plete  cessation  of  the  bruit  (February  6,  1890)  and  disappear¬ 
ance  of  all  subjective  and  objective  symptoms.  The  patient  is 
now  capable  of  doing  all  kinds  of  work  coming  within  his  do¬ 
main  without  the  least  disturbance  or  annoyance,  and  considers 
himself  perfectly  cured. 


130 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jocb., 


the 


NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 


Published  by 
D.  Appleton  &  Co. 


Edited  by 
Frank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  AUGUST  2,  1890. 


A  SENSELESS  PANIC  OYER  LEPROSY. 


From  this  week’s  report  of  contagious  diseases  in  New  \ork 
it  will  be  seen  that  a  case  of  anaesthetic  leprosy  has  been  re¬ 
ported.  The  patient  is  a  young  man,  aged  twenty  years,  a  na 
tive  of  Central  America,  who  has  been  attending  school  in  this 
country  for  more  than  a  year.  The  symptoms  of  the  disease 
did  not  appear  until  after  an  attack  of  influenza  during  the 
past  winter,  and  at  first  the  true  character  of  the  complaint 
was  not  recognized,  hut  when  a  definite  diagnosis  was  made 
and  the  case  reported  to  the  board  of  health  the  patient  was 
forcibly  removed,  by  order  of  the  board,  to  North  Brothers 
Island. 

We  must  deprecate  this  action  of  the  board,  that  seems 
based  upon  the  fear  of  leprosy  that  probably  most  persons  en¬ 
tertain  as  a  result  of  biblical  reading.  Why  should  the  treat 
ment  indicated  in  Leviticus  be  followed  in  this  disease,  while 
many  of  the  other  sanitary  injunctions  of  the  Old  Testament 
are  properly  ignored?  Should  our  treatment  of  such  cases  be 
traditional  or  scientific?  True,  this  action  of  the  board  has 
two  precedents  in  this  country  ;  one,  the  instance  in  which  the 
Philadelphia  Board  of  Health  exercised  its  authority  in  forcibly 
confining  two  lepers  in  1888,  and  the  other  the  one  in  which  in 
St.  Louis  an  unfortunate  leper  was  taken  from  his  friends  by 
order  of  the  local  board  of  health  and  confined  in  a  lazaretto 
until  he  died.  In  the  latter  case  a  slight  effort  was  made  to 
secure  the  release  of  the  patient  by  habeas-corpus  proceedings; 
and  the  tenor  of  the  popular  impression  regarding  the  disease 
can  not  be  better  illustrated  than  by  the  fact  that  there  was  a 
stampede  from  the  court-room,  even  the  wearer  of  the  judicial 
ermine  sharing  in  the  fright,  when  it  was  learned  that  the  leper 
in  person  had  been  brought  into  court.  Had  a  consumptive 
been  brought  into  the  room  it  is  needless  to  say  that  no  such 
alarm  would  have  been  created;  and  yet,  conceding  the  most 
ultra  virulence  to  leprosy  and  the  justifiability  of  the  most  ex¬ 
treme  views  held  by  lepraphobists,  it  can  not  he  held  that 
the  disease  is  as  contagious  as  tuberculosis,  or  that  it  causes 
even  a  small  percentage  of  as  many  deaths  as  the  latter. 

The  sanitary  regulation  authorizing  inspectors  of  the  Ma 
rine  Hospital  Service  to  exclude  leprous  immigrants  is  an  excel¬ 
lent  one,  because  such  persons  will  probably  become  public 
charges.  Nevertheless,  even  with  this  regulation,  we  doubt 
if  an  American  citizen  could  either  be  legally  excluded  from  the 
country  or  be  confined  as  a  virtual  prisoner  in  a  lazaretto,  be¬ 
cause  he  had  unfortunately  acquired  leprosy  during  a  residence 
in  certain  foreign  countries.  At  a  recent  meeting,  in  June  last, 
of  the  representatives  of  the  State  and  local  boards  of  health, 
at  Nashville,  an  effort  was  made  to  obtain  the  adoption  by  that 


body  of  regulations  requiring  the  isolation  of  lepers  in  the 
United  States.  The  evidence  that  supported  the  theory 
of  the  acute  contagiousness  of  leprosy  in  this  country  was 
considered  so  inconclusive  that  this  association  ot  experts 
declined  to  adopt  the  regulations  advocated  by  one  or  two 
radical  members. 

In  Minnesota,  South  Carolina,  Florida,  Louisiana,  and  Cali¬ 
fornia  there  are  cases  of-leprosy.  In  the  last-named  State  th< 
patients  are  principally  Chinese,  and,  on  account  of  the  suscep 
tibility  of  that  race  to  the  mild  contagion  of  the  disease,  leper- 
are  isolated.  But  in  none  of  the  other  States  named  has  anj 
attempt  been  made  to  isolate  the  patients  ;  yet  there  is  no  evi 
dence  that  the  disease  has  increased  in  any  of  them  during  tb< 
past  century,  and  there  is  but  a  single  authentic  record  of  th< 
disease  being  acquired  by  association  in  this  country.  This  lat 
ter  case  was  in  a  Roman  Catholic  priest  attending  leprous  pa 
t.ients  in  Charity  Hospital,  New  Orleans;  it  was  supposed  tha 
he  acquired  it  by  the  custom  of  inunction  of  the  dying.  H 
was  an  American  Father  Damien  who  received  no  honors  i> 
his  own  country. 

That  the  Bacillus  leprce  can  cause  the  disease  by  inocula 
tion  is  uncertain,  for  in  the  case  of  a  condemned  criminal  ir 
oculated  in  1884,  in  whom  the  leprous  bacilli  were  found  i 
the  cicatrix  in  1885,  he  did  not  show  signs  of  general  infectio 
until  1889.  Again,  consider  for  one  moment  the  many  yeai 
that  Father  Damien  was  exposed  to  the  disease  before  he  at 
quired  it.  Besides  the  micro-organism,  certain  factors  of  cl 
mate,  environment,  and  food  seem  requisite;  possibly,  beside 
what  Jonathan  Hutchinson  has  designated  as  “some  vei 
special  kind  of  poison  of  rare  occurrence  taken  in  connectio 
with  food.”  Certainly  climate  exercises  a  potent  influent 
in  keeping  the  disease  in  abeyance,  as  has  been  proved 
cases  of  Englishmen  that  have  acquired  leprosy  in  coloni 
possessions  and  have  lived  in  fairly  good  health  on  returnii 
to  England. 

To  deprive  an  individual  of  his  liberty  is  a  very  serio' 
matter,  and,  in  view  of  the  fact  that  contagious  diseases  of  f 
greater  danger  to  public  health  than  leprosy  are  treated  at  tl 
domicile,  there  seems  to  be  no  good  reason  for  such  arbitral' 
though  well-intended,  action  as  that  taken  by  the  board 
health.  If  experience  with  the  West  Indians  that  are  the  lepe 
in  Florida,  the  Acadian  descendants  that  constitute  the  Loui 
ana  lepers,  or  the  Norwegian  lepers  in  Minnesota,  justified 
belief  in  a  danger  to  this  community  in  permitting  this  patie 
to  reside  with  his  family,  the  case  would  be  different.  But 
cite  the  illustration  of  a  primitive  people  like  the  Sandwi 
Islanders,  that  have  been  successively  decimated  by  contagio 
diseases,  and  in  every  way  shown  their  inability  to  resist  d 
eases  less  noxious  to  the  white  race,  or  of  the  unsanitarily  si- 
ated  natives  of  India,  as  reasons  for  our  better-circumstanc 
population  fearing  the  spread  of  a  disease  that  occasiona 
presents  itself  among  us,  is  to  ignore  the  therapeutic  resour 
of  our  profession — for  cures  of  lepers  have  been  reported  a 
to  place  as  naught  the  hygienic  advantages  of  civilized  comn 
nities. 


igust  2,  1890.] 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


THE  HARLEM  ABORTION  CASE. 

A  case  of  criminal  abortion  that  has  lately  come  to  light  in 
rlem  presents  more  than  the  usual  array  of  horrors;  fortu- 
ely,  by  that  very  fact  it  is  likely  to  prove  useful  among  the 
nmunity.  The  public  prosecutor  expects  to  prove  that  a  girl 
ained,  or  her  lover  obtained  for  her,  the  ghastly  services  of 
diysician  to  assist  her  in  avoiding  maternity,  and  that  she 
d  in  consequence  of  his  interference.  The  physician  is  a 
;nsed  practitioner,  but  his  name  does  not  appear  in  the 
dical  Register,  and  it  is  stated  that  he  has  previously  been 
ler  what  the  police  considered  well-grounded  suspicion  of 
having  been  concerned  in  the  criminal  production  of  abor- 
i.  The  special  features  of  horror  in  the  case  are  said  to  be 
t  the  girl  was  taken  to  a  squalid  tenement,  where  she  had 
lody  to  nurse  her  but  a  repulsive  woman  employed  by  the 
■tor;  that,  after  she  had  died,  her  remains,  wrapped  only  in 
old  quilt,  were  carried  by  the  doctor  himself,  at  dead  of 
ht,  to  a  complaisant  undertaker’s  shop;  that  this  undertaker 
ained  a  burial  permit  on  the  doctor’s  certificate  that  the 
l’s  death  had  resulted  from  rheumatism  of  the  heart,  the 
ne  assigned  to  the  deceased  being  fictitious;  that  she  was 
■ied  secretly,  the  fact  of  her  death  being  withheld  from  her 
itives;  that  the  story  of  the  wrong  that  had  been  done  her 
ae  to  light  only  after  some  very  clever  detective  work  based 
a  conversation  casually  overheard  by  an  officer  on  an  de¬ 
ed  railway  train;  and,  finally,  that  the  poor  creature's  dead 
ly  was  exhumed,  subjected  to  a  medico-legal  examination, 

1  held  until  it  had  advanced  so  far  in  decomposition  as  to  be 
gbt  that  the  coroner’s  jury  found  sickening. 

This  is  indeed  an  atrocious  case.  That  the  public  appre- 
;es  its  atrociousness  is  shown  by  threats  to  lynch  the  old 
tor.  It  is  idle  to  hope  that  contemplation  of  the  case  will 
'e  aDy  considerable  deterrent  influence  on  the  monsters  who 
ke  a  practice  of  criminal  abortion  ;  they  will  simply  chuckle 
1  congratulate  themselves  that  they  are  not  such  blunderers 
he  doctor  in  this  case  has  shown  himself  to  be.  But  the 
son  can  not  be  wholly  lost  to  the  community.  We  have  no 
station  of  seeing  the  public  conscience  perceive  the  fact 
t  criminal  abortion  is  always  murder,  whether  the  woman 
ishes  or  survives ;  but  what  we  do  expect  is  an  increase  in 
number  of  those  who  appreciate  the  terrible  risk  insepara- 
from  recourse  to  induced  abortion,  and  consequently  will 
every  means  to  avoid  the  crime  for  fear  of  the  consequences. 
8,  of  course,  can  not  be  accounted  a  gain  to  public  morality, 
Us  natural  results  must,  nevertheless,  conduce  to  the  public 
3ty.  What  we  should  like  to  see  established  as  an  adjuvant 
some  provision  whereby  indiscreet  women  who  find  them 
res  pregnant  out  of  wedlock  may  be  allured  of  decent  sup- 
t  and  secrecy  until  they  are  relieved  of  their  embarrassment 
fhe  birth  of  a  full-time  child  and  recovery  from  the  disabili- 
1  th®  lying  in  period.  We  believe  that  institutions  for 
’  Purpose,  properly  managed,  would  do  more  to  break  up  the 
hd  practice  of  abortion  than  all  the  eloquence  that  has  ever 
n  brought  to  bear  in  picturing  its  immorality. 


131 


MINOR  PARAGRAPHS. 

INTUSSUSCEPTION  TREATED  WITH  THE  AID  OF  BARNES’S 

BAG. 

Rivington,  of  London  ( British  Medical  Journal ),  has  em¬ 
ployed  Barnes’s  bag  in  the  treatment  of  two  cases  of  intussus¬ 
ception.  The  first  patient  was  a  man  presenting  a  constriction 
of  the  rectum  and  an  intussusception  of  limited  extent  which 
could  be  felt  from  the  rectum.  Upon  the  introduction  and  in¬ 
flation  of  the  bag  the  tumor  readily  receded  and  soon  disap¬ 
peared,  not  to  return.  The  second  patient  was  a  child,  seven 
months  old,  with  a  history  of  vomiting  and  passages  of  liquid 
and  blood  for  two  weeks.  The  bowel  was  found  to  be  pro¬ 
lapsed  and  the  ileo-csecal  valve  formed  the  apex  of  the  invagi- 
nated  portion.  Partial  reduction  was  easily  effected,  but  all 
attempts  at  complete  reduction  by  insufflation  or  the  injection  of 
fluid  utterly  tailed.  A  Barnes’s  bag  was  introduced  simply  fur 
the  purpose  of  retaining  the  mass.  It  was  removed  twice  a  day 
to  allow  of  the  escape  of  liquid  passages.  At  the  end  of  two 
days,  without  any  other  attempt  at  reduction,  the  intussuscep¬ 
tion  had  entirely  disappeared.  Whether  peristaltic  action  ex¬ 
erted  fruitlessly  for  the  expulsion  of  the  bag  had  assisted  in  the 
reduction,  or  whether  it  had  been  accomplished  by  the  collection 
of  gas  above  the  bag,  is  uncertain.  The  action  of  the  bag  was 
evidently  quite  different  in  the  two  cases.  It  would  seem  to  be 
a  valuable  adjunct  to  other  methods  of  treatment  in  intussus¬ 
ceptions  that  readily  recur  on  replacement  or  do  not  disappear 
entirely  under  the  use  of  injections  of  air  or  liquid. 


AR1STOL  IN  OZA1NA. 

According  to  the  Lancet ,  Dr.  Lowenstein  strongly  recom¬ 
mends  the  employment  of  aristol — iodide  of  thymol — in  ozmna. 
It  is  said  that  the  foetor  ceases  and  the  ulcerations  heal,  with 
consequent  disappearance  of  the  scabby  crusts.  It  is  given  pure 
in  insufflations,  and  is  also  used  as  a  collodion  (aristol,  1  part; 
flexible  collodion,  10  parts)  applied  to  the  ulcerations.  It  should 
be  kept  in  dark  glass  bottles,  because  it  is  decomposed  by  light. 
Its  very  slight  odor  makes  it  a  most  desirable  substitute  for 
iodoform. 


METHYLENE  BLUE  AS  AN  ANALGESIC. 

In  methylene  blue  that  is  free  from  chloride  of  zinc  or  other 
impurity,  Professor  Ehrlich  and  Dr.  Lippman,  says  the  Lancet, 
have  found  a  safe  analgesic  that  is  cheaper  than  antipyrine  and 
can  be  administered  hypodermically  without  causing  pain.  It 
was  given  subcutaneously  in  grain  doses;  internally  from  a 
grain  and  a  half  to  four  grains  were  given,  though  fifteen  grains 
a  day  produced  no  toxic  symptom. 


SALOL  IN  CHOLERA. 

In  the  Indian  Medical  Gazette  for  September,  1889,  Sur¬ 
geon-Major  C.  F.  Nicholson  reported  a  number  of  cases  of 
cholera  successfully  treated  with  salol.  In  the  May  number  of 
the  same  journal,  of  this  year,  Dr.  Ilehir  reports  eleven  cases  of 
cholera  treated  with  salol,  all  of  which  ended  in  recovery  ;  while 
among  seventy-seven  cases  of  that  disease  treated  with  bichlo¬ 
ride  of  mercury,  thirty- nine— -or  44  7  per  cent.— were  fatal. 
Lowenthal’s  investigations  of  the  germicidal  properties  of  salol 
on  the  comma  bacillus  suggested  the  practical  application  of  that 
drug.  It  was  administered  every  two  hours,  in  ten-grain  doses, 
with  fifteen  minims  of  spirit  of  chloroform.  The  severe  symp¬ 
toms  gradually  disappeared,  the  exosmotic  process  in  the  intes¬ 
tinal  canal  ceased,  and  the  patients  retained  fluids  that  were 


132 


MWO R  PA RA  G RA PHS. — ITEMS. — LETTERS  TO  THE  EDITOR.  [N.  Y.  Med.  Jottb., 


given.  There  was  a  shortening  of  the  period  of  convalescence, 
with  absence  of  the  symptoms  of  unemia.  In  the  same  journal 
Surgeon  J.  Stevenson  reports  four  cases  of  cholera  treated  with 
salol  that  ended  fatally.  In  only  two  of  the  cases  did  any  im¬ 
provement  follow  its  use.  Of  course,  more  extensive  statistics 
are  requisite  before  definite  conclusions  regarding  the  utility  of 
the  drug  in  cholera  can  be  drawn. 


THE  FOUNTAINS  OF  NEW  YORK. 

The  supply  of  water  delivered  in  New  York  having  become 
abundant  for  the  time  being,  owing  to  the  flow  through  the  new 
aqueduct,  it  has  been  proposed  to  set  the  public  fountains  going. 
Some  doubt  has  been  expressed,  however,  as  to  whether  there 
is  yet  a  sufficient  head  of  water  to  make  them  flow  to  their  old- 
time  height.  Be  this  as  it  may,  the  new  supply  is  soon  to  he 
turned  off,  according  to  the  announcements  made,  and  held  back 
either  altogether  or  in  great  part  until  the  work  of  repairing 
defects  in  the  new  aqueduct  is  completed— probably  for  a  num¬ 
ber  of  weeks.  This  being  the  case,  it  would  be  well,  we  think, 
to  forego  the  pleasure  of  seeing  the  fountains  play  until  an  ade¬ 
quate  supply  of  water  can  be  made  permanent ;  then,  by  all 
means,  let  the  fountains  be  put  in  action. 


AN  ABUSE  OF  THE  AMBULANCE  SYSTEM. 

An  odd  story  is  told  in  the  newspapers  of  one  of  the  hospital 


ambulance  wagons  having  been  summoned  three  times  to  con¬ 
vey  one  man  to  the  hospital,  and  of  its  having  been  sent  prompt¬ 
ly  each  time,  although  on  the  first  occasion  it  had  been  ascer¬ 
tained  that  the  case  was  not  of  a  nature  to  render  hospital  treat¬ 
ment  necessary.  It  is  said  that  when  the  last  call  was  answered 
the  patient  was  put  under  arrest,  instead  of  being  taken  to  the 
hospital,  and  “sent  up”  on  a  charge  of  having  committed  a  mis¬ 
demeanor.  It  seems,  therefore,  that  this  course  can  be  pursued 
in  cases  of  persistent  ambulance  calls  on  trivial  grounds,  hut  it 
is  hard,  if  the  account  is  true,  that  this  particular  patient  should 
have  been  the  first  to  be  punished,  for  his  friends  allege  that  it 
was  they  and  not  he  who  sent  the  calls. 


ITEMS,  ETC. 

Infectious  Diseases  in  New  York.— We  are  indebted  to  the  Sanitary 

Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  July  29,  1890: 


THE  PHONOGRAPH  AS  A  DISSEMINATOR  OF  DISEASE. 


DISEASES. 

Week  ending  July  22. 

Cases. 

Deaths. 

24 

43 

1 

215 

72 

7 

1  0 

7 

7 

0 

10 

21 

0 

0 

Cerebro-spinal  meningitis . 

Leprosy . 

Week  ending  July  29. 


Cases. 


34 

28 

5 

156 

75 

8 

1 


Deaths. 


8 

6 

4 

8 

31 

0 

0 


The  New  York  State  Medical  Association. — The  eighth  specia 
meeting  of  the  Fifth  District  Branch  was  held  at  Kingston  on  Tuesdat 
July  22d,  under  the  presidency  of  Dr.  William  McCollom,  of  Brooklyr 
The  programme  included  A  Practical  Study  of  the  Region  of  the  Spin 
and  Pathological  Changes  occasioned  in  it  by  Traumatisms,  by  Dr.  T.  E 
Manley;  A  Strange  Case,  by  Dr.  J.  G.  Porteous;  and  A  Case  of  Acut 
Purulent  Pleurisy— Pleurotomy,  followed  by  Rapid  Recovery. 

The  Chicago  Polyclinic.— Dr.  G.  Fiitterer  has  been  appointed  pn 
fessor  of  internal  medicine,  Dr.  F.  C.  Hotz  professor  of  Ophthalmol 
gy,  Dr.  E.  Fletcher  Ingals  professor  of  laryngology,  Dr.  Charles  1 
Stillman  associate  professor  of  orthopaedic  surgery,  Dr.  P.  S.  Hay< 
associate  professor  of  electro-therapeutics,  and  Dr.  J.  M.  Patton  ass 
ciate  professor  of  medicine. 

The  Death  of  Dr.  R.  C.  Word,  a  prominent  Georgia  practitione 
took  place  at  Decatur  on  the  20th  of  July.  The  deceased  had  for  raai 
years  been  an  associate  editor  of  the  Southern  Medical  Record  ai 
teacher  of  physiology  in  the  Southern  Medical  College,  of  Atlanta. 

Dr.  Nicholas  Senn’s  Surgical  Bacteriology. — A  French  translate 
of  this  very  valuable  work,  by  Dr.  A.  Broca,  has  just  been  published 

Change  of  Address.— Dr.  A.  M.  Phelps  and  Dr.  W.  0.  Plimpton, 
No.  40  West  Thirty-fourth  Street. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Cm 
of  the  United  States  Navy  for  the  week  ending  July  26,  1890: 

Stone,  L.  H.,  Assistant  Surgeon.  Ordered  to  the  U.  S.  Receiving-sl 

New  Hampshire. 

Uric,  J.  F.,  Assistant  Surgeon.  Detached  from  the  U.  S.  Receivii 

aliin  Npw  HamDshire  and  ordered  to  the  U.  S.  Receiving-ship  V 


It  is  reported  that  the  Philadelphia  Park  Commissioners 
have  ordered  the  disuse  of  the  public  phonographs  heretofore 
in  use  in  Fairmount  Park,  on  account  of  the  danger  of  their 
serving  to  disseminate  disease.  This  danger  is  doubtless  very 
slight,  like  that  of  injury  to  the  ear,  and  probably  neither  danger 
is  worth  consideration  if  the  instrument  is  kept  reasonably  clean 
and  used  properly ;  but  its  promiscuous  use  in  a  public  park 
does  not  seem  to  admit  of  perfect  security  in  this  respect,  and 
the  announcement  that  the  phonograph  company  intends  to 
substitute  a  plate  ear-piece  for  the  penetrating  one  now  in  use, 
avowedly  for  the  reason  that  there  are  persons  who  object  to 
the  present  form,  goes  to  show  that  the  Philadelphia  Commis¬ 
sioners  are  not  the  only  people  who  entertain  the  idea  of  dan¬ 
ger  in  the  phonograph. _ 


bash. 

Norton,  Oliver  D.,  Passed  Assistant  Surgeon.  Granted  leave  of  : 
sence  for  the  month  of  August. 

Babin,  H.  J.,  Surgeon.  Granted  one  month’s  leave  of  absence  fr 
July  23d. 

Society  Meetings  for  the  Coming  Week: 

Tuesday,  August  5th:  Hampden,  Mass.,  District  Medical  Society  (Spri 
field). 


fetters  to  tbt  <&bifor. 


THE  WEST  VIRGINIA  STATE  BOARD  OF  HEALTH. 


THE  RETIREMENT  OF  PROFESSOR  YON  BRUCKE. 

IIofrath  Ernst  von  Brucke,  who  for  many  years  has  been 
the  professor  of  physiology  in  the  University  of  Vienna,  is  re¬ 
ported  as  having  given  his  farewell  lecture  recently,  on  reach¬ 
ing  the  age  at  which  retirement  is  called  for.  A  number  of  the 
other  professors  formed  a  part  of  the  audience  on  the  occasion, 
and,  together  with  the  students,  cheered  von  Briicke  as  he 
entered  the  room. 


Charleston,  W.  Va.,  July  23,  189( 

To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  The  State  Board  of  Health  of  West  Virginia  has  j 
closed  its  annual  session  of  1890.  A  communication  was] 
sented  from  the  State  Board  of  Health  of  Illinois  asking  the 
operation  of  the  State  board  of  West  Virginia  to  raise 
standard  of  instruction  in  the  medical  colleges  and  to  requi 
three-years’  course. 


133 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES. 


ugust  2,  1890.J 

In  accordance  with  the  request,  the  following  preamble  and 
solutions  were  presented : 

“  Whereas ,  The  growing  importance  of  the  careful  prepara- 
)n  of  medical  students  for  entering  upon  the  responsible  posi- 
ms  as  physicians  and  surgeons,  and  as  a  means  of  protecting 
e  citizens  of  West  Virginia  against  charlatans,  as  well  as  en¬ 
gaging  and  fostering  the  laudable  efforts  of  reputable  medi- 
1  schools  and  colleges  to  raise  the  standard  of  medical  educa- 
ro ;  therefore, 

“  Resolved,  That  the  board  earnestly  recommends  that  all 
edical  schools  and  colleges  require  attendance  upon  three  full 
•urses  of  lectures,  besides  satisfactory  evidence  of  preparatory 
mcation,  attested  by  diploma  or  certificate  from  a  reputable 
•liege,  academy,  or  high  school,  and  a  certificate  from  a  regu- 
r  physician  as  to  a  full  course  of  professional  study,  as  requi- 
;e  for  graduation.” 

It  is  mortifying  to  me  to  say  the  board  did  not  carry  out  the 
ntiment  of  the  resolutions,  which  were  unanimously  adopted, 
ut  of  four  applicants,  two  passed.  One  of  them  to  my  certain 
lowledge  has  never  seen  a  medical  college,  but  professes  to 
tve  received  some  instruction  from  a  gentleman  who  passed 
e  State  board  a  few  years  ago.  He  has  a  country  school 
acher’s  education. 

The  other  gentleman  has  attended  one  course  of  lectures, 
hich  is  that  much  to  his  credit.  The  code  of  the  State  of  West 
irginia  says :  “  The  board  shall  take  cognizance  of  the  interests 
the  life  and  health  of  the  inhabitants  of  the  State,”  etc.,  for 
inch  a  solemnized  oath  is  required. 

Now,  I  ask  how  in  the  name  of  the  profession  can  the  State 
•ard  of  West  Virginia  have  at  heart  the  welfare  of  the  people 
ter  passing  such  ill-prepared  men,  because  we  all  know  how 
•orly  prepared  a  man  is  after  he  has  studied  with  his  precep- 
r  for  one  year  and  has  attended  his  two  full  courses  of  lect- 
es,  and  the  board  is  certainly  aware  of  the  same  fact,  because 
ey  earnestly  recommend  a  three-years’  course  at  a  reputable 
edical  college. 

And  we  further  know  that  a  man  is  not  capable  of  practic- 
g  medicine  and  surgery  without  first  receiving  clinical  instruc¬ 
ts  at  the  bedside  by  professional  teachers.  Any  man  who  is 
fortunate  as  to  pass  the  State  board  is  entitled  to  all  the 
ivileges  and  immunities  which  are  guaranteed  to  a  regular 
; aduate  of  medicine,  and  I  venture  to  say  that  nine  tenths  of 
!ch  manufactured  physicians  will  know  less  as  they  grow 
ler.  1  have  not  attempted  in  my  remarks  to  criticise  the 
ard;  I  simply  want  to  place  them  before  the  profession  at 
■ge  and  let  it  delegate  hereafter  to  them  their  professional 
tding.  F.  S.  Thomas,  M.  D. 


NITRATE  OF  POTASSIUM  IN  INTERMITTENT  FEVER. 

Hillsboro,  III.,  July  22,  1890. 

1  Me  Editor  of  the  New  York  Medical  Journal  : 

Sir:  In  the  Virginia  Medical  Monthly  for  February,  1890, 
r*  D.  Hunter  professes  to  have  made  the  discovery  that 
itrate  of  potassium  will  cure  ague. 

I  called  the  attention  of  the  profession  to  the  antiperiodic 
operty  possessed  by  this  drug  in  a  paper  published  in  the  St. 
'uis  Medical  and  Surgical  Journal  in  1859  or  1860,  and  again 
the  Boston  Medical  and  Surgical  Journal  some  time  in  ’63, 
or  ’5.  I  have  lost  my  journals  by  fire,  and  therefore  can  not 
exact  as  to  date. 

I  was  induced  to  make  a  trial  of  this  remedy  after  being  as- 
ied  by  an  old  “  backwoods  ”  hunter  that  a  large  dose  of  gun- 
"der  (which  he  usually  took  in  whisky),  given  at  the  incep- 
1  'u  the  cold  stage,  would  almost  always  abort  the  paroxysm, 


and  that,  if  there  should  be  any  fever,  it  would  be  very  light.  I 
found  this  to  be  true,  and  at  once  attributed  the  cure  to  the  po¬ 
tassium  nitrate,  and  upon  trial  found  I  was  correct. 

When  the  price  of  quinine  was  high  it  was  a  roost  excellent 
substitute,  but,  as  it  lacks  the  tonic  effect,  the  cinclioua  alka¬ 
loids,  at  present  prices,  are  preferable. 

Amos  Sawyer,  M.  D. 


fjroteTfrinp  of  Sonnies. 


RICHMOND,  VA.,  ACADEMY  OF  MEDICINE  AND 

SURGERY. 

Meeting  of  June  10,  1890. 

The  President, -Dr.  W.  W.  Parker,  in  the  Chair. 

( Reported  by  Dr.  J.  W.  Hewson ,  Richmond.) 

A  Peculiar  Case  of  Indigestion.— Dr.  J.  N.  Upshur  re¬ 
ported  the  history  of  a  peculiar  case  occurring  in  a  lady  of  fifty- 
four  years  very  much  “run  down ’’from  mental  and  phjsical 
overwork.  The  peculiar  feature  was  a  severe  pain,  spasmodic 
in  character,  occurring  periodically  about  every  ten  days.  Its 
seat  was  about  the  pylorus  and  downward  and  to  the  right 
along  the  edge  of  the  ribs.  When  the  speaker  first  saw  her  she 
had  three  of  these  attacks,  at  intervals  of  about  twelve  hours. 
The  first  he  had  relieved  in  a  few  hours  with  morphine  and 
atropine  hypodermically,  the  two  last  with  one  fiftieth-grain 
doses  of  nitroglycerin,  administering  it  twice  for  the  second,  and 
only  once  for  the  third  attack.  No  eructation  of  gas  and  water 
followed  the  last  of  the  three,  as  had  been  the  case  always  be¬ 
fore.  The  general  treatment  given  was  a  light  nutritious  diet, 
attention  to  the  bowels,  and  a  tonic  of  phosphate  of  iron,  quinine, 
and  strychnine.  She  had  no  recurrence  of  the  pain.  Nitro¬ 
glycerin  had  been  suggested  to  the  speaker’s  mind  by  the  fact 
that  the  pain  in  its  acuteness  resembled  the'  spasm  of  angina 
pectoris.  He  had  much  confidence  in  nitroglycerin  for  the  re¬ 
lief  of  the  oedema,  dyspnoea,  and  cardiac  distress  of  Bright’s 
disease.  He  had  tried  it  with  much  success  for  the  temporary 
relief  of  aggravated  sciatica.  Though  it  was  slower  in  action, 
its  effects  were  more  permanent  than  those  of  nitrite  of  amyl. 

Meeting  of  June  21/.,  1890. 

A  Sequela  of  La  Grippe. — The  President  reported  the 
history  of  the  case  of  a  robust  young  man  who  had  been  af¬ 
flicted  with  influenza  a  short  time  ago,  this  being  accompanied 
by  au  inflammation  and  considerable  swelling  of  the  muscles  of 
the  neck,  and  this  in  turn  being  followed  by  a  frightful  eruption 
of  vesicular  character  over  the  whole  body,  very  much  like 
chicken-pox.  It  was  particularly  marked  upon  the  hips  and 
inner  side  of  the  thighs,  where  it  resembled  and  might  have 
been  mistaken  for  confluent  small-pox.  The  eruption  continued 
ten  days  or  two  weeks,  leaving  the  extremities  first  and  gradu¬ 
ally.  There  was  no  fever,  very  slight  constitutional  disturb¬ 
ance  of  any  kind,  and  no  itching  of  consequence. 

Singular  Experience  with  Scarlet  Fever  and  Measles. 
— Dr.  W.  B.  Grey  reported  in  reference  to  two  children, 
aged  respectively  two  and  four  years,  affected  with  scarla¬ 
tina,  the  older  one  of  whom,  just  about  the  commencement  of 
desquamation,  developed  the  eruption  of  measles.  In  four 
or  five  days  the  younger  did  the  same.  Furthermore,  said 
the  speaker,  about  this  time  the  father,  an  old  man,  took  scar¬ 
let  fever. 


134 


BOOK  NO  TICES. — REP  OR  TS  ON  THE  PROGRESS  OF  MEDICINE.  [N.  Y.  Mep.  Jour., 


Hsematoma  Anris.— Dr.  Charles  M.  Shields  reported  the 
history  of  a  case  occurring  in  a  lawyer  of  about  sixty  yeais  of 
age,  and  perfectly  sound  in  mind  (the  trouble  very  rarely  ap¬ 
pearing  except  in  the  insane).  About  a  month  before  the  ap¬ 
pearance  of  the  growth  the  man  had  suddenly  lost  conscious¬ 
ness  oue  day,  and,  in  falling,  bad  bruised  the  side  of  his  face 
corresponding  to  the  trouble.  The  speaker  had  enlarged  au 
opening  tound  upon  the  anterior  wall  of  the  canal,  about  half  an 
inch  from  the  external  orifice.  The  cavity  into  which  it  led 
would  hold  about  five  or  six  drachms.  The  discharge  was  very 
offensive.  A  wash  of  peroxide  of  hydrogen  was  prescribed. 
From  one  Saturday  night  until  the  following  evening  the  patient 
had  five  or  six  lueumrrhages,  losing  in  all  about  twenty  or  thirty 
ounces  of  blood.  The  only  resource  fur  perfect  control  of  the 
flow  was  packing  the  cavity  with  cotton  saturated  in  Monsel’s 
solution.  The  speaker  thought  the  man  would  recover,  but 
with  a  considerable  scar. 

Dr.  M.  D.  Hoge  reported  the  history  of  a  case  of  a  man  who 
since  an  attack  of  la  grippe  had  fallen  into  a  state  of  melan¬ 
cholia  almost  amounting  to  insanity.  He  suffered  excessively 
from  nervousness  and  from  an  intense  pain  the  head,  the  latter 
being  treated  successively  with  morphine,  cocaine,  and  bromide 
of  potassium.  He  still  complained  of  great  pain  in  his  head, 
until  one  night  he  pounded  himself  over  the  head  with  a  poker 
until  he  had  peeled  off  a  large  piece  of  scalp  and  produced 
enormous  haemorrhage.  He  then  felt  better.  Some  time  after, 
the  Speaker  found  a  sequestrum  of  bone  (a  portion  of  the  ex¬ 
ternal  table.)  in  the  wound,  which  he  removed,  and  the  part 
began  to  heal  beautifully.  The  man  was  very  much  depressed 
all  along,  and  believed  himself  going  crazy.  He  complained  of 
hearing  voices.  The  speaker  reasoned  him  out  of  that  state 
and  pronounced  him  now  upon  the  road  to  recoveiy. 

The  President  thought  the  hearing  of  voices  a  pretty  sure 

sign  of  insanity. 


belongs,  and  to  relegate  it  largely  to  the  generous  care  of  the 
neurologist,  marks  the  trend  of  medical  thought  in  reference  to 
certain  respiratory  and  cardiac  affections.  Dr.  May  s  recent  re¬ 
ports  of  cases  cured  by  hypodermics  of  strychnine  and  atropine, 
and  Dr.  Schmiegelow’s  clinical  observations,  make  the  outlook 
of  asthmatic  sufferers  more  hopeful. 


BOOKS  AND  PAMPHLETS  RECEIVED. 


took  ftoitws. 


Asthma ,  considered  specially  in  Relation  to  Nasal  Disease.  By 
E.  Schmiegelow,  M.  D.,  Consulting  Physician  in  Laryngolo¬ 
gy  to  the  Municipal  Hospital,  and  Director  of  the  Otola- 
ryngological  Department  in  the  Polyclinic  at  Copenhagen. 
London  :  H.  K.  Lewis,  1890.  Pp.  90. 

This  essay  contains  an  historical  review  ot  theories  relating 
to  asthma;  due  justice  to  Hack  for  calling  attention  to  condi 
tions  that  had  passed  unnoticed,  together  with  criticisms  ot  his 
exaggerated  views;  and  conclusions  based  on  experience  and 
investigation  that  are  truly  interesting.  The  author  considers 
asthma  a  bulbar  neurosis,  consisting  of  an  excessive  reflex  irri¬ 
tability  of  the  respiratory  center.  He  thinks  that  this  neurosis 
may  result  from  depressive  factors,  such  as  childbirth,  bleeding, 
continued  fever,  etc. ;  that  when  this  disorder  appears  in  ap¬ 
parently  healthy  individuals,  without  trace  of  other  nervous  phe¬ 
nomena,  it  is  presumabl y  caused  by  frequent  and  strong  irritations 
conducted  to  the  respiratory  centers  from  the  nasal  fibers  of  the 
trigeminus,  and  to  this  cause  may  be  added  irritation  of  other 
and  more  remote  nerves,  such  as  the  laryngeal  and  pulmonary 
branches  of  the  pneumogastric,  or  of  any  sensitive  nerve  what¬ 
ever  ;  that  the  suppression  of  peripheral  irritation  alone  as  in 
the  treatment  of  nasal  disease— or  combined  with  general  nerve 
tonic  treatment,  may  prevent  asthmatic  attacks;  and  that  nasal 
disorders  may  exist  accidentally  in  asthmatic  persons  without 
having  the  slightest  aetiological  relation  to  the  attacks.  An  ef¬ 
fort  to  find  out  what  asthma  really  is,  to  place  it  where  it  really 


Annual  of  the  Universal  Medical  Sciences.  A  Yearly  Report  of  the 
Progress  of  the  General  Sanitary  Sciences  throughout  the  World. 
Edited  by  Charles  E.  Sajous,  M.  D.,  Lecturer  on  Laryngology  and  Rhi- 
nology  in  Jefferson  Medical  College,  Philadelphia,  etc.,  and  Seventy  As- 
sociate  Editors,  assisted  by  over  Two  Hundred  Corresponding  Editors, 
Collaborators,  and  Correspondents.  Illustrated  with  Chromo-litho¬ 
graphs,  Engravings,  and  Maps.  Vols.  I,  II,  III,  IV,  and  V.  Philadel¬ 
phia  and  London:  F.  A.  Davis,  1890. 

Lecyons  cliniques  sur  les  maladies  de  l’appareil  locomoteur  (os,  articu¬ 
lations,  muscles).  Par  le  Dr.  Kirmisson,  Professeur  agrege  de.la 
Faculte  de  medecine;  chirurgien  de  l’Hopital  des  enfants  assistes,  etc. 
Avec  40  figures  dans  le  texte.  Paris:  G.  Masson,  1890.  Pp.  viii-350. 

[Prix,  lOfr.J  , 

Les  anesthesiques :  physiologie  et  applications  chirurgicales.  Pai 

A.  Dastre,  Professeur  de  physiologie  &  la  Sorbonne.  Paris :  G.  Masson 

1890.  Pp.  xi-306.  [Prix,  5fr.] 

Practical  Sanitary  and  Economic  Cooking  adapted  to  Persons  ot 
Moderate  and  Small  Means.  By  Mrs.  Mary  Hinman  Abel.  The  Lomt 
Prize  Essay.  Published  by  the  American  Public  Health  Association 

1890.  Pp.  xi-190. 

A  Natural  Method  of  Physical  Training.  Making  Muscle  and  re 
ducing  Flesh  without  Dieting  or  Apparatus.  By  Edwin  Checkley.  Thin 
Edition.  Fully  illustrated  from  Photographs  taken  especially  for  thi 
Treatise.  Brooklyn:  William  C.  Bryant  &  Co.,  1890.  Pp.  4-7  to  152 
Protoplasm  and  Life.  Two  Biological  Essays.  By  Charles  F.  Cox 
M.  A.  New  York:  N.  D.  C.  Hodges,  1890.  Pp.  3  to  67. 

Gunshot  Wounds  of  the  Abdomen.  By  Aug.  Schachner,  M.  D.,  o 
Louisville.  [Reprinted  from  the  Annals  of  Surgery.] 

The  Creasote  Treatment  of  Tuberculosis,  with  a  Description  of 
New  Inhaler,  and  Impure  Creasote  the  Cause  of  Failure  m  the  Treat 
ment  of  Pulmonary  Tuberculosis.  By  G.  W.  Daywalt,  M.  D.,  Sa 
Francisco,  Cal.  [Reprinted  from  the  Occidental  Medical  Times.] 

On  Conical  Stump  after  Amputation  in  Children,  with  Especial  Re 
erence  to  its  Physiological  Causes  and  Prognosis.  By  Charles  A.  Power 
M  D.  [Reprinted  from  the  Medical  Record.] 

'  Annual  Report  of  the  Board  of  Health  of  the  Health  Department! 
the  City  of  New  York,  for  the  Year  ending  December  81,  1889. 

Second  Annual  Report  of  the  Health  Department  of  the  City* 
Mansfield,  Ohio,  for  the  Year  commencing  March  1,  1889,  and  endir 
February  28,  1890.  By  R.  Harvey  Reed,  M.  D.,  Health  Officer. 

State  Board  of  Health.  Report  of  Willis  G.  Tucker,  M.  D.,  Ph.I 
Analyst  of  Drugs. 

Dei  doveri  del  medico  verso  la  societA  Lezione  di  chiusura  al  cor 
di  clinica  propedeutica  e  patologia  speciale  medica,  fatta  all’  universi 
di  Perugia.  Por  Dott.  Carlo  Ruata.  [Estratto  dalla  Salute  pubbhea 
The  Treatment  of  the  Acutely  Insane  in  General  Hospitals.  By 
P.  Spatling,  M.  D.  [Reprinted  from  the  Medical  Record.] 


fUgortss  on  the  Progress  of  PcDicuu. 


PHYSIOLOGY. 


By  LOUISE  G.  RABINOVITCH,  M.  D., 

PHILADELPHIA. 


On  the  Period  of  Muscular  Contraction  during  which  Heat  beg 
to  Discharge.— Of  the  known  fact  that  voluntary  or  induced  muscu 
contraction  is  accompanied  by  heat  production,  the  period  during 
contraction  that  corresponds  to  the  production  of  heat  is  not  kno 


August  2,  1890.] 


135 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


M.  Maurice  Mendelsohn  ( Complex  rend,  de  la  soc.  de  biol.,  No.  ‘27,  1889) 
experimented  for  several  years  with  the  view  of  determining  this  pe¬ 
riod.  He  found  most  satisfactory  the  use  of  Bernshein’s  differential 
rheotome  that  communicates  to  the  muscle  momentary  excitations  at 
rapid  intervals  and  of  equal  duration  ;  it  enables  also,  during  the  inter¬ 
vals,  to  shut  off  the  muscular  thermo-electric  current  for  an  extremely 
short  time. 

He  was  enabled  to  estimate  the  interval  between  the  moment  of 
muscular  excitation  and  the  discharge  of  heat;  it  is  given  in  figures 
from  0‘005  to  0'006  of  a  second.  This  interval  constituting  the  latent 
period  of  muscular  heat  production  appears  to  be  inferior  to  the  dura¬ 
tion  of  the  period  of  muscular  contraction,  that  amounts,  according  to 
Helmholtz,  to  0‘01,  and  according  to  M.  Mendelsohn  himself  to  from 
0‘007  to  0'008  of  a  second. 

He  concludes  from  this  that  the  beginning  of  the  production  of 
heat  in  the  muscle  is  going  on  already  during  the  latent  period  of  mus¬ 
cular  contraction. 

The  fact  seems  of  importance  to  the  author  from  several  stand¬ 
points.  It  shows,  in  the  first  place,  that  the  production  of  heat  in  the 
muscle  precedes  the  mechanical  effect  of  the  excitation.  It  proves,  fur¬ 
ther,  that  the  latent  period  of  the  muscular  contraction  is  not  at  all  a 
period  of  muscular  inactivity,  but  that  during  this  short  lapse  of  time 
there  is  already,  subsequent  to  the  excitation,  discharge  of  certain  vital 
forces.  The  muscular  contraction  is  then  only  an  ultimate  and  final 
effect  of  certain  micro-chemical  processes  (or  electrical,  assuming  that 
the  electro-negative  variation  of  the  muscle  current  precedes  the  muscle 
contraction)  which  are  going  on  during  the  persistence  of  the  latent 
muscular  period,  and  whose  first  effect  is  to  produce  heat.  The  heat  is 
being  produced  during  the  period  of  muscular  contraction,  and  to  a 
very  slight  extent,  or  not  at  all,  during  the  period  of  relaxation. 

On  Some  of  the  Effects  of  Cold  on  the  Human  Body. — M.  Fere  (ibid.) 
has  studied  the  subject  and  obtained  the  following  results : 

1.  Simple  exposure  of  the  naked  body  to  the  air  at  a  temperature  of 
from  18°  to  20°  C.  suffices  to  induce  within  several  minutes  an  aug¬ 
mentation  of  pressure  in  the  radial  artery,  which  may  amount  to  from 
200  to  300  grammes  at  the  end  of  ten  minutes.  The  increase  takes 
place  even  when  the  pressure  is  as  high  as  800  to  900  grammes.  This 
fact  explains  why  sudden  exposure  to  a  low  temperature  is  apt  to  lead 
to  rupture  of  the  blood-vessels  that  have  been  previously  altered.  The 
augmented  pressure  thus  determined  explains  also  the  occurrence  of 
epilepsy  subsequent  to  exposure  to  cold.  Among  the  physiological  phe¬ 
nomena  caused  by  exposure  to  cold  the  author  mentions  the  occurrence 
of  considerable  supersecretion  from  the  axillary  sudorific  glands ;  this 
is  so  marked  in  some  cases  that  an  actual  stream  of  sweat  is  set  up. 
The  fact  is  of  importance  with  reference  to  the  question  of  the  sudorific 
axillary  secretion  that  is  considered  to  depend  upon  electrical  excitation 
of  the  rhachidian  and  costal  regions.  The  author  has  not  succeeded  in 
obtaining,  by  the  same  means,  the  secretion  of  sweat  in  the  axilla,  if 
care  was  taken  to  avoid  exposure  of  a  considerable  area  of  the  skin. 
This  supersecretion,  after  the  author,  goes  to  show  also  that  the  reflex 
vaso-constricting  influence  of  cold  is  not  so  general  as  is  supposed. 

2.  Epileptic  patients  have  been  observed  to  be  enabled  to  avert  an 
epileptic  fit  by  swallowing  quickly  a  glass  of  cold  water  just  at  the  be¬ 
ginning  of  this  premonitory  obnubilation;  this  means  proved  to  be 
fruitless  when  it  was  too  near  the  period  of  loss  of  consciousness.  The 
following  observed  phenomena  are  given  as  an  explanation  to  account 
for  the  above  effect :  By  means  of  Bloch’s  sphygmometer  the  patient’s 
arterial  pressure  during  the  normal  state  has  been  ascertained  to  be 
from  800  to  850  grammes ;  after  the  sudden  ingestion  of  twenty-four 
centilitres  of  ice-water,  the  arterial  pressure  amounted  to  from  1,050  to 
1,200  grammes.  Within  a  period  of  from  five  to  six  minutes  after  the 
ingestion  of  the  liquid  the  pressure  returned  to  the  normal  standard. 
The  augmented  arterial  pressure  has  been  observed  to  be  less  in  case 
fhe  same  quantity  of  cold  water  is  ingested  in  divided  doses. 

The  augmentation  of  the  surface  blood-pressure  is  explained  by  the 
constricting  action  of  the  cold  on  the  abdominal  vessels.  The  occur¬ 
rence  of  syncope  and  other  accidents  under  the  influence  of  ingested 
cold  is  presumed  to  depend  upon  a  possible  reflex  constriction  of  the 
encephalic  vessels. 

Assuming  that  the  increased  blood-pressure  constitutes  one  of  the 


physiological  conditions  of  an  epileptic  discharge,  it  is  questioned  if  the 
artificial  induction  of  high  blood-pressure,  as  is  the  case  in  ingesting 
cold,  does  not  act  by  substitution,  causing  at  the  same  time  a  partial 
spasm  capable  of  interfering  in  due  time  with  the  epileptic  discharge. 

By  subjecting  one  hand  to  a  temperature  higher  than  the  surround¬ 
ing,  and  so  determining  in  that  hand  a  greater  amount  of  blood,  M. 
Fere  has  been  successful  in  realizing  the  counter-proof  of  the  fact  that, 
in  general,  psychomotor  excitations,  or  depressions,  are  characterized 
respectively  by  an  augmentation  or  diminution  of  the  energy  of  volun¬ 
tary  movements,  and  shortening  or  lengthening  of  the  period  of  reac¬ 
tion. 

On  the  Retrograde  Circulation  in  the  Venous  Blood-Current. — M. 

J.  Thomayer  (ibid.)  alludes  to  the  fact  that  auscultation  over  markedly 
dilated  varicose  veins  of  the  lower  limbs  at  the  time  when  the  patient 
is  straining,  as  during  cough  or  other  exertion  leading  to  contraction  of 
the  abdominal  wall,  gives  frequently  a  murmur  identical  to  the  bruit  de 
diable  of  anaemic  patients.  Touching  the  dilated  vessel  gently  with  the 
finger,  the  bruit  de  diable  is  felt  to  be  induced  by  a  jerk  of  blood  propa¬ 
gating  in  the  vein  from  the  center  to  the  periphery,  at  the  moment  that 
the  patient  coughs  or  exerts  contraction  of  the  abdominal  muscle.  In 
cases  of  general  dilatation  of  the  saphenous  vein,  narrowing  of  the  same 
by  gently  compressing  it  gives  the  same  murmur  below  the  point  of 
compression. 

M.  Thomayer  sees  as  cause  for  the  murmur  the  retrograde  blood-cur¬ 
rent  occasioned  by  the  intrathoracic  or  intra-abdominal  pressure.  He 
thinks  that  in  the  normal  blood-vessels  the  same  phenomenon  takes  place 
under  the  influence  of  the  same  agents  ;  this  retrograde  circulation  must 
take  place,  it  is  supposed,  if  not  in  general,  at  least  in  the  veins  of  the 
lower  limbs  at  the  level  of  the  first  venous  valves.  Basing  his  idea  on 
the  existence  of  the  current  under  pathological  conditions,  in  varicose 
veins,  the  author  is  inclined  to  accept  it  as  a  possible  normal  physiolog¬ 
ical  phenomenon,  though  it  can  not  be  obtained  as  such,  for  the  reason 
of  its  propagation  being  interfered  with  by  the  venous  valves  ;  he  sup¬ 
poses  that  physiologically  it  exists  at  least  in  the  vena  cava  inferior,  and 
in  other  veins  deprived  of  valves.  He  points  out  that  the  interest  that 
this  fact  offers  is  that  it  explains  the  origin  of  the  retrograde  metasta¬ 
sis  described  by  von  Recklinghausen,  and  also  disturbances  of  circula¬ 
tion  occurring  in  diseases  accompanied  by  cough  and  tenesmus ;  it 
finally  shows  that  the  bruit  de  diable  in  anajmia  depends  upon  the  ve¬ 
nous  walls  (dilatation?)  rather  than  upon  the  pathological  condition  of 
the  blood. 

On  Exploration  of  the  Movements  of  the  Tongue. — By  modifying 
M.  Bloch’s  apparatus,  M.  Ch.  Fere  (id.,  No.  15,  1889)  has  constructed 
a  glosso-dynamometer  that  enables  him  to  study  the  resistance  to  press¬ 
ure  of  the  tongue  in  its  five  principal  directions.  He  thinks  this  con¬ 
trivance  will  prove  of  good  service  in  the  study  of  neuropathic  disturb¬ 
ances  of  the  tongue. 

The  description  of  the  mode  of  application  of  the  instrument  is 
given,  and  it  is  stated  that  under  normal  conditions  the  resistance  to 
pressure  from  above  downward,  or  the  energy  of  the  movement  of  ele¬ 
vation  of  the  tip  of  the  tongue,  varies  from  700  to  850  grammes  ;  that 
of  lowering,  from  600  to  800  grammes ;  the  resistance  to  lateral  press¬ 
ure  is  from  600  to  850  grammes ;  and,  finally,  protruding  the  tongue 
resists  a  pressure  of  from  700  to  900  grammes. 

These  measurements  are  well  utilized  in  unilateral  disturbances  of 
the  tongue.  The  author  opposes  the  generally  admitted  belief  that  dis¬ 
turbances  of  articulated  speech  can  exist  without  at  the  same  time 
alteration  of  the  movements  of  the  tongue ;  for,  he  states,  the  cerebral 
organs  of  sensibility  or  movements  are  the  seat  of  reflex  phenomena, 
and  descending  degeneration  is  possible  in  cases  of  lesions  in  Broca’s 
region,  as  well  as  in  cases  of  lesions  of  the  motor  regions.  Direct  ex¬ 
plorations  show  the  coincidence  of  disturbance  of  lingual  movements 
with  that  of  articulated  speech.  The  statement  is  confirmed  by  the 
following  facts : 

1.  In  two  aphasic  patients  with  slight  hemiplegia  there  was  no  ap¬ 
parent  alteration  of  mobility  of  the  tongue,  and  examination  revealed 
decreased  resistance  to  pressure  that  amounted  to  from  250  to  300 
grammes  on  the  right  side  ;  the  movements  of  elevation,  depression, 
and  protrusion  were  from  100  to  200  grammes  less  than  the  normal. 

2.  In  three  hysterical  patients  that  had  been  aphasic  by  suggestion 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


|N.  Y.  Med.  Jour., 


186 


the  diminution  of  resistance  to  pressure  from  right  to  left  amounted  to 
from  200  to  300  grammes. 

3.  In  several  epileptic  patients  with  speech  disturbances  subsequent 
to  an  attack,  the  resistance  to  pressure  was  diminished  to  various  de¬ 
grees  in  all  directions.  On  an  average  it  is  200  grammes  below'  that 
obtained  in  the  same  individual  about  two  or  three  hours  after  the 
attack. 

4.  A  general  paralytic  patient  with  marked  disturbance  of  speech 
gives  almost  negative  resistance  in  all  directions,  though  he  performs 
conscious  efforts  and  makes  free  movements  of  the  tongue  in  every 
direction. 

5.  A  congenital  deaf  and  dumb  subject  presented  diminution  of  re¬ 
sistance  in  all  directions  amounting  to  from  280  to  300  grammes. 

The  author  further  says  that  M.  Charcot’s  statement  of  the  exist¬ 
ence  of  unilateral  glosso-labial  spasm  on  the  side  opposite  to  the  para¬ 
lyzed  half  of  the  body  in  hysterical  patients,  and  M.  Bressaud,  M. 
Marie,  and  M.  Belin’s  confirmation  of  the  frequency  of  the  occurrence 
of  this  symptom,  must  be  accepted  with  reserve,  for,  in  eight  hysterical 
patients  affected  to  some  extent  with  hemimyasthenia  of  the  limbs,  he 
found  decreased  resistance  of  the  tongue  to  pressure  on  the  side  corre¬ 
sponding  to  the  paralyzed  half  of  the  body.  In  three  cases  with 
marked  myasthenia  the  lingual  resistance  on  the  side  corresponding  to 
the  affected  side  of  the  body  was  almost  absent,  whereas  on  the  oppo¬ 
site  side  it  amounted  to  from  650  to  '700  grammes. 

On  two  of  those  patients  that  presented  right  anaesthesia  and  amy- 
asthenia  the  author  observed  that,  under  the  influence  of  suggested 
aphasia,  the  lingual  resistance  on  the  same  side  was  still  further  re¬ 
duced,  while  the  increase  on  the  left  side  was  50  in  one  and  100 
grammes  in  the  other  patient. 

Similar  facts  are  stated  to  be  of  frequent  occurrence  in  hysterical 
patients  and  in  those  subject  to  suggested  paralysis. 

On  Lavation  of  the  Blood  in  Infectious  Diseases. — MM.  A.  Dastre 
and  P.  Loye  (id.,  No.  14,  1889)  related  in  the  Arch,  de  phys.,  1888, 
their  studies  on  intravenous  injections  of  water,  in  which  it  was 
demonstrated  that,  by  observing  certain  precautions,  a  considerable 
quantity  of  water  can  be  introduced  into  the  circulatory  apparatus 
without  causing  any  accidents  to  the  animal.  The  injected  liquid 
passes  from  the  blood  into  the  tissues,  returns  back  into  the  blood, 
and  the  excess  of  water  is  finally  rejected  by  the  kidneys. 

It  was  shown  also  that  the  rejected  excess  of  water  did  not  contain 
any  essential  elements  to  nutrition,  but  indifferent  ingredients  and  urea 
particularly  wras  swept  away  by  the  process  of  lavation. 

On  the  strength  of  this,  the  authors  expected  that,  in  case  of  blood 
infection,  lavation  of  the  blood  would  lead  to  artificially  increased  elim¬ 
ination  of  harmful  substances  introduced  into  the  system  either  directly 
or  by  intoxication.  In  all  cases  of  experimental  intoxication  where  the 
method  of  lavation  was  used,  though  the  quantity  of  secreted  urine  was 
increased,  the  animals  succumbed  always  an  hour  before  those  in  which 
the  disease  was  left  to  its  natural  course. 

The  authors  suggest  two  points  in  explanation  of  the  acceleration 
of  the  course  of  infection :  First,  under  the  influence  of  the  operation 
of  lavation  the  vital  resistance  is  considerably  diminished ;  this  diminu¬ 
tion  is  of  little  consequence  in  the  normal  organism,  but  under  patho¬ 
logical  conditions  serves  to  aggravate  symptoms.  Secondly,  by  lava¬ 
tion  infectious  matter  is  diffused  and  distributed  in  all  parts  of  the 
body,  and  this  hastens  to  lessen  the  vital  resistance  of  the  tissues. 

The  presumption  that  the  increased  elimination  of  urine  would  in¬ 
terfere  with  or  compensate  for  the  artificial  supply  of  poison  in  the  ex¬ 
periments  not  having  been  realized,  the  authors  suppose  that  either  the 
toxic  matter  generated  by  the  microbes  is  not  at  all  filtered  by  the 
kidneys,  or  else  this  is  done  in  a  deficient  measure.  Upon  this  subject 
they  expect  to  dwell  in  future. 

The  Passage  of  Oxyhaemoglobin  into  the  Gall-bladder  after  Death. 

— MM.  E.  Wertheimer  and  E.  Meyer  (id.,  No.  26,  1889)  relate  that  the 
gall-bladder  taken  from  an  animal  that  was  killed  two  or  three  hours 
previously  contains  almost  always  oxyhemoglobin.  Experiments  con¬ 
tradict  the  hypothesis  that  this  is  due  to  post-mortem  secretion  that 
is  furnished  by  the  dead  hepatic  cells,  v'hose  diminished  activity  leads 
to  incomplete  elaboration  of  the  coloring  matter  of  the  blood. 

The  experiments  consist  in  ligating  the  cystic  duct  immediately 


after  the  death  of  the  animal ;  the  oxyhaemoglobin  occurs  as  before ; 
the  same  takes  place  on  extirpating  the  gall-bladder  and  exposing  it  to 
the  air  for  several  hours. 

The  explanation  given  is  that  it  depends  upon  a  cadaveric  phenome¬ 
non  the  mechanism  of  which  is  probably  the  following:  The  vesicular 
epithelial  lining  losing  its  vitality,  allows  transudation  of  the  bile 
through  it  and  its  blood-vessels  ;  the  red  blood  cells  are  dissolved  by 
the  action  of  the  bile,  the  oxyhaemoglobin  is  discharged,  and  then  dif¬ 
fuses  toward  the  cavity  of  the  gall-bladder,  mixing  at  the  same  time 
with  the  bile  contained  therein. 

The  same  observations  have  been  made  on  different  animals,  dogs, 
rabbits,  guinea-pigs,  and  on  some  specimens  of  bile  taken  from  cada¬ 
vers.  • 

The  authors  had  announced  as  a  peculiarity  the  fact  of  the  almost 
constant  presence  of  oxyhaemoglobin  in  the  bile  of  animals  with  an  arti¬ 
ficially  reduced  temperature.  At  present  they  are  enabled  to  interpret 
the  fact,  and  do  not  admit  now  the  peculiarity  to  depend  upon  the  arti¬ 
ficially  reduced  temperature.  The  more  constant  presence  of  oxyhsemo- 
globin  in  the  bile  of  animals  that  died  a  normal  death  than  in  that  of 
animals  killed  by  means  of  freezing  is  ascribed  to  the  reduced  vitality 
of  the  hepatic  cells  in  the  latter. 

It  is  suggested  that  it  might  prove  of  service  in  legal  medicine 
to  determine  the  exact  moment  of  the  occurrence  of  the  cadaveric 
alteration,  having  as  a  guide  the  occurrence  of  oxyhaemoglobin  in  the 
bile. 

On  Nutrition  in  Hysteria. — The  literature  on  the  subject  shows  that 
all  authors  agree  with  M.  Empereur,  who,  in  his  essay  on  the  nutrition 
in  hysteria  (1876),  concluded  that  the  assimilation  in  hysterical  subjects 
wms  absent,  because  disassimilation  did  not  take  place.  He  formulated 
the  same  by  saying  :  “  Elies  ne  maigrissent  pas  parce  qu’elles  ne  deper- 
dent  rien,  et,  ne  deperdant  rien,  il  leur  est  inutile,  sinon  nuisible,  de 
manger.”  M.  Gilles  de  la  Tourette  (id.,  No.  30,  1889),  with  his  interne 
in  pharmacy,  M.  H.  Cathelineau,  undertook  to  contribute  to  the  same 
question  on  the  ground  of  the  urinary  excreta  in  hysterical  patients  of 
both  sexes.  They  divide  the  patients  into  two  groups  :  1,  normal, 
and  2,  pathological  hysterical  patients,  the  first  being  those  that  pos¬ 
sess  permanent  physical  stigmata  establishing  the  diagnosis  of  the  neu¬ 
rosis,  and  the  second  those  presenting,  in  addition,  the  series  of  the 
various  accidents  characterizing  a  full  hysterical  fit. 

I.  Ten  hysterical  persons  of  the  first  group,  including  seven  women 
and  three  men,  wrere  examined,  and  it  was  found  that,  though  it  was 
true  that  they  did  not  accept,  as  a  rule,  the  ordinary  food,  yet  in  the 
particular  food  that  they  often  had  a  desire  for  exclusively  they  found 
enough  of  nourishing  material  sufficient  to  keep  even  a  normal  person 
in  a  good  condition  of  health.  From  seventy-nine  analyses  of  specimens 
of  urine  voided  in  the  twenty-four  hours,  the  examination  having  refer¬ 
ence  to  the  volume,  solids,  urea,  and  phosphoric  acid,  the  authors  con¬ 
clude  that  iu  what  they  called  normal  hysterical  patients  the  nutrition 
differs  in  no  respect  from  that  in  normal  persons. 

II.  In  the  patients  of  the  second  group  the  pathological  phenomena 
regarding  the  attack  were  studied  specially  with  regard  to:  1,  the  con¬ 
vulsive  attack  in  four  periods ;  2,  the  attack  limited  to  one  of  these 
periods,  or  having  in  this  period  a  predominating  epileptoid,  lethargic 
form,  etc. ;  3,  the  attack  of  the  type  of  partial  epilepsy;  4,  the  attack  of 
rhythmic  chorea,  cough,  yawning,  etc. 

The  urinary  analyses  for  the  twenty-four  hours,  comprising  the  time 
from  the  beginning  to  the  end  of  the  attack,  enable  the  authors  to  state 
that  in  a  convulsive  and  the  various  other  hysterical  attacks  there  is — 
1,  decrease  of  the  urinary  solids,  of  the  urea  and  phosphates ;  2,  the 
ratio  of  the  earthy  to  the  alkaline  phosphates  being  normally  as  1  to  3, 
becomes  during  an  attack  as  1  to  2,  and  often  as  1  to  1.  This  the  au¬ 
thors  called  inversion  of  the  formula  of  phosphates. 

The  volume  of  the  urine  for  the  twenty-four  hours  is  more  frequent¬ 
ly  diminished,  though  the  first  micturition  following  the  attack  is  gen¬ 
erally  greater  than  an  ordinary  one,  and  this  leads  to  the  polyuria,  when 
the  latter  exists. 

The  authors  think  that  chemically  the  various  grave  forms  of  hys¬ 
teria— epileptoid,  cataleptic,  delirious,  lethargic,  etc. — are  to  be  con¬ 
sidered  simply  as  prolonged  hysterical  attacks  with  accentuation  of  all 
phenomena  that  are  observed  in  a  simple  attack. 


August  2,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


137 


From  the  study  of  the  curve  of  urinary  excreta  during  the  period  of 
an  attack  it  is  concluded  that  there  is  a  decrease  in  the  urinary  ele¬ 
ments  in  the  beginning  of  the  attack,  then  a  return  to  the  normal,  and 
finally  an  increase  before  the  discharge  of  the  attack.  This  increase, 
it  is  said,  before  and  during  the  day  of  the  attack  does  not  depend  upon 
the  alimentation ;  the  latter  has  been  negative  in  most  of  the  patients 
that  were  under  observation  during  the  attacks.  It  is  inferred  from 
the  fact  that  the  phenomena  are  dependent  upon  the  hysterical  attack 
itself,  and  not  upon  inanition. 

Clinically  the  importance  attached  to  the  fluctuation  of  the  curve  of 
the  urinary  excretions  is  that  it  enables  to  foresee  the  extent  of  the  du¬ 
ration  of  the  coming  attack,  and  to  predict  the  return  to  the  normal 

condition. 

Regardless  of  the  variety  of  the  attack,  the  body  is  said  to  lose  in 
weight  during  this  period,  and,  according  to  its  duration,  from  200  to 
300  grammes  per  day,  and  to  return  rapidly  to  the  normal  after  the 

attack. 

The  statements  are  illustrated  by  the  following  tables  of  urinary 
analyses  : 

Comparison  between  Partial  Symptomatic  and  Partial  Hysterical  Epi¬ 
lepsy. 


Patient, ' 
age  34  ; 
weight, 
72  kilos. 
Patient, < 
age  48 ; 
weight, 
58  kilos,  j 
Patient,  | 
age  29 ;  | 
weight,  I 
49  kilos.  I 


Coexistence  and 


ME. 

Volume 

of  Solids, 

urine*  j 

Urea.* 

PHOSPHORIC  ACID. 

Earthy. 

Alka¬ 

line. 

Total. 

C.C.  |  Grin. 

Grm. 

Grm. 

Grm. 

Grm. 

Normal 

1,450  |  45-00 

2315 

0-66 

1-87 

253 

state. 

Access. 

1,700  '  49-20 

61-20 

1-07 

2-48 

3-55 

Normal 

1,200  43-60 

19-00 

0-49 

1-46 

1-95 

state. 

Access. 

1,260  53*00 

22  00 

065 

1-75 

2-40 

Normal 

1,080  45-20 

19-50 

2-17 

state. 

Access. 

910  30-80 

855 

1-70 

37  to  100 
43  to  100 
35  to  100 
37  to  100 


Patient, 
age  21  ; 
weight, 
72  kilos. 
Patient, 
age  28; 
weight, 
51  kflos. 


Differentiation  of  an  Hysterical  Attack  and  an  Epilep¬ 
tic  Access  in  the  same  Person. 


)  Normal 
I  state. 
Hysteria. 
J  Epilepsy. 
1  Normal 
state. 


Normal 

1,150 

44-40 

22-00 

0-70 

1-72 

2-42 

40  to  100 

state. 

Attack. 

1,350 

33  00 

1400 

0-56 

0-92 

1-48 

63  to  100 

Access. 

1.320 

48-00 

27-00 

0-87 

2-05 

2-92 

42  to  100 

Normal 

1,200 

52-15 

2400 

0-57 

1-73 

2-30 

32  to  100 

state. 

Attack. 

1,190 

41-00 

18-00 

0-76 

1  20 

1-96 

63  to  100 

Access. 

1,150 

56-20 

3105 

0-69 

1-88 

2-57 

36  to  100 

f  Hysteria. 
J  Epilepsy. 


On  the  strength  of  the  urinary  analysis,  M.  Empereur’s  conclusions 
ire  pronounced  erroneous. 

It  is  shown  in  the  table  that  chemically  a  hysterical  constitutes  the 
everse  of  an  epileptic  attack.  An  attack  of  true  or  partial  symptom- 
itic  epilepsy  is  to  be  recognized  by  the  considerable  elevation  of  the 
irinary  constituents,  whereas  a  hysterical  attack  in  shape  of  any  of  its 
various  torms  is  to  be  recognized  by  a  considerable  diminution  of  the 
<ame.  In  two  cases  of  hysteria  with  stigmata  without  attacks  the  au- 
hors  recognized  the  coexistence  of  true  epileptic  accesses.  In  conclusion, 
t  is  said  that  this  work  is  the  first  that  positively  establishes  the  diag- 
losis  in  doubtful  cases. 

Anaesthesia  in  Frogs  by  Deficiency  of  Oxygen  (Presented  by  M. 
dorat).  M.  Reboul  (id.,  No.  22,  1889)  produces  asphyxia  in  the  frog 
ither  by  exclusion  of  air  or  keeping  it  in  a  vessel  with  inert  gas ;  after 
l-  certain  time  the  frog  becomes  immobilized  and  insensible.  With 
(reservation  of  the  circulatory  movements  the  frog  gives  all  symptoms 
ibserved  in  ordinary  anaesthesia.  Exposing  it  to  the  air,  it  gradually 
eturns  to  the  normal. 

The  author  suggests  the  use  of  this  method  of  anesthetization  for 
elicate  experimental  work  on  cold-blooded  animals.  Physiologically,  the 
act  is  mentioned  to  be  of  interest  from  the  view  that,  under  the  influ- 
nce  of  asphyxia  by  privation  of  oxygen,  the  properties  of  the  nervous 
ystem  disappear  gradually  in  the  order  observed  under  the  action  of 
he  ordinary  anaesthetics. 

On  the  Lowering  of  the  Body  Temperature  in  Men  after  suggested 
■oss  of  Sensibility  to  Heat  and  Cold.— M.  M.-J.  Mares  (id.,  No.  24,  1889) 


Relation  , 
between  ! 

the  phos-  Observations, 
phoric  I 
acids.  I 


Partial 
!  symp- 
r  tomatic 
epilepsy. 


Partial 

hysteri¬ 

cal 

epilepsy. 


had  stated  that  in  mammalia  the  hibernal  sleep  was  a  hypnotic  phe¬ 
nomenon  in  which  the  animal  lost  the  sensibility  of  cold,  which  is  the 
principal  regulator  of  temperature  in  hmmothermic  animals  ;  that  by 
artificially  reducing  the  body  temperature  a  warm-blooded  animal  was 
converted  into  a  cold-blooded  one,  and  fell  into  hibernal  sleep.  With 
the  return  of  the  sensibility  to  cold  there  is  an  increase  in  the  production 
of  heat  by  reflex  way ;  the  animal  resumes  the  physiological  tempera¬ 
ture  and  is  free  from  hibernal  sleep.  On  the  strength  of  this  theoretical 
consideration,  M.  J.  Mares  undertook  a  series  of  hypnotic  experiments 
which  proved  fruitless  on  animals  but  successful  on  men.  The  results 
are  elaborately  represented  in  figures  that  show  the  decided  influence 
of  suggested  loss  of  sensibility  to  cold  and  heat  on  the  physiological 
temperature. 

In  one  case  the  sublingual  temperature  is  recorded  to  have  been 
37T  C.  at  8.30  a.  m.,  and  34-5°  C.,  after  the  suggestion,  at  8.30  p.  m. 
In  another  the  figures  were,  respectively,  3 7°  C.  at  8.30  a.  m.,  and  35-5° 
C.  at  8.30  p.  m.,  after  suggestion. 

In  both  cases,  after  restitution  of  the  sensibility  to  cold,  all  un¬ 
pleasant  symptoms  subsided,  and  the  temperature  returned  to  the 
normal. 

The  phenomenon  is  supposed  to  be  due  to  disturbance  in  the  regula¬ 
tion  of  the  temperature  caused  by  the  hypnotic  suggestion  of  loss  of 
sensibility  to  cold,  by  virtue  of  which  the  external  loss  of  body  heat 
surpasses  the  proportionate  internal  supply,  until  finally  the  thermic 
source  is  exhausted  and  there  is  actual  interference  with  the  normal 
equilibrium  between  the  loss  and  repair  of  heat  production. 

MM.  Mares  and  Hellich  think  for  this  reason  that  the  influence  of 
suggestion  is  not  limited  to  the  functions  of  volition  and  consciousness  ; 
they  do  not  accept  Bernheim’s  statement  of  the  suggestive  influence 
being  purely  psychical. 

It  is  further  said  that  the  lowering  of  the  body  temperature  subse¬ 
quent  to  suggested  loss  of  sensibility  to  cold  and  heat  is  a  physiologi¬ 
cal  experiment  indicating  the  causal  connection  between  the  sensibility 
to  cold  and  the  production  of  heat,  and  that  this  sustains  the  doctrine 
deduced  from  experiments  by  physico-chemical  methods  that  the  sensi¬ 
bility  of  the  nervous  system  to  heat  and  cold  is  the  main  regulator  of 
the  constancy  of  temperatue  in  warm-blooded  animals. 

It  is  put  forward  as  a  proved  fact  that  hibernal  sleep  is  a  hypnotic 
phenomenon  in  which  the  animal  loses  sensibility  of  cold,  and  that  men 
too,  by  losing  sensibility  to  temperature,  fall  into  hibernal  sleep  or  ap¬ 
parent  death.  The  surprising  tales  about  the  Indian  fakirs  seem  to  the 
authors  to  depend  upon  auto-hypnosis  leading  to  loss  of  sensibility, 
which  is  followed  by  complete  inertia  of  the  nervous  system  suspending 
all  vital  functions. 

On  the  Influence  of  Oxygen  Inhalations  on  the  Variation  of  the 
Respiratory  Rhythm  in  Diphtheritic  Patients.— In  the  Children’s  Hos¬ 
pital  M.  P.  Langlois  (id.,  No.  13,  1889)  has  experimented  on  children 
with  infectious  diphtheritic  angina  without  the  existence  of  a  false 
membrane  in  either  the  larynx  or  the  trachea,  and  on  those  that  pre¬ 
sented  all  the  symptoms  of  croup  before  and  after  tracheotomy.  About 
thirty  litres  of  oxygen  were  used  for  each  case  within  from  twenty  to 
twenty-five  minutes.  The  respiratory  tracings  were  taken  by  means  of 
Marey’s  double  cardiograph. 

The  modifications  of  the  form  of  the  respiratory  movements  under 
similar  circumstances  had  been  studied  already  by  Ledoux-Levard 
(Recherches  sur  la  respiration  dans  le  croup ,  These,  1881),  and  the  au¬ 
thor  paid  special  attention  to  the  variation  in  the  frequency  of  the  same 
movements. 

Acceleration  of  the  respiratory  rhythm  during  the  oxygen  inhala¬ 
tions  was  observed  as  a  constant  result.  It  begins  with  the  inhalation 
and  lasts  as  long  as  this  is  maintained. 

Though  the  frequency  of  the  respiration  is  increased,  it  is  of  a  less 
dyspnoeic  character.  Both  inspiration  and  expiration  are  more  brisk 
and  energetic,  and  performed  with  less  difficulty.  The  child  is  more  in 
a  condition  of  polypnoea  than  of  dyspnoea. 

The  acceleration  of  the  respiratory  rhythm  caused  by  oxygen  inhala¬ 
tions  seeming  to  be  in  contradiction  with  Rosenthal’s  statement  of  the 
role  of  anoxaemia  as  an  exciting  agent  of  the  respiratory  center,  M. 
Langlois  explains  as  follows :  Under  the  influence  of  prolonged  sub¬ 
asphyxia  depending  upon  laryngeal  stenosis,  and  perhaps  upon  the 


138 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jouk., 


specific  action  of  the  secreted  septic  product  of  the  diphtheritic  micro¬ 
organisms,  the  entire  organism,  and  the  bulbar  centers  particularly,  are 
oppressed,  which  causes  diminution  in  the  respiratory  incitations.  But 
under  the  influence  of  the  inhaled  oxygen  the  superoxidation  of  the 
blood  diminishes  the  vital  depression,  and  the  child  reacts  quickly  in 
resuming  sufficient  pulmonary  ventilation. 

Haematospectroscopic  Notes  on  Hysterical  and  Epileptic  Subjects. — 
M.  Ch.  Fere  (id.,  No.  7,  1889)  has  reported  the  comparative  examina¬ 
tions  of  hysterical  and  epileptic  subjects,  and  has  found  the  duration  of 
reduction  to  be  longer  on  the  anaesthetic  side  in  hysterical  persons.  The 
duration  of  the  disappearance  of  the  principal  haemoglobin  band  in  the 
same  varies  greatly,  and  the  conditions  of  such  variations  can  often 
be  determined.  Thus,  in  induced  sleep  it  is  augmented ;  there  is 
decided  augmentation  especially  in  lethargia;  in  one  such  case  the 
duration  amounted  to  88",  instead  of  72",  and  in  another  to  82",  instead 
of  63".  In  somnambulistic  subjects  the  duration  of  reduction  can  be 
varied  either  by  inducing  different  emotional  conditions  or  simply  by 
exciting  the  organs  of  special  senses.  M.  Henocque  had  already  men¬ 
tioned  that  in  normal  subjects  muscular  exercise  and  massage  lead 
to  augmentation  of  the  activity  of  reduction ;  the  momentary  effect 
of  muscular  exercise,  massage,  hydrotherapy,  and  static  electricity 
is  to  increase  decidedly  the  activity  of  reduction  in  hysterical  persons. 
The  influence  of  cutaneous  excitations,  or  of  excitations"  of  the  special 
senses,  is  manifested  with  the  same  intensity.  Suggested  emotions  in 
somnambulism,  persisting  during  the  period  of  consciousness,  give 
analogous  variations  ;  sthenic  emotions  are  accompanied  by  a  diminu¬ 
tion,  and  asthenic  by  an  augmentation  of  the  duration  of  reduction. 

With  reference  to  the  phenomena  of  nutrition  in  relation  to  the  nor¬ 
mal  psychical  conditions,  Apjohn  ( Dublin  Hosp.  Rep.,  1830,  v,  p.  532) 
had  contributed  an  observation  on  his  own  person,  stating  that  there 
was  considerable  diminution  of  the  exposed  carbon  dioxide  under  the 
influence  of  temporary  mental  depression. 

M.  Fer6  has  been  enabled  to  observe  in  hysterical  persons,  in  whom 
the  activity  of  reduction  is  already  decreased,  a  still  further  augmenta¬ 
tion  of  the  duration  of  reduction  under  the  influence  of  suggested  de¬ 
pressive  emotions. 

The  lowering  of  the  nutritive  process  is  in  relation  not  only  with 
depressive  emotions,  but,  too,  according  to  M.  Henocque,  with  the  men¬ 
tal  or  physical  fatigue,  and  subsequently  with  exaggerated  activity  fol¬ 
lowing  marked  peripheral  or  mental  excitations.  In  case  the  duration 
of  reduction,  under  these  conditions,  is  not  increased,  it  is  to  be  ascribed 
to  the  fact  that  excessive  nervous  discharges  are  apt  to  be  followed  by 
a  diminution  of  the  quantity  of  oxyhsemoglobin. 

Accidental  lowering  of  nutrition,  occurring  in  the  course  of  mental 
depression  and  subsequent  to  marked  excitations,  can  serve  as  a  basis  of 
explanation  of  the  fact  that  any  nervous  discharges — such  as  psychical 
or  mental  fatigue,  traumatic  or  moral  shock — are  apt  to  contribute  to  the 
diminution  of  the  feeble  nutritive  activity  of  certain  subjects,  and  in¬ 
duce  what  M.  Bouchard  called  “  maladies  par  ralentissement  de  la  nutri¬ 
tion,”  this  affection  being  more  apt  to  manifest  itself  on  the  side  of  the 
body  previously  predisposed  by  other  disturbances.  The  diminished  re¬ 
sistance  to  intoxication  and  infectious  diseases  under  the  influence  of  de¬ 
pressing  conditions  is  to  be  explained  by  the  existing  diminished  nutri¬ 
tive  processes.  The  knowledge  of  the  modifications  of  the  activity  of 
exchanges,  under  the  influence  of  peripheric  excitations,  that  might  be 
manifested  as  either  mental  or  moral  emotions,  contributes  to  the  ad¬ 
mission  of  the  intimate  correlation  between  the  psychical  and  moral 
conditions.  Comparing  the  variation  of  the  duration  of  the  oxyhasmo- 
globin  reduction  with  that  of  the  time  of  reaction  in  hysterical  per¬ 
sons,  M.  Fere  says  (id.,  1889,  p.  671,  Note  sur  le  temps  de  reaction 
chez  les  hvsteriques  et  les  epileptiques)  it  is  evident  that  both  phe¬ 
nomena  undergo  parallel  variations  under  the  same  influences.  Though 
it  is  impossible  to  establish  definite  proportions,  it  is  permissible  to 
state  that  the  duration  of  the  time  of  reaction  varies  as  the  duration  of 
the  oxyhaemaglobin  reduction,  or,  as  the  author  states,  in  other  words, 
the  time  of  intellectual  activity  is  in  relation  with  the  activity  of  nutri¬ 
tion.  Mental  pathology  can  furnish,  it  is  said,  other  illustrations  dem¬ 
onstrating  that  intelligence  is  a  function  of  the  nutrition.  With  M. 
Henocque,  the  author  refers  to  the  diminution  of  the  activity  of  the 
oxyhaemoglobin  reduction  in  epileptics,  adding  that  this  accident  coin¬ 


cides  with  the  existence  of  a  reduced  quantity  of  oxyhaemoglobin  in  the 
blood,  as  he  found  it  in  his  observations  on  epileptic  patients  to  be 
nine  per  cent.,  whereas,  according  to  M.  Henocque,  general  patients 
of  the  hospital  present  thirteen  per  cent,  of  oxyhaemoglobin.  Among 
the  different  causes  that  could  account  for  the  decidedly  reduced  per¬ 
centage  of  oxyhaemoglobin  in  epileptics  the  author  is  convinced  that  an 
attack  is  the  main  factor,  for  always  after  the  attack  he  found  the  rela¬ 
tive  reduction  to  amount  to  from  one  to  two  percent.,  this  disappearing 
within  the  few  days  following  the  attack. 

The  reduction  manifests  itself  not  immediately  following  the  attack, 
but  some  time  after,  which  has  not  been  determined  as  yet ;  it  amounts 
to  over  three  per  cent.,  regardless  even  of  the  forced  alimentation  that 
may  be  administered  to  the  patient.  This  fact,  it  is  said,  corresponds 
with  the  statement  of  the  decreased  quantity  of  oxyhaemoglobin  sub¬ 
sequent  to  intense  nervous  discharges ;  it  serves  also  to  explain  the  oc¬ 
currence  of  acute  anaemia  consequent  on  violent  emotions  (D.  Duck¬ 
worth,  On  Acute  Anaemia  due  to  Fright,  Brit.  Med.  Jour.,  1873,  ii,  p. 
226). 

The  author  thinks  it  possible  that  the  blood  alteration  is  an  impor¬ 
tant  factor  in  the  cause  of  death  during  the  stage  of  an  epileptic  attack. 

All  this  goes  to  show  the  relation  and  coincidence  of  mental  troubles 
with  defective  nutrition.  The  deductions  from  that  knowledge  and  the 
practical  indication  based  on  the  same,  M.  Fere  states,  have  already 
been  dwelt  upon  by  Weir  Mitchell. 

On  Auto-intoxication  of  Renal  Origin,  with  Elevation  of  Tem¬ 
perature  and  Dyspnoea. — M.  R.  Ldpine  (Abeille  med.,  No.  27,  1889). 
The  contrast  is  drawn  between  the  effect  of  ligating  the  ureters  and 
the  introduction  of  a  cannula  into  the  same,  the  cannula  communicating 
with  a  reservoir  that  contains  water,  to  which  some  sodium  chloride  is 
added  in  the  proportion  of  0'7  per  cent. ;  the  pressure  of  the  water  is 
made  sufficient  to  interfere  with  the  outflow  of  urine,  and  to  somewhat 
fill  the  kidney  with  this  solution.  In  case  the  ureters  are  ligated  the 
animal  succumbs  within  about  three  days ;  with  the  gastro-intestinal 
irritation  there  is  lowering  of  the  central  temperature.  In  the  second 
case  the  symptoms  of  vomiting  and  diarrhoea  are  absent,  but  foaming 
at  the  mouth  is  present ;  both  the  central  and  peripheral  temperature 
rise  progressively,  and  almost  at  the  same  time  the  respiration  assumes 
a  special  expiratory  type — is  lowered  at  first,  then  much  accelerated 
and  becomes  noisy ;  sometimes  there  is  some  subsultus  of  the  limbs ; 
the  central  temperature  continues  to  rise,  and  within  a  few  hours  the 
animal  succumbs  with  a  temperature  varying  from  40°  to  42°  C.  As 
soon  as  this  temperature  is  reached  nothing  can  prevent  the  fatal  issue, 
even  if  the  urine  is  allowed  hastily  to  flow  as  usual.  It  is  not  admitted 
that  the  accident  is  due  to  the  entrance  of  water  into  the  renal  system, 
since  intravenously  a  considerably  larger  quantity  of  saline  water  can 
be  infused  without  provoking  any  fever  or  other  disturbances ;  but  the 
water  passing  through  the  renal  system  is  charged  with  renal  inter¬ 
stitial  juice,  acquires  a  thermogenic  and  dyspnoeic  action.  The  noxious 
effect  of  this  interstitial  juice  of  the  kidneys  is  confirmed  by  the  follow¬ 
ing  experiment :  The  kidneys  of  a  dog  killed  by  acute  haemorrhage  are 
crushed  in  sterilized  water,  and  after  filtration  an  intravenous  injection 
of  the  liquid  is  made  in  a  smaller  dog.  At  the  lapse  of  four  hours  the 
central  temperature  rises  to  40'1  C.,  the  animal  is  oppressed,  there  are 
agitation  and  foaming  from  the  mouth,  the  symptoms  being  the  same 
as  those  obtained  from  an  animal  subject  to  urinary  counter-pressure. 

The  conclusion  is  that  the  healthy  kidney  contains  thermogenic,: 
dyspnoeic,  and  other  principles.  This  the  author  admits  optionally,  for 
in  his  experiments  either  one  or  the  other  poison  predominated,  as 
could  be  judged  from  the  symptoms. 

A  Case  of  Association  of  Cardiac  Inhibition  with  each  Inspiratory 
Effort. — M.  L.  Capitan  (Arch,  de  phys.  norm,  et  pathol.,  No.  3,  1889) 
quotes  Brown-Sequard's  recent  experiments,  demonstrating  that  pro¬ 
nounced  respiratory  movements — such  as  are  observed  in  dogs  that  are 
made  to  breathe  in  an  atmosphere  mixed  with  carbon  dioxide — are  apt 
to  completely  inhibit  the  heart  during  either  the  inspiratory  or  expira 
tory  act. 

The  author  had  an  opportunity  of  observing  carefully  the  occur¬ 
rence  of  similar  phenomena  in  a  human  subject. 

The  patient  poisoned  with  morphine  remained  in  complete  coma  dur 
ing  twenty-four  hours  ;  no  therapeutic  agent  could  arouse  him.  Th< 


August  2,  1890.] 


NEW  INVENTIONS. 


139 


The  improved  Loring,  which  is  now  more  in  use  than  any  other,  has 
some  objections.  Experience  has  proved  tome  and  others  that  one  can 
not  see  as  distinctly  through  two  strong  lenses  as  through  a  single  lens 
of  the  same  strength  as  the  two  combined.  Another  objection  is  that  it 
has  to  be  removed  from  the  eye  every  time  a  change  is  required,  which 
is  not  a  very  small  matter  if  one  is  pressed  for  time.  Some  other  oph¬ 
thalmoscopes  are  too  mechanical,  without  sufficient  combinations  of 


the  weaker  lenses,  and  sufficient  in  the  stronger  lenses  only  by  a  com¬ 
bination  of  two. 

The  ophthalmoscope  I  have  devised  has  two  discs — one  with  convex 
and  the  other  with  concave  lenses  of  seventeen  each,  the  numbers  of 
which  are  the  same  in  both  discs,  running,  as  you  will  see  in  the  cut,  as 
follows:  0-25  D.,  0‘50  D.,  0‘75  D.,  1  D.,  2  D.,  3  D.,  4  D.,  5  D.,  6  D. 
7  D.,  8  D.,  9  D.,  10  D.,  11  D.,  13  D.,  16  D.,  and  20  D.  The  last  eight 
have  focal  distances  in  inches— 5|",  6",  4|",  4",  3^",  3",  2-J",  and  2"— 
which  are  sufficient  without  interposing  another  lens.  Each  disc  is 
supplied  with  a  revolving  wheel  immediately  below  and  just  above  the 
handle.  Moving  down  the  wheel  on  the  right  side  increases  the 


■espiration  was  exceedingly  rapid,  deep,  regular — from  32  to  36  per 
ninute.  The  pulse  was  very  rapid,  quick,  tolerably  strong  and  regular — 
from  160  to  180  per  minute.  Toward  the  twenty-sixth  hour,  the  respi¬ 
ration  maintaining  its  previous  type,  the  pulse  presented  a  rhythmical 
rregularity  with  distinct  periods  of  suspension,  and  within  the  four 
succeeding  hours  was  characterized  by  the  following  peculiarities  :  The 
expiration  lasted  from  one  to  one  second  and  a  fraction  ;  during  this 
period  five  pulsations  could  clearly  be  counted.  At  the 
moment  of  the  beginning  of  inspiration  the  pulse  was  sus¬ 
pended,  and  no  pulsation  could  be  felt  during  the  entire 
period  of  inspiration,  which  lasted  for  about  half  a  minute. 

With  the  commencement  of  expiration  the  pulse  reap¬ 
peared,  beating  again  five  times  during  this  period.  The 
cardiac  beats  could  not  be  obtained  distinctly  for  the 
reason  of  the  presence  of  numerous  rales  in  the  chest. 

This  cardiac  inhibition  during  inspiration  lasted  in  a  very 
regular  manner  until  the  thirty-sixth  hour.  Both  respira¬ 
tion  and  pulse  diminished  in  amplitude  and  intensity  re¬ 
spectively,  the  former  having  ceased  progressively,  then 
the  pulse,  which  presented  the  same  peculiarity  to  the 
ast  during  one  of  the  acts  of  respiration. 

The  author  thinks  that  the  fact  confirms  distinctly 
Brown-Sequard’s  statement. 

Appearance  of  Red  Marrow  in  a  Case  of  Acute 
Anaemia. — M.  Lepine  ( Lyon  medical ,  No.  22,  1889)  pre¬ 
sented  to  the  Societe  des  sciences  medicales  a  trans¬ 
verse  section  of  the  superior  portion  of  the  femur,  taken 
from  a  woman  seventy  years  of  age,  who  had  died  of 
icute  haemorrhage.  The  bone  marrow  was  colored  red, 
is  in  infants,  instead  of  being  adipose. 

M.  Augagneur  questions  whether  the  profound  anae¬ 
mia  in  tertiary  syphilis  has  not  its  origin  in  the  bone 
esions,  taking  into  consideration  the  persistence  of  in¬ 
terference  with  haematosis  and  its  being  accompanied 
with  the  train  of  symptoms  of  osteocopic  pains  and  gum¬ 
matous  infiltration  of  the  bones. 

M.  Lepine  states  that  in  similar  syphilitic  cases  he 
las  found  in  the  red  marrow  large  cells  holding  in  their 
nterior  blood  cells.  The  former  are  supposed  to  absorb 
he  latter,  and  then  destroy  them. 

In  this  connection  Cohnbeim  is  quoted,  in  his  de¬ 
scription  of  red  marrow  containing  cells  of  a  transitory 
ype  between  marrow  and  blood  cells. 

M.  Lepine  thinks,  without  giving  actual  demonstration,  that  this 
special  coloration  of  the  marrow  is  met  with  in  the  bones  of  the  entire 
skeleton;  he  has  found  this  in  the  stermun,  humerus,  and  femur.  M. 
Augagneur  thinks  the  characteristic  of  the  marrow  is  the  presence  of 
vhat  are  called  myeloplaxes  containing  red  cells,  which  are  considered 
)y  some  authors  as  the  result  of  inflammation. 


Jleto  Jfitbenfions,  etc. 


strength  of  the  convex  lenses  to  the  right,  and  moving  down  the  wheel 


A  NEW  OPHTHALMOSCOPE. 

By  S.  M.  Payne,  M.  D., 

LECTURER  ON  OPHTHALMOLOGY  IN  THE  NEW  YORK  POLYCLINIC  ;  ASSISTANT 
SURGEON,  MANHATTAN  EYE  ANB  EAR  HOSPITAL. 

Having  had  considerable  experience  with  various  ophthalmoscopes 
landed  to  me  by  beginners  in  ophthalmoscopy,  to  explain  their  manner 
»f  working,  and  also  the  experience  of  making  examination  of  eyes 
vith  them,  I  found  none  of  them  that  exactly  filled  the  requirements  in 
dl  cases.  In  some  of  the  single  disc  ophthalmoscopes  there  is  too 
:reat  a  difference  in  the  strength  of  the  lenses  to  make  a  minute  ex- 
nnination  of  the  fundus,  corresponding  to  the  examination  made  with 
he  test  lenses.  In  other  single  disc  ophthalmoscopes  the  strongest 
ens  is  not  sufficiently  strong  to  make  a  minute  examination  of  the 
ornea  and  lens. 


on  the  left  side  increases  the  strength  of  the  concave  lenses  to  the  left. 
The  wheels  are  very  easily  manipulated  with  the  thumb  for  one  and  the 
index  finger  for  the  other.  In  measuring  an  eye  to  correspond  with 
the  result  obtained  by  the  test  lenses,  every  025  D.  can  be  obtained, 
on  either  disc,  up  to  11  D„  by  placing  0‘75  D.,  OoO  D.,  0'25  D.  of  the 
opposing  disc  over  each  successive  lens,  after  the  first  four  lenses, 
which  differ  by  0'25  D.,  without  combination ;  and  every  1  D.  from  1 1 
D.  to  20  D.  can  be  obtained  by  placing  of  the  opposing  disc  1  D.  over 
13  D.,  2  D.  and  1  D.  over  16  D.,  and  3  D.,  2  D.,  and  1  D.  over  20  D. 
A  ou  will  notice  that  the  strongest  lens  used  in  combination  with  a 
strong  lens  is  3  D.,  which  is  used  only  to  make  one  combination,  2  D. 
only  two,  and  1  D.  only  three  combinations.  The  combinations  of  the 
opposing  1  D.,  2  D.,  and  3  D.  are  only  necessary  in  the  refraction  of  a 
high  degree  of  myopia,  as  the  refraction  of  hypermetropic  eyes  does  not 
run  higher  than  1 1  D.,  including  aphakia.  Another  good  feature  of  its 


140 


MISCELLANY. 


[N.  Y.  Mkd.  Jons. 


working  is  that,  while  looking  at  the  front  of  an  eye  with  the  +  20  D., 
one  downward  move  of  the  right  wheel  brings  the  fundus  into  view ;  by 
looking  only  through  the  aperture,  if  very  indistinct,  one  upward  move 
of  the  left  wheel  will  bring  —  20  D.  over  the  aperture,  two  moves 
—  16  D.,  and  so  on,  quickly  finding  if  myopia  exist,  and  the  amount. 
Every  turn  of  one  or  both  discs  will  give  any  combination  found  in  the 
most  complete  test  case  without  taking  the  ophthalmoscope  from  the 
eye.  The  mechanical  construction  of  the  instrument  has  been  very 
perfectly  carried  out  by  Messrs.  GaNun  &  Parsons,  opticians,  of  5 
West  Forty-second  Street. 

266  Madison  Avenue. 


Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  July  26th : 


CITIES. 

Week  ending — 

Estimated  popu¬ 
lation. 

Total  deaths  from 
all  causes. 

DEATHS 

FROM 

— 

09 

01 

© 

x: 

O 

© 

> 

* 

_c 

>* 

K 

S. 

12 

S 

y 

© 

.© 

*C 

CC 

> 

c2 

’E 

* 

> 

01 

> 

«2 

3 

XZ 

>> 

h 

B 

> 

p 

o 

© 

a 

K 

© 

> 

© 

t- 

8 

C f) 

ei 

X 

4 

xz 

xz 

Ch 

5 

00 

© 

1 

© 

JS 

1 

bfi 

•2  XZ 
§•  =? 
M  S 
is 

New  York,  N.  Y. 

July  19. 

1,633,748 

941 

5 

7 

13 

11 

15 

Philadelphia,  Pa . 

1,064,277 

553 

13 

2 

10 

1 

9 

Brooklyn,  N.  Y . 

July  19. 

'871,852 

523 

1 

2 

17 

2 

11 

Baltimore,  Md . 

500,343 

248 

9 

1 

4 

1 

3 

St  Louis,  Mo . 

July  12 

450^000 

198 

2 

3 

3 

2 

Boston,  Mass . 

July  19. 

420^000 

219 

1 

7 

i 

Cincinnati,  Ohio . 

July  18. 

325,000 

123 

6 

7 

Cleveland,  Ohio . 

June  28. 

260^000 

77 

6 

2 

1 

3 

Cleveland,  Ohio . 

July  5. 

260^000 

93 

4 

1 

5 

Washington,  D.  C  . . . 

July  19. 

250,000 

122 

in 

1 

1 

Pittsburgh,  Pa . 

July  19. 

240,000 

125 

6 

5 

5 

Louisville,  Ky . 

July  19. 

227,000 

73 

4 

i 

Minneapolis,  Minn... 

July  12. 

200,000 

51 

1 

2 

M inneapolis,  Minn. . . 

July  19. 

200,000 

60 

1 

2 

Kansas  City,  Mo . 

July  12. 

150,000 

70 

3 

Rochester,  N.  Y . 

July  6. 

130,000 

23 

Rochester,  N.  Y . 

July  12. 

130,000 

45 

1 

1 

Providence,  R.  I . 

July  19. 

130,000 

62 

Richmond,  Va . 

July  12. 

100^000 

37 

1 

Nashville,  Tenn . 

July  19. 

72,256 

38 

« 

1 

1 

Fall  River,  Mass . 

July  19. 

69*000 

48 

Charleston,  S.  C. . 

Julv  19. 

60,145 

34 

2 

1 

Toledo,  Ohio . 

July  19. 

50.000 

26 

1 

1 

Manchester,  N.  H. . . . 

July  19. 

43,700 

Portland,  Me . 

July  19. 

42,000 

12 

1 

Galveston,  Texas _ 

July  4. 

40.000 

18 

Galveston,  Texas. . . . 

July  11. 

40,000 

12 

1 

Binghamton,  N.  Y . . . 

July  19. 

35,000 

13 

Yonkers,  N.  Y . 

July  19. 

31,949 

22 

1 

Newport,  R.  I . 

Julv  17. 

19,  66 

2 

1 

Rock  Island,  Ill . 

July  13. 

16,000 

3 

Pensacola,  Fla . 

July  12. 

15,000 

11 

2 

* 

Poisoning  by  Antifebrine. — “  Dr.  J.  Vierhuff,  of  Subbath,  in  Cour- 
land,  communicates  to  the  St.  Petersburger  medicinische  Wochenschrift 
the  notes  of  a  case  of  antifebrine  poisoning,  which  show  what  dangers 
people  run  who  dose  themselves  with  drugs  of  this  class.  A  healthy 
young  married  woman,  who  had  been  in  the  habit  of  taking  antifebrine 
for  headache,  feeling  the  pain  come  on  early  one  morning  last  summer, 
took,  fasting,  about  a  teaspoonful  of  the  drug  in  some  water.  In  about 
ten  minutes,  the  headache  not  being  relieved,  she  repeated  the  dose, 
which  her  husband  remarked  might  prove  dangerous.  She  consequent¬ 
ly  took  a  glass  of  milk  and  some  alum  water  in  order  to  produce  vomit¬ 
ing,  which  she  succeeded  in  doing,  but  immediately  afterward  giddiness, 
singing  in  the  ears,  throbbing  in  the  temples,  and  a  dull  pain  in  the 
head,  together  with  a  feeling  of  weakness,  came  on,  and  the  face  as¬ 
sumed  a  livid  hue.  When  seen  four  hours  after  the  drug  had  been 
taken  the  face  was  a  livid  color,  the  lips  blue,  the  pupils  contracted, 
but  the  heart,  temperature,  and  mental  condition  were  normal.  An 
aperient  and  a  stimulant  were  ordered.  Shortly  afterward  the  patient 
became  suddenly  collapsed,  the  pulse  could  not  be  counted,  and  the 
breathing  was  very  shallow  ;  in  fact,  the  woman  appeared  to  be  dying. 
The  soles  of  the  feet  were  brushed,  vinegar  was  rubbed  on  the  face, 
and  cold  water  sprinkled  over  the  face  and  chest ;  also  a  mixture  of 


camphorated  oil  and  ether  was  ordered  for  injecting  subcutaneously. 
While  this  was  being  procured  several  syringefuls  of  dilute  spirit,  which 
was  all  that  could  be  obtained,  were  injected  and  the  patient  was 
brought  round,  though  for  three  hours  and  a  half  her  condition  ap¬ 
peared  hopeless.  Then,  after  recovering  somewhat,  collapse  again 
came  on,  and  recourse  was  had  to  an  intravenous  injection  of  a  solution 
of  common  salt,  which  appeared  to  act  most  beneficially.  In  about 
fourteen  hours  after  the  drug  had  been  taken  the  patient  was  out  of 
danger.  After  that  she  continued  to  improve,  though  she  complained 
of  debility  and  pain  in  the  limbs  for  a  week.  Dr.  Vierhutf  remarks 
that  the  serious  symptoms  were  probably  due  largely  to  the  patient’s 
taking  the  antifebrine  on  an  empty  stomach.” — Lancet. 


ANSWERS  TO  CORRESPONDENTS. 

No.  327. — The  new  law  has  not  gone  into  effect.  If  you  have  a 
New  York  State  diploma,  you  have  only  to  register  at  the  County 
Clerk’s  office.  If  your  diploma  was  not  issued  by  a  New  York  State 
college,  you  should  have  it  certified  to  by  Dr.  Austin  Flint,  and  then 
register  at  the  County  Clerk’s  office.  • 

No.  328. — In  Buffalo. 

To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  .\ 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ■,  we  alivays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal ,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (5)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  fut 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors ,  are 
not  suitable  for.  publication  in  this  journal ,  cither  because  they  art 
too  long ,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases ,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters ,  whether  intended  for  publication  or  not ,  must  contain  the 
writer's  name  and  address ,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter ,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal ,  will  be  answered  by 
number ,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  semi  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor ,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  HEW  YORK  MEDICAL  JOURNAL,  August  9,  1890. 


#  right  n  l  Communications. 


THE  PRESCRIPTION  OF  EXERCISE.* 

By  THOMAS  M.’  BULL,  M.  D. 

It  is  the  object  of  this  paper  not  so  much  to  lay  down 
■ertain  rules  in  regard  to  the  best  method  of  developing 
he  body  by  exercise,  and  to  bring  forward  facts,  figures, 
ud  specimens  to  prove  these  statements,  as  to  lay  before 
our  minds  a  few  ideas  of  what  may  be  gained  by  exercise, 
nd  to  give  a  brief  description  of  some  general  principles 
ouching  their  application. 

I  do  not  intend  to  advance  anything  new  or  startling, 
>ut  merely  to  present  a  few  ideas,  partly  the  result  of  prac- 
ical  experience  and  partly  theoretical,  which  may  help 
omewhat  when  next  you  wish  to  prescribe  exercise. 

It  is  a  well-known  fact  that  eminent  physicians  of  the 
ame  school  even,  and  sometimes  the  attendants  at  the 
line  hospital,  treat  the  same  diseases  in  very  different,  ofteu 
1  diametrically  opposite,  ways.  Frequently  a  well-known 
ractitioner  comes  forward  with  a  series  of  cases  of  some 
avere  malady  treated  with  colored  water,  from  which  the 
jsults  were  as  good  or  even  better  than  from  the  employ - 
ient  of  regular  methods.  The  irregulars  of  every  school, 
•om  those  who  use  sugar  pellets  to  those  who  use  only  faith 
od  prayer,  are  very  fond  of  exhibiting  their  cures  and 
hallenging  comparison  with  the  regular  practitioners.  The 
lea  of  giving  specific  drugs  for  certain  diseases  is  pretty 
ell  abandoned  with  the  exception  of  a  very  few  ;  and  even 
le  famous  elixir  of  life,  which  a  few  short  months  a^o 
romised  so  much,  has  been  dropped  into  oblivion. 

It  is  owing  to  this  general  chaotic  condition  of  medi- 
nal  therapeutics  that  in  the  last  few  years  the  attention  of 
hysicians  has  been  much  more  generally  given  to  methods 
t  cure  and  prevention  which  did  not  involve  the  giving  of 
rugs.  As  a  consequence,  the  science  of  hygiene  has  been 
ore  thoroughly  investigated  lately,  and  the  therapeutic 
’es  of  such  measures  as  external  applications,  electricity, 
)ld  and  heat,  diet,  climate,  baths,  massage,  and  exercise 
e  more  often  employed  now  than  ever  before. 

It  is  only  with  the  consideration  of  the  last  of  these 
easures  that  this  paper  is  concerned,  since  ii  has  seemed 
1  me  that  not  enough  prominence  has  been  given  bv  phv- 
cians  to  the  beneficial  effects  which  come  from  muscular 
;ercise  properly  taken.  One  reason  why  physicians  have 
)t  prescribed  exercise  more  is  probably  because  they  have 
>t  had  the  time  to  look  into  the  subject  thoroughly  and 
e  what  may  be  accomplished  by  it.  Another  is  from  the 
fficulty  in  getting  busy  people  to  carry  out  these  prescrip¬ 
ts,  and  still  a  third  is  because  physicians,  not  having  a 
?ht  idea  of  how  certain  ends  were  to  be  accomplished, 
‘d  recommended  exercises  which,  although  faithfully  car¬ 
d'd  out,  would  not  achieve  what  was  wanted. 

For  a  doctor  to  tell  a  patieut  to  “  take  exercise  ”  is  about 

*  Read  before  the  New  York  County  Medical  Association,  June  16, 

90. 


equivalent  to  saying  “take  medicine,”  and  is  likely  to  be 
followed  by  about  the  same  results.  A  patient  may  injure 
himself  by  taking  exercise  of  the  wrong  kind,  quantity,  or 
intensity,  the  same  as  by  taking  a  wrong  drug  or  dose. 
The  sooner  doctors  realize  that  they  must  be  more  specific 
and  careful  in  prescriptions  of  this  character  the  better.  It 
is  also  as  important  to  make  the  exercise  pleasant  as  it  is  to 
make  medicines  palatable  ;  otherwise  it  will  not  be  taken 
regularly  or  with  any  relish.  In  order  to  prescribe  exercise 
with  benefit  it  is  necessary  to  have  clearly  before  our  minds 
what  may  be  accomplished  by  it.  The  following  seem  to 
be  the  most  common  indications  for  its  prescription  : 

1.  To  preserve  the  health  of  sedentary  people. 

2.  To  reduce  deformities. 

3.  To  alter  weight. 

4.  To  overcome  a  tendency  to  hereditary  and  organic 
disease. 

I.  Every  physician  is  familiar  with  the  long  list  of  ills 
which  are  certain,  sooner  or  later,  to  fasten  on  those  who 
lead  strictly  sedentary  lives — headache,  nervousness,  sleep¬ 
lessness,  neuralgias,  disorders  of  the  stomach  and  liver,  con¬ 
stipation,  haemorrhoids,  and  the  thousand  and  one  indefinite 
ailments  which  render  life  miserable  both  to  the  patient 
and  physician.  All  of  these  can  to  a  large  extent  be  pre¬ 
vented,  and  most  of  them  benefited  and  cured,  by  exercise 
properly  regulated  as  to  time,  amount,  and  accompani¬ 
ments.  Exercise  acts  here  as  the  great  balance-wheel  to 
keep  up  constant  motion  in  all  parts.  It  will  enable  the 
sedentary  man  to  eat  and  digest  more,  to  sleep  better,  and 
to  go  at  his  work  with  a  greater  vim  than  any  other  thing. 
What  the  special  indications  are  for  each  one  of  these  dis¬ 
orders  it  would  probably  be  useless  to  try  to  discover  or 
carry  out.  But  the  general  rules  in  prescribing  for  seden¬ 
tary  men  are  as  follows  : 

1.  Consider  the  man  and  prescribe  something  which 
can  be  carried  out.  Don’t  tell  a  clerk  on  eight  dollars  a 
week  to  go  horseback-riding  at  two  dollars  an  hour,  or  try 
to  have  a  two-hundred-and  fifty-pound  man  ride  a  bicycle, 
because  these  means  are  those  you  enjoy.  Don’t  try  to 
force  the  inland  resident  to  row,  or  the  one  who  dwells  at 
the  seaside  to  climb  mountains.  All  are  good  enough  in 
their  places  and  in  proper  cases,  but  as  a  prescription  they 
are  not  so  likely  to  be  carried  out  as  something  more 
suitable. 

2.  Whatever  you  prescribe  to  patients,  have  them  begin 
gradually.  The  novelty  of  a  thing  will  be  apt  to  make  a  man 
overwork  at  first,  in  which  case  he  is  sure  to  be  disgusted 
the  next  day  and  not  likely  to  try  it  again  if  he  thinks  he 
will  have  the  same  experience.  I  have  known  a  piano 
player  so  used  up  by  his  first  few  minutes  with  a  pair  of 
..ndian  clubs  that  he  never  touched  them  again.  So  always 
give  the  caution  and  tell  them  that  if  soreness  or  stiffness 
follows,  it  will  quickly  wear  away,  and  soon  no  amount  of 
exertion  will  make  them  sore. 

3.  Whenever  you  prescribe  exercise  of  any  kind,  be  sure 
you  are  acquainted  with  the  state  of  the  heart,  lungs,  and 
arteries  of  the  patient.  Also  see  if  he  is  ruptured  or  liable 
to  be.  It  will  certainly  increase  his  respect  for  you  and 


BULL:  THE  PRESCRIPTION  OF  EXERCISE. 


[N.  Y.  Mkd.  Joub., 


142 


rom  a  front  to  a  side,  horizontal,  either  free  or  against  the 


make  him  more  apt  to  follow  out  your  prescription  if  you 
insist  on  inquiring  into  these  matters  before  prescribing.  A 
man  liable  to  apoplexy  on  excitement  or  afflicted  with  a 
double  aortic  murmur  certainly  ought  not  be  in  a  foot-ball 
rush  line,  or  one  with  a  commencing  inguinal  hernia  in  a 
tug-of-war,  and  a  great  deal  of  the  odium  which,  in  the 
minds  of  many,  rests  on  athletics,  might  be  avoided  if  only 
those  liable  to  trouble  were  told  so  before  commencing 
work.  Remember  that  if  you  prescribe  athletics  your  pre¬ 
scription  can  not  be  carried  out  on  rainy  or  very  cold  or 
muddy  days,  or  in  winter.  The  advantage  which  athletic 
has  over  gymnastic  work  is,  of  course,  due  to  the  fact  that 
it  is  done  in  the  open  air,  and  you  can  secure  the  good 
effect  of  an  occasional  contact  with  mother  earth,  besides 
the  additional  influence  of  the  sun,  wind,  and  water.  But 
at  least  one  half  of  the  time  it  is  impossible  to  take  athletic 
exercise  with  pleasure  or  benefit.  So,  at  the  same  time  you 
give  an  athletic  prescription,  instruct  your  patient  to  take 
proper  exercise  also  at  home  or  in  a  gymnasium,  else,  if  the 
weather  is  such  as  it  has  been  for  the  last  two  years,  he  will 
be  most  of  the  time  out  of  training.  Remember  that 
man  is  a  gregarious  animal;  that  exercises  which  taken 
alone  would  be  very  irksome,  if  performed  in  a  class  are 
very  pleasing.  It  requires  more  nerve  and  perseverance 
than  most  men  possess  to  take  exercise  for  which  they  have 
no  particular  liking, ‘the  same  as  they  would  a  dose  of  medi¬ 
cine.  But  if  they  see  others  doing  the  same  things  if  a 
little  emulation  is  excited — and  especially  if  music,  march¬ 
ing,  and  other  attractions  are  introduced,  that  which  before 
was  disagreeable  soon  becomes  a  positive  pleasure.  It  is 
for  this  reason  that  a  well-regulated  public  gymnasium,  if 
easily  accessible,  is  better  than  a  home  gymnasium. 

Then,  again,  be  careful  to  instruct  your  patients  what  to 
do  immediately  after  exercise  ;  they  are  liable  to  throw 
themselves  on  the  ground  or  stand  in  draughts  while  stil 
perspiring,  and  then  blame  the  exercise  for  the  soreness  or 
bronchitis  which  they  experience.  I  have  been  a  daily,  or 
at  least  a  tri-weekly,  visitor  at  a  gymnasium  for  six  years, 
and  during  that  time  have  had  but  one  cold.  Let  them 
understand  that  the  motion  must  not  cease  until  they  have 
had  a  cool  bath  and  a  rub  with  a  coarse  towel  (or  the  rub 
alone),  and  have  their  clothes  on.  I  have  never  seen  any 
one  catch  cold  from  exercise  who  faithfully  carried  out 
these  directions. 

II.  Overcoming  Deformities. — The  principal  deformities 
we  may  endeavor  to  overcome  by  exercise  are  the  following: 
Round  or  drooping  shoulders;  flat  or  hollow  chest;  head 
too  far  forward ;  one-sidedness ;  deficiencies ;  spinal  curva¬ 
ture. 

The  general  principle  to  be  observed  in  overcoming 
deformities  by  means  of  exercise  is  putting  the  patient 
in  the  correct  position  to  overdevelop  the  muscles  which 
tend  to  bring  the  parts  into  this  position,  and  keep 
them  there.  The  studying  out  of  just  what  part  needs 
developing  is  often  very  complicated,  as  in  the  case  of 
spinal  curvature. 

In  the  case  of  round  shoulders  the  movements  to  be 
used  are  those  which  tend  to  develop  the  interscapular  mus¬ 
cles.  These  may  be  developed  best  by  carrying  the  hands 


resistance  of  pulley  weights  or  dumb-bells. 

Sloping  or  drooping  shoulders  may  be  elevated  by  in¬ 
creasing  the  size  and  power  of  the  muscles  which  raise  the 
shoulders,  the  scaleni  and  trapezius  principally.  The  best 
motion  for  this  is  to  carry  the  hands  free  or  with  resistance 
from  bells,  weights,  or  rubber  straps  from  a  side  parallel 
below7  to  a  side  parallel  above.  The  same  motion  which 
-ends  to  carry  the  shoulders  back  also  brings  out  the  flat  or 
hollow  chest.  The  systematic  protrusion  of  the  chest  will 
also  help,  and,  by  contracting  the  abdominal  walls  and  forc¬ 
ing  the  contents  up  into  the  thorax,  as  is  done  when  we 
stand  rigidly  erect,  we  may  help  greatly  to  bring  out  the 
flat  or  hollow  chest. 

A  very  common  and  very  bad  deformity  is  produced 
when  the  head  is  allowed  to  droop  forward.  This  is  gen¬ 
erally  accompanied  by  a  sinking  in  of  the  chest,  round 
shoulders,  and  a  protrusion  of  the  abdomen.  The  muscles 
to  be  strengthened  here  are  the  posterior  cervical.  A  very 
good  way  to  do  this  is  by  bending  the  head  forward,  giasp- 
ing  the  occiput  between  the  clasped  hands,  then  slowly 
pulling  it  erect,  all  the  while  opposing  the  action  by  the 
hands.  If  any  one  does  not  believe  that  this  motion  will 
make  a  man  hold  his  head  up,  try  it  slowly  ten  times  and 
then  let  go ;  the  head  will  be  as  erect  as  the  most  enthusi¬ 
astic  drill  sergeant  could  desire,  and  the  continuing  of  th( 
exercise  several  times  daily  with  an  effort  to  stand  erect 
will  certainly7  overcome  this  habit.  The  cure  of  one-sided- 
ness  (and  by  one-sidedness  I  mean  the  opposite  of  ambidex 
terity),  theoretically  is  very  simple,  practically  will  requirt 
an  amount  of  patience  which  few  of  us  possess.  But  by 
using  the  left  hand  in  every  place  where  it  can  be  substi 
tuted  for  the  right,  in  all  the  manipulations  ot  th-e  toilet,  ii 
cutting  food,  in  playing  tennis  or  fencing,  especially  whei 
contending  with  an  inferior  adversary,  very  much  may  1> 
done  to  make  the  left  hand  as  strong  and  dexterous  as  th 

right. 

To  a  certain  extent  parts  which  are  naturally  smalle 
than  they  should  be  may  be  increased  by  exercise.  0 
course,  every  muscle  has  its  limit  beyond  which  it  can  no 
be  developed;  but  few  of  those  we  may  be  called  on  t 
prescribe  for  have  reached  that  limit.  The  only  rule  is  t 
use  sufficiently,  but  not  overuse,  the  muscles  of  that  par' 
In  this  way  the  arm  or  forearm,  leg  or  thigh,  may  be  deve 
oped  and  the  circumference  of  the  chest  increased  often  i 
a  short  space  of  time.  I  have  frequently  seen  the  circun 
ference  of  the  arm  at  the  biceps  increase  two  inches  an 
the  circumference  of  the  chest  four  inches  during  one  ye^ 
after  ordinary  growth  had  ceased. 

In  the  same  way  the  muscles  of  the  neck  may  be  ei 
larged  and  made  more  beautiful  by  bending,  twisting,  an 
rotating  it.  Some  even  allege  that  a  thin-faced  man  ina 
have  his  countenance  become  “  plump  and  pleasing  ”  by  tl 
contraction  and  exercise  of  the  facial  muscles.  This  lool 
well  in  theory,  but,  not  having  had  any  experience  with  tl 
method,  I  can  not  say  what  its  results  in  practice  are. 

The  general  subject  of  spinal  curvature  is  altogether  tc 
great  to  be  more  than  mentioned  in  a  paper  like  this.  B 
I  believe  that  more  may  be  done  toward  preventing  it  ai 


August  9,  1890.] 


GILLIAM:  TIG  DOULOUREUX. 


143 


overcoming  it  when  present  by  exercise  than  in  any  other 

way. 

The  most  common  form  of  lateral  curvature  is  where 
there  is  a  double  curve,  the  convexity  being  toward  the 
right  above  at  about  the  level  of  the  scapula  and  toward 
the  left  below.  This  is  generally  produced  by  the  habit  of 
carrying  children  on  one  side  only,  by  overuse  of  one  side, 
and  by  sitting  with  the  right  side  at  the  desk  in  school. 

There  is  a  great  diversity  of  opinion  about  the  best  way 
of  curing  it.  The  way  generally  adopted  now  is  to  exer¬ 
cise  the  muscles  over  the  convexity,  or,  placing  the  patient 
in  a  straight  position  if  possible,  to  give  exercise  while  in 
that  position.  Pulley  weights  are  a  very  valuable  adjunct 
in  the  treating  of  this  oftentimes  very  troublesome  de¬ 
formity. 

Always  in  trying  to  overcome  deformities  remember 
what  a  potent  factor  the  will  is,  and  that,  in  order  to  be  suc¬ 
cessful,  one  must  constantly  endeavor  to  have  the  patient 
do  all  he  can  by  his  own  will.  This  is  especially  true  in 
regard  to  the  deformities  which  can  for  the  moment  be 
greatly  improved  by  muscular  action,  such  as  those  of  the 
shoulders,  chest,  and  neck.  Indeed,  I  believe  that  the  won¬ 
derfully  erect  carriage  of  the  West  Point  cadet  is  due  as 
much  to  the  esprit  de  corps  there  as  to  the  famous  setting-up 
drill.  This  drill,  however,  is  admirably  adapted  to  produce 
and  maintain  an  erect  carriage,  and  I  would  recommend  it 
to  any  one  who  wishes  to  acquire  one.  It  may  be  found  in 
Upton’s  Military  Tactics. 

III.  It  seems  almost  like  quackery  to  say  that  the  same 
measure  will  either  increase  or  diminish  weight.  But,  as 
an  adjuvant  to  other  measures,  I  know  of  nothing  better 
than  exercise. 

In  order  to  reduce  weight  it  is  necessary  that  heavy  and 
long-continued  exercise  be  taken.  In  addition,  heavy  cloth¬ 
ing  or  a  sweater  should  be  worn,  and  then,  if  water  or  any 
other  fluid  is  abstained  from  and  the  supply  of  fluid  di¬ 
minished,  it  is  certain  that  the  weight  must  come  down. 
The  trouble  here  is  that  fat  men  are  generally  indisposed  to 
exertion  and  can  not  confine  themselves  to  this  rigid  train¬ 
ing  for  any  length  of  time,  and  it  requires  the  will  of  an 
“  Iron  Chancellor”  to  keep  up  the  necessary  regimen. 

To  increase  weight  an  opposite  course  should  be  taken 
— only  just  enough  exercise  to  give  a.  good  appetite  and  di¬ 
gestion  and  sound  sleep  ;  then,  if  plenty  of  good,  nutritious, 
and  fat-forming  food  is  taken,  together  with  tonics  if  neces¬ 
sary,  we  are  doing  all  we  can  to  increase  weight. 

I  have  often  seen  men’s  weight  increase  or  diminish 
many  pounds  as  the  result  of  following  out  these  plans. 
It  is  easier  generally  to  diminish  than  increase,  if  the  pa¬ 
tient  will  work  hard  enough  and  obey  directions  implicitly. 

IV.  It  is  not  certain  whether  the  tendency  to  organic 
or  hereditary  disease  may  be  overcome  by  exercise  in  all 
eases  or  not.  The  subject  is  too  great  to  enter  into  in  a  paper 
ot  this  kind  and  without  a  large  and  long  experience  in  the 
prescription  and  effects  of  exercise.  But  it  seems  reason¬ 
ably  certain  that  in  pulmonary  diseases,  if  the  lungs  are  kept 
thoroughly  aerated  and  expanded  daily,  there  would  not  be 
anywhere  near  as  much  liability  of  the  tubercle  bacillus  find¬ 
ing  lodgment  in  some  unused  spot. 


Then  the  high  grade  of  general  health  which  a  proper 
amount  of  exercise  tends  to  develop  .is  the  best  possible 
safeguard  against  the  encroachment  of  morbific  germs. 
This  is  shown  well  in  the  case  of  ordinary  colds.  I  have 
repeatedly  seen  people  who,  before  taking  exercise  regu¬ 
larly,  were  afflicted  with  colds  nearly  all  the  time,  but  after¬ 
ward  had  a  great  many  fewer  or  none  at  all.  And  right  here 
I  should  like  to  mention  a  little  plan  to  avoid  taking  cold 
when  exposed  to  a  draught.  Many  of  us  are  frequently  ex¬ 
posed  to  draughts  when  we  are  in  company  and  can  not 
avoid  them.  If  a  person  in  this  position  would  rapidly  and 
strongly  contract  the  large  body  muscles,  or  opposite  plates 
of  those  attached  ,  to  the  limbs,  by  means  of  which  a  great 
deal  of  force  may  be  exerted  and  but  little  motion  caused, 
he  will  have  no  fear  of  a  draught  producing  a  chill.  By 
contracting  in  this  way  the  muscles  which  cause  adduction 
of  the  arms  while  the  arms  are  at  the  side,  I  can  in  a  short 
time  produce  a  very  comfortable  state  of  perspiration,  and 
certainly  ward  off  any  bad  effects  of  a  draught. 

In  regard  to  the  effect  of  exercise  on  diseases  of  the 
heart,  I  have  seen  cases  which  were  diagnosticated  by  several 
physicians  as  mitral  regurgitant  gradually  grow  less  promi¬ 
nent  and  disappear.  I  have  often  seen  cases  where  the  heart 
sound  was  roughened,  accentuated,  or  indistinct,  improve 
rapidly  and  acquire  a  perfect  sound  when  the  onlv  change 
was  in  taking  regular  exercise.  In  the  case  of  hearts,  when 
the  only  trouble  was  excessive  rapidity,  intermittency,  or 
irregularity,  I  have  seen  improvement  follow  very  rapidly. 
And  I  believe  that  one  of  the  best  prophylactics  against  the 
development  or  extension  of  almost  any  hereditary  or  or¬ 
ganic  disease  is  muscular  exercise  properly  taken.  And,  in 
conclusion,  I  should  like  to  say  that,  in  my  opinion,  the  value 
of  exercise  is  not  exceeded  by  that  of  any  single  therapeutic 
measure.  I  am  certain  that  all  of  us  have  seen  patients  for 
whom  it  would  do  more  than  any  other  thing  consistent 
with  their  lives  and  occupations. 

And  if  we  were  able  to  intelligently  prescribe,  and  so 
get  all  the  good  possible  out  of,  exercise,  I  am  confident 
we  should  be  able  to  do  many  patients  more  good  than  in 
any  other  way. 


TIC  DOULOUKEUX 

RESULTING  FROM  AN  EXOSTOSIS  ON  THE  SEPTUM  NAR1UM.* 
By  E.  M.  GILLIAM,  M.  D., 

COLUMBUS,  OHIO.  . 

As  this  is  the  age  of  invention,  so  it  is  the  progressive 
era  of  medicine.  Investigators  of  to-day  are  making  strenu¬ 
ous  efforts  to  advance  new  facts,  while  teaching  is  being  put 
on  a  practical  instead  of  a  theoretical  basis.  This  continu¬ 
ous  contention  for  advancement  is  not  confined  to  any  one 
particular  branch,  but  each  has  its  champions,  who  are  im¬ 
proving  on  the  tenets  of  their  predecessors. 

This  is  evidenced  not  only  in  eye,  ear,  gynaecological, 
and  surgical  work,  but  also  in  that  branch  which,  but  a  few 
years  back,  was  in  its  incipiency,  but  has  recently  been 
brought  forward  as  dealing  with  the  fons  et  origo  of  many 

*  Read  before  the  Central  Ohio  Medical  Society. 


144 


GILLIAM:  TIG  DOULOUREUX. 


[N.  Y.  Med.  Jour., 


important  neuroses.  I  refer  to  rhinology.  To  such  reflex 
troubles  as  neuralgia,  hemicrania,  chorea,  epilepsy,  neuras¬ 
thenia,  and  asthma,  which  sometimes  result  from  pathological 
conditions  in  the  nasal  cavities,  we  may  give  credence,  but 
whether  many  other  diseases  of  supposed  reflex  origin  can 
be  attributed  also  to  such  abnormities  is  as  yet  a  question 
sub  judice,  for  a  true  reflex  physiology  teaches  us  that  three 
conditions  are  essential :  1,  a  sensitive  nerve  fiber;  2,  this 
must  be  in  connection  with  a  central  nervous  cell ;  3,  the 
latter  connected  with  a  motor  organ.  Flint  ascribes  to  the 
term  reflex  any  generation  of  nerve  force  which  occurs  as  a 
consequence  of  an  impression  received  by  a  nervous  center. 
It  is  probable  that  no  part  of  the  body  is  so  susceptible  to 
reflex  tendencies  as  the  respiratory  tract,  and  one  of  its 
most  exposed  parts  is  that  of  the  nasal  mucous  membrane. 

This  membrane  has  an  exceedingly  delicate  nerve  struct¬ 
ure  ramifying  through  it,  and  abounds  in  blood-vessels.  With¬ 
out  going  into  the  intricate  details  of  the  anatomical  struct¬ 
ure  of  the  turbinated  bodies,  I  shall  only  call  attention  to 
the  most  salient  points  which  concern  us  at  present. 

These  bodies,  numbering  three  in  each  chamber,  are  cov¬ 
ered  by  mucous  membrane,  having  on  its  external  surface 
flat  epithelium,  and  the  deeper  layer  forms  the  periosteum 
•of  the  turbinated  bones.  Between  these  two  layers  there  is 
abundant  lymph  tissue,  studded  with  numerous  glands  whose 
function  is  to  secrete  mucus.  The  arterial  supply  is  derived 
principally  from  the  spheno-palatine  artery.  The  capillaries 
are  divided  into  three  sets — one  set  being  distributed  to 
the  periosteum,  the  second  to  the  glands,  and  the  third  to 
the  surface.  The  nerve  supply  is  derived  from  the  olfactory 
nasal  branch  of  the  trigeminus  and  filaments  from  Meckel’s 
ganglion. 

Hypertrophied  turbinated  bodies  are  perhaps  the  most 
frequent  cause  of  nasal  stenosis.  Now  this  condition  may 
be  brought  about  by  continuous  irritation  of  the  erectile 
tissue,  causing  either  a  diminution  or  paresis  of  the  contrac¬ 
tile  powers,  resulting  ultimately  in  an  increase  of  fibrinous 
material.  What  is  the  result  ?  Occlusion  or  partial  steno¬ 
sis  of  the  chamber,  damming  up  the  secretions,  producing 
decomposition,  which  in  turn  irritates  and  perpetuates  the 
low  grade  of  inflammation  already  existing,  by  this  means 
adding  new  material  to  the  hypertrophied  state. 

This,  in  connection  with  a  deviated  septum  or  bony 
growth,  may  eventually  result  in  a  reflex  neurosis  by  the 
contiguous  surfaces  encroaching  on  each  other,  producing 
pressure  and  nerve  irritation. 

Such  conditions  are  sometimes  met  with  in  those  per¬ 
sons  whose  occupation  requires  them  to  breathe  certain  ir¬ 
ritants,  such  as  workers  in  acids,  file- works,  or  places  where 
much  dust  is  continuously  circulating.  Bony  growths  are 
also  frequently  found  in  the  nasal  cavity.  The  most  com¬ 
mon  is  that  of  the  spinous  process  which  arises  from  the 
superior  maxillary  bone,  projecting  and  causing  partial  oc¬ 
clusion  of  the  inferior  meatus. 

The  septum  narium  at  its  junction  with  the  anterior  floor 
often  becomes  thickened  by  increase  of  its  cartilaginous 
tissue  and  may  produce  a  process  of  the  size  of  a  pea.  This 
condition  may  arise  from  a  gouty  or  rheumatic  state  of  the 
system.  The  tubercle  of  Zuckerkandl  is  sometimes  mis¬ 


taken  for  an  exostosis,  as  it  occasionally  attains  considera¬ 
ble  dimensions.  Exostoses  may  also  appear  on  the  septal 
wall  and,  in  exceptional  cases,  cause  more  or  less  irritative 
disturbance.  In  the  following  case  such  actually  occurred, 
and,  by  removal  of  the  cause,  resulted  in  a  complete  relief  if 
not  a  permanent  cure. 

Mr.  J.  G.,  aged  fifty-six,  rugged  in  appearance,  hereditary 
tendencies  and  habits  good,  had  for  several  years  past  been 
a  great  sufferer  from  tic  douloureux.  Many  physicians  were 
consulted,  but  only  temporary  benefit  was  received.  On  advice, 
he  repaired  to  the  dentist  to  have  his  teeth  examined,  in  hopes 
of  eliciting  a  cause.  Several  decayed  teeth  were  extracted  and 
other  operations  performed,  but  all  in  vain ;  the  trouble  still  per¬ 
sisted.  The  pain  started  at  the  upper  lip,  darting  along  the  left 
side  of  the  nose  to  the  forehead. 

These  pains  were  paroxysmal  and  atrocious,  during  which  he 
would  pace  the  floor,  wringing  his  hands  while  tears  coursed 
down  his  cheeks.  The  attacks  followed  each  other  in  rapid  suc¬ 
cession,  incapacitating  him  for  business  weeks  at  a  time.  When 
they  were  very  severe  in  character  the  left  side  of  the  face  would 
swell ;  and  as  for  food,  he  dare  not  indulge  for  fear  of  aggravat¬ 
ing  the  pain.  This  condition  existed  for  some  time,  becoming 
much  worse  in  damp  and  cold  weather,  ameliorating  during  dry 
spells. 

In  the  early  part  of  October.  1888,  he  consulted  Dr.  D.  Tod 
Gilliam,  who  advised  an  operation.  A  few  days  after,  assisted 
by  the  writer,  Dr.  Gilliam  performed  stretching  of  the  supra-or- 
hital  and  infra-orbital  nerves.  This  gave  relief  until  September, 
1889,  a  period  of  nearly  eleven  months,  when  the  patient  came 
to  the  office  saying  the  paroxysms  had -returned,  but  not  so  se¬ 
verely  as  before.  Noting  the  somewhat  stuffed  condition  of  the 
nose,  the  thought  struck  me  that  perhaps  that  organ  would  re¬ 
veal  something  that  might  help  us  out.  On  examination,  there 
was  found  an  extensive  hypertrophied  condition  of  the  inferior 
turbinated  body  in  the  left  chamber,  and  on  the  septum  narium 
behind  the  junction  of  the  vomer  and  triangular  cartilage  a 
hard,  immovable  body,  light-pink  in  color,  and  bleeding  easily 
when  touched  with  a  probe. 

This  proved  to  be  an  exostosis  and  impinged  firmly  against 
the  inferior  turbinated,  entirely  occluding  the  lower  channel  of 
the  nares.  On  applying  a  four-per-cent,  solution  of  cocaine,  the 
membrane  covering  the  inferior  turbinated  bone  retracted  slight¬ 
ly,  allowing  the  probe  to  pass  between  it  and  the  bony  growth, 
revealing  an  excoriated  surface  on  the  mucous  membrane.  Stat¬ 
ing  to  him  the  character  of  the  nasal  trouble  and  the  possibility 
of  it  being  the  cause  of  the  neuralgia,  I  advised  as  a  dernier  Ten- 
sort  an  operation,  to  which  he  readily  consented. 

On  September  20th,  after  cleansing  the  cavity  with  Dobell’s 
solution,  cotton  plugs  saturated  with  a  four-per-cent,  solution 
of  cocaine  were  introduced  to  procure  as  much  dilatation  as 
possible.  After  inserting  a  bivalve  speculum  and  thoroughly 
illuminatingby  means  of  condensed  light,  a  sharp-pointed,  curved 
bistoury  was  used  to  separate  the  mucous  membrane  covering 
the  exostosis.  This  being  done,  Bosworth’s  nasal  saw  was 
brought  into  play  and,  after  much  trouble,  the  growth  removed, 
leaving  a  slight  depression  in  the  septal  wall.  During  the  opera¬ 
tion  the  haemorrhage  was  profuse,  ofttiines  obscuring  the  field 
completely  from  view,  the  cocaine  seeming  to  have  no  effect  in 
curtailing  it.  The  operation  was  almost  devoid  of  pain.  After 
cleansing  again  with  Dobell’s  solution,  a  tampon  of  absorbent 
cotton  saturated  with  cocaine  was  inserted,  which  seemed  tc 
have  the  effect  of  restricting  the  flow  of  blood. 

The  patient  returned  on  the  23d  saying  his  nose  felt  some¬ 
what  freer,  and  that  he  had  had  no  recurrence  of  the  pain  to 
speak  of  since  the  operation. 


August  9,  1890.] 


ADAMS:  A  CASE  OF  1NVA  OINA  TION  OF  TEE  BOWEL. 


145 


After  cleansing  the  wound  it  was  found  to  be  healing  kindly, 
and  on  the  10th  of  October  it  was  entirely  well.  It  was  next 
thought  best  to  reduce  the  inferior  turbinated  body. 

Instead  of  pursuing  the  older  method  of  smearing  a  probe 
with  chromic  acid  and  running  it  along  the  elevated  surfaces  of 
the  mucous  membrane,  by  which  means  unnecessarily  much 
tissue  and  glands  are  destroyed,  a  more  conservative  course  was 
resorted  to,  which  consisted  in  pinning  down  the  mucous  mem¬ 
brane  to  the  underlying  structures.  A  slender  probe  being 
dipped  in  mucilage,  then  into  the  chromic  acid,  enough  of  the 
crystals  will  adhere  to  form  a  bead  on  the  end  of  the  probe 
when  held  over  a  flame.  Now,  having  the  tissues  thoroughly 
contracted  by  cocaine,  the  probe  is  touched  only  to  those  parts 
which  by  their  elevated  aspect  reveal  an  abnormal  amount  of 
fibrinous  deposit.  This  has  the  effect  of  constricting  perma¬ 
nently  the  venous  sinuses  and  arterial  channels,  cutting  off  the 
excessive  nutrition  to  the  parts  without  obliterating  or  hinder¬ 
ing  the  function  of  the  mucous  glands. 

These  applications  were  made  at  intervals  of  one  week  until 
he  had  had  five  stances.  By  this  time  the  membrane  was  pinned 
thoroughly  down,  leaving  quite  enough  space  for  a  free  current 
of  air. 

From  the  day  of  the  operation  to  the  present  time  he  has 
had  no  recurrence  of  the  trouble,  so  that,  although  I  am  not 
prepared  to  state  whether  the  result  will  be  permanent,  I  am 
convinced  of  the  nasal  trouble  being  the  salient  factor  in  the 

case. 


A  CASE  OF  INVAGINATION  OF  THE  BOWEL. 

By  M.  M.  ADAMS,  M.  D., 

GREENFIELD,  IND. 

Noble  H.,  eleven  years  of  age,  while  at  play  sus¬ 
tained  a  heavy  fall  on  his  back  by  being  tripped 
backward  by  a  schoolmate.  He  soon  became  very 
sick,  and  went  home  complaining  of  cramp  in  his 
stomach  and  abdominal  pains.  From  September  5 
to  15,  1885,  I  had  treated  him  for  an  attack  of  en¬ 
teritis,  and  at  that  time  I  was  apprehensive  of  ob¬ 
struction,  because  of  the  difficulty  experienced  in 
moving  his  bowels,  there  being  a  tenderness  and 
elevation  in  the  right  iliac  region,  but  no  marked 
tumor.  This,  however,  passed  away  after  a  free 
movement  of  the  bowels,  but  every  few  months  I 
supplied  the  family  with  a  phial  of  anodyne  and 
stimulant  to  relieve  sudden  and  severe  attacks  of 
pain  in  the  stomach  and  bowels,  which  were  attrib¬ 
uted  to  indigestion,  relief  being  obtained  by  a  few 
loses  followed  by  a  cathartic,  leaving  him  very  sore 
for  a  few  days,  as  in  the  case  of  one  having  had 
n-amp  colic.  He  was  a  boy  of  light  weight,  nervous, 
und  endowed  with  more  than  ordinary  courage  and 
endurance  for  one  of  his  years.  On  December  16, 

1889,  I  was  applied  to  for  a  remedy  for  the  pain 
•aused  by  his  fall.  Relief  did  not  follow,  as  in  former 
ittacks,  and  at  ten  o’clock  on  December  17th  I  was 
sent  for. 

On  my  arrival  I  noted  the  anxious  expression 
ff  countenance  usually  observed  in  cases  of  wounds 
if  the  bowels.  He  was  lying  on  his  right  side  with 
<nees  drawn  up,  and  evincing  signs  of  severe  suffer- 
ng-  The  history  of  the  fall  was  detailed  to  me,  and 
L  was  further  informed  that  soon  after  the  fall  he 
iad  had  two  copious  evacuations  from  the  bowels,  largely  com- 
>osed  of  blood. 


the  boy’s  mother  until  the  day  of  my  visit.  Up  to  this  time  I 
had  made  no  examination,  but  I  at  once  suspected  invagination 
of  the  bowel.  Placing  my  hand  on  his  abdomen  and  moving 
the  palmar  surface  from  the  upper  to  the  lower  part,  I  at  once 
located  a  tumor  in  the  right  iliac  region,  extending  well  up 
toward  the  hypochondrium,  thus  supporting  my  suspicion  as  to 
the  intussusception.  He  had  vomited  a  green,  watery  fluid  a 
few  times  through  the  night  and  morning,  but  there  was  no 
faecal  odor.  The  abdomen  was  not  distended — in  fact,  it  felt 
flaccid  and  empty. 

I  prescribed  a  sixteenth  of  a  grain  of  morphine  with  a  quar¬ 
ter  of  a  grain  of  calomel  every  hour  for  a  few  hours,  until  nausea 
ceased,  allowing  no  cold  water,  but  a'  liberal  quantity  of  hot 
When  I  saw  him,  at  6  p.  m.,  he  had  become  quiet,  his  stomach 
retained  ingesta,  and  he  was  allowed  some  milk  with  barley- 
water.  A  rectal  injection  of  three  pints  of  hot  salt  water 
brought  away  clotted  blood,  and  the  water  was  stained  a  cherry- 
red,  as  was  the  next  injection,  six  hours  later,  but  no  faecal 
matter  was  discharged. 

December  18th ,  8  A.  M. — No  fever;  pulse  quite  regular  and 
100  in  a  minute;  tongue  rather  dry,  slightly  coated,  and  of  a 
grayish-brown  tinge;  abdomen  very  tender  over  the  ascending 
colon,  and  tumor  very  distinct.  He  craves  water  often. 

19th. — He  is  growing  very  restless,  requiring  anodynes  every 
three  or  four  hours  to  enable  him  to  be  kept  in  bed.  Morphine, 
one  eighth  of  a  grain  ;  atropine,  one  one  hundred  and  fiftieth 
of  a  grain,  administered  at  such  intervals. 

For  the  next  three  days  he  remained  about  the  same  ;  there 
was  no  vomiting,  no  fever,  and  the  pulse  ranged  from  100  to 
I  120.  He  was  fed  on  milk  and  barley-water,  and  copious  ene- 


mata  of  milk  were  given  every  three  or  four  hours.  A  few 
This  fact  had  not  been  made  known  even  to  times  the  enemata  brought  away  faecal  matter,  which  rendered 


146 


STOW  ELL:  BLINDNESS  FOLLOWING  CEREBROSPINAL  MENINGITIS.  [N.  Y.  Med.  Jour., 


the  case  a  little  more  hopeful.  The  fact  of  the  haemorrhage 
being  an  early  symptom  rendered  it  hazardous  to  use  forcible 
injections. 

23d—  Dr.  S.  M.  Martin  was  called  in  consultation.  The  pa¬ 
tient’s  pulse  112  to  120  morning  and  evening,  abdomen  greatly 


distended,  no  vomiting.  Urine  has  been  passed  every  four  to 
five  hours  in  fair  quantity,  but  usually  when  the  patient  was  up 
to  discharge  the  injected  milk. 

24th,  8  A.  If.— Rested  well  the  first  half  of  the  night.  At 
midnight  the  pain  returned  with  renewed  severity.  Abdomen 
more  tympanitic.  Treatment  continued. 

25th ,  8  A.  M. — Quiet  and  bright.  Bowels  less  tense.  At 
8  p.  m.  he  became  restless,  the  usual  dose  not  affecting  him. 
Chloroform  by  inhalation  was  resorted  to  to  palliate  his  suffer¬ 
ing.  At  about  eleven  o’clock  stercoraceous  vomiting  set  in. 

26th,  8  A.  M. — Pulse  barely  perceptible,  surface  cool,  tem¬ 
perature  97°  F.  No  faecal  matter  passed  after  the  last  few  in¬ 
jections,  though  they  had  been  used  to  the  full  capacity  of  the 
colon.  Brandy  by  the  rectum  was  resorted  to,  with  milk  every 
three  hours.  Aromatic  spirits  of  ammonia  and  wine  were  given 
alternately;  morphine  and  atropine  as  before.  At  2  p.  m.  Dr. 
Comstock  and  Dr.  Boots  were  called  to  see  the  case.  The 
patient  had  but  partially  rallied  from  the  collapsed  condition  of 
the  morning.  All  that  had  been  done  was  fully  indorsed,  but 
no  satisfactory  conclusion  as  to  the  exact  diagnosis  could  be  ar¬ 
rived  at.  All  concurred  in  an  unfavorable  prognosis  and  in  the 
opinion  that  a  few  hours  would  end  the  patient’s  sufferings. 
Treatment  was  continued. 

At  about  10  o’clock  a.  m.  on  the  27tli  vomiting  ceased,  and 
up  to  January  3,  1890,  the  patient  rested  well  for  several  hours 
at  a  time,  and  the  injections,  which  were  continued,  failed  to 
bring  away  either  blood  or  faeces.  On  the  8d,  however,  vomit¬ 
ing  returned  at  about  6  p.  m.,  and  continued  for  twenty-four 
hours,  when  death  ensued. 

Twelve  hours  after  death  a  post-mortem  was  made.  Rigor 
mortis  fairly  well  marked,  no  post-mortem  changes.  On  open¬ 
ing  the  abdomen,  it  was  found  that  the  omentum  had  been  nearly 


all  absorbed,  only  a  few  floating  shreds  remaining.  The  colon 
was  empty,  both  transverse  and  descending;  the  small  intestine 
was  distended  with  gas.  The  tumor  was  found  to  consist  of  a 
portion  of  ileum,  several  inches  of  which  had  passed  through 
the  ileo-csecal  valve  into  the  ascending  colon.  The  accompany¬ 
ing  illustrations  show  the  coiled  condition  of  the 
impacted  bowel,  which  was  gangrenous.  No  in¬ 
flammatory  action  had  been  set  up  except  a  receDt 
patch  in  the  right  hypochondrium,  a  patch  of 
peritonitis.  There  was  one  little  ulcer  in  the  je¬ 
junum  that  would  admit  a  darning  needle,  but  it 
was  agglutinated  so  that  no  contents  of  the  bowel 
had  escaped.  All  of  the  abdominal  viscera  pre¬ 
sented  a  macerated  appearance,  and  there  was  a 
little  viscid  liquid  in  the  peritoneal  sac. 

Dr.  Martin  was  called  in  consultation  at 
about  the  time  the  faeces  were  returning  with 
the  injections  (December  23d).  We  were  of 
the  opinion  at  that  time  that  an  obstruction 
existed  in  the  bowels,  but  could  not  determine 
as  to  its  character.  We  were  somewhat  con¬ 
fused,  too,  by  the  absence  of  stercoraceous  vom¬ 
iting  up  to  the  ninth  day,  and  the  (to  us)  un¬ 
usually  large  quantity  of  blood  in  the  stools  and 
passed  in  injections  under  our  observation. 

Query :  Would  a  physician  or  surgeon  have 
been  justified  in  making  an  exploratory  incision 
to  ascertain  the  true  condition  of  the  case? 
Would  there  have  been  a  reasonable  proba¬ 
bility  of  benefiting  the  patient  by  an  operation 
under  the  circumstances  ? 


BLINDNESS 
FOLLOWING  CEREBRO-SPINAL  MENINGITIS, 

WITH  RECOVERY  AFTER  TWO  YEARS.* 

By  WILLIAM  L.  STOWELL,  M.  D. 

Joseph  K.,  born  April  28,  1887.  Well  until  March,  1888; 
then  had  an  attack  of  cerebro- spinal  meningitis  from  which  he 
recovered  slowly  in  about  six  weeks.  Before  he  had  entirely 
recovered  it  was  observed  that  he  was  blind.  The  eyes  kept 
their  normal  external  appearance. 

In  August,  1888,  the  boy  came  under  my  care  for  acute  lobar 
pneumonia.  He  was  then  blind  and  had  nystagmus  of  both  eyes. 
Although  the  temperature  reached  105°  and  the  pulse  over  200 
to  the  minute,  he  made  a  complete  recovery  from  the  lung 
trouble. 

In  October,  1888,  he  went  through  a  regular  attack  of 
measles. 

In  February,  1889,  his  ailment  was  croup. 

He  enjoyed  good  health  from  that  date  until  March  16, 1890, 
at  which  time  a  cup  of  hot  tea  was  spilled  on  his  right  shoulder 
and  chest.  This  caused  only  usual  symptoms  until  three  o’clock 
the  next  afternoon,  when  he  began  to  have  violent  convulsions 
which  continued  until  nine  o’clock.  At  that  time  I  saw  him, 
and  gave  chloroform,  followed  by  bromide  of  potassium  and 
chloral.  The  convulsions  were  most  marked  in  the  left  half 
of  the  body. 

*  Read  before  the  Section  in  Paediatrics  of  the  New  York  Academy 
of  Medicine,  May  8,  1890,  and  the  patient  presented. 


August  9,  1890.] 


ABBE:  PARANEPHRIC  CYSTS. 


The  next  morning  he  was  found  to  be  paralyzed  in  the  up¬ 
per  and  lower  extremities  of  that  side,  and  there  was  some 
paresis  ot  the  face.  The  tongue  is  deviated  slightly  to  the  left. 
Some  rigidity  followed,  but  this  is  gradually  disappearing. 

To  return  to  the  feature  of  special  interest,  last  summer  the 
child’s  eyes  were  examined  at  the  New  York  Eye  and  Ear  In¬ 
firmary,  and  the  diagnosis  of  atrophy  of  the  optic  nerves  was 
made. 

This  was  in  accord  with  my  own  diagnosis,  which  had  been 
optic  neuritis  with  atrophy  following. 

I  had  regarded  the  prognosis  as  very  bad  indeed.  About 
six  months  since,  the  family  observed  that  the  child  appeared  to 
notice  movements  and  to  use  the  left  eye.  He  now  sees  quite 
well  with  the  left  eye,  but  less  clearly  with  the  right,  in  which 
there  is  still  nystagmus.  The  optic  disc  in  the  left  eye  is  getting 
to  its  normal  condition.  That  of  the  right  eye  is  bluish  in  tint 
and  the  vessels  are  indistinct  in  it.  Hearing  and  mental  facul¬ 
ties  good  from  time  of  recovery  from  the  meningitis. 


As  this  is  only  a  clinical  report,  I  will  make  no  further 
observations  on  the  pathology,  etc. 


PARANEPHRIC  CYSTS.* 

By  ROBERT  ABBE,  M.  D. 

The  variety  of  cystic  tumors  one  may  encounter  in  the 
abdominal  cavity  is  not  great. 

Ovarian,  parovarian,  salpingeal,  in  the  female,  and  hy¬ 
datid,  pancreatic,  distended  gall-bladder,  and  hydronephrotic 
cysts  and  pus  collections,  which  are  common  to  both  sexes, 
are  about  all  which  one  will  find.  Exceptionally  one  may 
meet  a  cystic  tumor  that  will  have  an  entirely  different 
clinical  history  and  require  different  treatment.  There  may 
be  variations  of  the  above,  as  the  cyst  of  an  extra-uterine 
pregnancy,  or  one  of  the  class  under  consideration  which 
heretofore  may  have  been  ranked  with  hydronephrosis  of 
die  common  type.  It  is  proper  that  they  should  be  differ¬ 
entiated,  clinically  and  anatomically,  and  it  is  with  a  view 
o  giving  a  suitable  rank  to  this  efiass  that  I  present  the 
nstory  of  two  striking  cases  that  were  extremely  puzzling 
o  me  until  laparotomy  cleared  up  the  nature  of  both  : 

Case  I.  Large  Paranephric  Cyst;  Exploratory  Laparoto- 
ny  ;  Incision  and  Lumbar  Drainage;  Cholesterin  in  the  Fluid  ; 
Recovery.  A  lady  of  forty-eight  years,  referred  to  me  from  Dr. 
ellet,  of  Hamburg,  N.  J.,  was  in  fair  condition  when  first  seen  by 
ue  on  August  12,  1889.  She  gave  no  history  of  special  illness  ex¬ 
cept  an  attack  of  inflammation  of  the  kidneys  lasting  two  weeks 
eventeen  years  ago.  Since  that  time  the  functional  activity  of 
lie  kidney  has  been  normal  and,  as  far  as  she  has  been  aware 
tothing  unusual  has  occurred  in  the  appearance  of  her  urine’ 
Me  had  excellent  digestion  and  health.  No  members  of  her 
armly  ever  had  tumors  of  any  description.  She  had  seven 
Inldren  in  the  past  twelve  years  without  unusual  event.  Four 
ears  ago  she  first  noticed  a  swelling  of  her  left  side,  not  hard, 
nd  extending  from  the  left  loin  toward  the  groin,  about  as  long 
nd  as  broad  as  her  hand.  It  was  painless  and  did  not  seem  to 
*  ow  for  two  years  or  more.  Her  health  not  being  affected,  she 

alt  T6ed  t0  it8  presence’  thouSh  she  says  she  at  first  con- 
.  *  u  r  ^  ^10mas’  wh°  said  it  was  connected,  lie  thought 

•ith  her  kidney.  As  it  enlarged  it  filled  the  left  iliac  fossa,  en- 

Read  before  the  New  York  Surgical  Society,  April  23,  1890. 


147 


croached  on  the  median  line,  passed  the  level  of  the  umbilicus 
and  grew  upward  to  the  ribs.  During  the  past  few  weeks  it 

has  grown  much  more  rapidly,  and  there  has  been  a  dull  achimr 
in  the  back.  6 

Hu  general  health  has  not  deteriorated. 

On  examination,  a  large  tumor  was  found  to  fill  the  left  half 
of  the  abdomen,  extending  across  to  the  opposite  iliac  fossa.  It 
seemed  like  a  large  cyst,  constricted  somewhat  vertically  the 
median  portion  dome-shaped,  with  the  navel  at  the  summit. 

.  Tlie  tumor  fiped  the  left  iliac  fossa  and  extended  well  across 
into  the  right.  It  rose  into  the  left  lumbar  and  hypochondriac 
region  and  raised  the  costal  cartilages.  A  sulcus  marked  its  sur¬ 
face  obliquely  to  the  left  of  the  median  line,  and  in  this  portion 
was  resonance,  as  of  an  adherent  intestine  lying  more  or  less  ver¬ 
tically  Elsewhere  the  tumor  was  entirely  dull  on  percussion 
Auscultation  was  negative. 

Vaginal  examination  reveals  a  large  patulous  cervix  the 
uterus  pushed  backward  and  to  the  right,  and  movable  inde¬ 
pendently  of  the  tumor.  The  latter  fills  the  anterior  portion  of 
tbe  pelvis  and  gives  a  sense  of  resistance  like  a  thin-walled  cyst. 
Ihe  general  appearance  was  of  an  ovarian  cystoma  of  large  size 
composed  mainly  of  two  principal  cysts.  The  most  unaccount¬ 
able  feature  was  the  oblique  intestine  confined  to  its  surface 
This  was  suspected  to  be  adherent.  On  account  of  her  history 
that  Dr.  Thomas  had  thought  it  renal  in  the  early  stage  the 
urine  was  carefully  observed.  It  was  of  rather  low  specific 
gravity,  1-010;  acid;  no  albumin,  and  contained  a  few  pus  cells 
and  epithelium— not  enough  to  give  the  slightest  suspicion  of 
renal  trouble. 

On  August  14,  1889, 1  made  exploratory  median  laparotomy, 
the  cyst  presented  at  once  in  the  incision,  but  differed  en¬ 
tirely  in  appearance  from  an  ovarian  cyst.  It  was  invested  by  an 
independent  loose  peritoneal  covering,  with  large  vessels  travers¬ 
ing  it  laterally.  The  presenting  adherent  intestine  was  evidently 
the  descending  colon  raised  from  its  normal  bed.  The  hand 
being  introduced  into  the  abdomen,  was  passed  over  the  face  of 
the  tumor  downward  to  ascertain  its  base  of  origin.  It  dipped 
well  down  into  the  pelvis,  then  up  behind  it  freely  to  the  ilio¬ 
lumbar  region.  Laterally  it  passed  over  the  smooth  surface 
into  a  sulcus  in  the  left  loin,  where  the  peritomeum  reflected  on 
to  the  tumor  at  the  site  of  the  normal  colon,  which,  however 
had  been  raised  faraway  from  its  site.  On  the  median  side  the 
hand  passed  around  the  cyst  and  returned  beneath  it  to  the 
region  of  the  left  kidney.  Above,  it  passed  freely  over  the  top 
and  reaching  the  diaphragm,  slipped  down  behind  the  cyst  again 
to  tbe  kidney  region. 

It  was  evident  then,  from  all  sides,  that  the  tumor  originated 
about  the  left  kidney,  and  that  it  had  best  be  opened  posteriorly. 
At  the  same  time,  to  avoid  opening  the  peritoneal  cavity  pos¬ 
teriorly,  it  would  be  necessary  to  keep  well  behind  the  reflec¬ 
tion  of  lumbar  parietal  peritoneum.  Therefore,  while  protect¬ 
ing  the  anterior  wound  with  hot  compresses,  yet  maintaining 
my  hand  within  to  define  the  peritoneal  limits,  I  made  a  free 
lumbar  incision  as  if  for  colotomy.  Rapid  evacuation  of  the  con¬ 
tents  took  place  and  the  cyst  collapsed  so  completely  that  it  was 
difficult  to  detect  its  remaining  thin  walls  by  the  hand  in  the 
abdomen.  The  colon  descended  nearly  to  its  normal  site. 

Ihe  most  noticeable  feature  observed  was  the  spread-out 
kidney.  It  was  not  distended,  but  flattened  out  against  the  loin 
a  crater-like  rim  being  felt  on  its  surface,  marking  the  bed  from 
which  the  cyst  sprung.  This  was  an  unmistakable  feeling,  and 
was  recognized  by  manipulation  through  the  lumbar  as  well  as 
the  abdominal  wound,  but  best  from  in  front.  Some  time  was 
taken  to  discover  if  possible  any  connection  between  the  cyst 
and  the  pelvis  of  the  kidney,  but  no  sense  of  distended  calyces 
or  funnel-shaped  pelvis  was  present;  and  it  was  completely 


ABBE:  PARANEPHRIC  CYSTS. 


[N.  Y.  Med.  Jour,, 


148 


evident  that  the  cyst  was  independent  of  the  renal  pelvis.  The 
anterior  wound  was  closed,  and  large  drainage-tubes  introduced 
through  the  lumbar  wound  into  the  cyst. 


He  seemed  to  he  in  good  health,  excepting  that  he  had  a  tu¬ 
mor  in  his  side  that  gave  him  a  little  pain. 

His  normal  pulse  was  55.  Temperature  varied  from  98°  to 
99°  during  two  weeks’  observation  before  operation. 

Examination  showed  a  globular  tumor  of  the  abdomen  in 
the  right  hypochondriac  region,  the  apex  of  which  lay  between 
the  point  of  the  tenth  rib  and  the  navel.  Palpation  showed  it 
to  be  of  very  even  surface,  but  more  prominent  near  the  point 
of  the  tenth  rib.  It  sloped  equally  in  all  directions.  The  loin 
was  also  filled  by  it,  so  that  pressure  there  raised  the  summit,  but 
there  was  no  lumbar  prominence  as  there  was  in  front.  The  liver 
boundary  was  raised  three  quarters  of  an  inch  upward.  The  tu¬ 
mor  descended  to  the  level  of  the  navel  and  extended  across  the 
median  line.  This  was  discovered  rather  by  palpation  than  per¬ 
cussion.  The  colon  was  pushed  downward.  There  had  been 
no  jaundice.  The  urine  was  normal.  Palpation  in  different 
attitudes  revealed  a  lateral  movement  of  the  mass  of  two  inches. 
There  was  no  history  of  renal  colic,  with  its  characteristic 

pain. 

On  first  examination,  my  conclusion  was  that  we  had  to  deal 
j  with  a  greatly  distended  gall-bladder.  The  following  points 
were  a  fair  guide  to  this  decision:  1.  There  was  hn  absence  of 
history  of  renal  symptoms.  2.  The  tumor  was  evidently  a  fluid 
one.  3.  The  position  was  considerably  higher  in  the  abdomen 
than  the  tumor  of  hydronephrosis.  4.  The  rotund  fullness  was 
most  pointed  at  the  apex  of  the  tenth  rib  and  enlarging  thence 
toward  the  navel.  5.  The  history  of  this  attack  of  acute  pain, 
with  two  preceding  ones  in  former  years,  was  like  that  of  gall¬ 
stone  impaction.  During  the  two  weeks  following  the  patient 
had  no  pain;  walked  about  and  drove  out. 


The  fluid  evacuated  was  as  remarkable  as  the  cyst.  It  meas¬ 
ured  between  ten  and  twelve  pints,  was  of  a  pinkish  milky 
jolor,  thin,  turbid,  and  glistening  with  myriads  of  clrolesterin 
crystals,  which,  on  standing,  deposited  to  the  amount  of  one 
fifth  the  bulk  of  fluid.  The  latter  was  of  specific  gravity  1-030 ; 
contained  a  large  quantity  of  albumin  ;  microscopically,  choles¬ 
terol,  red  blood-cells,  a  large  number,  and  a  trifling  number  of 
pus  cells;  large  multinuclear  cells,  granular  round  cells,  irregu¬ 
lar  granular  masses,  and  free  fat.  The  patient  made  a  speedy 
and  uninterrupted  convalescence.  The  urine  was  watched  for 
possible  appearance  of  crystals  of  cholesterin,  which  certainly 
had  not  appeared  before  operation.  On  the  day  following  op¬ 
eration  a  trace  of  albumin,  a  few  casts,  and  a  few  cholesterin 
crystals  were  found,  but  never  afterward.  These  may  readily 
be  explained  by  the  manipulation  and  probing  during  the  opera¬ 
tion,  which  may  easily  have  lacerated  some  part  of  the  delicate 
sac.  No  urine  ever  appeared  at  the  lumbar  wound. 

Under  irrigation  and  drainage  the  cyst  closed,  so  that  in  four 
weeks  it  would  hold  but  four  ounces  on  distension.  In  six 
weeks  she  was  discharged  cured,  a  slight  sinus  remaining  which 
healed  soon  after  her  return  home.  Since  that  date,  more  than 
six  months,  the  patient  has  remained  perfectly  well ;  has  gained 
thirty  pounds  in  weight,  and  is  actively  employed  at  home. 

The  second  case  presented  itself  three  months  later. 

Case  II.— The  patient  was  a  young  lawyer,  aged  twenty- 
three  years,  of  good  physique.  About  the  1st  of  September  he 
was  taken  with  acute  pain  in  the  right  hypochondrium,  nearly 
in  the  region  of  the  gall-bladder,  and  simultaneously  noticed  a 
large  swelling  at  the  site  of  the  present  tumor.  When  he  was 
seven  years  old,  and  again  at  fifteen,  he  remembers  to  have  had 
similar  attacks.  He  had  no  fever  with  this  attack  and  the  pain 

gradually  subsided. 

He  came  under  the  care  of  Dr.  Kinnicutt  and  Dr.  Draper, 
with  whom  I  saw  him  on  October  3,  1889. 


Further  examination  showed  a  slight  increase  in  growth 
across  the  median  line,  with  less  fullness  between  the  navel  and 
the  tenth  rib.  While  admitting  the  possibility  of  this  tuinoi 
springing  from  the  kidneys  after  the  fashion  of  the  paranephric 
cysts,  the  case  previously  narrated  being  fresh  in  my  memory 
I  was  yet  more  inclined  to  regard  it  as  occupying  the  site  of  tin 


Angust  9,  1890.] 


ABBE:  PARANEPHRIC  CYSTS. 


149 


gall-bladder  when  distended.  It  may  have  had  a  little  more 


latitude  of  motion  than  a  gall-bladder  of  similar  size,  and  pos¬ 
sibly  could  be  said  to  be  more  full  in  the  lumbar  region  than 
that.  i 

The  patient  was  eating  and  sleeping  well.  Urine  was  nor¬ 
mal  in  specific  gravity  and  reaction  ;  had  no  albumin,  or  sflgar, 
or  abnormal  elements  on  microscopical  examination.  The  pres¬ 
ence  of  the  tumor,  however,  was  a  menace  to  him,  and  there¬ 
fore,  after  consultation  with  Dr.  Draper,  Dr.  Kinnicutt,  and  Dr. 
Bull,  I  operated  under  ether  on  October  22,  1889.  Incision 
vertical,  as  for  cholecystotomy.  On  opening  the  abdominal 
cavity,  the  presenting  surface  of  the  tumor  was  at  a  glance,  as  in 
the  former  case,  seen  to  be  covered  by  the  posterior  peritoneal 
wall  of  the  abdominal  cavity,  indicated  by  the  appearance  of 
the  large  vessels  travel-sing  it  laterally,  and  by  the  relatively 
loose  attachment  of  peritoneum  to  the  tumor.  The  fingers, 
passed  into  the  cavity,  found  the  liver  free,  but  pushed  upward, 
and  the  gall-bladder  normal.  Passing  backward,  the  possibility 
of  hydatid  cyst  springing  from  the  liver  was  excluded.  The 
slope  of  the  thmor  in  all  directions  was  backward  toward  the 
loin.  It  was  free  from  adhesions  on  every  side. 

While  conducting  these  explorations  somewhat  vigorously, 
the  peritoneal  layer  investing  the  tumor  was  seen  to  grow  rap¬ 
idly  oedematous  and  puff  up  so  as  to  fill  the  incision.  Growing 
raoidly  thinner,  it  burst  open  in  the  wound  as  I  attempted  to 
secure  it  with  forceps,  and  gave  exit  to  a  rapid  flow  of  watery, 
colorless,  limpid  fluid,  sufficient  of  which  was  caught  for  exami¬ 
nation.  The  presenting  rent  was  secured  in  the  wound,  and 
the  fluid  kept  out  of  the  peritoneal  cavity.  The  rent  was  en¬ 
larged,  and  the  flow  seen  to  come  from  the  loose-meshed  retro¬ 
peritoneal  tissue.  The  tumor  so  rapidly  disappeared  and  its 
remnant  sank  back  into  the  loin  so  quickly  that  it  was  difficult 
to  identify  any  distinct  cyst  wall  among  the  cellular  tissue,  and 
it  was  deemed  unwise  to  strip  up  the  peritoneum  for  further 
exploration.  The  evacuation  being  completed,  an  estimate  was 
made  that  two  pints  of  fluid  had  escaped. 

A  digital  examination  of  the  site  of  the  tumor  was  made. 
The  rent  in  the  peritoneum  was  two  inches  above  the  colon  at 
its  hepatic  flexure.  The  liver  was  entirely  uninvolved.  The 
finger  passed  backward  to  the  aorta  and  renal  vessels,  thence 
downward  around  the  colon  and  over  it  to  the  kidney,  whose 
entire  surface  was  palpated.  The  lower  end  was  round, 
smooth,  and  normal.  The  rest  of  its  surface  was  not  quite  as 
even  as  natural,  and  was  spread  out  into  four  flattened  lobula¬ 
tions.  The  collapsed  tumor  sac  and  adjacent  colon  fell  back  so 
is  to  cover  this  area,  and  no  trace  of  other  abnormal  condition 
3ould  be  discovered.  The  posterior  rent  was  therefore  stitched 
to  the  abdominal  incision  and  the  latter  closed,  except  for 
drainage  of  the  retroperitoneal  space,  through  which  the  fluid 
'ad  escaped.  My  original  intention  had  been  to  drain  poste¬ 
riorly  if  I  found  such  a  renal  cyst,  but  the  bursting  of  the  sac 
reqaired  anterior  drainage. 

Ihe  cyst  fluid  was  of  very  low  specific  gravity — D003.  It 
contained  a  trace  of  albumin  ;  no  urine  salts  ;  no  bile  salts;  no 
lydatid  elements  ;  some  chlorides.  During  evacuation  hydatid 
laughter  cysts  were  watched  for  but  not  seen.  The  diagnosis, 
therefore,  must  remain  of  thin-walled  cyst  of  the  surface  of  the 
ddney,  growing  so  as  to  distort  the  organ  by  surface  pressure. 

After  operation,  free  drainage  of  limpid  fluid  continued  for 
hirty-six  hours,  when  it  rapidly  lessened,  and  his  convalescence 
■vas  uninterrupted.  His  temperature  fell  to  normal  in  four  or 
we  days.  On  the  fourth  day  he  had  considerable  albumin  ap¬ 
pear  in  his  urine,  with  casts.  All  disappeared  during  the  four 

lays  succeeding,  and  he  was  discharged  cured  during  the  fourth 

■veek. 

He  has  since  been  carefully  examined  by  Dr.  Draper,  nearly 


six  months  after  operation,  and  he  remains  free  from  all  signs 
of  trouble. 

There  seems  in  the  cases  given  to  be  evidence  that  in 
both  we  had  renal  cysts  not  of  the  usual  type  of  hydrone¬ 
phrosis.  The  pelves  of  the  kidneys  were  not  the  seat  of 
distension,  and  excepting  that,  through  scratching,  a  few 
cholesterin  crystals  entered  the  urinary  channel  a  few  hours 
after  operation,  there  was  no  contamination  of  the  urine 
by  the  cyst  contents. 

The  retention  cysts  of  the  renal  cortex  resulting  from 
fibrous  change  in  granular  kidney  are  usually  multiple  and 
rarely  attain  much  size.  They  are  bilateral  also.  Congeni¬ 
tal  cysts  are  very  rare  and  due  to  cystic  degeneration  of 
rudimentary  tubes.  The  kidney  substance  is  not  left  in 
bulk  as  in  the  cases  narrated,  but  attenuated  or  wanting, 
and  the  victims  of  this  deformity  are  apt  to  have  other  de¬ 
formities  and  die  in  infancy.  Simple  cysts  and  paranephric 
cysts,  however,  are  of  a  class  by  themselves  that  directly 
concern  the  surgeon  by  their  rarity  and  importance. 

The  pathology  of  their  origin  is  not  easily  ascertained, 
as  they  have  usually  so  attenuated  the  capsule  of  the  gland 
and  compressed  the  neighboring  cortex  as  to  make  it  im¬ 
possible  to  say  whether  they  sprang  from  the  meshes  of  the 
cellular  layer  beneath  the  capsule,  or  from  the  Malpighian 
corpuscles,  or  from  their  investing  cellular  layer,  or  from 
lymphatic  channels.  The  contents  of  the  cyst  give  no  clew 
to  its  origin  ;  they  are  as  various  as  in  cysts  elsewhere, 
varying  from  clear  aqueous  contents  of  very  low  specific 
gravity  and  containing  a  trace  of  albumin  and  salt  through 
every  grade  of  colloid  and  straw-colored  serum.  Usually 
clear,  they  may  have  such  ingredients  as  cholesterin,  which 
results  from  the  degeneration  of  any  fatty  or  cellular  sub¬ 
stance,  or,  as  seems  most  probable,  of  blood.  They  never 
have  urinous  elements  in  solution. 

This  uncertainty  as  to  origin  entitles  such  tumors  as 
have  been  described  to  the  name  of  paranephric  cysts, 
resting  upon  the  kidney,  there  being  no  evidence  that  they 
arise  within  the  cortex.  The  recorded  cases  are  not  very 
numerous.  They  have  been  known  to  grow  to  larger  pro¬ 
portions  than  the  first  one  I  have  mentioned,  and  to  have 
been  mistaken  for  ovarian  tumors.  This  seems  extremely 
easy  to  do  if  one  regards  the  shape  and  fluctuation  of  the 
tumor  and  the  appearance  of  the  patient.  If  an  early  his¬ 
tory  of  growth  in  the  ilio-hypochondriac  region  can  be 
elicited,  or  if  the  physical  examination  reveals  a  course  of 
the  intestine  over  its  surface,  such  as  the  colon  took  in  one 
case  under  consideration,  it  would  give  a  strong  point  toward 
differential  diagnosis.  In  my  second  case  the  relation  of 
the  colon  was  also  of  interest,  it  being  pushed  down  and  in 
front  ot  the  tumor.  This  is  perhaps  one  of  the  best  points 
for  diagnosis  that  the  colon  is  usually  in  front  of  a  renal 
tumor.  Yet,  as  Morris  says,  an  exceptionally  large  renal 
tumor  will  push  the  colon  aside,  and,  on  the  other  hand,  a 
portion  of  intestine  will  occasionally  though  rarely  fasten 
itself  in  front  of  an  ovarian  cyst. 

As  regards  the  second  case,  which  resembled  a  dis¬ 
tended  gall-bladder,  I  may  say  on  reviewing  it  that  the 
tumor,  while  not  less  prominent  than  a  gall-bladder  cyst, 
was  perhaps  less  pyriform ,  more  movable  laterally ,  and  some- 


150 


ABBE:  A  CASE  OF  HEMIPLEGIC  EPILEPSY. 


[N.  Y.  Med.  Jodb.> 


what  more  easily  raised  by  lumbar  pressure  than  even  a 
large  gall-bladder  would  have  been.  Its  position  was  too 

high  for  the  usual  hydronephrosis. 

The  successful  treatment  of  all  serous  cysts  by  incision 
and  drainage  makes  it  probable  that  no  other  treatment 
would  have  been  more  successful  or  less  dangerous  in  these 
cases.  The  first  case  of  large  cyst  shows  that  a  lumbar  in¬ 
cision  without  guidance  from  within  would  have  probably 
penetrated  the  peritoneal  sac  before  entering  the  cyst,  on 
account  of  the  persistent  reflection  of  the  peritonaeum  close 
to  the  kidney,  in  spite  of  the  fact  that  the  colon  had  been 
raised  to  the  surface  of  the  cyst.  Exploratory  aspiration 
also  would  have  allowed  the  muddy  cholesterin  fluid  to 
empty  somewhat  into  the  peritonaeum  if  puncture  had  been 
made  anywhere  but  close  to  the  kidney. 


A  CASE  OF  HEMIPLEGIC  EPILEPSY, 

PROBABLY  DIABETIC,  SIMULATING  CEREBRAL  ABSCESS.* 
By  ROBERT  ABBE,  M.  D. 

The  case  the  history  of  which  I  am  about  to  nari  ate 
presents  features  of  much  interest  to  the  physician  as  well 
as  the  surgeon,  and  bears  directly  on  diagnosis  in  cerebral 

surgical  disease. 

The  patient  was  an  active  man  of  forty-four  years  and  in 
exceptionally  good  health  until  attacked  by  the  grippe  on  last 
Christmas.  His  influenza  was  of  a  severe  type-general  pains, 
prostration,  sore  throat,  cough.  The  sore  throat  seems  to  have 
been  the  worst,  and  swallowing  was  difficult.  Two  or  three 
days  later  severe  pain  began  in  the  left  ear,  and  suppurative 
otitis  media  was  established.  The  discharge  diminished  but 
never  ceased.  He  was  unable  to  resume  work,  lost  flesh  and 
strength.  There  were  no  cerebral  symptoms,  and  he  was  able 
to  be^bout.  A  few  days  after  the  onset  of  his  trouble— that 
is  about  January  1st— he  observed  a  marked  increase  in  the  fre¬ 
quency  and  quantity  of  urination,  but  no  examination  of  it  was 

then  made.  .  .  . 

In  February  he  noticed  a  growing  difficulty  in  giving  ex¬ 
pression  to  certain  words.  This  and  the  patient’s  general  con¬ 
dition  seemed  a  little  worse  on  alternate  days.  He  had  one  or 
two  headaches  weekly,  mostly  left-sided,  with  tendency  to  ver¬ 
tigo.  Became  rather  somnolent. 

°  On  March  4th  he  became  dizzy,  his  legs  gave  way,  and 
he  fell  while  walking  in  the  street.  A  sensation  “  like  a  shock 
of  wind,”  as  he  expressed  it,  seemed  to  start  in  the  right,  foot 
and  spread  very  rapidly  over  the  right  leg,  arm,  and  side.  The 
paresis  seemed  to  come  on  gradually,  as  he  felt  less  and  less 
able  to  walk,  and  finally  dropped,  not  unconscious  but  unable 

to  walk.  .  „ 

March  9,  1890. — Admitted  to  St.  Luke’s  Hospital,  under  Dr 

George  L.  Peabody’s  care.  Examination  showed  that  the  pa. 
tient  had  a  mitral  murmur;  no  paralyses;  no  deviation  of 
tongue;  no  amesthesia.  Pupils  reacted  to  light.  Knee-jerk 
absent.  The  other  reflexes  were  present,  the  plantar  rather  ex¬ 
aggerated.  There  was  a  purulent  discharge  from  the  left  ear, 
with  perforation  of  the  drum.  His  skin  was  dry,  tongue  coated 
with  brown  fur,  but  moist.  Pulse,  80;  temperature,  normal. 
The  patient  was  somnolent.  About  an  hour  after  admission  he 
began  to  have  convulsive  movements  of  the  right  side,  begin¬ 
ning  in  the  foot,  was  given  a  hypnotic,  and  slept.  The  next 


*  Read  before  the  New  York  Surgical  Society,  April  23,  1890. 


morning  he  was  able  to  walk  with  a  limp.  After  breakfast 
another  convulsion  of  the  right  leg,  lasting  half  an  hour.  There 
was  some  paresis  of  the  leg  and  hyperiesthesia  of  the  right  side, 
passing  away  quickly.  Also  a  slight  transient  aphasia,  llis 
chief  complaint  was  of  general  weakness  and  the  discharge  from 

the  ear. 

The  urine  was  acid.  Specific  gravity,  1 '042.  Sugar,  thirty- 
two  grains  to  the  ounce.  No  albumin.  No  casts.  The  ear  was 
frequently  syringed  with  boric-acid  solution,  and  he  was  given 
bichloride  of  mercury,  gr.  t.  i.  d.,  with  diabetic  diet.  During 
the  following  week  his  urine  increased  in  quantity  from  forty 
to  eighty-six  ounces,  and  the  sugar  diminished  to  twenty- six 
grains.  There  were  several  times  each  day  attacks  of  numbness 
of  the  right  arm  and  leg,  with  considerable  loss  of  power.  Hie 
patient  could  stand  but  not  walk.  He  could  not  grasp  with  his 
right  hand.  There  were  no  optic  symptoms.  During  the  at¬ 
tacks  there  was  hesitation  in  speaking  and  difficulty  in  pro¬ 
nouncing  some  words.  The  mind  was  dull,  but  there  was  no 
loss  of  memory.  The  attacks  lasted  from  a  few  seconds  to  five 
or  ten  minutes  and  went  off  as  suddenly  as  they  came  on. 
There  was  a  vague  history  of  early  syphilis,  aDd  he  was  given 
eight  doses  daily  of  iodide  of  potassium,  forty  grains  each. 

On  March  14th  convulsive  movements  of  the  right  arm  and 
hand  were  noticed,  and  to  a  much  less  degree  of  the  right  leg 
and  foot.  These  lasted  only  a  few  seconds  and  were  followed 
by  a  stupid  condition.  Aphasia  followed  each  attack. 

Yah. _ At  least  two  attacks  daily  were  associated  with  con¬ 

vulsive  movements  of  the  right  hand  and  arm.  Mouth  open 
widely ;  eyes  closed.  On  coming  out  of  one  attack  he  was 
unconscious  that  it  had  happened.  Examined  by  Dr.  M.  A. 
Starr  with  Dr.  Peabody,  no  retinal  changes  were  present. 

20th. _ Up  to  this  date  he  had  been  having  three  or  more 

marked  epileptic  seizures  daily,  beginning  with  numbness  of  the 
right  leg  and  arm,  andsucceded  by  severe  spasmodic  convulsions 
limited  to  these  members.  It  now  extended  to  the  same  side  of 
the  face.  His  temperature  also  rose  to  101°,  having  previously 
been  normal,  or  nearly  so.  Evidence  of  mastoid  inflammation 
also  developed  rapidly,  and  in  twenty-four  hours  a  well-marked 
suppurative  mastoiditis  was  found,  and  he  was  transferred  to 
my  care  for  surgical  relief. 

His  urine  still  showed  no  albumin  or  casts,  but  sugar, 
twenty-four  grains  to  the  ounce.  During  the  succeeding 
twenty-four  hours  six  similar  epileptic  seizures  occurred,  wboly 
limited  to  the  right  side.  He  was  seen  by  Dr.  Dana,  who  noted 
also  some  anesthesia,  as  well  as  diminished  muscular  power  ot 
the  right  side.  It  was  thought  possible  there  might  be  an  ex¬ 
tension  of  suppuration  by  perforation  from  the  mastoid,  causing 
pressure  upon  the  portions  of  the  brain  indicated  by  the  parts 
involved  in  the  seizures— namely,  the  centers  for  the  leg,  arm 
and  face,  and  for  speech.  Preparation  was  made  to  operate 
upon  the  mastoid,  and,  if  indicated,  to  trephine  also  over  the  as¬ 
cending  frontal  convolution. 

March  21st.— The  patient  was  etherized  and  the  mastoid  well 
excavated  of  all  suppurative  tissue.  A  piece  of  loose  seques¬ 
trum  was  found  within  the  bone.  The  bone  was  so  far  removed 
as  to  undermine  the  dura  constituting  the  floor  of  the  latera 
sinus,  and  still  further  in  a  space  the  size  of  the  finger  nail  of  the 
roof  of  the  petrous  portion.  Into  these  openings  the  direc  oi 
was  passed  between  bone  and  dura  mater  for  an  inch  in  different 
directions,  but  no  intracranial  pus  was  found. 

It  was  thought  best  to  defer  further  operation. . 

After  this  the  convulsive  twitchings  were  slight,  but  re 
curred  every  half  hour  or  less  all  the  next  day,  lasting,  how 
ever  only  a  minute.  His  tongue  deviated  to  the  right.  His  lip 
were  drawn  to  the  right.  Between  attacks  he  seemed  fairly  in 
telligent,  but  could  not  express  himself.  He  would  sometime 


August  9,  1890.] 


DUNN:  A  CASE  OF  REFLEX  AMBLYOPIA. 


151 


repeat  words  suggested  correctly  after  vain  attempts  to  make 

himself  underwood. 

On  the  second  day  after  operation  the  convulsions  were  more 
violent  though  not  so  frequent,  and  his  general  sense  was  more 

blunted. 

On  the  third  day  I  felt  that  the  indications  Avere  more  than 
ever  for  irritation  of  the  cortex  of  the  suspected  convolution. 
The  wound  was  in  perfect  condition,  yet  the  temperature  rose  on 
this  day  to  102°,  pulse  varying  from  72  to  100  at  different  hours — 
on  the  whole,  a  disproportionately  slow  one.  The  convulsions 
were  wholly  localized  and  the  aphasia  more  complete,  suggest¬ 
ing  a  left-side  lesion  directly  related  to  the  left-ear  condition. 

On  March  24th,  therefore,  I  trephined  with  a  one-inch  tre¬ 
phine  just  in  front  of  the  lower  end  of  the  Rolandic  fissure  as 
mapped  out  for  me  by  Dr.  Dana.  The  dura  and  brain  seemed 
normal  but  a  little  full.  Arachnoid  fluid  normal.  A  small  punct¬ 
ure  was  made  in  the  pia  and  a  director  gently  pressed  into  the 
presenting  convolution  for  an  inch  in  three  directions.  Neither 
suppuration  nor  tumor  was  found.  The  dura  was  therefore 
sutured  with  fine  catgut  and  the  wound  closed. 

The  operation  had  no  appreciable  effect  on  the  condition  of 
things.  The  convulsions  were  repeated  every  twenty  minutes 
as  before,  and  on  the  following  day  became  more  general,  both 
sides  of  the  body  and  face  participating.  His  aphasia  grew  more 
complete. 

On  the  third  day  the  convulsions  abated  in  frequency ;  only 
one  occurred  in  the  night  and  eight  in  the  day.  These  were 
general  though  more  marked  on  the  right.  He  seemed  to  un¬ 
derstand  everything  that  was  said  and  done,  but  could  not  make 
himself  understood. 

On  the  fifth  day  the  convulsions  came  hourly,  were  more  se¬ 
vere  and  more  general.  He  gave  evidence  of  exhaustion  from 
this  cause.  His  pulse  became  weaker.  Temperature  rose  to 
105-5°  just  before  death,  and  he  died,  after  a  few  hours,  of 

coma. 

The  autopsy  was  made  ten  hours  after  death  by  Dr.  Thacher, 
and  was  watched  with  great  interest  by  Dr.  Peabody,  Dr.  Starr, 
Dr.  Kinnicutt,  Dr.  Robinson,  Dr.  Bangs,  and  others,  besides  my¬ 
self.  The  brain  and  membranes,  as  far  as  gross  examination  re¬ 
vealed,  were  in  an  absolutely  normal  condition. 

No  trace  of  pus  was  found  anywhere,  even  in  the  temporal 
bone.  The  arteries  at  the  base  and  throughout  the  brain  were 
scrutinized  and  found  apparently  normal. 

Many  close  sections  were  made  in  the  region  about  the  Ro¬ 
adie  fissure  as  well  as  elsewhere,  and  a  more  normal  appear- 
ng  brain  it  would  be  difficult  to  find.  The  site  of  puncturing 
ivas  exactly  in  the  hand  and  face  convolutions,  and  no  harm  had 
’ome  from  the  use  of  the  director. 

(The  linear  scar  in  the  brain  substance  is  here  shown.) 

Further  examination  of  the  body  showed  an  abdominal  ad- 
lesion  matting  together  the  pancreas,  spleen,  and  transverse 
:olon.  The  pancreas  was  atrophied  to  a  fibrous  relic  about  one 
piarter  its  normal  bulk.  No  suppurative  process  could  be  de- 
ected.  It  was  impossible  to  say  Avhether  this  was  a  recent  or 
ong-standing  lesion. 

Further  consideration  of  the  history  and  revelations  of 
he  autopsy  led  to  the  conviction  that  the  train  of  remarka¬ 
bly  delusive  symptoms  resulted  from  the  poisoning  of  his 
ystem  through  the  diabetic  poison.  This  suppurative  rnas- 
oiditis  was  undoubtedly  the  determining  cause  of  irrita- 
ion  of  the  left  convolutions. 

Bibliography . 

A.  Reference  Hand-book  of  the  Med.  Sciences. 

(Dr.  Kinnicutt,  Med.  Rec.,  New  York,  vol.  xxiv,  p.  221.) 


1.  Facial  hemiplegia  ;  the  patient  died  in  syDcope  with  sud¬ 
den  hemiplegia  of  the  body. 

2.  Landesburg  mentions  a  case  of  paralysis  of  the  abducens- 

3.  Dementia  paralytica,  Hamilton,  N.  Y.  Med.  Journ .,  xl, 
1-5. 

Locomotor  ataxia,  tabes  dorsalis,  insanity,  and  hemiplegia, 
are  all  mentioned  as  occurring  in  conjunction  with  diabetes 
mellitus. 

B.  Guy's  Hospital  Reports ,  vol.  xliv,  1886-1887,  p.  189. 

(Pavy,  On  Clinical  Aspect  of  Glycosuria.  Brit.  Med.  Journ., 
1885,  ii,  p.  1049.) 

“  Dr.  Pavy  states  that  nervous  symptoms,  especially  spinal 
ones,  are  very  apt  to  accompany  diabetes.  He  has  seen  ataxia 
associated  with  it  in  a  great  many  cases,  the  symptoms  coming 
on  either  simultaneously  or  at  different  times.  There  may  be 
pains  in  the  limbs,  a  feeling  of  heaviness  iD  the  feet,  darting  or 
lightning  pains,  hyperaesthesia,  deep-seated  pain  in  the  bones, 
and  loss  of  knee-jerks.” 

Bouchard  and  Marie  and  Guignon,  in  an  abstract  in  Brit. 
Med.  Journ.,  1887,  i,  p.  236,  direct  special  attention  to  the  loss 
of  knee-jerks. 

Nervous  symptoms  occurred  in  one  form  or  another  in  sev¬ 
enty-one  out  of  one  hundred  and  sixty-eight  cases  at  Guy’s. 


A  CASE  OF  REFLEX  AMBLYOPIA 

CURED  BY 

SECTION  OE  THE  SUPRA-ORBITAL  NERVE. 

By  JOHN  DUNN,  M.  D., 

RICHMOND,  VA. 

The  patient,  a  young  man,  aged  nineteen,  came  under  my 
observation  the  latter  part  of  October,  1889.  He  complained 
of  dimness  of  vision,  which,  he  said,  was  getting  gradually 
worse,  and  of  a  constant  pain  in  both  eyes. 

In  the  winter  of  1886  the  patient,  then  aged  sixteen,  was 
struck  in  the  right  eye  with  a  snow-ball.  He  did  not,  however, 
attribute  his  loss  of  sight  to  the  blow,  as  it  was  some  months 
afterward  that  the  visual  trouble  began.  The  pain  from  the 
blow  had  been  so  severe  that  for  a  time  nothing  except  mor¬ 
phine  would  give  him  any  relief.  In  the  spring  of  1887  he 
suffered  much  from  neuralgia  in  the  neighborhood  of  both  eyes. 
In  June  his  eyesight  began  to  fail  him,  though  be  was  able  to 
continue  his  studies  until  the  following  December.  From  this 
time  until  October,  1889,  he  was  under  treatment  for  his  eyes, 
which  continued  to  get  steadily  worse. 

In  October,  1889,  the  following  was  the  condition  of  the 
eyes:  A  spasmodic  winking  of  the  lower  lid  of  O.  D.  is  very 
marked,  occurring  from  twelve  to  fifteen  times  a  minute.  This 
twitching  of  the  lid  began  soon  after  the  eye  was  struck  and 
had  never  entirely  ceased  ;  at  times  it  occurs  much  more  fre¬ 
quently  than  at  others.  A  strong  light,  as  that  from  an  ophthal¬ 
moscope,  increases  the  number  of  spasms  per  minute  markedly, 
while  u  a  cold  wind  will  make  that  eye  wink  every  second  in 
the  minute.”  There  was  no  corresponding  movement  of  the 
left  lower  lid.  Both  eyes  show  an  irritable  condition  of  the 
conjunctiva,  which  is  in  a  state  of  active  byperaamia.  A  bright 
light  or  an  attempt  to  use  the  accommodation  for  more  than  a 
very  short  time  causes  the  eyes  to  fill  with  tears.  Running  from 
the  outer  margins  of  both  corneae  to  the  external  canthus  of  the 
eye  were  several  small  blood-vessels,  so  enlarged  and  full  of 
blood  that  one  could  readily  be  led  to  seek  for  some  irritating 
foreign  body  in  the  outer  canthal  region. 

The  cornea,  aqueous,  lens,  and  vitreous  were  perfectly  clear. 
Iris  normal.  Pupil  responded  most  delicately.  The  tension  of 


DUNN:  A  CASE  OF  REFLEX  AMBLYOPIA. 


[N.  Y.  Med.  Jock., 


152 


both  eyes  was  rather  greater  than  normal,  perhaps  T  +  1.  The 
anterior  chamber  shallower  than  might  be  expected  in  a  normal 
eye.  The  optic  discs  and  retinae  were  perfectly  normal.  Neither 
veins  nor  arteries  were  overfilled.  Both  eyes  weie  painful  at 
all  times.  The  pain  in  the  right  eye  had  been  constantly  present 
for  two  years,  though  it  had  been  much  worse  at  some  times 
than  at  others.  So  painful  was  this  eye  in  damp  or  wet  weather 
that  the  patient  had  long  since  learned  to  remain  indoors  “  in 
bad  weather.”  Cold  wind  also  caused  the  eyes  to  pain  and 
water.  The  pain  in  the  right  eye  had  made  its  appearance  some 

months  before  that  in  the  lett. 

The  patient  complained  also  of  a  gray  cloud  before  both  eyes, 
denser  before  O.  D.  This  cloud  made  its  appearance  about  a 
year  ago  and  had  been  growing  denser  ever  since.  This  cloud, 
which  appears  to  be  “  always  floating  by,”  is,  like  the  pain  and 
spasmodic  twitching  of  the  right  lower  lid,  subject  to  variations 
At  times,  while  it  is  scarcely  distinguishable,  it  never  entirely 
disappears,  and  its  general  increase  in  density  from  month  to 
month  is  remarked  by  the  patient.  It  is  present  before  both 
eyes;  denser  before  the  right.  In  appearance  “  it  is  simply  a 
floating  gray  cloud  with  its  circumference  denser  than  its  cen¬ 
ter.”  When  it  first  made  its  appearance,  patient  thought  his 
glasses  were  soiled,  and  endeavored  by  wiping  them  to  clear 
away  the  cloud.  At  dusk  the  patient’s  eyesight  is  very  bad,  and 
at  night  he  can  distinguish  no  one  passing  him. 

The  ball  of  0.  D.  is  very  sensitive  to  pressure,  considerably 
more  pain  being  caused,  however,  when  the  ball  is  pressed  upon 
through  the  upper  than  when  through  the  lower  lid.  O.  S.  is 
also  sensitive  to  pressure,  though  less  so  than  O.  L>. 

Muscular  equilibrium  undisturbed.  Examination  for  defects 
of  the  color  sense  omitted. 

V.,  O.  D.  =  ;  O.  S.  =  Glasses  give  no  improvement. 

With  both  eyes  patient  can  make  out  Jaeger  1,  p.  p.  =  12  cm. ; 
p.r.  =  16  cm.  With  O.  D.,  Jaeger  3,  p.  p.  =  8  cm.;  p.  r.  = 
16  cm.  With  O.  S.,  Jaeger  1,  p.  p.  =  12  cm. ;  p.  r.  =  IV  cm. 
To  do  this,  however,  the  patient  requires  the  strongest  light, 
and  must  be  allowed  to  read  very  slowly.  Reading  newspaper 
type  for  more  than  a  few  minutes  at  a  time  is  impossible. 

Under  atropine,  Y.  for  O.  D.  =  ;  O.  S.  =  tinr-  Ref 

copy  gives  H.  D.,  as  measure  of  both  eyes.  No  astigma 
tism.  With  +  f  D.,  V.  for  O.D.  remains  while  for  0.  S. 
it  becomes  ||.  No  glass  improves  beyond  this. 

Tested  with  the  perimeter,  the  field  of  vision  for  both  eyes 
is  found  contracted— that  for  O.  D.  very  much  more  than  that 
for  O.  S.  (Vide  Chart  1.)  The  contraction  is  concentric. 


lent  condition.  His  whole  family,  he  said,  had  suffered  much 
from  failure  of  their  eyesight,  and  patient  was  willing  to  attrib¬ 
ute  his  loss  of  sight  to  an  “  inherited  tendency.”  The  patient 
says  he  had  syphilis  about  two  years  ago.  Unfortunately,  the 
physician  to  whom  he  had  applied  when  he  had  his  “  sores  ” 
was  not  in  good  standing,  and  had  prescribed  a  course  of  patent 
medicines.  From  the  patient’s  account  of  the  symptoms,  it  was 
extremely  doubtful  whether  he  had  ever  had  syphilis,  of  which 
there  was  in  October,  1889,  not  the  slightest  trace. 

The  treatment  for  the  eye  affection  had  been  very  varied. 
Enucleation  had  been  suggested  as  a  possible  resource  after  the 
involvement  of  the  second  eye. 

This  was  the  condition  of  affairs  when  the  patient  pre¬ 
sented  himself  in  October,  1889.  My  diagnosis  after  a  consid¬ 
eration  of  the  symptoms  was  glaucoma  simplex,  due  to,  per¬ 
haps,  some  reflex  cause,  for  I  had  in  my  mind  at  the  time 
Lennox  Browne’s  report  of  a  case  of  glaucoma  cured  by 
eradication  of  a  nasal  polyp.  There  were  many  symptoms  of 
glaucoma  lacking,  and  the  diagnosis  was  unsatisfactory.  To  see 
if  in  any  way  syphilis — though  no  definite  ocular  lesion  could 
be  determined,  or  even  suggested  itself — were  a  factor  in  the 
disturbances,  the  patient  was  made  to  undergo  for  three  weeks 
an  active  course  of  mercury  and  potash.  During  this  time  the 
pharyngeal  tonsil  was  removed  and  the  enlarged  middle  turbi¬ 
nates  were  reduced.  The  eye  symptoms  in  no  way  improved. 
The  patient  then,  at  my  suggestion,  visited  another  oculist. 
“  Tobacco  ”  was  suggested  “  as  having  something  to  do  with  the 
amblyopia,”  and  a  course  of  outdoor  exercise  and  strychnine 
advised.  Though  tobacco  amblyopia  seemed  far  less  probable 


cos 

>XIl90° 


II 

X 

\w 

997/ / 

\\So°M 

Oil  ITT' 

"M 

f-H  III 

170,0’ 

IV 

vni 

Chart  No.  2.— Fields  of  vision,  April  12,  1890. 


COS 

0X1190° 


COD 

=  XI190° 


'  VI  »#"  ®VI  ^ 

Chart  No.  1. — Fields  of  vision,  October  29,  1889. 


The  general  health  of  the  patient  had  always  been  good, 
though  he  suffered  much  from  “sore  throat  and  catarrh.”  Ex¬ 
amination  revealed  an  enlarged  pharyngeal  tonsil,  superadded 
to  a  chronic  laryngo-pharyngitis  resembling  much  in  appearance 
that  found  in  people  of  rheumatic  tendencies.  In  addition,  there 
was  a  moderate  hypertrophy  of  the  middle  turbinates  ante¬ 
riorly.  No  posterior  turbinate  enlargement.  Teeth  in  excel- 


in  view  of  the  symptoms  than  glaucoma  simplex,  in  deference 
to  the  oculist’s  great  reputation  no  objection  was  opposed  to  the 
treatment.  The  patient  submitted,  with  the  result  that  on  Feb¬ 
ruary  7,  1890,  vision  for  O.  D.  was  and  for  0.  S. Abso¬ 
lutely  no  improvement,  while  the  range  of  accommodation  for 
reading  was  considerably  reduced.  On  April  12th  the  range  of 
accommodation  was  in  0.  D.  only  2  cm.,  while  for  O.  S.,  Jaeger 
1,  it  was  also  only  2  cm.  (p.  p.,  16  cm. ;  p.r.,  18  cm.).  Ike 
patient  complained  greatly  of  insomnia,  which,  he  said,  had 
troubled  him  for  some  months.  Examination  with  the  perime¬ 
ter  shows  that  the  fields  of  vision  have  changed  but  little  since 
October.  (Vide  Chart  2.)  The  weather  had  been  warm,  and 
the  twitching  of  the  right  lower  lid  had  been  consequently  less 
frequent,  while,  with  strong  illumination,  0.  S.  could  read 
In  passing  my  finger  above  the  right  eye,  I  noticed  that  each 
time  it  passed  over  the  supra-orbital  nerve  there  was  a  cor¬ 
responding  twitching  of  the  right  lower  lid.  This  fact  sug¬ 
gested  many  possibilities,  and  an  immediate  section  of  the  supra¬ 
orbital  nerve  was  advised.  The  patient  agreed.  The  operation 
was  done  subcutaneously.  The  point  of  a  small  knife  was 
forced  to  the  bone,  external  to  the  nerve,  in  the  supra-orbital 
notch,  and  the  handle  of  the  knife  then  depressed.  I  could  feel 
that  the  nerve  was  cut  entirely  through.  The  bleeding  amount¬ 
ed  to  nothing.  A  piece  of  adhesive  plaster  was  the  dressing. 


August  9,  1890.] 


EMERSON:  CONGENITAL  STENOSIS  OF  TEE  DUODENUM. 


153 


Immediately  after  the  section  of  the  nerve  the  patient  remarked  : 

“For  the  first  time  in  three  years  can  I  wink  my  right  eye 
without  pain.”  Pressure  on  the  nerve  no  longer  produces  spasm 

of  {he  lower  lid. 

April  15th—  Wound  healed  without  trouble.  Right  side  of 
the  forehead  painful  as  patient  attempts  to  move  skin  on  his 
forehead;  spasmodic  twitching  of  right  lower  lid  has  disap¬ 
peared.  Patient  says  he  feels  as  if  left  eye  had  improved  more 

than  right. 

"V  O.  D.  =  ;  O.  S.  =  |§. 

mh.— April  20th  was  a  cold,  damp  day,  and  patient  suf¬ 
fered  much  from  pain  in  0.  D. 

\ .,  O.  D.  =  with  +  f-  D.  =  jfafo ;  0.  S.  =  with  + 
|  D.,  two  letters  in 

Applied  constant  current,  positive  pole  to  back  of  neck, 
negative  over  course  of  supra-orbital  nerve  and  over  upper  eye¬ 
lid  of  0.  D.  The  application  was  extremely  painful,  causing 
the  eye  to  become  bloodshot  and  to  water  profusely.  The  ap¬ 
plication  lasted  three  minutes.  The  pain  caused  by  it  lasted 
thirty-six  hours,  most  of  which  time  patient  spent  in  bed. 

29th.  "V .,  O.  D.  =  Are?  O,  S.  = 

Applied  constant  current  again.  Application  caused  little 
or  no  pain. 

May  2d.— V.,  0.  D.  =  ;  O.  S.,  If. 

Field  of  vision  of  O.  D.  is  still  slightly  contracted,  although 
less  than  that  of  O.  S.  was  originally.  Field  of  O.  S.  has  be¬ 
come  normal.  (  Vide  Chart  No.  3.)  Current  again  applied  for 
five  minutes. 

c.os  ‘  cod 


Chabt  No.  3.— Fields  of  vision,  May  3,  1890. 

8th.— Y.,  0.  D.  =  ff ;  O.  S.  =  If. 

July  16th.— No  return  of  any  symptom  of  reflex  trouble. 

Thus,  in  less  than  four  weeks  after  section  of  the  supra¬ 
orbital  nerve  the  vision  of  0.  D.  had  increased  from  ^  to  If, 
while  that  of  0.  S.  from  ff  to  If.  The  pain  has  entirely  disap¬ 
peared  from  both  eyes.  Both  fields  of  vision  are  normal.  The 
cloud  before  the  eyes  was  seen  once  or  twice  soon  after  the  op¬ 
eration,  but  has  now'  disappeared.  There  is  now  no  longer  a 
twitching  of  the  right  lower  lid.  The  conjunctive  have  lost 
their  hyperemic  condition,  and  the  irritated  appearance  of  the 
vessels  running  from  the  outer  canthus  to  the  cornea  has  disap¬ 
peared.  The  patient  has  got  his  books  out  again,  and,  on 
May  7th,  read  two  hours  without  fatigue  to  his  eyes.  The  neu¬ 
ralgia  has  disappeared,  and  with  it  the  patient’s  inability  to 
sleep.  In  short,  the  cure  has  been  perfect. 

Remarks. — This  case  has  been  reported  thus  at  length 
because  of  its  completeness ;  because,  as  a  case  of  reflex 
amblyopia,  it  leaves  no  doubt  as  to  its  origin;  and,  fur¬ 
ther,  because  it  shows  how  perfect  may  be  the  return  ad 
integrum  of  the  functions  of  an  organ  which  for  years  has 
been  disabled  through  a  reflex  agency.  Moreover,  it  adds 
one  more  to  the  many  pleas  that  a  careful  search  should 
always  be  made  for  a  reflex  cause  in  troubles  which  have  no 
definite  pathological  lesion.  Reference  has  been  made  to 


the  treatment  ot  the  case  other  than  the  section  of  the 
supra-orbital  nerve,  because  it  is  of  interest  in  showing  the 
uselessness  of  general  remedies  in  reflex  troubles  whose 
source  is  a  definite  anatomical  lesion.  As  in  all  reflex 
troubles,  this  case  presents  many  points  of  interest.  The 
pathogeny  of  the  amblyopia?  The  case  adds  little  to  any 
of  the  hypotheses  that  have  been  formed  to  settle  this  ques¬ 
tion.  The  direct  cause  that  kept  up  the  reflex  symptoms? 
It  seems  more  than  probable  that  the  blow  so  injured  the 
sheath  of  the  supra-orbital  nerve  that  an  adhesion  formed 
between  the  sheath  and  the  adjacent  tissues.  This  adhe¬ 
sion,  then,  could  have  become  the  source  of  continuous 
trouble,  since  each  movement  of  the  upper  lid,  as  in  wink¬ 
ing,  or  each  contraction  of  the  skin  over  the  forehead,  as  in 
frowning,  would  have  dragged  upon  the  nerve  by  means  of 
the  adhesion.  Or  continuous  pressure  may  have  been  ex¬ 
erted  upon  the  nerve  through  cicatricial  contraction  left  as 
the  result  of  a  perineuritic  inflammation  set  up  by  the  blow. 
In  either  case  the  question  arises  whether  the  cure  obtained 
through  simple  section  of  the  nerve  at  the  seat  of  adhesion 
or  contraction  will  be  permanent.  The  influence  of  wind 
and  damp  weather  in  increasing  the  pain  in  the  eye  seem 
to  point  rather  to  a  subacute  inflammation  of  the  nerve  it¬ 
self.  If  so,  then  had  the  section  of  the  nerve  or  the  appli¬ 
cation  of  the  electric  current  the  greater  share  in  procuring 
a  cure  which  may  be  looked  upon  as  permanent  ?  The 
order  in  which  the  eye  symptoms  developed,  the  fact  that 
vision  did  not  begin  to  fail  for  six  months  after  the  blow 
was  given,  the  gradual  but  sure  increase  in  the  symptoms, 
the  almost  complete  abolition  of  the  range  of  accommoda¬ 
tion  for  small  objects — these  all  furnish  food  for  reflection, 
and  seem  in  more  than  a  vague  way  to  point  us  to  nerve 
exhaustion  as  the  prime  factor  in  the  pathogeny  of  reflex 
troubles,  nerve  exhaustion  called  forth  by  continuous  ex¬ 
cessive  energy  due  to  a  continuous  point  of  irritation  in  a 
nerve  filament  closely  allied  to  the  organ  in  which  the  reflex 
symptoms  show  themselves.  The  question,  too,  whether, 
as  a  result  of  this  blow,  there  would  have  been  in  course  of 
time  a  real  degeneration  of  the  organ  of  sight  comes  up. 
At  all  events,  after  three  years  and  a  half  have  elapsed,  dur¬ 
ing  the  whole  of  which  time  the  reflex  cause  had  been  at 
work,  the  removal  of  the  cause  does  away  almost  im¬ 
mediately  with  the  effects. 


CONGENITAL  STENOSIS  OF  THE  DUODENUM. 

IIA1MA  T EMESIS ;  DEATH  ON  THE  FIFTH  DAY;  AUTOPSY* 

By  J.  H.  EMERSON,  M.  D. 

N.  B.,  male,  the  fifth  child  of  healthy  parents,  was  born  on 
April  24th  after  a  normal  and  easy  labor  of  about  fifteen  hours. 
Weight,  eight  pounds  and  a  half;  circulation  perfect.  Ap¬ 
peared  well  nourished  and  well  developed  in  every  respect. 
When  about  thirty-three  hours  old  the  child  suddenly  and  with¬ 
out  any  apparent  cause  spat  up  or  regurgitated  about  half  an 
ounce  or  more  of  rather  dark  blood,  partly  mixed  with  mucus. 
This  effort  involved  some  choking,  and  was  followed  by  some 


*  Read  before  the  Section  in  Paediatrics  of  the  New  York  Academy 
of  Medicine,  May  8,  1890. 


154 


EMERSON:  CONGENITAL  STENOSIS  OF  TEE  DUODENUM. 


[N.  Y.  Med.  Jour., 


blueness  and  coldness  of  the  extremities.  The  same  thing  was 
repeated  four  or  five  hours  later,  but  with  less  effort  and  dis¬ 
turbance,  and  after  this  recurred  at  intervals  and  in  varying  but 
not  large  amount  for  eight  or  nine  hours  longer.  The  nurse  re¬ 
ported  that  there  had  been  a  trace  of  a  reddish  stain  in  the  mu¬ 
cus  from  the  mouth  since  birth.  The  bowels  had  moved  freely 
before  the  blood-spitting  began — a  dark,  tarry  stool.  The  child 
evinced  no  desire  for  food,  and  would  make  no  effort  to  take 
the  breast.  Gave  no  sign  of  suffering  except  when  raising  the 
blood  from  the  throat,  which  act  was  accompanied  by  some 
gagging,  but  hardly  a  vomiting  effort.  Some  blood  also  escaped 
through  the  nostrils.  No  cough.  No  fever.  No  disturbance  of 
respiration.  Examination  of  the  surface  of  the  body  and  of  the 
mouth  and  fauces  revealed  nothing  abnormal.  The  attempt  was 
made  to  give  one  drop  of  spirits  of  turpentine  in  water,  also 
subsequently  a  little  milk  and  water  and  some  minute  scraps  of 
ice,  but  it  is  doubtful  if  anything  was  swallowed  at  this  time, 
and  these  attempts  only  led  to  increased  regurgitation  and 
bleeding.  Another  stool  at  this  time  contained  only  meconium  ; 
no  trace  of  altered  blood.  When  the  child  was  about  forty-six 
hours  old  Dr.  A.  Jacobi  saw  him  in  consultation,  and  made  a 
thorough  examination  without  being  able  to  satisfy  himself  as  to 
the  source  of  the  haemorrhage,  although  we  concluded  that  the 
symptoms  pointed  to  its  coming  from  somewhere  low  in  the 
pharynx.  A  weak  solution  of  alum  and  potassium  chlorate  was 
prescribed,  to  be  applied  in  the  pharynx  hourly  with  a  camel’s- 
hair  brush.  From  about  this  time  no  more  red  blood  was  ejected, 
although  there  was  a  slight  brownish  stain  to  the  mucus  from 
the  mouth.  During  the  succeeding  tbirty-six  hours  the  child 
received  small  quantities  of  milk  and  water,  with  a  few  drops  of 
brandy,  also  some  breast  milk  from  a  spoon,  but  would  not  nurse, 
although  he  swallowed  better.  At  the  expiration  of  this  time 
— viz.,  when  about  three  days  and  a  half  old — he  vomited  a 
large  quantity  of  dark-brown  watery  and  grumous  fluid,  which 
also  poured  through  the  nostrils,  and  a  similar  discharge  took 
place  now  and  then  in  greater  or  less  quantity,  and  not  always 
with  an  effort  of  vomiting,  until  his  death.  Some  of  this  mate¬ 
rial,  scraped  from  the  napkin  and  examined  with  the  micro¬ 
scope,  appeared  to  be  of  an  oily  character,  contained  some  colos¬ 
trum  corpuscles,  and  also  altered  blood-corpuscles.  The  dis¬ 
charges  from  the  bowels  had  the  same  character  as  the  earlier 
ones,  and  contained  no  trace  of  sweet-oil,  of  which  a  teaspoon¬ 
ful  was  twice  administered  by  the  mouth.  The  last  evacuation, 
only  about  three  hours  before  death,  was  stained  with  bile. 
The  child  died  when  four  days  and  ten  hours  old,  emaciated, 
but  not  extremely  exsanguinated. 

The  following  is  the  report  of  the  autopsy  by  Dr.  W.  B. 
James : 

N.  B.,  aged  four  days,  male,  died  on  April  28th,  p.  m. 

Autopsy,  April  29,  1890,  1.30  p.  m. 

Body  well  nourished.  Length,  48  ctm. 

Heart:  Foramen  ovale  patent,  0‘1  ctm. ;  otherwise  normal. 

Lungs  normal. 

Peritonaeum  normal. 

Stomach  is  markedly  dilated.  From  cardiac  orifice  to  py¬ 
lorus,  measured  on  greater  curvature,  is  17  ctm.  Pyloric  orifice 
dilated,  2  ctm.  diameter.  Duodenum  markedly  distended,  3 
ctm.  in  diameter,  the  distention  reaching  to  a  point  immediately 
above  the  orifice  of  the  common  bile  duct,  at  this  point  the 
lumen  of  the  duodenum  terminating  abruptly.  Fluid  can  not 
be  forced  below  this  point  from  the  stomach,  nor  can  air  be 
forced  from  the  intestine  upward  into  the  stomach. 

A  probe,  medium-sized,  can  be  passed  through  the  constric¬ 
tion,  which  appears  to  be  not  complete. 

Stomach  contains  a  large  amount  of  brownish-black,  fluid, 
somewhat  grumous  material. 


Small  intestine,  below  the  above-mentioned  constriction, 
normal. 

Large  intestines  normal. 

Oesophagus :  Immediately  above  cardiac  orifice  is  a  firm, 
dark-red,  oblong  thrombus,  2’5  ctm.  in  length,  firmly  attached 
to  posterior  wall  of  oesophagus. 

Upper  part  of  oesophagus  and  pharynx  normal.  Liver  nor¬ 
mal.  Kidneys  normal.  Bladder  normal. 

Microscopic  examination  of  the  above-mentioned  thrombus, 
with  oesophagus  wall,  showed  erosion  of  the  mucous  membrane 
immediately  beneath  the  thrombus.  The  exact  nature  of  the 
process  giving  rise  to  the  bleeding  could  not  be  made  out. 

It  should  also  be  noted  that  at  the  autopsy  the  intestine 
below  the  constriction  in  the  duodenum  was  found  almost 
entirely  empty,  containing  but  a  very  little  dark  meconium 
in  the  lower  portion,  while  its  upper  part  was  stained  yel¬ 
low  with  bile  for  a  few  inches. 

I  would  call  your  attention  to  a  few  points  of  special 
interest. 

Both  the  abnormal  conditions  here  presented  are  of  very 
rare  occurrence.  As  to  the  lesion  of  the  oesophagus,  I  have 
not  succeeded  in  finding  an  account  of  any  such  condition, 
haemorrhage  from  that  canal  being  attributable  either  to 
traumatism,  to  heterologous  deposits,  or  to  antecedent  dis¬ 
ease,  either  constitutional  or  local,  none  of  which  were  pres¬ 
ent  in  this  case.  The  one  most  nearly  resembling  it  is  re¬ 
ported  by  Henoch  [Lectures  on  Children's  Diseases ,  vol.  i, 
transl.  from  4th  German  edition  by  John  Thomson,  Lon¬ 
don,  New  Sydenham  Society,  1889,  p.  68).  He  says :  “The 
following  case  stands  alone.  A  child  of  five  days,  admitted 
October  1,  1881.  Since  the  third  day  of  life,  repeated 
vomiting  of  blood  and  black  bloody  stools.  The  child 
sickly,  shriveled,  anaemic ;  extremities  cold ;  anal  aperture 
covered  with  bloody  faeces.  Pulse  imperceptible  ;  tempera¬ 
ture,  87’8°  F.  Takes  no  nourishment.  Death  that  even¬ 
ing.  Post-mortem:  General  anaemia ;  spleen  normal.  Im¬ 
mediately  over  the  cardia,  a  ring  of  ulceration,  an  inch 
and  five  eighths  long,  surrounding  the  whole  oesophagus. 
The  suhmucosa  remained  free ;  it  was  swollen  and  infiltrated 
with  grayish-white  matter.  The  ulcer  sharply  defined  above ; 
otherwise  everything  normal.  We  were  unable  to  throw 
any  light  upon  the  origin  and  nature  of  this  oesophageal 
ulcer.” 

The  occlusion  of  the  duodenum  was  not  structurally  ab¬ 
solute,  although  the  canal  was  impervious  to  both  air  and 
fluid.  Its  condition  resembled  a  gathering  together  of  all 
the  tissues  of  the  gut  at  that  point,  much  as  a  bag  is  drawn 
together  by  a  string.  In  regard  to  the  pylorus,  Ziegler  says 
(■ Text-book  of  Pathological  Anatomy  and  Pathogenesis , 
transl.  by  Donald  MacAlister,  New  York,  1887,  p.  617): 
“Complete  atresia  of  the  pylorus  is  very  rare,  but  stenosis 
or  abnormal  contraction  is  more  frequent  (R.  Maier).”  Nor 
does  the  state  of  things  here  seem  identical  with  that  re¬ 
ferred  to  by  Widerhofer  (Gerhardt,  Kinderkranlcheiten,  vol. 
iv,  part  2,  p.  353),  where  he  says  that  the  lumen  of  the 
stomach  or  intestine  may  he  narrowed  or  obliterated  by 
partitions,  the  origin  of  which  is  not  well  understood. 

Another  question  which  naturally  arises  is  whether 
there  was  any  causative  relation  between  *the  haemorrhage 
I  and  the  coexisting  stenosis  of  the  duodenum.  In  other 


August  9,  1890.] 


CHAPIN:  NOTE  ON  OI1L  ORA  LA  HIDE. 


155 


words,  is  it  probable  that  the  effort  of  vomiting  caused  a 
lesion  of  the  mucous  membrane  of  the  oesophagus,  and  so 
hemorrhage,  in  analogy  with  the  case  of  rupture  of  the 
oesophagus  of  the  Dutch  admiral,  as  reported  by  Boerhaave? 
The  history  of  the  case  would  negative  this  theory,  for  the 
vomiting  was  never  violent,  the  raising  of  red  blood  was  the 
earliest  symptom  noted,  and  it  took  place  before  any  kind 
of  food  or  drink  had  been  taken  into  the  stomach. 

With  reference  to  diagnosis,  it  may  be  said  that  the  non- 
appearance  of  blood  in  the  evacuations  from  the  bowels, 
while  it  distinguished  this  case  from  those  of  melaena, 
might  have  given  a  hint  of  the  possible  existence  of  an  oc¬ 
clusion  of  some  part  of  the  alimentary  canal,  especially 
when  coupled  with  the  fact  that  the  sweet-oil  swallowed 
also  failed  to  show  itself  in  the  dejecta. 


NOTE  ON  CHLORALAMIDE. 

By  WARREN  B.  CHAPIN,  A.  M.,  M.  D. 

The  cases  in  which  I  have  used  chloralamide  have  been 
mostly  those  of  insomnia  of  a  very  persistent  character,  in 
some  of  which  all  other  hypnotics  had  failed.  Although  my 
experience  with  the  drug  has  been  confined  mostly  to  one 
class  of  cases — those  of  insomnia  depending  on  some  nervous 
affection — I  have  seen  enough  of  its  action  to  convince  me 
that  not  only  does  it  fail  to  possess  all  the  virtues  attributed 
to  it,  but,  owing  to  its  uncertain  action  and  the  many  un¬ 
pleasant  symptoms  which  it  produces,  it  is  inferior  to  most 
of  the  other  new  hypnotics. 

It  is  maintained  that  chloralamide  has  no  effect  on  the 
respiration  or  circulation,  and  can  be  given  in  cardiac  cases 
almost  with  impunity.  In  doses  under  three  grammes  I 
believe  chloralamide  to  be  harmless ;  but  when  given  in 
larger  doses  it  will  produce  effects  on  the  circulatory  and 
respiratory  systems  that  are  ominous  of  what  rnay  happen 
if  it  is  not  used  with  caution.  In  one  instance,  two  hours 
after  having  administered  a  dose  of  three  grammes  to  a 
robust  patient,  I  was  sent  for  by  the  family,  as  the  patient 
was  “acting  queerly.”  I  found  her  sleeping  very  heavily, 
could  be  aroused  with  difficulty,  respirations  labored  and 
124,  and  with  a  pulse  of  105.  In  larger  doses  I  have  seen 
much  more  pronounced  effects,  and  I  would  certainly  be 
very  cautious  in  giving  this  drug  in  cardiac  cases. 

Its  action  as  a  hypnotic  is  very  uncertain,  taking  effect 
in  some  cases  in  a  very  few  minutes,  while  in  others  its 
action  is  delayed  for  several  hours,  or  else  has  no  effect  at 
all.  Sulphonal,  to  which  it  is  claimed  to  be  superior,  is  un¬ 
certain  in  its  action,  but  can  usually  be  relied  on  in  certain 
cases,  while  chloralamide  can  not  be  depended  upon  to  act 
twice  alike  on  the  same  patient.  In  one  patient  it  produced 
no  effect  except  headache,  nausea  and  vomiting,  and  great 
restlessness  for  eight  hours,  when  the  patient  fell  into  a  heavy 
sleep  which  lasted  for  twelve  hours.  On  the  following  day 
at  5  p.  m.  I  gave  the  patient,  under  like  conditions,  the  same 
dose  as  on  the  preceding  day  ;  in  half  an  hour  she  was 
asleep,  and  slept  for  only  two  hours.  Repeated  doses  had 
no  effect,  but  a  moderate  dose  of  chloral  was  successful.  In 


some  cases  it  appears  to  be  accumulative,  especially  if  given 
in  its  undissolved  form,  and  I  have  known  a  second  dose  to 
have  such  a  depressing  effect  on  the  heart  as  to  render 
stimulants  necessary.  If  four  grammes  fail  to  produce 
sleep,  it  is  useless  to  repeat  the  dose. 

Although  in  some  cases  it  causes  a  refreshing  sleep,  with 
no  unpleasant  after-effects,  yet  just  as  often  does  it  cause 
headache,  which  is  sometimes  very  distressing,  nausea,  great 
restlessness,  or  depression.  I  find  these  unpleasant  symp¬ 
toms  almost  invariably  occur  when  its  administration  fails 
to  produce  sleep.  A  feeling  of  exhilaration  lasting  for  an 
hour  or  two  often  occurs  after  taking  this  drug.  A  patient 
told  me  it  always  made  her  feel  as  though  she  had  taken  a 
pint  of  champagne ;  afterward  she  would  become  restless, 
then  depressed,  but  it  would  never  make  her  sleep. 

In  other  hands  chloralamide  may  prove  all  that  is 
claimed  for  it,  but  after  giving  it  a  fair  trial  I  have  ceased 
to  use  it  in  my  practice. 

114  West  One  Hundred  and  Fourth  Street. 


A  PECULIAR  GROWTH  OF  HAIR  ON  THE  FACE. 
By  RICHARD  B.  FAULKNER,  M.D., 

ALLEGHENY,  PA. 

LTnable  to  find  another  instance  of  the  growth  of  hair 
from  a  cicatrix,  the  following  is  therefore  presented  as  one 
of  interest : 

Miss  L.,  aged  twenty,  received  a  burn  on  the  left  cheek  from 
a  cooking-stove  when  a  child.  The  skin  was  blistered,  of  course, 
by  the  burning.  The  scar  which  resulted  is  oval  in  appearance, 
half  an  inch  wide  by  an  inch  and  a  half  in  length,  very  percepti¬ 
bly  elevated,  and  of  a  dense  fibrous  consistence  throughout  the 
entire  thickness  of  the  derma. 

Burns  commonly  destroy  the  hair  follicles  ;  blit  in  this  case 
a  growth  of  hair  appeared  upon  the  scar.  A  brown  pigmentary 
deposit  also  occurred.  Most  of  the  hair  was  jet  black,  and  much 
of  it  an  inch  and  more  in  length.  The  lady  is  a  brunette,  a 
school-teacher.  At  least  twelve  hundred  hairs  were  growing 
from  the  scar  when  she  applied  to  me.  She  is  not  of  a  hairy 
nature. 

I  removed  the-entire  growth  of  hair  with  the  electric  needle. 
There  is  no  sign  of  its  reappearance.  The  pigmentary  deposit 
is  becoming  fainter  ;  the  cartilage-like  hardness  is  giving  place 
to  a  softer  feeling.  Much  down  still  covers  the  cicatrix,  but  I 
have  consoled  the  lady  with  the  statement  that  when  the  hard¬ 
ness  is  removed  and  the  pigment  entirely  gone,  the  unusual 
quantity  of  down  will  likely  cease  to  annoy  her. 

Case  second  is  that  of  a  lady  sixty-five  years  of  age,  addicted 
to  the  use  of  a  caustic  depilatory  for  twenty  years,  which  had 
so  irritated  the  skin  as  to  cause  trifacial  neuralgia.  The  skin 
had  become  so  irritable  that  the  application  of  water  was  almost 
unendurable. 

She  had  a  beard  and  mustache  of  rather  manly  proportions. 
The  hair  shafts  were  very  thick,  and  the  roots  long  and  strong. 
The  depilatory  seemed  to  me  to  be  a  wonderful  stimulant  in 
producing  the  strong,  healthy  roots.  I  immediately  stopped  the 
use  of  the  depilatory,  and  ordered  oxide-of-zinc  ointment  every 
night  and  morning.  I  removed  from  her  face  four  thousand 
hairs.  They  show  no  tendency  to  return.  The  neuralgia  is 
cured  by  the  measures  noted. 


156 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jock., 


THE 


NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 


Published  by 
D.  Appleton  &  Co. 


Edited  by 
Frank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  AUGUST  9,  1890. 


In  addition  to  the  good  accomplished  by  the  national  com¬ 


mittees  mentioned,  we  must  allude  to  the  aid  that  has  undoubt¬ 


edly  been  rendered  to  visitors  unaccustomed  to  German  ways 
by  a  committee  of  foreign  physicians  sojourning  in  Germany 


for  purposes  of  study.  Moreover,  the  comfort  of  lady  visitors 
has  doubtless  been  highly  promoted  by  a  committee  consisting 
of  Berlin  physicians’  wives.  The  number  of  sections  has  been 
increased  from  eighteen  to  twenty  by  the  establishment  of  a 


3 

l 


THE  TENTH  INTERNATIONAL  MEDICAL  CONGRESS. 

From  the  dispatches  thus  far  received  from  Berlin  it  is  safe 
to  infer  that  the  Congress  is  sitting  under  conditions  that  have 
never  been  surpassed  as  regards  satisfactory  work.  The  attend¬ 
ance  is  very  large,  notably  large  from  North  America,  and  the 
organization  of  the  Congress  at  large  and  of  the  several  sections 
is  such  as  to  impart  the  utmost  weight  to  the  proceedings.  The 
latter  fact  is  due  to  the  good  sense  displayed  by  the  organizing 
committee;  the  former  has  doubtless  been  decidedly  promoted 
by  the  plan  adopted  in  most  countries  of  establishing  a  national 
committee  {Landes- Comite).  The  United  States  and  Canada 
joined  in  the  formation  of  such  a  committee  consisting  of  Dr. 
Abraham  Jacobi  (chairman),  Dr.  William  H.  Draper,  and  Dr. 
William  T.  Lusk,  of  New  York;  Dr.  William  Pepper,  of  Phila¬ 
delphia;  Dr.  Reginald  H.  Fitz,  of  Boston;  Dr.  William  Osier, 
of  Baltimore;  Dr.  Samuel  C.  Busey,  of  Washington;  Dr.  F. 
Peyre  Porcher,  of  Charleston;  Dr.  Henry  Hun,  of  Albany; 
and  Dr.  J.  Stewart,  of  Montreal.  The  United  Kingdom  had  a 
committee  consisting  of  three  sections,  sitting  respectively  in 
London,  Edinburgh,  and  Dublin,  presided  over  by  Sir  James 
Paget,  Dr.  Grainger  Stewart,  and  Sir  William  Stokes.  The 
other  countries  that  adopted  this  plan,  together  with  the  chair¬ 
men  of  the  committees,  as  stated  in  a  recent  issue  of  the  Prager 
medicinische  Wochenschrift ,  are:  Belgium,  Dr.  Thiry,  of  Brus¬ 
sels  ;  Denmark,  Dr.  C.  Lange,  of  Copenhagen ;  Italy,  Dr.  Mosso, 
of  Turin;  Mexico,  Dr.  Lavista,  of  Mexico;  the  Netherlands, 
Dr.  B.  J.  Stokvis,  of  Amsterdam ;  Norway,  Dr.  S.  Laache,  of 
Christiania;  Austria-Hungary,  Dr.  Theodore  Meynert,  of 
Vienna;  Russia,  Dr.  W.  Paschutin,  of  St.  Petersburg;  Sweden, 
Dr.  Holmgren,  of  Upsala;  Switzerland,  Dr.  Kocher,  of  Bern; 
and  Spain,  Dr.  Basilio  San  Martin,  of  Madrid. 

It  will  be  noted  that  France  does  not  figure  in  this  list.  At 
one  time  it  looked  as  if  the  animosity  engendered  by  the 
Franco-Prussian  War  would  lead  the  French  to  hold  aloof  from 
the  Congress  almost  altogether,  and  more  recently  certain  by¬ 
gone  expressions  used  by  Virchow,  the  president  of  the  Con¬ 
gress,  were  brought  forward  by  men  who  might  have  been  en¬ 
gaged  in  better  business,  to  give  our  French  brethren  the  im¬ 
pression  that  they  would  not  be  welcome  at  Berlin;  but  the 
best  of  the  French  medical  journals  have  most  commendably 
deprecated  and  sought  to  counteract  this  mischievous  course, 
and  Virchow  has  himself  explained  that  one  of  the  passages 
quoted  from  his  writings  ought  not  to  be  irritating  when  taken 
with  the  context.  This  being  the  case,  there  seems  reason  to 
expect  that  the  final  reports  will  show  that  many  of  the  physi¬ 
cians  of  France  have  entered  frankly  into  the  work  of  the  Con. 
gress. 


Section  in  Orthopaedic  Surgery  and  a  Section  in  Railway  Hy¬ 
giene.  All  things  considered,  the  Berlin  Congress  seems  likely 
i;o  go  on  record  as  in  no  wise  behind  previous  meetings,  whether 
’or  the  value  of  the  work  done  or  for  the  good  feeling  mani¬ 
fested  by  those  engaged  in  it. 


THE  ETIOLOGICAL  CLASSIFICATION  OF  MENTAL  DISEASES. 

In  the  July  number  of  the  American  Journal  of  Insanity 
there  is  an  interesting  article,  entitled  Is  Puerperal  Insanity  a 
Distinct  Clinical  Form?  by  Dr.  W.  L.  Worcester,  of  the  State 
Lunatic  Asylum  at  Little  Rock,  Arkansas.  The  question  under 
discussion  by  the  author  is  as  to  whether  or  not  puerperal  in¬ 
sanity  presents  a  clinical  picture  by  which,  without  a  knowl¬ 
edge  of  the  history  of  the  case,  it  can  be  distinguished  from  in¬ 
sanity  unconnected  with  childbearing.  He  gives  the  histories 
of  eight  cases  presenting  a  great  variety  of  symptoms,  such  as 
excitement  and  depression,  delusions,  illusions,  and  hallucina¬ 
tions,  suicidal  and  violent  impulses,  mental  confusion,  and  cata¬ 
lepsy  ;  but  it  is  not  clear  to  him  that  there  was  any  one  symp¬ 
tom  common  to  all  the  cases,  although  mental  confusion  in 
greater  or  lesser  degree  was  present  in  most  of  them  and  per¬ 
haps  in  all  those  reported,  for  he  calls  to  mind  an  instance  that 
occurred  under  his  observation  in  the  Michigan  Asylum  in 
which  the  patient  seemed  very  clear-headed,  and  “  certainly 
manifested  great  ingenuity  and  judgment  of  a  certain  sort  in 
mischief.” 

Assuming  a  maniacal  onset  and  mental  confusion  as  invaria¬ 
ble  characteristics  of  puerperal  insanity,  instead  of  being  mere¬ 
ly  its  most  usual  manifestations,  would  that,  Dr.  Worcester 
asks,  be  sufficient  to  warrant  its  separation  as  a  distinct  dis¬ 
ease?  His  own  observations  would  lead  him  to  answer  this 
question  in  the  negative,  for  the  reason  that  similar  cases  are 
not  at  all  uncommon  in  men  and  in  non-puerperal  women.  He 
has  treated  a  number  of  patients,  both  male  and  female,  whose 
symptoms,  so  far  as  he  has  been  able  to  judge,  resembled  those 
of  the  cases  of  puerperal  insanity  recorded  in  his  article  quite 
as  much  as  they  resembled  those  of  the  others;  and  their  cases, 
he  thinks,  apart  from  setiological  considerations,  were  as  much 
entitled  to  be  classed  with  the  puerperal  cases  as  the  latter 
were  to  be  classed  together.  Finally,  he  has  not  been  able  to 
discover  anything  in  the  symptoms,  whether  considered  sepa¬ 
rately  or  collectively,  that  would  enable  him  to  say  with  confi¬ 
dence,  in  the  absence  of  a  history  of  the  case  or  of  physical  evi¬ 
dences  of  recent  confinement,  that  the  case  of  a  given  patient 
was  one  of  puerperal  insanity. 

By  implication  Dr.  Worcester’s  article  tells  against  the  util- 


August  9,  1890.] 


MINOR  PARAGRAPHS. 


157 


ity  of  theaetiological  classification  of  mental  diseases  in  general, 
especially  those  imputed  to  masturbation  and  to  the  menopause. 
Not  a  few,  he  remarks,  are  skeptical  as  to  the  value  of  any  sys¬ 
tem  of  classification,  but  unsystematized  knowledge,  he  goes  on 
to  say,  is  a  constant  irritation  to  the  scientific  mind  and  a  hin¬ 
drance  to  progress,  and  probably  the  worst  classification  that 
was  ever  devised  is  better  than  none  at  all. 


MINOR  PARAGRAPHS. 

THE  ELECTRICAL  EXECUTION. 

On  Wednesday,  the  6th  inst.,  the  first  judicial  execution  by 
electricity  took  place  in  Auburn  Prison.  The  procedure  re¬ 
sulted  in  the  death  of  the  criminal,  but  that,  so  far  as  we  are 
aware,  is  the  result  of  the  method  heretofore  in  use,  and,  judg¬ 
ing  from  the  press  accounts,  we  see  no  reason  why  the  new  plan 
should  be  preferred  to  the  time-honored  hanging.  The  current 
is  said  to  have  been  applied  two  or  three  times,  but  probably 
the  repetition  was  unnecessary.  Undoubtedly,  as  is  alleged, 
the  man’s  consciousness  was  abolished  instantly,  and  the  subse¬ 
quent  twitchings  and  respiratory  efforts  were  in  no  wise  mani¬ 
festations  of  suffering;  but  the  same  may  be  said  of  a  well-con¬ 
ducted  execution  by  hanging.  As  for  the  element  of  sensa¬ 
tionalism,  it  certainly  was  not  avoided  in  this  case.  That  the 
method  of  execution  was  a  merciful  one  is  hardly  credible,  for 
it  is  not  the  death  itself,  but  the  elaborate  preparation  for  it 
that  must  be  agonizing.  Public  opinion,  we  think,  will  hardly 
permit  another  criminal  to  be  executed  in  this  manner. 


FOLLICULAR  DERMATITIS  IN  COTTON-SPINNERS. 

Dr.  H.  Leloir,  of  Lille,  has  observed  a  form  of  follicular  and 
circumfollicular  inflammation  to  be  very  frequent  in  male 
cotton-spinners,  and  has  contributed  an  account  of  his  observa¬ 
tions  to  the  Annales  de  dermatologie  et  de  syphiligraphie.  It 
appears  from  an  abstract  of  the  article  given  in  the  Deutsche 
Medizinal-Zeitung  that  the  affection  is  confined  chiefly  to  the 
front  of  the  thigh,  and  is  attributed  to  the  action  of  the  highly 
irritating  mineral  oils  used  in  freeing  the  cotton  fiber  from 
grease.  The  workmen  wipe  their  greasy  hands  on  their  trou¬ 
sers,  which  soon  become  saturated  with  the  oil.  The  trouble 
•may  be  prevented  by  using  special  trousers  while  at  work  and 
having  them  thoroughly  cleansed  at  frequent  intervals. 


MINERS’  NYSTAGMUS  AND  THE  SAFETY-LAMP. 

Attention  having  lately  been  called  in  the  Engineer  to  a 
belief  prevalent  among  miners  to  the  effect  that  the  safety-lamp 
is  injurious  to  the  eyes,  the  British  Medical  Journal  remarks 
that  nystagmus  is  the  only  affection  of  the  eyes  to  which  miners 
are  specially  liable,  and  shows  that  miners’  nystagmus  is  not 
caused  by  the  safety-lamp,  but  by  the  oblique  upward  direction 
in  which  the  miner  is  obliged  to  hold  his  eyes  as  he  lies  on  his 
side  in  the  operation  known  as  “holing,”  i.  e.,  undermining  a 
block  of  coal.  Nystagmus  occurs  only  in  mines  where  “hol¬ 
ing”  is  practiced,  and  there  it  is  observed  whether  the  safety- 
lamp  is  used  or  not. 


SECRECY  IN  LYING-IN  HOSPITALS. 

Last  week  we  expressed  the  hope  of  seeing  institutions  es¬ 
tablished  here  for  enabling  women  pregnant  out  of  wedlock  to 
be  assured  of  decent  support  and  secrecy  until  they  were  re¬ 
lieved  of  their  embarrassment  by  the  birth  of  a  full-time  child 


and  recovery  from  the  disabilities  of  the  lying-in  period.  This 
we  said  in  the  interest  of  the  restriction  of  criminal  abortion. 
In  the  course  of  an  essay  on  the  proper  measures  for  remedying 
the  depopulation  of  France,  an  abstract  of  which  appears  in  a 
recent  number  of  the  Union  medicale ,  M.  Lagneau  advocates 
the  establishment  of  such  institutions,  and  alludes  to  their  ex¬ 
istence  in  Vienna.  The  officers  and  employees  are  sworn  to 
secrecy,  and  there!*  a  woman  may  be  delivered  and  leave  her 
child  behind  her  when  she  is  ready  to  be  discharged,  without 
her  identity  being  made-known. 


THE  TERM  “HEART-FAILURE.” 

In  the  Medical  News  Dr.  Frank  W.  Thomas,  of  Germantown, 
Pa.,  relates  a  case  of  death  intra  partum  after  a  rather  copious 
uterine  haemorrhage,  which,  however,  can  not  have  been  the 
cause  of  death,  for  reasons  given.  Only  trifling  lesions  were 
found  post  mortem,  and  the  author  infers  that  death  was  owing 
simply  to  failure  of  the  heart’s  action.  In  spite,  therefore,  of 
the  fact  that,  of  late,  “registry  bureaus,  coroners’  clerks,  and 
closet  pathologists  ”  have  refused  to  accept  “heart-failure  ”  as 
a  cause  of  death,  he  argues  in  favor  of  the  term  as  expressive  of 
what  really  takes  place  in  certain  cases. 


EARLY  MATERNITY. 

Dr.  Barton  Cooke  Hirst,  professor  of  obstetrics  in  the  Uni¬ 
versity  of  Pennsylvania,  contributes  a  short  article  to  the  Au¬ 
gust  number  of  the  University  Medical  Magazine  which  goes 
far  to  show  that,  from  the  point  of  view  of  the  mother’s  health, 
precocious  maternity  does  not  involve  the  evils  that  are  usually 
ascribed  to  it.  He  gives  brief  notes  of  the  cases  of  twenty  girls 
who  were  delivered  at  ages  varying  from  fourteen  to  sixteen 
years  in  the  Maternity  Hospital,  four  of  them  under  his  own 
observation.  In  each  of  the  four  cases  under  his  own  care  the 
labor  was  easy  and  uncomplicated,  the  infant  was  well  devel¬ 
oped,  and  the  mother’s  supply  of  milk  was  ample;  and  he  in¬ 
fers  from  the  absence  of  any  record  to  the  contrary  that  the 
sixteen  others  were  normal  also. 


BROMOFORM  IN  WHOOPING-COUGH. 

The  Lancet  cites  the  experience  of  Dr.  Hugo  Lowenthal,  of 
Berlin,  in  the  treatment  of  whooping-cough  with  bromoformin 
doses  of  from  two  to  five  drops  three  or  four  times  a  day.  The 
dose  is  simply  dropped  into  a  teaspoonful  of  water,  in  which  it 
floats  in  the  form  of  a  bead.  Generally  an  amelioration  of  all 
the  symptoms  was  produced  promptly.  In  a  very  few  cases 
sleepiness  and  lassitude  were  produced,  and  in  one  instance  a 
semi-comatose  state  was  the  result,  but  this  yielded  readily  to 
subcutaneous  injections  of  ether,  and,  after  the  resolution  of 
an  intercurrent  pneumonia,  the  use  of  bromoform  was  re¬ 
sumed. 


A  FRENCH  STUDENT  ON  GERMAN  STUDENTS. 

A  French  student’s  impressions  of  German  university  life 
are  given  in  brief  in  the  Lyon  medical.  One  reaches  Germany, 
he  says,  with  the  idea  that  the  studies  there  are  very  hard,  and 
that  the  German  students  do  more  work  than  the  French  stu¬ 
dents;  but  one  presently  dismisses  this  idea,  and  gets  the  notion 
that  the  German  students  hardly  work  at  all.  On  further  ac¬ 
quaintance  with  them,  however,  it  appears  that  in  a  German 
university,  as  in  any  other,  there  are  those  who  work  little  and 
those  who  work  much,  the  former  masking  the  latter  because 
more  is  seen  of  them. 


158 


MINO  R  PA  RA  G  RA  PHS.—I  TEMS. 


[N.  Y.  Med.  Jour., 


THE  INDORSEMENT  OF  FOREIGN  DIPLOMAS. 

We  were  in  error  in  our  answer  to  correspondent  No.  827 
in  last  week’s  issue.  The  new  law  went  into  effect  on  the  24th 
of  June,  and  by  its  provisions  foreign  diplomas  held  by  persons 
not  previously  licensed  in  the  State  of  New  York  must  be  in¬ 
dorsed  by  the  Board  of  Regents  of  the  University,  on  the  rec¬ 
ommendation  of  a  legally  constituted  board^f  examiners. 


THE  PRIMARY  SYNCOPE  OF  CHLOROFORM  ANAESTHESIA. 

According  to  an  abstract  of  a  recent  discussion  of  the  dan¬ 
gers  of  chloroform  amesthetization,  before  the  French  Academy 
of  Medicine,  published  in  the  Province  medicale,  M.  A.  Gudrin 
imputed  the  syncope  that  sometimes  proves  fatal  early  in  the 
administration  of  the  ansesthetic  to  the  irritant  action  of  its 
vapor  on  the  pituitary  nerves.  To  prevent  it,  he  recommended 
forcible  closure  of  the  nostrils  so  that  the  patient  would  breathe 
through  the  mouth  only. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  August  5,  1890  : 


DISEASES. 

Week  ending  July  29. 

W  eek  ending  Aug.  5. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

34 

8 

35 

7 

Scarlet  fever . 

28 

6 

49 

6 

Cerebro-spinal  meningitis . 

5 

4 

6 

5 

Measles . 

156 

8 

171 

13 

Diphtheria . 

75 

31 

69 

22 

Varicella . 

3 

0 

0 

0 

Leprosy . 

1 

0 

0 

0 

The  Medical  Society  of  Virginia  will  hold  its  twenty-first  annual 
meeting  at  Rockbridge  Alum  Springs,  beginning  on  September  2d.  An 
address  to  the  public  and  the  profession  will  be  given  by  Dr.  John  S. 
Apperson,  of  Marion.  On  the  morning  of  the  second  day  the  president, 
Dr.  Oscar  Wiley,  will  deliver  his  annual  address. 

Immediately  after  the  president’s  address  and  after  its  recommenda¬ 
tions  have  been  disposed  of,  the  subject  for  general  discussion — The 
Treatment  of  Summer  Diarrhoea  of  Children — will  be  called.  The  dis¬ 
cussion  will  be  opened  by  a  paper  by  the  appointed  leader,  Dr.  C.  T. 
Lewis,  of  Clifton  Forge.  Dr.  John  N.  Upshur,  of  Richmond,  will  fol¬ 
low  with  a  paper  having  the  same  title. 

Reports  on  advances  in  the  eight  departments  of  the  medical  sci¬ 
ences  will  be  called  for  in  the  following  order,  and  continued  as  the 
order  of  business  through  Thursday  until  completed :  Anatomy  and 
physiology,  by  Dr.  H.  H.  Levy,  of  Richmond.  Chemistry,  pharmacy, 
materia  medica,  and  therapeutics,  by  Dr.  Henry  V.  Gray,  of  Roanoke. 
Obstetrics  and  diseases  of  women  and  children,  by  honorary  fellow  Dr. 
J.  Edgar  Chancellor,  of  the  University  of  Virginia.  In  this  section  the 
following  paper  will  be  read  :  What  class  of  cases  of  pelvic  disease 
require  operation  ?  by  Dr.  I.  S.  Stone,  of  Lincoln.  Practice  of  medicine, 
by  Dr.  W.  H.  Bramblett,  of  Pulaski  City.  In  this  section  the  follow¬ 
ing  paper  will  be  read :  Suppurative  diseases  of  the  kidneys — their 
diagnosis  and  treatment,  by  Dr.  Edward  McGuire,  of  Richmond.  Sur¬ 
gery,  by  Dr.  William  L.  Robinson,  of  Danville,  who  will  limit  his  re¬ 
port  to  diseases  and  injuries  of  the  intestines — their  surgical  treatment, 
with  pathological  specimens  from  experimental  work.  In  this  section 
the  following  papers  will  be  read :  Permanent  drainage  of  the  bladder 
by  means  of  a  special  cannula  introduced  above  the  pubes,  by  Dr.  G.  B. 
Johnston,  of  Richmond ;  the  present  position  of  abdominal  surgery  in 
America,  by  Dr.  Joseph  Price,  of  Philadelphia  ;  the  value  of  early  ex¬ 
ploratory  incision  as  an  aid  in  the  diagnosis  of  surgical  diseases  of  the 
abdominal  cavity,  by  Dr.  Edward  Ricketts,  of  Cincinnati ;  subject  not 
definitely  stated,  by  honorary  fellow  Dr.  Hunter  McGuire,  of  Rich¬ 


mond  ;  hip-joint  disease,  with  description  of  an  original  splint  therefor, 
by  invited  guest,  and  delegate  from  the  New  York  State  Medical  So¬ 
ciety,  Dr.  A.  M.  Phelps,  of  New  York;  treatment  of  appendicitis,  by 
Dr.  Joseph  Hoffman,  of  Philadelphia.  Ophthalmology,  otology,  and 
laryngology,  by  Dr.  Robert  L.  Randolph,  of  Baltimore.  In  this  section 
the  following  papers  will  be  read :  Importance  of  nasal  surgery  and 
nasal  therapeutics  in  the  treatment  of  aural  catarrh,  by  Dr.  Joseph  A. 
White,  of  Richmond  ;  a  plea  for  early  operation  in  cataract  and  strabis¬ 
mus  in  children,  by  Dr.  Charles  M.  Shields,  of  Richmond ;  boils  in  the 
ear,  by  Dr.  John  Herbert  Claiborne,  Jr.,  of  New  fork;  the  modern 
treatment  of  strabismus,  by  Dr.  Alexander  Duane,  of  Norfolk ;  title 
not  definitely  decided,  by  Dr.  Laurence  Turnbull,  of  Philadelphia  ;  rela¬ 
tions  of  refractive  errors  and  muscular  defects  in  asthenopia,  ocular 
headache,  etc.,  by  Dr.  Joseph  A.  White,  of  Richmond.  Neurology  and 
psychology,  Dr.  M.  D.  Iloge,  Jr.,  of  Richmond.  Hygiene  and  public 
health,  by  Dr.  I.  R.  Godwin,  of  Fincastle. 

The  American  Dermatological  Association  will  hold  its  fourteenth 
annual  meeting  at  Richfield  Springs,  N.  Y.,  on  the  2d,  3d,  and  4th  of 
September,  under  the  presidency  of  Dr.  Prince  A.  Morrow,  of  New 
York.  The  programme  includes  an  address  by  the  president ;  Observa¬ 
tions  on  Prurigo,  Clinical  and  Pathological,  by  Dr.  R.  W .  f  aylor ;  Pru¬ 
rigo  in  the  Negro,  by  Dr.  R.  B.  Morrison ;  A  Clinical  Study  of  Pruritus 
Hiemalis,  by  Dr.  W.  T.  Corlett ;  A  Study  on  Pruritus,  by  Dr.  E.  B. 
Bronson  ;  Note  relative  to  a  Case  probably  of  Cancer  en  cuirasse,  by  Dr. 
J.  N.  Hyde;  A  Case  of  Atrophia  Maculosa  et  Striata  following  Typhoid 
Fever,  by  Dr.  F.  J.  Shepherd;  Electrolysis  in  the  Treatment  of  Lupus 
Vulgaris,  by  Dr.  G.  T.  Jackson;  Immigrant  Dermatoses,  by  Dr.  J.  C. 
White ;  Notes  on  some  Rare  Cases,  by  Dr.  G.  H.  Fox ;  Cases  of  Cuta¬ 
neous  Tuberculosis,  with  Histological  Studies,  by  Dr.  J.  T.  Bowen ; 
Cases  from  the  Hopkins  Hospital  Clinics,  by  Dr.  R.  B.  Morrison ;  Plica, 
by  Dr.  H.  W.  Stelwagon ;  The  Treatment  of  Erysipelas,  by  Dr.  C.  W. 
Allen ;  Remarks  on  the  Treatment  of  Dermatitis  Herpetiformis,  by  Dr. 
L.  A.  Duhring;  The  Treatment  of  Ringworm  and  Favus  of  the  Scalp, 
by  Dr.  H.  W.  Stelwagon;  Notes  on  Pilocarpine  in  Dermatology,  by  Dr. 
H.  G.  Klotz ;  and  A  Report  on  Aristol,  by  Dr.  C.  W.  Allen. 

An  Honorary  Degree. — The  Journal  of  the  American  Medical  As¬ 
sociation  announces  that  Fort  Wayne  College  has  conferred  the  hon¬ 
orary  degree  of  LL.  D.  on  Dr.  IV.  W.  Dawson,  of  Cincinnati. 

The  late  Dr.  William  Brodie,  one  of  the  best-known  physicians  of 
Detroit,  died  on  the  30th  of  July,  at  the  age  of  sixty-seven.  The  de¬ 
ceased  was  a  native  of  England,  and  a  graduate  of  the  College  of  Phy¬ 
sicians  and  Surgeons,  New  York,  of  the  class  of  1850. 

The  Death  of  Professor  Arnold. — The  Prager  medicinische  Wochen- 
schrift  announces  that  Dr.  Friedrich  Arnold,  emeritus  professor  of  anat¬ 
omy  in  the  University  of  Heidelberg,  died  recently  in  the  eighty-eighth 
year  of  his  age. 

The  Death  of  an  Aged  Physician. — Dr.  Isidore  Labatut,  who  died 
recently  in  New  Orleans,  is  said  to  have  been  the  oldest  physician  in 
the  United  States.  He  was  born  in  April,  1793. 

The  Antiseptic  Treatment  of  Typhoid  Fever.— “  According  to  Dr. 
Petresco,  who  has  been  employing  bisulphide  of  carbon  in  the  treat¬ 
ment  of  typhoid  fever,  the  difference  in  the  mortality  of  cases  treated 
in  this  way  from  that  of  cases  treated  according  to  more  usually  recog¬ 
nized  systems  is  very  considerable.  The  mixture  prescribed  was  of  the 
strength  of  two  per  cent.,  the  vehicle  being  mint  water.  Of  this  mixt¬ 
ure  from  three  to  four  ounces  were  ordered  daily.  The  mortality  of 
typhoid  in  Bucharest  is  generally  from  twenty-five  to  thirty-eight  per 
cent.,  but  under  the  bisulphide-of-carbon  treatment  Dr.  Petresco  lost 
only  ten  per  cent,  of  his  cases.  Even  more  remarkable  were  his  re¬ 
sults  with  B-naphthol,  of  which  from  forty-five  to  sixty  grains  were 
given  per  diem.  Under  this  treatment  he  lost  only  four  per  cent,  of  the 
cases.  Sometimes  wet  sheet  packing  was  combined  with  the  internal 
medication,  sometimes  not.  He  states  that  not  only  was  the  mortality 
diminished  under  bisulphide  of  carbon  or  /3-naphthol,  but  that  the 
whole  course  of  the  disease  was  rendered  milder,  and  there  was  a  re¬ 
markable  immunity  from  serious  complications.” — Lancet. 


August  9,  1890. J  ITEMS.— LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES. 


159 


Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Arm;/,  from  July  27  to  August  2,  1890  : 

Price,  Curtis  E.,  Captain  and  Assistant  Surgeon,  is,  with  the  approval 
of  the  Acting  Secretary  of  War,  granted  leave  of  absence  for  ten 
days.  Par.  3,  S.  0.  176,  A.  G.  0.,  Washington,  D.  C.,  July  29, 
1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  August  2 ,  1890 : 

Blackwood,  N.  J.,  Assistant  Surgeon.  Ordered  to  duty  in  the  Bureau 
of  Medicine  and  Surgery. 

Wales,  P.  S.,  Medical  Director.  Ordered  to  duty  in  charge  of  the  Mu¬ 
seum  of  Hygiene. 

Marine-Hospital  Service. — Official  List  of  Changes  of  Stations  and 
Duties  of  Medical  Officers  of  the  United  States  Marine-Hospital  Service 
for  the  three  weeks  ending  July  26,  1890 : 

Bailhaciie,  P.  H.,  Surgeon.  Granted  leave  of  absence  for  seven  days. 
July  26,  1890. 

Hutton,  W.  H.  H.,  Surgeon.  To  proceed  to  Chicago,  Ill.,  on  special 
duty.  July  24,  1890. 

Godfrey,  John,  Surgeon.  Granted  leave  of  absence  for  thirty  days. 
July  21,  1890. 

Peckham,  C.  T.,  Passed  Assistant  Surgeon.  When  relieved  at  Memphis, 
Tenn.,  to  proceed  to  St.  Louis,  Mo.,  and  assume  command  of  the 
Service.  July  9,  1890. 

Devan,  S.  C.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence  for 
twenty-five  days.  July  15,  1890. 

Kalloch,  P.  C.,  Passed  Assistant  Surgeon.  Orders  of  July  6th,  to  St. 

Louis,  Mo.,  revoked.  July  8,  1890. 

Williams,  L.  L.,  Passed  Assistant  Surgeon.  Relieved  from  duty  at 
Baltimore,  Md.,  and  to  assume  command  of  the  Service  at  Memphis 
Tenn.  July  8,  1890. 

Perry,  T.  B.,  Assistant  Surgeon.  To  proceed  to  Baltimore,  Md.,  for 
temporary  duty.  July  17,  1890. 

Stoner,  J.  B.,  Assistant  Surgeon.  Granted  leave  of  absence  for  thirty 
days.  July  21,  1890. 

Hussey,  S.  H.,  Assistant  Surgeon.  To  proceed  to  Pittsburgh,  Pa.,  for 
temporary  duty.  July  18,  1890. 

Young,  G.  B.,  Assistant  Surgeon.  Granted  leave  of  absence  for  fifteen 
days  on  account  of  sickness.  July  12,  1890. 

Stimpson,  W.  G.,  Assistant  Surgeon.  To  proceed  to  Buffalo,  N.  Y.,  for 
temporary  duty.  July  12,  1890. 

Houghton,  E.  R.,  Assistant  Surgeon.  To  report  to  the  medical  officer 
in  command,  New  York  Marine  Hospital,  for  temporary  duty.  July 
14,  1890. 

Promotion. 

Magruder,  G.  M.,  Passed  Assistant  Surgeon,  to  rank  as  such  from 
July  12,  1890. 

Appointments .' 

Houghton,  E.  R.,  Assistant  Surgeon,  to  rank  as  such  from  July  12, 
1890. 

Benedict,  A.  L.,  Assistant  Surgeon,  to  rank  as  such  from  July  24, 
1890. 


Setters  ter  %  <?£bi:lcrr. 


THE  PIN-WIRING  TREATMENT  OF  FRACTURE  OF  THE 

PATELLA. 

Hillary  Place,  Leeds,  England,  July  19,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal  : 

Sib:  In  your  issue  of  June  21st  I  notice  a  letter  by  Dr. 
Frank  S.  Low,  in  which  he  advocates  the  treatment  of  simple 


fracture  of  the  patella  by  wiring  by  means  of  pins  placed  above 
the  upper  fragment  and  below  the  lower,  both  being  outside  the 
joint. 

I  have  already  not  only  advocated  but  practiced  this  method 
of  treatment  on  several  occasions,  and  had  the  honor  of 
showing  one  of  my  cases  before  the  London  Clinical  Society 
in  1889. 

A  full  account  of  the  method  of  procedure  will  be  found 
in  the  Clinical  Society’s  Transactions. 

A.  W.  Mayo  Robson. 


roteebings  uf  Societies, 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  OBSTETRICS  AND  GYNAECOLOGY. 

Meeting  of  May  22,  1890. 

Dr.  R.  A.  Murray  in  the  Chair. 

Artificial  Prolapse  of  the  Uterus ;  its  Risks.— Dr.  II.  c. 

Coe  read  a  paper  with  this  title.  He  thought  that  artificial 
prolapse  of  the  uterus  was  only  brought  about  either  for  the 
purpose  of  making  a  thorough  examination  or  of  facilitating 
operative  procedures  on  this  organ.  Judging  from  the  amount 
of  literature  on  this  subject  in  the  foreign  journals  and  publica¬ 
tions,  it  would  seem  that  this  practice  was  indulged  in  to  a 
much  greater  extent  there  than  in  this  country,  where  it  had 
now  become  almost  obsolete.  That  it  had  been  productive  of 
considerable  harm  there  could  be  no  question.  Dragging  these 
parts  out  of  all  anatomical  relations,  even  if  there  was  no  dis¬ 
ease  present,  had  of  itself  been  the  cause  of  much  trouble. 
Where  there  was  disease  around  the  uterus  the  procedure  was 
decidedly  unsafe.  While  this  method  had  been  used  as  a  rou¬ 
tine  in  the  aid  to  diagnosis  and  to  render  more  easy  operations 
upon  the  cervix,  the  speaker  thought  that  it  showed  a  lack  of 
skill  on  the  part  of  the  diagnostician  and  operator  to  have  to 
resort  to  such  practice,  and  that  cures  were  really  very  rare 
where  such  a  method  was  necessary.  The  dangers  to  be  appre¬ 
hended  from  the  procedure  were  numerous.  The  tissues  were 
apt  to  be  overstretched  even  if  in  a  normal  condition.  Again 
there  was  danger  of  straining  the  already  relaxed  tissues. 
Rupture  of  the  tubes  and  ovaries  was  an  accident  to  be  looked 
for,  and  also  the  setting  up  of  peri-oophoritis  by  dragging  on  the 
broad  ligaments.  Any  of  these  complications  were  liable  to 
come  on  after  artificial  prolapse.  The  writer  did  not  operate 
upon  an  immovable  uterus  with  it  in  the  normal  position,  and 
would  under  no  consideration  drag  it  down  at  such  a  time.  The 
writer  had  seen  several  cases  where,  with  the  patients  under 
anaesthesia,  the  uterus  was  found  to  be  freely  movable,  and  yet 
accidents  had  resulted  after  this  practice.  The  skilled  operator 
ought  not  to  find  it  necessary  to  pull  down  the  uterus,  but  mere¬ 
ly  to  steady  it  in  the  normal  position  for  any  of  his  manipula¬ 
tions. 

Dr.  II.  T.  Hanks  agreed  with  the  writer  of  the  paper  as  to 
the  question  of  danger  of  such  procedures,  but  said  that  when 
it  was  necessary  he  resorted  to  the  method.  He  had  been  much 
impressed  with  the  dangers  that  patients  were  exposed  to  in  the 
routine  of  clinic  examinations,  as  they  were  frequently  found  to 
be  much  worse  on  the  days  following  such  visits. 

Dr.  II.  J.  Boldt  had  formerly  resorted  to  artificial  prolapse 
in  every  case  that  came  to  his  clinic.  He  was  quite  sure  that 
he  had  had  frequent  trouble  following  such  examinations,  and. 


160 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mud.  Joor., 


as  he  had  gained  nothing  in  diagnosis  by  this  means,  he  had  now 
discarded  the  practice.  It  was  his  custom,  when  making  a  thor¬ 
ough  examination,  to  place  the  patient  under  an  anaesthetic  and 
to  examine  the  parts  with  them  as  nearly  in  the  normal  position 
as  possible,  using  the  utmost  antiseptic  precautions. 

Dr.  A.  P.  Dudley  had  laid  down  two  cardinal  rules  from 
which  he  never  deviated.  Those  were,  first,  that  he  always 
used  every  care  in  his  antisepsis,  and,  secondly,  that  he  never 
made  traction  on  the  uterus  when  there  was  any  existing  ten¬ 
derness.  He  thought  that  in  the  examination  of  fleshy  women 
the  bimanual  method  did  not  give  good  results,  but  that  in  these 
cases  a  finger  in  the  rectum  and  another  in  the  vagina  was  more 
satisfactory.  He  was  also  quite  sure  that  many  cases  of  acute 
trouble  had  followed  artificial  prolapse. 

Dr.  McLean  heartily  indorsed  the  sentiments  expressed  by 
the  writer  of  the  paper  and  the  gentlemen  who  had  preceded 
him.  He  did  not  think  that  as  a  routine  this  method  was  much 
followed  in  this  country  simply  as  an  aid  to  diagnosis,  but  that 
it  was  confined  to  the  operation  of  trachelorrhaphy. 

Dr.  G.  M.  Edebohls  said  that  he  had  had  no  experience  with 
this  method,  but  did  not  think  it  impossible  that  the  evil  results 
might  be  due  to  some  other  cause  than  traction  on  the  uterus 
alone,  as  the  introduction  of  a  sound  was  done  at  every  exami¬ 
nation.  He  thought  that  all  operators  had  been  guilty  of  more 
or  less  traction  on  the  uterus  at  sometime  or  other,  and  that  he 
had  seen  deaths  following  such  trivial  causes.  He  was  not  sure 
whether  they  had  not  been  due  to  sepsis  rather  than  to  trauma¬ 
tism. 

The  Chairman  had  seen  a  number  of  bad  results  following 
artificial  prolapse,  but  thought  that  some  of  the  troubles  might 
be  due  to  the  introduction  of  the  sound.  It  was  not  uncommon 
after  trachelorrhaphy  to  find  the  anatomical  results  perfect  but 
the  pelvic  trouble  much  worse. 

The  Immediate  Repair  of  Injuries  to  the  Pelvic  Floor. 
— This  was  the  subject  of  a  paper  by  Dr.  I.  H.  Hance.  He 
thought  that  in  the  present  aseptic  practice  of  midwifery  the 
operation  had  the  best  chances  of  success,  and  that  only  under 
the  most  exceptional  circumstances  should  it  be  put  off.  He 
confined  his  immediate  operation  to  those  cases  in  which  the 
laceration  had  not  extended  through  into  the  rectum.  These 
were  either  where  there  was  a  clean  cut  through  the  perinaeum, 
or  through  the  skin  and  perinaeum  to  one  side  or  other  of  the 
median  line.  There  was  another  class  in  which  this  immediate 
repair  offered  good  results,  and  that  was  where  the  posterior 
vaginal  wall  had  been  ruptured  without  laceration  of  the  skin. 
The  speaker  thought  that  there  ought  to  be  no  difficulty  in  rec¬ 
ognizing  these  incomplete  lacerations  at  or  just  before  delivery, 
thus  gaining  time  to  make  the  necessary  preparations  to  repair 
them  at  once.  For  the  operation  the  patient  was  placed  in  the 
lithotomy  position.  The  parts  were  then  washed  with  an  anti¬ 
septic  solution.  The  first  suture  was  introduced  high  up  in  the 
vagina  above  the  tear.  If  the  laceration  had  extended  up  on 
both  sides,  they  were  to  be  repaired  separately,  great  care  be¬ 
ing  taken  to  get  the  lips  of  the  wound  in  perfect  apposition. 
After  as  many  sutures  had  been  introduced  as  were  necessary 
to  accomplish  this,  another  douche  was  given,  the  parts  were 
dusted  with  iodoform,  a  pad  was  applied,  and  the  legs  were  tied 
together,  to  remain  so  for  twenty-four  hours.  The  bowels  were 
moved  on  the  third  day.  The  speaker’s  reason  for  beginning  the 
suturing  high  up  on  the  vaginal  wall  was  that  by  this  means  the 
formation  of  pockets  was  avoided,  and  also  that  he  thought  this 
method  offered  the  best  results  for  the  restoration  of  the  pelvic 
floor.  Statistics  on  the  subject  showed  that  the  largest  per¬ 
centage  of  successful  operations  on  the  pelvic  floor  were  those 
of  immediate  repair,  the  percentages  of  cures  ranging  all  the 
way  from  thirty-eight  per  cent,  to  ninety  per  cent.  Another 


deduction  from  careful  research  was  that,  of  all  priraiparse,  fully 
twenty-five  per  cent,  suffered  more  or  less  laceration.  The  au¬ 
thor  then  related  the  histories  of  several  cases  of  various  de¬ 
grees  of  lacerations,  and  the  special  method  adopted  in  each 
particular  case,  the  operation  in  all  yielding  perfect  results.  In 
closing  his  paper  he  said  that  the  two  points  to  be  closely  ob¬ 
served  that  success  might  attend  the  immediate  operation  were, 
first,  the  careful  adaptation  of  the  lips  of  the  wound,  number¬ 
ing  the  sutures  to  individual  requirements;  and,  secondly,  the 
observance  of  strict  antiseptic  precautions. 

Dr.  C.  T.  Jewett  thought  it  possible  that,  if  labor  was  re¬ 
tarded,  the  percentage  of  lacerations  could  be  reduced.  In  his 
method  of  suturing  he  had  combined  the  vaginal  and  skin  suture, 
but,  of  course,  the  vaginal  was  better  if  the  laceration  was  high 
up.  He  did  not  pass  the  suture  around  the  wound,  as  be  thought 
by  this  means  there  was  too  much  tension  and  puckering  of  the 
tissues,  but  through  the  lips  of  the  wound,  using  as  many  catgut 
sutures  as  it  required  to  make  apposition  perfect.  He  used  cat¬ 
gut  sutures,  because  he  had  always  found  them  satisfactory. 
In  a  case  where  there  seemed  to  be  danger  of  laceration  it 
was  his  practice  to  perform  double  episiotomy,  and  then,  im¬ 
mediately  after  delivery,  to  repair  the  injury. 

Dr.  Dudley  thought  that  it  was  alw’ays  best  to  repair  such 
injuries  at  once.  He  delivered  his  patients  in  Sims’s  position, 
which  gave  him  an  opportunity  of  watching  the  perinaeum  and 
preventing  laceration.  If  this  occurred,  notwithstanding  pre¬ 
cautions,  this  position,  at  least,  afforded  easy  access  to  the  in¬ 
jury.  With  one  finger  in  the  rectum,  the  wound  was  closed 
with  an  over-and-over  stitch.  The  speaker  did  not  pass  the 
suture  around  the  wound ;  by  this  means  he  thought  there  was 
danger  of  exerting  too  much  pressure  on  the  tissues.  He  had 
as  yet  his  first  failure  in  the  immediate  operation  to  report. 

Dr.  Edebohls  thought  that  it  was  the  duty  of  the  accou¬ 
cheur,  in  justice  both  to  himself  and  to  the  patients,  to  have  the 
laity  understand  that  such  accidents  could  not  always  be  helped. 
He  had  performed  a  number  of  immediate  operations,  and  had 
had  no  failures.  He  agreed  with  the  writer  of  the  paper  when 
he  said  that  the  vagina  would  begin  lacerating  before  the  peri- 
nteum.  This  possibility  could  be  ascertained  by  digital  exami¬ 
nation  before  delivery,  and  preparation  be  made  for  imme¬ 
diate  repair  as  soon  as  delivery  was  accomplished.  He  used 
silk-worm  gut  in  this  operation  and  introduced  his  first  suture 
at  the  apex  of  the  tear,  and  continued  them  down  to  the  pos¬ 
terior  commissure.  He  had  never  been  called  upon  to  introduce 
more  than  seven  sutures  to  bring  the  parts  together.  It  was 
not  his  practice  to  introduce  a  finger  into  the  rectum,  because  he 
wanted  his  fingers  to  remain  aseptic.  He  had  lately  adopted  the 
method  of  allowing  the  ends  of  the  high  sutures  to  remain  long, 
so  as  to  admit  of  easy  removal.  In  several  cases  he  had  left  the 
uppermost  sutures  in  situ  for  several  weeks,  until  the  perinaeum 
had  become  strong,  before  removing  them,  and  had  found  no 
evil  results  from  this  practice.  He  had  recently  made  an  im¬ 
mediate  operation  on  a  patient  with  complete  laceration,  which 
had  resulted  in  perfect  restoration  of  the  integrity  of  the  parts. 

Dr.  Mavette’s  methods  were  essentially  the  same  as  those 
practiced  by  Dr.  Hance.  He  also  made  it  a  point  to  use  plenty 
of  sutures.  It  was  his  experience  to  find  tears  in  the  median  line 
more  or  less  infrequent.  He  briefly  reported  the  histories  of  fifty 
cases,  with  varying  degrees  of  laceration,  in  which  the  immediate 
repair  was  made,  primary  union  taking  place  in  fifty-eight  per 
cent,  of  the  cases.  He  did  not  do  his  operation  until  oozing 
had  ceased,  for  fear  of  a  blood-clot  forming  and  preventing 
primary  union.  At  the  end  of  twenty-four  hours  after  opera¬ 
tion  a  douche  of  1  to  8,000  bichloride  was  used  in  every  case. 

Dr.  McLean  always  repaired  the  damage  as  soon  as  possible. 
He  thought  the  best  apposition  could  be  got  early,  as  in  a  few 


August  9,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


1*61 


hours  the  parts  would  surely  shrink  away  from  each  other.  He 
thought  that,  where  the  parts  fitted  nicely  together,  two  or 
three  sutures  were  quite  enough  to  maintain  apposition  until 
healing  had  taken  place.  He  thought  it  au  injustice  to  patients 
not  to  do  the  immediate  operation. 

Dr.  Hanks  thought  that  the  question  was  not  sub  ju dice. 
but  that  all  had  agreed  it  should  be  done  at  once.  Of  the  ne¬ 
cessity  of  leaving  no  point  of  sepsis  there  could  be  no  doubt, 
and  that  the  good  results  of  the  operation  depended  upon  the 
condition  of  the  tissues  and  asepsis. 

Dr.  Coe  reported  a  case  of  complete  laceration  in  which  the 
immediate  operation  was  done,  using  the  continuous  catgut 
suture,  success  being  perfect.  He  was  in  favor  of  always  doing 
the  repair  at  once,  and  he  used  as  many  sutures  in  the  primary 
as  in  the  secondary  operation. 

The  Chairman  thought  that  it  was  still  a  question  as  to  how 
this  injury  should  be  repaired,  but  that  it  should  be  done  at 
once  there  was  no  doubt.  He  thought  that  the  vaginal  suture 
was  the  best,  for,  if  the  skin  only  were  taken  up,  the  deeper 
parts  were  apt  to  fall  away  and  form  pockets.  He  did  not  like 
the  use  of  an  odoriferous  antiseptic,  because  it  disguised  or 
covered  up  one  of  the  important  diagnostic  features  of  change 
going  on  in  the  wound  upon  which  much  dependence  was 
placed. 


ROYAL  ACADEMY  OF  MEDICINE  IN  IRELAND. 

SECTION  IN  ANATOMY  AND  PHYSIOLOGY. 

Meeting  of  March  Lj,  1890. 

The  President,  Dr.  Purser,  in  the  Chair. 

Professor  Birmingham  exhibited  (1)  a  right  lung,  the  upper 
and  inner  parts  of  which,  including  the  whole  of  the  apex,  were 
marked  off  by  a  deep  fissure  as  a  supernumerary  lobe;  the  fis¬ 
sure  was  occupied  by  a  fold  of ‘pleura,  in  the  free  margin  of 
which  the  arch  of  the  azygos  vein  was  contained.  By  this  fold 
of  pleura  the  upper  part  of  the  pleural  sac  was  partitioned  off, 
as  a  pocket-like  cavity,  in  which  the  supernumerary  lobe  lay. 
The  anomaly  was  explained  by  supposing  that  the  azygos  vein 
had  been  displaced  laterally,  and  that  the  heart  in  descending 
had  pulled  the  vein  through  the  substance  of  the  lung  external 
to  the  apex ;  (2)  the  two  halves  of  the  nasal  fossae — one  with 
the  mucous  membrane  removed,  the  other  with  the  membrane 
intact — in  which  there  was  almost  complete  absence  of  the 
ethmo-  and  maxillo-tu rhinal  bones. 

Professor  Cunningham  remarked  upon  the  rarity  of  the  con¬ 
dition. 

Professor  Bennett  considered  that  it  was  not  pathological. 

The  Lantern  as  an  Aid  to  Anatomical  Demonstrations. 

— Professor  Birmingham  gave  a  demonstration  of  the  magic 
lantern  applied  to  the  illustration  of  anatomical  lectures.  He 
pointed  out  that  the  lantern  might  be  used  in  daylight  in  a 
theatre  with  a  head-light,  if  the  screen  was  provided  with  a 
projecting  canopy,  so  that  the  penumbra  might  be  produced  on 
its  surface.  He  explained  the  making  of  slides,  either  by  pho¬ 
tography  or  by  the  hand ;  the  latter  method  gave  the  most 
striking  results  for  anatomical  purposes.  They  were  drawn 
with  a  fine  pen  in  Indian  ink,  either  upon  prepared  glass,  pre¬ 
pared  sheets  of  mica,  or  upon  thin  sheets  of  gelatin,  which  were 
afterward  placed  between  two  sheets  of  glass.  He  had  been 
using  this  means  of  illustration  (in  addition  to  blackboard  dia¬ 
grams  in  colored  chalks)  daily  for  two  years,  and  he  had  found 
it  thoroughly  satisfactory.  He  confidently  advocated  the  sys¬ 
tematic  use  of  the  lantern  for  anatomical  illustration.  He  then 
showed  a  large  number  of  diagrams  illustrating  anatomical  sub¬ 
jects. 


The  President  said  that  he  had  made  experiments  with  the 
lantern  in  his  own  theatre,  but  his  results  were  not  so  good  as 
Professor  Birmingham’s  when  the  theatre  was  not  completely 
darkened.  However,  he  did  not  think  that  the  lantern  ought 
to  be  allowed  to  replace  diagrams  in  colored  chalks. 

Collective  Investigation— On  the  motion  of  Professor 
Cunningham,  the  interim  reports  of  the  Collective  Investigation 
conducted  in  the  Anatomical  Department  of  Trinity  College 
were  read  by  the  gentlemen  who  had  charge  of  the  different 
investigations,  as  follows: 

I.  Dr.  W.  Henry  Thompson — Formation  of  the  Portal  Vein. 
—  Out  of  fifty-three  cases  the  inferior  mesenteric  ended  in  the 
splenic  in  thirty,  in  the  superior  mesenteric  in  twenty,  and  in 
the  angle  between  both  in  three.  Out  of  forty-four  cases  the 
coronary  ended  in  the  portal  in  twenty-six  cases,  in  the  splenic 
in  eighteen.  Four  chief  “types”  of  portal  were  found  in  the 
forty-four  subjects — (1)  found  in  sixteen  the  inferior  mesenteric 
joined  splenic,  coronary  entered  portal;  (2)  found  in  eleven 
the  inferior  mesenteric  joined  the  superior,  coronary  entered 
splenic ;  (8)  found  in  seven  both  inferior  mesenteric  and  coro¬ 
nary  entered  splenic ;  and  (4)  found  in  seven  neither  inferior 
mesenteric  nor  coronary  joined  splenic;  former  joined  superior 
mesenteric;  latter  joined  portal.  The  first  of  these  was  consid¬ 
ered  normal.  Out  of  forty-six  cases  the  portal  vein  was  formed 
at  the  level  of  second  lumbar  vertebra  in  thirty-two. 

II.  Messrs.  A.  C.  O’Sullivan  and  O.  L.  Robinson — The 
Arrangement  of  the  Renal  Arteries. — Forty-three  subjects  ex¬ 
amined.  In  number  they  varied  from  one  to  four.  One  or 
more  arteries  always  entered  the  hilum ;  in  eighteen  cases  an 
accessory  artery  entered  at  the  upper  or  lower  border ;  acces¬ 
sory  arteries  arose  from  aorta  or  renals,  except  in  one  case, 
from  the  common  iliac.  In  forty-six  cases  all  branches  passed 
between  vein  and  ureter,  in  six  they  inclosed  vein  and  ureter, 
in  eleven  inclosed  vein  only,  in  six  ureter,  and  in  other  six  all 
the  arteries  passed  in  front  of  vein. 

III.  Mr.  J.  J.  Long — The  Relation  of  the  Internal  Maxil¬ 
lary  Artery  to  the  External  Pterygoid  Muscle. — Eighty-eight 
arteries  examined.  The  artery  ran  superficial  to  the  muscle  in 
fifty  per  cent,  of  the  cases,  and  then  entered  between  its  two 
heads.  In  forty-two  cases  the  artery  lay  deeper  than  the  ex¬ 
ternal  pterygoid;  in  nineteen  of  these  cases  the  inferior  dental 
and  in  seven  cases  the  lingual  nerve  passed  down  superficial  to 
the  artery. 

IY.  Mr.  0.  E.  Stokes — The  Tuberculum  Laterale  of  the 
Astragalus. — Seventy-two  cases  examined.  Two  examples  of  os 
trigonum  found,  in  each  case  connected  to  the  astragalus  by  a 
synovial  joint,  which  communicated  with  the  posterior  astragalo- 
calcaneal,  and  in  each  case  the  os  trigonum  gave  partial  attach¬ 
ment  to  the  posterior  fasciculus  of  the  external  lateral  ligament 
of  the  ankle  joint. 

Professor  Cunningham  reminded  the  Section  that  this  was 
the  second  report  of  the  collective  investigation  read  before  the 
Academy.  Last  year  different  and,  in  his  opinion,  more  inter¬ 
esting  subjects  had  been  taken  up  and  reported  upon.  A  some¬ 
what  similar  collective  investigation  was  instituted  late  last  year 
in  connection  with  the  Anatomical  Society  of  Great  Britain  and 
Ireland,  which  it  was  proposed  to  extend  to  all  the  schools  in 
these  countries;  this  placed  the  anatomical  department  with 
which  he  was  connected  in  a  dilemma.  While  extremely  anx¬ 
ious  to  take  part  in  the  general  work,  yet  they  felt  that  this 
result  ought  to  belong  to  the  Academy  of  Medicine  in  Ireland. 
After  some  correspondence  on  the  matter  it  had  been  arranged 
that  the  programme  of  the* Anatomical  Society  should  be  adopt¬ 
ed,  but  that  the  reports  from  the  Irish  branches  should  be  read 
at  the  Academy  of  Medicine  in  Ireland,  published  in  its  Trans¬ 
actions,  and  then  handed  over  to  the  Anatomical  Society. 


162 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


Professor  Birmingham  said  that  the  gentlemen  who  had 
carried  out  the  investigation  deserved  the  thanks  of  the  Section 
for  the  interesting  reports  which  they  had  just  read.  He  pointed 
out  that  Dr.  Thompson’s  report  on  the  termination  of  the  infe¬ 
rior  mesenteric  vein  differed  from  the  results  of  Treves,  who 
found  that  the  vein  terminated  in  the  splenic  in  only  eighteen 
per  cent,  of  his  hundred  cases.  Treves  considered  this  ending  a 
sign  of  higher  development.  Would  Dr.  Thompson’s  results 
therefore  point  to  the  conclusion  that  the  Irish  whom  he  exam¬ 
ined  were  more  highly  developed  than  those  examined  by 
Treves  ? 

Professor  Bennett  was  glad  that  the  reports  of  the  collect¬ 
ive  investigation  had  been  brought  before  their  Academy,  in¬ 
stead  of  being  handed  over  to  the  Anatomical  Society.  Some 
years  ago  there  had  been  a  collective  investigation  instituted  in 
London  for  the  purpose  of  examining  into  the  pathology  of 
hydrophobia.  He  had  fortunately  obtained  a  spinal  cord  at  a 
post-mortem  in  a  case  of  hydrophobia;  he  had  sent  the  cord 
intact  as  directed  to  London,  but  from  that  day  to  this  he  had 
never  heard  one  word  about  that  cord.  So  he  thought  they  had 
better  do  their  own  work  at  home. 

The  Parieto-occipital  and  Calcarine  Fissures  of  the 
Brain ;  their  Development  and  Relation  to  the  Calcar  Avis. 
— Professor  Cunningham  made  a  communication,  illustrated 
with  diagrams,  on  the  development  of  the  parieto-occipital  and 
calcarine  fissures  and  their  relation  to  the  calcar  avis.  He  re¬ 
ferred  to  the  conflicting  views  held  regarding  the  development 
of  these  fissures,  the  difficulty  in  connection  with  their  study 
being  due  to  the  fact  that  their  origin  was  synchronous  with  that 
of  the  transitory  fissures  of  the  brain,  and  they  lay  in  series  with 
them.  For  those  early  fissures  corresponding  in  position  to  the 
parieto-occipital  and  calcarine  he  proposed  the  name  of  “  pre¬ 
cursors  ”  of  these  fissures.  He  traced  the  connection  between 
the  precursors  and  the  permanent  fissures,  and  showed  how  the 
history  of  either  of  the  two  fissures  might  be  made  out,  not  only 
in  the  brain  of  the  seven  months’  foetus,  but  even,  in  most  cases, 
in  the  adult  brain.  He  also  adduced  phylogenetic  evidence  in 
reviewing  the  question,  but  he  showed  that  this  was  in  several 
respects  at  variance  with  the  ontogenetic  evolution  of  the  fis¬ 
sures  under  consideration. 

Professor  Birmingham  said  that  the  fissures  discussed  by 
Professor  Cunningham  were  very  unsatisfactorily  dealt  with  in 
the  usual  descriptions  of  their  development.  He  asked  what 
eminence  each  fissure  produced  in  the  interior,  if  each  produced 
a  separate  eminence  in  the  adult  brain. 

Professor  Cunningham  replied  that  there  was  one  eminence 
in  the  interior — the  calcar  avis — which  belonged  sometimes  to 
the  calcarine,  sometimes  to  the  parieto-occipital  fissure,  ac¬ 
cording  as  the  stem  of  the  “  Y  ’’-shaped  fissure  formed  in 
the  adult  by  the  union  of  these  two  fissures  belonged  to  the 
former  or  the  latter  fissure. 

SECTION  IN  PATHOLOGY. 

Meeting  of  March  21 ,  1890. 

The  President,  Dr.  Bennett,  in  the  Chair. 

Lympho-sarcoma  of  the  Neck. — Dr.  J.  K.  Barton  presented 
the  following  case  of  lympho-sarcoma  of  the  neck :  A  tumor,  oc¬ 
cupying  the  whole  of  the  right  side  of  the  neck,  had  been  grow¬ 
ing  for  four  years,  the  first  three  of  which  it  was  only  of  the  size 
of  a  filbert-nut.  It  had  then  suddenly  commenced  to  grow,  and 
attained  its  present  size  in  three  months.  Fluctuation  was  elicit¬ 
ed  in  one  part.  Edges  undefined.  Diagnosis,  a  lympho-sarcoma, 
which  had  burst  through  the  capsule  and  had  become  diffused 
through  all  the  structures  of  the  neck.  The  patient,  a  strong, 


robust  countryman,  had  become  subject  to  fits  of  a  remarkable 
kind.  He  had  suddenly  become  pale,  fell  over  if  sitting  up,  his 
pulse  disappeared,  and  he  had  lost  consciousness  for  about  a  min¬ 
ute.  He  had  then  recovered ;  his  color  and  pulse  had  returned, 
and  he  had  sat  up.  An  operation  was  performed,  to  see  how 
far  the  growth  could  be  removed,  in  the  course  of  which  the 
common  carotid  artery  of  the  right  side  of  the  neck,  lying  be¬ 
hind  the  tumor  and  compressed  by  it,  was  found  to  be  com¬ 
pletely  occluded.  At  its  bifurcation  a  rent  was  torn  in  it,  but 
no  blood  escaped;  it  was  firmly  occluded  lower  down.  The 
speaker  drew  attention  to  three  pathological  facts  of  interest: 
1,  the  growth  of  the  tumor  ;  2,  the  fits  from  which  the  patient 
suffered,  which  may  have  been  produced  by  the  compression  of 
the  pneumogastric  nerve  by  the  tumor ;  3,  the  occlusion  of  the 
carotid  artery  by  the  pressure  of  the  growth  upon  it  and 
around  it. 

Tumor  of  the  Brain ;  Atrophy  of  the  Right  Kidney, 
with  Compensatory  Hypertrophy  of  the  Left  Kidney.— 

Dr.  JosEPn  Redmond  showed  the  brain  and  kidney  which  were 
removed  from  the  body  of  a  patient,  aged  twenty-nine,  who 
died  in  the  Mater  Misericordiaa  Hospital  on  April  30,  1889. 
The  patient  had  received  a  severe  blow  of  a  baton  over  the  right 
ear  in  December,  1888,  which  had  stunned  him  somewhat. 
From  that  time  until  his  death  he  had  complained  of  severe  pain 
in  the  right  side  of  his  head,  and  had  also  suffered  from  fits, 
which  had  occurred  at  intervals  of  about  a  week.  During 
these  attacks  he  was  apparently  unconscious,  but  the  patient 
stated  that  he  was  thoroughly  conscious  of  all  that  was  passing 
around  him  at  the  time.  These  attacks  were  characterized  by 
some  of  the  ordinary  symptoms  which  were  present  in  epileptic 
seizures;  the  patient  simply  sank  into  an  apparently  uncon¬ 
scious  condition,  which  lasted  for  ten  or  fifteen  minutes.  On 
the  evening  of  his  death  the  patient  had  had  a  number  of  such 
attacks,  during  one  of  which  he  had  expired.  The  autopsy 
showed  a  slight  depression  at  the  posterior  portion  of  the  right 
parietal  bone,  to  which  the  dura  mater  adhered.  On  examining 
the  brain,  a  tumor  somewhat  larger  than  a  pigeon’s  egg  was 
found  in  the  region  of  the  angular  and  supramarginal  gyri, 
which  extended  into  the  substance  of  the  hemisphere.  The 
right  kidney  was  found  to  be  atrophied  and  the  left  hyper¬ 
trophied. 

Dr.  MoWeeney  said  the  peripheral  portion  of  it  consisted 
of  sinall-celled  structure,  but  the  internal  portion  of  the  tumor 
was  structureless.  It  was  surrounded  by  thick  connective  tis¬ 
sue,  in  which  could  be  seen  numerous  small  thickened  blood¬ 
vessels.  The  specimen  under  the  microscope  showed  the  disap¬ 
pearance  of  the  nerve-fibers  from  the  cortex  of  the  brain  in  the 
immediate  neighborhood  of  the  tumor.  The  latter  was  of  a 
syphilitic  character,  as  far  as  he  could  make  out.  He  did  not 
see  any  reason  to  regard  it  as  tubercular.  There  was  a  small 
scar  in  the  liver,  which  looked  like  a  result  of  tertiary  syphilis. 
Why  he  regarded  the  tumor  as  syphilitic  was  that  it  involved 
both  the  pia  mater  and  the  dura  mater,  which  were  adherent 
together. 

Lupus  of  the  Larynx. — Dr.  Walter  Smith  exhibited  the 
larynx  of  a  man  who  had  died  of  pneumothorax  consequent 
upon  extensive  tubercular  disease  of  the  lungs.  There  was  also 
amyloid  degeneration  of  the  liver,  spleen,  kidneys,  and  intes¬ 
tines.  Fourteen  years  previously  Dr.  Bennett  had  successfully 
performed  the  Indian  operation  for  an  artificial  nose,  owing  to 
the  destruction  effected  by  old-standing  lupus  of  the  face.  At 
the  post-mortem  examination  both  lungs  were  found  riddled 
with  vomicae.  Tubercle  bacilli  were  found  in  their  contents. 
The  larynx  was  involved  to  a  considerable  extent.  The  free 
edge  of  the  epiglottis  had  nearly  disappeared;  what  remained 
was  thickened  and  irregular.  There  was  no  ulceration  of  the 


August  9,  1890.] 


SPECIAL  ARTICLES. 


163 


cords,  true  or  false.  Between  the  arytsenoids  were  severa 
pyramidal  outgrowths,  projecting  above  and  below  the  riraa 
glottidis.  The  case  illustrated  the  supervention  of  tubercular 
phthisis  upon  cutaneous  lupus,  and  was  compared  with  Leloir’s 
case  of  lupus  of  tho  face,  tongue,  and  larynx,  published  in  the 
International  Atlas  of  Rare  Skin  Diseases. 

Rupture  of  the  Heart.— The  President  exhibited  a  case  of 
rupture  of  the  heart.  The  man  had  been  found  dead  on  the 
railway  with  several  fractures  of  the  limbs  and  a  scalp  woynd, 
but  no  fracture  of  the  skull.  They  found  no  external  sign  or 
trace  of  injury  to  the  thorax  in  front.  A  large  portion  of  the 
sternum  was  detached  from  the  rest  of  the  skeleton  and  thrust 
down  on  the  underlying  viscera,  all  the  costal  cartilages  being 
broken  as  well  from  the  second  to  the  eighth.  The  pericardium 
and  the  pleura  were  found  full  of  blood.  At  the  apex  of  the 
right  ventricle  there  was  a  large  rupture.  There  was  another 
great  rent  into  the  right  auricle.  There  was  no  laceration, 
neither  was  there  any  blood-clot  in  the  heart,  nor  any  rupture 
of  the  valves  or  of  the  chordm  tendineae.  In  the  auricular  ap¬ 
pendix  and  the  musculi  pectinati  there  were  two  small  ruptures. 
In  the  back  of  the  heart,  at  the  left  auricle,  in  the  interval  be¬ 
tween  the  entrance  of  the  pulmonary  veins,  there  were  two  or 
three  large  lacerations.  The  left  auricular  appendix  was  rupt¬ 
ured  ;  but  the  left  ventricle  was  free  of  rupture,  or  of  any  lesion 
w  hatever.  Clearly  what  happened  was,  that,  the  heart  being 
full  of  blood,  pressure  of  the  detached  bone  burst  the  whole  of 
the  three  chambers. 


Special 

LETTERS  TO  MY  HOUSE  PHYSICIANS. 

By  WILLIAM  OSLER,  M.  D., 

BALTIMORE. 

Letter  II. 

Bern,  May  SI,  1890. 

Dear  T. :  Within  an  hour  after  reaching  Basel  we  were  in  the  Ve- 
saUanum,  as  the  anatomical  institute  is  called,  looking  for  the  skele¬ 
ton  which  Vesalius  presented  to  the  university  when  he  was  here  in 
1542-’43  supervising  the  printing  of  his  great  work.  Historically  this 
is  probably  the  most  interesting  museum  specimen  in  existence,  and  to 
Professor  Roth  is  due  the  credit  of  determining  accurately  the  fact  of 
its  association  with  Vesalius.  Several  years  ago  he  sent  me  his  paper 
on  the  subject,  an  abstract  of  which  you  will  find  in  the  Medical  Nevis 
for  1887  (or  1888),  in  an  editorial  note.  The  plates  of  his  work  were 
drawn  from  this  skeleton,  which  is  treasured  by  the  Basel  faculty  as  a 
most  precious  relic.  Above  the  glass  case  in  which  it  is  contained  is  the 
inscription  :  “  Mdnnliches  Skelet  das  der  Meister  der  Anatomie  Andreas 
I  esal,  aus  Brussel ,  der  hiesigen  Universitdt  schenkte  als  er  15//.3  sich  in 
Basel  aufhielt  um  der  Druck  seines  grossen  anatomischen  Werkes  zu  be- 
sorgen.'"  Well  may  he  be  called  the  Master  of  Anatomy,  the  great  Re¬ 
former  in  Medicine,  for  his  work  loosened  the  chains  of  tradition  in 
which  the  profession  had  been  fast  bound  for  centuries.  His  was  a  bold 
and  venturesome  spirit  which  could  dare  dispute  the  statements  of  Ga¬ 
len  and  Hippocrates,  dogmas  revered  by  the  physicians  of  the  sixteenth 
century  as  are  to-day  those  of  Calvin  and  of  Luther  by  certain  theo¬ 
logians.  Professor  Roth  has  recently  published  an  interesting  paper 
( Quellen  einer  Vesalbiographie ,  Basel,  1889),  in  which  he  has  given  the 
results  of  his  researches  among  the  archives  of  the  University  of  Padua, 
and  he  has  determined  definitely  for  the  first  time  the  date  and  place  of 
the  graduation  of  Vesalius — Padua,  December  5,  1537.  Please  note, 
too,  that  he  was  a  young  man  when  he  published  his  great  work,  an¬ 
other  illustration  of  the  theory  upon  which  I  am  always  harping,  that  a 
man’s  productive  years  are  in  the  third  and  fourth  decades. 

It  is  not  a  little  remarkable  that  the  skeleton  should  be  in  such  a 


state  of  preservation  ;  but  above  it  lies  another,  prepared  by  Felix  Plater, 
a  renowned  Basel  professor  of  the  sixteenth  century,  also  in  excellent 
condition. 

The  Basel  Hospital  is  an  old  building  but  very  conveniently  arranged 
and  with  beautiful  gardens,  in  the  middle  of  which  is  a  large  summer 
ward  for  women  and  children.  I  am  much  indebted  to  Director  Hoch 
for  his  kindness  in  showing  me  the  different  departments.  In  the  op¬ 
erating  room  the  table  is  constructed  of  zinc  with  a  hot-water  chamber, 
above  which  is  a  perforated  plate  so  that  irrigation  can  be  carried  out. 
The  warming-pan — of  which  it  is  practically  only  a  special  example — 
is  also  perforated  in  the  middle  for  the  escape  of  the  solutions.  I  am 
sure  that  for  prolonged  operations  this  is  a  great  advantage  in  counter¬ 
acting  the  depression  so  liable  to  occur  both  from  the  shock  and  from 
the  anmsthetic.  Not  ten  days  ago  I  saw  the  same  arrangement  in  use 
at  the  Physiological  Laboratory  of  University  College,  London,  in  a  pro¬ 
longed  experiment  upon  the  brain  of  a  monkey.  Professor  Schafer  told 
me  that  they  had  found  the  animals  stood  the  operations  very  much  bet¬ 
ter  and  revived  more  promptly  if  the  body  temperature  was  kept  up  in 
the  artificial  way.  So  important  did  he  seem  to  think  it  that  additional 
hot  water  was  put  in  at  the  end  of  about  an  hour  and  a  half. 

We  found  Professor  Socin  in  the  operating-room  with  a  class  of 
about  thirty  men,  a  patient  on  the  table,  and  a  senior  student  in  the 
arena,  who,  during  the  course  of  an  hour,  underwent  a  most  searching 
examination  on  tuberculosis  of  joints  and  on  the  particular  case  before 
them.  It  was  certainly  a  most  instructive  method  of  procedure,  and  it 
was  fortunate  the  poor  patient  was  deaf,  as  the  questions  of  prognosis 
and  of  treatment  were  discussed  thoroughly.  Amputation  of  the  leg 
was  then  performed,  as  the  disease  had  progressed  too  far  for  resection. 
We  could  not  but  feel,  however,  that  it  was  hard  to  keep  the  poor  man 
waiting  on  the  table.  Certainly  the  ward  would  have  been  the  more 
appropi’iate  place  for  the  instruction.  The  Basel  students  have  an  ex¬ 
ceptionally  clear  and  decisive  teacher  of  surgery ;  here  again  the  col¬ 
ored  chalks  on  the  blackboard  were  used  at  least  half  a  dozen  times  to 
illustrate  special  features  ,pf  the  disease  and  steps  of  the  operation. 

Professor  Immerniann  has  charge  of  the  medical  clinic,  and  has  a 
conveniently  arranged,  though  not  large,  clinical  laboratory.  The  lect¬ 
ure-room  is  attached  to  the  medical  wards,  and  we  heard  for  half  an 
hour  a  very  practical  talk  on  the  treatment  of  acute  Bright’s  disease. 
A  point  specially  insisted  upon  in  the  later  stages  was  the  flushing  of 
the  tubes  by  a  plentiful  supply  of  liquids.  Then  the  class  was  taken 
into  one  of  the  men’s  medical  wards,  and  a  student  examined  a  case  of 
typhlitis,  upon  which  the  comments  of  Professor  Immerniann  were  very 
interesting.  The  young  man  had  been  seized  five  days  before  with  pain 
in  the  right  iliac  region,  not  of  an  agonizing  character,  and  moderate 
fever,  so  that  he  had  to  give  up  work.  He  had  not  been  particularly 
constipated  prior  to  the  onset  of  the  pain,  but  he  had  had,  several 
years  ago,  a  somewhat  similar  attack.  The  examination  showed  simply 
pain  on  deep  pressure  in  the  right  iliac  fossa,  no  tumor,  no  signs  of 
peritonitis.  The  case  was  regarded  as  one  of  appendicitis,  and,  as  the 
symptoms  had  progressively  improved,  the  treatment  was  confined  to 
the  administration  of  opium  and  the  use  of  local  applications.  Great 
stress  was  laid  on  the  absence  of  tumor  as  a  differential  point  in  the 
diagnosis  of  appendicitis  and  typhlitis  from  faecal  impaction.  I  gath¬ 
ered  that  Professor  Iramerman  believed  in  the  existence  of  a  typhlitis 
apart  from  appendix  disease ;  and  the  tumor,  which  is  more  apt  to  be 
present  in  these  cases,  may  be  due  either  to  primary  impaction  or  to 
faecal  stasis  in  the  caecum  in  consequence  of  the  inflammation.  Now, 
this  was  a  case  which  illustrated  the  point  I  mentioned  in  my  letter  to 
L.  I  have  not  the  slightest  doubt  that,  if  a  laparotomy  had  been 
performed,  an  inflamed  and  adherent,  possibly  a  perforated,  appendix 
would  have  been  found,  yet  the  lad  was  recovering  under  ordinary 
measures.  Still,  the  risks  are  very  great,  balancing  those  of  an  oper¬ 
ation  even  at  this  early  stage,  as  perforation  into  the  general  perito- 
meum  is  always  imminent,  and  then  there  is  the  liability  to  recurrence, 
as  shown,  indeed,  in  this  case. 

In  the  Vesalianum  one  of  the  Privat  Docenten,  von  Lenhossek, 
showed  us  the  method  of  preserving  subjects,  which  is  that  of  Las- 
towski,  of  Geneva.  An  injection  of  glycerin  with  carbolic  acid,  with 
a  little  alcohol,  is  first  made,  and  then  the  ordinary  Teichmann’s  mass, 
consisting  of  putty  and  bisulphide  of  carbon,  with  a  suitable  coloring 


BOOK  NOTICES. 


[N.  Y.  Mbd.  Joub., 


164 

ingredient.  A  preliminary  washing  out  of  the  blood-vessels  is  advisa¬ 
ble.  In  Geneva  the  subjects  are  wrapped  in  sheets,  which  are  sprinkled 
with  water,  and  Ramsay  Wright  tells  me  that  the  bodies  were  in  an  ex¬ 
cellent  state  of  preservation.  \  on  Lenhossek  said  that  they  found  it 
necessary  to  use  alcohol  in  the  tanks.  The  muscles  are  certainly  veiy 
well  kept  by  this  method,  and  the  dissection  is  said  to  be  easier  than  in 
bodies  preserved  with  the  bichloride  of  mercury. 

In  the  pathological  laboratory  Professor  Roth  showed  us  a  recent 
specimen  of  enormous  epithelioma  which  had  developed  in  an  old  leg 
ulcer,  the  result  of  a  fracture  many  years  before.  The  tumor  had  in¬ 
volved  the  bone  and  the  leg  had  to  be  amputated.  Under  his  direction, 
Dr.  Dubler,  the  assistant,  has  been  making  an  interesting  research  on 
suppuration,  which  has  just  been  published.  He  comes  to  the  conclu¬ 
sion,  from  a  very  large  series  of  experiments,  that  the  pus  formation 
which  follows  the  injection  'of  chemical  substances  is  the  result  of  a 
delimiting  inflammation  about  a  primary  necrotic  area,  and  in  the  same 
way  bacteria  act  by  causing  a  necrosis,  which  the  suppuration  removes, 
so  that  there  is  no  essential  difference  between  the  process  in  the  two 
cases. 

Here  in  Bern  we  found  a  model  hospital  on  the  pavilion  plan,  situated 
on  a  sloping  hill  on  the  outskirts  of  the  town,  and  from  the  wards  there 
is  a  magnificent  view  of  the  Bernese  Oberland.  The  appearance  of  the 
pavilions,  rising  one  above  the  other  in  the  grounds,  is  very  effective) 
and  the  new  Royal  Victoria  Hospital  in  Montreal,  which  is  also  to  be 
on  the  side  of  a  hill,  will,  I  think,  resemble  this  very  much.  The  Patho¬ 
logical  Institute  is  a  large,  separate  building,  with  every  possible  con¬ 
venience  for  teaching  and  research.  Professor  Langhans  was  kind 
enough  to  show  us  all  his  treasures,  not  the  least  interesting  of  which 
was  the  skeleton  of  a  bicapitate  monster,  presented  to  the  university 
over  a  hundred  years  ago  by  the  great  Haller,  who  was  a  Swiss,  and 
who  lived  near  Bern,  I  believe,  after  his  retirement  from  Gottingen. 
In  the  post-mortem  theatre  I  was  glad  to  see  that  to  the  students’  desks 
towels  were  attached,  a  convenience  rarely  met  with. 

The  medical  clinic  is  in  charge  of  Professor  Sahli,  a  comparatively 
young  man,  appointed  last  year.  There  are  two  stories  in  the  chief  medical 
pavilion,  with  four  wards,  and  there  is  accommodation  for  about  eighty 
patients.  Connected  with  it  by  a  covered  passage  is  the  lecture-room, 
with  seats  for  about  one  hundred  students.  A  very  complete  electrical 
equipment  and  tables  for  urinary  and  microscopical  examination  are  on 
either  side  of  the  arena.  There  were  eighty-four  students  at  the  clinic, 
eighteen  of  whom  were  women.  After  a  careful  analysis  with  a  student 
of  the  chief  points  in  the  history  and  treatment  of  whooping-cough,  a 
case  of  diabetes  was  brought  in  from  the  wards,  and  the  next  Prakti- 
cant  on  the  list  happened  to  be  a  woman,  who  went  through  the  ordeal 
of  questions  in  the  various  modes  of  testing  for  sugar  in  the  urine. 
The  saccharometer  of  Hermann  and  Pfister  was  shown,  and  then,  after 
the  clinic,  those  students  who  so  desired  had  an  opportunity  of  seeing 
the  practical  working  of  the  apparatus.  On  either  side  of  the  amphi¬ 
theatre  is  the  clinical  laboratory,  with  bacteriological,  chemical,  and  mi¬ 
croscopical  rooms,  large,  admirably  equipped,  and  very  convenient  to 
the  wards.  Bern  is  one  of  the  Swiss  schools  most  frequented  by 
women,  of  whom  about  fifty  are  at  present  in  attendance.  I  was  told 
by  one  of  the  professors  that  they  were  good  students ;  as  a  rule,  very 
attentive  and  industrious,  but  not  always  sufficiently  prepared  in  the 
preliminary  subjects.  Those  at  the  lecture  were  all  young,  but  1  did 
not  see  one  who  looked  likely  to  become  the  Trotula  of  the  twentieth 
century. 


gooli  Notices. 


Insomnia  and  its  Therapeutics.  By  A.  W.  Macfarlane,  M.  D., 
Fellow  of  the  Royal  College  of  Physicians,  Edinburgh;  Fel¬ 
low  of  the  Royal  Medical  and  Chirurgical  Society  of  London, 
etc.  London:  H.  K.  Lewis,  1890.  Pp.  xv-866. 

The  physiology  of  sleep,  the  value  of  insomnia  as  a  symptom 
in  varied  psychic  and  physical  conditions — neuroses,  organic 


nerve  troubles,  toxic  states — and  the  treatment  best  adapted 
to  each  and  all,  together  with  hints  and  cautions  concerning 
certain  peculiarities  in  the  manifestations  of  waketulness,  form 
a  most  interesting  volume  that  is  alike  valuable  and  delightful 
reading.  The  work  is  plain,  practical,  clinical,  and  is  the  last 
word  upon  a  subject  of  peculiar  moment  to  Americans,  who 
are  literally  the  most  wide-awake  nation  in  the  world,  insom¬ 
nia  being  the  price  paid  for  making  business  our  only  recrea- 
tioij.  Even  a  passing  view  of  Dr.  Macfarlane’s  book  must  give 
us  pause  and  show  how  evil  wakeful  ways  can  be  mended. 


Practical  Photo-micrography  by  the  Latest  Methods.  By  An¬ 
drew  Pringle,  F.  R.  M.  S.,  President  of  the  Photographic 
Convention  of  the  United  Kingdom,  1889,  etc.  New  York: 
The  Scovill  and  Adams  Company,  1890.  Pp.  185. 

The  author  gives  in  this  book  practical  instructions  in  the 
photography  of  microscopic  specimens,  and  has  written  espe¬ 
cially  for  those  who  follow  the  natural  and  medical  sciences 
rather  than  for  amateur  investigators.  Whoever  is  interested 
in  an  art  which,  like  all  forms  of  photography,  has  its  captivat¬ 
ing  qualities,  will  find  in  Mr.  Pringle’s  well-illustrated  volume 
a  thorough  and  trustworthy  guide. 


A  Treatise  on  Headache  and  Neuralgia ,  including  Spinal  Irrita¬ 
tion  and  a  Disquisition  on  Normal  and  Morbid  Sleep.  By 
J.  Leonard  Corning,  M.  A.,  M.  D.,  Consultant  in  Nervous 
Diseases  to  St.  Francis’s  Hospital,  etc.  With  an  Appendix. 
Eye-strain,  a  Cause  of  Headache.  By  David  Webster, 
M.  D.,  Professor  of  Ophthalmology  in  the  New  York  Poly¬ 
clinic.  Illustrated.  Second  Edition.  New  York:  E.  B. 
Treat,  1890.  Pp.  10-15  to  259.  [Price,  $2.75.] 

The  principal  change  in  this  edition  is  the  addition  of  a 
short  article  by  Dr.  Webster,  in  which  he  gives  the  details  of  a 
number  of  cases  in  which  correction  of  refractive  errors,  im¬ 
paired  accommodation  or  insufficiency  of  the  extrinsic  ocular 
muscles,  has  relieved  persistent  headache.  Otherwise  the  work 
seems  to  merit  the  same  praise  and  to  be  open  to  the  same 
criticism  as  the  first  edition.  In  many  respects  it  is  very  valua¬ 
ble.  The  author’s  inventive  ability  may  stand  him  and  the  pro¬ 
fession  in  good  stead.  The  work  is  very  readable  and  well  got 
up. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

Diseases  of  the  Rectum  and  Anus,  their  Pathology,  Diagnosis,  and 
Treatment.  By  Charles  B.  Kelsey,  A.  B.,  M.  D.,  Professor  of  Diseases 
of  the  Rectum  at  the  New  York  Post-graduate  Medical  School  and 
Hospital,  etc.  Third  Edition,  rewritten  and  enlarged.  With  Two 
Chromo-lithographs  and  One  Hundred  and  Sixty-eight  Illustrations. 
New  York:  William  Wood  &  Co.,  1890.  Pp.  x— 483. 

Familiar  Forms  of  Nervous  Disease.  By  M.  Allen  Starr,  M.  D., 
Ph.  D.,  Professor  of  Diseases  of  the  Mind  and  Nervous  System,  College 
of  Physicians  and  Surgeons,  New  York.  With  Illustrative  Diagrams 
and  Charts.  New  York :  William  Wood  &  Co.,  1890.  Pp.  xii-339. 

A  Pharmacopoeia  for  Diseases  of  the  Skin,  containing  a  Concise 
Formula,  Baths,  Rules  of  Diet,  Classification,  and  Therapeutical  Index. 
Edited  by  James  Startin,  Senior  Surgeon  to  the  London  Skin  Hospital, 
etc.  Second  Edition.  London :  Harrison  &  Sons,  1890.  Pp.  4-5 
to  35. 

Cases  of  Successful  Operation  for  Bulbo-membranous  Close  Strict¬ 
ure  by  Internal  Urethrotomy.  By  E.  R.  Palmer,  M.  D.,  Louisville,  Ky. 

A  Case  of  Locomotor  Ataxia  associated  with  Nuclear  Cranial  Nerve 
Palsies  and  with  Muscular  Atrophies.  By  Frederick  Peterson,  M.  D. 
[Reprinted  from  the  Journal  of  Nervous  and  Mental  Diseases.] 

The  Reconstruction  of  Deformed  Noses  by  grafting  a  Portion  of 
the  Finger.  By  James  P.  Parke/,  M.  D.,  of  Kansas  City,  Mo.  [Re¬ 
printed  from  the  Medical  News.] 


August  9,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


165 


A  Case  of  Haematoma  of  the  Ovary  following  Chronic  Catarrhal 
Salpingitis,  with  Operation  and  Recovery.  By  R.  Harvey  Reed,  M.  D. 

Extra-uterine  Pregnancy.  The  History  of,  by  Dr.  W.  G.  Milten- 
berger.  Laparotomy  for,  with  Report  of  a  Successful  Case,  by  Dr.  T. 
A.  Ashby.  Review  and  Discussion,  by  Dr.  H.  A.  Kelly.  Papers  read 
before  the  Obstetrical  and  Gynaecological  Society  of  Baltimore,  January 
4  and  February  11,  1890. 

An  Investigation  into  the  Aetiology  of  Phthisis.  By  Heneage  Gibbs, 
M.  D.,  and  E.  L.  Shurly,  M.  D.  II.  On  the  Clinical  History  of  Phthisis 
Pulmonalis.  By  E.  L.  Shurly,  M.  D.,  IV.  On  the  Aetiology  and  Local 
Treatment  of  Phthisis  Pulmonalis.  By  E.  L.  Shurly,  M.  D.  [Reprint¬ 
ed  from  the  American  Journal  of  the  Medical  Sciences.] 

A  Successful  Case  of  Nephrectomy.  By  George  Ben  Johnston, 
M.  D.,  Richmond,  Va.  [Reprinted  from  the  Virginia  Medical  Monthly.] 


gejmts  on  %  |jro0wss  of  Jpc&khu. 


DERMATOLOGY. 

By  GEORGE  THOMAS  JACKSON,  M.  D. 

Aristol  is,  according  to  Eichhoff  {Monatshft.  f.  p.  Dermat.,  1890,  x, 
85),  a  dermatological  therapeutical  remedy  of  great  usefulness.  Last 
year  this  physician  gave  the  weight  of  his  authority  to  medicated  over 
fatty  soaps,  presenting  their  virtues  in  most  enthusiastic  phrases.  With 
no  less  enthusiasm  does  he  now  introduce  to  us  “aristol,”  and  were  all 
he  says  of  it  substantiated  by  future  experience,  we  should  then  have  a 
specific  and  sure  cure  lor  varicose  ulcers,  seborrhoeal  eczema,  lupus  vul¬ 
garis  (! !),  psoriasis,  trichophytosis  capitis  (! !),  scabies,  and  ulcerating 
syphilides  (! !).  His  prophetic  vision  descries  surgical  joint  and  bone 
diseases,  gynaecological  complaints,  tuberculosis,  whether  general  or 
local,  and  constitutional  syphilis  flying  discomfited  and  falling  dead 
before  this  combination  of  iodine  and  thymol.  The  drug  is  described 
as  insoluble  in  alcohol,  in  glycerin,  and  in  water,  and  soluble  in  ether 
and  in  fatty  oils.  It  combines  all  the  virtues  of  iodoform  and  thymol 
without  the  disagreeable  odor  of  the  former.  It  may  be  used  in  the 
strength  of  ten  per  cent.  Thus  far  the  only  thing  that  has  not  yielded 
to  its  power  is  the  soft  sore. 

Aristol  in  the  Treatment  of  Naso-pharyngeal  Syphilis. — This  new 
drug  has 'found  another  admirer  in  the  person  of  Dr.  Schuster,  of 
Aachen,  who  reports  ( Monatshft .  f.  prakt.  Dermat.,  1890,  x,  262)  very 
favorably  upon  its  use  in  naso-pharyngeal  syphilis.  The  case  reported 
was  one  of  ulceration  of  the  pharynx  and  nose,  and  the  treatment  con¬ 
sisted  in  applying  to  the  parts  finely  pulverized  aristol  by  means  of  a 
powder-blower.  Inunctions  and  iodide  of  potassium  were  also  em¬ 
ployed  in  the  way  of  general  treatment.  Within  ten  days  there  was  a 
great  improvement  of  all  the  conditions,  and  within  three  weeks  the 
throat  was  well  and  the  nose  nearly  so.  [Which  was  the  most  active 
agent  here  in  promoting  recovery  ?  In  testing  new  remedies,  the  new 
remedy  should  be  used  alone,  otherwise  the  test  is  of  little  value.  This 
is  often  forgotten.] 

Aristol  in  the  Treatment  of  Psoriasis. — Dr.  Schirren,  Assistant 
Physician,  Lassar’s  Clinic,  reports  {Berlin,  klin.  Woch.,  March  1 7,  1890) 
good  results  in  the  treatment  of  ten  cases  of  psoriasis  by  means  of  this 
new  drug.  It  acts  slower  than  chrysarobin  or  pyrogallol.  The  strength 
of  the  ointment  used  was  ten  per  cent. 

Hydroxylamine  in  the  Treatment  of  Skin  Diseases  has  been  found 
by  Dr.  Groddeck,  of  Berlin  {Monatshft.  f.  prakt.  Dermat.,  1890,  x,  162), 
to  be  superfluous,  as  we  already  have  many  other  agents  that  are  better. 
He  tried  it  in  twenty-three  cases,  and  found  it  practically  worthless.  It 
is  poisonous  in  strong  solutions,  and  also  irritating  to  the  skin. 

The  Pathogenesis  of  Erythema. — Besnier  gives  us  {Annal.  de  derm, 
et  de  syph.,  1890,  i,  1)  a  study  of  the  pathogenesis  of  erythema  multi¬ 
forme  and  scarlatiniforme,  which  he  intends  as  an  introduction  to  a  re¬ 
construction  of  our  ideas  in  regard  to  the  whole  class  of  erythemas. 
The  same  form  of  erythema  may.  be  idiopathic,  primitive,  or  autoge¬ 
nous  ;  may  arise  from  some  toxic  agent  from  without  or  an  infectious 


element  developed  from  within  in  the  course  of  some  morbid  state.  All 
individuals  are  not  equally  susceptible  to  erythemas,  and  this  individual 
predisposition  is  an  element  of  the  first  order  in  the  pathogenesis  of 
erythema.  It  is  inborn  in  most  subjects  and  shows  itself  in  infancy  by 
a  peculiar  susceptibility  to  all  pruriginous  dermatoses.  In  these  cases  it 
is  permanent.  In  others  it  is  acquired  under  the  action  of  some  morbid 
state  of  the  body,  and  is  then  transitory  and  secondary.  The  individual 
predisposition  being  present,  common  causes  act  to  call  out  the  eruption, 
either  by  setting  at  work  the  morbid  aptitude  and  provoking  the  de¬ 
termination,  or  by  placing  the  individual  in  an  inferior  state  of  resist¬ 
ance  and  creating  the  pathological  opportunity,  or  favoring  the  evolu¬ 
tion  of  the  pathogenous  element  in  the  organic  apparatus.  Such  is  the 
action  of  cold,  one  of  the  principal  common  causes  of  erythema  multi- 
forme.  When  the  external  circumstances  are  very  pronounced,  many 
individuals  who  are  predisposed  to  erythema  may  be  affected  at  the  same 
time,  but  they  never  produce  true  epidemics.  What  have  been  called 
epidemics  of  erythema  multiforme  are  not  such  in  fact,  but  are  simply 
erythemas  secondary  to  zymotic  diseases,  such  as  cholera,  influenza,  dys¬ 
entery,  etc.,  or  ar£  abortive  and  wrongly  diagnosticated  cases  of  conta¬ 
gious  fevers,  such  as  rubeola,  or  certain  alimentary  intoxications,  all  of 
which  disappear  if  the  accidental  cause  is  removed.  Erythema  multi¬ 
forme  is  a  vaso-motor  disturbance  producing  a  determination  of  blood 
to  the  skin,  diffuse  albuminous  oedema,  serous  exudation,  and  finally 
desquamative  exfoliation.  These  pathological  processes  are  not  exclu¬ 
sively  confined  to  erythema,  but  are  well  marked  in  it.  The  agent  that 
will  excite  an  angeioneurosis  and  an  erythema  is  neither  unique  nor 
specific.  It  may  act  from  without  exclusively  upon  the  surface,  or  may 
be  produced  within  in  all  sorts  of  ways.  External  irritants,  absorption 
of  septic  substances,  poisonous  inoculations,  microbian  proliferations, 
adulterations  of  the  blood,  autogenous  or  other,  may  each  and  all 
produce  an  identical  erythema.  But  the  irritant  itself  is  not  specific, 
nor  can  it  give  rise  to  erythema  in  another  healthy  subject.  It  would 
seem  that  the  exciting  irritation  is  conveyed  to  the  vaso-motor  centers 
and  thence  reflected  upon  the  skin.  There  is  no  proof  of  the  presence 
of  any  irritating  material  in  the  regions  where  the  erythema  is  mani¬ 
fested.  Owing  to  our  want  of  knowledge  of  the  anatomy  and  physiolo¬ 
gy  of  the  vaso-motor  system,  it  is  very  difficult  for  us  to  determine  with 
precision  the  relation  between  the  erythema  and  its  cause.  Our  clinical 
studies  of  diseases  complicated  with  erythema  are  obscured  in  their  Re¬ 
sults  by  the  fact  that  medicines  are  often  administered  at  the  same  time. 
T  or  a  long  time  rheumatism  has  been  thought  to  have  a  causal  relation 
to  erythema  multiforme.  In  reality  it  does  not  have  erythema  as  one 
of  its  symptoms,  but  it  may  give  rise  to  it  like  any  other  infectious  dis¬ 
ease,  either  directly  by  its  proper  infectious  principle,  or  secondarily 
either  by  producing  a  deuteropathic  infection  or  by  rendering  the  indi¬ 
vidual  susceptible  to  the  action  of  medicines  given  for  its  cure.  In 
cholera  it  is  difficult  to  say  whether  the  erythema  is  due  to  irritation  of 
the  nerve  centers  by  autogenous  alterations  in  the  fluids  of  the  body,  or 
to  the  action  of  medicines  that  are  generally  given  in  large  amounts. 
In  gonorrhoea  it  is  always  a  question  as  to  the  cause  of  the  erythema. 
It  may  arise  from  the  disease  itself.  Less  often  do  the  balsams  give 
rise  to  it,  and  when  the  erythema  occurs  while  a  patient  is  taking  bal¬ 
sams,  it  often  of  itself  disappears  without  stopping  the  drugs.  Typhoid 
fever  serves  but  as  a  preparation  for  the  erythemas  that  arise  in  its 
course  as  the  result  of  medication  or  auto-toxasmia.  In  puerperal  fever* 
infectious  endocarditis,  tuberculosis,  syphilis,  and  leprosy,  the  same  un¬ 
certainty  of  the  cause  of  the  erythema  is  to  be  noted. 

Erythema  scarlatiniforme  is  an  erythema  with  a  febrile  movement 
during  a  part  or  the  whole  of  its  course  which  may  be  cut  short  or  last 
for  several  weeks  or  months.  This  form  is  of  a  scarlatinal  type  and  apt 
to  return.  Its  diagnosis  is  often  difficult,  as  it  resembles  scarlet  fever 
so  closely.  But  its  non-specific  character,  its  variable  and  prolonged 
course,  the  simultaneous  appearance  and  prolonged  coexistence  of  the 
eruption  and  the  desquamation,  its  non-contagiousness,  and  its  relaps¬ 
ing  character,  place  it  in  the  category  of  the  erythemas.  In  some  cases 
it  goes  beyond  the  bounds  of  erythema  and  takes  on  the  nature  of  a 
dermatitis.  The  pathogenic  conditions  of  erythema  scarlatiniforme  are 
as  obscure  and  complex  as  those  of  erythema  multiforme.  An  individ¬ 
ual  predisposition  and  intolerance  to  a  number  of  very  varied  causes  are 
essential  to  its  production  ;  thus  we  have  cases  due  to  cold  and  recur- 


166 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jock., 


ring  every  year,  to  the  use  of  mercury  internally  and  externally,  to  the 
action  of  the  sun,  and  to  other  varied  causes.  All  of  these  may  produce 
erythemas  resembling  each  other  exactly.  Moreover,  in  these  predis¬ 
posed  individuals  the  effect  will  last  long  after  the  cause  has  ceased  to 
act,  and  will  often  be  disproportioned  to  it. 

Epithelioma  Contagiosum  (the  new  name  for  molluscum  contagi- 
osum)  has  been  subjected  once  more  to  a  careful  study  for  the  purpose 
of  finding  out  what  it  really  is.  Torok  and  Tommasoli  ( Monatshft .  /. 
prakt.  Dermat.,  1890,  x,  149)  declare  the  disease  to  be  contagious,  and 
cite  several  unmistakable  instances  of  contagion.  Inoculation  experi¬ 
ments  proved  negative  in  their  results.  Bacteriological  and  chemical 
investigations  have  convinced  our  authors  that  the  disease  is  not  due  to 
a  parasite.  The  various  findings  of  other  investigators  that  have  been 
given  out  as  parasites  our  authors  declare  to  be  merely  artificial  prod¬ 
ucts  of  the  methods  used  by  them.  Though  they  have  failed  in  their 
inoculation  experiments  and  have  been  unable  to  find  a  parasite,  still 
they  do  not  lose  faith  in  the  contagiousness  of  the  disease. 

Lichen  Ruber  and  its  Relation  to  Lichen  Planus. — Toward  the  so¬ 
lution  of  the  vexed  question  of  the  relationship  of  these  two  diseases 
H.  von  Hebra  contributes  an  article  in  the  Monatshefte  f.  prakt.  Dermat ., 
1889,  x,  101.  He  first  carefully  separates  lichen  ruber  acuminatus  from 
pityriasis  rubra  pilaris,  giving  the  diagnosis  in  the  form  of  parallel  col¬ 
umns,  as  follows : 


Pityriasis  rubra  pilaris. 

1.  Develops  in  the  epidermis. 

2.  Efflorescences  bear  scales 
from  the  beginning,  and  often  con¬ 
sist  of  accumulations  of  epidermic 
scales  alone  which  can  readily  be 
scratched  off. 

3.  Efflorescences  limited  to  fol¬ 
licle  mouths,  especially  those  of 
hair  follicles. 

4.  Extensor  surfaces  of  the  ex¬ 
tremities  especially  affected. 

5.  Microscopically  consist  of 
thickening  of  the  epidermis,  with 
lengthening  of  the  interpapillary 
projections  of  the  rete  mucosum 
in  certain  places. 

6.  Color  of  efflorescences  scarce¬ 
ly  differs  from  that  of  the  skin  at 
the  beginning.  Afterward  becomes 
rosy  or  brownish-red  from  consecu¬ 
tive  hypertemia. 

7.  Roughness  of  the  extensor 
surfaces  of  the  extremities,  and 
satin-like  smoothness  on  the  truna, 
with  fine  scales. 

8.  No  accompanying  subjective 
symptoms. 

9.  No  implication  of  the  gen¬ 
eral  health. 


10.  Spontaneous  recovery,  or 
chronicity  without  danger  to  the 
patient. 

11.  Cured  by  purely  local 
means,  though  often  obstinate. 


12.  Little  or  no  pigmentation 
left. 

1 3.  Does  not  affect  the  mucous 
membranes. 


Lichen  ruber  acuminatus. 

1.  Develops  in  the  cutis. 

2.  From  the  beginning  they 
are  smooth  and  glistening.  Scales 
form  only  late  in  the  disease. 


3.  Are  not  limited  to  the  folli¬ 
cle  mouths. 

4.  Flexor  surfaces  more  affect¬ 
ed  than  extensor  surfaces. 

5.  Marked  collections  of  round 
cells  in  the  papillary  layers  of  the 
corium. 


6.  From  beginning  a  bright 
red,  becoming  darker,  and  may 
change  to  deep  rusty  brown. 

7.  Everywhere  thickening  and 
roughness  of  the  skin,  increasing 
with  the  age  of  the  disease. 

8.  Unbearable  itching,  great 
burning,  restlessness,  and  jerking 
movements  of  the  limbs. 

9.  Fever,  oedema  (especially  of 
lower  extremities),  albuminuria, 
sleeplessness,  general  prostration, 
and  loss  of  weight. 

10.  Often  ends  in  death,  al¬ 
ways  attended  with  marasmus. 

11.  Cured,  if  at  all,  by  consti¬ 
tutional  treatment,  as  with  arsenic. 
Unna’s  ointment  of  mercury  and 
carbolic  acid  good. 

12.  Deep-brown,  even  black¬ 
ish-brown,  pigmentation  left  which 
may  last  for  months. 

13.  Affects  mucous  mem¬ 
branes,  especially  of  mouth  and 
vagina. 


As  to  the  relation  between  lichen  ruber  acuminatus  and  lichen 
planus,  he  believes  that  they  are  one  and  the  same  disease,  because 
he  has  seen  cases  in  which  a  general  lichen  ruber  acuminatus  cleared 
away  to  be  followed  by  a  lichen  planus  ;  and  also  cases  that  began 
as  lichen  planus  to  end  as  lichen  ruber  acuminatus.  A  case  of  each  is 
given. 

Leprosy. — The  subject  of  leprosy  is  now  engaging  the  attention  of 
the  medical  profession  to  a  marked  degree.  In  the  Monatshft.  f.  prakt. 
Dermatol.,  1890,  No.  5,  we  find  abstracts  from  three  Norwegian  articles 
on  leprosy’.  The  first  is  from  Hansen  (A  ordiskt  med.  Arkiv.,  Bd.  xxi, 
No.  4),  who  has  been  studying  leprosy  among  the  Norwegians  in  the 
United  States.  He  examined  one  hundred  and  sixty-one  subjects  who 
had  either  brought  the  disease  with  them  or  who  had  become  affected 
shortly  after  arriving  in  the  country.  He  found  that  the  disease  took 
the  same  course  with  them  here  as  it  does  in  Norway.  He  found  not  a 
single  instance  of  infection  of  others  from  these,  or  a  single  case  in 
which  the  disease  had  been  passed  on  to  the  children.  He  believes  that 
infection  has  been  escaped  on  account  of  the  more  cleanly  habits  of  the 
Norwegians  living  here,  and  the  fact  that  the  lepers  have  been  given 
separate  rooms  and  beds.  Kaurin  (Norsk.  Magazin  f.  Lcegevidenskab. 
1889,  iv,  5)  believes  that  contagion  is  the  chief  cause  of  leprosy,  and 
cites  twenty  cases  of  leprosy  to  support  his  thesis.  Danielsen  ( Report 
of  the  Lungegaardshospital  for  1886 — ’88)  writes  of  the  therapeutics  of 
the  disease.  He  has  found  salicylate  of  sodium  uniformly  useful  in 
the  anaesthetic  form  of  the  disease,  while  in  the  tubercular  form,  espe¬ 
cially  in  acute  outbreaks,  it  lessens  the  fever  and  causes  the  new  tuber¬ 
cles  to  disappear.  The  old  tubercles  require  external  treatment.  Ich- 
thyol  proved  valueless.  Unna’s  chrysarobin-salieylic-acid-creasote-ich- 
thyol  treatment  has  so  far  been  of  doubtful  value.  Chaulmoogra  oil 
and  salicylate  of  mercury  influenced  the  disease  unfavorably.  Iodide 
of  potassium  favors  the  production  of  new  tubercles  so  long  as  the 
disease  is  active.  It  is  therefore  useful  as  a  test  of  cure.  If  it  is 
administered  and  no  new  lesions  appear,  then  the  disease  is  probably 
cured. 

Tuberculosis  Verrucosa  Cutis. — A  case  of  this  rare  disease  is  re¬ 
ported  by  Dr.  Brugger,  of  Wurzburg  (Virchow’s  Archiv ,  ix,  1890,  524) 
The  disease  affected  the  right  leg  of  the  patient.  Tubercle  bacilli  were 
found  in  the  tissues,  and  the  disease  was  successfully  conveyed  to  a 
guinea-pig  by  inoculation.  The  disease  resembles  lupus,  but  is  to  be 
distinguished  from  it  by  the  absence  of  lupus  tubercles,  by  the  charac¬ 
ter  of  its  cicatrix,  which  is  superficial,  and  by  not  relapsing  in  the  scar. 
From  syphilis  it  differs  in  the  slowness  of  its  course.  From  elephanti¬ 
asis  doubtful  cases  can  be  diagnosticated  only  by  the  microscope  and  by 
inoculation  experiments.  It  is  probably  identical  with  verruca  necro- 
genica.  We  can  explain  the  occurrence  of  lupus  in  one  case,  tubercu¬ 
losis  cutis  in  another,  and  tuberculosis  verrucosa  cutis  in  a  third,  dis¬ 
eases  all  depending  upon  one  and  the  same  cause,  only  upon  the  suppo¬ 
sition  that  individual  predisposition  is  an  active  determining  element  in 
the  disease.  It  is  possible  that  a  general  tuberculosis  may  start-  from 
the  local  infection  which  gives  rise  to  the  disease  under  consideration. 
Treatment  consists  in  excision  of  the  growth  or  in  scraping  it  out,  and 
the  subsequent  application  of  caustics. 

Paget’s  Disease  of  the  Nipple  forms  the  subject  of  an  exhaustive 
study  by  L.  Wickham  (Annal.  de  derm,  et  de  syph.,  1890,  i,  44).  Be¬ 
ginning  with  a  review  of  the  history  of  the  disease,  he  shows  that  Paget 
had  a  clear  idea  of  the  individuality  of  it,  as  he  first  described  it  as  a 
“  chronic  inflammation  ”  of  the  nipple.  Then  the  idea  of  its  being  a 
chronic  eczema  developed,  Butlin  in  1876  so  describing  it.  But  this 
view  held  sway  but  for  one  year.  Then  the  impression  gained  ground 
that  the  disease  was  a  special  dermatosis,  a  peculiar  form  of  epitheli¬ 
oma.  Various  views  were  entertained  in  regard  to  the  interpretation 
of  the  microscopical  appearances  of  the  disease,  till  at  last  Darier,  in  a 
thesis  upon  the  disease,  declared  that  he  had  discovered  a  parasite  that 
caused  it.  Before  describing  the  pathology  of  the  disease,  it  is  well  to 
give  a  description  of  the  disease  itself.  It  is  characterized  by  a  chronic 
inflammation  of  the  skin,  and  of  the  glands  and  their  ducts,  followed  by 
the  formation  of  an  epithelioma.  Though  most  often  located  upon  the 
breast,  in  one  case  it  has  been  seen  upon  the  scrotum.  It  is  rare  before 
forty  years  of  age ;  then  it  develops  slowly  and  becomes  epitheliomatous 
after  from  two  to  six  years,  though  it  may  become  so  in  a  few  months, 


August  9,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICI  RE. 


167 


or  not  for  twenty  years.  It  most  often  affects  the  right  breast,  begin¬ 
ning  always  at  the  nipple.  At  its  upper  surface  there  are  corneous  con¬ 
cretions,  little  tenacious  crusts,  beneath  which  there  exists  at  first  an 
itching,  erythematous  redness,  and  afterward  ulceration  and  fissures. 
From  this  time  the  nipple  shows  a  tendency  to  retract.  The  areola  is 
progressively  invaded,  and  we  have  a  bright-red  surface,  moist,  des¬ 
quamating  or  crusted  in  places,  finely  mammillated,  bleeding  easily,  and 
sharply  circumscribed.  Upon  the  surface  there  are  disseminated  isl¬ 
ands  of  a  brilliant  red  and  dry  cicatricial  appearance.  Teleangeiectases 
may  be  seen  here  and  there.  The  process  seems  to  be  superficial  and 
gives  to  pressure  a  slight  papyrus-like  induration.  Burning  and  itching 
sensations  give  the  disease  the  appearance  of  eczema  rubrum,  but  in 
doubtful  cases  close  observation  of  the  border  of  the  disease  will  de¬ 
cide  the  doubt.  It  is  always  sharply  defined,  most  often  taking  the 
form  of  a  red  or  pale  rose  slight  packing  ( bourrelet )  raised  upon  the 
sound  skin.  Upon  its  surface  are  dilated  capillaries,  and  at  times 
there  is  a  slight  desquamation  beyond  it.  The  disease  slowly  extends 
over  the  areola  upon  the  breast,  taking  often  a  rounded  or  oval  shape. 
The  nipple  is  then  retracted  completely,  and  frequently  is  the  seat  of 
ulceration.  At  times  it  begins  as  a  hard  lump  deep  down  in  the  skin. 
Once  established  as  a  cancer,  it  develops  more  rapidly.  Ganglionic  en¬ 
largement  only  occurs  late  in  the  disease,  as  a  rule. 

Darier,  in  1889,  read  a  paper  upon  the  disease  before  the  Society  of 
Biology  in  Paris,  which  was  published  in  the  Bulletin  medical.  He  then 
demonstrated  that  the  disease  was  due  to  single-celled  parasites  of  the 
order  of  cocci  or  psorosperms  and  class  of  sporozoaria.  These  para¬ 
sites  have  beeu  found  before,  but  were  wrongly  interpreted  as  cells 
undergoing  transformation,  either  in  the  way  of  degeneration  or  of  pro¬ 
liferation.  The  discovery  of  these  psorosperms  is  of  great  importance 
from  a  diagnostic  standpoint,  as  they,  being  found  in  the  scales  or  in 
scrapings  from  a  suspicious  case,  will  establish  the  diagnosis.  They 
were  found  by  our  author  in  a  piece  of  the  growth  on  the  scrotum 
which  Crocker  showed  to  the  London  Pathological  Society  as  a  case 
resembling  Paget’s  disease  of  the  nipple.  The  treatment  of  a  case  of 
Paget’s  disease  is  also  modified  by  their  discovery.  When  the  lesion  is 
still  superficial  and  non-ulcerated,  it  should  be  treated  with  chloride  of 
zinc,  followed  by  mercurial  plaster ;  or  with  iodoform.  It  is  possible 
by  these  means  to  bring  about  a  cure.  When  there  is  ulceration,  but 
not  much  induration,  the  surface  should  be  energetically  scraped  and 
covered  with  antiseptic  dressings.  When  a  nodule  is  formed,  or  there 
is  marked  induration  under  an  ulcerative  surface,  the  disease  must  be 
cut  out. 

Tumors  of  the  Scalp.— A.  Poncet  (Rev.  de  chirurg .,  1890,  xi,  244) 
reports  a  rare  case  which  has  come  under  his  observation  in  which  the 
head  of  the  patient  was  covered  with  a  great  number  of  tumors — about 
sixty  in  all.  They  were  so  numerous  that  their  edges  touched.  They 
varied  in  size  from  that  of  a  pea  to  that  of  a  tomato,  and  were  of  irregular 
form,  though  often  round.  Here  and  there  they'  were  ulcerated.  They 
were  freely  movable  and  here  and  there  pedunculated.  In  color  they 
varied  from  that  of  the  normal  skin  to  a  violaceous  hue.  Upon  them 
there  was  scarcely  any  hair,  while  between  them  there  were  thick  tufts. 
They  were  hard  to  the  touch  and  not  fluctuating  to  pressure.  The  head 
gave  a  nauseous  odor,  due  to  a  mixture  of  epithelial  and  fatty  fermenta¬ 
tion.  There  was  enlargement  of  the  submaxillary  glands.  Similar 
tumors  were  located  upon  the  body  in  the  dorsal  region.  These  tumors 
appeared  when  the  man  was  twenty-one,  and  ulcerated  only  upon  in¬ 
jury.  The  man  was  fifty-three  years  old  and  in  excellent  health.  His 
occupation  was  that  of  a  sawyer,  and  the  tumors  are  supposed  to  have 
originated  in  the  sebaceous  glands,  to  have  been  excited  by  injury,  and 
to  be  of  the  nature  of  Billroth’s  cylindroma,  a  species  of  sarcoma.  A 
number  were  excised  and  showed  no  tendency  to  return. 

The  Coincidence  of  Psoriasis  and  Syphilis  is  not  so  very  infrequent. 
Neumann  says  ( Wien.  med.  Woch .,  xl,  1890,  257)  that  when  the  two 
diseases  occur  together,  the  diagnosis  is  made  by  watching  the  lesions 
for  the  development  of  a  darker  shade  of  red  than  is  seen  in  psoriasis; 
by  the  effect  of  treatment,  an  antisyphilitic  plan  curing  the  disease 
rapidly  if  syphilis ;  and  by  the  microscopical  examination,  the  round 
cells  being  pigmented  in  syphilis. 

Electrolysis  applied  to  the  Initial  Sclerosis  as  a  Means  for  the 
Abortive  Treatment  of  Syphilis  is  the  attractive  title  of  a  paper  by 


Peroni  in  the  Giorn.  ital.  del.  mal.  ven.  e  della  pellc  for  September, 
1889.  He  believes  that  the  initial  lesion  of  syphilis  should  be  regarded 
as  a  purely  local  lesion  until  there  is  some  evident  reaction  on  the  side 
either  of  the  lymphatics  of  the  genitals  or  of  the  glands  themselves. 
He  recognizes  the  difficulty  of  making  a  positive  diagnosis  between  the 
initial  lesion  and  a  chancre  (soft  sore),  and  he  regards  induration  of 
the  sore  to  be  the  most  reliable  symptom  in  differential  diagnosis. 
Believing  that  the  initial  lesion  is  a  purely  local  process,  he  thinks 
that  he  can  abort  the  onset  of  syphilis  by  destroying  the  initial  lesion. 
The  best  time  for  the  operation  is  before  any  symptom  of  glandular  or 
lymphatic  infection  presents,  and  when  the  sore  has  existed  for  less 
than  seven  days.  The  best  method  for  destroying  the  initial  lesion  is 
first  to  disinfect  the  part  by  means  of  wrapping  it  completely  up  in 
cotton  saturated  with  a  solution  of  bichloride  of  mercury  (l  to  1,000), 
and  leaving  it  on  for  twenty  minutes.  The  part  is  then  anaesthetized 
with  cocaine,  and,  when  that  is  accomplished,  the  sclerosis  is  de¬ 
stroyed  by  electrolysis.  To  accomplish  this  he  uses  a  diamond-shaped 
lance  an  eighth  of  an  inch  wide  and  a  quarter  of  an  inch  long.  This, 
attached  to  the  negative  pole  of  a  galvanic  battery,  is  thrust  into  the 
tissues  at  a  distance  of  about  three  eighths  of  an  inch  from  the  edge  of 
the  sclerosis  and  to  about  half  that  depth  beneath  it.  When  the  lan¬ 
cet  is  in  place  the  current  is  closed  and  allowed  to  pass  for  from 
half  a  minute  to  six  or  seven  minutes,  according  to  the  size  of  the 
sclerosis.  In  this  way,  if  the  patient  bears  the  operation  well,  the 
whole  ulcer  may  be  destroyed  at  one  sitting,  this  effect  being  shown  by 
the  sclerosis  being  changed  into  a  whitish  pultaceous  mass,  which  may 
be  moved  freely  without  pain.  The  operation  is  at  times  followed  by 
oedema  of  the  part  that  may  last  a  day  or  so.  Under  an  antiseptic 
dressing  the  wound  generally  heals  in  a  few  days.  Twenty-nine  cases 
were  operated  upon  in  the  manner  described,  of  which  twenty-one  gave 
positive  results.  [A  further  report  will  be  made  by  the  author.  It  is 
to  be  hoped  that  in  the  mean  time  he  will  use  a  milliamphremeter,  so 
that  he  may  give  us  some  approximately  exact  idea  of  the  current 
strength  he  employs.] 

The  Treatment  of  Syphilis  by  Subcutaneous  Injection  of  Mer¬ 
curial  Preparations. — Dr.  Leloir  and  Dr.  Tavernier,  of  Paris,  having 
practiced  this  method  of  treating  syphilis  in  all  sorts  of  syphilitic  cases 
during  two  years,  now  (Giorn.  ital.  d.  mal.  ven.  e  del.  ptlle,  1889,  xxiv, 
247)  give  a  statistical  report  of  their  experience  and  a  summary 
of  their  conclusions.  In  all  they  made  1,573  injections.  Of  these, 
875  were  of  one  part  calomel  to  twelve  parts  liquid  vaseline,  a  half 
Pravaz  syringeful  being  thrown  into  the  sacro-lumbar  muscles,  and 
repeated  once  a  week  ;  642  were  of  the  yellow  oxide  of  mercury,  pre¬ 
pared  and  used  in  the  same  manner  as  the  calomel ;  and  56  were  of 
“gray  oil,”  consisting  of  twenty  parts  of  pure  mercury,  forty  parts  of 
liquid  vaseline,  and  five  parts  of  the  ethereal  tincture  of  benzoin,  of 
which  a  third  of  a  syringeful  was  injected  every  ninth  day.  They 
found  ( 1 )  that  these  injections  acted  specially  upon  the  erythematous 
syphilide  and  upon  the  secondary  cutaneous  eruptions  ;  (2)  that  the 
injections  of  calomel  and  of  the  yellow  oxide,  especially  the  first,  often 
caused  these  eruptions  to  disappear  with  a  surprising  rapidity,  or,  as 
they  named  it,  a  “true  brutality”  ;  (3)  that  the  calomel  acts  most  in¬ 
tensely,  and  the  gray  oil  least ;  (4)  that  all  three  are  much  more  ener¬ 
getic  in  their  effects  than  any  internal  method  of  medication,  though 
much  rougher;  (5)  that  their  action  on  syphilides  of  the  mucous  mem¬ 
brane,  especially  mucous  patches,  is  very  slight,  and,  even  while  the  in¬ 
jections  are  being  practiced,  numerous  mucous  patches  will  appear ; 
(6)  that  their  action  upon  tertiary  syphilides  is  very  uncertain,  as  they 
very  often  resist  the  injections  and  have  to  be  treated  by  inunctions  and 
the  local  application  of  mercury.  The  principal  inconveniences  from  this 
method  of  medication  are  the  following  :  1.  The  local  or  radiating  pain 
caused  by  them,  sometimes  most  violent,  and  capable  at  times  of  pre¬ 
venting  walking.  This  may  last  from  one  to  nine  or  more  days.  2. 
Paralysis  of  the  lower  extremities.  3.  Vertigo  and  headache.  4. 
Eruption  of  mucous  patches  in  the  mouth  on  the  fourth  or  fifth  day 
after  the  injection.  5.  A  mercurial  dermatitis  about  the  point  of  the 
injection.  6.  Mercurial  stomatitis,  often  slight,  sometimes  severe  and 
long-continued.  7.  A  simple  or  bloody  diarrhoea  some  time  during  the 
interval  between  the  injections.  8.  Non-suppurating  cutaneous  tumors, 
sometimes  filled  with  a  reddish  serum.  The  treatment  met  with  much 


[N.  Y.  Mkd.  Jodr. 


168 

opposition  in  hospital  practice,  many  patients  preferring  to  leave  the 
hospital  rather  than  submit  to  it.  Relapses  seemed  to  be  more  fre¬ 
quent  and  precocious  in  cases  treated  by  this  method  than  in  those 
treated  by  mercurial  inunctions.  The  calomel  injections  produced  the 
greatest  number  of  disorders.  The  gray  oil  is  the  most  inoffensive, 
but  also  the  least  active.  The  practical  deductions  from  their  experi¬ 
ence  are:  1.  The  use  of  subcutaneous  injections  of  mercury  should  be 
limited  to  the  early  eruptions  on  the  skin.  2.  They  may  be  resorted  to 
when  it  is  necessary  to  produce  a  very  rapid  effect  on  these  eruptions. 
3.  They  are  specially  if  not  exclusively  applicable  to  hospital  patients, 
or  fo  those  \\ho  can  remain  in  bed  for  a  few  days.  4.  It  is  a  good 
means  for  treating  prostitutes.  5.  Its  action  upon  mucous  patches  is 
very  bad.  6.  It  does  not  prevent  relapses.  7.  In  many  cases  it  fails 
to  cure,  and  recourse  must  be  had  to  inunctions.  8.  It  should  not  be 
used  against  the  late  syphilides  except  in  those  exceptional  cases  in 
which  it  is  necessary  to  use  mercury  internally  at  the  same  time  with 
its  local  use  and  the  administration  of  the  iodide  of  potassium.  9.  It 
is  contra-indicated  in  cerebral  and  spinal  syphilis,  in  visceral  syphilis,  in 
pregnant  women,  and  in  infants.  The  only  advantage  of  the  method 
is  the  rapidity  of  its  action.  But  this  advantage  is  more  than  balanced 
by  its  inconveniences. 


Ptsrdlang. 


Maltine  and  Sterilized  Milk. — In  an  editorial  the  Cincinnati  Lan¬ 
cet-Clinic  for  July  5,  1890,  says  : 

The  heat  of  the  last  two  weeks  has  been  remarkable  as  occurring 
so  early  in  the  season,  it  being  very  rare  indeed  for  fatal  sunstrokes  to 
occur  in  the  first  summer  month.  More  than  a  score  have  already 
taken  place  in  this  city,  while  the  news  of  the  daily  press  informs  us 
of  a  similar  mortality  in  other  cities  and  towns,  while  even  those  who 
live  in  the  country  are  not  exempt  from  the  fatal  effects  of  the  sun. 

Reports  of  sunstroke  are  usually  of  the  heat-effects  on  adults,  while 
the  direct  and  indirect  effects  on  the  infant  population  are  many  times 
as  great.  Too  often  their  main  nutrient,  milk,  has  become  tainted  or 
poisoned  from  the  absorption  of  germs  and  gases,  making  of  it  a  dan¬ 
gerous  article  of  food  and  productive  of  summer  enteritis  or  other  trouble 
that  leads  to  a  fatal  termination. 

At  this  time  of  the  year  it  is  a  good  plan  to  have  all  milk  sterilized 
as  soon  as  possible.  This  is  a  very  simple  process,  and  consists  of  put¬ 
ting  the  milk  in  a  clean  bottle,  loosely  corking  with  a  clean,  new  cork, 
and  then  placing  the  bottle  in  a  vessel  of  water,  and  heating  it  slowly 
to  the  boiling  point,  this  temperature  being  continued  for  forty-five 
minutes ;  then  tightly  cork  the  bottle  and  set  it  in  a  cool  place  until 
needed  for  use. 

The  nutrient  properties  of  the  milk  are  not  destroyed,  or  even  weak¬ 
ened,  by  this  process,  but  for  most  persons  it  is  more  easily  digested 
and  is  more  nourishing. 

Babies,  children,  and  adults,  in  hot  weather,  should  live  as  much  as 
possible  in  the  shade,  where  there  is  the  freest  possible  circulation  of 
pure  air.  Long  and  frequent  cool  baths  for  infants  are  very  conducive 
to  their  health  and  comfort.  There  is  nothing  like  a  long  cool  bath  to 
relieve  the  discomfort  of  prickly  or  summer  heat,  following  this  with  a 
little  anointing  of  the  creases  of  the  skin  with  cold  cream,  vaseline,  or 
fresh  lard. 

In  cases  of  looseness  of  the  bowels,  a  few  doses  of  the  ordinary 
chalk  mixture  will  usually  furnish  the  desired  relief.  This  should  be 
given  in  tablespoonful  doses  and  after  every  stool.  Where  there  is  a 
weakening  of  vitality,  with  very  great  propriety  and  advantage  tea¬ 
spoonful  doses  of  maltine  may  be  added  to  the  sterilized  milk,  the 
diastatic  power  of  maltine  being  capable  of  rendering  soluble  and  di¬ 
gestible  any  starchy  food  that  may  be  in  the  stomach.  Starch  foods, 
such  as  Irish  potatoes  and  breads,  have  often  been  regarded  as  the  im¬ 
mediate  and  irritating  cause  of  infantile  enteric  disorders.  In  part  this 
may  be  true,  and  yet  these  starch  foods  were  the  very  ones  the  lacteals 


and  absorbents  were  crying  for  and  needed  to  stay  the  waste  that  was 
going  on  with  fatal  rapidity. 

Right  here  the  inestimable  value  of  maltine,  with  its  diastatic  solv¬ 
ent  properties,  is  quickly  made  manifest  in  changing  the  character  of 
the  discharges  and  causing  an  irritant  factor  to  become  one  of  nutri¬ 
tion;  given  in  sterilized  milk,  the  benefit  of  both  is  obtained. 

In  the  city  it  is  a  good  thing,  in  every  possible  case,  to  send  the 
mother  and  infant  out  to  the  parks  and  suburbs  for  one,  two,  or  three 
hours  after  sundown.  The  car  ride  is  easy,  while  a  shawl  or  other  gar¬ 
ment  spread  on  the  grass  will  afford  a  genuine  relief  and  change  from 
the  mother’s  lap  or  cradle. 

A  little  instruction  from  the  family  physician  to  his  patrons  in 
these  simples  may  be  the  means  of  saving  many  valuable  lives ;  nor 
should  the  physician  take  it  for  granted  that  his  clients  are  informed  in 
such  matters,  for  very  intelligent  people  sometimes  are  very  ignorant 
of  the  plainest  hygienic  rules.  This  is  especially  the  case  in  regard  to 
the  care  of  very  young  children.  We  recently  saw  an  illustration  of 
this  in  a  very  intelligent-appearing  mother,  who  did  not  even  know 
how  to  hold  her  infant  in  positions  of  comfort  to  the  babe  and  ease  to 
herself.  Even  in  such  matters  as  this  the  doctor  may  give  wholesome 
advice. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  ”  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  ( 1 )  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of— we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor ,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


MISCELLANY. 


THE  NEW  YORK  MEDICAL  JOURNAL,  August  16,  1890. 


e ft u res  anti  Stresses, 


SURGICAL  MYCOSES. 

A  CLINICAL  LECTURE, 

DELIVERED  AT  THE  PHILADELPHIA  HOSPITAL. 

By  ERNEST  LAPLACE,  M.  D., 

PROFESSOR  OF  PATHOLOGY  AND  CLINICAL  SURGERY  IN  THE  MEDICO-CIIIRURGICAL 
COLLEGE  OF  PHILADELPHIA  ;  VISITING  SURGEON  TO  PHILADELPHIA  HOSPITAL 

ETC.  ’ 

Lecture  I. 

Reported  by  WILLIAM  BLAIR  STEWART,  M.  D. 

I  wish  to  draw  your  attention  this  morning  to  a  num- 
>er  ot  cases  that  should  not  be  considered  singly — not  this, 
hat,  and  the  other  affection — but  a  condition  that  I  wish 
Tou  to  consider  under  the  name  of  surgical  mycosis. 

Mycosis  is  an  affection  due  to  the  development  in  the 
issues  of  some  fermentative  agent,  fungus,  or  germ.  In 
urgery  we  deal  mostly  with  diseases  of  the  exterior  of  the 
>ody,  such  as  tumors,  enlargements,  or  solution  of  continu- 
iv  ;  enlargements  that  remain  as  enlargements  for  a  long 
irae,  or  else,  by  suddenly  ulcerating,  turn  into  an  ulcer  or 
olution  of  continuity.  To  specify  and  start  a  list  of  surgi- 
al  mycoses,  I  will  speak  first  of  tuberculosis. 

Tuberculosis,  as  you  all  know,  until  1882  was  something- 
ague  in  the  minds  of  pathologists,  and  not  until  Koch  es&- 
iblished  the  identity  of  tuberculosis  of  the  lungs  and  other 
rgans  did  we  begin  to  understand  the  disease. 

This  patient  comes  to  us  with  an  affection  of  his  joints, 
'n  close  physical  examination,  it  was  found  that  the  apices 
f  his  lungs  were  infiltrated,  and  we  know  he  is  tuberculous, 
[is  elbow  and  wrist  are  swollen  and  infiltrated  with  a  sub- 
ance  that  is  cheesy,  and,  on  probing,  it  was  found  that  the 
irtilage  of  the  joint  had  disappeared  and  dead  bone  was 
>und.  The  cheesy  substance  is  so  typical  that  we  know  it 
the  result  of  tubercular  degeneration,  so  that  there  is  no 
ason  why  we  should  not  pronounce  this  a  case  of  tuber- 
ilosis  of  the  elbow  joint,  and  if  we  would  apply  a  thera- 
Hitic  measure  it  would  require  amputation. 

I  will  show  you  all  the  cases  I  have  this  morning  at  once 
dore  operating,  and  demonstrate  to  you  the  great  similarity 
at  pervades  their  aetiology.  The  next  case  is  one  of  cheesy 
■generation  of  the  cervical  glands.  The  same  process  has 
ken  place  in  the  glands  of  the  neck,  and  we  have  that 
eesy  product  of  tuberculosis.  Here  you  can  see  the 
jrno-mastoid  muscle  running  across  this  opening,  and 
around  it  is  the  same  cheesy  material  that  you  saw 
the  former  case.  The  neck  is  infiltrated.  I  want  in 
is  case  to  call  your  attention  only  to  the  identity  of  the 
ocess. 

Next  is  a  case  of  carbuncle  that  is  nearly  well,  but  is 
Tical  enough  for  illustration.  You  all  have  seen  a  car- 
ncle  and  you  know  how  large,  painful,  and  ill-defined  it 
1  and  when  it  approaches  suppuration  a  crucial  incision  is 
'eded.  \  ou  notice  several  so-called  openings,  or  heads, 

Gn  which  comes  yellow,  cheesy  matter.  There  is  dis- 
oration  around  it  and  it  is  hard  and  boggy.  This  pus 
>unds  with  germs  which  are  named  Streptococcus  pyoge¬ 


nes  aureus ,  Streptococcus  pyogenes  albus,  Streptococcus  pyo¬ 
genes  cit  reus,  and  liacillus  pyocyaneus. 

These  are  found  in  ordinary  furuncle,  but,  for  some  rea¬ 
son  or  other,  several  furuncles  form  in  the  same  place,  and, 
when  so  formed,  we  call  it  a  carbuncle. 

Next  are  two  cases  of  pronounced  epithelioma.  I  wish 
you  to  remember  the  appearance  of  the  tuberculosis  of  the 
[  glands  and  arm  and  draw  the  analogy  between  epithelioma 
and  tuberculosis  of  the  skin.  Here  is  a  large  epithelioma. 
Ibis  patient  had  a  small  wart  that  was  removed  a  year  ago 
but  returned.  The  growth  is  in  a  rapid  state  of  develop¬ 
ment,  is  movable,  and  does  not  affect  the  superior  maxillary 
bone.  What  I  want  to  draw  your  attention  to  is  the  fact 
that  here  is  a  fungus-like  growth  that  develops  rapidly  and 
is  recurrent.  It  has  recurred  in  this  case  just  as  tubercular 
growths  recur  when  they  have  been  improperly  removed. 

This  is  a  patient  whose  left  cheek  I  wish  you  to  see  first. 
There  is  a  tumor,  large,  adherent,  non-fluctuating,  and  a 
slight  ulceration  near  the  base.  If  you  saw  this  tumor 
alone  you  would  be  puzzled  as  to  a  diagnosis  between 
syphilis,  tuberculosis,  and  cancer;  but,  in  view  of  this  pa¬ 
tient’s  history,  we  are  warranted  in  diagnosticating  it  on  first 
sight.  The  tumors  of  both  sides  of  the  face  are  of  the  same 
nature— epithelioma.  The  point  of  interest  is  that  here  is 
a  tumor  that  bears  a  close  resemblance  to  tuberculosis,  since 
it  has  involved  the  same  tissues  as  tuberculosis  and  looks 
like  it.  May  we  not  be  led  to  think  it  may  be  caused  by 
something  analogous  to  the  cause  of  tuberculosis  ? 

Here  is  a  case  of  senile  gangrene.  You  find  the  arterial 
circulation  perfect  to  the  middle  of  the  limb.  It  is  a  case 
of  soft  gangrene  and  the  obstruction  is  in  the  veins.  Gan¬ 
grene  is  death  of  the  part  due  to  a  cutting  off  of  nutrition— 
the  circulation.  The  leg  presents  an  emphysema  below  due 
to  sulphureted  hydrogen  and  carbon-dioxide  gas  that  are 
the  result  of  the  fermentative  process  in  the  limb.  Why 
does  it  putrefy  ?  Because  vitality  has  disappeared  by  a  ces¬ 
sation  of  circulation.  This  alone  would  not  cause  putrefac¬ 
tion,  but  we  must  have  the  germs  present  to  destroy  the 
tissues  or  cause  this  suppuration.  You  know  that  if  we 
take  a  piece  of  meat,  boil  it  and  can  it,  it  will  keep  for  a 
long  time  and  not  spoil ;  but  the  dead  tissues  of  this  leg,  bv 
exposure  to  the  atmosphere,  have  been  infected  by  germs, 
and  the  putrefaction  called  gangrene  was  the  result.  In 
this  case,  then,  there  was  an  arrest  of  the  circulation  and 
then  an  infection  by  germs.  This  is  another  illustration  of 
|  a  surgical  mycosis. 

The  next  case  is  one  in  which  the  diagnosis  is  not  per¬ 
fectly  clear,  and  must  be  treated  symptomatically  until  we 
find  the  true  aetiology  of  it.  Here  is  a  woman  who  came 
into  the  wards  two  weeks  ago  and  presented  a  tumor  of  the 
neck  that  came  rather  suddenly  and  appeared  to  be  inti¬ 
mately  connected  with  the  thyreoid  body  and  which  would 
rise  and  fall  with  the  act  of  deglutition.  In  a  few  days  the 
growth  limited  itself  and  spread  to  the  right,  and  did  not 
rise  and  fall  with  deglutition.  Yesterday  it  presented  symp¬ 
toms  of  acute  inflammation  and  was  highly  fluctuating.  Al¬ 
though  I  am  not  positive  as  to  a  diagnosis,  yet  I  am  positive 
that  there  is  fluid  here,  owing  to  the  acute  inflammatory  pro- 


Med.  Jock., 


cess,  especially  on  the  surface.  Whatever  it  is,  it  is  due  to  a 
rapid  proliferation  of  cells  of  one  of  two  kinds— either  it 
is  filled  with  pus,  or  else  there  is  a  rapidly  developing  epi¬ 
thelioma  of  one  of  the  lymphatic  glands,  and  in  this  case 
we  would  find  a  growth  consisting  of  epithelial  tissue,  giv¬ 
ing  a  soft  and  fluctuating  appearance  that  you  find  in  this 
condition. 

Before  we  operate  on  this  patient  I  wish  to  dilate  on  the 
idea  that  I  have  brought  before  you  of  arranging  such  facts 
under  a  heading  that  refers  them  to  their  aetiology.  It 
is  only  in  that  way  that  we  can  put  surgery  on  a  more 
scientific  basis,  by  reasoning  from  an  setiological  standpoint 
rather  than  from  a  clinical  aspect,  as  many  diseases  have  the 
same  aetiology,  and  the  same  mycoses  will  demand  the  same 

treatment.  t 

Such  consideration  has  only  been  possible  since  Koch 

demonstrated  the  tubercle  bacillus.  Then  came  Rosenbach 
with  the  discovery  of  the  germs  of  suppuration  and,  neces¬ 
sarily,  the  cause  of  ulceration,  for  there  is  a  disintegration 
of  the  skin  over  the  place  that  has  suppurated.  Other  ex¬ 
periments  were  made  on  ulcerations  that  were  not  of  this 
form,  until  Israel,  who  came  in  1884  and  described  actino¬ 
mycosis,  which  is  the  so-called  ray  or  star  fungus  disease 
and  exists  in  the  bovine  species.  The  fungus  enters  the 
mouth  and  alimentary  tract,  and  is  carried  by  the  blood  and 
develops  on  the  face,  or  on  the  surface  of  the  thoracic  cavity, 
and  causes  infiltration  and  ulceration,  in  which  these  germs 
have  been  found.  Just  as  these  germs  have  been  found  to 
cause  suppuration,  so  these  ray  fungi  have  caused  this  dis¬ 
ease  of  actinomycosis,  also  a  surgical  mycosis. 

Anthrax  is  the  next  affection  due  to  a  peculiar  germ. 
It  is  also  called  malignant  pustule,  or  splenic  fever  of  ani¬ 
mals.  Butchers  and  tanners  are  especially  liable  to  it. 
They  have  a  wound  on  their  hand  which  becomes  infected 
by  this  peculiar  germ  and  develops  the  disease  malignant 

pustule,  which  is  very  dangerous. 

As  to  syphilis,  you  may  consider  it  under  the  same 
heading.  Lustgarten  described  the  bacillus  of  syphilis,  but 
it  has  not  been  positively  demonstrated. 

Although  complete  researches  have  not  been  made  as 
to  the  cause  of  cancer,  yet  the  researches  of  Scheuerlein 
are  sufficient  to  establish  the  presence  of  a  germ— the  same 
germ  for  epithelioma  and  cancer.  In  order  to  prove  a  germ 

we  must  subject  it  to  four  tests : 

1.  We  must  find  the  same  germ  always  present  in  the 

same  affection. 

2.  The  germ  must  be  isolated  and  grown. 

3.  The  germ  must  be  inoculated  and  produce  the  same 

disease. 

4.  The  germ  must  be  found  the  same  after  inocula¬ 
tion. 

It  has  been  found  that  the  rat  is  very  susceptible  to  can¬ 
cer,  and  we  can  inoculate  it  and  cause  a  growth  like  cancer. 
Finally,  you  see  what  progress  has  been  made  in  the  aeti¬ 
ology  of  surgical  affections,  simplifying  the  matter  anc 
bringing  it  down  to  irritants  in  the  body.  Let  us  hope  that 
the  coming  generation  will  make  as  great  improvements  in 
the  treatment  as  the  past  has  in  the  aetiology  of  surgical 
mycoses 


A  REPORT  OF 

SEVEN  OPERATIONS  UPON  THE  KIDNEY* 

By  WILLIAM  D.  HAMILTON,  M.  D., 


COLUMBUS,  OHIO. 


Renal  surgery  may  be  said  to  have  received  its  first 
legitimate  impetus  in  1869,  when  Simon,  of  Heidelberg,  re¬ 
lieved  a  patient  suffering  from  ureteric  fistula  by  removing 
the  kidney  of  the  affected  side  through  a  lumbar  incision. 
The  growth  of  this  phase  of  abdominal  procedure  has  been 
rapid  from  that  time  to  this,  and  certain  operations  on  the 
kidney  are  looked  upon  to-day  as  conservative  undertak¬ 
ings.  No  paper,  however  brief,  would  be  complete  which 
omitted  the  name  of  that  master  of  renal  surgery,  Mr. 
Henry  Morris,  of  Middlesex  Hospital,  London  ;  while  the 
valuable  contributions  of  Thornton,  Tait,  Hahn,  Bennett 
May,  Lange,  and  many  others,  deserve  prominent  mention 

in  this  connection. 

The  cases  forming  the  subject  of  this  paper  are  six  in 
number,  and  are  all  that  have  come  under  the  observation 
of  the  writer  in  the  last  three  years  in  which  an  operation 
was  allowed.  There  were  two  neplirorrhaphies,  two  nephrot¬ 
omies,  two  nephrectomies,  and  one  incision,  with  drainage, 
for  perinephric  suppuration  in  a  case  of  movable  kidney. 
In  a  paper  read  before  the  Ohio  State  Medical  Society  at 
Toledo,  in  June,  1887,  a  successful  nephrectomy,  after  pre¬ 
liminary  exploratory  incision,  was  described.  Hence  it  will 
be  seen  that  nine  operations  on  the  kidney  comprise  the 
entire  experience  of  the  writer  in  this  department  of  sur 
gery,  and  that,  although  in  three  instances  the  kidney  was 

removed,  all  the  patients  recovered. 

Judging  from  this  list,  the  observations  of  Mr.  Grei^ 

Smith  and  others  would  seem  to  be  correct: 

1.  When  the  kidney  is  not  greatly  enlarged,  lumba 
nephrectomy  is  easier  and  safer  for  the  general  surgeon  t( 
perform  than  the  anterior  operation. 

2.  A  preliminary  nephrotomy  lessens  the  danger  of  ne 

phrectomy.  i 

Absolute  cleanliness  was  observed.  A  bath  and  laxa 

tive  preceded  the  operation  in  each  case.  The  bowels  wer 
thoroughly  emptied,  a  simple  diet  having  been  persisted  i 
for  some ‘days.  At  the  time  of  operation  the  loin  wa 
scrubbed  with  soap  and  water,  washed  with  ether,  and  aftei 
ward  with  a  warm  sublimate  lotion.  Antiseptic  irrigatio 
was  freely  resorted  to.  In  the  preparation  of  hands,  mstri 
ments,  sponges,  and  everything  else  that  could  influent' 
the  result,  as  great  care  was  exercised  as  though  the  pentc 
neal  cavity  were  to  be  invaded.  I  would  here  emphasi? 
the  great  importance  of  having  the  patient  covered  wit 
warm  woolen  blankets,  except  about  the  field  of  ineisio: 
In  this  way  the  pleura  is  less  liable  to  give  rise  to  troub 
by  becoming  inflamed  after  operation. 

CaseI.  Tubercular  Suppuration  of  the  Kidney  ;  Nephrotomr 

Nephrectomy  Three  Months  Later  ;  Recovery.— Mrs.  K.,  a  sto 


*  Read  before  the  Northern  Ohio  Medical  Society,  June,  1890. 


August  16,  1890.] 


HAMILTON:  SEVEN  OPERATIONS  UPON  THE  KIDNEY. 


171 


German  woman,  aged  twenty-two;  residence,  Columbus;  mar¬ 
ried  one  year,  and  had  never  conceived.  Has  always  menstru¬ 
ated  regularly.  In  childhood  she  was  treated  successfully  for 
hip  disease,  and,  although  she  limps  slightly,  has  nothing  else 
to  show  for  her  early  misfortune.  She  had  never  had  pain  so 
intense  that  it  could  properly  be  called  renal  colic.  Examina 
tion  showed  the  lungs  to  behealthy.  For  several  months  prior 
to  her  admission  to  the  hospital  she  had  been  losing:  flesh  and 
strength.  It  was  on  account  of  frequency  in  urinating  that 
she  consulted  a  physician.  Every  such  act  was  attended  with 
scalding  pain.  At  night  her  sleep  was  invariably  interrupted 
in  this  way.  Her  appetite  was  poor.  For  four  months  she 
had  had  chilly  sensations,  a  rise  of  temperature,  and  occa¬ 
sional  night-sweats.  During  the  few  weeks  in  which  she  was 
under  observation  her  pulse  was  never  less  than  100,  and 
her  temperature  ranged  from  100-5°  to  102-7°  F.  A  dull, 
aching  pain  had  existed  in  both  loins,  especially  in  the  right 
me,  during  the  previous  few  months,  and  was  subject  to 
accasional  exacerbations.  She  had  observed  that  her  urine, 
usually  cloudy  during  her  illness,  was  clearer  and  less  in  quan¬ 
tity  when  the  right  lumbar  pain  was  most  intense.  A  sandy 
lediment  bad  been  visible  a  few  times.  Blood  had  never  been 
seen  in  the  urine.  Riding,  walking,  or  any  sudden  movement 
ilways  hurt  her.  Aside  from  such  aggravating  causes,  she  suff¬ 
ered  more  in  the  morning  than  at  other  times.  Pressure  over 
he  left  loin  caused  no  inconvenience,  but  on  the  right  side  was 
'^stressing  to  her.  No  enlargement  of  the  kidney  or  tumor  was 
liscernible  through  the  thick  parietes. 

Examination  of  the  urine  showed  that  the  reaction  was  in- 
ariably  acid  and  that  pus  was  always  present.  Neither  casts 
ior  tubercle  bacilli  were  ever  discovered.  Sounding  the  bladder 
odicated  the  absence  of  stone.  Vesical  irrigation  with  a  warm 
olution  of  boric  acid  gave  temporary  relief. 

Diagnosis. — Pyelitis,  with  possibly  stone  in  the  kidney. 

Operation ,  October  13,  1888. — Ether  narcosis.  Oosto-iliac 
pace  was  very  short.  A  hard  pillow  having  been  placed  be- 
ieath  the  sound  side,  thus  putting  the  right  loin  on  the  stretch, 
n  incision  was  made  four  inches  and  a  half  long,  below  and 
-arallel  to  the  last  rib,  terminating  two  inches  and  a  half  from 
he  spine.  It  was  extended  for  a  distance  of  an  inch  vertically 
ownward  at  its  inner  end.  The  fatty  capsule  was  normal  and 
ot  strongly  adherent.  The  kidney,  enlarged  to  several  times 
he  ordinary  dimensions,  was  lobulated  and  fluctuant.  Explora- 
ory  puncture  revealed  an  inodorous  mixture  of  pus,  urine,  and 
arum.  An  incision  into  the  renal  substance  permitted  the  free 
ischarge  of  this  fluid.  Carrying  in  the  finger,  the  organ  was 
mnd  to  be  converted  into  a  sacculated  tumor,  the  various  com- 
artments  of  which  contained  fluid.  No  stone  was  found, 
borough  irrigation  with  bichloride  solution  was  employed,  a 
ubber  drain  was  inserted  into  the  kidney  substance,  and  the 
■ound  was  closed  with  silk  stitches.  Her  convalescence  was 
neventful,  the  wound  healing  except  in  the  track  of  the  drain- 
ge-tube,  where  urine  and  pus  continued  to  discharge. 

There  was  an  entire  subsidence  of  pain  and  hectic,  and  the 
fine  voided  in  the  natural  way  became  perfectly  clear  and 
'as  free  from  albumin.  She  grew  stronger,  her  color  improved, 
nd  but  for  the  presence  of  the  fistulous  opening,  her  health 
’ould  have  been  perfect.  She  was  advised  to  have  the  kidney 
amoved  in  order  to  get  rid  of  this  source  of  irritation  and  an- 
ovance;  and  accordingly  re-entered  the  hospital. 

Operation,  January  19,  1889. — Incision  through  the  old 
icatrix.  The  various  anatomical  layers  were  matted  together 

as  to  render  them  difficult  of  recognition.  Owing  to  the 
uckness  of  the  parietal  fat  and  the  density  of  the  scar,  the  iso- 
ition  ot  the  kidney  was  by  no  means  easy.  The  proper  cap- 
ffe  having  been  incised,  the  fingers  were  used  in  separating  the 


adhesions  between  capsule  and  kidney  until  finally  it  was  gen¬ 
erally  freed.  At  this  point  the  greatest  obstacle  to  the  com¬ 
pletion  of  the  operation  was  encountered.  Although  diminu¬ 
tion  in  size  had  supervened  as  a  result  of  the  nephrotomy  of 
three  months  before,  the  great  depth  at  which  the  pedicle  had 
to  be  secured,  and  the  fact  that  fully  the  upper  two  thirds  of  the 
organ  lay  behind  the  projecting  rib  and  intercostal  space,  added 
to  the  delay,  and  frequent  efforts  to  ligate  the  pedicle  resulted 
in  failure.  Finally  a  wire  6craseur  was  passed  around  it,  and 
included  in  its  grasp  vein,  artery,  ureter,  and  a  small  amount  of 
renal  tissue.  In  order  to  deliver  the  kidney  it  was  cut  away 
piecemeal,  the  constrictor  being  tightened  during  the  dissec¬ 
tion.  Thorough  irrigation  followed  and  the  ecraseur  was  left 
in  the  wound.  Considerable  pain  marked  her  convalescence. 
There  was  very  little  fever  and  the  urine  remained  clear.  The 
instrument  was  tightened  from  day  to  day  as  the  pedicle  loos¬ 
ened,  and  it  came  away  four  weeks  after  the  operation.  Ano¬ 
dynes  were  employed  to  subdue  the  localized  pleuritic  inflam¬ 
mation  that  followed.  She  was  discharged  a  few  days  later, 
aDd  has  since  remained  in  good  health.  A  small  sinus  lasted 
for  some  months,  but  finally  ceased  to  give  rise  to  annoyance. 

Case  II.  Supposed  Case  of  Renal  Calculus ;  Preliminary 
Exploratory  Incision  ;  Temporary  Relief ;  Recurrence  ofHaema- 
turia  ;  Nephrectomy  ;  Recovery. — Miss  J.  P.,  aged  twenty-six; 
residence,  Delaware,  Ohio.  Had  been  an  invalid  for  five  years 
and  a  half,  during  the  latter  part  of  which  time  she  had  painful 
micturition  as  often  as  four  or  five  times  hourly,  night  and  day. 
She  had  several  attacks  of  renal  colic,  four  of  which  were  very 
severe.  The  worst  one  had  occurred  just  prior  to  her  admission 
to  the  hospital.  For  two  years  previous  to  operation  she  had 
never  been  free  from  hsematuria.  Pain  was  always  referred  to 
the  left  loin,  which  was  tender  on  pressure,  although  there  was 
no  sign  of  enlargement.  She  was  reduced  in  flesh  and  weighed 
eighty-five  pounds.  She  was  a  bedridden  invalid  most  of  the 
;ime.  Her  father  had  died  of  phthisis  pulmonalis,  and  she  had 
incipient  disease  of  the  same  character.  Her  last  attack  of  renal 
colic,  in  April,  1889,  continued  a  week,  was  very  severe,  and  a 
arge  quantity  of  clear  blood  was  passed.  The  urine  usually 
contained  blood  finely  mixed  with  it.  No  pus,  casts,  albumin, 
or  sabulous  matter  could  be  detected.  Tenderness  in  the  left 
oin  was  so  marked  that  she  flinched,  even  when  under  ether,  if 
pressure  was  applied  to  that  part  of  the  body.  Sounding  for 
vesical  calculus  yielded  negative  results,  and  a  careful  use  of  the 
nstrument  failed  to  discover  any  papillomatous  tumor  or  other 
irregularity  in  the  wall  of  that  viscus.  Examination  by  the 
rectum  and  by  conjoined  manipulation  produced  like  negative 
results.  Her  alvine  evacuations  and  menstruations  were  regu¬ 
ar  and  presented  no  peculiarities.  In  the  previous  year  she 
lad  habitually  observed  that  the  hsematuria  was  aggravated 
during  the  premenstrual  week.  All  attempts  to  relieve  this 
condition  by  rest  and  medication  failed.  Urethral  dilatation 
and  antiseptic  vesical  irrigation  likewise  were  of  no  avail. 
Something  must  be  done  to  relieve  tbe  continual  drain  upon 
aer  strength.  An  exploratory  left  lumbar  incision  was  advised 
and  was  performed  by  Dr.  Charles  S.  Hamilton.  The  usual 
dan  was  adopted.  The  organ  was  found  upon  exposure  to  be 
slightly  above  the  average  in  size,  smooth,  and  free  from  in¬ 
durations  in  its  substance.  All  parts  of  it  were  carefully  ex¬ 
amined  with  the  finger.  A  systematic  series  of  punctures  was 
made,  but  no  abnormity  was  discovered.  The  wound  was 
closed,  a  drain  was  inserted,  and  healing  was  prompt.  For  a 
week  there  was  entire  cessation  of  the  haomaturia  and  very 
little  pain,  the  quantity  of  urine  voided  in  twenty-four  hours 
remaining  the  same  as  before — i.  e.,  from  one  to  two  pints.  The 
fact  that  a  subsidence  of  symptoms  had  taken  place  for  the  first 
time  in  a  year  after  extensive  puncture  of  the  left  kidney  was 


HAMILTON :  SEVEN  OPERATIONS  UPON  THE  KIDNEY. 


[N.  Y.  Med.  Jock., 


172 


regarded  as  strong  presumptive  evidence  that  the  organ  of  that 
side  had  an  important  relation  to  the  hsematuria. 

Furthermore,  the  bleeding,  pain,  and  scalding  in  passing 
water  had  returned  with  redoubled  intensity,  and  greatly  dis¬ 
couraged  the  patient.  She  was  advised  to  submit  to  a  second 
operation,  and  if,  after  incisions  into  the  renal  substance,  no  ex¬ 
planation  of  the  hmmorrhage  could  be  found,  nephrectomy  was 
to  be  done. 

Operation ,  May  15,  1889.— Having  fresh  in  mind  the  difficul¬ 
ties  encountered  in  previous  nephrectomies,  I  followed  the  very 
valuable  suggestion  of  Lange  by  resecting  the  twelfth  rib,  so  as 
to  give  increased  room  for  the  necessary  manipulations.  The 
incision  through  the  former  cicatrix  was  easily  accomplished,  as 
union  was  not  yet  firm.  An  extension  of  it  at  an  acute  angle, 
joining  the  inner  end  of  the  former  one,  resulted  in  the  forma¬ 
tion  of  a  V-shaped  Hap.  The  muscles  were  well  cleared  away 
in  the  dissection  toward  the  median  line,  which  greatly  facili¬ 
tated  the  operation.  A  coarse  silk  ligature  secured  the  pedicle 
en  masse.  Her  convalescence  was  tedious.  She  had  no  hema¬ 
turia,  voided  healthy  urine  freely,  and  gave  no  anxiety  on  ac¬ 
count  of  ugly  renal  symptoms.  Owing  to  the  free  exposure  of 
the  pleura,  the  unavoidable  chilling  of  the  left  side  from  having 
it  uncovered  during  the  operation,  and  the  cooling  effects  of 
evaporation  following  irrigation,  she  had  a  sharp  attack  of 
pleurisy  with  effusion.  This,  however,  finally  yielded  to  appro¬ 
priate  measures,  the  wound  healed  kindly,  and  she  has  gained 
in  flesh  and  strength.  She  is  now  in  good  health,  weighs  one 
hundred  and  nine  pounds,  and  is  filling  a  responsible  clerical 
position. 

This  case  is  one  involving  rather  unscientific  interfer¬ 
ence  in  that  the  kidney  is  apparently  healthy.  It  involves 
a  startling  and  apparently  unjustifiable  empiricism.  The 
explauation  of  the  hfematuria  and  pain  I  am  unable  to  give. 
The  supposition  that  a  small  calculus  became  lodged  in  the 
ureter  and  escaped  detection  may  explain  it.  Again,  early 
tubercular  involvement  might  account  for  it.  The  justi¬ 
fication  would  seem  to  lie  in  this  fact,  that  a  young  woman 
who  had  been  a  confirmed  invalid  for  three  years  has  been 
restored  to  health  and  usefulness.  It  may  well  be  added 
that  an  operator  should  feel  better  satisfied  when,  in  addi¬ 
tion  to  having  his  patient  get  well,  he  is  able  to  indicate 
clearly  the  pathological  reason  for  the  course  pursued.  She 
has  had  amenorrhoea  since  the  last  operation,  and  it  is  hard 
to  convince  her  that  the  uterine  appendages  were  not  also 
removed. 

Case  III.  Movable  Kidney  ;  Nephrorrhaphy ;  Recovery. — Mrs. 
hT.  B.,  aged  thirty,  sent  by  Dr.  0.  F.  Coyle,  of  Gabon,  Crawford 
County,  Ohio,  had  had  both  menstrual  aud  premenstrual  pain 
for  nine  years.  Had  soreness  in  the  left  inguinal  region.  The 
most  severe  pain  was  that  which  preceded  menstruation  for 
several  days,  and  was  of  a  bearing-down  character.  The  effort 
to  walk  any  distance  caused  pain.  A  copious  stool  was  attendee 
with  soreness  in  the  region  of  the  left  kidney.  Examination 
showed  a  tumor  descending  on  the  left  side  to  a  level  with  the 
anterior  superior  spine  when  the  patient  stood  upright.  It  was 
freely  movable,  and,  if  the  horizontal  posture  was  assumed,  it 
could  readily  be  forced  into  the  loin.  On  October  5,  1889,  an 
incision  was  made  below  the  last  rib,  similar  to  that  described 
above.  The  fatty  capsule  was  found  to  be  very  loose.  The 
proper  capsule  was  incised.  Silk  stitches  were  made  to  include 
skin,  subcutaneous  structures,  and  both  capsules,  the  fatty  cap¬ 
sule  being  pulled  taut  in  such  a  manner  that  the  excess  lay  out¬ 
side  the  wound.  No  febrile  disturbance  ensued,  and  healing  by 


granulation  was  the  result.  The  organ  has  remained  in  its 
proper  place,  and  she  is  free  from  symptoms  that  could  he  at¬ 
tributed  to  the  pathological  condition  alluded  to. 

Case  IV.  Suppurating  Kidney ;  Nephrotomy  ;  Recovery.— 
Mrs.  G.  T.,  of  Columbus,  was  referred  to  me  by  Dr.  N.  R. 
Coleman,  who  had  diagnosticated  a  suppurating  left  kidney. 
Was  twenty-seven  years  old,  had  been  married  nine  months, 
and  her  menstrual  life  had  been  a  normal  one.  There  was  noth¬ 
ing  pointing  to  the  existence  of  pelvic  suppuration.  In  her 
sixth  year  she  had  severe  pain  in  the  left  side,  al  ways  aggi  av ated 
hy  riding  or  jolting.  The  only  period  of  her  life  in  which  she 
had  enjoyed  entire  immunity  from  suffering  was  that  extending 
from  the  twenty-first  to  the  twenty-fourth  year.  She  had 
always  been  subject  to  renal  colic.  With  the  exception  of  the 
interval  alluded  to,  she  never  passed  a  month  without  one  such 
experience.  The  pain  started  in  the  loin  and  followed  the  j 
ureter.  She  estimated  that  forty  attacks  had  occurred  in  the 
ast  three  years,  and  they  had  been  steadily  increasing  in  sever- 
ty.  Furthermore,  pus  had  been  observed  for  the  first  time  in 
the  urine,  and  had  increased  in  quantity  until  it  became  \erj 
profuse.  No  stone  or  sabulous  matter  was  ever  visible. 

The  average  amount  of  urine  excreted  in  twenty-four  hours, 
when  Dr.  Coleman  first  saw  her,  was  one  quart,  and  half  of  it 
was  purulent.  Reaction  always  acid.  Vomiting  bad  never 
taken  place. 

The  weight  of  the  patient  was  seventy  pounds,  whereas  for¬ 
merly  it  had  been  one  hundred  and  thirty.  It  is  uncommon 
even  in  advanced  phthisis  to  see  greater  emaciation.  The  left 
hypochondrium  and  loin  were  exceedingly  tender  and  quite 
prominent,  especially  at  a  point  an  inch  behind  the  midaxillary 
line  in  the  center  of  the  costo-iliac  space.  Upon  palpating  the 
left  loin,  a  hard,  tender,  rounded,  smooth  swelling  filled  the  upper 
part  of  this  space  and  encroached  upon  the  hypochondrium. 
It  was  all  the  more  apparent  on  account  of  her  extreme  ema¬ 
ciation.  The  same  tests  applied  to  the  other  side  elicited  an 
apparently  healthy  condition.  The  average  pulse  was  90,  tem¬ 
perature  99-37°.  Diagnosis  confirmed.  Nephrotomy.  On  No¬ 
vember  19,  1889,  an  incision  in  the  most  tender  part  of  the  loin 
found  the  fatty  capsule  tough,  indicating  inflammatory  changes 
A  needle  brought  pus.  The  knife,  being  inserted,  opened  a  large 
abscess  cavity,  the  contents  of  which  were  very  foul.  A  pin; 
and  a  half  of  this  material  was  discharged.  The  kidney  was 
extensively  disorganized.  After  thorough  washing  out  with  t 
weak  sublimate  solution  and  the  insertion  of  a  rubber  drainage 
tube,  the  wound  was  closed.  No  untoward  symptoms  wen 
present,  and  she  got  well  rapidly.  Her  appetite  became  goo< 
and  she  took  on  flesh  at  such  a  rate  that  she  gained  sixtv-thre' 
pounds  in  six  months.  The  urine  is  normal,  she  is  free  fron 
pain,  and,  aside  from  the  fact  that  she  has  an  inoffensive  sinus 
her  health  is  excellent. 

Case  V.  Movable  Kidney  ;  Nephrorrhaphy;  Cure.— Mrs.  E 
R.  K.,  of  Plain  City,  Madison  County,  Ohio,  was  sent  to  me  b; 
Dr.  J.  II.  Gardner,  of  that  place,  with  the  above  diagnosis 
She  was  twenty-seven  years  old,  had  been  married  five  yean 
had  one  child  three  years  old,  and  had  miscarried  at  the  sixt 
month  soon  after  marriage.  She  dated  her  disability  from  tb 
latter  event.  Her  menstruations  have  been  regular,  and  for  seve 
years  had  been  painful.  During  the  last  six  months  she  ha 
dragging  pain  for  a  week  prior  to  menstruation.  Beginning  i 
the  right  loin  and  following  the  direction  of  the  ureter  of  tb£ 
side,  there  was  continual  soreness,  aggravated  at  times  by  stanc 
ing  or  walking.  A  smooth,  ovoid  'tumor  could  he  detected  o 
the  right  side.  It  was  freely  movable  between  the  upper  part  ( 
the  right  inguinal  and  the  lumbar  regions.  Its  shape  was  tb; 
of  the  kidney.  A  singular  fact  in  her  case  was  this:  that  lyic 
on  the  back  frequently  caused  her  pain  to  increase,  and  at  sue 


August  16,  1890.] 


BROWN:  A  CASE  OF  SEVERE  HAEM  A  TURIA. 


173 


times  standing  erect  gave  her  relief.  In  the  last  two  years  and 
a  half  she  had  had  twelve  attacks  of  severe  pain  in  that  part  of 
the  abdomen  indicated.  The  urine  was  normal.  There  was  no 
nausea.  The  diagnosis  of  movable  kidney  was  confirmed,  and 
nephrorrhaphy  was  done  January  25, 1890.  The  same  plan  was 
idopted  as  in  Case  III,  the  skin,  fatty,  and  fibrous  tissue  being 
secured  with  silk  stitches,  the  fatty  layer  having  been  pulled 
;aut  while  the  redundant  tissue  was  allowed  to  remain  on  the 
nitside.  Free  scratching  of  the  kidney  was  resorted  to,  so  that 
in  abundant  plastic  exudate  would  be  thrown  out.  In  this,  as 
n  Case  IV,  Mr.  Morris’s  suggestion  of  stuffing  the  wound  lightly 
ivith  gauze  was  used  and  with  good  effect.  Healing  by  granu- 
ation  resulted,  and  there  was  an  entire  absence  of  unpleasant 
symptoms.  This  patient  has  unquestionably  been  entirely  re- 
ieved,  so  that  she  now  enjoys  perfect  health.  She  has  gained 
ifteen  pounds  in  weight. 

Case  VI.  Movable  Kidney  ;  Nephrorrhaphy  attempted  ;  Peri- 
lephrie  Suppuration  found ;  Incision  and  Drainage;  Failure 
o  Jind  the  Kidney  ;  Recovery  ;  Improvement. — Mrs.  C.  A.  W., 
>f  Columbus,  a  delicate  woman,  aged  fifty,  married  twenty-one 
’ears,  had  four  children,  the  youngest  ten  years  old.  She  had 
lot  yet  ceased  to  menstruate.  Ten  years  previously,  after  the 
firth  of  the  last  child,  she  had  typhoid  fever  followed  by  severe 
mins  in  right  foot,  on  account  of  which  she  wore  a  supporting 
hoe  for  two  years.  This  was  followed  by  severe  pains  in  the 
mck,  for  which  a  plaster  jacket  was  put  on  and  worn  for  three 
aonths  with  some  relief.  One  year  prior  to  admission  she  had 
relapse  and  her  health  became  poor.  She  had  rigors,  loss  of 
ppetite,  flesh,  and  strength.  Micturition  occurred  fifteen  to 
wenty  times  in  twenty-four  hours,  accompanied  with  burning 
ain,  referred  to  the  neck  of  the  bladder.  When  standing  or 
talking,  her  form  was  stooped.  A  movable  lump  descended  to 
ifithin  an  inch  of  the  level  of  the  navel.  She  had  pain  in  the 
ight  kidney  and  ureter,  and  was  only  comfortable  when  lying 
n  that  side. 

Specific  gravity  of  urine,  1-020.  Traces  of  albumin.  Diag- 
osis,  movable  kidney. 

Operation ,  February  18,  1890.— The  usual  lumbar  incision 
n-  nephrorrhaphy  was  made.  Opening  the  loin,  a  large  quantity 
f  inoffensive  pus  escaped.  It  resembled  thick  mayonnaise 
ressing.  The  kidney  could  not  be  found.  Irrigation  was  thor- 
ughly  carried  out  and  a  drainage-tube  was  inserted.  Her  re- 
avery  was  tedious,  but  was  not  marked  by  intensity  of  symp- 
>ms.  She  was  discharged  from  the  hospital  four  weeks  later, 
he  has  gained  several  pounds  in  flesh,  and  can  stand  and  walk 
rect  without  pain.  The  kidney  can  now  be  located  where  it  is 
rmly  fixed  nearly  as  high  as  it  should  be.  She  feels  well  as 
>ng  as  the  sinus  discharges.  There  is  now  about  twelve  per 
3nt.  of  pus  in  the  urine. 

In  cases  where  perinephric  suppuration  attends  a  mov- 
ble  kidney,  failure  to  find  the  organ  at  the  time  of  opera- 
on  has  occasionally  resulted.  In  this  case  the  improve- 
icnt  in  position  is  probably  due  to  contraction  of  the 
>scess  cavity — i.  e.,  the  distended  fatty  capsule.  The 
tdical  operation  of  removal  may  yet  have  to  be  done. 

A  New  Alkaloidal  Reagent. — “M.  Brociner  finds  that  sulphotellu- 
te  of  ammonium  in  solution  in  sulphuric  acid  gives  characteristic 
dors  with  certain  alkaloids.  Thus  with  digitaline  it  gives  a  reddish 
olet  tint,  gradually  becoming  more  intense ;  with  chelidonine  it  gives 
first  no  reaction,  but  in  a  few  seconds  a  green  color  becomes  appar- 
it,  becoming  more  pronounced  in  about  four  minutes ;  with  apomor- 
une  it  gives  a  violet  color  ;  with  narcotine  a  fugitive  rose  tint ;  and 
irceine  becomes  first  yellow,  passing  to  a  dirty  green,  finally  turning 
violet.’’ — British  and  Colonial  Druggist. 


A  CASE  OF  SEVERE  HEMATURIA; 

NEPHRECTOMY  BY  DR.  McBURNEY. 

RECOVERY* 

By  F.  TILDEN  BROWN,  M.  D. 

0.  G.,  twenty-six  years  of  age,  five  years  married,  three 
children.  No  miscarriages.  Family  history  markedly  gouty. 
Health  previous  to  the  first  attack  of  hsematuria  had  been  good, 
except  for  two  periods  of  marked  and  somewhat  critical  anaemia. 
The  first  of  these  occurred  two  years  before  marriage,  the  sec¬ 
ond  a  year  later. 

In  March,  1888,  when  her  second  child  was  four  months  old, 
appeared  the  first  recognized  trouble  with  the  right  kidney,  and 
attributed  to  over-exertion  in  caring  for  her  child.  The  symp¬ 
toms  as  now  recalled  were  sudden  and  marked  haematuria ; 
pain  in  the  right  kidney  region,  radiating  to  the  distribution  of 
the  anterior  crural  nerve  below  Poupart’s  ligament;  fever  reach¬ 
ing  at  the  highest  104°  F.  Her  attendant  at  this  time,  a  man  of 
great  experience  and  marked  ability,  diagnosticated  the  rupture 
of  some  renal  vessel.  Acute  pain  and  haemorrhage  disappeared 
rather  suddenly  at  the  end  of  five  days.  The  only  subjective 
sequence  was  a  sense  of  dull  pain  in  the  right  side  and  thigh 
when  she  was  tired.  Examination  of  the  urine  on  one  or  two 
occasions  after  this  attack  is  said  to  have  shown  considerable 
pus.  However,  the  patient  felt  well  enough  to  dispel  any 
thought  on  her  own  part  of  chronic  disease. 

The  second  attack  occurred  in  August,  1888,  when  she  was 
two  months  pregnant.  As  the  patient  made  a  sudden  jump  and 
strain  to  seize  a  child  from  a  wave  on  the  sands  she  experienced 
a  sharp  pain  in  the  right  side.  . 

On  reaching  home  twenty  minutes  later  she  found  her  urine 
heavily  charged  with  blood.  This  attack  was  characterized  by 
a  repetition  of  the  symptoms  of  the  first,  with  the  exception 
that  the  fever  was  not  so  high.  In  this,  as  in  the  first  attack, 
the  repeated  use  of  a  stiff  catheter  was  necessary,  not  as  it  is 
ordinarily  used,  but  to  punch  back  the  blood-clots  blocking  up 
the  sphincter  vesicas  and  preventing  micturition. 

Diagnosis  by  a  different  physician,  renal  calculus;  and 
treatment  in  accordance  was  followed  by  rather  sudden  recov¬ 
ery  from  acute  symptoms  in  about  the  same  time  as  was  the  first 
attack. 

Third  attack,  October  26, 1889,  at  which  time  I  first  saw  the 
patient  professionally,  and  learned  that  an  hour  before  at  the 
first  morning  urination  she  noticed  a  marked  hsematuria,  and 
at  the  moment  thought  it  a  menstrual  manifestation,  which  was 
welcomed  because  there  was  some  reason  to  believe  herself  two 
months  pregnant ;  and  for  the  dissipation  of  this  she  had  re¬ 
cently  resorted  to  the  hardest  riding,  domestic  fatigues,  and 
Turkish  baths.  The  night  before,  on  going  up  stairs,  she  felt  some 
pain  in  the  back,  but  the  night  had  been  passed  free  from  any 
discomfort.  A  second  micturition  shortly  after  the  first  was 
more  heavily  charged  with  blood  and  attended  with  some  pain, 
as  large  blood-clots  passed  the  urethra.  Synchronously  with 
the  appearance  of  hsematuria,  pain  was  first  felt  in  the  right 
side.  This  pain  was  continuous,  but  at  times  much  augmented, 
with  an  extension  of  the  painful  area  to  Poupart’s  ligament  and 
some  in  the  leg  below.  Clots  collecting  in  the  bladder  were 
already  troublesome  in  retarding  urination. 

Physical  examination  of  the  suspected  region  showed  ten¬ 
derness  on  pressure  between  the  twelfth  rib  and  the  crest  of 
the  ilium.  Antero  posterior  palpation  with  one  hand  compress¬ 
ing  this  region  and  a  little  lower  was  equally  sensitive.  No 
tumefaction  was  appreciable;  percussion  was  normal.  Vaginal 


*  Read  before  the  American  Association  of  Genito-urinary  Surgeons. 


174 


BROWN:  A  CASE  OF  SEVERE  HAEM  A  TURIA. 


[N.  Y.  Med.  Jocb., 


examination  relative  to  ureter  and  bladder  was  negative.  Tem- 
perature  (sublingual),  100-2°;  pulse,  76. 

The  examination  of  urine  showed  specific  gravity  1  *030 ; 
color,  deeply  stained  with  blood  evenly  distributed.  Reaction 
very  acid  ;  sediment,  moderately  copious. 

Microscopical  Examination. — Blood-corpuscles  in  greatquan- 
tity  ;  pus-corpuscles  in  quantity  ;  great  numbers  of  a  long  rod 
bacillus  ;  no  crystals  of  any  kind. 

Chemical  Examination. — Albumin,  one  eighth  bulk. 

Diagnosis. — Renal  calculus.  Treatment  was  instituted  to 
meet  the  prominent  indications — viz.,  pain  and  haemorrhage. 

For  the  next  four  days  the  patient’s  condition  continued 
much  the  same,  except  that  exacerbations  of  pain  were  more 
severe.  The  afternoon  temperature  reached  a  higher  point, 
108°.  Clots  collecting  in  the  bladder  were  now  more  painful 
to  pass.  The  patient  at  each  micturition  was  compelled  to  re¬ 
sort  to  the  punching  process  with  the  silver  catheter.  Any 
movement  in  bed  caused  distress  in  the  kidney  region,  and  pal¬ 
pation  of  it  showed  increasing  tenderness.  Many  of  the  clots 
were  as  large  as  and  resembling  a  poached  egg,  while  several, 
thicker  than  a  pencil  and  five  inches  long,  were  evidently  casts 
of  the  ureter. 

At  this  time  Dr.  McBurney  was  called  in  consultation,  the 
result  of  which,  after  careful  examination  of  the  patient  and  a 
review  of  the  history,  was  to  support  the  diagnosis,  at  the  same 
time  advising  a  continuance  of  the  expectant  plan  of  treatment, 
until,  as  the  previous  attacks  led  one  to  hope,  an  early  and  sud¬ 
den  cessation  of  the  hasmaturia  would  permit  a  clearer  appre¬ 
ciation  of  the  renal  affection  to  be  gained  by  repeated  urinary 
analysis.  Fluid  extract  of  ergot  was  added  to  the  treatment. 

During  the  next  five  days  the  patient  had  been  constantly 
approaching  a  more  serious  condition.  Anaemia  was  now  very 
marked.  Nausea  and  vomiting  had  seriously  interfered  with 
taking  the  requisite  food.  Increasing  pain  was  demanding  mor¬ 
phine  in  greater  quantity.  Clots  had  so  distended  and  irritated 
the  urethra  that  every  micturition  was  a  source  of  anxiety. 
Ergot  had  seemed  to  increase  both  renal  pain  and  haemorrhage; 
in  consequence  it  was  discontinued  after  two  days.  Twice  these 
symptoms — pain  and  haematuria — had  for  a  short  time  very  en¬ 
couragingly  diminished,  but,  without  appreciable  cause,  returned 
in  a  few  hours  as  bad  as  or  worse  than  before.  At  this  juncture 
the  patient’s  condition  seemed  to  me  to  demand  surgical  inter¬ 
ference.  The  patient  craved  it,  and  her  family,  realizing  that 
this  attack  was  so  much  more  serious  in  every  particular  than 
former  ones,  were  equally  solicitous. 

Dr.  McBurney  was  asked  to  perform  nephrotomy.  To  this 
he  agreed,  making  the  appointment  for  two  days  later,  Novem¬ 
ber  5th,  should  no  improvement  be  reported  in  the  mean  time. 

On  gross  examination  the  two  specimens  of  urine  passed 
just  before  operation  were  but  faintly  blood-colored.  Not¬ 
withstanding  this,  in  the  face  of  the  previous  disappointments, 
it  was  not  deemed  advisable  to  credit  this  suggestion  as  per¬ 
manent. 

The  total  quantity  of  urine  passed  during  the  twenty-four 
hours  before  operation  was  thirty-six  ounces. 

Operation. — All  the  evidence  pointed  strongly  toward  the 
existence  in  the  kidney  of  a  calculus,  and  the  rapidly  failing 
condition  of  the  patient  called  for  immediate  and  energetic  meas¬ 
ures.  The  operation  was  begun  with  the  intention  of  exposing 
the  surface  of  the  kidney,  in  order  that  the  organ  might  be 
thoroughly  searched.  After  every  antiseptic  precaution  hac 
been  taken,  a  four-inch  incision  was  made  just  below  and  in  the 
line  of  the  last  rib  on  the  right  side.  The  outer  edge  of  the 
kidney  was  readily  exposed,  and  then  the  posterior  surface  laic 
bare.  The  operator  failed  to  detect  any  foreign  body  in  the 
pelvis  of  the  kidney.  On  the  posterior  surface  in  the  lower 


half  a  small,  hard,  elevated  spot,  perhaps  a  quarter  of  an  inch 
in  diameter,  led  to  the  belief  that  a  calculus  might  be  imbedded 
in  the  substance  of  the  organ  at  this  point.  A  round  needle 
was  thrust  first  into  this  spot  and  then  into  many  other  parts  of 
the  kidney  without  result.  The  anterior  surface  was  then  un¬ 
covered,  and  by  bimanual  examination  a  rapid  but  thorough 
search  was  made,  which  was  equally  unsuccessful  in  discover¬ 
ing  a  cause  for  hcematuria.  Further  loss  of  time  in  the  search 
for  calculus  seemed  unwarranted  in  view  of  the  already  pros¬ 
trated  condition  of  the  patient.  No  other  means  of  putting  an 
end  to  what  would  certainly  have  been  a  fatal  haemorrhage  re¬ 
mained  for  consideration  but  the  shutting  off  of  the  blood- 
supply,  which  could  only  be  accomplished  by  the  extirpation  of 
the  kidney.  This  plan  was  not  difficult  to  carry  out,  and  was 
executed  as  rapidly  as  possible.  The  kidney  was  still  more  com¬ 
pletely  enucleated  from  its  fatty  envelope  and  drawn  well  into 
the  wound,  and,  as  time  was  all-important,  the  vessels  and  ure¬ 
ter  were  included  in  a  single  heavy  catgut  ligature,  at  as  great 
a  distance  from  the  kidney  as  possible.  The  kidney  was  then 
cut  away.  No  haemorrhage  followed,  and  the  wound  was  closed 
with  deep  and  superficial  sutures,  a  large  drainage-tube  being 
introduced  at  each  extremity  of  the  wound.  A  heavy  antisep¬ 
tic  dressing  was  applied.  Although  scarcely  any  blood  had  been 
lost  during  the  operation,  the  patient  was  markedly  shocked  at 
its  close,  and  required  hypodermic  stimulation  and  heat  to  es¬ 
tablish  reaction. 

The  subsequent  report  is  condensed  from  copious  notes. 
Every  specimen  of  urine  passed  was  measured,  freshly  bottled, 
numbered,  and  almost  immediately  examined  at  the  patient’s 
house,  where  I  was  constantly  present  for  the  ten  days  follow¬ 
ing  and  well  equipped  for  this  work. 

November  6th. — For  the  first  twenty-four  hours  after  oper¬ 
ation  temperature  averaged  102-5°,  pulse  130,  respiration  22 ; 
total  urine,  23£  ounces. 

The  early  part  of  this  period  was  characterized  by  moderate 
shock.  Afterward  the  prominent  symptoms  were  nausea  and 
vomiting;  muscular  twitching,  especially  during  sleep;  deep 
flushing  of  the  face;  a  complete  numbness  in  the  right  leg;  at 
times  free  perspiration.  The  first  urine  was  passed  eight  hours 
and  a  half  after  operation — in  amount  four  ounces.  It  con¬ 
tained  some  blood,  but  not,  as  before,  evenly  distributed  through¬ 
out  the  urine,  as  is  the  case  when  these  fluids  are  mingled  in 
the  kidney.  This  urine  then  represented  the  new  scanty  secre¬ 
tion  which  was  contaminated  in  the  bladder  by  the  blood- 
charged  urine  forced  from  the  removed  kidney  just  before  or 
during  the  operation. 

After  this  the  urine  was  free  from  blood,  except  as  found 
microscopically. 

7th  (second  day). — Average  temperature,  102°;  average 
pulse,  128  ;  total  urine,  20J  ounces.  The  patient  continues  in 
the  same  condition,  experiencing  nausea,  twitching,  localized 
flushing,  and  sweating.  Specimen  of  urine  No.  8,  passed  at  11 
a.  m.,  was  the  first  in  which  renal  casts  were  found.  The  four 
following  specimens  showed  epithelial  and  granular  casts  in  in¬ 
creasing  numbers,  and  albumin  in  increasing  quantity-,  amount¬ 
ing  at  the  most  to  one  fifth  bulk. 

Dr.  McBurney  visited  the  patient  to-day.  The  wound  wae 
redressed  for  the  first  time.  It  was  in  an  absolutely  aseptic  con¬ 
dition,  and  showed  union  throughout  its  entire  length  close  up 
to  the  drainage-tubes. 

Owing  to  nausea,  rectal  alimentation  has  been  given  at  time- 
during  the  day. 

8th  (third  day). — Average  temperature,  100-2°;  average 
pulse,  118;  total  urine,  21|  ounces.  This  appears  to  have  beet 
the  most  critical  day  experienced  by  the  patient  subsequent  t( 
the  operation.  Although  the  pulse  and  temperature  are  lower 


August  16,  1890.] 


BROWN:  A  CASE  OF  SEVERE  HAEM  A  TUR1A. 


175 


such  other  symptoms  as  constant  nausea  and  vomiting,  great 
restlessness,  dryness  of  the  skin,  persistent  muscular  twitching, 

aDd  for  the  first  twelve  hours  diminished  urinary  secretion _ al 

combined  to  cause  alarm.  Early  in  the  afternoon  infusion  of 
digitalis  is  given  per  rectum.  Hot  poultices  packed  about  the 
kidney,  and  a  combined  hot-air  steam  bath  given  in  bed.  To 
this  the  skin  promptly  responded,  and  sweating  was  continued, 
with  few  interruptions,  for  twenty-four  hours.  Besides  which 
the  urinary  secretion  was  somewhat  augmented. 

9th  (fourth  day).— Average  temperature,  99°;  average  pulse, 
104;  total  urine,  19£  ounces.  Patient  passed  a  better  night 
than  at  any  time  since  the  operation.  Number  of  renal  casts 
is  much  diminished.  Quantity  of  albumin  slight.  Some  nau¬ 
sea.  No  vomiting.  Patient  begins  taking  etrophanthus,  five 
drops  every  four  hours. 

10th  (fifth  day). — Average  temperature,.  100’4°;  average 
pulse,  118;  total  urine,  18-J-  ounces.  Albumin  is  again  appear¬ 
ing  in  greater  quantity.  Casts  with  renal  epithelium  and  a  few 
blood-corpuscles  are  once  more  noticeable.  The  work  thrown 
upon  the  single  kidney  is  evidently  embarrassing  its  functional 
power,  and  the  entire  organism  acts  in  sympathy  with  its  labored 
working.  The  wound  is  redressed.  A  slight  suppurative  con¬ 
dition  is  found  about  each  drainage-tube,  attributable,  undoubt¬ 
edly,  to  the  copious  sweating  which  had  worked  under  the 
dressing,  soiling  it,  and  carrying  septic  material  to  the  wound. 
Hereafter  dressing  of  the  wound  was  done  daily. 

11th  (sixth  day). — Average  temperature,  99'4°;  average 
pulse,  111;  total  urine,  20|  ounces.  Patient’s  general  condi¬ 
tion  slightly  improved,  especially  the  gastric  symptoms,  and  is 
sleeping  better.  Albumin  has  again  diminished.  No  casts 
found. 

12th  (seventh  day). — Average  temperature,  98*8° ;  average 
pulse,  10c  ;  total  urine,  32  ounces.  Patient  is  complaining  of 
general  discomfort.  Occasional  heavy  pains  in  the  back.  Some 
ragged,  decolorized  clots  or  membranes  were  wiped  from  the 
vulva  after  micturition. 

13th  (eighth  day). — Average  temperature,  99°;  average  pulse, 
103;  total  urine,  24^  ounces.  Condition  same  as  previous  day 

lltth  (ninth  day). — Average  temperature,  99-8°;  average 
pulse,  110;  total  urine,  28  ounces.  As  . the  recently  anticipated 
symptoms  of  miscarriage  became  fairly  manifest  I  lent  all  aid 
to  facilitate  the  process,  and  at  noon  the  foetus  with  amnion 
and  fluid  came  away  intact.  A  uterine  douche  of  carbolic-acid 
solution  was  given. 

15th  (tenth  day). — Average  temperature,  98-8°;  average 
pulse,  102;  total  urine,  39  ounces. 

For  three  days  after  this  miscarriage  the  patient’s  condition 
was  bad,  notwithstanding  her  lower  temperature  and  pulse-rate 
as  well  as  a  notable  increased  urinary  secretion.  The  loss  of 
blood  was  considerable  and  the  utter  prostration  very  pro¬ 
nounced.  In  fine,  the  patient’s  ultimate  powers  of  resistance 
seemed  to  have  reached  their  limit.  An  odor  emanating  from 
the  entire  body  accentuated  these  other  warnings.  Fortunately, 
the  digestive  organs  were  now  relieved  of  reflex  uterine  embar¬ 
rassment  and  were  able  to  retain  and  assimilate  the  really  large 
quantities  of  food  and  drink  forced  upon  them.  Improvement 
was  at  once  manifest.  The  elimination  of  urine  on  this  day 
(November  18th)  was  sixty-five  ounces.  Henceforth  convales¬ 
cence  was  rapid  and  complete.  A  month  later  the  patient 
weighed  ten  pounds  more  than  ever  before,  and  was  said  by 
her  family  and  friends  to  look  better  than  she  had  for  several 
years.  I  have  made  regular  urinary  examinations  at  stated  in¬ 
tervals  during  the  seven  months  since  this  operation  was  done, 
and  find  an  average  report  to  be  about  as  follows  :  Total  urine 
in  tweuty-four  hours,  47  ounces;  specific  gravity,  1*018;  color, 
faintly  opaque ;  reaction,  over-acid  ;  sediment  slight. 


Microscopical  Examination.— Oxalate  of  calcium  crystals; 
very  few  pus-corpuscles ;  always  a  number  of  rod  bacteria. 

Chemical  Examination.— Never  phospbatic  or  albuminous. 

The  kidney  was  submitted  to  Professor  Delafield,  whose  re¬ 
port  is  as  follows:  “The  mucous  membrane  of  the  pelvis  of 
the  kidney  is  considerably  thickened  and  its  free  surface  is 
somewhat  roughened.  The  layer  of  epithelial  cells  is  in  place, 
but  these  cells  are  changed  by  post-mortem  conditions.  The 
muscular  portion  of  the  mucous  membrane  is  considerably 
thickened.  There  is  a  growth  of  round-celled  tissue  beneath 
the  epithelium,  which  in  places  forms  small  papillae,  and  there 
are  irregular  infiltrations  of  the  same  round-celled  tissue  in  the 
thickness  of  the  mucous  membrane.  The  same  changes  exist 
in  the  mucous  membrane  of  the  calices.  Evidently  there  has 
existed  a  chronic  pyelitis  with  the  production  of  new  tissue. 
From  a  mucous  membrane  altered  in  this  way  there  could  verv 
well  be  a  good  deal  of  bleeding.” 

In  conversation  with  Dr.  Delafield  he  expressed  the  opinion 
that  the  original  cause  of  this  dangerous  haemorrhagic  pyelitis 
was  doubtless  a  calculus  which  had  probably  escaped  among 
the  large  and  numerous  blood-clots  which  had  been  passed.  But 
it  is  clear,  from  the  whole  history  of  the  case,  that  a  chronic 
condition  had  long  since  been  established  which  was  in  itself 
capable  of  giving  rise  to  fatal  haemorrhage,  although  the  proba¬ 
ble  original  cause— viz.,  calculus— had  disappeared.  Therein  lies 
the  chief  interest  of  the  case. 

The  literature  of  kidney  operations  recounts  a  number 
of  cases  where  the  symptoms  of  renal  calculus  existed,  but 
where  nephrotomy,  needle  puncture,  and  manual  examina¬ 
tion  failed  to  verify  the  diagnosis.  A  number  of  these 
cases  are  reported  to  have  been  improved  or  permanently 
cured,  seemingly,  by  the  examination.  It  is  impossible  to 
think  that  these  particular  cases  could  have  been  similar  to 
the  one  I  now  report,  for,  given  a  haemorrhagic  pyelitis  and 
subject  it  to  this  treatment,  it  would  of  necessity  result  in 
the  aggravation  of  all  symptoms.  In  this  connection  I  can 
not  refrain  from  calling  attention  to  the  brilliant  apprecia¬ 
tion,  on  the  operator  s  part,  of  the  exigencies  encountered 
in  this  case,  for,  when  the 'calculus  we  expected  was  not 
found,  the  masterly  conception  and  execution  of  an  imme¬ 
diate  nephrectomy  in  the  face  of  very  unfavorable  condi¬ 
tions  will  receive  the  recognition  it  deserves,  whereas  it  is 
now  easy  to  appreciate  that  a  so-called  conservative  step  at 
this  juncture  would  unquestionably  have  resulted  in  a  rapid 
sinking  of  the  patient  from  the  lnemorrhagic  state  already 
existing  and  intensified  by  traumatic  exploration. 

It  is  conceded  that  there  are  few  operations  where  cool 
and  clear  judgment  on  the  part  of  the  operator  are  so  ne¬ 
cessary  as  where,  under  certain  or  uncertain  conditions,  it 
must  be  decided  whether  or  not  to  extend  a  nephrotomy  to 
nephrectomy. 

The  effect  of  nephrectomy  upon  the  remaining  kidney, 
even  when  this  is  healthy,  is  always  marked.  Whether  this 
is  to  be  ascribed  to  direct  reflex  through  the  nerves  of  the 
sympathetic  and  cerebro-spinal  systems,  or  to  the  sudden 
and  burdensome  physiological  demands  upon  it,  is  unset¬ 
tled.  In  most  cases  probably  these  two  embarrassing  fac¬ 
tors  are  united. 

One  observed  fact  points  strongly  to  the  reflex  inhibition 
as  the  more  important — viz.,  where  nephrectomy  is  per¬ 
formed  on  an  organ  long  since  useless  by  cystic  disten- 


176 


MACKENZIE :  BULBO-NUOLEAR  DISEASE. 


[N.  Y.  Med.  Joub., 


tion,  its  ureter  blocked  by  inflammatory  adhesion  around 
an  imbedded  calculus.  Here  the  other  kidney  has  for  some 
time  accustomed  itself  to  the  performance  of  double  duty, 
yet  here  the  same  reflex  shock  may  readily  result  in  tem¬ 
porary,  complete,  or  gradually  increasing  suppression. 

I  have  not  been  able  to  find  reference  to  any  case  like 
the  one  here  reported,  where  renal  disease  simulating  calculus 
was  attended  with  alarming  haemorrhage,  where  nephrec¬ 
tomy  was  necessary  to  save  life,  and  where  a  thorough 
patho-liistological  examination  of  the  entire  organ  showed 
only  a  chronic  pyelitis  to  be  the  cause  of  so  serious  a  com¬ 
plication. 

Consequently  I  would  claim  originality  for  this  case  in 
that  heretofore,  even  if  suspected,  no  such  procatarctic  cause 
for  severe  haematuria  has  b6en  shown  by  operation  and 
pathological  examination.  Haemorrhagic  pyelitis  or  chronic 
pyelitis  with  acute  haemorrhagic  exacerbations  would  best 
designate  the  disease. 


A  SUGGESTION 

CONCERNING  THE  INTIMATE  RELATIONSHIP  BETWEEN 

BTJLBO-NUCLEAR  DISEASE 
and  certain  obscure  neurotic  conditions  of 
THE  UPPER  AIR-PASSAGES* 

By  JOHN  NOLAND  MACKENZIE,  M.  D., 

BALTIMORE. 

The  reciprocal  relationship  between  lesions  of  the  cen¬ 
tral  nervous  apparatus  and  certain  morbid  phenomena  ex 
hibited  in  the  upper  respiratory  tract  is  a  subject  of  sur¬ 
passing  interest,  and  one,  strange  to  say,  upon  which  com¬ 
paratively  little  original  work  has  been  done.  There  has 
been  too  great  a  tendency  for  specialists  to  confine  research 
within  exact  anatomical  limits  and  within  too  contracted  a 
sphere  of  observation. 

The  intimate  connection  between  a  large  number  of  af¬ 
fections  of  the  upper  air-tract  and  the  sympathetic  and 
cerebro-spinal  systems  of  nerves  irresistibly  obtrudes  itself 
upon  the  recognition  of  even  the  most  superficial  observer, 
and  it  is  therefore  all  the  more  remarkable  that  attention 
has  not  been  sufficiently  drawn  in  the  direction  of  such  an 
obvious  fact.  Except  in  the  case  of  certain  paralytic  affec¬ 
tions,  whose  pathology  is  often,  but  by  no  means  always, 
sufficiently  obvious,  the  subject  is  either  passed  by  in  silence 
by  text-books  on  laryngology,  or  dismissed  with  a  page  or 
two  of  glittering  medical  generalities  which  amount  simply 
to  a  confession  of  learned  ignorance.  Words  take  the  place 
of  explanation,  and  the  more  they  multiply  the  more  vague 
and  indistinct  the  subject  becomes. 

There  are  a  host  of  obscure  neurotic  phenomena  seen  in 
the  upper  air-tract  that  suggest  themselves  at  once.  Not  to 
multiply  examples,  take,  for  instance,  the  disease  known  as 
“  functional  aphonia,”  or  the  affection  to  which  Sir  Morell 
Mackenzie  has  given  the  name  of  “spasm  of  the  tensors  of 
the  vocal  cords.”  What  do  we  know  concerning  the  pa¬ 
thology  of  either  one  of  these  affections  ?  The  conclusion 


*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


is  resistless  that  they  are  in  some  w7ay  connected  with  cen¬ 
tral  trouble,  and  yet  we  know  absolutely  nothing  of  their 
primary  causes.  We  know  by  empirical  clinical  experience 
that  the  former  disease  can  be  cured  by  the  application 
of  electricity  within  the  larynx,  or,  for  that  matter,  upon 
any  indifferent  part  of  the  throat,  and  that  the  latter  is  in 
the  vast  majority  of  cases  incurable.  However  we  may  de¬ 
lude  ourselves  and  our  patients  into  the  belief  that  in  the 
first  case  we  accomplish  a  cure  by  direct  stimulation  ot  the 
laryngeal  muscles,  regard  for  absolute  truth  compels  the 
confession  that  we  do  so  by  a  sort  of  miracle,  so  to  say,  of 
psychic  impression  \  while  in  the  second  case  we  do  not 
cure,  because  we  have  no  anatomical  or  pathological  basis  to 
go  upon. 

I  have  in  numerous  former  publications,  which  are  fa¬ 
miliar  to  most  of  you  and  to  which  I  need  not  therefore  re¬ 
fer,  endeavored  to  point  out  the  intimate  union  between 
certain  obscure  respiratory  troubles  and  disorders  of  the 
sympathetic  nervous  system,  and  have  formulated  a  number 
of  propositions  which,  I  believe,  may  enable  us  to  approach 
more  nearly  the  scientific  generalization  of  a  host  of  phe¬ 
nomena  whose  kinship  has  never  before  been  sufficiently 
considered. 

While  in  some  quarters  I  have  encountered  adverse 
criticism,  and  while  open  always  to  correction,  my  subse¬ 
quent  clinical  experience  encourages  the  belief  that  my 
former  conclusions  were  in  the  main  correct.  But  while  the 
testimony  of  our  special  senses  must  accord  to  the  sympa¬ 
thetic  an  important  role  in  the  pathology  of  many  obscure 
affections  of  the  upper  air-tract,  it  must  not  be  forgotten 
that  it  is  often  only  one  factor  in  the  mechanism  of  the 
attack,  while  in  other  cases  the  cerebro-spinal  system  is  the 
agent  most  conspicuously  concerned.  It  is  this  part  of  the 
subject  that  I  desire  to  speak  of  to-day. 

I  shall  submit  these  remarks  to  you  simply  as  a  sugges¬ 
tion,  and,  in  order  to  provoke  discussion,  will  read  some 
notes  from  a  case  which  came  long  ago  under  my  observa¬ 
tion,  not  because  they  contain  anything  strikingly  original, 
but  solely  to  give  those  who  may  follow  me  in  the  discus¬ 
sion  something  tangible  upon  which  to  base  their  remaiks. 

Mrs.  X.,  aged  about  forty,  consulted  me  nine  years  ago  with 
the  following  history  : 

She  had  enjoyed  good  health  up  to  ten  years  prior  to  con¬ 
sultation,  when  her  husband  died  a  drunkard.  Prior  to  and 
after  his  death  she  had  had  a  great  deal  of  domestic  trouble. 
Examination  of  her  family  history  and  that  of  her  husband  re¬ 
veals  nothing  positive.  She  has  never  had  syphilis,  nor  received 
any  injury  in  any  part  of  the  body.  Her  circumstances  have 
always  been  good  and  habits  temperate,  and  she  is  not  natuially 
inclined  to  a  nervous  temperament.  For  some  time  prior  to  her 
husband’s  death  domestic  sorrow  had  led  to  much  mental  ex¬ 
citement. 

Shortly  after  his  death,  while  cleaning  her  room  and  appar¬ 
ently  in  perfect  health,  her  face  became  suddenly  drawn  down¬ 
ward  and  outward  to  one  side  (the  left).  This  was  especially 
noticeable  about  the  angle  of  the  mouth.  There  was  no  diffi¬ 
culty  in  articulation  and  no  other  symptoms,  and  the  attack 
passed  off  in  three  days  under  treatment.  Following  the  at¬ 
tack  there  was  an  interval  of  apparent  health  up  to  within 
about  a  year  before  she  consulted  me.  She  had  been  washing 
clothes  all  day  in  the  yard,  and  awoke  the  next  morning  to 


August  16,  1890.] 


SGHWEIO:  THE  GALVANO-CAUTERY  IN  THROAT  PRACTICE. 

- - - - - - - 


177 


find  that  she  had  lost  power  in  her  right  hand.  Sensation  in 
the  fingers  was  abolished,  so  that  she  could  not  pick  up  things 
nor  hold  them  in  her  hand.  She  could  grasp  the  hand  of  her 
physician  only  with  difficulty.  With  this  was  associated  numb¬ 
ness  and  tingling  in  the  extremities  without  loss  of  power,  ant 
twitching  of  one  of  the  tendons  in  the  palm.  The  tingling  sen¬ 
sation  extended  into  the  throat  and  gave  rise  to  considerable 
malaise.  She  ascribed  this  attack  to  having  carried  the  wet 
clothes  on  her  arm  during  the  day  before.  These  symptoms 
lasted  about  a  week,  and  as  they  were  disappearing  she  noticec 
slight  difficulty  in  articulation,  causing  her  to  mumble  her 
words.  There  was  no  aphasia.  This  grew  worse,  and  she  com¬ 
plained  of  some  oppression  in  the  chest.  At  the  same  time  she 
noticed  that  her  mouth  was  drawn  a  little  to  the  left  side.  She 
took  to  bed,  and  in  about  a  week  began  to  improve.  Her  speech 
became  clear,  but  she  complained  of  pain  in  the  throat  and  legs, 
the  latter  becoming  swollen.  All  these  symptoms  disappeared, 
however,  and  several  weeks  after  their  subsidence,  while  sweep¬ 
ing  her  room,  she  was  suddenly  seized  with  a  foaming  at  the 
mouth  and  puffing  outward  of  the  cheeks;  had  no  other  symptoms 
except  tingling  in  the  right  hand.  No  fall,  convulsion,  etc.  She 
walked  up  stairs  immediately,  but  could  only  mumble  out  a  few 
unintelligible  words.  When  the  violence  of  the  attack  had  passed 
off  she  noticed  a  weakness  of  the  tongue,  with  difficulty  in  its 
protrusion  and  difficulty  also  in  articulation.  At  this  time  her 
legs  were  swollen,  and  she  had  tingling  sensations  in  them  with 
formication.  The  trouble  with  the  tongue  grew  gradually  worse, 
and  about  six  weeks  before  seeing  me  first  noticed  slight  dys¬ 
phagia,  especially  in  the  deglutition  of  liquids.  At  the  same 
time  she  was  taken  with  pain  in  the  back  of  the  neck  and 
shooting  pains  in  the  band.  These,  together  with  occasional 
flushes  of  heat  in  the  head,  passed  away.  She  remained  in  the 
above  condition  until  two  weeks  prior  to  consultation,  when  she 
began  to  talk  through  her  nose.  She  has  lost  flesh  lately. 

Symptoms  on  Admission. — Face  has  a  characteristic  lacry- 
mose  appearance,  with  a  tinge  of  alarm.  The  mouth  is  length¬ 
ened  and  drawn  closely  across  the  teeth ;  its  angles  are  de¬ 
pressed  and  the  naso-labial  sulci  deepened.  The  tongue  can  be 
protruded,  but  with  difficulty,  and  she  can  not  lift  it  to  the  roof 
of  the  mouth,  nor  can  she  place  it  above  the  upper  lip.  Its 
movements  are  slow  and  evidently  require  effort  to  effect  them. 
It  is  long,  sharp,  covered  with  a  foul,  white  fur,  but  has  no  ap¬ 
pearance  of  atrophy,  nor  are  there  any  fibrillar  movements.  Its 
sensation  is  good  and  taste  is  unimpaired.  There  are  small 
tumors  at  its  tip  (fibrillar?).  The  lips  look  normal  (the  patient 
thinks  they  are  larger  than  usual).  Can  blow  out  a  light  at  a 
foot  from  the  mouth,  but  at  a  greater  distance  fails  to  do  so. 
Can  not  whistle  or  kiss,  but  can  close  and  open  the  mouth  per¬ 
fectly.  Attempts  at  laughing  result  in  a  ludicrous  expression 
of  the  face.  The  muscles  of  the  mouth  and  pharynx  react  but 
feebly  to  the  faradaic  current.  Sensibility  is  intact.  There  is 
no  paresis  or  loss  of  sensibility  in  the  other  muscles  of  the  face, 
head,  and  eyes.  There  is  some  difficulty  in  mastication,  and 
fhe  patient’s  laugh  degenerates  into  a  grimace. 

1  here  is  complete  paralysis  of  the  soft  palate  and  uvula,  and 
the  reflex  excitability  there  and  in  the  pharynx  is  notably 
diminished,  so  that  these  parts  can  be  irritated  without  provok¬ 
ing  anything  but  a  feeble  response.  Sensibility  and  muscular 
irritability  are  not  impaired.  There  is  some  congestion  of  the 
parts,  but  otherwise  their  appearance  is  normal.  There  is  no 
Reflection  of  the  uvula. 

Rhinoscopic  examination  of  posterior  nares  and  nasal  phar¬ 
ynx  negative. 

The  laiynx  is  normal  in  appearance,  but  its  reflex  excitabil¬ 
ity  is  much  diminished.  This  is  especially  noticeable  on  the 
epiglottis,  whose  surface  can  be  irritated  without  provoking 


the  slightest  motion.  There  never  has  been  the  slightest 
trouble  with  vocalization,  except  slight  fatigue  on  exertion. 
There  is  great  difficulty  in  expiratory  efforts,  such  as  gargling, 
coughing,  etc.  She  has  a  small  amount  of  dyspncea,  which  be¬ 
comes  considerable  on  exertion.  The  saliva  is  not  increased  in 
quantity,  but  is  thick  and  tenacious  from  admixture  with  the 
buccal  mucus,  and  has  to  be  withdrawn  from  the  mouth  with 
the  finger.  The  difficulty  in  expectoration  is  considerable. 
During  sleep  she  is  often  awakened  by  a  sense  of  suffocation, 
only  relieved  by  withdrawal  of  the  mucous  secretion.  During 
the  daytime  her  handkerchief  has  to  be  constantly  held  to  the 
mouth  to  catch  the  abundant  secretion. 

Ihe  patient  speaks  in  a  mumbling  manner  difficult  to  com¬ 
prehend,  and  as  though  there  was  some  difficulty  in  closing  the 
glottis,  although  the  excursions  of  the  vocal  cords  are  normal, 
as  seen  with  the  laryngoscope.  No  aphasia,  no  confusion  of 
words  or  syllables. 

The  light  hand  and  both  legs  show  great  muscular  weak¬ 
ness.  There  is  pain  in  the  right  leg  and  stiffness  and  tender¬ 
ness  about  the  neck. 

Temperature  normal ;  pulse  regular,  120;  respiration  30. 

The  patient’s  temperament  since  her  attack  has  been  nerv¬ 
ous.  Her  friends  say  that  without  apparent  cause  she  breaks 
out  into  spells  of  noisy  weeping,  followed  by  equally  unaccount¬ 
able  laughter.  Her  intelligence  is  intact,  appetite  poor,  bowels 
regular. 

These  observations  and  the  history  of  the  case  were  taken 
at  her  first  and  only  visit,  for,  receiving  an  unfavorable  prog¬ 
nosis,  she  never  returned,  and  I  am  therefore  unable  to  give 
any  further  particulars.  The  above-mentioned  data  are, 
however,  abundantly  sufficient  to  establish  the  bulbar-nuclear 
nature  of  the  trouble.  It  is  unnecessary  to  comment  in  de¬ 
tail  on  this  case.  It  is  one  with  which  the  neurologist 
more  than  the  laryngologist  has  to  do,  but  it  is  the  repre¬ 
sentative  of  a  class  of  cases  from  which  both  may  derive 
instruction.  If  specialists  in  the  different  departments  of 
medicine  would,  instead  of  standing  aloof  from  each  other, 
combine  the  special  knowledge  they  possess  in  a  common 
endeavor  to  elucidate  the  difficult  problems  which  daily 
confront  us,  the  hostile  cry  of  ignorant  criticism  would  be 
forever  silenced  by  their  discoveries  for  the  common  weal. 


THE  USE  AND  ABUSE  OF  THE 
GALVANO-CAUTERY  IN  THROAT  PRACTICE* 
By  HENRY  SCHWEIG,  M.  D. 

Since  the  accession  of  the  galvano-cautery  to  the  ranks 
of  recognized  therapeutic  resources  its  use  has  become  more 
and  more  restricted  to  a  certain  class  of  cases,  and  the  indi¬ 
cations  for  its  employment  have  been  from  year  to  year 
more  clearly  and  sharply  defined.  In  no  class  of  ailments, 
lowever,  has  this  been  more  strongly  exemplified  than  in 
the  disorders  occurring  in  the  upper  respiratory  tract,  so 
Rat  to-day  it  may  be  safely  assumed  that,  while  there  ex¬ 
ist  differences  of  opinion  regarding  the  employment  of  the 
galvano-cautery  in  individual  cases,  still  there  can  exist  no 
1W0  opinions  in  the  matter  of  the  general  broad  indications 
for  its  use.  Many  failures  are  recorded  and  negative  results 

*  Read  before  the  Section  in  Laryngology  and  Rhinology  of  the  New 
York  Academy  of  Medicine,  May  27,  1890. 


SCHWEIG:  THE  GALVANO-CAUTERY  IN  THROAT  PRACTICE.  [N.  Y.  Med.  Jour, 


178 

are  not  few,  but  careful  analysis  and  investigation  will  not 
infrequently  discover  either  improper  selection  of  cases  or 
a  want  of  knowledge  regarding  the  technique  of  galvano- 
caustic  operations. 

In  throat  practice  the  first  class  of  cases  in  which  the 
galvano  -  cautery  promised  brilliant  results  was  vascular 
growths,  and  this  was  based  mainly  on  the  knowledge  of 
the  haemostatic  properties  of  the  ferrum  candens.  While 
some  observers  reported  brilliant  results,  others  had  only 
failures  to  chronicle,  and  with  these  conflicting  data  the 
perpetuation  of  certain  operative  procedures  seemed  any¬ 
thing  but  assured.  The  ablation  of  tumors,  removal  of 
papillomata,  condylomata,  tonsils,  and  mucous  polypi, 
and  amputation  of  the  uvula  were  accomplished  by  the 

cautery. 

Of  cases  that  have  come  under  observation  during  the 
past  decade,  those  yielding  particularly  favorable  results 
were,  in  first  order,  vascular  growths  and  -  anterior  nasal 
hypertrophies,  and  also  slight  deflections  of  the  septum,  hy¬ 
pertrophy  of  turbinated  tissue,  granular  pharyngitis,  hyper¬ 
trophied  tonsils,  adenoid  vegetations  in  the  vault  of  the 
pharynx,  and  papillary  enlargements  at  the  base  of  the 
tongue.  In  the  larynx  the  results  have  not  been  so  encour¬ 
aging.  In  anterior  nasal  and  turbinated  hypertrophies  the 
most  brilliant  and  lasting  results  can  be  obtained,  and  it  is 
in  just  this  class  of  cases  where  a  want  of  knowledge  of  the 
technique  of  cautery  work  does  much  mischief. 

It  should  be  borne  in  mind  that  from  the  first  moment 
of  the  closing  of  the  circuit  there  is  a  steady  increase  of 
heat  in  the  nasal  cavity,  and  that  scorching  and  interference 
with  the  integrity  of  the  surrounding  tissues  becomes  a 
source  of  menace,  and  that  adequate  protection  of  the  con¬ 
tiguous  structures  should  be  secured.  The  apparent  reac¬ 
tion  so  frequently  noticed  after  cauterization  with  the  gal- 
vano-cautery  is  in  reality  no  reaction,  but  a  scorching  pure 
and  simple,  and  inexcusable  on  account  of  its  easy  avoid¬ 
ance.  Another  cause  for  complaint  in  this  class  of  cases 
has  been  the  large  areas  of  destruction  remaining  alter  the 
employment  of  the  cautery,  showing  dry,  glistening  patches 
where  the  muciparous  glands  had  been  destroyed.  Here  is 
evidence  of  the  unskillful  use  of  a  valuable  therapeutic 
agent,  as  the  method  of  subcutaneous  destruction  by  the 
galvano-cautery,  when  properly  practiced,  leaves  the  lining 
membrane  of  the  nose  practically  intact,  and  still  completely 
destroys  any  redundant  tissue  that  may  exist.  In  the  spur¬ 
like  deflections  of  the  septum  much  can  be  done  to  remedy 
the  deformity  without  the  pain  and  danger  attending  the 
use  of  the  trephine,  saw,  drill,  and  chromic  acid.  No  open 
surface  remains  to  suppurate  or  serve  as  an  avenue  for  the 
entrance  of  septic  matter,  very  slight  or  no  pain  is  felt 
during  the  operation  if  cocaine  is  employed,  and  very  little 
after,  there  is  no  haemorrhage,  and  the  slough  is  thrown  off 
in  a  comparatively  short  time. 

But  it  is  mainly  in  the  pharynx — which,  on  account  of 
its  accessibility,  is  most  frequently  treated — that  the  abuse 
of  the  cautery  is  carried  to  its  extreme.  Permanent  cica¬ 
tricial  contractions  of  the  pillars  of  the  fauces  and  ragged 
tonsils  riddled  with  holes  testify  to  this.  I  know  of  no 
other  portion  of  the  upper  air-passages  more  sensitive  to 


the  action  of  the  cautery  than  the  faucial  pillars,  and  I  have 
often  observed  contractions  following  the  free  or  incautious 
use  of  the  cautery  here  which  rendered  deglutition  and 
respiration  painful. 

That  frequent  complaint  of  singers  and  public  speakers, 
granular  pharyngitis,  in  which  bunches  of  enlarged  follicles 
have  coalesced,  forming  elevated  vascular  ridges  and  inter¬ 
fering  with  proper  voice  production,  is  amenable  to  no  other 
treatment  that  yields  as  good  results  as  the  galvano-cautery. 
We  have  here  all  the  conditions  that  call  for  a  destructive 
agent  that  can  be  easily  handled,  is  free  from  danger  when 
properly  used,  and  the  action  of  which  can  be  limited  to  a 
nicety,  destroying  just  enough  of  the  hypertrophied  tissue 
to  leave  a  smooth  and  free  surface. 

Here  as  well,  however,  the  destructive  process  may  be 
carried  too  far  and  a  condition  far  worse  than  the  original 
one  substituted  if  the  potency  of  the  agent  employed  is 
not  borne  in  mind.  It  suffices  simply  to  puncture  each  ele¬ 
vation.  A  double  effect  is  thus  secured,  as,  in  addition  to 
destruction  of  tissue,  we  also  secure  a  slight  amount  of  con¬ 
traction  in  the  cicatrices.  Beneficial  as  this  is,  so  haimful 
is  it  when  carried  too  far,  leaving,  as  it  does,  deep  and  an¬ 
noying  contractions. 

Until  a  very  recent  date  operations  at  the  base  ot  the 
tongue  were  attended  with  much  haemorrhage  and  pain, 
and  interfered  seriously  with  deglutition.  At  the  present 
day,  with  the  aid  of  the  galvano-cautery  and  the  lndo-plati- 
num  wire  snare,  enlargements  of  the  papillae,  for  instance, 
can  be  reduced  with  ease,  or  can,  if  desired,  be  more  slowly 
and  perhaps  more  effectually  removed  by  repeated  punct¬ 
ures  with  the  cautery  point. 

May  I  be  permitted  in  this  connection  to  again  call  at¬ 
tention  to  the  subcutaneous  method  of  destroying  growths?* 
I  have  found  it  of  great  service  in  a  number  of  cases  of 
marked  enlargement  of  the  papillae  at  the  base  of  the  tongue. 
Iu  fact,  it  applies  to  all  vascular  growths,  the  destruction  of 
which  it  is  desired  to  secure  without  interfering  with  the 
integrity  of  the  mucous  or  cutaneous  surface  and  without 
leaving  any  appreciable  breach  of  surface.  Too  much  stress 
can  not  be  laid  on  the  advantages  of  this  method  of  operat¬ 
ing,  as  many  dangers  are  avoided  thereby  and  a  clear  field 
for  operating  is  secured,  as  there  is  no  haemorrhage  to  in¬ 
terfere.  For  a  fuller  description,  reference  may  be  had  to 
the  article  quoted  above. 

A  word  as  to  the  form  of  battery  to  be  employed.  All 
batteries  which  depend  for  their  action  on  the  immersion  of 
elements  at  the  time  of  operation  should  be  discarded,  as, 
from  the  moment  the  elements  come  in  contact  with  the 
exciting  fluid,  the  strength  of  the  current  becomes  gradu¬ 
ally  less  and  polarization  begins.  This  objection  does  not 
obtain  in  the  Grove  system ;  but  a  more  serious  objection 

_ the  employment  of  two  acids,  and  the  necessity  of  almost 

daily  refilling  of  the  battery— makes  this  practically  useless. 
The  only  form  of  battery  which  should  be  employed,  and 
which  can  be  relied  upon  to  lurnish  a  current  of  uniform 
strength  at  all  times,  is  the  storage  battery,  and  this  should 

*  Reflex  Symptoms  of  Nasal  Disease.  By  Dr.  H.  Schweig.  Med. 
Record ,  Jan.  22,  1886. 


August  16,  1890.] 


FRIEDENW  ALD :  REGENT  INVESTIGATIONS  IN  STRABISMUS. 


179 


in  every  case  be  provided  with  a  German-silver  wire  rheo¬ 
stat. 

It  is  impossible  with  the  many  forms  of  electrodes  used 
in  connection  with  a  cautery  battery  to  supply  a  current 
which,  without  certain  modifications,  will  bring  all  electrodes 
to  a  uniform  degree  of  heat,  but  with  a  properly  constructed 
rheostat  this  can  be  regulated  to  a  nicety.  About  ten  years 
ago,  when  the  storage  system  came  into  more  general  use, 
it  occurred  to  me  to  establish  a  permanent  cautery  plant  on 
my  operating  table,  and  this  has  so  simplified  the  use  of 
the  cautery  that  I  may  be  permitted  to  describe  it. 

In  a  closet  convenient  to  the  office  a  number  of  gravity 
cells  are  placed  and  connected  by  insulated  wires  with  the 
storage  cells,  which  are  placed  under  the  table.  From  the 
storage  cells  connections  lead  to  two  binding-posts  fixed  on 
the  table,  and  between  these  two  posts  is  placed  a  rubber  but¬ 
ton  connected  by  means  of  a  vertical  rod  with  a  rheostat  di¬ 
rectly  under  it,  but  concealed.  By  raising  or  lowering  the 
rod — i.  e .,  by  decreasing  or  increasing  the  resistance — any  de¬ 
sired  degree  of  incandescence  can  be  obtained,  and  the  heat 
of  the  lightest  as  well  as  the  heaviest  burner  nicely  regulated. 
The  importance  of  this  device  becomes  more  apparent  in 
the  use  of  the  wire  snare,  as,  with  the  gradual  diminution  in 
the  size  of  the  loop,  the  current  must  be  diminished.  The 
same  current  which  heats  a  loop  of  an  inch  to  a  red  heat 
would  bring  a  half-inch  loop  to  a  state  of  white  heat, 
and  destroy  a  still  smaller  one.  The  gravity  cells  remain 
permanently  connected  with  the  storage  battery,  which  is 
being  constantly  charged  and  is  always  ready  for  use,  and 
can  be  detached  from  its  connections  in  the  fraction  of  a 
minute  if  required  for  use  elsewhere.  The  only  attention 
which  this  plant  requires  is  the  addition  every  two  or  three 
weeks  of  a  quantity  of  water  to  the  gravity  cells  sufficient 
to  compensate  for  loss  by  evaporation,  and  the  occasional 
addition  of  sulphate  of  copper  to  prevent  exhaustion  of  the 
cells.  In  this  manner  the  use  of  the  cautery  is  stripped  of 
all  its  complications  and  becomes  a  matter  easily  controlled. 
A  word  of  warning  as  to  large  electrodes  and  heavy,  thick 
insulating  material.  In  the  nose  and  throat  small  electrodes 
only  are  required,  as  the  more  slowly  we  operate  the  greater 
the  assurance  that  there  will  be  no  haemorrhage;  and  in 
working  in  cavities — the  nose,  for  instance — the  room  is  so 
restricted  that  the  working  space  is  seriously  diminished 
by  a  heavy  insulator,  and  the  field  of  operation  is  also  ob¬ 
structed. 

In  a  word,  in  the  use  of  the  galvano-cautery  the  sur¬ 
geon  requires  much  fine  discrimination  and  tact,  and  needs 
not  alone  a  thorough  knowledge  of  the  technique  of  his 
work,  but  also  a  knowledge  of  the  construction  of  the  in¬ 
strument  employed  by  him,  for  without  that  he  will  not  be 
in  a  position  to  meet  the  many  little  annoyances  that  may 
be  caused  by  bad  contact,  improper  connections,  and  breaks 
in  the  circuit.  As  a  rule,  the  electrode  should  be  heated  to 
H  cherry-red,  and  in  nasal  surgery  the  surrounding  parts 
protected  by  a  proper  device.  I  find  that  the  ordinary 
metal  aural  speculum  answers  every  purpose. 

The  advantages  of  the  cautery  can  be  summarized  in 
a  few  words. 

Its  employment  is  not  followed  by  haemorrhage,  pro¬ 


vided  care  is  observed  not  to  tear  the  electrode  from  tissues 
to  which  it  may  adhere,  but  allowing  it  to  burn  its  way  out, 
as  it  were. 

It  is  a  powerful  haemostatic. 

Its  advantage  over  other  destructive  agents  lies  in  the 
fact  that  its  action  can  be  controlled  and  localized  to  a 
nicety,  and  does  not  extend,  ‘as  in  the  case  of  the  stronger 
acids,  to  contiguous  structures. 

There  is  no  reaction  and  the  process  of  repair  is  rapid. 

There  can  be  no  doubt  that  many  operators  have  dis¬ 
carded  the  cautery  owing  to  bad  or  unsatisfactory  results 
which  might  have  been  avoided  by  a  closer  study  of  the 
action  of  the  agent  employed  by  them,  and  it  is  my  firm 
belief  that  those  observers  who  have  not  yet  employed  the 
cautery  will  gain  from  its  use  results  both  satisfactory  and 
convincing. 

26  East  Twentieth  Street. 


RECENT  INVESTIGATIONS  IN  STRABISMUS. 

By  HARRY  FRIEDENWALD,  A.  B.,  M.  D., 

BALTIMORE, 

LECTURER  ON  OPHTHALMOLOGY  AND  OTOLOGY, 

COLLEGE  OF  PHYSICIANS  AND  SURGEONS,  BALTIMORE  ; 

LATE  ASSISTANT  TO  PROFESSOR  HIRSCHBERG,  BERLIN. 

Since  the  appearance  of  Professor  Schweigger’s  mono¬ 
graph  on  strabismus,  ophthalmology  has  lost  the  peace  of 
mind  it  had  previously  enjoyed  in  this  respect.  Its  tran¬ 
quil  faith  in  the  theories  of  its  great  masters  was  disturbed. 
Donders  and  Graefe  and  all  the  other  leaders  in  the  science 
bad  taught  that  a  squinting  eye  gives  up  all  its  visual  func¬ 
tion  in  that  part  of  the  field  which  is  common  to  both  eyes, 
that  its  impressions  were  “excluded,”  and  thus  they  ex¬ 
plained  the  amblyopia  generally  found  in  such  eyes  (and 
therefore  termed  amblyopia  ex  anopsia )  and  the  absence  of 
diplopia. 

But  Schweigger  found,  or  confidently  believed  he  had 
found,  that  all  this  was  false,  and  called  it  a  “history  of 
errors.”  From  him  we  learn  that  the  strabotic  eye  yields 
its  full  complement  in  the  common  visual  act,  and  that  the 
amblyopia  mentioned  above  is  congenital,  in  no  way  differ¬ 
ing  from  ordinary  congenital  amblyopia,  and,  far  from  being 
the  result  of  strabismus,  is  in  itself  a  factor  in  its  produc¬ 
tion.  Abandoning  the  old  theory  of  the  “  innate  identity  ” 
of  corresponding  retinal  areas,  which  had  necessitated  the 
“exclusion  theory,”  he  regarded  the  faculty  of  binocular 
vision  as  acquired,  and,  as  such,  as  easily  unlearned  in  early 
youth,  and  that  in  strabismus  new  associations  take  the 
place  of  earlier  acquired  relations.  Thus  he  escapes  the  dif¬ 
ficulty  of  explaining  the  absence  of  diplopia. 

New  facts  bearing  upon  this  discussion  were  few,  and 
the  matter  has  remained  a  disputed  question.  Light  has, 
however,  been  thrown  upon  this  subject  recently.  Dr. 
Hirschberger,  of  Munich,  published  an  article  entitled 
The  Binocular  Field  of  Vision  of  the  Strabotic,*  embody¬ 
ing  the  results  of  a  long  series  of  examinations  and  experi¬ 
ments  made  while  assistant  at  the  ophthalmological  clinic 
of  the  Munich  University.  This  article  must  be  looked 

*  Binoculares  Gesiehtsfeld  Schielender.  Yon  Dr.  Karl  Hirschber¬ 
ger.  Munch,  medicin.  Wochenschr.,  1890,  No.  10. 


180 


FRIEDENWALD:  REGENT  INVESTIGATIONS  IN  STRABISMUS.  [N.  Y.  Med.  Jour., 


upon  as  the  most  valuable  and  important  contribution  that 
has  been  offered  in  deciding  this  question. 

Having  seen  him  examine  many  of  his  patients,  and 
having  verified  his  results  by  frequently  repeating  his  ex¬ 
aminations  for  myself,  I  can  testify  to  his  results.  The  re¬ 
markable  facts  revealed,  and  their  interest  and  many-sided 
importance,  lead  me  to  bring  an  account,  as  far  as  he  has 
published  it,  before  the  American  profession. 

Recognizing  that  the  mooted  question  could  be  solved 
in  no  other  way  than  by  accurately  determining  in  strabis¬ 
mus  the  part  played  by  each  eye  in  vision,  and  not  in  cer¬ 
tain  parts  of  the  field  of  vision  only,  but  throughout  the 
whole  field,  Hirschberger  devised  a  method  of  examining 
as  simple  as  it  is  efficient  and  ingenious. 


He  examined  the  field  at  the  perimeter,  leaving  both 
eyes  open,  the  non-deviating  eye  being  directed  upon  the 
center ;  the  test  object  used  was  a  spot  of  blue  color,* 
and  a  plate  of  glass  of  the  complementary  color — yellow — 
was  held  before  one  eye.  To  the  eye  seeing  through  the 
yellow  glass  the  spot  appeared  black,  and  so  it  was  easy  to 
distinguish  throughout  the  field  where  it  appeared  black 
and  where  blue,  or,  in  other  words,  when  it  was  seen  by  one 
eye  and  when  by  the  other. 

Subjecting  cases  of  divergent  strabismus  of  moderate 
degree  to  such  an  examination,  he  found  a  composite  figure 
resulting  similar  to  Fig.  1.  This  represents  the  field  of  a 
case  of  divergence  of  the  left  eye  of  35°.  The  yellow  glass 
was  held  before  the  right  eye.  The  shaded  portion  shows 
where  the  blue  spot  was  looked  upon  as  black,  the  field  of 
the  right  eye  ;  the  clear  part  where  it  was  recognized  as  blue, 
the  field  of  the  left  eye.  This  proves  that  the  field  of  the  left 
squinting  eye  is  somewhat  restricted  in  binocular  vision ,  for, 
under  normal  circumstances,  it  should  extend  about  35° 
farther  to  the  right,  as  is  shown  when  examined  singly  ; 
hence  there  is  exclusion  in  the  squinting  eye.  If,  however, 

*  A  blue  spot  was  preferred,  because  the  normal  field  of  vision  for 
this  color  is  almost  as  large  as  for  white. 


the  experiment  is  reversed,  the  colored  glass  being  placed 
before  the  squinting  eye,  we  find  that  the  form  of  the  sepa¬ 
rate  fields  remains  unchanged,  the  field  of  the  normal  right 
eye  extending  to  about  20°  on  the  nasal  side,  while  in  mo¬ 
nocular  vision  it  extends  to  40°  or  50°.  This  discloses  a 
fact  hitherto  unknown — that  in  binocular  vision  the  non- 
deviating  eye  yields  up  a  part  of  its  field  for  the  benefit  of 
the  squinting  eye  ;  that  there  is  exclusion  in  the  non-deviating 
eye!  This  fact,  as  surprising  and  remarkable  as  it  is,  can 
be  verified  in  most  cases  of  strabismus. 

The  binocular  field  of  vision  in  these  cases  consists  of 
portions  of  the  fields  of  each  eye  added  to  each  other  with¬ 
out  overlapping  or  having  parts  in  common,  in  this  respect 
differing  greatly  from  the  binocular  field  of  non-squinting 
eyes.  There  is  a  sharp  line  dividing  the  two  portions. 

To  test  the  degree  of  the  exclusion  of  visual  percep¬ 
tion,  the  reflex  of  a  candle-light  from  a  small  plane  mirror 
was  used,  and  it  was  found  that  not  even  this  intense  light 
was  seen  in  those  parts  which  had  been  marked  out  pre¬ 
viously  as  the  areas  of  exclusion  in  each  eye. 

The  size  of  the  areas  of  exclusion  was  generally  found 
to  be  in  an  inverse  ratio  to  the  degree  of  the  angle  of  the 
divergent  strabismus. 

Examining  the  binocular  fields  in  convergent  squint  in 
the  same  manner,  they  were  found  more  or  less  as  repre¬ 
sented  in  Fig.  2.  This  is  the  field  of  a  case  of  convergence 


of  30°  of  the  left  eye.  The  yellow  glass  was  held  before 
the  right  eye ;  a ,  a  are  entirely  controlled  by  the  right  eye, 
b,  b  by  the  left;  c,  c  are  variable,  in  some  cases  belonging  to 
the  one,  in  others  to  the  other  eye,  occasionally  to  both. 
As  in  the  case  of  divergence,  reversing  the  glass  does  not 
alter  the  form  of  the  separate  fields. 

Though  the  figures  in  the  cases  of  divergent  and  con¬ 
vergent  squint  appear  very  different  at  first  glance,  it  is  evi¬ 
dent,  firstly,  that  in  both  cases  the  macular  region  of  the 
squinting  eye  has  exclusive  control  of  its  part  of  the  field  of 


August  16,  1890.] 


OIBNEY:  THE  BONE  DISEASES  OF  CHILDHOOD. 


181 


vision,  the  non-squinting  eye  yielding  up  its  function  there 
entirely,  and,  secondly,  that  the  most  lateral  part  on  the  side 
of  the  squinting  eye  beyond  the  area  of  the  normal  field  of 
the  other  eye  is  entirely  allotted  to  the  squinting  one. 

The  regularity  of  these  results  was  such  that  these 
statements  may  be  looked  upon  as  general  laws.  There 
are  but  few  exceptions  to  the  first.  When  the  angle  of 
strabismus  is  so  small  that  the  macular  regions  almost  cover 
each  other.  In  this  case  the  macula  of  the  squinting  eye 
yields  up  its  function  entirely.  The  effect  of  this  upon  the 
vision  of  the  squinting  eye  was  very  evident.  In  a  number 
of  cases  of  very  slight  divergent  strabismus  vision  had  been 
permanently  lost  in  the  temporal  part  of  the  retina,  includ¬ 
ing  the  macular  region  (those  parts  where  exclusion  had 
taken  place).  That  this  was  not  congenital  amblyopia  but 
due  to  the  exclusion  was  beautifully  illustrated  in  a  case  of 
a  young  farmer  whom  Ilirschberger  examined  twelve  years 
after  he  had  been  operated  upon  for  a  high  degree  of  diver¬ 
gent  strabismus.  At  the  time  of  the  operation  the  boy,  then 
aged  nine,  had  one  third  normal  vision,  as  the  hospital  record 
shows.  Twelve  years  later  the  strabismus  was  exceedingly 
slight,  but  central  vision  had  been  lost  and  the  patient  could 
only  count  fingers  eccentrically.  In  this  case  it  was  evident 
that  the  great  failure  of  vision  was  due  to  exclusion. 

In  cases  of  strabismus  of  variable  degree  complete  exclu¬ 
sion  could  not  be  found  in  any  part  of  the  field,  and  di¬ 
plopia  was  easily  called  forth.  The  same  is  true  of  peri¬ 
odic  strabismus  or  of  strabismus  that  has  not  become  fully 
established.  These  cases  form  other  exceptions  to  the  laws 
stated  above. 

The  projection  of  the  strabotic  eye  was  examined  and 
found  in  accordance  with  the  strabotic  position  ;  in  other 
words,  objects  seen  entirely  by  the  squinting  eye  are  “  pro¬ 
jected  ”  in  their  proper  positions  in  space  and  not  displaced 
as  in  cases  of  ocular  paralysis.  This  projection  is  not  con¬ 
genital,  but  depends  upon  the  position  of  the  eye,  as  is 
shown  by  changes  which  it  undergoes  when  the  relative 
position  of  the  eyes  is  altered  by  an  operation  which  either 
relieves  the  strabismus  entirely  or  diminishes  it.  In  this 
false  projection  lies  the  explanation  of  the  peculiar  diplopia 
often  found  after  strabismus  operations — a  diplopia  equal 
to  the  angle  between  strabotic  and  the  subsequent  position. 

This  strabotic  projection  is  lost  in  a  few  days,  or  may 
last  for  weeks  or  even  months,  the  eye  finally  adapting  itself 
to  its  new  position.  It  was  found  that  the  whole  retina 
does  not  undergo  this  change  at  one  time,  but  that  the  pe¬ 
ripheral  parts  adapt  themselves  much  more  rapidly,  so  that 
a  careful  examination  will  sometimes  detect  various  forms 
of  projection  in  different  parts  of  the  field  of  vision  for  the 
same  eye,  and,  in  consequence,  different  kinds  of  diplopia. 

Conclusions. — The  facts  brought  out  by  the  article  are : 

1.  Exclusion  of  certain  parts  of  the  field  of  vision  is  not 
only  possible  in  strabismus,  but  takes  place  in  the  non-devi¬ 
ating  as  well  as  in  the  squinting  eye. 

2.  The  binocular  field  of  vision  of  the  strabotic  is  made 
up  of  parts  of  the  field  of  each  eye ,  these  parts  rarely  over¬ 
lapping  at  any  point. 

3.  That  part  of  the  field  of  the  squinting  eye  which  cor¬ 
responds  with  the  macular  region  of  the  non-squinting  eye  is 


always  suppressed ,  and ,  vice  versa ,  that  part  of  the  field  of  the 
non-deviating  eye  which  covers  the  part  upon  which  the  mac¬ 
ula  of  the  squinting  eye  is  directed  is  likewise  suppressed. 
There  is  a  sharp  line  of  demarkation  dividing  the  macular 
areas  of  the  two  parts  of  the  binocular  field. 

4.  When  the  degree  of  strabismus  is  very  slight ,  the  mac¬ 
ula  of  the  squinting  eye  suppresses  its  image  for  the  benefit 
of  the  macula  of  the  other  eye.  This  is  the  only  case  where 
the  macula  of  the  squinting  eye  does  not  take  any  share  in 
vision,  and  is  an  exception  to  No.  3. 

5.  The  degree  of  amblyopia  depends  upon  the  part  that  the 
macula  of  the  squinting  eye  plays  in  binocular  vision ,  this 
being  the  explanation  of  the  enormous  differences  in  the 
strabotic  amblyopia. 

6.  The  squinting  eye  learns  to  project  images  properly. 

The  corollaries  to  be  drawn  are  numerous.  I  shall  only 

call  attention  to  tbe  importance  of  early  operations,  espe¬ 
cially  when  the  strabismus  is  of  slight  degree,  and  of  per¬ 
fectly  correcting  cases  of  high  degree,  the  dangers  of  slight 
degrees  as  far  as  central  vision  is  concerned  being  much 
greater.  The  importance  of  training  in  binocular  vision  sub¬ 
sequent  to  operating  is  likewise  fully  shown  by  these  facts. 

922  Madison  Avenue. 


OPERATIVE  PROCEDURES 
IN  THE  BONE  DISEASES  OF  CHILDHOOD.* 
By  V.  P.  GIBNEY,  A.  M.,  M.  D. 

It  is  with  a  certain  degree  of  diffidence  that  I  appear 
before  the  Surgical  Society  without  a  paper  on  Appendi¬ 
citis  or  Suprapubic  Cystotomy.  The  title  I  have  chosen 
for  some  remarks  this  evening  will  suggest,  I  hope,  to  the 
members  a  rather  important  branch  of  the  surgical  art,  and 
my  object  in  calling  your  attention  to  this  subject  is  to 
bring  out  a  discussion  on  the  management  of  the  diseases 
and  deformities  incident  to  childhood.  The  most  common 
form  of  disease  in  the  class  of  subjects  referred  to  is  tuber¬ 
cular  osteitis. 

I  am  well  aware  that  the  general  surgeon  looks  upon  an 
orthopaedic  surgeon  as  a  mechanician  purely.  If  his  ap¬ 
pliances  succeed  in  correcting  deformity  and  curing  disease, 
he  is  applauded.  If  the  reverse  occurs,  we  are  spoken  of 
in  a  patronizing  way,  and  the  lament  is  expressed  that  a 
surgeon  was  not  consulted !  While  many  operators  speak 
and  write  quite  sanguinely  of  their  operative  procedures  in 
bone  and  joint  diseases,  there  are  a  certain  number,  whose 
judgment  is  excellent  and  whose  skill  is  unquestionable, 
who  speak  deprecatingly  of  such  procedures.  The  writer 
of  the  present  essay  is  convinced  that  the  orthoptedic  sur¬ 
geon  should  be  familiar  with  operations  on  bones  that  en¬ 
ter  into  the  formation  of  the  joint.  He  is  also  convinced 
that  the  success  of  these  operations  depends  largely  upon 
the  mechanical  protection  given  to  the  limb  or  joint  during 
the  reparative  process,  and  even  long  subsequent  to  the  re¬ 
parative  process. 

Our  hospitals  are  so  acute  in  their  character  that  cases 
requiring  a  long  course  of  treatment  are  seldom  admitted. 

*  Read  before  the  New  York  Surgical  Society,  May  14,  1890. 


182 


OIBNEY:  THE  BONE  DISEASES  OF  CHILDHOOD. 


[N.  Y.  Mbd.  Jouk., 


When  such  cases  are  admitted,  the  aim  is  to  operate  as 
quickly  as  possible,  to  get  healing  of  wounds  with  as  little 
•delay  as  possible,  and  then  order  a  discharge  to  make  room 
for  others.  It  is  admitted  at  the  outset  that  operations 
performed  at  the  proper  time  and  in  the  proper  manner 
contribute  largely  not  only  to  the  relief,  but  the  cure  of 
tubercular  bone  lesions  in  children.  It  is  urged,  likewise, 
that  proper  mechanical  means,  whether  in  the  shape  of 
plastic  apparatus  or  steel  appliances,  should  supplement  these 
operative  procedures  ;  and  it  is  also  stated  as  a  matter  of 
fact  that  the  element  of  time  still  plays  an  important  r61e 
in  the  successful  management  of  these  cases.  The  difficul¬ 
ties  which  still  attend  the  complete  eradication  of  tubercu¬ 
lous  foci,  even  under  the  most  favorable  circumstances, 
make  rapid  cures  of  comparative  infrequence.  Not  only 
one,  but  many  operations  are  required  in  many  cases  to  ob¬ 
tain  the  maximum  amount  of  benefit. 

Disease  of  the  Vertebrae. — In  Pott’s  disease  of  the  spine, 
which  is  the  most  common  form  of  disease  affecting  the 
column,  we  have,  as  you  all  know,  an  inflammatory  process 
in  the  body  of  the  vertebra.  We  are  not  sufficiently  ad¬ 
vanced  as  yet  to  locate  definitely  the  special  body  in  which 
the  lesion  occurs.  We  know  that  the  process  is  seldom 
confined  to  a  single  vertebra.  For  this  reason  we  hesitate 
to  explore  the  body  of  a  single  vertebra,  and  it  is  considered 
good  surgery  to  wait  until  we  can  more  definitely  fix  upon 
the  number  involved.  Notwithstanding  that  many  cases 
have  been  reported  wherein  good  results  have  been  ob¬ 
tained,  the  general  impression  is  that  the  cases  so  reported 
will  not  stand  a  close  investigation  when  looking  for  end 
results. 

The  procedure  which  is  most  generally  adopted  now  in 
affections  of  the  column  is  what  is  known  as  laminectomy, 
which  has  for  its  object  the  removal  of  the  thickened  tissue 
surrounding  the  spinal  cord.  The  operation  is  done,  there¬ 
fore,  for  compression  myelitis.  While  I  have  had  no  per¬ 
sonal  experience  in  this  operation,  I  feel  that  it  is  often  jus¬ 
tifiable,  and  that  a  certain  proportion  of  cases  can  be  cured. 
The  surgeon  who  becomes  expert  in  dealing  with  the  lamina 
is  sure  to  get  a  certain  number  of  brilliant  results.  Of 
course,  he  must  select  his  cases.  A  child  who  has  been 
paraplegic  for  a  long  time,  and  has  had  what  is  regarded  as 
the  best  mechanical  treatment — one  who  has  had  rest  in  bed 
without  benefit — may  properly  be  regarded  as  a  subject  for 
this  operation.  My  own  way  of  managing  a  case  of  Pott’s 
paraplegia  or  compression  myelitis  differs  somewhat  from 
the  ordinary  routine,  and  neurologists  do  not  all  agree  with 
me  as  to  the  value  of  potassium  iodide.  My  plan,  then,  is 
to  apply  a  solid  plaster-of-Paris  jacket,  with  a  head  spring, 
and  not  rest  satisfied  until  I  have  a  perfect  fit.  ,  I  begin  at 
once  with  moderately  large  doses  of  the  potassium  iodide, 
given  in  Vichy  or  milk,  and  increase  rapidly  up  to  fifty  or 
sixty  grains,  three  times  a  day  ;  sometimes  I  go  beyond  this 
point.  I  keep  the  patient  in  a  recumbent  posture,  or  in  a 
wheeled  chair,  with  the  limbs  not  too  dependent,  and  avoid 
lifting  or  handling  as  much  as  possible.  A  perseverance  in 
this  course  of  treatment  for  six  months  ought  to  yield  good 
results.  If  a  good  result  does  not  follow  in  this  length  of 
time,  I  put  the  patient  in  bed,  with  weight  and  pulley  at 


each  end,  and  continue  the  potash.  Where  they  are  old 
enough,  I  employ  the  Paquelin  cautery  two  or  three  times 
a  week,  light  strokes,  over  the  spinous  processes.  Every 
case,  I  think,  should  have  the  benefit  of  this  treatment. 
It  takes  a  long  time,  sometimes  a  year  ora  year  and  a  half, 
but  the  child  is  comparatively  comfortable ;  it  grows  fat, 
as  a  rule  ;  can  be  wheeled  out  of  doors,  and  many  excellent 
results  have  been  recorded.  If  all  this  fails,  then  I  should 
have  recourse  to  laminectomy.  The  parts  can  be  easily 
reached,  and  a  careful  amount  of  dissection  will  enable  one 
to  remove  the  pachymeningeal  thickening  that  produces  the 
constriction  of  the  cord.  The  necessity  for  fixation  after 
an  operation  of  this  kind  still  exists,  and  the  value  of  the 
operation  can  be  greatly  enhanced  by  proper  mechanical 
support.  Before  undertaking  an  operation  of  this  kind, 
however,  it  would  be  well  to  have  a  neurologist  go  over  the 
muscles  with  the  current,  and  find  how  much  degeneration 
exists  and  what  muscles  are  liable  to  benefit  by  having  the 
compression  removed  from  the  cord. 

Osteitis  of  the  Hip. — The  operations  for  disease  at  this 
joint  are  as  follows:  Partial  arthrectomy,  excision  more  or 
less  complete,  curetting  of  sinuses,  division  of  muscles  and 
tendons  for  the  correction  of  deformity,  osteotomy,  and 
amputation.  Cases  come  to  the  attention  of  the  surgeon  in 
the  first,  second,  or  third  stages.  It  is  my  belief  that  if  a 
suitable  apparatus  can  be  applied  to  a  patient  in  the  first 
stage  of  the  disease  and  proper  attention  can  be  given  this 
for  a  period  varying  from  one  to  two  years,  a  cure  will 
result.  By  cure  I  mean  resolution  of  the  inflammatory 
process  with  restoration  of  the  function  of  the  joint. 
The  responsibility  in  such  a  case  is  divided  about  equally 
between  the  parent  and  the  surgeon.  The  parent  can  not 
be,  or  is  not,  convinced  of  the  importance  of  following 
closely  every  direction  given.  The  surgeon  has  so  little 
faith  in  apparatus  that  his  instructions  are  not  clear  and 
well  defined.  He  manifests  this  lack  of  faith  in  various 
ways.  The  patient  is  keen  enough  to  perceive  it,  and 
hence  the  instructions,  although  given  with  the  tone  of 
authority,  are  not  followed.  The  reason  why  operative  pro¬ 
cedures  are  not  employed  in  this  stage  of  the  disease  is  the 
uncertainty  in  the  mind  of  the  surgeon  as  to  the  nature  of 
the  disease.  He  either  is  or  is  not  convinced  that  the  le¬ 
sion  is  tubercular.  He  is  too  prone  to  accept  the  state¬ 
ment  of  the  parents  that  not  a  trace  of  anything  hereditary 
exists  in  either  member  of  the  family.  He  pins  his  faith 
to  some  trivial  fall,  without  even  taking  the  trouble  of  a 
cross  examination.  Authorities  even  speak  of  simple  cases 
and  tubercular  cases.  I  have  been  for  a  long  time  con¬ 
vinced  of  the  importance  of  calling  every  case  of  hip  disease 
in  a  child  tubercular.  I  do  this  in  spite  of  numerous  opin¬ 
ions  given  by  surgeons  and  physicians  who  discuss  from  a 
theoretical  standpoint  the  nature  of  the  bacillus.  I  do  it 
because  it  forewarns  me,  and,  being  forewarned,  1  am  fore¬ 
armed.  Without  entering  into  any  dissertation  on  splints, 
what  are  best  and  what  are  worthless,  I  prefer  to  say  a  word 
about  the  principles  governing  the  management  of  a  case  in 
this  early  stage.  The  aim  is  to  protect  the  joint  against 
every  trauma.  In  order  to  do  this,  some  form  of  perineal 
crutch  or  axillary  crutch  must  be  employed.  Trauma  may 


August  16,  1890.] 


OIBNEY:  THE  BONE  DISEASES  OF  CHILDHOOD. 


183 


;ome  in  various  ways.  It  may  come  from  retiex  spasm, 
rom  a  blow  or  bruise,  a  fall  or  a  strain.  The  trauma  in 
Teases  the  hyperccmia  about  the  focus  of  disease.  It  per 
nits  the  inflammatory  area  to  extend  until  the  joint  is  in- 
olved  more  or  less  seriously.  Knowing,  as  we  do,  pretty 
veil  the  history  of  tuberculosis,  we  must  not  expect  resolu- 
ion  to  take  place  in  a  short  time.  The  reparative  process 
s  exceedingly  slow.  If  the  patient  does  not  do  well  on  a 
tortable  splint,  then  he  should  be  confined  to  bed  with 
raction  or  with  absolute  immobilization.  The  value  of  tre 
Inning  the  trochanter  and  neck  of  the  femur  has  not  been 
illy  impressed  upon  the  profession,  and  hence  its  employ 
lent  has  not  been  general.  Furthermore,  the  friends  of  the 
atient  are  slow  to  accept  any  operative  procedures  upon  a 
fint  which  is  not  deformed.  Much  valuable  time  is  there 
>re  lost,  and  when  the  operation  is  done  it  is  probably  too 
ite.  I  doubt  very  much  whether  it  is  worth  while  to  waste 
me  discussing  this  point. 

Take,  now,  the  case  that  comes  to  our  notice  in  the 
icond  stage,  or  the  stage  of  deformity,  with  or  without 
irscess,  it  matters  little.  The  number  of  surgeons  who  pro 
ss  to  effect  a  perfect  cure  in  a  case  of  this  kind  are  very 
w.  Unfortunately,  some  of  those  who  do  make  this  state 
ient  do  not  enjoy  professional  confidence.  We  have  to  ad 
it,  therefore,  that  complete  restoration  of  function  is  practi 
tlly  out  of  the  question.  The  aim,  then,  is  to  conduct  the 
ise  to  an  issue  with  the  minimum  amount  of  deformity  and 
ith  resolution  of  the  inflammatory  area.  The  adhesions 
hich  have  taken  place  as  a  result  will  generally  remain, 
ore  or  less  deformity  will  result,  but  a  very  good  result 
n  in  many  cases  be  secured  with  the  proper  use  of  appara- 
s.  It  is  also  difficult  to  prevent  the  increase  of  deformity 
this  stage,  however  great  the  co-operation  at  home.  It 
a  comfort  to  know,  however,  that  the  little  patient  can  be 
ved  from  pain,  can  lead  an  out-of-door  life,  and  can  get 
dl  with  a  trifling  amount  of  inconvenience.  It  is  in  this 
tge  that  operations  are  of  great  value.  If  an  abscess 
■n  be  recognized  in  the  gluteal  region,  coming  apparently 
>m  the  digital  fossa,  a  good,  clean  excision  can  be  made 
th  happy  results.  Even  a  partial  arthrectomy  here  yields 
' od  results-  If  the  abscess,  however,  appears  on  the  pos- 
l  ior  aspect  of  the  thigh,  on  the  anterior  aspect,  or  in  the 
ac  fossa,  an  extensive  operation,  in  my  judgment,  is  not 
<  led  for.  If  the  operation  is  done,  however,  it  should  be 
nde  very  thorough.  My  own  observation  on  operations 
1  ne  under  the  conditions  named  is,  that  sufficient  after-pro- 
[  fi°n  is  not  afforded.  The  wounds  are  very  nearly  healed, 
fistulous  track  remains,  the  general  health  has  improved 
isiderably ,  the  patient  is  put  upon  a  pair  of  crutches  or  a 
tock”  splint  from  the  instrument-maker,  and  discharged. 
le  result  is  a  recurrence  of  the  deformity,  an  extension  of 
'  diseased  area,  and  a  very  short  limb. 

Cases  presenting  in  the  third  stage  are  the  best  for  op- 
-  third  stane  is  meant  not  only  deformity, 
actual  shortening  of  the  limb,  which  shortening  is  due 
change  in  the  relationship  which  the  neck  sustains  to  the 
'  or  a  pathological  dislocation.  These  are  the  cases  of 
>  ients  that  usually  enter  hospitals ;  “  dernier  ressort  ”  means 
'  ‘Sion  or  amputation.  Generally  the  parts  are  riddled  with 


sinuses,  and  it  is  next  to  impossible  to  completely  remove 
all  disease.  I  rom  a  pretty  caieful  observation  of  such  cases, 
it  seems  to  me  that  the  best  plan  is  to  postpone  operations 
so  long  as  the  general  health  can  be  maintained,  and  so  long 
as  the  patient  is  not  suffering  acutely.  A  good  plan  also  is 
to  curette  sinuses,  aim  to  reach  the  diseased  foci  one  by  one, 
eradicate  by  degrees,  and  finally,  when  the  sinuses  are  all 
closed,  do  an  osteotomy  below  the  trochanter  minor,  a  Gant 
operation,  bring  the  limb  down  parallel  with  its  fellow,  get 
osseous  union  as  soon  as  possible,  protect  the  joint  for  some 
months  afterward  by  a  splint,  then  resort  to  a  high  shoe, 
and  a  good  result  is  almost  sure  to  follow.  If  amyloid  de¬ 
generation  threatens,  it  seems  to  me  that  amputation  is 
preferable  to  an  excision.  It  depends  a  great  deal  upon 
one’s  surgical  judgment  as  to  the  propriety  of  an  excision. 
If  this  operation  fail,  then  an  amputation  can  be  employed. 

Osteitis  of  the  Knee. — The  means  we  have  at  our  dis¬ 
posal  now  for  correcting  a  deformity  at  the  knee  enables 
us  to  conduct  a  case  to  a  successful  issue.  If  abscesses  or 
sinuses  exist,  all  surgeons,  I  think,  are  agreed  that  an  ex¬ 
cision  is  rarely  called  for.  The  operation  of  arthrectomy 
or  partial  arthrectomy  with  subsequent  protection  of  the 
'imb  during  a  long  period  yields  better  final  results  than 
any  excision.  One  reason  that  surgeons  refrain  from  excis¬ 
ion  in  young  children  is  a  knowledge  of  the  growth  of  the 
bone  at  the  epiphysis.  They  have  long  since  learned  that 
the  bone  is  stunted  in  growth  by  removing  the  epiphysis. 
Another  reason,  which  is  not  generally  given,  but  which  is 
of  weight,  is  the  tendency  of  the  deformity  to  recur.  A 
radical  operation  in  the  hands  of  a  surgeon  is  thought  to  be 
all-sufficient.  A  month’s  or  a  few  months’  protection  of  the 
parts  generally  suffices.  The  case  passes  from  under  obser¬ 
vation,  and  in  the  course  of  a  year  or  several  years  the  de¬ 
formity  has  relapsed.  T  his  has  occurred  in  a  certain  num¬ 
ber  that  have  come  under  my  own  observation.  I  have  two 
cases  now  under  treatment— one  in  the  Out-patient  Depart¬ 
ment  and  one  in  the  hospital.  The  former  is  in  a  boy 
twelve  or  thirteen  years  of  age,  who  had  an  excision  done 
in  one  of  the  city  hospitals  when  he  was  two  years  of  age. 
The  operation  seemed  to  be  thorough.  He  had  the  usual 
after-treatment,  and  seven  years  subsequently  came  under 
my  notice  at  the  hospital  with  a  rectangular  knee,  both 
bones  very  much  shortened,  and  his  gait  was  most  distress¬ 
ing.  There  was  complete  synostosis  at  the  knee,  and  it  was 
necessary  to  remove  a  large  wedge-shaped  piece  of  bone  in 
order  to  correct  the  deformity.  He  is  now  wearing  a  pos¬ 
terior  splint  and  an  immense  frame  for  a  high  shoe.  The 
case  in  the  hospital  is  that  of  a  boy  of  five  or  six  years,  who 
has  had  several  operations — one  an  excision  and  two  partial 
arthrectomies — and  his  limb  is  not  only  greatly  shortened, 
but  bowed  and  much  deformed. 

There  are  several  osteotomies  for  the  correction  of  de¬ 
formity  about  the  knee,  but  these  will  suggest  themselves 
to  the  surgeon,  and  individual  judgment  must  be  the  guide. 
Osteotomy  is  usually  for  the  correction  of  deformity. 

The  judicious  use  of  plaster  of  Paris  is  a  great  help  to 
us  in  such  cases.  The  splint  I  employ  after  the  deformity 
is  corrected  is  that  known  as  the  Thomas  splint,  which 
means  a  perineal  crutch. 


184 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jour., 


THE 


NEW  YORK  MEDICAL  JOURNAL, 


A 

Published  by 
D.  Appleton  &  Co. 


Weekly  Review  of  Medicine. 

Edited  by 

Frank  P.  Foster,  M.  D. 


in  connection  with  typhoid  fever;  the  localization  of  the  heat- 
producing  cerebral  function ;  the  action  of  morphine  and 
a  number  of  its  derivatives ;  the  influence  of  bile  on  pan¬ 
creatic  digestion ;  the  comparative  digestibility  of  ditlerent 
starches;  and  the  chemico-physical  character  of  certain  pro- 
teids.  Possibly  none  of  these  investigations  would  have  re- 


NEW  YORK,  SATURDAY,  AUGUST  16,  1890. 


THE  RELATION  OF  AMERICAN  MEDICAL  SOCIETIES  TO 
SCIENTIFIC  RESEARCH. 

Of  the  several  reasons  that  have  interfered  with  the  prose¬ 
cution  of  original  research  by  American  physicians,  aside  from 
the  fast  disappearing  obstacle  of  insufficient  educational  equip¬ 
ment,  probably  the  most  potent  have  been  what  some  are 
pleased  to  term  the  essentially  practical  nature  of  the  Ameri¬ 
can,  that  causes  him  to  look  askance  on  any  work  not  promis¬ 
ing  a  pecuniary  return  ;  and  a  lack  of  money  necessary  to  pur¬ 
chase  apparatus,  drugs,  and  the  other  paraphernalia  requisite 
for  any  special  research. 

Many  of  our  physicians  have  made  valuable  contributions  to 
medical  science  by  investigations  that  have  required  considera¬ 
ble  expenditure  not  only  of  time  but  of  money  as  well.  Un¬ 
doubtedly  there  are  some  medical  men  in  this  country  that 
would  to-day  be  glad  to  work  a  solution  of  some  physiological 
or  pathological  problem  if  supplied  with  the  necessary  appurte¬ 
nances  for  such  work. 

At  a  few  of  our  universities  a  limited  number  of  scholar¬ 
ships  might  be  made  use  of  by  recent  medical  graduates  to  pur¬ 
sue  a  course  of  special  investigation;  but  what  seems  to  be 
needed  are  means  whereby  a  qualified  man,  in  a  village  or  town 
that  has  no  university,  can  employ  his  leisure  and  gratify  his 
tastes  and  inclinations  in  conducting  some  scientific  research. 
Some  State  medical  societies  offer  a  prize  for  the  best  essay  on 
any  professional  subject  that  is  the  result  of  original  investiga¬ 
tion;  and  for  several  years  a  portion  of  the  Bovlston  prize  fund 
has  been  thus  offered.  But  prizes  are  not  the  means  by  which 
the  desired  end  may  be  attained. 

The  recent  report  of  the  Scientific  Grants  Committee  of  the 
British  Medical  Association  has  suggested  the  desirability  of 
our  State  and  national  medical  associations  considering  the 
adoption  of  a  similar  plan  to  theirs.  During  the  past  year  that 
association  has  spent,  in  money  advanced  to  physicians  for  the 
expenditures  necessary  in  making  special  investigations,  a  sum 
equal  to  twenty-four  hundred  dollars.  In  different  parts  of 
Great  Britain  investigators  have  been  studying  various  prob¬ 
lems,  such  as  the  inoculation  of  carcinoma  and  sarcoma  on  the 
lower  animals  from  man;  the  vaso-motor  functions  of  the  cere¬ 
bral  cortex ;  animal  heat,  and  also  the  invention  of  a  suitable 
heat-measuring  and  heat-recording  apparatus  for  accurately  es¬ 
timating  the  precise  heat  product  of  animals  ;  an  investigation 
of  the  constitution  of  certain  pathological  effusions;  anthrax 
albumose ;  the  coagulation  of  egg  and  serum  albumin,  vitellin, 
and  serum  globulin  by  heat ;  the  proteids  of  urine  and  albu¬ 
minuria  ;  whether  the  muscles  of  adduction  and  abduction  of 
the  vocal  bands  have  cortical  cerebral  centers ;  the  ptomaines 


ceived  a  prize  if  offered  in  competition  to  any  society.  And 
yet  they  are  all  of  value  in  tending  toward  the  ultimate  solu¬ 
tion  of  various  problems ;  and  they  indicate  the  possibility  of 
larger  fields  of  usefulness  for  our  numerous  American  societies 
than  any  that  they  have  yet  entered  upon. 


SURGEON  PARKE  AND  THE  MEDICAL  PROFESSION. 

Dr.  Parke,  whose  brilliant  services  with  the  Emin  Pasha 
Relief  Expedition  have  excited  the  admiration  of  the  civilized 
world,  was  on  the  6th  of  June  last  presented  by  the  editors  of 
the  Lancet  with  a  massive  silver  salver,  and  on  the  evening  of  the 
same  dav  was  the  guest  of  a  brilliant  representative  gatheiing 
of  the  m'embers  of  the  medical  profession,  who  had  assembled 
to  do  him  honor  at  a  dinner  at  the  Criterion  Restaurant,  Sir 
Andrew  Clark  presided.  Mr.  Jonathan  Hutchison,  Sir  James 
Paget,  Sir  Prescott  Hewitt,  Sir  Joseph  Fayrer,  Sir  Spencer 
Wells,  and  many  other  distinguished  members  of  the  profession 
were  present.  After  several  speeches  suitable  to  such  an  occa¬ 
sion  had  been  made,  Surgeon  Parke,  amid  great  applause,  rose 
to  respond  and  made  a  very  modest  speech,  in  the  course  of 
which  he  said  that  he  would  remind  the  company,  if  they 
were  not  already  tired  of  hearing  about  Africa,  that  it  was  just 
three  years  and  three  months  before  that  Mr.  Stanley  started 
from  England  to  bring  relief  to  Emin  Pasha — not  to  bring  him 
away  from  Africa,  but  to  bring  him  relief.  With  a  force  of 
about  eight  hundred  strong,  they  started  from  the  mouth  of  the 
Congo  on  March  18,  1887.  The  shortest  time  any  of  them 
spent  in  the  forest  was  one  hundred  and  sixty-two  days.  The 
pygmies  or  dwarfs  they  met  stood  about  three  or  four  feet  high, 
had  tiny  hands  and  feet,  with  fairly  good  features,  and  were 
bright  and  intelligent.  They  were  covered  all  over  with  down, 
such  as  is  seen  on  the  cheeks  of  a  boy  of  eighteen  or  nineteer 
in  this  country.  The  European  provisions  that  the  party  tool 
with  them  were  finished  within  a  month.  The  two  bottles  o 
brandy  which  each  had  were  also  soon  exhausted.  They  hai 
exactly  the  same  food  as  the  natives— bananas,  with  occasion 
ally  a  goat  a  week  divided  among  six  or  eight. 

The  Europeans  survived  much  better  than  the  natives  did 
Of  the  two  Europeans  who  died,  one  died  from  climatic  cause 
and  the  other  was  murdered.  Emin  Pasha  was  qualified  ii 
medicine  by  a  German  degree,  of  which  he  was  very  prouc; 
He  spoke  twenty-two  languages,  of  which  he  could  write  an 
read  thirteen.  When  they  started  he  (Surgeon  Parke)  took  tb 
precaution  of  vaccinating  the  majority  of  the  men,  and  whe 
the  epidemic  of  small-pox  broke  out  only  four  were  attache 
by  the  disease,  and  none  of  them  died.  On  the  other  hand,  tl 
camp-followers,  who  had  not  been  vaccinated,  took  the  disea 
in  a  bad  form  and  died  in  great  numbers.  After  a  three  yeai 


August  16,  1890.] 


MINOR  PARAGRAPHS. 


185 


march  across  Africa  they  reached  Zanzibar  with  Emin  Pasha. 
He  wished  to  place  on  record  the  great  admiration  he  and  his 
brother  officers  felt  for  their  illustrious  leader,  Mr.  Stanley. 


MINOR  PARAGRAPHS. 

RECURRING  MULTIPLE  OSTEITIS  AMONG  PEARL 
WORKERS. 

In  a  recent  number  of  the  CentralUatt  fur  Chirurgie  there 
is  an  article  by  Dr.  Levy  on  the  hitherto  little-known  disease 
which  attacks  workers  in  pearl.  The  first  formal  observations 
upon  the  phases  of  the  affection  were  made  in  Vienna,  when 
tome  twenty-five  cases  were  reported.  The  author  has  seen 
ive  cases  during  the  past  four  years  in  Berlin.  These  had  oc¬ 
curred  among  the  younger  workers.  After  from  four  to  six 
/ears  of  such  emplo}  ment  a  form  of  osteitis  would  appear  in¬ 
volving  principally  the  maxillary  bones.  The  symptoms  were 
ouud  to  subside  with  a  change  of  occupation,  hut  would  reap- 
>ear  in  some  other  locality  upon  resumption  of  the  pearl  work, 
n  one  of  the  cases  the  patient  had  suffered  recurring  inflam- 
nation  of  the  scapulte,  and  in  another  the  lower  half  of  the 
emur  had  become  involved,  exclusive  of  the  epiphysis.  Dr. 
^evy  is  of  the  opinion  that  the  affection  is  caused  by  the  pearl- 
hell  dust  which  fills  the  air  during  the  grinding  process  and 
usinuates  itself  into  the  patient’s  system.  Just. how  it  operates 
hen  is  an  open  question  pending  further  elucidation. 


LOCAL  TUBERCULAR  INFECTION. 

In  a  recent  number  of  the  British  Medical  Journal  report  is 
mde  of  an  accident  which  befell  Dr.  Gutzman,  of  Berlin,  and 
ffiicb  may  serve  as  a  warning  to  surgeons  and  pathologists  to 
e  careful  in  the  handling  of  tuberculous  tissues.  On  February 
9tb,  while  Dr.  Gutzman  was  holding  an  autopsy  in  the  case  of 
patient  who  had  died  of  acute  miliary  tuberculosis,  the  nail 
f  his  right  middle  finger  was  slightly  raised  from  the  matrix, 
pricking  sensation  was  experienced  at  the  tip  of  the  finger, 
ut  no  wound  could  be  seen.  The  hand  was  thoroughly  disin- 
:cted  in  a  sublimate  solution  and  alcohol,  and  the  incident 
>rgotten.  On  March  20th  the  end  of  the  finger  became  pain- 
d,  a  small  abscess  being  found  under  the  nail.  This  was 
)ened,  and  the  pus  removed,  on  being  ex'amined  by  Ehrlich’s 
ethod,  was  found  to  contain  three  tubercle  bacilli.  The  cav- 
y  was  cleaned  out  and  disinfected  with  alcohol.  So  far  there 
is  been  no  lymphangeitis  or  glandular  involvement  and  no  rise 
temperature.  Dr.  Gutzman  regards  the  case  as  an  example 
local  tubercular  infection. 


PROFESSIONAL  AND  COMMERCIAL  CONFIDENCE. 

TnE  August  number  of  the  Virginia  Medical  Monthly  asks 
we  will  not  retract  our  statement  in  regard  to  a  certain  New 
irk  commercial  house,  that  it  u  still  deserves  and  receives  the 
nfidence  of  the  medical  profession.”  This  is  a  journal  of 
edicine,  not  one  of  finance,  and  financial  transactions  are  not 
oper  subjects  for  its  comments,  unless  they  involve  medical 
'ints,  and  we  should  not  have  alluded  to  our  contemporary’s 
tide  on  the  house  in  question  but  for  the  reason  that  it  cited 
etter  published  by  us  from  which  it  seemed  to  draw  conclu- 
•nsthatwe  did  not  and  do  not  look  upon  as  warrantable.  The 
'mthly  now  makes  its  own  accusation  against  the  firm,appar- 
tlv  relating  to  business  matters.  With  such  matters,  as  we 
ve  said  before,  we  have  nothing  to  do,  and  we  have  no  refer- 
•ee  to  them  when  we  speak  of  a  house  as  deserving  and  re- 
•  ving  the  confidence  of  the  medical  profession,  but  to  the 


character  of  its  dealings  with  the  profession,  and  that  fact  our 
readers  doubtless  understood  ;  hence  we  have  no  retraction  to 
make. 

SUBBENZOATE  OF  BISMUTH  IN  THE  TREATMENT  OF  SOFT 

CHANCRE. 

A  recent  issue  of  the  Medicinisch-chirurgisches  Central - 
Blatt  contains  an  article  by  Dr.  E.  Finger,  of  Vienna,  in  which 
are  given  the  results  of  his  therapeutic  endeavors  with  sub¬ 
benzoate  of  bismuth  as  a  topical  application  in  the  treatment  of 
soft  chancre.  The  compound  is  described  as  being  made  by 
heating  nitrate  of  bismuth  with  potassium  nitrate  and  sodium 
benzoate.  The  precipitate,  subbenzoate  of  bismuth,  is  collected 
on  a  filter,  washed  with  water  and  alcohol,  and  dried.  The  au¬ 
thor  reports  its  use  in  sixteen  cases.  Some  stinging  sensations 
follow  its  application,  but  these  are  not  severe.  Six  or  eight 
applications  were  sufficient  to  secure  a  healthy  surface,  the 
dressing  being  made  twice  in  twenty-four  hours.  Dr.  Finger 
seems  to  consider  the  subbenzoate  a  valuable  substitute  for 
iodoform  and  the  more  violent  cauterizing  drugs  where  they  are 
contraindicated. 

MICROBES  IN  HAILSTONES. 

Truly  in  the  midst  of  life  we  are  in  death.  A  recent  num¬ 
ber  of  the  British  Medical  Journal  states  that  Dr.  Fontin,  a 
Russian  observer,  has  demonstrated  the  existence  of  pernicious 
microbes,  of  terrestrial  origin,  in  hailstones.  He  has  found  that 
the  water  produced  by  the  melting  of  the  hailstones  used  in  the 
experiments  yielded  an  average  of  729  bacteria  to  the  cubic 
centimetre.  The  fungi  of  yeast  and  mold  were  absent,  but 
nine  different  bacteria  were  discovered,  including  the  Bacillus 
mycoides.  As  the  abiding  place  of  this  bacillus  is  the  earth,  the 
fact  that  it  and  its  pestilential  congeners  can  be  carried  to  the 
heavens  and  returned  here  with  hail,  rain,  and  snow,  and  di¬ 
rectly  convey  infection,  is  another  of  the  discoveries  which? 
while  adding  perchance  to  the  glory  of  science,  show  the  bliss¬ 
fulness  of  ignorance. 

PRESERVALINE. 

In  the  bright  lexicon  of  commerce  this  is  the  name  of  one 
of  a  number  of  preparations  sold  to  milk-dealers  to  enable 
them,  by  adding  it  to  their  milk,  to  palm  off  stale  milk  on  the 
community.  It  is  supposed  to  consist  mainly  of  boric  or  of 
salicylic  acid.  Ten  per  cent,  of  tbe  milk  furnished  by  dealers 
supplying  Brooklyn  is  said  to  have  had  one  of  these  substances 
added  to  it.  The  persons  concerned  profess  that  the  milk  is 
not  made  injurious  by  this  procedure,  but  it  is  very  obvious 
that  it  may  become  injurious  under  certain  circumstances,  and 
the  State  Dairy  Commission  is  quite  right  in  declining  to  leave 
that  question  to  the  milkmen’s  discretion.  Certainly  the  com¬ 
munity  has  a  right  to  be  protected  from  surreptitious  drugging. 


HEMATURIA  AND  GARDEN  RHUBARB. 

Several  correspondents  of  the  Lancet  have  recently  report¬ 
ed  some  unusual  urinary  troubles  consequent  upon  eatiDg  ordi¬ 
nary  rhubarb,  or  pie-plant  as  it  is  occasionally  called.  The 
symptoms  are  frequency  of  micturition,  hsematuria,  dysuria,  and 
lumbar  pains.  This  effect  of  the  rhubarb  seems  dependent  upon 
the  use  of  hard  water  for  drinking  purposes,  the  oxalic  acid  of 
the  rhubarb  combining  with  the  calcium  in  the  water  and  form¬ 
ing  numerous  small  crystals  of  oxalate  of  calcium  that — it  is  sug¬ 
gested — lacerate  the  uriniferous  tubules  in  passing  through  them. 
Similar  consequences  have  been  noted  after  eating  gooseberries 
and  acid  apples;  and  an  explanation  of  obscure  urinary  troubles 
in  localities  where  hard  water  is  used  is  thus  afforded. 


minor  paraoraphs.-items.-letters  to  the  editor. 


[N.  Y.  Med.  Jodr., 


186 


and  a  ornHuHtp  of  the  Yale  Medical  College. 


THE  TOXICITY  OF  BILIRUBIN. 

Dr.  G.  de  Bruin,  in  an  Amsterdam  thesis,  arrives  at  the  fol¬ 
lowing  conclusions  regarding  bilirubin  :  That,  as  Bouchaul  af¬ 
firms,  not  only  is  it  a  poison  to  the  organism,  hut,  moreover,  it 
has  properties  more  toxic  than  the  other  biliary  constituents, 
and  is  a  more  intense  poison  to  the  heart  of  the  frog  and  piob- 
ably  also  to  the  mammalian  heart;  that  it  occasions  disorders 
in  the  parenchyma  of  the  kidneys;  and  that  it  is  probably  a 
poison  to  the  central  nervous  system. 


THE  TREATMENT  OF  INCIPIENT  INSANITY. 

In  a  June  number  of  the  Lancet  commendatory  reference 
is  made  to  the  steps  taken  by  the  West  Riding  County  Coun¬ 
cil  in  its  effort  to  check,  if  possible,  the  increase  of  insan¬ 
ity  in  that  county.  The  approved  arrangement  at  the  West 
Riding  Asylum  affords  an  opportunity  for  free  medical  con¬ 
sultation  to  those  suffering  from  mental  or  nervous  diseases, 
especially  in  the  early  stages.  The  attempt  thus  to  treat  in¬ 
sanity  in  its  incipiency  has  been  so  far  successful  that  it  has 
been  decided  to  extend  the  system  to  other  asylums.  This  sub¬ 
ject  has  of  late  received  serious  attention  at  the  hands  of  the 
New  York  Neurological  Society,  the  aim  being  an  early  adop¬ 
tion  of  some  plan  which  will  afford  opportunity  for  the  study 
and  treatment  of  insanity  in  its  earlier  forms. 


ANTIPYRINE  IN  ERYSIPELAS. 

Dr.  Favre,  of  Fribourg,  says  the  British  Medical  Journal , 
has  reported  an  unusually  severe  case  of  erysipelas  showing  the 
high  curative  value  of  antipyrine.  A  woman,  aged  thirty  years, 
suffered  from  facial  erysipelas  accompanied  by  somnolence, 
vomiting,  constipation,  and  high  fever.  In  spite  of  applications 
of  cold,  carbolic  acid,  ichthyol,  corrosive  sublimate,  strips  of 
adhesive  plaster,  etc.,  the  morbid  process  gradually  extendec 
over  the  scalp,  neck,  chest,  upper  extremities,  abdomen,  and 
buttocks.  On  the  tenth  day  the  administration  of  antipyrine 
was  begun,  with  the  result  that  the  febrile  symptoms  were  at 
once  decidedly  reduced,  the  eruption  soon  ceased  to  spread,  and 
the  patient’s  subjective  state  was  greatly  improved. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  August  5,  1890 : 


DISEASES. 

Week  ending  Aug.  5. 

Week  ending  Aug.  12 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever, . 

35 

7 

40 

5 

Scarlet  fever . 

49 

6 

28 

2 

Cerebro-spinal  meningitis . 

6 

5 

3 

2 

Measles . 

171 

13 

109 

8 

Diphtheria . 

6n 

22 

36 

1  . 

11 

Varicella . 

1  0 

0 

0 

Westphal’s  Successor. — It  has  been  announced  repeatedly  from  Ber¬ 
lin  that  Dr.  Grashey,  of  Munich,  would  succeed  Professor  Westphal. 
For  some  reason  this  appointment  has  not  been  consummated,  for  we 
are  now  informed,  through  the  Lancet,  that  Dr.  Friedrich  Jolly,  professor 
of  mental  therapeutics  at  Strassburg  since  1873,  has  been  chosen  for 
the  place.  Dr.  Jolly  is  about  forty-six  years  of  age,  and  has  a  reputa¬ 
tion  for  original  research  in  his  department  and  for  literary  ability. 

Dr.  William  Nelson  Blakeman,  of  New  York,  died  on  Sunday,  the 
10th  inst.,  in  the  eighty-sixth  year  of  his  age.  The  deceased  was  a 


From  the  time  of  his  graduation,  in  1832,  until  within  three  or  four 
years  of  his  death  he  was  engaged  in  general  practice  in  New  York. 

The  Honorary  Degree  of  LL.  D.  has  been  conferred  by  Dartmouth 
College  on  Dr.  Edward  Cowles,  the  superintendent  of  the  McLean 
Asylum  in  Massachusetts. 

Change  of  Address.— Dr.  William  A.  Valentine’s  new  number  is  45 
West  Thirty-fifth  Street. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  August  9,  1890 : 

Wales,  P.  S.,  Medical  Director.  Ordered  in  charge  of  the  Museum  of 
Hygiene,  Washington,  D.  C. 

Bright,  George  A.,  Surgeon.  Ordered  to  the  U.  S.  Steamer  Constella¬ 
tion.  M 

Mackie,  B.  S.,  Surgeon.  Detached  from  the  U.  S.  Steamer  Constellation 
and  ordered  to  Naval  Hospital,  Philadelphia,  for  medical  treatment. 
Derr,  E.  Z.,  Surgeon.  Ordered  to  the  U.  S.  Steamer  Minnesota. 
Waggener,  J.  R.,  Surgeon.  Detached  from  the  U.  S.  Steamer  Minne¬ 
sota  and  ordered  to  the  U.  S.  Steamer  Kearsarge. 

Moore,  A.  M.,  Surgeon.  Detached  from  the  U.  S.  Steamer  Kearsarge 
and  granted  three  months’  sick  leave. 


•getttrs  to  % 


THE  SUPRA-ORBITAL  PRESSURE  TEST  OF  MALINGERING. 

U.  S.  S.  Pensacola,  August  1 ,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal  : 

Sir:  It  may  be  of  interest  to  the  readers  of  the  article  by 
Dr.  J.  T.  Eskridge,  published  in  this  Journal  of  July  26th,  to 
know  that  supra-orbital  pressure  in  cases  of  true  epilepsy  has 
no  effect.  Supra-orbital  pressure  has  been  practiced  frequently 
by  me  while  house  surgeon  to  the  Chambers  Street  Hospital, 
New  York,  in  cases  of  malingering,  hysteria,  alcoholic  coma 
and  delirium  tremens,  with  remarkable  success.  I  published 
in  the  Record  for  August  27,  1887,  an  article  on  this  subject, 
and  agree  with  Dr.  Eskridge’s  account  of  his  successes.  Could 
you  refer  me  to  the  observation  of  “a  German  physician  ’ 
upon  this  same  point?  He  was  mentioned  in  Dr.  Eskridges 
article.  Rute  L.  von  "Wedekind,  M.  D., 

Assistant  Surgeon ,  U.  S.  Navy. 


.ARSENITE  OF  COPPER  IN  DIARRHOEA. 

240  West  Thirty-fourth  Street,  New  York,  August  J  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir  :  I  wish  to  call  the  attention  of  your  readers  to  the  value 
of  arsenite  of  copper  in  the  treatment  of  diarrhoea,  dysentery, 
cholera  morbus,  and  cholera  infantum.  I  have  not  lost  a  single 
patient  with  cholera  infantum  since  I  began  to  use  it.  It  is 
given  largely  diluted  with  water,  and  is  not  at  all  disagreeable 
to  take.  I  think  it  was  Dr.  John  Aulde,  of  Philadelphia,  who 
first  advocated  its  use,  about  two  years  ago.  I  have  used  it 
about  thirty  times  within  a  few  weeks  without  a  single  failure. 
It  is  put  up  in  tablets  of  Tfg-  of  a  grain,  one  of  which  is  to  be 
dissolved  in  four  ounces  of  water,  and  a  teaspoonful  of  the  solu¬ 
tion  (containing  of  a  grain)  taken  every  fifteen  minutes 
for  the  first  hour  and  then  every  hour  until  relief  is  obtained. 
For  children  proportionally  smaller  doses  are  used.  I  feel  sure 
that  arsenite  of  copper  may  be  made  to  reduce  the  mortality  by 
cholera  infantum  as  bichloride  of  mercury  has  reduced  that  by 
diphtheria.  Branch  Clark,  M.  D. 


August  16,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


187 


.  .  .  .  * 

fjrocccbings  of  .Societies. 

AMERICAN  LARYNGOLOGICAL  ASSOCIATION. 

Txcelfth  Annual  Congress ,  held  at  Baltimore ,  on  Thursday , 
Friday ,  and  Saturday ,  J/ay  2,9,  50,  and  31,  1890. 

The  President,  Dr.  John  N.  Mackenzie,  of  Baltimore, 
in  the  Chair. 

The  Relationship  between  Bulbo-nuclear  Disease  and 
Obscure  Neurotic  Conditions  of  the  Upper  Air-passages.— 

The  President  read  a  paper  on  this  subject.  (See  page  176.) 

Dr.  F.  H.  Bosworth  was  invited  by  the  Chair  to  open  the 
discussion.  He  said  I  regard  the  case  as  very  interesting,  but 
I  can  not  agree  with  the  author  that  its  bulbo-nuclear  nature 
has  been  clearly  established.  It  seems,  on  the  contrary,  that 
the  evidence  presented  would  establish  the  diagnosis  as  neuritis 
and  uot  bulbar  disease. 

The  President:  Of  what  nerve? 

Dr.  Bosworth:  Of  the  trifacial  particularly.  This,  how¬ 
ever,  is  merely  a  suggestion.  If  it  is  bulbar  disease,  we  should 
decide  what  form.  Is  it  a  clot?  or  a  thrombus?  Is  it  soften¬ 
ing?  or  a  tumor?  Bulbar  disease  is  not  enough  ;  we  should  be 
able  to  state  its  nature  as  well  as  its  place.  To  my  mind  the 
case  is  not  of  this  kind,  but  may  be  a  neuritis. 

Dr.  D.  B.  Delavan  :  This  subject  in  general  is  perhaps  the 
most  interesting  one  in  the  laryngology  of  to-day,  and  is  cer¬ 
tainly  the  newest  and  least  understood.  The  fact  that  emi¬ 
nent  diagnosticians  disagree,  and  that  they  advance  ingenious 
theories  of  pathology  only  to  have  them  overthrown  by  post¬ 
mortem  investigation,  shows  that  we  are  only  on  the  threshold 
of  the  matter.  Ever  since  Gottstein,  following  the  example  of 
Hughlings  Jackson,  called  attention  to  the  frequency  with  which 
laryngeal  paralyses  of  central  origin  were  due  to  bulbar  lesioD, 
there  has  been  observed  a  tendency  to  refer  all  cases  with  simi¬ 
lar  symptoms  to  bulbar  disease. 

Garel  has  lately  reported  two  cases  in  which  the  laryngeal 
paralysis  was  produced,  not  by  bulbar  disease,  but  by  a  cortical 
lesion.  While  it  has  been  fully  established  that  many  cases  are 
due  to  bulbar  lesion,  it  is  also  possible  that  the  same  symp¬ 
toms  may  depend  upon  a  central  disease  of  other  than  bulbar 
origin.  . 

M  bile  it  may  not  be  possible  to  distinguish  these  cases  now, 
future  observation  will  enable  us  to  determine  more  accurately 
the  diagnosis  between  them.  A  paper,  by  a  well  known  pa¬ 
thologist,  upon  the  laryngological  relations  of  tabes,  or  locomo¬ 
tor  ataxia,  is  soon  to  appear,  in  which  that  subject  is  very  thor¬ 
oughly  and  philosophically  considered,  the  writer  especially 
dwelling  upon  the  subject  of  laryngeal  crises  in  tabes.  The 
conjoined  study  of  such  cases  by  laryngologists,  neurologists, 
and  pathologists  is  particularly  desirable. 

Dr.  Bosworth:  I  fail  to  recall  any  well-authenticated  case 
of  laryngeal  paralysis  in  which  the  symptoms  were  due  to  cor¬ 
tical  lesion ;  any  case  of  central  disease  where  it  was  shown 
post  mortem  that  the  cause  of  the  paralysis  was  not  in  the  bulb 
and  was  in  the  brain.  In  the  noted  case  referred  to  by  Dr. 
Delavan,  the  reporter  has  had  reasons  submitted  to  him  for 
naking  a  change  in  his  diagnosis  since  that  case  was  published. 
Gottstein’s  cases  attracted  attention  to  this  subject,  but  he  did 
lot  go  much  further  than  Hughlings  Jackson,  who,  from  a  series 
-if  clinical  observations,  concluded  that  the  source  of  the  paraly- 
-is  of  the  laryngeal  muscles  was  in  the  medulla. 

Dr.  Delavan:  In  reply  to  the  last  remark,  physiological 
-Xperiuients  upon  monkeys,  dogs,  and  cats  have  clearly  shown 
hat  a  cortical  center  for  the  larynx  does  exist  in  them  ;  if  it  is 


present  in  the  lower  animals,  as  has  been  conclusively  proved, 
it  is  proper  to  assume,  by  analogy,  that  such  a  center  also  exists 
in  man.  Even  if  it  has  not  yet  been  fully  demonstrated  by 
post-mortem  examination,  this  failure  may  be  owing  to  faulty 
methods  and  imperfect  investigation.  The  center  undoubtedly 
exists.  There  are  cases  in  which  laryngeal  paralysis  has  oc¬ 
curred,  and  in  which  no  bulbar  lesion  was  found  after  careful 
search,  where  the  lesion  was  evidently  in  the  brain.  In  the 
cases  I  have  reported  the  existence  of  a  bulbar  lesion  was  dem¬ 
onstrated  ;  there  are  other  cases  on  record  where  there  was  no 
such  lesion  found,  but  where,  on  the  other  hand,  there  was  dis¬ 
tinct  lesion  of  the  cortex. 

Dr.  Bosworth:  Psychical  centers  for  the  larynx  in  the  cor- 
j  tex  I  am  willing  to  admit,  but  not  motor. 

The  President  inquired  what  experiments  were  referred  to 
as  those  upon  which  Jackson’s  views  were  based. 

Dr.  Bosworth:  Jackson’s  views  were  not  based  upon  ex¬ 
periments,  but  upon  cases.  Some  years  ago,  in  a  paper  upon 
this  subject,  the  speaker  discussed  this  question,  and  the  whole 
subject  was  gone  over.  There  are  practically  but  two  forms  of 
laryngeal  paralysis — abductor  paralysis  and  recurrent  laryngeal 
paralysis. 

The  President:  In  closing  the  discussion,  I  have  only  one 
thing  to  say.  Dr.  Bosworth  seems  to  doubt  the  diagnosis  of 
bulbar  disease  in  the  case,  and  believes  it  to  be  one  of  neuritis 
of  the  trifacial  nerve.  How  trifacial  neuritis  could  produce 
the  symptoms  recorded  I  am  at  a  loss  to  know.  Unless  the  tri¬ 
facial  was  distributed  to  the  throat  and  back  of  the  neck,  the 
oesophagus,  tongue,  and  other  organs,  the  dorsal  region  and 
lower  extremities,  as  well  as  to  the  face,  loss  of  its  function  could 
not  produce  the  phenomena  present  in  the  patient.  The  symp¬ 
toms  as  recorded  correspond  closely  with  those  presented  by 
others  as  symptomatic  of  bulbar  disease,  and  I  can  only  con¬ 
clude  that  he  must  have  failed  to  hear  the  notes  of  the  case  as 
I  read  them. 

(To  be  continued.) 


ROYAL  ACADEMY  OF  MEDICINE  IN  IRELAND. 

SECTION  IN  MEDICINE. 

Meeting  of  April  11,  1890. 

The  President,  Dr.  Attiiill,  in  the  Chair. 

Massage. — Dr.  Kendal  Franks  read  a  paper  on  this  sub¬ 
ject.  He  began  by  a  historical  sketch  to  show  that  this  meth¬ 
od  of  treatment  was  not  a  novel  one,  that  it  dated  back  to  the 
earliest  times,  and  was  used  among  all  the  nations  of  the  world. 
It  fell  into  disrepute  among  physicians  and  surgeons,  becau.-e  it 
was  allowed  to  fall  into  the  hands  of  charlatans  and  quacks; 
but  that  in  recent  times  it  had  been  revived,  and  had  been  taken 
up  and  practiced  by  leaders  in  the  profession  in  every  country, 
and,  owing  cbietiy  to  anatomical  and  physiological  advances, 
massage  had  secured  a  position  in  therapeutics  from  which  it 
could  not  well  be  removed.  He  then  explained  its  physiological 
modus  operand i,  and  showed  that  the  effects  it  produced  could 
scarcely  be  brought  about  by  other  means.  He  quoted  cases  to 
.-how  its  power  in  neurasthenia,  and  quoted  one  case  to  show 
that  even  when  massage  was  followed  immediately  by  a  fall  in 
the  temperature  of  the  body,  this  was  not  always  a  contra-indi¬ 
cation  to  its  use.  Another  illustration  showed  how  its  effects 
were  interfered  with  by  unsanitary  conditions,  but  that  a  good 
result  immediately  followed  a  change  of  lodgings.  General 
neuralgic  pains,  accompanied  by  sciatica  on  one  side,  with  a  his¬ 
tory  of  fourteen  years,  was  cured  by,  firstly,  nerve-stretching  of 
the  sciatic,  and,  secondly,  by  general  massage.  An  aggravated 
case  of  insomnia,  with  great  depression,  existing  on  and  off  for 
years,  yielded  completely  to  a  course  of  this  treatment.  The 


proceedings  of  societies. 


[N.  Y.  Med.  Jouk., 


188 

use  of  massage  in  certain  paralytic  affections  was  dealt  with, 
and  the  cases  in  which  it  was  likely  to  succeed  were  indicated. 
These  were  illustrated  by  the  history  of  a  case  of  infantile-pa¬ 
ralysis,  and  by  a  case  of  complete  paraplegia  of  both  legs  from 
the  hips  down,  which  followed  a  severe  attack  of  malarial  ty¬ 
phoid  fever  contracted  in  Cyprus.  The  treatment,  which  ex¬ 
tended  over  the  best  part  of  a  year,  was  followed  by  complete 
cure.  The  speaker  advocated  a  modified  system  of  massage  in 
cases  of  gout,  by  which  he  had  found  that  a  fresh  attack  of  the 
disease  was  long  delayed,  and  immediate  relief  was  speedily  at¬ 
tained.  In  surgical  cases  local  massage  was  frequently  useful, 
and  produced  astonishing  results  in  recent  sprains  and  fractures. 

In  a  case  of  Pott’s  fracture,  massage  was  employed  eighteen 
days  after  the  accident,  and  the  patient  was  enabled  to  walk 
with  ease,  with  a  freely  movable  and  painless  joint  twenty-two 
days  later.  A  boy,  aged  fifteen  (who  was  exhibited  at  the 
meeting),  with  a  transverse  fracture  of  both  bones  of  the  leg, 
was  abfe  to  raise  the  leg  from  the  bed  without  assistance  on  the 
twentieth  day,  and  was  able  to  walk  about  with  a  light  support 

on  the  leg  on  the  twenty-sixth  day. 

Dr.  Cox  believed,  from  what  he  had  read  of  the  experience 
of  Weir  Mitchell  and  Playfair,  that  the  importance  of  massage, 
carried  out  in  detail,  combined  with  high  feeding,  rest,  and  iso¬ 
lation,  could  not  be  exaggerated ;  but,  of  course,  bodily  exercise 
achieved  better  results  than  massage  in  stimulating  respiration 

and  the  circulation  of  the  blood. 

Dr.  Ormsby  said  he  had  had  considerable  experience  with 
massage  since  1880,  and  he  was  fully  sensible  of  the  utility  of 
that  method  of  treatment  in  suitable  cases;  for  instance,  in  the 
case  of  a  young  lady,  who  for  nearly  three  years  occupied  a  re¬ 
cumbent  position  suffering  from  hystero- paralysis,  he  bad 
adopted  massage  as  part  of  the  Weir-Mitchell  treatment,  and  it 
had  proved  highly  beneficial,  after  almost  every  other  form  of 
treatment  had  failed ;  but  there  were  many  cases  in  which 
hysterical  young  ladies,  when  the  treatment  was  abandoned, 
relapsed.  Massage  of  itself  would  not  suffice.  He  had  more 
faith  in  Weir-Mitch ell’s  treatment,  which  combined  massage 
with  seclusion,  rest,  electricity,  and  dietetics.  While  regarding 
massage  as  a  valuable  agent  in  suitable  cases,  he  was  satisfied 
that  it  was  not  a  cure-all,  and  that  from  its  indiscriminate  use 
it  was  desirable  the  treatment  should  be  placed  on  a  scientific 
basis.  He  held  that  massage  in  surgery  for  recent  fractures  was 
wholly  out  of  place,  and  he  could  not  understand  how  any  sur¬ 
geon  of  experience  would  adopt  it  in  a  compound  fracture  or  a 
Pott’s  fracture.  In  the  case  of  the  valet  referred  to  it  might 
have  been  that  there  was  no  fracture  at  all.  It  was  not  uncom¬ 
mon  to  find  instances  of  resident  pupils  putting  up  accidents  as 
fractures  which,  on  examination  by  the  visiting  surgeon,  proved 
not  to  be  fractures. 

Dr.  Tobin  mentioned  that  in  the  northern  parts  of  India  he 
had  seen  massage  adopted  to  put  horses  into  marketable  condi¬ 
tion  with  the  minimum  expenditure  of  material.  Balls  coin- 
posed  largely  of  ghee  and  sugar  were  shoved  into  the  horse’s 
throat,  and  some  hours  afterward  the  animal  was  massaged  at 
the  particular  parts  where  development  was  desired.  The 
masseur  with  gloved  hands  pounded  the  flesh  at  those  parts; 
but  the  horse  was  never  exercised,  and  so  the  required  develop¬ 
ment  was  brought  about  in  the  cheapest  way.  Although  the 
horses  were  bought  in  large  numbers  for  the  artillery,  he  did 
not  consider  the  animals  were  in  condition  to  “  go,”  their  lungs 
and  heart  not  being  in  a  corresponding  state  of  development. 
Hence  he  thought  it  was  advisable  to  combine  exercise  with 
massage.  Indeed,  remembering  how  old  the  practice  of  mas¬ 
sage  was,  it  seemed  anomalous  that  medical  men  should  have 
abandoned  it  for  their  patients,  while  they  kept  it  in  force  for 
their  horses,  which  always  throve  when  well  groomed. 


Dr.  Wallace  Beatty  said  he  had  had  experience  ot  a  re¬ 
markable  instance  in  1884  of  the  benefit  of  massage.  An  array 
medical  man  who  had  been  in  India  had  got  intermittent  fever 
and  had  lost  the  power  of  digestion,  so  that  he  had  been  unable 
to  take  anything  but  milk,  and  that  in  small  quantity.  Any 
other  food  had  produced  heartburn  and  made  him  miserable. 

A  Dublin  physician,  who  had  treated  him  for  two  or  three 
months  without  doing  any  good,  was  of  opinion  that  he  had 
malignant  disease  of  the  stomach.  At  length  the  patient  had 
come  to  him,  and  he  had  seen  him  along  with  Dr.  Head.  \  a- 
rious  things  had  been  fruitlessly  tried.  The  patient  was  losing 
flesh— from  ten  stone  he  had  gone  down  to  seven,  and  his 
tongue  had  been  constantly  furred.  As  a  last  resource,  he  had 
proposed  to  try  massage ;  and  the  patient,  having  consented,  had 
been  placed  in  the  Adelaide  Hospital,  where  his  brother,  who 
was  a  strong  man,  was  also  accommodated  in  order  to  massage 
him.  Id  nine  days  his  tongue  had  got  clean,  he  had  gained  a 
stone  in  weight,  and  from  that  out  his  progress  to  recovery  had 
gone  on  till  he  was  able  to  resume  duty  in  Dublin. 

Dr.  M.  A.  Boyd  said  he  had  had  some  five  or  six  cases 
treated  by  massage,  and  two  of  these  with  such  success  as  to 
make  a  great  impression  upon  him.  One  was  that  ot  a  lady, 
aged  fifty,  who  had  had  sciatica  of  two  years’  standing,  for 
which  she  bad  been  blistered,  fired,  and  punctured,  and  received 
hypodermic  injections  of  morphine,  and  even  electricity,  with¬ 
out  avail.  At  last  he  had  tried  massage,  and  in  three  weeks  the 
pain  had  disappeared.  The  lady  had  remained  well  for  two 
months,  when  she  had  got  sciatica  in  the  opposite  side.  After 
three  weeks’  treatment  by  massage  the  pain  had  disappeared 
altogether.  The  other  case  was  one  of  alcoholic  neuritis,  which, 
havfng  resisted  treatment  by  electricity,  had  been  ultimately 
cured  by  massage.  Dr.  Franks  had  omitted  to  notice  that  very 
important  group  of  paralytic  cases— namely,  paralysis  depend¬ 
ing  on  neuritis.  .  . 

Dr.  Alfred  Smith  said  he  had  found  massage  beneficial  in 

cases  of  prolapse  of  the  uterus,  and  of  accumulations  of  the  pel- 
vis,  the  products  of  cellulitis,  as  he  had  already  detailed  in  a 
communication  which  he  had  read  before  the  Obstetrical 
Section. 

Dr.  Heuston  observed  that  he  had  employed  massage  with 
signal  success  in  a  case  of  traumatic  paraplegia.  A  soldier  in 
the  Egyptian  campaign  had  been  occupied  at  earthworks  which 
had  fallen  in,  buryrng  him  in  the  debris.  When  dug  out  he  had 
been  found  to  be  insensible,  and  upon  being  restored  he  had  had 
paraplegia.  He  had  been  sent  to  the  base  hospital  at  Cairo,  and 
thence  he  had  been  invalided  home  to  Netley,  where  he  had 
been  kept  for  a  year,  till  he  could  move  about  on  crutches. 
Having  been  discharged,  he  had  gone  home,  and  after  a  couple 
of  years  he  had  been  able  to  go  about  with  the  aid  of  sticks. 
Then  he  had  suffered  from  his  bowels  and  suppression  of  urine. 
Having  taken  him  into  the  Adelaide  Hospital,  under  massage 
treatment  he  had  recovered,  and  had  been  able  to  walk  aboul 
in  two  months,  when  be  had  been  discharged  cured. 

Dr.  Ninian  Falkiner  suggested  the  utility  of  massage  ii 
amenorrhcea  to  bring  on  the  menstrual  flow. 

Dr.  Franks  replied.  Massage  would  be  found  beneficial  h 
infantile  paralysis,  owing  to  the  great  developmental  power  u 
the  child,  while  it  was  not  so  likely  to  succeed  in  arresting  pro 
gressive  atrophy  in  the  adult.  Dr.  Ormsby’s  strictures  on  tb 
use  of  massage  in  fractures  were  founded  on  theory  onlj 
There  was  no  error  in  diagnosticating  the  fracture,  and  he  wa 
satisfied  that  the  results  described  had  been  achieved  by  raae 
sage,  which  he  believed  would  be  the  great  treatment  of  tb 
future  for  fractures.  He  did  not  refer  to  compound  fractures 
in  which  he  would  hesitate  to  employ  massage ;  nor  could  h 
speak  positively  of  the  treatment  in  certain  oblique  fractures,  c 


August  16,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


189 


fractures  about  the  neck  of  the  thigh  bone.  But  what  he 
claimed  for  massage  was  that  it  induced  rapidity  of  union  with¬ 
out  deformity  by  preventing  adhesions  from  forming  around 
joints.  As  regarded  the  interesting  cases  referred  to  by  Dr. 
Smith,  he  had  himself  advised  massage  in  a  case  of  retroflexed 
uterus,  for  which  a  pessary  was  used.  The  pessary  was  re¬ 
moved,  and,  massage  having  been  tried,  the  uterus  became  nor¬ 
mal,  and  there  was  no  need  to  put  in  a  pessary  again. 

SECTION  IN  STATE  MEDICINE. 

Meeting  of  April  25,  1890. 

The  President,  Dr.  Foot,  in  the  Chair. 

The  Infectious  Diseases  (Notification)  Act,  1889— Dr. 

Cosgrave  read  a  paper  on  this  subject  and  its  extension  to 
Dublin.  Breach  of  confidence  might  apply  to  voluntary  notifi¬ 
cation,  but  once  notification  was  required  by  the  Legislature, 
there  was  no  breach  of  confidence,  but  the  notification  was  put 
on  the  same  footing  with  a  certificate  of  cause  of  death  or  of 
successful  vaccination.  Dr.  Cameron,  of  Leeds,  had  shown  that 
voluntary  notification  had  only  dealt  with  from  one  case  in  five 
to  one  case  in  three,  and  then  often  after  the  power  of  doing 
good  was  gone.  The  small  fee  was  objectionable  from  a  medi¬ 
cal  man’s  point  of  view,  but  a  guinea  fee  would  be  decidedly 
objectionable  to  the  rate-payers.  The  act  came  into  force  in 
Dublin  on  March  1st,  but  had  not  yet  been  acted  upon.  When 
it  was,  its  success  would  depend  upon  the  skill  and  tact  of  the 
sanitary  officials  and  upon  the  hearty  co-operation  of  the  medi¬ 
cal  men.  The  sanitary  officials  ought  to  be  skilled  and  to  be 
required  to  pass  an  examination  under  some  independent  body 
before  being  appointed.  The  act  was  already  in  force  among 
three  fourths  of  the  population  of  Great  Britain,  and  the  medi¬ 
cal  officers  of  health  had  generally  reported  in  its  favor. 

The  President  said  it  was  one  thing  for  the  Legislature  to 
lay  down  a  scheme  for  discovering  the  causes  of  disease,  track¬ 
ing  its  sources  and  stamping  it  out,  but  it  was  another  to  carry 
out  that  scheme  successfully;  and,  in  his  opinion,  the  workabil¬ 
ity  of  compulsory  notification  would  depend  on  the  general 
practitioners.  He  missed  from  the  act  the  salutary  provision 
of  insisting  on  having  observation  wards  for  the  reception  of 
cases  of  doubtful  diagnosis,  such  as  were  at  present  attached  to 
some  of  the  general  hospitals.  It  would,  he  thought,  be  action¬ 
able  if  a  person  erroneously  notified  as  suffering  from  diphtheria 
or  scarlatina  were  bundled  off  to  a  hospital  for  infectious  dis¬ 
eases  and  there  got  one  of  those  infectious  diseases. 

Dr.  William  Moore  was  glad  to  learn  from  Dr.  Cosgrave’s 
personal  experience  that  compulsory  notification  was  not  in  the 
slightest  degree  irksome.  He  regarded  the  system  as  being  of 
enormous  advantage.  The  probability  of  the  advantage  of  the 
system  in  epidemics  of  small-pox  or  scarlatina  was  indicated  by 
the  fact  that  in  one  outbreak  forty  cases  were  traceable  to  the 
existence  of  scarlatina  in  a  milkman’s  shop.  He  deprecated  the 
shabby  treatment  of  the  profession  by  the  Legislature  in  award¬ 
ing  the  miserable  pittances  of  2a.  Gd.  and  la.  as  fees. 

Dr.  Grimshaw,  Registrar-General,  said  that  the  principal 
difficulty  turned  on  the  question  of  removal  to  hospital  of  the 
cases  notified  without  risk.  There  must  always  be  the  diffi¬ 
culty  of  mistaken  diagnosis;  and  hence  it  was  incumbent  on 
the  health  authorities  of  the  city  to  see  that  proper  observation 
wards  were  provided  for  the  reception  of  doubtful  cases.  In¬ 
deed,  he  considered  it  would  be  little  short  of  criminal  neglect 
if  such  wards  were  not  provided.  The  idea  that  people  could 
not  get  two  infectious  diseases  at  the  same  time  was  dead  and 
buried  long  ago;  and,  therefore,  he  thought  the  leaders  of  the 
medical  profession  should  press  upon  the  authorities  the  neces¬ 
sity  of  making  provision  for  the  difficulties  of  mistaken  diag¬ 


nosis.  He  did  not  think  there  was  any  grievance  in  having  to 
notify  infectious  diseases.  As  to  the  physician  disclosing  the 
patient’s  confidence,  once  compulsory  notification  became  the 
law  of  the  land,  the  question  of  confidence  was  at  an  end. 
Every  medical  officer  of  health  whom  he  had  spoken  to  testified 
to  the  diminution  of  disease  as  the  result  of  notification. 

Dr.  R.  Montgomery  thought  that  the  opinion  of  the  Section, 
as  indicated  in  the  remarks  of  the  Registrar-General,  should  be 
communicated  to  the  Dublin  Corporation  and  the  Board  of 
Guardians,  so  that  observation  wards  might  be  provided  for 
doubtful  cases. 

Dr.  Doyle  was  of  opinion  that  the  interests  of  general 
practitioners  would  suffer  under  the  act  unless  they  were  en¬ 
abled  to  follow  their  cases  into  hospital.  Even  at  present  there 
were  many  cases  of  persons  well  able  to  pay  who,  by  going  into 
hospital  for  operations,  were  lost  to  the  general  practitioners. 
While  he  was  not  an  opponent  of  compulsory  notification,  he 
would  devise  some  means  of  avoiding  the  injustice  of  depriving 
general  practitioners  of  their  pay  cases. 

Dr.  Cosgrave,  in  reply,  said  the  public  health  authorities 
were  bound  to  provide  proper  accommodation  where  it  did  not 
exist.  In  Cork  Street  Hospital  observation  wards  were  worked 
with  great  care  to  prevent  the  mixing  of  different  infectious 
diseases.  It  was  the  fever  wards  in  general  hospitals  that  were 
so  dangerous.  He  considered  the  smallness  of  the  fee  fixed  by 
the  act  a  necessity,  and  suggested  that  those  who  did  not  care  to 
take  it  might  let  it  go  to  the  Medical  Benevolent  Fund. 

The  State  Medicine  Qualification.— Dr.  Grimshaw  read  a 
paper  on  this  subject. 

The  President  was  of  opinion  that  there  ought  to  be  two 
qualifications,  a  higher  and  a  lower,  in  state  medicine — a  lower 
grade  for  the  common-sense  practical  man,  with  a  good  nose, 
and  knowing  something  of  the  rough  diagnosis  of  infectious 
disease,  and  the  higher  for  those  who  would  be  called  on  to  ad¬ 
vise  in  the  weighty  matters  of  social  science. 

Dr.  William  Moore  held  that  the  humblest  in  the  community 
were  entitled  to  the  best  advice;  and  he  thought  that  the  ma¬ 
jority  of  the  examining  bodies  had  accepted  the  suggestions  of 
the  General  Medical  Council. 

The  Boarding-out  System  for  the  Insane.— Dr.  Conolly 
Norman  read  a  paper  on  the  boarding  out  of  pauper  lunatics. 
While  asylums  were  a  matter  of  necessity  for  a  large  number  of 
the  insane,  they  could  never  be  made  homes.  Therefore  such 
lunatics  as  could  live  outside  asylums  would  be  happier  and  bet¬ 
ter,  if  under  suitable  supervision,  than  those  who  were  incar¬ 
cerated  in  public  institutions  for  life.  Economic  and  other  con¬ 
siderations  were  of  less  consequence  than  the  advantage  that 
might  accrue  to  the  insane  under  favoring  circumstances  and 
under  a  well-worked  system  of  boarding  out.  The  speaker 
briefly  considered  the  working  of  the  Gheel  system  and  the 
Scotch  boarding  out.  He  very  strongly  condemned  certain 
features  in  Gheel — the  boarding  out  of  dirty  and  semi-dirty 
patients,  the  boarding  out  of  patients  in  estaminets,  the  use  of 
restraint,  and  the  too  great  liberty  accorded  to  some  better-class 
patients.  The  Scotch  system  afforded  a  better  model.  He  laid 
down  the  conditions  necessary  to  render  patients  suitable  for 
boarding,  and  the  restrictions  and  safeguards  under  which  such 
a  system  must  be  worked.  He  differed  with  the  Scotch  authori¬ 
ties  in  objecting  generally  to  the  boarding  out  of  epileptics. 
He  referred  to  the  special  enactments  of  the  Scotch  law  on  this 
subject,  and  briefly  to  Mr.  Trevelyan’s  Irish  bill,  which  did  not 
become  law,  one  object  of  which  was  to  found  a  boarding-out 
system  in  Ireland. 

Dr.  William  Moore  said  the  increase  of  lunacy  in  the  County 
Antrim  was  occupying  the  attention  of  a  committee  as  regarded 
the  disposal  of  harmless  lunatics,  and  the  provision  of  further 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mud.  Joor., 


190 


accommodation  to  meet  the  increase.  The  boarding-ont  plan 
suggested  a  means  of  providing  for  the  harmless  lunatics  with¬ 
out  incurring  the  cost  of  building  a  big  asylum. 

Dr.  R.  Montgomery  said  he  had  had  experience  of  the  suc¬ 
cess  of  the  boarding-out  system. 

Dr.  Doyle  mentioned  that  the  son  of  a  patient  of  his  own 
had  spoken  of  Gheel  in  the  highest  terms  from  personal  experi¬ 
ence.  The  charge  was  £40  a  year  in  his  case. 

Dr.  Conolly  Norman,  in  reply,  said  there  was  no  doubt  that 
Gheel  had  done  very  good  work ;  but  there  was  too  much  free¬ 
dom  there  on  the  one  hand,  and  too  much  restraint  on  the  other, 
and  so  it  was  not  up  to  his  ideal  of  the  treatment  of  lunatics. 
He  did  not  approve  of  sending  lunatics  to  workhouses,  as  being 
institutions  with  all  the  faults  of  the  lunatic  asylums  and  very 
few  of  an  asylum’s  virtues. 


SECTION  IN  SURGERY. 

Meeting  of  March  28,  1890. 

The  President,  Mr.  Meldon,  in  the  Chair. 

Cicatricial  Stricture  of  the  (Esophagus.— Mr.  Kendal 
Franks  read  a  paper  embodying  the  histories  of  four  cases  of 
cicatricial  stricture  of  the  oesophagus.  The  first  case  was  that 
of  a  girl,  aged  twenty,  the  details  of  which  were  published  in 
the  Medical  Press  and  Circular  in  1882.  The  treatment  em¬ 
ployed  in  this  case  was  forcible  rupture  of  the  stricture,  with 
the  subsequent  daily  passage  of  bougies  The  treatment  occu¬ 
pied  over  two  months:  Now,  at  the  end  of  eight  years,  she 
was  perfectly  well.  The  second  case  was  that  of  a  lady,  aged 
thirty,  who  came  under  treatment  in  December,  1883.  The 
history  of  dysphagia  extended  over  nearly  fourteen  years.  The 
treatment  employed  was  gradual  dilatation  with  bougies,  and  it 
occupied  nearly  seven  months.  She  had  enjoyed  perfect  free¬ 
dom  from  dysphagia  ever  since.  A  bougie  was  passed  for  her 
about  twice  a  year.  The  third  case  was  that  of  a  lady,  aged 
forty -three,  who  came  under  treatment  in  June,  1886,  for  dys¬ 
phagia,  dating  back  for  nearly  fifteen  years.  The  treatment 
adopted  was  electrolysis,  with  the  occasional  passage  of  bougies. 
The  treatment  was  employed  on  sixteen  separate  days.  She 
had  had  no  difficulty  in  swallowing  since  then.  The  fourth 
case  was  that  of  a  railway  guard,  aged  sixty-eight,  who  came 
up  for  treatment  on  the  17th  of  December  last.  The  history  of 
dysphagia  went  back  seven  or  eight  years.  Two  strictures  ex¬ 
isted— one  four  centimetres  below  the  upper  end  of  the  oesopha¬ 
gus,  the  other  four  to  six  centimetres  above  the  lower  end 
The  treatment  adopted  was  immediate  rupture  of  the  strictures, 
the  passage  of  bougies  daily,  and  electrolysis.  The  treatment 
occupied  a  month.  The  patient  gained  twenty-eight  pounds  in 
weight  in  less  than  three  months,  and  could  swallow  his  food 
with  ease.*  The  passage  of  a  large  bougie  was  employed  every 
second  day  still  by  Dr.  Ford,  of  Waterford,  under  whose  care 
the  patient  was  at  present. 

The  speaker  pointed  out  the  remarkable  contrast  in  the 
duration  of  the  treatment  between  the  cases  in  which  electrol¬ 
ysis  was  employed  and  those  in  which  it  was  not,  but  that 
further  evidence  was  required  to  ascertain  if  this  contrast  were 

constant. 

^  Hamilton  said  cases  of  stricture  of  the  OBSophagus  wore 
by  no  means  common,  and  one  of  the  most  mysterious  prob 
lems  in  surgery  was  as  to  how  they  took  place  at  all.  Of  the 
three  methods  of  treatment  submitted  for  consideration  in  Mr. 
Franks’s  paper,  he  would  adopt  that  of  gradual  dilatation,  or, 
that  failing,  then  of  electrolysis,  rather  than  the  method  of 
sudden  and  rapid  dilatation  by  means  of  the  instrument  ex- 

Mr.  W.  Tiiornley  Stoker  concurred  with  Mr.  Hamilton. 


ure. 


The  treatment  which  he  had  been  in  the  habit  of  using  was  that 
of  gradual  dilatation,  and  he  condemned  that  of  internal  ceso- 
phagotomy. 

Mr.  Edgar  Flinn  said  he  saw  the  second  patient  whose  case 
had  been  described.  She  was  suffering  from  an  ordinary  ca¬ 
tarrh,  but  she  was  in  perfect  health,  save  nervous  debility,  be¬ 
ing  apprehensive  of  a  return  of  the  stricture. 

°Mr.  T.  Myles,  without  questioning  the  accuracy  of  Mr. 
Franks’s  diagnosis,  would  feel  hardly  justified  in  assuming  that 
all  the  cases  described  were  cases  of  purely  fibrous  strictures. 
He,  too,  agreed  with  Mr.  Hamilton  as  to  the  inadvisability  either 
of  cutting  operations  on  the  oesophagus,  or  of  forcible  dilata¬ 
tion,  as  its  walls  were  thin,  unresisting,  and  easily  penetrable, 
even  with  the  point  of  a  comparatively  blunt  instrument. 

Mr.  Franks,  in  reply,  said  the  instrument  which  he  used, 
dilated  to  its  fullest  extent,  would  not  injure  any  normal  oesoph¬ 
agus,  as  being  within  the  size  of  the  normal  oesophagus  in 
health.  As  regarded  diagnosis,  the  history  of  his  cases  differed 
entirely  from  that  of  neurotic  cases  in  which  the  dysphagia  was 
intermittent ;  and,  as  a  rule,  in  oesophageal  strictures  the  diag¬ 
nosis  could  not  be  certain  without  passing  a  bougie.  He  did 
not  think  he  bad  been  mistaken  in  his  diagnosis,  and  he  had  no 
doubt  that  the  cases  were  cases  of  cicatricial  or  fibrous  striet- 
The  electrolysis  facilitated  the  use  of  the  bougies. 

A  Rare  Case  of  Congenital  Form  of  Ranula.— Dr.  Edgar 
Flinn  said,  in  a  paper  read  before  the  Moscow  Medical  Society, 
by  Dr.  N.  Muller,  on  Ranula  in  New-born  Children,  he  stated 
that  in  the  foundling  hospital  at  Moscow  four  or  five  cases  of 
congenital  ranula  had  been  observed  during  a  period  of  seven 
years  in  about  eighty  thousand  children.  And  the  London 
Medical  Record,  of  December,  1877,  mentioned  that  up  to  tlmt 
period  there  were  only  two  known  instances  of  this  affection 
on  record— one  published  by  Dubois  in  1833,  and  a  second  of 
more  recent  date  by  M.  Lombard.  Mr.  Bryant  recorded  two  cases, 
both  probably,  he  stated,  congenital,  and  Sir  W.  Ferguson  one. 

The  case  of  ranula  under  notice  resembled  that  class  of  tumoi 
noticed  by  Fairlie  Clark;  it  presented  some  peculiar  and  inter 
esting  features,  which  were  deemed  worthy  of  recording,  mor< 
especially  as  the  growth  was  noticed  on  the  second  day  aftei 
birth,  and  the  subject  was  now  nearly  twenty-nine  years  old 
The  patient  was  admitted  into  St.  Michael  s  Hospital,  Kings 
towD,  under  Dr.  Flinn’s  care.  He  presented  a  peculiar  appear 
ance ;  at  first  sight  he  gave  one  the  impression  that  he  was  suffer 
ing  from  acute  glossitis.  His  mouth  was  wide  open,  and  it  wa 
with  great  difficulty  he  could  articulate;  the  tumor  very  nearl 
filled  the  entire  cavity  of  the  mouth.  The  tongue  was  pusbe 
upward  and  far  backward,  and  could  with  difficulty  be  felt  wit 
the  tip  of  the  finger.  The  growth  also  projected  beneath  th 
jaw  into  the  mylo-hyoid  space,  and  assumed  an  elongated  shap< 
In  this  situation,  being  about  five  to  six  inches  in  length,  it  wj 
hidden  from  view  by  the  patient’s  beard,  and  was  as  large  as 
good-sized  orange.  The  projection  into  the  cavity  of  the  mout 
commenced  to  cause  inconvenience  about  eight  months  prior  ' 
the  date  of  his  admission,  and  for  over  a  month  he  had  exper 
enced  great  difficulty  in  swallowing;  he  daily  essayed  to  g 
some  solid  food  down,  but  it  was  quite  an  ordeal  to  do  so,  as 
required  a  good  deal  of  manipulation  to  get  the  food  to  tl 
back  of  the  mouth.  There  was  a  continual  dribbling  of  saliv 
and  he  was  unable  to  lie  down  in  a  recumbent  position  for  fe 
of  suffocation.  On  examining  the  tumor,  fluctuation  was  qui 
evident  in  the  mass  in  the  mouth,  hut  in  the  neck  it  partook 
a  more  solid  nature.  The  treatment  that  suggested  itself  on  I 
admission  was  to  aspirate  that  portion  of  the  mass  within  t 
mouth,  which  was  done  at  once.  Nearly  fifteen  ounces  of  fh 
of  a  creamy  nature  was  drawn  off,  and  gave  him  great  relb 
he  could  speak  more  distinctly,  but  found  difficulty  in  raovi 


August  16,  1890.] 


SPECIAL  ARTICLES. 


191 


his  tongue  forward.  For  a  day  or  so  the  tumor  rapidly  filled 
again  in  the  mouth,  and  was  aspirated  a  second  and  a  third  time, 
large  quantities  of  a  similar  fluid  as  before  being  drawn  off'. 
The  mass  now  on  the  neck  became  softer,  and  deep-seated  fluc¬ 
tuation  could  be  detected.  It  was  then  decided  to  lay  open  the 
tumor  from  the  neck,  which  was  done  by  a  deep  incision,  and 
which  gave  vent  to  some  five  ounces  of  a  thick,  brown,  pulta- 
ceous  matter,  offensive  in  odor.  The  cavity  was  scooped  care¬ 
fully  out  and  a  drainage-tube  inserted,  and,  after  a  day  or  so, 
there  was  some  suppuration  and  a  free  discharge  of  pus.  Sub¬ 
sequently  the  patient  left  the  hospital  freed  from  the  unsightly 
mass  that  had  disfigured  him  for  so  many  years.  Tbe  case  was 
considered  of  interest  from  the  fact  of  this  tumor  being  so  long 
in  existence,  the  patient  being  now  nearly  twenty-nine  years 
old. 

Mr.  W.  Thornley  Stoker  exhibited  the  photograph  of  a 
girl,  aged  four,  who  had  a  congenital  tumor  occupying  the 
tongue  and  floor  of  the  mouth  to  such  an  extent  that  she  could 
not  shut  her  mouth  since  her  birth.  Having  cut  into  it,  be 
found  it  was  a  cyst — a  ranula— filled  with  a  thick  fluid  of  abomi¬ 
nable  odor.  He  drained  it  by  a  large  drainage-tube  passed 
transversely  through  the  floor  of  the  mouth  below  the  tongue, 
but  no  sooner  was  the  tube  taken  out  than  the  sac  filled  again 
with  pus.  At  length  he  drained  it  from  the  floor  under  the 
tongue,  and  it  healed  with  ease  and  rapidity.  Owing  to  the 
fact  that  the  child  had  never  been  able  to  close  the  mouth,  the 
molar  teeth  struck  each  other,  while  the  upper  and  lower  in¬ 
cisors  were  an  inch  distant,  the  jaw  retaining  its  abnormal 
position.  He  proposed  to  put  an  elastic  apparatus  on  at  night, 
with  a  view  to  raise  the  front  of  the  jaw  by  gradual  pressure. 

Mr.  Hamilton  also  related  an  instance  of  the  value  of  treat¬ 
ment  by  a  bold  external  incision  for  ranula,  emptying  the  tumor 
by  means  of  a  free  incision  along  the  base  of  the  jaw. 

Mr.  Flinn,  in  reply,  regretted  that  the  urgency  of  his  case 
at  the  time  prevented  him  from  getting  the  patient  photo¬ 
graphed. 


Serial 

LETTERS  TO  MY  HOUSE  PHYSICIANS. 

By  WILLIAM  OSLER,  M.  D., 

BALTIMORE. 

Letter  III. 

Munich,  May  27,  1S90. 

Dear  R. :  At  Zurich  we  found  Professor  Eichhorst  just  about  to  go 
off  for  the  day,  but  he  very  kindly  took  us  through  wards  full  of  in¬ 
structive  cases,  among  which  were  very  many  of  pneumonia,  which  he 
said  was  almost  epidemic.  There  are  special  pavilions  for  contagious 
diseases,  and  we  were  very  much  interested  to  see,  for  the  first  time, 
the  cases  of  phthisis  isolated,  a  plan  which  had  been  carried  out  here 
for  some  years.  Perhaps  in  old  hospitals  with  insufficient  ventilation 
this  precaution  may  be  necessary,  but  the  experiments  of  Cornet  show 
that  the  bacilli  are  not  always  present  in  the  dust  of  wards  in  which 
there  are  patients  with  phthisis.  The  question  is  one  attracting  a  great 
deal  of  attention  in  Germany,  and  I  send  you  a  paper  by  Professor 
Finkelnburg,  of  Bonn,  in  which  he  advocates  strongly  the  erection  of 
public  sanatoria  for  consumptives.  Another  pamphlet  on  this  subject 
by  Comet —  Wie  scliutzt  man  sichgegen  die  Schwindsucht  ? — will  also  inter¬ 
est  you.  The  main  point  which  he  maizes  is  the  prevention  of  the  des¬ 
iccation  of  the  sputa  by  the  stringent  use  of  spit-cups  and  the  proper 
disinfection  of  the  same.  Professor  Eichhorst’s  clinical  laboratories  are 
large,  conveniently  arranged  rooms,  two  of  which  are  especially  equipped 
for  bacteriological  and  chemical  work.  The  latter  is  in  charge  of  a 
young  chemist,  not  a  medical  man  who  makes  reports  on  regular  forms. 


This  seems  to  me  a  great  advantage,  particularly  when  there  are  elab¬ 
orate  and  complicated  analyses  to  be  made.  Here,  too,  we  found  the 
system  of  hydrotherapy  in  use  in  the  treatment  of  typhoid  fever,  and 
the  mortality  had  been  reduced  to  the  extremely  low  point  of  five  per 
cent. 

Professor  Klebs  was  away,  but  one  of  his  assistants  showed  us  the 
pathological  laboratory.  We  were  also  very  disappointed  not  to  have 
seen  Professor  Forel,  who  was  at  the  Montpellier  festival.  We  spent  a 
delightful  day  with  Professor  Gaule,  the  physiologist.  He  first  demon¬ 
strated  some  of  his  remarkable  histological  specimens,  particularly  a 
series  of  the  frog’s  testis  at  different  months  of  the  year,  prepared  by 
his  method,  which  you  will  find  in  any  of  the  recent  histological  manu¬ 
als.  Not  only  in  the  testis,  in  which,  in  certain  animals,  we  should  ex¬ 
pect  marked  seasonal  changes,  but  in  other  organs,  such  as  the  liver, 
he  holds  there  are  variations  in  the  constitution  of  the  cell  protoplasm 
throughout  the  year.  Mrs.  Gaule,  an  American  lady  and  a  well-known 
histologist,  is  an  active  co-worker  in  the  microscopical  department  of 
the  laboratory. 

I  was  still  more  interested  in  the  brain  of  a  dog  which  had  had  a  re¬ 
markable  experimental  history.  The  center  for  the  left  foreleg  was  first 
destroyed,  with  the  result  of  a  paralysis,  which  gradually  disappeared. 
Then  the  corresponding  center  in  the  right  side  was  destroyed,  with  the 
effect  of  producing  paralysis  of  the  forelegs  on  both  sides  and  loss  of 
intelligence,  so  that  the  dog  lost  knowledge  of  his  tricks  and  was,  in 
fact,  like  a  puppy.  He  regained  power  in  the  legs  and  was  gradually 
re-educated,  with,  however,  great  trouble,  by  one  of  the  lady  students 
of  the  laboratory.  Then  a  portion  of  the  brain  on  the  right  hemisphere 
behind  the  left-leg  center  was  removed,  with  the  result  of  paralysis  of 
the  leg,  after  which  the  animal  was  killed.  The  experiment  is  chiefly 
of  interest  as  showing  substitution  of  function  somewhat  similar  to  that 
which  took  place  in  Barlow’s  celebrated  case  of  aphasia  in  which  the 
patient,  after  recovery  from  the  effect  of  an  embolus  on  the  left  middle 
cerebral,  gradually  regained  the  power  of  speech,  which  was  again  lost 
in  a  second  attack,  when  an  embolus  plugged  the  artery  of  the  right 
side. 

In  lecturing,  Professor  Gaule  uses  the  projection  lantern  very  fre¬ 
quently,  and  has  it  so  arranged  that  the  image  is  thrown  from  behind 
the  lecture-room  upon  a  glass  screen  behind  the  movable  blackboard. 
I  have  never  seen  microscopic  objects  so  beautifully  projected,  and  the 
technique  was  carried  to  such  perfection  that  even  the  movement  of 
the  ciliated  epithelium  could  be  seen  from  all  parts  of  the  room. 

Munich  is  the  largest  of  the  three  Bavarian  schools,  and  I  was  particu¬ 
larly  anxious  to  see  the  arrangements  of  the  medical  clinic,  which  were 
reported  to  be  unequaled  in  Europe.  Unfortunately,  we  came  in  the 
midst  of  the  Whitsuntide  holidays,  when  the  lectures  had  ceased  and 
the  laboratories  were  deserted.  Professor  von  Ziemssen  (whose  name 
is  one  of  the  most  familiar  to  the  profession  of  English-speaking  coun¬ 
tries)  was  at  home,  and  very  kindly  showed  us  the  clinical  institute, 
which  is  attached  as  a  wing  to  one  side  of  the  main  hospital  building. 
It  was  erected  in  1878,  and  when  I  tell  you  that  the  cost  was  over 
$50,000  you  will  have  some  idea  of  its  extent.  The  ground  floor  is  de¬ 
voted  largely  to  outdoor  medical  work — the  ambulatorium,  as  it  is 
called — and  to  rooms  for  the  assistants  and  docents,  with  suitable  ar¬ 
rangements  for  demonstrations  and  classes.  The  second  floor  has  the 
professors’  private  rooms,  the  library,  a  room  for  the  records,  the  audi¬ 
torium,  a  large  chemical  laboratory,  and  a  series  of  four  rooms  com¬ 
municating  with  each  other  for  microscopical,  bacteriological,  and  elec¬ 
trical  work.  The  institute  is  unusually  rich  in  apparatus  for  experi¬ 
mental  research,  and  going  from  room  to  room  and  listening  to  the 
description  of  treasures  of  all  sorts  for  clinical  investigation,  I  realized, 
as  never  before,  what  the  Queen  of  Sheba  felt  when  she  said,  after  see¬ 
ing  the  treasures  of  Solomon,  “  that  there  was  no  more  spirit  in  her.” 
The  files  of  the  Deutsches  Archiv  fur  klinische  Medicin  for  the  past 
twelve  years  show  a  record  of  good  work  of  which  the  director  of  the 
institute  may  well  feel  proud.  The  hospital  notes  are  very  carefully 
kept  and  pigeon-holed,  first  by  months,  then  at  the  end  of  the  year 
bound  loosely  according  to  the  disease.  With  an  index  of  the  names 
and  another  of  the  diseases,  .any  case  can  in  this  way  be  referred  to  in 
a  few  minutes.  Of  models  we  were  shown  a  number  illustrating  the 
alterations  in  position  and  size  of  the  stomach — some  in  plaster,  others 


192 


reports  on  the  progress  of  medicine. 


[N.  Y.  Med.  Jouk.’ 


in  papier-mache.  Dilatation  of  this  organ  is  very  much  more  common 
here  than  with  us,  owing  to  the  enormous  quantities  of  beer  consutnec . 
Some  of  the  men  connected  with  the  breweries  are  said  to  drink  from 
twelve  to  twenty  litres  daily.  Yoit  makes  the  statement  that  the  aver¬ 
age  consumption  of  beer  in  Munich  is  two  litres  and  a  half  per  capita 
daily.  It  is  cheap  and  good,  a  litre  costing  only  twenty-four  or  twenty- 
six  pfennigs ;  and  when  one  sees  the  crowded  state  of  the  beer-houses 
at  all  hours  of  the  day,  Voit’s  estimate  appears  very  moderate.  The 
influence  of  the  beer  is  shown  in  another  way — viz.,  in  inducing  hyper¬ 
trophy  of  the  heart,  upon  the  frequency  of  which  in  Munich  and  on  its 
association  with  beer  drinking  Professor  Bollinger  has  recently  written 
Yon  Ziemssen  thought  that  it  was  the  combination  of  hard  work  with 
heavy  drinking  that  rapidly  raised  the  aortic  blood-pressure  and  was  so 
dangerous.  The  cases  were  met  with  chiefly  in  those  whose  occupa¬ 
tions  necessitated  great  muscular  exertion,  such  as  draymen  and  porters. 
Though  less  common,  these  cases  are  by  no  means  rare  in  our  large 
cities"  among  men  who  work  hard  and  who  at  the  same  time  drink 

heavily. 

Within  the  past  ten  years  Munich  has  gradually  acquired  a  thor¬ 
ough  drainage  system,  and  we  were  shown  a  set  of  charts  in  course  of 
preparation  for  the  Berlin  Congress,  illustrating  the  remarkable  reduc¬ 
tion  in  the  number  of  cases  of  typhoid  fever.  In  certain  sections  of  the 
city,  formerly  much  affected,  the  disease  is  now  almost  unknown.  The 
chart  showing  the  hospital  experience  during  this  period  follows  the 
same  falling  curve.  Munich  is  now  one  of  the  healthiest  of  the  conti- 
-  nental  cities,  whereas  it  formerly  had  an  exceptionally  high  death-rate, 
particularly  from  zymotic  diseases.  The  medical  wards  are  m  the  part 
of  the  hospital  adjoining  the  clinical  institute,  but,  as  the  building  is  \  cry 
old,  the  arrangement  of  the  rooms  is  not  very  satisfactory.  A  new  sur¬ 
gical  department  is  nearly  completed.  Professor  von  Ziemssen  lives  in 
a  separate  house  within  the  hospital  grounds,  so  that  he  is  not  far  from 
his  work  and  can  readily,  as  he  expressed  it,  stand  like  a  colossus  with 
one  foot  in  the  wards  and  the  other  in  the  laboratory.  It  is  a  pleasure 
to  think  that  one  who  has  done  so  much  for  the  profession  is  so  well 
provided  for  and  has  everything  that  a  teacher  or  investigator  could 
desire  or  deserve. 

We  took  advantage  of  the  vacation  and  went  to  Ober-Ammergau  to 
see  the  Passion  Play.  The  crucifixion  scene  is  frightfully  realistic, 
every  detail  represented,  even  to  the  piercing  of  the  side,  from  which 
the  blood— an  aniline  fluid,  I  suppose— flows  freely.  A  problem,  much 
discussed  of  old,  why  Christ  should  have  died  after  so  comparatively 
short  a  time  upon  the  cross  seemed  to  my  mind  to  receive  its  solution 
in  the  mental  and  physical  exhaustion  consequent  upon  the  trials  of 
the  preceding  twenty-four  hours.  There  is  a  remarkable  book  dealing 
with  this  subject  by  Dr.  Stroud,  Theory  of  the  Physical  Cause  of  the 
Death  of  Christ ,  in  which  he  argues  that  it  was  due  to  rupture  of  the 
heart;  but  this  would  be  highly  improbable  in  a  vigorous,  healthy  man 
of  thirty-three. 

In  looking  over  the  Passion  Play  literature,  we  find  a  long  account 
of  the  performance  in  1830  by  Oken,  the  anatomist,  and  it  was.  ex¬ 
tremely  interesting  to  find  that  this  description  of  the  play  as  given 
sixty  years  ago  might  have  been  written  of  this  year’s  representation. 


Htprts  on  Ijjt  frogrtss  of  Shamtu. 


OBSTETRICS. 


By  ANDREW  F.  CTJRRIER,  M.  D. 

The  Practical  Means  employed  to  provoke  Premature  Labor  (Bois- 
sard,  France  med.,  Jan.  10,  1890).— The  object  of  all  the  agents  which 
are  used  to  excite  premature  labor  artificially  is  to  provoke  uterine  con¬ 
tractions,  and  all  means  which  are  used  should  permit  the  least  possi¬ 
ble  deviation  from  normal  labor.  Among  the  agents  which  may  be  used 
are  :  1,  uterine  douches  ;  2,  the  introduction  of  dilating  bodies  into  the 
uterus  ;  3,  the  introduction  of  exciting  bodies  ;  4,  the  introduction  of 
bodies  which  are  both  dilating  and  exciting.  The  dilating  or  exciting 


bodies  are  represented  by  tents  of  sponge  or  laminaria,  bougies,  bags, 
or  balloons.  Uterine  douches  were  frequently  used  a  few  years  since. 
Such  a  method  should  be  rejected  because  it  is  slow,  unreliable,  and 
dangerous.  Many  serious  results  have  been  recorded  in  connection  with 
its  use.  Of  the  tents  it  is  difficult  to  render  those  of  sponge  aseptic,  but 
those  of  laminaria  may  be  made  quite  aseptic  by  dipping  them  for 
twenty-four  hours  in  an  ethereal  solution  of  iodoform.  It  is  easy  to  in¬ 
troduce  them,  but  they  are  liable  to  slip  out  unless  secured  by  a  vaginal 
tampon.  Perforation  of  the  membranes  is  an  infallible  way  of  bring¬ 
ing  on  labor,  but  it  is  very  slow,  and  favors  vicious  presentations.  The 
use  of  the  bougie  is  also  slow  as  to  its  results  ;  it  may  be  inefficacious 

and  may  be  attended  with  accidents. 

Of  all  the  excitant  and  dilating  methods,  the  author  gives  prefer¬ 
ence  to  the  instrument  of  Tarnier  or  to  that  of  Ribes.  The  former  is 
a  rubber  balloon  and  will  usually  do  its  work  in  from  twenty  to  twenty- 
four  hours. 

Ribes  has  also  devised  a  balloon  30  to  33  centimetres  in  circumfer¬ 
ence  and  holding  640  grammes  of  liquid.  It  will  dilate  not  only  the 
neck,  but  the  entire  vulvo-vaginal  canal.  Two  facts  have  been  noticed 
j  in  connection  with  the  use  of  this  dilator— rapidity  of  delivery  and  con- 
I  stancy  of  results,  the  average  duration  of  labor  in  observed  cases  being 
twelve  to  fourteen  hours.  The  material  from  which  it  is  made  is  thin, 
and  it  may  easily  be  introduced  with  the  forceps.  The  possible  incon¬ 
veniences  in  its  use  are  the  necessary  rupture  of  the  membranes,  the 
breaking  away  of  the  placenta,  procidentia  of  the  limbs  and  cord  of  the 
foetus,  and  the  displacement  of  the  foetus.  One  or  another  of  these 
accidents  occurred  in  one  third  of  the  cases  treated  by  Ribes’s  method, 
though  mother  and  child  were  saved  in  every  case.  The  author  con¬ 
cludes  as  follows : 

1.  Of  all  the  means  which  have  thus  far  been  devised  for  producing 
premature  labor,  the  balloons  of  Tarnier  and  of  Ribes  are  the  most  effi- 
cient. 

2.  In  spite  of  the  inconveniences  or  difficulties  which  may  result 
from  the  introduction  of  a  large  balloon  into  the  uterine  cavity,  the  in¬ 
strument  of  Ribes  may  be  depended  upon  to  give  the  most  rapid  and 
constant  results. 

Extra-uterine  Pregnancy  (Pinard,  Concours,  Dec.  28,  1889).— Three 
cases  are  narrated  in  which  operative  procedures  were  resorted  to.  all 
of  them  ending  in  recovery.  This  question  is  propounded  :  An  extra- 
uterine  pregnancy  has  proceeded  almost  to  term  before  it  is  recognized 
the  foetus  is  dead — what  is  one  to  do  ?  One  can  not  advise  indefinite 
expectancy.  It  would  be  dangerous  to  reckon  upon  the  transformation 
of  the  foetal  sac  into  lithopaedion,  for  such  a  change  is  of  rare  occur¬ 
rence.  If  intervention  is  determined  upon,  when  should  it  take  place? 
Most  authors  caution  against  waiting  for  the  explosion  of  accidents 
which  attend  suppuration.  On  the  other  hand,  should  one  operate  as 
soon  as  possible  after  the  death  of  the  foetus  ?  The  author  agrees  with 
Kaltenbach,  Fraenkel,  Litzmann,  Werth,  and  Maygrier  that  one  need 
not  operate  immediately  after  the  death  of  the  foetus  unless  there  are 
special  indications  therefor.  Six  weeks  after  the  death  of  the  foetus 
the  circulation  within  the  foetal  sac  ceases,  and  then  it  will  be  safe  to 
operate;  earlier  than  this  there  is  great  danger  from  haemorrhage. 
There  are  two  methods  of  operating — by  elytrotomv,  the  cyst  being 
opened  through  the  vagina,  and  by  laparotomy.  The  first  should  be 
preferred  if  the  cyst  dips  deeply  into  the  pelvis,  the  bladder  and  uterus 
being  displaced  laterally  and  the  placenta  not  being  implanted  in  the 
lower  part  of  the  cyst.  In  other  cases  laparotomy  should  be  practiced. 
If  laparotomy  is  performed  and  the  cyst  is  found  to  have  extensive  ad¬ 
hesions  to  the  intestines  and  bladder,  it  is  better  to  suture  the  cyst  to  the 
edges  of  the  abdominal  wound  and  then  open  it  and  extract  the  foetus. 
If  the  placenta  does  not  come  away  readily,  it  is  better  to  leave  it  in  situ 
I  and  allow  it  to  come  away  spontaneously.  The  cord  may  be  removed 
at  its  placental  insertion,  and  the  cavity  may  then  be  irrigated  with  a 
warm  saturated  solution  of  /3-naphthol.  The  wound  should  then  be 
closed  except  for  a  space  six  or  seven  centimetres  in  length,  through 
which  the  placenta  may  protrude.  Two  large  drainage-tubes  may  then 
be  placed  in  the  lower  angle  of  the  wound,  and  the  latter  be  covered 
with  carbolized  gauze.  Over  this  an  abundance  of  cotton  should  be 
.placed,  and  the  entire  dressing  should  be  secured  with  a  pressure  band- 
I  age.  The  cavity  of  the  cyst  will  contract  rapidly,  and  in  fifteen  or 


August  16.  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


193 


twenty  days  it  will  have  disappeared.  In  two  months  the  entire  wall 
of  the  cyst  will  have  disappeared. 

Hot  Irrigations  subsequent  to  Parturition  (Deipser,  Jour,  de  med , 
Feb.  9,  1890). — There  are  obstetricians  who  think  that  if  a  labor  has 
not  called  for  repeated  examinations  or  operative  treatment  there  is 
no  necessity  for  antiseptic  treatment  of  the  genital  passages,  on  the 
ground  that  no  irrigations  are  indicated  if  there  is  no  suspicion  of  in¬ 
fection.  But  it  is  better  that  the  accoucheur  should  act  as  if  accidents 
were  about  to  happen  after  labor,  and  take  the  necessary  precautions. 
Should  he  wait  three  or  four  days  until  accidents  have  occurred,  he  is 
liable  to  reproach.  What  agent  should  be  preferred  for  irrigating  pur¬ 
poses  ?  Sublimate  has  given  rise  to  accidents  with  some,  though  it  has 
given  excellent  results  to  others.  Carbolic  acid  is  no  longer  popular 
with  physicians  or  midwives.  Creoline  seems  to  meet  with  general  ap¬ 
proval  at  present,  and  should  be  used  immediately  after  labor  and  for 
the  six  succeeding  days  in  solutions  with  a  temperature  of  50°  C.  The 
temperature  of  the  water  in  itself  opposes  the  multiplication  of  germs. 
The  injection  current  will  wash  away  blood-clots  from  the  uterine  mu¬ 
cous  membrane  and  any  other  foreign  matter  which  may  be  there.  As 
antiseptic  substances  are  ordinarily  used,  the  injected  solutions  are  at 
the  temperature  of  the  blood.  This  is  not  sufficiently  elevated  and  may 
prove  dangerous  by  favoring  relaxation  of  the  uterus.  If  the  injected 
solution  has  a  temperature  of  50°  C.,  it  will  produce  irritation  and 
uterine  contraction.  One  can  therefore  use  these  injections  either  to 
stop  post-partum  haemorrhage  or  to  increase  the  efficiency  of  uterine 
contraction.  A  portion  of  the  water  used  in  vaginal  irrigation  will 
penetrate  the  uterus.  It  will  do  no  harm,  but,  on  the  contrary,  will 
favor  the  production  of  uterine  contraction,  and  will  also  assist  in  dis¬ 
solving  and  washing  away  fragments  of  tissue  which  should  have  been 
expelled  in  the  course  of  labor. 

The  Caesarean  Operation  and  its  Clinical  Results  (Martin,  An.  de 
Ofjst .,  Gin.  y  Ped.,  November,  1889). — The  following  conclusions  are 
reached  by  the  author  : 

1.  One  should  insist,  as  a  hygienic  measure,  upon  the  medical  super¬ 
vision  of  all  cases  in  which,  by  reason  of  pelvic  disproportion,  it  may 
be  necessary  to  resort  to  Caesarean  section.  In  such  cases  it  may  be 
feasible  to  resort  to  premature  artificial  labor,  with  the  birth  of  a  via¬ 
ble  foetus. 

2.  Among  modern  operations  the  Caesarean  section  should  be  es¬ 
teemed  of  primary  importance  in  its  varieties — the  Sanger  and  the 
Porro-Miiller  operations. 

3.  Among  all  parturient  women  with  contracted  pelvis,  in  whom 
exist  indications  for  operative  procedure,  preference  should  be  given 
to  the  Caesarean  operation  above  the  different  methods  of  embryotomy, 
as  it  is  more  humane  and  offers  better  results  for  both  mother  and 

child. 

4.  The  Caesarean  operation  should  be  performed  alter  dilatation  of 
the  cervix  and  prior  to  rupture  of  the  amniotic  sac,  such  a  plan  offer¬ 
ing  the  best  prospects  of  success. 

5.  Listerian  methods  should  be  followed  with  all  care  whenever  the 
Caesarean  operation  is  performed. 

A  statistical  table  is  published  with  this  paper,  which  shows  that 
seventy  per  cent,  of  the  improved  Caesarean  operations  have  resulted 

successfully. 

The  Use  of  Anaesthetics  by  Midwives  (Budin,  Concours,  Feb.  15, 
1890). — A  report  upon  this  subject  was  recently  read  before  the  Paris 
Academy  by  the  author.  The  role  which  has  heretofore  been  played 
by  midwives  in  the  propagation  of  puerperal  fever  was  first  referred  to, 
and  then  the  question  would  naturally  arise,  What  antiseptic,  if  any, 
should  be  placed  in  their  hands  ?  for  epidemics  of  puerperal  fever  are 
more  or  less  prevalent  in  the  practice  of  midwives,  and  antiseptics  are 
the  proper  means  for  attacking  the  disease.  The  first  suggestion  would 
be  that  boiled  water  should  be  used,  but  this*Would  not  be  sufficient  to 
destroy  germs,  even  supposing  that  the  midwives  were  sufficiently  care¬ 
ful  in  cleansing  their  hands,  forearms,  and  nails.  Hence  it  would  seem 
necessary  that  midwives  should  be  allowed  or  required  to  use  antisep¬ 
tics.  There  are  many  antiseptics,  however,  and  it  is  expecting  too 
much  that  midwives  should  be  acquainted  with  their  varying  power 
and  the  different  ways  of  using  them  ;  besides,  many  of  them  consider 
such  agents  useless,  and  would  not  employ  them  unless  required  to  do 


so.  Their  use  should  therefore  be  simplified  as  much  as  possible,  and 
the  commission  which  took  the  matter  into  consideration  at  the  request 
of  the  official  authority  recommended  that  only  one  antiseptic  be  given 
to  midwives,  and  that  this  should  be  as  efficacious  as  possible  without 
exposing  the  midwives  or  patients  to  intoxication  or  cauterization.  It 
should  also  be  cheap  and  easily  kept  and  carried.  The  author  consid¬ 
ered  in  succession  the  merits  of  boric  acid,  creolin,  naphthol,  carbolic 
acid,  and  sublimate,  the  last  of  which  was  preferred,  with  the  objec¬ 
tion,  however,  that  in  certain  doses  it  was  toxic  and  might  injure  the 
patients.  In  answer  to  this  objection,  it  may  be  said  that  very  few 
people  are  excessively  sensitive  to  sublimate  when  used  in  the  form  of 
vaginal  irrigation,  and  the  author,  in  an  extensive  experience  with  it 
since  1882,  has  seen  nothing  severer  than  an  occasional  attack  of  gin¬ 
givitis  or  erythema.  Of  the  sixteen  fatal  cases  -which  have  been  re¬ 
ported  as  resulting  from  its  use,  the  influence  of  sublimate  in  some  of 
them  is  questionable.  In  fourteen  of  them  intra-uterine  injections  had 
been  made  with  solutions  of  1  to  1,000  or  1  to  2,000;  in  only  two  of 
them  had  there  been  no  intra-uterine  injections.  In  the  latter  there 
had  been  extensive  rupture  of  the  perinaeum,  and  irrigation  with  a  1-to- 
1,000  solution  of  sublimate  was  practiced  during  the  operation  of  sut¬ 
uring  it.  In  some  of  the  cases  there  had  been  nephritis,  or  profound 
anaemia  fram  haemorrhage,  or  retention  of  the  placenta  within  the  uter¬ 
ine  cavity,  and  thus  intoxication  from  mercury  had  been  favored. 
Intra-uterine  injections  should  not  be  made  by  midwives,  and,  should 
fever  or  any  other  abnormal  condition  follow  the  parturition,  the  serv¬ 
ices  of  a  physician  are  at  once  to  be  procured.  Compared  with  carbolic 
acid,  it  may  be  said  that  the  effect  of  sublimate  upon  the  new-born  is 
far  more  favorable. 

The  Action  of  Hot  Water  on  the  Uterus  during  the  Pregnant  and 
Puerperal  States  (Pinard,  Jour,  de  med.,  Feb.  9,  1890). — This  subject 
includes  the  use  of  hot  water  during  pregnancy,  during  labor,  during 
delivery,  and  during  the  involution  of  the  uterus. 

The  ancients  forbade  the  use  of  baths  during  pregnancy  from  fear 
of  abortion  or  premature  labor.  Kiwisch  proposed  a  method  to  do  away 
with  this  traditional  fear.  Investigations  made  during  the  last  few 
years  have  shown  that  water  at  45°  to  50°  C.,  while  acting  as  an  ener¬ 
getic  stimulant  to  smooth  muscular  fiber,  can  not  produce  contractions 
sufficient  to  interrupt  the  course  of  pregnancy.  If  injections  of  hot 
water  aie  used  in  such  a  way  that  traumatism  is  not  produced,  there 
need  be  no  fear  of  provoking  labor  pains.  Hence  the  elytritis  which 
may  exist  during  pregnancy  can  and  ought  to  be  treated  by  irrigation 
with  medicated  hot  solutions. 

Hot  injections,  whether  intravaginal  or  intra-uterine,  have  a  marked 
effect  upon  the  contractility  of  the  uterus  during  labor.  The  latter 
have  a  more  decided  and  intense  action  than  the  former.  Hot  water 
as  an  oxytocic  does  not  modify  the  physiological  characters  of  the 
uterine  pains.  The  contractions  which  follow  the  use  of  vaginal  irriga¬ 
tion  have  a  more  marked  amplitude]  and  longer  duration,  but  are  not 
more  frequent  in  the  majority  of  cases.  They  are  more  efficacious, 
however,  and  shorten  labor.  They  should,  therefore,  be  used  in  cases 
in  which  the  period  of  dilatation  lasts  longer  than  the  average.  Espe¬ 
cially  should  they  be  used  in  cases  in  which  the  death  of  the  foetus  and 
the  rupture  of  the  foetal  sac  demand  a  rapid  expulsion,  and  this  rule 
applies  as  well  for  cases  of  abortion  as  for  those  of  labor  at  term.  Hot 
irrigations  have  the  same  action  during  the  period  of  delivery  as  during 
the  precedent  period  of  labor.  To  their  oxytocic  action  is  added  the 
haemostatic.  If  to  a  woman  who  is  attacked  with  uterine  haemorrhage 
one  gives  an  intra-uterine  injection  with  water  at  46°  to  50°  C.,  the 
uterus  will  contract  energetically  and  by  and  by  the  water  will  return 
from  the  uterus  uncolored.  Of  course  the  uterus  must  first  be  relieved 
of  all  clots.  Hot  water  also  exercises  a  decided  effect  on  the  uterus 
during  the  period  of  involution,  the  latter  process  being  hastened  by 
its  use.  The  metrorrhagia  which  may  occur  at  this  period  will  yield  to 
irrigations  with  water  at  46°  C. 

Alcohol  in  the  Treatment  of  Puerperal  Fever  (Martin,  Ctrlbl.  f. 
Gyn.,  1889,  No.  31). — This  paper  contains  an  account  of  eighteen  cases, 
— fifteen  of  septicaemia  and  three  of  pyaemia — in  which  alcohol  was  ad¬ 
ministered  as  a  means  of  treatment  in  accordance  with  the  rules  recom¬ 
mended  by  Breisky  and  Conrad  in  1876.  All  of  the  patients  were  seen 
in  private  practice  and  had  been  treated  locally  or  by  the  internal  use 


194 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jotjb., 


of  antipyretics  before  they  came  under  the  author’s  observation.  When 
seen  by  him  they  were  in  a  very  bad  condition,  the  prognosis  being 
very  unfavorable.  Alcohol  was  prescribed  for  all  of  them  in  the  form 
of  brandy,  rum,  champagne,  burgundy,  etc.  In  all  cases  the  alcohol 
was  well  tolerated.  Of  the  eighteen  patients,  thirteen  recovered,  three 
died  from  puerperal  infection,  one  of  the  other  two  from  phthisis,  and 
the  other  from  pulmonary  cedema.  Martin  believed  that  the  benefit  of 
the  alcohol  consisted  rather  in  the  stimulation  of  the  heart  than  in  the 
reduction  of  the  temperature.  The  alcohol  was  used  as  an  adjuvant  to 
local  treatment  and  to  the  use  of  antipyretics,  and  it  was  found  that  it 
could  be  used  in  large  quantities  without  fear  of  intoxication,  and  in 
conjunction  with  milk,  eggs,  etc.  Martin  concluded  that  alcohol  was  a 
most  valuable  remedy  in  puerperal  fever  which  could  be  used  in  desper¬ 
ate  cases  without  fear  of  disagreeable  secondary  results. 

In  the  discussion  of  the  paper  Schulein  stated  that  he  had  used 
alcohol  in  large  quantities  in  the  treatment  of  puerperal  fever  and  with 
good  results. 

Gottschalk  referred  to  the  free  use  of  alcohol  in  the  treatment  of 
five  cases  of  puerperal  fever  under  his  observation ;  four  of  them  were 
cases  of  septicaemia  and  one  of  pyaemia.  In  all  the  cases  there  was 
diffuse  peritonitis.  After  having  once  disinfected  the  genitals  thor¬ 
oughly  in  these  cases,  local  treatment  was  suspended,  the  treatment  be¬ 
ing  limited  to  large  doses  of  alcohol  and  nitrogenous  foods.  The  alco¬ 
hol  was  given  in  the  form  of  brandy,  500  to  1,000  grammes  being  given 
in  the  course  of  twenty-four  hours.  To  allay  vomiting,  cocaine  was 
given  with  good  result.  In  one  of  the  cases  baths  were  administered, 
resulting  in  the  lowering  of  the  temperature  and  improvement  of  the 
appetite.  In  another  patient  the  alcohol  produced  intoxication,  with 
loss  of  consciousness  and  delirium.  It  was  then  dispensed  with,  strong 
coffee  was  administered,  an  ice  cap  was  placed  upon  the  head,  and  the 
bad  symptoms  disappeared,  the  fever  and  peritonitis  gradually  yielding. 

Olshausen  did  not  think  it  had  been  clearly  demonstrated  that  alco¬ 
hol  was  essential  in  puerperal  septicaemia,  especially  since  he  had  seen 
severe  cases  of  the  disease  cured  without  its  use.  In  cases  in  which 
there  was  no  diffuse  peritonitis  one  could  not  say  whether  a  cure  was 
due  to  the  therapeutic  agent  employed  or  to  the  fact  affection  was  mild 
in  character,  and,  if  there  were  diffuse  peritonitis,  alcohol  was  of  as 
little  value  as  all  other  remedies.  In  the  last-mentioned  disease  baths 
were  unsuitable,  for  every  movement  of  the  patient  was  attended  with 
pain.  In  cases  of  prolonged  or  chronic  pyaemia  with  persistent  eleva¬ 
tion  of  the  temperature  baths  might  be  used,  and  alcohol  would  supply 
sufficient  force  to  enable  the  patient  to  resist  the  disease.  He  did 
mean  to  discourage  the  use  of  alcohol  in  cases  of  acute  puerperal  septi¬ 
caemia. 

The  Microbiology  of  the  Cervical  Canal  in  Endometritis  (Solovyoff, 
An.  de  Obst.,  Ginecop.  y  Ped.,  February,  1890). — The  author’s  investi¬ 
gations  were  made  in  connection  with  Slavjansky’s  clinic  to  determine 
whether  the  genital  canal  in  women  contained  pathogenic  microbes. 
Experiments  were  made  upon  forty-five  women  and  the  following  con¬ 
clusions  were  reached : 

1.  In  the  great  majority  of  cases  of  endometritis,  but  not  in  all, 
there  are  micro-organisms  in  the  cervical  canal. 

2.  In  cases  of  acute  puerperal  endometritis  there  are  pyogenic  mi¬ 
crobes  in  the  secretions  of  the  cervical  canal. 

3.  In  the  secretions  of  chronic  cervical  endometritis  inoffensive  mi¬ 
crobes  are  far  more  frequently  found  than  morbific  ones. 

4.  The  clinical  investigation  of  cases  of  chronic  endometritis  will 
not  enable  one  to  distinguish  cases  in  which  the  microbes  are  pyogenic 
from  those  in  which  they  are  not. 

5.  Animals  which  are  inoculated  with  pyogenic  microbes  show,  in 
some  cases,  morbid  conditions  in  which  the  virulence  of  the  microbes 
has  not  been  attenuated. 

6.  It  must  be  admitted  that  there  is  a  possibility  that  these  microbes 
will  infect  the  organism  when  the  conditions  favor  their  penetrating  the 
tissues. 

*7.  As  in  some  of  the  cases  in  which  there  are  pyogenic  microbes 
there  exists  the  possibility  of  pregnancy  and  of  parturition  at  term,  and 
as  at  this  time  and  during  the  puerperal  period  there  may  be  condi¬ 
tions  favorable  to  infection,  we  must  admit  the  possibility  of  infection 
by  microbes  existing  in  the  genital  canal  prior  to  this  period. 


8.  External  antisepsis  and  antisepsis  of  the  individual  do  not  offer 
a  positive  assurance  that  the  parturient  and  puerperal  conditions  will 
be  aseptic. 

Ectopic  Pregnancy  (Tait,  Ctrlbl.  f.  Gyn.,  April  12,  1890). — Tait  pre¬ 
fers  the  above  name  to  the  old  one,  extra-uterine  pregnancy,  because 
the  so-called  interstitial  form,  as  well  as  that  form  which  occurs  in  one 
horn  of  the  uterus,  is  not  strictly  extra-uterine.  The  author  thinks  that 
the  fertilization  of  the  ovum  takes  place,  as  a  rule,  in  the  uterus,  and 
that  it  can  only  attain  to  those  portions  of  the  genitals  which  are  situ¬ 
ated  higher  up  when  the  normal  ciliated  epithelium  of  the  tubes  is  de¬ 
stroyed.  The  office  of  this  epithelium  is  not  only  to  propel  the  ovum 
forward  into  the  uterus,  but  also  to  prevent  the  entrance  of  the  sper¬ 
matozoa  into  the  tubes.  Hence  only  when,  as  a  result  of  some  precedent 
morbid  process,  the  ciliated  epithelium  is  injured  or  destroyed,  can 
spermatozoa  get  into  the  tube  and  fertilize  an  ovum.  The  mucous 
membrane  of  the  tube  then  having  become  similar  to  that  of  the  uterus, 
the  ovum  is  enabled  to  imbed  itself  in  it.  Many  cases  give  evidence 
that  a  desquamative  salpingitis  has  been  present.  In  some  cases  the 
condition  becomes  suspicious  if  the  woman  has  been  sterile,  or  if 
several  years  have  elapsed  since  her  last  pregnancy.  Tait  doubts 
the  possibility  of  a  true  ovarian  pregnancy,  but,  if  it  should  occur, 
its  course  and  danger  would  not  differ  materially  from  those  of  tubal 
pregnancy. 

Pregnancy  may  take  place  in  either  of  the  three  divisions  of  the 
tube,  the  interstitial,  the  middle,  or  the  infundibulum.  The  interstitial 
form  is  rare,  Tait  having  seen  but  one  case  and  knowing  of  but  six  in 
England.  Its  course  is  always  fatal.  One  does  not  know  anything  of  its 
existence  until  rupture  occurs,  which  may  not  take  place  before  the 
sixth  month,  and  usually  does  not  before  the  fourth  month.  The  loss 
of  blood  is  then  so  great  that  death  usually  results  in  a  few  minutes; 
the  rent  is  also  a  large  one,  being  10  or  12  centimetres  long.  The  only 
means  of  saving  life  would  be  the  performance  of  hysterectomy,  and 
the  prognosis  would  be  bad  even  if  one  were  promptly  at  hand  to  per¬ 
form  it.  Rarer  still  is  the  variety  in  which  there  is  development  at  the 
infundibulum,  only  three  specimens  of  this  variety  being  in  the  Hun¬ 
terian  museum.  With  regard  to  the  third  variety,  in  which  the  middle 
portion  of  the  tube  is  involved,  it  is  important  to  consider  the  nature  of 
the  peritoneal  covering.  The  distensibility  of  the  tube  is  very  limited, 
and  it  becomes  still  less  distensible  owing  to  the  spongy  nature  of  the 
placental  structure.  Rupture  does  not  take  place  later  than  the  twelfth 
week.  According  to  the  location  of  the  placenta  will  the  rupture  take 
place  into  the  abdominal  cavity  or  between  the  layers  of  the  broad  liga¬ 
ment,  and  this  fact  furnishes  a  means  of  differentiation  between  two 
different  varieties.  In  the  first  variety  the  haemorrhage  will  be  per¬ 
sistent,  in  the  second  it  will  usually  cease.  There  will  be  many  more 
favorable  conditions  in  the  latter  than  in  the  former  variety,  for  death 
will  usually  end  the  scene  before  the  physician  can  arrive.  As  to  diag¬ 
nosis,  the  two  varieties  of  rupture  and  haemorrhage  are  easily  distin¬ 
guished.  With  the  bleeding  into  the  abdominal  cavity  there  is  only  an 
illy  defined  feeling  of  fluctuation,  and  in  Douglas’s  space  there  is  a  soft 
swelling.  With  the  intraligamentous  hemorrhage,  on  the  other  hand, 
there  is  a  circumscribed  round  tumor  in  the  pelvis,  which  may  reach  to 
the  navel,  and  perceptibly  fluctuates.  The  vaginal  walls  and  the  whole 
pelvic  cellular  tissue  are  as  hard  as  a  board.  In  severe  cases  the  press¬ 
ure  of  the  extravasated  masses  of  blood  will  cause  a  stricture  of  the  rec¬ 
tum  which  may  require  months  for  its  healing.  If  we  bear  in  mind  the 
general  symptoms  of  the  early  stages  of  pregnancy,  as  well  as  the  ir¬ 
regular  but  frequent  haemorrhages  which  occur  with  this  condition,  we 
will  be  able  to  determine  the  diagnosis.  Subsequent  rupture  of  this 
haematocele  will  produce  phenomena  which  may  lead  one  to  suppose 
that  the  haemorrhage  has  been  direct  from  the  vessels  into  the  abdomi¬ 
nal  cavity.  Should  one  puncture  such  a  haematoma  in  the  broad  liga¬ 
ment,  the  pressure  derived  from  the  blood  would  be  removed  and  the 
haemorrhage  would  begin  anew.  In  about  one  tenth  of  the  cases  the 
hemorrhage  is  slight,  the  blood  is  quickly  absorbed,  the  foetus  develops 
to  the  fourth  or  fifth  month,  then  dies,  and  then  is  absorbed  or  under¬ 
goes  suppuration.  Then  comes  perforation  into  the  rectum  or  bladder, 
with  discharge  of  pus  and  foetal  bones.  The  foetus  may,  however,  go 
on  to  complete  development,  the  peritonaeum  being  enormously  dis¬ 
tended.  The  peritonaeum  may  be  raised  in  the  course  of  the  develop- 


August  16,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


195 


ment  of  the  foetus  from  the  anterior  wall  of  the  uterus,  the  bladder,  and 
the  abdominal  parietes,  nearly  to  the  navel.  In  such  case  one  should 
operate  and  endeavor  to  obtain  a  living  child.  Such  children  may  be 
well  developed,  and  Tait  has  rescued  three  in  this  way.  Electricity  may 
be  used  if  tubal  pregnancy  can  be  diagnosticated  before  rupture  has  oc¬ 
curred,  but  he  believes  this  is  seldom  possible,  and  he  has  never  been 
able  to  do  it.  He  has  always  been  summoned  when  rupture  has  oc¬ 
curred  and  the  patient  is  in  collapse.  If  at  such  a  time  the  haemor¬ 
rhage  is  intraperitoneal,  electricity  will  not  arrest  it.  If  it  is  intraliga¬ 
mentous,  then  perhaps  no  interference  will  be  necessary.  If  the  result 
would  be  fatal  without  interference,  then  one  must  act  in  accordance 
with  simple  surgical  principles — that  is,  seek  for  and  tie  the  bleeding 
vessel  as  soon  as  possible. 

Obstetric  Operations  in  the  Practice  of  Midwives  (Ahlfeld,  Ctrlbl.f. 
Gyn.,  April  12, 1890). — The  question  as  to  the  operations  which  midwives 
should  be  allowed  to  do  is  one  which  should  be  discussed  among  physi¬ 
cians,  and  rules  should  be  laid  down  which  the  midwives  should  not 
transgress.  For  the  future  it  seems  to  be  agreed,  at  least  in  certain 
parts  of  Germany,  that  midwives  may  manage  breech  presentations  un¬ 
der  certain  restrictions — that  is,  they  may  superintend  the  birth  of  the 
arms  and  the  head.  It  is  possible  that  this  is  too  great  a  concession, 
as  the  statistics  of  midwives’  practice  show  that  the  number  of  still¬ 
born  infants  in  breech  presentations  is  quite  large.  The  delivery  of 
the  breech  and  the  feet  should  not  be  attempted  by  midwives.  Drag¬ 
ging  upon  the  presenting  feet,  and  so  hastening  the  progress  of  labor, 
may  seem  proper  enough  to  a  midwife,  but  it  may  be  an  element  of 
danger  by  bringing  the  head  into  an  unfavorable  position,  or  by  pro¬ 
ducing  severe  lesions  of  a  cervix  which  is  not  yet  sufficiently  dilated, 
or  by  inducing  too  great  constriction  of  the  child’s  neck  and  producing 
its  death.  The  only  condition  which  would  justify  the  midwife  in  tak¬ 
ing  this  step  would  be  profuse  haemorrhage,  with  placenta  praevia  and 
a  well-dilated  os.  Even  in  such  cases  it  would  probably  be  better  that 
the  midwife  should  merely  bring  down  a  foot,  so  that  the  breech  of  the 
child  might  act  as  a  tampon  for  the  bleeding  area. 

Still  more  important  is  the  question  as  to  the  wisdom  of  allowing 
midwives  to  perform  internal  version  and  removal  of  the  placenta.  In 
the  author’s  section  of  country  the  statistics  of  midwives’  practice 
show  that  version  has  seldom  been  done  by  them.  This  is  partly  ow¬ 
ing  to  their  hesitancy  in  undertaking  such  an  operation,  and  partly 
owing  to  the  ease  of  obtaining  skilled  professional  assistance.  The 
author’s  opinion  is  that  such  work  should  not  be  done  by  midwives,  and 
the  operation  is  usually  easier  if  the  midwife  has  not  complicated  mat¬ 
ters  by  attempting  to  perform  it.  There  are  exceptions,  of  course,  in 
very  isolated  places,  where  skilled  physicians  can  not  be  had.  Mid¬ 
wives  should  also  not  be  allowed  to  separate  the  placenta  from  the 
womb.  This  may  result  in  a  few  deaths  from  haemorrhage,  but  proba¬ 
bly  far  fewer  than  if  midwives  were  allowed  to  use  their  own  discre¬ 
tion  in  such  matters. 

Investigations  concerning  the  Quantity  of  Haemoglobin  in  the 
Blood  during  the  Last  Months  of  Pregnancy  and  during  the  Puerpe- 

rium  (Reinl,  Deutsche  med.  Zeitung ,  No.  27,  1890). — The  author’s  in¬ 
vestigations  were  made  upon  fifty-one  hospital  patients  who  were  preg¬ 
nant,  and  were  compared  with  investigations  upon  ten  healthy  non¬ 
pregnant  women.  The  spectrophotometer  was  used  for  the  determina¬ 
tion  of  the  haemoglobin,  and  the  blood  used  for  experimentation  was 
diluted  one  hundred  and  fifty  times  with  a  ten-per-cent,  solution  of  so¬ 
dium  carbonate.  The  haemoglobin  in  the  healthy  non-pregnant  women 
was  found  to  be  12-24  per  cent.  In  ten  of  the  pregnant  women  the 
average  haemoglobin  content  was  12'99  per  cent.  In  the  remaining 
forty-one  the  average  was  10  per  cent.  In  order  to  ascertain  the  rela¬ 
tion  between  the  haemoglobin  and  the  red  corpuscles,  the  latter  were 
counted  in  the  ten  non-pregnant  women  and  found  to  average  4,797,300 
to  the  cubic  centimetre  of  blood.  This  number  was  exceeded  in 
twenty-one  of  the  pregnant  women,  the  average  being  5, 166,000.  This 
high  average  pertained  to  pregnant  women  who  were  in  favorable  con¬ 
ditions  of  life  up  to  the  time  when  they  were  received  at  the  hospital. 
The  investigations  showed  conclusively  that  those  women  who  were 
"ell  nourished — that  is,  received  an  abundance  of  albumin  during  their 
■’tav  in  the  hospital — always  experienced  an  increase  in  the  quantity  of 
albumin  as  well  as  in  the  red  corpuscles  in  their  blood.  Chloro-amemie 


conditions  were  not  met  by  the  author  in  this  investigation ;  but  simple 
anmmia  in  pregnant  women  may  easily  develop  under  the  influence  of 
social  and  individual  conditions,  and  there  is  always  a  lessening  in  the 
number  of  red  corpuscles  pari  passu  with  the  lessening  of  the  haemo¬ 
globin.  The  author  disputes  the  theory  that  pregnancy  is  to  be  con¬ 
sidered  in  the  light  of  an  anaemia-causing  condition.  It  was  always 
demonstrated  that  those  who  came  into  the  hospital  in  an  anaemic  and 
hungry  condition  lost  their  anaemia  under  the  favorable  dietetic  and 
hygienic  conditions  to  which  they  were  there  subjected.  Simple  oligo- 
chromaemia  does  not  exist  during  pregnancy,  but  it  does  exist  in  com¬ 
bination  with  oligocvthaemia.  In  thirty-seven  cases  which  were  investi¬ 
gated  subsequent  to  the  parturition,  the  haemoglobin  was  found  dimin¬ 
ished  in  twenty-one,  in  two  it  was  unchanged,  and  in  fourteen  it  was 
increased.  The  changes  in  the  number  of  red  corpuscles  in  these  cases 
were  for  the  most  part  co-ordinate  with  the  changes  as  to  haemoglobin. 
The  lessening  of  the  haemoglobin,  which  was  observed  during  labor  in 
twenty-one  cases,  was  changed  to  an  increase  in  seventeen  of  the  cases 
on  the  sixth  or  seventh  day  of  a  normal  puerperium.  The  red  corpuscles 
increased  similarly  in  number.  The  foregoing  results  are  not  offered 
as  absolutely  typical,  since  the  influence  of  the  hospital  may  have  had 
some  bearing  in  the  case. 

The  Prognosis  as  to  the  Probability  of  Pregnancy  following  the 
Conservative  Caesarean  Section  (Torggler,  Prag.  med.  Woch .,  No.  13, 
1890). — In  comparing  the  results  of  the  conservative  Caesarean  section 
with  those  of  such  operations  as  perforation  and  the  induction  of  pre¬ 
mature  labor,  one  must  regard  not  only  the  facts  as  to  mortality  and 
morbidity,  but  also  the  question  of  subsequent  fertility,  which,  accord¬ 
ing  to  some  authors,  is  very  unfavorably  influenced  by  the  Caesarean  op¬ 
eration.  On  May  13,  1889,  the  author  induced  premature  labor  at  the 
thirty-fifth  week  of  pregnancy  upon  a  woman  upon  whom  Schauta  had 
performed  the  Caesarean  section  December  1,  1886.  This  case  sug¬ 
gested  the  question  of  the  probable  prognosis  as  to  subsequent  preg¬ 
nancies  following  the  performance  of  such  operations.  To  the  table  of 
Caruso,  containing  histories  of  136  such  operations,  the  author  adds  36 
cases,  the  operations  in  12  of  the  cases  being  in  the  years  1888  and 
1889,  and  in  24  in  previous  years.  Of  these  171  cases,  132  were  reported 
cured,  and  of  the  latter  number  3  died  shortly  afterward  from  causes 
independent  of  the  operation.  In  6  others  pregnancy  was  an  impossi¬ 
bility  because  of  certain  complications.  There  were,  therefore,  124 
women  who  were  capable  of  subsequent  pregnancy.  In  this  number 
13  conceptions  have  been  reported  occurring  in  12  women.  This  would 
signify  a  fertility  of  9'6  percent,  in  the  course  of  seven  years,  while,  ac¬ 
cording  to  Mataeus,  eleven  times  as  many  conceptions  occurred  in  a  simi¬ 
lar  number  of  women  who  were  subjected  to  the  operations  with  which 
the  Ctesarean  section  is  here  compared.  With  women  who  have  under¬ 
gone  the  latter  operation  there  is  always  the  fear  of  having  it  repeated, 
which  operates  against  renewed  conception.  But  most  of  the  women 
in  this  table  were  single,  only  43  being  married.  Of  these  43  women,  4 
died  as  the  result  of  the  operation,  and  1  was  insusceptible  of  preg¬ 
nancy.  Among  the  remaining  38  there  were  9  pregnancies — that  is,  a 
fertility  of  23 ’6  per  cent.  From  these  figures  it  would  appear  that  fer¬ 
tility  after  Caesarean  section  is  not  greatly  impaired.  The  prognosis  as 
to  a  possible  future  pregnancy  may  be  modified  by  the  choice  of  mate¬ 
rial  for  suturing  the  uterine  wound.  Fehling’s  opinion  is  that  concep¬ 
tion  is  less  likely  to  recur  when  silver  wire  is  used  for  the  sutures,  but 
the  author  shows  that  this  view  is  incorrect.  In  the  171  cases  in  the 
table  silver  wire  was  the  suturing  material  in  43,  and  catgut  and  silk  in 
1 27  ;  in  the  remaining  case  the  material  is  not  stated.  Of  the  1 27  cases, 
28  died  from  the  operation,  1  died  87  days  afterward,  and  4  others  were 
insusceptible  of  conception.  The  question  as  to  the  influence  of  sutur¬ 
ing  material  is  therefore  limited  to  94  cases.  Of  this  number,  preg¬ 
nancy  recurred  in  6,  a  fertility  of  6'3  per  cent.,  or,  taking  only  the  mar¬ 
ried  women,  a  fertility  of  12  per  cent.  Of  the  43  cases  in  which  silver- 
wire  sutures  were  used,  30  were  susceptible  of  conception,  and  among 
this  number  there  were  8  pregnancies,  a  fertility  of  26-6  per  cent.,  or 
46*1  per  cent,  if  only  the  married  women  are  considered.  This  is  di¬ 
rectly  opposed  to  Fehling’s  theory  and  seems  to  show,  on  the  contrary, 
that  silver-wire  sutures  are  favorable  to  conception,  the  reason  probably 
having  something  to  do  with  the  condition  of  the  scar  in  the  uterus. 

The  author  also  touches  upon  the  dangers  which  may  ensue  when 


196 


MISCELLANY. 


[N.  Y.  Med.  Jock. 


pregnancy  and  labor  recur  after  Caesarean  section.  Judging  from  the 
small  quantity  of  material  at  hand  for  the  analysis  of  this  question,  the 
danger  is  not  materially  increased.  Perhaps  the  greatest  danger  is  from 
stretched  or  tense  adhesions  between  the  uterus  and  its  surroundings. 
These  are  less  numerous  with  the  use  of  silver  sutures  than  with  silk 
or  catgut. 


glisrellang. 


On  the  Strumous  Diseases  of  Childhood  and  their  Relation  to  Tu¬ 
bercle. — The  following  is  an  abstract  of  a  paper  prepared  by  Dr.  Thomas 
More  Madden,  of  Dublin,  for  the  recent  meeting  of  the  British  Medical 
Association : 

During  a  long  experience  as  physician  to  the  first  hospital  for  dis¬ 
eases  of  children  established  in  Ireland,  with  which  I  have  been  con¬ 
nected  since  its  foundation  in  1872,  the  increasing  prevalence  of  the 
strumous  and  tubercular  diseases  of  childhood  has  been  constantly 
brought  under  my  clinical  observation.  The  intimate  connection  and 
relation  between  these  conditions  was  pointed  out  nearly  a  quarter  of  a 
century  ago  in  my  work  on  Change  of  Climate ,  and  was  discussed  in  a 
paper  of  mine  in  the  Transactions  of  the  International  Medical  Congress 
of  1871,  as  well  as  last  year  in  my  article  on  Puberty,  in  Dr.  Keating’s 
recently  published  American  Cyclopaedia  of  Diseases  of  Children.  I 
refer  to  these  dates  merely  as  evidence  that  the  views  embodied  in  the 
following  brief  recapitulation  were  not  hastily  formed  nor  without  some 
experience  of  the  subject  referred  to.  The  increasing  proportion  of 
strumous  and  tubercular  affections  which  has  been  observed  of  late 
years  in  my  wards  in  the  Children’s  Hospital  is  probably  largely  ascrib- 
able  to  the  faulty  dietetic  and  hygienic  management  of  early  childhood, 
and  to  the  general  substitution  of  artificial,  and  in  many  instances  very 
unsuitable,  preserved  or  tinned  preparations  for  that  natural  or  fresh 
milk  which,  in  my  opinion,  is  essential  for  the  healthy  nutrition  of  chil¬ 
dren.  As  I  formerly  pointed  out,  and  the  observation  is  now  more  ap¬ 
plicable  than  was  the  case  ten  years  ago,  the  acute  forms  of  tuberculo¬ 
sis  common  during  childhood  resemble  the  infective  diseases  in  their 
origin  from  a  specific  germ,  whether  generated  in  the  body  or  intro¬ 
duced  from  without.  The  latter  is  probably  the  case  in  the  tubercular 
diseases  prevalent  among  the  children  of  the  poor,  in  whose  dietary 
various  forms  of  preserved  milk  foods  now  enter  largely,  as  it  seems 
difficult  to  conceive  any  certain  guarantee  that  the  cows  furnishing  the 
supply  may  not,  in  some  cases,  suffer  from  Perlsucht ,  this  disease  being 
very  prevalent  and  not  materially  affecting  the  quantity  of  milk.  More 
recently  Professor  Bollinger  has  shown  that  milk  may  prove  infectious 
whether  taken  from  cows  suffering  from  general  or  local  tuberculosis  ; 
in  his  experiments  only  a  few  drops  of  undiluted  milk  from  a  tuber¬ 
culous  cow  proved  sufficient  to  produce  miliary  tuberculosis  in  ani¬ 
mals.  Be  the  pathogenesis  of  tuberculosis  what  it  may,  however,  there 
can,  I  think,  be  no  question  as  to  the  fact  that  it  is  most  frequently  de¬ 
veloped  in  patients  who  bear  in  their  general  constitutional  condition, 
and  more  especially  in  their  glandular  system,  the  obvious  imprint  of 
the  strumous  diathesis.  Nor  is  it  to  be  wondered  at  that  in  children  thus 
constitutionally  enfeebled  the  struggle  for  existence  between  the  invad¬ 
ing  specific  micro-organisms  and  the  blood  corpuscles  or  leucocytes 
should  almost  invariably  so  speedily  terminate  in  the  fatal  victory  of 
the  prolific  bacilli  of  tubercle. 

The  Application  of  the  Vichy  Waters. — Dr.  Durand-Fardel  says  that 
in  gout  the  results  to  be  expected,  namely,  diminution  in  severity  and 
postponement  of  the  attacks,  are  better  assured  the  more  robust  and 
healthy  the  constitution  of  the  patient,  and  the  earlier  the  attack  is  an¬ 
ticipated  by  beginning  the  treatment.  In  uric-acid  gravel,  cessation  or 
amelioration  of  nephritic  colic  is  accomplished,  provided  the  kidneys 
are  intact.  The  calculi  become  smaller  or  even  disappear,  and  thus  are 
eliminated  without  provoking  painful  symptoms.  Visceral  obesity,  that 
is  to  say,  of  the  chest  or  abdomen,  is  very  positively  relieved.  The 
effect  is  less  pronounced  upon  the  accumulation  of  fat  in  the  peripheral 
regions.  In  diabetes,  especially  in  alimentary  diabetes  and  in  those 


forms  associated  with  obesity,  rapid  improvement  of  all  the  symptoms 
is  effected,  together  with  a  considerable  reduction  or  disappearance  of 
the  glycosuria.  A  subsequent  reappearance  of  the  latter  symptom  in 
constitutional  diabetes  does  not  in  general  reproduce  the  previous  dis¬ 
turbance  of  health,  which  may  perhaps  remain  in  a  satisfactory  condi¬ 
tion  for  a  very  long  time,  provided  the  treatment  is  repeated  occasion¬ 
ally.  In  biliary  calculi  and  hepatic  colics  considerable  improvement  is 
the  rule,  and  frequently  a  complete  cure  is  obtained.  The  same  is  true 
in  simple  congestion  of  the  liver,  chronic  hvperaemia,  and  the  early 
stages  of  cirrhosis  of  alcoholic  or  malarial  origin  or  dependent  upon 
venous  stasis  of  the  abdominal  viscera.  In  malarial  cachexia  or  in  that 
observed  in  warm  climates,  in  the  intestinal  catarrh  of  warm  climates, 
and  the  sequelae  of  dysentery,  the  waters  act  beneficially,  also  in  dys¬ 
pepsia  of  the  atonic  variety  or  that  caused  by  insufficient  secretion  of 
the  gastric  or  intestinal  glands.  A  resolving  action  is  exerted  upon 
most  of  the  congestions  of  the  abdominal  or  pelvic  regions,  with  the 
exception  of  scrofulous  adenitis,  on  congestion  of  the  spleen,  and  on 
simple  congestion  of  the  walls  of  the  stomach  (and  also  on  simple  ulcer 
of  this  organ),  on  such  intra-abdominal  tumors  as  are  capable  of  under¬ 
going  resolution,  on  iliac  and  circum-uterine  abscesses,  and  also  on  con¬ 
gestion  of  the  uterus.  _ 

To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  ”  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  alioays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (i)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  -to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  {2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of— we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  ( 3 )  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors,  arc 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  A  o  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  prof ession  who  send  us  information  of  matters  oj  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  August  28,  1890. 


tctnxtn  aitb 


CANCER. 

A  CLINICAL  LECTURE, 

DELIVERED  AT  THE  PHILADELPHIA  HOSPITAL. 

By  ERNEST  LAPLACE,  M.  D., 

B0FES90R  OF  PATHOLOGY  AND  CLINICAL  SURGERY  IN  THE  MEDICO-CHIRURGICAL 
COLLEGE  OF  PHILADELPHIA  ;  VISITING  SURGEON  TO  PHILADELPHIA  HOSPITAL, 

ETC. 

Lecture  II. 

Reported  by  WILLIAM  BLAIR  STEWART,  M.  D. 

Later  on  in  the  hour  I  will  operate  in  two  cases,  one 
f  which  will  be  a  case  of  skin  grafting,  according  to  the 
lethod  of  Thiersch,  for  two  ulcers  of  the  leg,  while  the 
ther  will  be  for  the  removal  of  a  number  of  venereal  warts 
oin  the  penis  of  a  man  who  is  suffering  with  gonorrhoea, 
lefore  speaking  of  these  cases  I  thought  I  would  take  this 
pportunity  of  addressing  you  on  a  question  of  vital  im- 
ortance  in  pathology,  and  to  bring  into  a  nutshell  and  have 
i  a  tangible  condition  what  is  known  of  the  fetiology  of 
le  affection  we  call  cancer. 

Cancer,  a  thing  of  such  dread  to  all  who  are  acquainted 
ith  it,  a  thing  so  difficult  to  diagnosticate  and  treat — can- 
ir,  the  bugbear  of  the  medical  student,  especially  when 
illed  on  to  distinguish  between  it  and  sarcoma  and  amy- 
id  growth,  etc.  To  begin  with  what  we  know  about  can- 
■r.  The  word  cancer  means  simply  a  crab,  so  named  by 
e  ancient  pathologists  from  its  eating  or  gnawing.  At 
ie  present  time.it  means  nothing  else  than  a  hyperplasia,  or 
.cessive  development,  of  the  cells  in  a  particular  part  of 
e  body.  Now,  these  cells  may  either  grow  on  the  surface 
id  bulge  out,  or  they  may  grow  on  the  surface  and  dip 
to  the  tissues.  According  as  they  do  one  or  the  other, 
ey  are  beuign  or  .malignant  growths.  Let  us  say,  by  way 
illustration,  it  began  on  the  surface  of  the  skin  in  the 
lithelium.  You  all  have  been  out  rowing,  and  have  no- 
c?d  how  callous  your  hand  would  become  and  how  here 
d  there  was  a  “  water-blister.”  The  oar  acts  as  an  irritant 
the  skin,  and  a  congestion  and  hypernutrition  is  the  re- 
lt ;  the  epithelial  cells  proliferate,  accumulate  in  the  one 
°t>  and  there  is  a  tumor  or  callus,  under  which  may  be 
und  blood  serum,  which,  being  absorbed,  leaves  thickened 
idermis. 

On  the  other  hand,  the  man  is  a  smoker  and  smokes  a 
pe.  The  pipe  always  rubs  the  same  spot.  That  man 
mes  from  a  family  of  cancerous  ancestors,  and  has  a  suit- 
le  soil  or  predisposition  to  cancer,  if  the  chances  are  given 
i  an  irritant  to  enter  the  tissues.  The  man  may  have  an 
rasion  on  his  lip ;  the  pipe  irritates  it  and  causes  a  hyper- 
uia.  I  urthermore,  there  is  another  element  that  comes 
and  this  is  a  micro-organism.  I  can  not  prove  to  you 
at  this  is  the  case,  nor  can  I  show  you  the  germ,  but  it  is 
icU  to  the  germs  that  we  know  are  the  cause  of  other 
ections.  In  the  case  of  the  thickened  epidermis  of  the 
■nd,  and  when  we  have  a  corn  on  our  foot,  we  have  an 
1  itant  acting  from  without;  but  in  epithelioma  the  irritant 
a  gerin  acts  in  the  tissues  and  causes  the  growing  epi¬ 


thelium  to  be  pushed  down,  and  causes  it  to  infiltrate  into 
the  tissues,  while  in  the  corn  it  is  simply  an  accumulation 
of  the  epithelial  cells  on  the  surface.  The  ordinary  corn  or 
callus  is  an  epithelioma  in  the  true  sense  of  the  word,  but 
time  and  usage  have  determined  us  not  to  call  this  an  epi¬ 
thelioma.  Now  let  us  return  to  our  smoker. 

The  pipe  has  irritated  the  crack  or  abrasion  of  the  lip. 
The  man  is  of  a  carcinomatous  diathesis ;  just  what  a  diathe¬ 
sis  is  we  do  not  know,  but  he  has  the  chemical  condition 
within  him  which  makes  him  a  suitable  soil  to  develop  can¬ 
cer.  Such  a  condition  is  tuberculosis,  that  spi'ings  up  from 
grief  or  exposure.  Many  thousand  people  smoke  a  pipe 
and  do  not  get  cancer,  because  they  do  not  have  the  di¬ 
athesis.  As  a  result  of  the  irritant,  the  cells  proliferate  and 
produce  a  chemical  substance  called  a  ptomaine.  This  in¬ 
creases  the  irritation  on  the  inside  and  causes  the  prolifera¬ 
tion  to  continue.  The  cells  do  not  accumulate  on  the  sur¬ 
face,  but  infiltrate  into  the  subcutaneous  tissue,  muscles, 
and  periosteum.  These  cells  proliferate  wherever  the  germs 
exist  to  irritate  them.  Remember,  then,  that  in  a  corn  the 
irritant  comes  from  without,  while  in  epithelioma  the  irri¬ 
tant  is  a  germ  which  acts  from  within.  So  much  for  epi¬ 
thelioma,  and  this  leaves  out  of  consideration  a  whole  class 
of  tumors  in  which  the  process  is  identical,  whether  on  the 
surface  of  the  skin  or  beneath  it.  Laying  this  aside,  let  us 
consider  that  character  of  growths  represented  by  fibrous 
tissue,  which  includes  all  fibroma,  sarcoma,  and  scirrhous 
cancers. 

The  processes  of  Nature  are  blind,  and  she  acts  just  as 
she  is  forced  to  act.  When  we  have  an  amputation,  the 
large  flaps  are  open,  and  a  dreadful  gap  has  been  made. 
The  surgeon  cleanses  the  wound,  renders  it  aseptic,  sews  it 
up,  and  trusts  to  Nature  to  cure  it.  All  the  elements  that 
are  concerned  in  cancer  are  brought  to  bear  here,  and  grow 
and  heal  the  wound.  The  very  elements  that  Nature  puts 
in  the  most  malignant  cancer  enter  into  the  process  of  heal¬ 
ing  wounds.  In  a  cut  or  wound,  as  a  result,  a  clot  forms 
in  the  mouths  of  the  vessels  and  checks  haemorrhage.  The 
blood  is  still  being  forced  into  the  vessels,  and  in  these  ves¬ 
sels  are  small  mouths  or  stomata  against  which  a  white 
blood  cell  fits.  The  cells  enter  the  stomata  and,  by  an  hour¬ 
glass  contraction,  escape  from  the  vessel  as  leucocytes,  giv¬ 
ing  us  the  phenomenon  of  diapedesis.  The  leucocytes  are 
destined  by  Nature  to  grow  into  fibrous  tissue  by  their, 
elongation.  When  millions  of  these  leucocytes  are  exuded 
into  the  wound,  we  say  it  is  covered  with  healthy  granula¬ 
tions.  These  soon  fill  the  wound,  and  it  is  found  that 
those  which  fill  the  bottom  of  the  wound  have  become 
fibrous  ;  above  this  come  the  spindle-shaped,  and  on  top 
the  round  cells.  Finally,  all  that  remains  to  complete  the 
healing  is  to  cover  it  with  epithelium.  If,  for  some  reason, 
the  leucocyte  had  not  grown,  but  had  been  killed,  it  would 
have  undergone  fatty  degeneration  and  given  us  a  pus  cell. 
You  must  retain  these  steps  and  follow  them  closely  if  you 
wish  to  get  the  least  accurate  notion  of  the  development  of 
cancer. 

You  will  find  nothing  but  fibrous  and  epithelial  tissues 
in  cancer,  but  they  are  arranged  differently  from  the  normal 


198  JUDSON:  CRITICISM  OF  WILLETTS  OPERATION  FOR  TALIPES  CALCANEUS.  [N.  Y.  Med.  Joup 


tissues  of  the  body.  Sarcoma  is  a  variety  of  fibroma.  Just 
as  epithelioma  is  a  variety  due  to  the  growth  of  epithelial 
cells,  fibroma  is  due  to  the  growth  of  fibrous  cells.  In 
fibroma  there  is  an  exudation  of  cells  from  a  vessel  which 
undergo  the  same  change  that  they  do  in  the  healing  ot  an 
ordinary  wound.  If  you  make  sections  ot  a  fibroma  and  ex¬ 
amine  them  with  the  microscope,  you  find  cells  of  different 
ages  representing  the  round,  spindle,  and  fibrous  cell,  all  in 
the  same  tumor.  When  you  find  the  fibrous  cells  in  excess, 
it  is  a  fibroma;  when  the  spindle  cells  predominate,  it  is  a 
spindle  cell  sarcoma;  and  if  the  round  cells  are  in  excess, it 
is  a  round-cell  sarcoma.  A  fibroma  and  a  sarcoma  are  ieally 
the  same  thing,  but  the  sarcoma  grows  much  more  rapidly 
than  the  fibroma.  A  fibroma  can  not  become  a  fibroma  un¬ 
til  it  has  undergone  the  same  process  of  growth  as  a  sar¬ 
coma. 

True  carcinoma  develops  either  as  the  soft  encephaloid 
or  hard  scirrhus  in  the  glands.  Just  as  we  have  the  epithe¬ 
lioma  on  the  surface,  we  may  have  a  growth  of  endothelial 
cells  in  a  gland,  giving  us  the  encephaloid  (brain-like)  can¬ 
cer.  When  the  mass  is  simply  composed  of  endothelial 
cells  with  a  very  small  amount  of  fibrous  tissue  and  without 
structure,  it  is  the  encephaloid.  A  scirrhus  is  nothing  else 
than  a  combination  of  an  encephaloid  and  fibrous  tissue  in 
which  the  fibrous  tissue  predominates.  It  is  much  harder 
than  the  encephaloid,  but  the  process  of  development  is  the 
same.  The  epithelial  cells  are  inclosed  with  fibrous  cells, 
forming  alveoli. 

We  next  come  to  consider  the  mucoid  and  amyloid  can¬ 
cers.  Nature  can  do  nothing  more  than  I  have  stated,  and 
these  cells,  growing  under  abnormal  circumstances,  die,  and, 
being  contracted  upon  by  the  fibrous  tissue,  undergo  amy¬ 
loid,  mucoid,  or  calcareous  degeneration,  giving  us  these 
forms  of  cancer. 

Metastasis.— To  my  mind,  the  very  best  proof  of  malig¬ 
nant  growths  being  due  to  a  micro-organism  is  the  element 
of  metastasis — that  element  by  which  a  growth,  if  not  prop¬ 
erly  removed,  will  break  out  anew  in  the  same  or  another 
place,  as  only  one  germ  is  required  to  develop  it.  A  tumor 
may  be  thoroughly  removed,  but,  if  a  neighboring  gland  is 
affected,  what  can  be  plainer  than  that  the  poison  has  trav¬ 
eled  along  the  lymphatics  and  developed  ?  Here  is  an  idea 
that  I  wish  to  submit  to  you  that  will  take  away  any  abso¬ 
lute  or  stereotyped  rule,  and  that  is  when  to  pronounce  a 
growth  benign  and  when  malignant.  Why  call  the  one 
growth  benign  and  the  other  malignant  ? 

The  thickened  epidermis  on  the  hand  is  benign  because 
the  irritant  that  produced  it  was  outside  of  the  body  and 
can  be  removed.  The  epithelioma  is  malignant  because  it 
returns  ;  the  irritant  in  the  tissues  has  not  been  completely 
removed.  There  is  one  more  growth,  and  that  is  the  lipo¬ 
ma.  A  lipoma  is  nothing  more  than  a  fibroma  in  some 
of  whose  cells  are  deposited  fat  globules.  The  oil  in  the 
cell  has  simply  pushed  the  nucleus  to  one  side.  A  fibrous 
cell  does  not  possess  the  power  of  infiltration  like  the  epi¬ 
thelial,  and  is  self-limiting  and  movable  as  a  rule  and  benign. 
True  cancer  is  immovable  because  it  infiltrates. 

Here  is  a  man  who  had  epithelioma  of  the  penis  that 
was  removed  a  year  ago,  and  now  he  comes  back  with  a 


similar  growth  in  his  groin.  W  hat  I  wish  to  call  your  at¬ 
tention  to  is  this  fact :  If  you  cut  into  this  tumor  and  pre¬ 
pare  microscopical  slides  from  the  different  portions  of  the 
tumor  and  give  them  to  a  pathologist  to  examine,  he  will 
Hve  this  report :  One  section  contains  epithelial  cells  all 
over  it,  and  he  would  pronounce  it  an  encephaloid.  If 
another  section  made  from  the  thickened  skin  were  given 
him,  he  would  say  epithelioma  of  a  malignant  type.  If  I 
cut  still  farther  up  he  would  say  sarcoma;  and  if  lower  down 
he  would  say  fibroma.  This  illustrates  the  great  caution 
necessary  in  making  a  diagnosis.  If  the  glands  are  involved 
it  is  a  carcinoma.  If  the  epithelial  tissue  is  involved  it  is 
an  epithelioma.  All  these  types  can  be  and  are  present  in 
the  same  growth. 

The  nature  of  a  cancer  therefore  depends  upon  the  na¬ 
ture  and  arrangement  of  the  cells  in  the  particular  section 
examined,  remembering  that  the  element  of  benignity  or 
malignancy  simply  refers  to  whether  the  irritant  which 
is  the  cause  of  the  growth  has  been  completely  removed 
from  the  system  or  not. 


Original  Communications. 


A  CRITICISM  OF  WILLETT’S  OPERATION 
FOR  TALIPES  CALCANEUS* 

By  A.  B.  JUDSON,  M.  D., 

ORTHOPAEDIC  SURGEON  TO  THE  OUT-PATIENT  DEPARTMENT  OF  THE 
NEW  TORK  HOSPITAL. 

The  object  of  Mr.  Willett’s  f  resection  is  to  shorten  th 
tendo  Achillis  and  other  fibrous  structures  at  the  back  o 
the  leg,  the  abnormal  length  of  which  produces  talipes  ca! 
caneus  with  its  characteristic  elevation  of  the  toe  and  dt 
pression  and  enlargement  of  the  heel. 

We  are  apt  to  speak  of  the  deformities  which  are  see 
in  orthopaedic  practice,  but  it  would  be  more  accurate  i 
many  cases  to  use  the  word  disability  instead  of  deformit; 
In  talipes  calcaneus,  for  instance,  the  deformity  is  not  in 
portant.  A  large  heel  and  a  small  anterior  part  of  the  fo< 
do  not  make,  in  an  ordinary  case,  a  bad  deformity.  Bi 
the  disability  attending  every  case  is  very  serious. 

In  the  normal  condition  the  action  of  the  muscles  ei 
ables  the  anterior  part  of  the  foot  to  support  the  body,  ar 
the  result  is  an  equable  gait,  the  weight  at  each  step  coi 
ing  first  on  the  heel,  and  then,  as  the  body  presses  forwar 
being  transferred  to  the  toe.  But  when  the  muscles  a 
paralyzed  the  patient  halts  and  is  seriously  crippled.  I 
has  the  stumping  gait  which  goes  with  a  peg-leg.  He  c; 
throw  no  weight  on  the  anterior  part  of  the  foot,  whit 
might  as  well  be  absent  so  far  as  its  usefulness  in  walkii 

*  Read  before  the  Orthopasdic  Section  of  the  New  \  ork  Acadenn 

Medicine,  March  21,  1890.  J 

I  Remarks  upon  Resection  of  the  Tendo  Achillis  in  Paralytic  Tali| 
Calcaneus.  Alfred  Willett,  F.  R.  C.  S.  St.  Bartholomew’s  Hospital  1 
port,  1880,  pp.  307-310.  Four  Cases  of  Talipes  Calcaneus  of  Parab 
Origin  treated  by  Excision  of  a  Portion  of  the  Tendo  Achillis. 
Walsham.  British  Medical  Journal ,  June  14,  1884,  pp.  1147,  1148. 


Angnst  23,  1890.]  JUDSON ;  CRITICISM  OF  WILLETTS  OPERATION  FOR  TALIPES  CALCANEUS. 

is  concerned.  A  similar  disability  was  produced  by  the 
American  aborigines,  who  amputated  the  anterior  part  of 
the  foot  (Lisfranc’s  operation)  to  prevent  the  escape  of  a 
captive  without  lessening  his  ability  to  labor. 

Dr.  Holmes,  using  the  accompanying  cut  as  an  illustra¬ 
tion  (Fig.  1),  analyzes  the  complex  act  of  walking  in  these 
words:  “Walking,  then,  is  a  perpetual  falling  with  a  per- 


199 


petual  self-recovery.  Man  is  a  wheel  with  two  spokes  (his 
legs)  and  two  fragments  of  a  tire  (his  feet).  He  rolls  suc¬ 
cessively  on  each  of  these  fragments  from  the  heel  to  the 
toe.  If  he  had  spokes  enough  he  would  go  round  and 
round  as  the  boys  do  when  they  ‘make  a  wheel’  with  their 
tour  limbs  for  its  spokes.  Hut,  having  only  two  available 
for  ordinary  locomotion,  each  of  these  has  to  be  taken  up 
as  soon  as  it  has  been  used  and  carried  forward  to  be  used 
again,  and  so  on  alternately  with  the  pair.”  *  Therefore, 
when  a  patient  is  disabled  by  paralytic  talipes  calcaneus,  it 
may  be  said  that  some  fragments  are  gone  from  the  felloes 
of  the  human  wheel. 

The  cause  of  the  tendinous  elongation  in  talipes  calca¬ 
neus  is  obvious.  At  every  step  the  foot  is  forcibly  flexed 
on  the  leg  without  adequate  muscular  resistance  at  the  heel, 
and  the  result  is  that  the  tendons  become  stretched  and  use¬ 
less.  In  a  normal  limb  the  muscles  at  the  back  of  the  leg  form 
a  group  of  remarkable  size  and  power,  the  principal  function 
of  which  is  to  sustain  the  body  when  the  foot  is  extended 
on  the  leg,  and  it  is  an  interesting  question  whether  the 
cicatricial  tissue  following  a  resection  of  the  tendo  Achillis 
is  able  to  resist  the  'weight  which  it  is  the  function  of  this 
great  muscular  group  to  uphold.  Extension  of  the  foot  on 
the  leg  while  the  limb  is  pendent  or  recumbent  may  be 
effected  by  the  action  of  a  few  muscular  fibers,  but  this 
function  is  of  no  importance  compared  with  the  powrer  to 
hold  the  body  on  tip-toe,  which  can  only  be  done  by  supreme 
muscular  exertion. 

In  order  to  demonstrate  clearly  the  severity  of  the  strain 
which  falls  on  the  muscles  of  the  calf  and  the  tendo  Achil- 
is,  I  have  made  the  machine  shown  in  Figs.  2  and  3,  in 
which  wooden  sticks  represent  the  leg  and  the  foot  and  a 

*  The  Human  Wheel;  its  Spokes  and  Felloes.  By  Oliver  Wendell 
Holmes.  The  Atlantic  Monthly,  May,  1863,  pp.  567-580.  Cut  used 

permission  of  the  publishers. 


spring  balance  the  tendo  Achillis.  The  weight  of  the  body 
is  represented  by  a  bag  of  shot  weighing  four  pounds.  The 
machine  can  be  balanced  in  an  upright  position  for  an  in¬ 
definite  time  by  a  light  touch  of  the  hand,  and  the  joint 
representing  the  ankle  is  adjustable  at  any  point  between 
the  heel  and  the  toe.  On  trial  of  the  machine  the  spring' 
balance  is  seen  to  vary  in  its  registry  when  the  joint  repre¬ 
senting  the  ankle  is  moved- to  a  new  point  between  the  heel 
and  the  toe.  When  it  is  near  the  toe  the  balance  registers 
a  small  fraction  of  a  pound,  and  when  it  is  at  a  point  near 
the  heel  the  balance  indicates  twenty  or  twenty-four  pounds, 
the  limit  of  the  scale. 

In  Fig.  2  the  ankle  is  half  way  between  the  heel  and  toe, 
and  the  balance  registers  four  pounds,  showing  that  if  the 
ankle  in  the  human  foot  were  midway  between  the  heel  and 


toe  the  strain  on  the  heel-cord  w'ould  equal  the  weight  of 
the  body.  In  Fig.  3  the  machine  is  so  adjusted  that  it 
measures  three  inches  from  the  ankle  to  the  heel  and  nine 
inches  from  the  ankle  to  the  toe,  a  proportion  which  ap¬ 
proximates  nature.  It  is  now7  seen  that  the  balance  regis¬ 
ters  twelve  pounds,  or  three  times  the  weight  of  the  bag  of 
shot  which  represents  the  body.  It  is  thus  demonstrated 
that  if  a  boy  weighs  one  hundred  pounds  the  strain  on  his 
tendo  Achillis  when  he  is  balancing  on  tip-toe  approximates 
three  hundred  pounds. 

It  is  noteworthy  that  the  strain  decreases  as  the  vertical 
ine  through  the  heel  approaches  the  vertical  drawn  through 
the  toe  and  the  center  of  gravity  and  disappears  when  these 
lines  coincide,  as  they  do  perhaps  in  the  extreme  poise  of 


200  JUDSON:  CRITICISM  OF  WILLETT'S  OPERATION  FOR  TALIPES  CALCANEUS.  [N.  Y.  Med.  Jopii, 


the  ballet-dancer.  But  in  the  ordinary  movements  and  in 
what  is  attempted  by  an  operation  it  is  impracticable  to  try 
to  reduce  the  strain  on  the  tendo  Achillis  by  exaggerated 


extension  of  the  foot  on  the  leg. 


Fig.  3. 


It  is  also  noteworthy  here  that,  if  the  gastrocnemius 
and  soleus  are  paralyzed,  it  is  impossible  for  the  smaller 
muscles  (the  flexor  longus  pollicis,  flexor  longus  digitorum, 
tibialis  posticus,  and  the  first  and  second  peronei)  to  sus¬ 
tain  unaided  the  weight  of  the  body,  not  only  from  their 
small  size,  but  also  because  they  act  at  a  peculiar  disadvan¬ 
tage.  The  tendons  of  these  muscles  pass  behind  the  mal 

leoli  to  be 


Fig.  4,  from  Marshall’s  Physiology ,  although  the  space  is 
doubtless  exaggerated  in  this  cut.  The  smaller  muscles  above 
mentioned,  acting  thus  at  a  still  greater  mechanical  disadvan¬ 
tage  than  the  soleus  and  gastrocnemius,  are  more  certain  than 
they  to  be  violently  stretched  when  the  weight  of  the  body 
falls  on  the  toe  in  the  absence  of  adequate  muscular  con¬ 
traction  at  the  heel.  The  muscles  in  question  are  therefore 
very  properly  left  out  of  our  calculations. 

That  the  tension  falling  on  the  heel  cord  greatly  exceeds 
■;he  corporal  weight  is  thus  seen  to  be  a  matter  of  physical 
demonstration.  It  is  also  found  to  be  in  accord  with  the 
’ormulse  of  mechanics.  It  has  long  been  recognized  that 
he  foot  is  a  lever  of  the 
second  order,  as  is  shown 
in  Fig.  4,  the  weight  (2) 
being  between  the  power 
(1)  and  the  fulcrum  (3). 

Fig.  5  also  shows  a 
lever  of  the  second  or¬ 
der,  the  forces  in  equilib¬ 
rium  about  the  fulcrum 
C  being  the  upward  ten¬ 
sion  of  the  heel  cord  at 
A,  represented  by  T,  and 
the  downward  pressure 
of  the  tibia  DB  at  B, 
represented  by  R.  The 
moments  being  equal,  T 
X  AC  =  R  X  BC.  As 
R  is  the  resultant  of 
the  tension  of  the  heel 
cord  and  the  resistance 

of  the  ground  at  C,  which  is  equal  to  the  weight  of 
the  body,  represented  by  W,  R  =  T  +  W.  Therefore 
T  X  AC  =  (T  +  W)  BC,  or  T  X  AC  =  T  X  BC  +  W  X 
BC,  or  T  X  AC  —  T  X  BC  =  W  X  BC.  But  AC  —  BC 

W  X  BC 


Fig.  5. 


=  AB.  Therefore  T  X  AB  =  W  X  BC,  or  T  = 


AB 


Fig.  4.* 


in¬ 
serted  on  the 
plantar  surface  of 
the  foot,  and  their 
ability  to  sustain 
the  weight  of  the 
body  is  to  be  esti¬ 
mated  as  though 
they  were  in  fact 
inserted  at  the 
posterior  borders 
of  the  malleoli. 
This  insertion  is 


evidently  much  nearer  the  point  of  motion  at  the  ankle  than 
the  posterior  extremity  of  the  os  calcis,  as  may  be  seen  in 


*  Outlines  of  Physiology.  By  John  Marshall.  American  Edition, 
1868,  p.  163,  Fig.  49.  Cut  used  by  permission  of  the  publisher. 


If,  now,  the  weight  of  the  body  is  one  hundred  and  fifty 
pounds  and  the  distance  from  the  ankle  to  the  toe,  BC,  is 
six  inches,  and  the  distance  from  the  ankle  to  the  heel,  AB, 
is  three  inches  (a  fair  statement  of  the  proportion,  which  is 
probably  greater  than  two  to  one  and  less  than  three  to 


900 


,  ,  ,  ...  150  X  6 

one),  the  tension  on  the  heel  cord  is - - - ,  or  ^ 


or 


three  hundred  pounds. 

In  this  demonstration  accuracy  would  require  the  forces 
to  be  considered  in  their  perpendicular  distance  from  the 
fulcrum,  but  practically  the  same  result  may  be  reached  by 
the  use  of  cosines,  as  in  a  valuable  paper  by  Dr.  William  E. 
Wirt  (. Medical  Record ,  June  28,  1890,  p.  725).  It  is  also 
to  be  borne  in  mind  that  the  tension  is  even  greater  than 
is  represented  above,  because  in  some  of  the  more  violent 
movements  of  the  body  the  strain  is  the  sum  of  weight  plus 
momentum. 

It  thus  becomes  difficult  to  believe  that  the  cicatricial 
tissue  formed  in  the  tendo  Achillis  after  resection  will  he 
able  to  endure  the  test  of  use.  It  is  not  likely  that  the 
cicatrix  is  ever  broken,  because  patients  habitually  guard 


August  29,  1890.]  JUBSON •  CRITICISM  OF  WILLETT'S  OPERATION  FOR  TALIPES  CALCANEUS. 


201 


such  a  point  from  undue  violence ;  but  there  is  certainly 
nothing  to  prevent  the  tendon  from  again  becoming  elon 
gated.  It  was  lengthened,  in  the  first  place,  by  the  weight 
of  the  body  repeatedly  falling  on  the  toe  in  the  absence  of 
adequate  contraction  in  the  muscles  of  the  calf.  Muscular 
power  is  still  absent,  and  the  tendon,  exposed  to  the  same 
strain,  will  again  become  elongated  in  the  cicatrix  or  in  the 
fibrous  tissue  above  or  below. 

I  do  not  remember  having  read  any  earlier  exposition  of 
the  mechanical  disadvantage  which  falls  to  the  lot  of  the 
tendo  Achillis  and  the  muscles  of  the  calf.*  It  is  not  prob 
able  that  this  important  point  has  been  entirely  overlooked. 
But  the  question  of  prior  recognition  and  appreciation  of 
the  adverse  lever  at  the  ankle  joint  is  less  important  than  to 
again  call  attention  to  a  simple  and  not  very  expensive 
method  of  mitigating,  by  mechanical  means,  the  disability 
which  accompanies  talipes  calcaneus. 

The  brace  in  question  supplies  the  place  of  the  anterior 
part  of  the  foot.  It  does  in  a  simpler  and  perhaps  more 
effective  manner  what  has  been  done  before  by  other  forms 
of  apparatus.  Its  object  is  to  prevent  the  foot  from  being 
flexed  on  the  leg  when  the  weight  of  the  body  falls  on  the  toe. 
A  growing  child  thus  affected  should  wear  this  simple  appa¬ 
ratus,  not  only  because  the  gait  is  thus  immediately  im 
proved,  but  also  persistently  through  the  period  of  growth, 
because  enlargement  of  the  heel  is  thus  prevented,  and  in 
after  life  the  gait,  without  the  brace,  is  much  better  than 
it  would  have  been  if  the  tendons  and  muscles  of  the  calf 
had  been  over-extended  at  every  step  during  the  time  of 
growth 

The  brace  restores  to  the  patient  the  ability  to  stand 
on  tip-toe,  and  to  use  the  anterior  part  of  the  foot  to  sus¬ 
tain  the  weight  of 


Fig.  6. 


the  body  in  ordi¬ 
nary  locomotion,  as 
well  as  in  the  more 
active  movements  of 
the  body.  Fig.  6  is 
copied  from  an  in¬ 
stantaneous  photo¬ 
graph  dated  1885  of 
a  patient,  at  that 
time  a  young  girl, 
whose  unaffected  leg 
measured  two  inches 
and  seven  eighths 
more  in  circumfer¬ 
ence  than  the  af¬ 
fected  one.  With¬ 
out  the  brace  she 


She  had  worn  the  brace  persistently  with  comfort  and  ad¬ 
vantage.  When  she  walks  carefully,  wearing  the  appa¬ 
ratus,  her  gait  is  free  from  the  slightest  defect.  She 
sometimes  lays  it  aside  to  please  importunate  but  mistaken 
friends,  but  insists  on  wearing  it  when  the  duties  of  house¬ 
keeping  are  urgent,  and  will  not  appear  out  of  doors  with¬ 
out  it. 

This  brace  should  be  made  without  a  joint  at  the 
ankle,  differing  in  this  respect  from  the  one  described  in 
detail  by  me  in  1885.*  Experience  has  shown  that  the 
joint  was  useless,  and  the  cause  of  frequent  and  expensive 
lepaiis.  In  some  cases,  also,  the  knee  becomes  slightly 
flexed,  evidently  because  habitual  flexion  is  necessary  to 
enable  the  tibia  to  press  against  the  padded  strap  at  the 
upper  part  of  the  apparatus.  It  is  therefore  desirable  to 
attach  the  upright  near  the  posterior  extremity  of  the  foot 
piece,  and  also  to  incline  it  back¬ 
ward  at  an  angle  (in  some  cases  10°), 
which  may  be  determined  for  each 
case  by  repeated  trials.  The  angle 
may  be  changed,  for  experiment,  by 
a  heavy  blow  delivered  in  an  antero-' 
posterior  direction  while  the  upright 
is  suitably  supported  at  each  end. 

Tn  other  respects  the  brace, 
shown  in  its  present  condition  in 
fig.  7,  is  unchanged,  and  continues 
in  use  by  a  number  of  patients.  It 
transfers  the  forces  of  weight  and 
momentum,  which  in  the  normal 
foot  are  received  at  the  ball  of  the 
toe,  to  the  upper  part  of  the  anterior 
surface  of  the  leg  near  the  tubercle 
of  the  tibia,  where  a  callus  and  an 
adventitious  bursa  are  produced. 


Fig. 


Adults  wear  it  con¬ 
stantly,  as  they  would  an  artificial  limb,  with  great  in¬ 
crease  of  their  ability  to  walk  well  and  far. 

In  many  cases  the  improvement  in  walking  is  partly  due 
to  an  apparent  increase  in  the  length  of  the  limb.  The 
brace  is  easy  to  adjust,  inexpensive,  almost  indestructible, 
and  certain  to  add  to  the  patient’s  comfort  and  ability.  If 
necessary,  webbing  may  be  attached  to  prevent  or  lessen 
the  valgous  condition  which  often  accompanies  talipes  cal¬ 
caneus. 

The  Madison,  East  Twenty-fifth  Street. 


an  not  put  the  smallest  fraction  of  her  weight  on  the  toe 
>f  the  affected  limb,  but  with  the  brace  applied  she  bai¬ 
lees  herself  on  tip-toe  with  ease,  as  shown  in  the  cut. 

,  When  I  examined  this  patient  recently,  after  an  inter- 
of  several  years,  the  (infantile)  paralysis  persisted,  as 
expected,  but  the  deformity  characteristic  of  talipes 
alcaneus  was  present  in  only  a  very  moderate  degree. 


.  *  ltde  report  of  the  January  meeting  of  the  Orthopedic  Section, 
vew  Yortc  Medical  Journal ,  March  1,  1890,  pp.  246-249. 


Hydracetin  in  Skm  Diseases. As  the  result  of  some  observations 
on  the  use  of  hydracetm  in  skin  diseases,  Dr.  E.  Basch  finds  himself 
unable  to  agree  at  all  fully  with  the  laudatory  accounts  which  have 
been  given  of  its  action  by  some  other  observers.  He  finds  that  it  is 
decidedly  poisonous,  even  when  applied  externally.  In  a  case  of  gen¬ 
eral  psoriasis,  where  a  ten-per-cent,  ointment  was  applied  to  a  third  of 
t  le  surface  of  the  body,  after  ten  days’  treatment  the  skin  and  mucous 
membranes  became  quite  pale,  and,  though  the  hydracetin  was  then 
stopped,  haemoglobin uria  and  jaundice  supervened.  The  pulse  became 
very  rapid,  but,  notwithstanding  the  constitutional  action  of  the  drug 
the  psoriasis  was  not  benefited.  Dr.  Basch  finds  that  hydracetin,  though 
a  powerful  reducing  agent  and  useful  in  small  patches  and  limited 
areas  of  psoriasis,  has  by  no  means  the  specific  effect  that  pyrogallol 
and  chrysarobin  apparently  have.” — British  and  Colonial  Druggist. 


*  Medical  Record ,  May  16,  1885,  pp.  538,  539. 


202 


UPSON:  ON  TWO  OASES  OF  MUSCULAR  DYSTROPHY. _ [N.  Y.  Med.  Joub., 


OX  TWO  CASES  OF  MUSCULAR  DYSTROPHY. 


By  HENRY  S.  UPSON,  M.  D., 

PHYSICIAN  TO  THE  LAKESIDE  AND  CITY  HOSPITALS,  CLEVELAND,  OHIO. 


Tiie  classification  of  diseases  is  a  by  no  means  unim¬ 
portant  subject  in  medicine,  and,  in  our  continued  igno¬ 
rance  of  final  causes,  is,  in  fact,  almost  the  chief  way  of 
increasing  the  existing  stock  of  medical  knowledge.  A 
perfect  classification  could  only  proceed  from  omniscience, 
and  can  not  be  hoped  for.  However,  there  are  certain 
broad  principles  which 


should  be  kept  in  view  in 
order  to  make  an  at  least 
useful  division  of  disease 
types ;  the  most  funda¬ 
mental  of  these  is  never 
to  generalize  except  from 
a  large,  in  fact  the  largest 
possible,  number  of  cases. 

It  is  true  some  new  dis¬ 
eases  have  been  described 
from  a  single  case ; '  but 
this  is  a  rather  danger¬ 
ous  precedent  to  follow. 

There  is  a  limit  to  the 
value  of  dividing  types  of 
disease  into  groups  and 
subgroups. 

The  dangers  of  over¬ 
classification  are  well 
shown  in  the  somewhat 
protean  disease  -  form 
known  as  muscular  dys¬ 
trophy.  This  affection,  a 
few  examples  of  which  had 
before  been  described  by 
an  English  observer  — 

Meryan — was  first  clearly 
marked  off  from  other 
trophic  disturbances  of 
the  muscular  system  in 
18(31  by  Duchenne,  of 
Boulogne.  His  descrip¬ 
tion  was  based  on  a  study 
of  thirteen  cases,  and  was 
soon  followed  by  the  pub¬ 
lication  of  several  cases  in 
Germany  and  England. 

The  name  under  which 
the  disease  has  usually 

been  described  is  the  one  proposed  by  Duchenne — pseudo- 
hypertrophic  muscular  paralysis.  Subgroups  soon  began  to 
appear  as  different  forms  of  the  affection  came  under  the  eye 
of  various  observers,  and  distinctions  were  made  according 
as  cases  were  affected  early  or  late  in  life  (juvenile  form  of 
Erb),  or  from  the  muscle  groups  which  happened  to  be 
early  affected  (face  and  arm  type  of  Landouzy,  Dejerine, 
and  others). 

It  has  become  evident  that  the  disease  may  begin  in 


an  endless  variety  of  ways,  and  there  is  a  growing  tend¬ 
ency  at  present  to  do  away  not  only  with  all  classifica¬ 
tion  from  a  regional  basis,  but  also  all  nomenclature  which 
may  be  misleading  as  to  the  as  yet  unknown  cause  of  the 
affection. 

At  one  time  the  involvement  of  the  facial  muscles  was 
a  source  of  contention  between  the  German  and  French 
observers.  This  feature  of  the  disease,  first  described  by 
Duchenne,*  has  been  for  some  reason  rare  in  Germany, 
although  sufficiently  common  in  France.  It  is  shown  in  a 

quite  marked  degree  in 
the  following  case,  which 
has  lately  come  under  my 
observation  : 


A.  J.,  a  boy  aged  seveD, 
parents  both  living  and 
healthy.  The  patient,  an 
only  child,  has  always  been 
rather  delicate,  but  was  con¬ 
sidered  moderately  well  un¬ 
til  six  months  ago.  Then  it 
was  noticed  that  there  was 
a  weakness  of  the  neck.  If 
the  head  fell  forward  it  was 
rather  difficult  to  get  it  back, 
and  there  was  some  bulging 
of  the  spine  at  the  back  of 
the  neck.  This  is  all  that 
the  patient  complained  of. 
About  a  month  ago  he  had 
the  measles,  from  which  he 
made  a  good  recovery. 

On  inspection,  the  pa¬ 
tient  is  a  frail-looking  boy, 
with  a  very  well  developed 
head.  The  face,  however, 
has  a  stupid  expression,  the 
upper  lip  being  very  thick 
and  the  mouth  open  the 
greater  part  of  the  time. 
The  whole  face  has  a  rigid 
appearance,  especially  no¬ 
ticeable  when  the  patient 
talks  or  laughs.  It  is  quite 
impossible  for  him  to  pucker 
his  lips  to  whistle  or  even 
to  blow ;  this  condition  of 
things  has  become  marked 
within  the  last  few  months. 

The  accompanying  pho¬ 
tograph  shows  very  well  the 
habitual  expression  of  the 
patient,  but  fails,  of  course, 
to  convey  an  adequate  idea  of  the  almost  entire  immobility  of 
the  face,  which  is  the  most  striking  feature  of  the  case.  The! 
palpebral  openings  are  equal;  the  pupils  are  equal  and  react  to 
light;  there  is  no  apparent  weakness  of  any  of  the  ocular  mus¬ 
cles,  and  no  diplopia.  The  arras  are  both  very  small,  the  del¬ 
toids  markedly  atrophic,  especially  the  right  one,  which  lias  al¬ 
most  entirely  disappeared.  The  arms  can  neither  of  them  be 


*  Paralysie  musculaire  pseudo-hypertrophique,  Paris,  1868,  p.  1®- 
Obs.  xii. 


UPSON:  ON  TWO  CASES  OB'  MUSCULAR  DYSTROPHY. 


203 


August  23,  1890.] 


raised  above  the  horizontal.  The  scapulro  project,  the  inferior 
angles  being  thrown  back,  giving  a  markedly  winged  appearance 
when  the  patient  stretches  his  arms  in  front  of  him.  The  cerv¬ 
ical  vertebrae  show  a  marked  curvature  backward,  due  apparently 
to  a  wasting  of  the  deep  muscles  of  the  neck  and  upper  part  of 
the  back.  The  muscles  of  the  lower  part  of  the  hack  seem  strong 
and  large  enough.  The  head  is  carried  well  back,  or,  if  allowed 
to  go  forward,  drops  on  the  chest.  There  is  no  lateral  curva¬ 
ture  of  the  spine,  and  no  tenderness  over  any  of  the  vertebra. 
The  abdomen  protrudes  somewhat.  The  thighs  and  legs  are  of 
good  size;  they  do  not  seem  at  all  hypertrophic,  and  are  fairly 
-trong. 

The  dynamometer  registers  a  grasp  of  4  with  the  right 
hand  and  14  with  the  left.  The  muscles  of  the  upper  ex¬ 
tremities  react  well  to  the  faradaic  current,  except  the  right 
leltoid,  which  does  not  react  at  all.  The  reaction  to  the  gal¬ 
vanic  current  is  normal  in  the  right  forearm  and  left  deltoid, 
fvCC>AnCC,  and  the  response  on  closure  of  the  circuit  is 
>rompt  and  rapid.  There  are  no  triceps  or  wrist  fetlexes. 
The  knee-jerks  are  slight,  but  are  distinctly  present.  There  is 
10  anesthesia.  The  patient  gets  up  from  the  floor  in  a  very 
peculiar  way  by  pushing  himself  with  his  head,  seemingly 
m  account  of  weakness  of  the  muscles  about  the  shoulders, 
vhich  prevents  him  from  assisting  himself  with  his  arms.  Once 
tarted,  however,  lie  raises  his  body  quite  easily  by  means  of  the 
nuscles  of  the  lower  part  of  the  back.  This  is  quite  different 
rom  the  characteristic  way  which  some  patients  have  of  rais- 
ng  themselves,  so  well  figured  by  Gowers  in  his  excellent  mono- 
raph,*  and  which  is  rendered  necessary  by  weakness  of  the  mus- 
les  of  the  small  of  the  back.  There  are  a  few  moist  rales 
wer  the  lungs;  the  percussion  note  and  breathing  sounds  are 
lormal. 

It  is  necessary  to  distinguish  this  case  from  the  paraly- 
is  of  Pott's  disease,  which  it  resembles  somewhat  on  ac- 
ount  of  the  curvature  of  the  cervical  vertebrae.  A  mo¬ 
unt’s  consideration  will  convince  us  that  the  atrophy  of 
he  muscles  is  much  greater  in  proportion  to  the  loss  of 
ower  than  is  ever  the  case  in  paralysis  from  pressure  on 
lie  cord.  In  this  connection  the  absence  of  the  reaction 
t  degeneration  is  also  significant.  This,  with  the  absence 
f  all  sensory  symptoms,  pains,  or  anaesthesiae,  especially 
ie  absence  of  tenderness  over  the  spine,  the  simple  bulg- 
ig  of  the  vertebrae  without  deformity,  and  the  positive 
tmptom  of  involvement  of  the  face,  is  ample  evidence 
i  excluding  caries  of  the  vertebrae  as  the  cause  of  the 
ouble. 

From  muscular  atrophy  of  spinal  origin  the  diagnosis  is 
°f  so  easy,  or  would  not  be  were  it  not  for  the  involvement 
I  the  face.  The  absence  of  the  reaction  of  degeneration  is 
>t  so  significant  as  would  at  first  sight  appear,  since  in  the 
tter  disease  the  process  is  so  gradual,  the  affected  muscles 
■mg  attacked  fiber  by  fiber,  that  in  any  given  muscle  there 
e  enough  healthy  fibers  to  give  the  normal  prompt  reac- 
°n  up  to  the  time  when  the  muscle  has  almost  diappeared. 
uscular  atrophy  of  spinal  type  has,  however,  certain  cliar- 
•teristics  in  its  mode  of  development.  It  is  apt  to  begin 
adult  life,  attacking  first  the  small  hand  muscles,  which 
3 re  are  not  affected  ;  above  all,  the  facial  muscles,  if  they 
e  involved,  present  the  clinical  picture  of  glosso-labio-la- 
ngeal  paralysis,  or  bulbar  paralysis,  which  certainly  is  not 
esent  in  this  case. 

Pseudo-hypertrophic  Paralysis,  a  Clinical  Lecture,  London,  1879. 


As  all  evidence  of  disease  of  the  spinal  cord  is  wanting, 
we  must  refer  the  case  to  the  class  of  muscular  dystrophies, 
and,  for  lack  of  a  better  name,  call  the  affection  pseudo-hy¬ 
pertrophic  muscular  paralysis. 

The  next  case  has  some  similarity  with  the  preceding- 
one,  but  is  unusual  in  developing  side  by  side  with  another 
nervous  affection  as  mysterious  in  its  origin  and  ultimate 
pathology  as  is  the  one  under  consideration. 

M.  T.,  a  bright,  intelligent-looking  girl  of  fifteen,  was  quite 
'veil  until  three  years  ago;  then  it  was  noticed  that  she  was 
walking  a,  little  lame.  This  gradually  increased,  and  a  jear  ago 
she  became  unable  to  get  her  left  heel  to  the  ground.  It  was 
also  noticed  three  years  ago  that  there  was  a  swelling  of  the 
throat,  which  has  since  become  more  marked.  The  patient  has 
complained  of  shortness  of  breath,  especially  on  going  up  stairs, 
but  has  had  no  palpitation  of  the  heart.  The  appetite  has  been 
poor  lately,  the  bowels  regular.  The  patient  is  one  of  four  chil¬ 
dren  ;  the  others  are  all  healthy. 


On  examination,  tne  eyes  are  somewhat  protr  uding  and  wide 
open,  but  can  be  readily  and  completely  closed.  This  protru¬ 
sion  has  been  noticed  by  the  child’s  mother,  and  has  increased 
of  late.  The  pupils  are  equal  and  react  to  light,  the  color  is 
good,  and  facial  muscles  normal  in  appearance  and  action.  The 
tongue  is  protruded  straight.  There  is  a  very  well  marked  en¬ 
largement  of  both  thyreoid  glands.  The  pulse  is  soft  and  regu¬ 
lar,  and  under  the  excitement  of  the  examination  104.  The 
heart  sounds  are  normal ;  there  is  no  murmur.  There  is  a 
marked  reddening  of  the  skin  where  the  clothing  touches  the 
body  ;  if  the  nail  is  diawn  across  the  skin,  in  a  few  moments  a 
bright-red  line  appears  and  persists  for  some  time.  The  arms, 
forearms,  and  deltoids  are  markedly  atrophic,  but  the  interossei, 
pectoral,  abdominal,  and  back  muscles  are  of  fair  size.  There 
is  no  distinct  paralysis  of  any  of  the  muscles.  All  the  move¬ 
ments  of  the  arms  can  be  carried  out,  but  weakly.  Grasp,  ac¬ 
cording  to  dynamometer,  18  with  right  hand,  17  with  left. 

To  the  faradaic  current  all  the  muscles  of  the  upper  ex¬ 
tremities  react,  except  the  extensors  of  the  fingers;  in  these  a 
reaction  can  be  obtained  only  in  the  right  extensor  minimi 
digiti.  To  the  galvanic  current  all  the  muscles  of  the  upper 
extremities  react  promptly,  and  KCC>AnCC. 

In  the  lower  extremities  all  of  the  muscles  seem  moderately 
wasted,  except  those  of  the  right  calf.  The  latter  is  plump  and 


204 


VAN  ARSDALE:  THE  ACTION  OF  PYOCTANIN  AS  AN  ANTISEPTIC.  [N.  Y.  Med.  Jqor., 


firm,  in  contrast  to  the  left  calf,  which  is  small  and  flabby. 
When  the  patient  stands  the  feet  are  held  rather  wide  apart ; 
the  right  heel  can  with  some  difficulty  be  brought  to  the  ground  ; 


the  left  foot  is  held  in  the  position  of  talipes  equipus  ;  the  heel 
can  not  be  brought  anywhere  near  the  floor.  Ihe  knee-jerks 
are  absent  on  both  sides.  The  muscles  all  of  them  act  fairly 
well,  although  weakly;  electrical  reactions  not  tested,  There 
is  no  protrusion  of  the  abdomen.  Sensibility  is  normal  all  over 
the  body. 

Ophthalmoscopic  Examination—  Optic  discs  clear,  of  a  rather 
pinkish  color.  Fuudus  of  both  eyes  normal. 

The  diagnosis  of  exophthalmic  goitre  is  obvious  in  this 
case,  from  the  enlargement  of  the  tliyreoids,  coincident  pro¬ 
trusion  of  the  eyeballs,  the  latter  not  yet  sufficiently  well 
marked  to  cause  von  Graefe’s  symptom,  and  the  so-called 
“tache  cerebrale,”  which  in  this  affection  is  sufficiently 
common. 

The  tremor  which  is  often  in  these  cases  very  marked 
is  replaced  by  another  set  of  motor  symptoms,  sufficiently 
characteristic,  and  which,  taken  together,  certainly  deserve 
to  be  ranked  as  pseudo-hypertrophy.  The  weakness,  the 
wasting  of  certain  muscle  groups  are  present,  and  with  them 
another  condition  which  is  found  in  many  of  these  cases,  a 
contracture  and  shortening  of  the  muscles,  leading  to  club¬ 
foot  and  other  deformities.  The  only  distinctly  hypertro¬ 
phic  muscles  at  present  are  those  of  the  right  calf,  although 
other  groups  may  have  been  enlarged  earlier.  Of  this  no 
history  can  be  obtained. 

It  is  almost  useless  to  speculate  on  the  probable  connec¬ 
tion  between  the  two  distinct  affections  from  which  this  girl 
is  suffering.  Trophic  and  vascular  disturbances  are  no  doubt 
intimately  related  in  their  dependence  on  nerve  supply,  but 
too  little  is  as  yet  known  in  this  field  to  warrant  any  con¬ 
clusions  from  such  a  case  as  the  present  one.  The  coinci¬ 
dence  of  two  such  affections  is,  however,  somewhat  sug¬ 
gestive. 

A  word  may  still  be  necessary,  on  the  distinction  of  the 
above  cases  from  those  forms  of  disease  which  are  marked 
bychanges  in  the  motor  ganglion  cells  of  the  cord.  That 


caution  is  necessary  in  postulating  disease  of  the  cord  from 
a  partial  reaction  of  degeneration,  even  when  it  occurs  to¬ 
gether  with  total  atrophy  of  the  small  hand  muscles,  is  evi¬ 
dent  from  the  case  so  carefully  examined  by  Schultze,*  in 
which  these  symptoms  were  present  and  in  which  not  only 
the  central  nerve  tissues,  but  also  the  peripheral  nenes, 
were  practically  normal.  I  believe  that,  even  in  cases 
which,  unlike  the  two  just  described,  present  no  muscular 
enlargements,  we  may  easily  go  wrong  in  assuming  an  or¬ 
ganic  basis  for  the  disease ;  and  in  these  two  cases  the 
absence  of  decided  evidence  of  a  nerve  lesion  is  given  much 
positive  value  by  the  marked  though  not  extensive  hyper¬ 
trophy  of  certain  muscle  groups. 

The  treatment  of  the  latter  case  has  as  yet  been  direct¬ 
ed  to  the  vascular  rather  than  the  trophic  disturbance.  With 
the  lapse  of  time  an  operation  for  the  relief  of  the  deformity 
may  become  advisable,  but  gives,  unfortunately ,  no  more  than 
a  prospect  of  temporary  relief. 


NOTE  ON  THE  ACTION  OF 
PYOCTANIN  AS  AN  ANTISEPTIC. 

By  W.  W.  VAN  ARSDALE,  M.  D., 

ATTENDING  SURGEON,  EASTERN  DISPENSARY  ; 

LECTURER  ON  SURGERY  IN  THE  NEW  YORK  POLYCLINIC. 

Among  the  antiseptic  agents  more  recently  introduced, 
pyoktanin,  one  of  the  aniline  dyes  recommended  as  a  dress¬ 
ing  for  wounds  by  Stilling  (1),  of  Strassburg,  has  appeared 
to  me,  during  a  brief  clinical  experience  with  it,  to  offer 
special  advantages  in  the  treatment  of  a  certain  class  of  sur¬ 
gical  affections.  I  therefore  believe  it  deserving  of  more 
general  attention,  and  do  not  hesitate  to  recommend  its  fur¬ 
ther  trial,  notwithstanding  the  adverse  criticisms  which  have 
appeared  regarding  it  in  the  German  medical  press  (2,  3,  6), 

I  am  indebted  to  Mr.  F.  A.  Stohlinann,  of  this  city,  for  first 
calling  my  attention  to  it,  which  he  did  in  May  of  this  year. 
Since  then  I  have  used  it  in  about  one  hundred  and  fifty 
cases,  representing  various  surgical  conditions  and  occur¬ 
ring,  for  the  most  part,  in  dispensary  practice.  The  cases 
in  which  it  proved  most  beneficial  were  superficial  wounds, 
ulcers,  abrasions,  excoriations,  burns,  and  all  kinds  of  granu¬ 
lating  surfaces.  With  its  action  on  mucous  membranes  I 
have  little  experience.  Only  one  preparation  was  used— -the 
violet  pyoctanin  of  Merck— and  it  was  always  employed  in 
an  aqueous  solution,  one  part  by  weight  in  a  thousand,  the 
solution  generally  being  prepared  fresh.  The  powder  and 
the  yellow  preparation  (auramine)  were  used  in  very  few 
cases  only.  With  this  solution  simple  absorbent  gauze  was 
saturated,  which  was  generally  applied  still  moist  to  the 
surface  to  be  dressed.  In  some  cases  the  gauze  was  kept  a 
day  or  two  and  applied  dry.  The  dressing  was  next  usually 
covered  with  a  protective,  hospital  oiled  paper  being  gen¬ 
erally  preferred,  this  manner  of  dressing  having  proved 
most  satisfactory  for  use  in  this  climate,  and  especially 
where  there  was  reason  to  fear  any  retention.  In  othei 
cases,  however,  as  in  fresh  aseptic  wounds,  the  protective 

*  Ueher  den  mit  Hypertrophie  verbundenen  progressiven  Muskel 
schwund,  und  dhrdiche  Krcmkheilsformen,  Wiesbaden,  1886, 


August  23,  1880.]  VAN  ARSDALE^  TBE_  ACTION  OF  PYOOTANIN  AS  AN  ANTISEPTIC. 


205 


was  left  off  with  more  advantage.  The  dressings  were 
allowed  to  remain  as  applied  for  three  days  on  the  average. 
Large  wounds  were  found  to  require  more  frequent  change. 

The  forbidding  appearance  of  the  solution  and  the  gauze 
did  not  meet  with  any  protest  or  remonstrance  on  the  part 
of  the  patients,  contrary  to  my  anticipations.  On  the  con¬ 
trary,  after  the  first  application,  the  patients,  of  their  own 
accord,  expressed  themselves  warmly  in  its  favor,  and  in 
every  instance  requested  to  be  dressed  “  with  the  blue  dress¬ 
ing.”  It  was  this  indorsement  of  its  properties  which  led 
me  to  continue  its  use.  The  intense  staining  qualities  of 
the  substance,  as  evidenced  on  its  contact  with  the  hands 
and  apparatus,  lose  some  of  their  terrors  when  one  learns  how 
readily  alcohol  or  tinct,  saponis  will  remove  such  stains  (4). 
This  property  appears  to  me  to  be  a  serious  objection  to 
the  use  of  the  powder.  The  gauze,  however,  may  be  im¬ 
pregnated  in  a  glass  dish  and  manipulated  with  forceps  and 
scissors  without  inconvenience.  In  fact,  the  coloring  prop¬ 
erties  appear  to  me  to  have  the  advantage  of  keeping  the 
dressings  unsoiled  by  unnecessary  contact,  as  well  as  of  af¬ 
fording  a  test  as  to  the  thorough  action  of  the  disinfectant. 

Under  the  treatment  above  described,  the  surfaces  of 
granulating  wounds  which  had  been  exposed  for  some  time 
to  the  air  did  remarkably  well.  Secretion  of  pus  was  fre¬ 
quently  cut  short  as  soon  as  the  dressing  was  used.  In 
most  cases,  however,  some  pus  continued  to  appear  in  the 
central  portions  of  the  dressings,  until  they  had  been 
changed  twice  or  three  times.  The  granulations  proper 
always  appeared  in  good  condition  under  the  dressing.  In 
no  case  did  exuberant  granulations  spring  up,  and  where 
such  were  present  at  the  time  of  applying  the  dressing,  they 
soon,  after  two  or  three  changes,  assumed  a  healthy  appear¬ 
ance.  The  pyoctanin  has  a  moderately  astringent  action 
on  the  granulations.  But  where  the  dressing  is  allowed  to 
remain  on  for  one  week  and  the  gauze  becomes  discolored 
by  the  action  of  the  pus,  the  granulations  appear  as  under 
other  dressings. 

The  epithelium  about  the  edges  of  the  wound  showed 
no  undesirable  conditions.  In  no  case  was  any  eczema  ob¬ 
served  about  the  wound,  nor  were  any  other  symptoms  of 
irritation  or  increased  serous  secretion  from  the  wound  ob¬ 
servable.  On  the  contrary,  the  dressings  appeared  to  favor 
the  rapid  and  healthy  growth  of  the  epithelium  over  the 
granulations,  so  that  ulcers  which  had  been  a  long  time 
healing  healed  very  much  more  rapidly  under  the  dressing 
described.  In  this  particular  lies  the  main  advantage  of 
pyoctanin  over  other  antiseptic  dressings  for  this  class  of 
wounds ;  the  moist  dressings,  with  the  exception,  perhaps, 
of  creoline,  are  more  irritant  to  the  wounds,  while  the 
powders  retard  the  growth  of  the  epithelium.  Burns,  too, 
showed  very  satisfactory  results  with  pyoktanin  dressings, 
and  compared  very  favorably  with  those  treated  with  fre¬ 
quent  oily  dressings. 

Necrotic  tissue  remains  uninfluenced  by  pyoktanin  ;  it 
is  not  even  readily  stained.  The  secretions  from  the  sound 
tissue  surrounding  the  necrotic  parts,  however,  being  min¬ 
imized  by  the  pyoctanin,  and  the  formation  of  pus  pre¬ 
vented,  the  eliminating  action  of  suppuration  is  much  in¬ 
terfered  with  by  this  agent.  Consequently  the  coming 


away  of  sloughs  and  the  cleansing  of  necrotic  ulcers  is  not 
hastened  by  pyoctanin,  but  is  retarded  in  the  same  manner 
as  by  other  antiseptics.  For  some  cases,  as  after  severe 
burns,  this  action  is  of  course  desirable ;  for  smaller  sloughs, 
wheie  rapid  healing  is  desired,  other  dressings  are  more 
advantageous.  It  may  be  stated,  however,  that  since  the 
action  of  the  pyoctanin,  applied  as  above,  does  not  pene¬ 
trate  through  the  slough,  the  elimination  of  the  necrotic 
portion  from  beneath  the  slough  in  infected  wounds  is  not 
essentially  interfered  with,  so  that,  while  eliminative  sup¬ 
puration  goes  on  beneath  the  slough,  the  formation  of  epi¬ 
thelium  goes  on  about  the  edges  of  the  necrosed  portion 
where  the  agent  has  access,  so  that  ulcers  so  treated  actu¬ 
ally  begin  to  heal  before  they  are  completely  cleansed. 

The  action  of  pyoctanin  on  fresh  wounds  is  very  much 
the  same  as  that  of  other  antiseptics ;  they  retain  their  nor¬ 
mal  conditions,  and  heal  by  primary  intention.  If  the  na¬ 
ture  of  the  solution  permitted  of  a  less  apprehensive  use  of 
the  stain  as  an  irrigating  fluid,  I  do  not  doubt  but  that  it 
would  prove  much  more  extensively  useful.  But  as  yet  I 
am  at  a  loss  to  see  how  the  solution  can  become  popular 
for  such  purposes. 

Venereal  ulcers  were  beneficially  influenced  by  applica¬ 
tion  of  the  dry  gauze  ;  secretion  was  diminished  and  for¬ 
mation  of  epithelium  hastened.  Syphilitic  (tertiary)  ulcers 
appear  less  influenced.  The  lengthy  time  of  cleansing,  the 
appearance  ot  the  slough,  and  the  pain  accompanying  syphi¬ 
litic  ulcerations,  are  the  same  as  under  other  dressing.  Com¬ 
pared  with  iodoform,  the  latter  appear  to  me  to  do  better 
under  iodoform,  while  the  venereal  ulcers  (chancroids)  do 
much  better  under  pyoctanin. 

In  no  case  coming  under  my  observation  has  there  been 
any  acute  infection  of  a  wound  under  a  pyoctanin  dressing; 
erysipelas,  phlegmons,  lymphangeitis,  lymphadenitis,  septi¬ 
caemia,  and  pyaemia  were  not  once  observed  as  secondary 
affections  after  application  of  the  dressings.  But  I  am  far 
from  attaching  much  importance  to  this  observation  in  con¬ 
sideration  of  the  small  number  of  cases  seen. 

In  conclusion,  I  may  say  that  pyoctanin  appears  to  me 
<o  kill  certain  kinds  of  pus  wherever  itcotnes  wholly  in  con¬ 
tact  with  it,  but  it  has  not  the  power  to  penetrate  sloughs, 
and,  where  septic  necrotic  processes  are  going  on,  frequent/ 
change  of  dressings  is  necessary.  It  is  non-irritant  to  wounds, 
and  keeps  granulations  in  good  condition.  It  also  insures 
the  patient’s  remaining  remarkably  free  from  pain  and  sub¬ 
jective  inconvenience.  But,  where  the  pain  is  deep-seated, 
or  due  to  other  conditions  than  those  of  the  superficial 
wound,  this  effect  of  pyoctanin  is  not  observed,  as  in  the 
’ollowing  case : 

A  robust  man  was  driving  a  cart  in  a  Brooklyn  park,  when 
lis  horse  became  unmanageable  and  kicked  him,  as  he  sat  on 
the  front  of  the  cart,  three  times  successively  on  the  leg.  Seen 
soon  after  by  me,  he  presented  a  longitudinal  wound  of  about 
’our  inches  in  length  immediately  below  the  tuberosity  of  the 
;ibia.  The  edges  were  contused;  at  the  bottom  the  bone  was 
aid  bare,  denuded  of  its  periosteum.  Dressing  with  pyoctanin, 
;he  wound  being  first  cleansed  with  pure  water,  (all  other  disin¬ 
fectants  being  avoided)  and  swabbed  with  moist  pyoktanin 
gauze;  coaptation  sutures  were  applied,  cocaine  being  employ  ed 
hypodermically  (Dr.  Whitaker).  The  wound  consequently  did 


206 


DODGE:  THE  EXAMINATION  OF  PERSONS  FOR  LIFE  INSURANCE.  [N.  Y.  Med.  Joub, 


well  and  presented  an  aseptic  course,  the  contused  edges  of  the 
wound  becoming  necrosed.  But  for  the  two  days  following 
the  accident  the  patient  suffered  severe  pain  at  the  seat  of  the 

injury. 


SOME  POINTS  IN 

THE  EXAMINATION  OF  PERSONS  FOR 

t  t  tt'Ij'  T'MQTTT?  A  NPF, 


I  may  add  that  pyoctanin  has  been  made  the  subject  of 
careful  bacteriological  investigation  by  Jaenicke  (6).  Still¬ 
ing  and  Wortmann,  who  tested  the  action  of  the  dye  on  pu¬ 
trefactive  bacteria,  found  (5)  that  it  killed  them  in  a  con¬ 
centration  of  1  in  4,000,  which  Jaenicke  confirms.  But  the 
latter  author  tested  its  action  on  pure  cultures  of  several 
kinds  of  pyogenic  micro-organisms.  In  bouillon  Staphylo¬ 
coccus  pyogenes  aureus  was  killed  by  the  addition  of  suffi¬ 
cient  pyoktanin  to  represent  a  solution  of  1  in  2,000,000.  The 
streptococcus  was  killed  by  1  in  250,000,  and  a  diplococcus  . 
resembling  the  pneumonia  coccus  by  1  in  1,000,000.  In 
blood  serum  the  action  was  less  pronounced,  the  staphylo¬ 
coccus  being  killed  by  1  in  500,000  only.  A  l-in-1,000 
solution  killed  the  Staphylococcus  aureus  in  one  minute 
and  the  streptococcus  in  five  minutes,  anthrax  bacilli  with¬ 
out  spores  being  killed  in  two  minutes  and  a  half,  while  the 
bacilli  of  typhoid  fever  were  not  killed  in  fifty  hours.  In 
a  dried  condition  the  staphylococcus  was  killed  by  a  l-ifi- 
1,000  solution  in  five  minutes,  but  when  suspended  in 
blood  serum  the  same  micro-organism  was  only  killed  after 
an  hour’s  exposure. 

From  these  data  Jaenicke  argues  that  the  drug  might  be 
good  as  an  inhibitory  agent  (to  sepsis),  but  not  as  a  disin¬ 
fectant,  where  it  would  necessarily  have  to  act  in  albumin¬ 
ous  media. 

Its  toxic  properties  were  also  estimated  by  the  same  au¬ 
thor.  Mice  survived  the  subcutaneous  injection  of  one  fifty- 
thousandth  part  of  their  weight  of  pyoctanin,  while  the  intra¬ 
abdominal  injection  of  a  fourth  of  this  quantity  killed  them. 

Its  non-coagulative  effect  on  albumin  has  been  recently 
pointed  out  by°Stilling  (7),  so  that  in  this  particular  it  has 
the  advantage  over  plain  sublimate  solutions. 

207  West  Fifty-sixth  Street. 

Literature  referred  to. 

1.  Stilling,  Die  Anilinfarbstoffe  und  ihre  Anwendung  in 
der  Praxis.  Erste  Mittheilung.  Strassburg,  1890.  Trilbner. 

"  2.  Bresgen,  Die  Verwendung  des  Pyoktanins  in  Nase  und 
Hals.  Deut.  med.  WocHenschr.,  1890,  xvi,  584  (No.  24). 

3.  Carl,  Ueber  die  Anwendung  der  Anilinfarbstoffe  als  An- 
tiseptica.  ’ Fortschritte  der  Med.,  1890,  viii,  371  (No.  10). 

4.  Wien.  med.  Wochenschr.,  1890,  xl,  937  (No.  22). 

5.  Berl.  Jclin.  Wochenschr.,  1890,  xxvii,  504  (No.  22). 

6.  Braunschweig  und  Jaenicke,  Ein  Beitrag  zur  Ivenntniss 
des  Pyoktanins.  Fortschr.  der  Med.,  1890,  viii,  405  (No.  11) ; 
460  (No.  12). 

7.  Stilling,  Ueber  die  Anwendung  der  Anilinfarbstoffe. 
Berl.  Jclin.  Wochenschr.,  1890,  xxvii,  531  (No.  24). 

A  New  and  Rapid  Test  for  Sugar— “  At  a  meeting  of  the  Austrian 
Surgical  Society  last  week,  Professor  Nothnagel  showed  a  handy  test 
for  sugar,  which  had  been  forwarded  to  him  by  Dr.  Becker,  of  Cairo. 
It  is  simply  a  visiting  card  saturated  with  a  solution  of  potash,  over 
part  of  which  is  drawn  a  covering  of  the  sulphate  of  copper,  and  the 
urine  applied.  The  card  is  then  laid  on  the  globe  of  a  lamp,  when  the 
saccharine  urine  will  color  the  card  brown,  and  this  color  will  be  the 
deeper  the  greater  the  amount  of  sugar.”— British  and  Colonial  Drug¬ 
gist. 


By  C.  L.  DODGE,  M.  D., 

KINGSTON,  N.  Y. 


Examination  for  life  insurance  requires  special  aptitude 
’or  this  particular  work.  “  To  one  who  is  thrown  much  with 
medical  examiners  it  will  be  seen  at  once  that  they  do  not, 
as  a  rule,  fully  comprehend  the  position  which  they  are 
called  to  fill”  (Keating).  A  patient  calling  upon  his 
physician  is  full  of  complaints,  anxious  to  acknowledge  all 
the  pains  and  symptoms  of  disease  he  may  be  suffering 
from,  and  ready  to  communicate  the  cause  and  history  of 
his  malady  ;  no  information  is  withheld,  and  no  questions 
are  evaded.  Not  so  in  the  examination  of  a  risk  for  life 
insurance. 

By  the  time  a  man  has  made  up  his  mind  to  insure  he 
has  learned  that  a  medical  examination  has  to  be  passed. 
This  the  average  man  dreads,  whether  he  is  willing  to  ad¬ 
mit  the  fact  or  not,  for  different  reasons.  A  considerable  ex¬ 
perience  in  the  examination  of  candidates  for  various  lodges 
where  sick  and  death  benefits  are  paid,  as  well  as  for  life 
insurance  proper,  warrants  the  correctness  of  this  state¬ 
ment,  First,  many  men  fear  that  a  rigid  examination  will 
disclose  some  bidden  disease,  or  tendency  thereto,  which 
they  would  prefer  to  remain  in  ignorance  of  until  they  dis¬ 
cover  it  for  themselves.  Others  realize  that  rejection  by 
one  company  will  operate  against  them  unfavorably  it  ap¬ 
plication  should  be  made  to  another.  Hence  the  dread  of 


rejection. 

For  these  reasons,  we  always  note  the  absence  of  frank¬ 
ness  so  characteristic  of  ordinary  patients. 

No  voluntary  statements  are  made  which  would  give 
color  to  poor  health,  past  or  present.  Symptoms  and  ail¬ 
ments  of  both  the  applicant  himself  and  of  his  family  con¬ 
nections  are  made  light  of  and  undervalued.  In  the  family 
history  it  is  quite  frequently  observed  that  the  applicant 
will  intrench  himself  behind  the  negative  information  con 
veyed  by  the  answer,  “  I  don’t  know,”  to  questions  of  vital 
importance  to  the  examiner  and  the  company.  Many  times 
these  questions  would  be  answered  quite  explicitly  if  the 
party  was  allowed  or  requested  to  call  again  with  the  de¬ 
sired  information. 

Medical  examiners  are  frequently  appointed  by  some 
of  our  largest  companies  arbitrarily,  and  with  very 
little  regard  to  fitness  or  qualifications.  If  a  man 
stands  well  socially,  or  happens  to  be  a  personal  friend 
of  the  agent,  local  or  general,  he  is  forthwith  appointed 
the  medical  examiner.  It  is  true  that  the  company  re 
quires  him  to  fill  out  a  blank,  furnished  for  this  pur¬ 
pose,  giving  the  college  he  graduated  from,  with  date, 
etc.;  but  what  does  all  this  amount  to  in  the  way  of 
showing  a  man’s  qualifications  as  a  scientific  physician  f 
I  will  venture  the  assertion  that  not  one  physician  in  ten 
has  a  work  devoted  to  the  subject  “  examinations  for  life 
insurance  ”  other  than  the  little  book  of  directions  fur¬ 
nished  by  some  companies.  Ten  years  ago  microscopy  and 


_ »0D0E:  THE  EXAMINATION  of  PERSONS  FOR  LIFE  INSURANCE, 


physical  diagnosis  *  were  not  taught  at  any  of  our  medical 
colleges  except  as  special  courses,  which  were  taken  by  less 
than  ten  per  cent,  of  medical  students.  How,  then,  I  ask, 


207 


same  roof,  drink  the  same  water,  eat  the  same  food,  and 
follow  the  same  occupation.  In  this  country  people  are 
continually  changing  their  residence,  their  occupation,  and, 


.  ..  \  ,  Al  „  ,  continually  cnanging  their  res  der.ce,  their  oceiimtimi  Qnrl 

r  “  e;P°  f°"  the  part  0f  ‘ >e  00mPanieS’  With  tlleir  h*P-  -  circumstances  win  permit,  their  mod  of  fe  If’  theJ 
hazard  way  of  appointment,  that  they  will  be  able  to  secure  lived  the  same  life  that  their  parents  and  grand!™  d  d 
hrst-class  men  to  act  as  their  medical  examiners  in  the  small-  they  would  be  surrounded  by  the  same  infl,!  d’ 

erct.es  and  country  towns?  The  medical  officer  at  the  home  doubtless  would  be  subject  to  the  sam  dleje  „  ektail 
thee  .  supposed  to  pass  finally  on  all  applications  received,  extent.  Some  diseases  seem  to  be  endemic" Certain  loea  i 

- "  “  -  “3 ts 

=:  C”.;  “xrr.1"  ••••■■o-  -»■“ 

par,  or  ,f  he  has  ever  suffered  from  a  disease  which  experi-  sometimes  of  advantage  in  the™  8  ” 

^ t f •; i- rr- “ 


j  uiiuouaiij  1  do L 

or  slow  pulse  per  se  should  not  cause  the  rejection  of  an 
otherwise  healthy  man. 

From  time  immemorial  morbid  characters  of  the  arterial 
pulse  have  been  ranked  among  the  most  important  of  ob¬ 
jective  symptoms.  The  pulse  is  a  valuable  aid  to  diagno¬ 
sis,  but  it  is  sometimes  misunderstood  and  misinterpreted. 


honor  and  sagacity  ot  their  medical  examiner,  and  he  has 
to  judge  by  the  applicant’s  general  appearance  and  previous 
habits  in  this  regard.  It  is  stated  by  Keating  that,  in  spite 
of  prevalent  belief,  consumption,  cancer,  apoplexy,  paraly¬ 
sis,  and  disease  of  the  kidneys  show  increase  of  mortal¬ 
ity  with  advance  of  years,  being  greatest  after  fifty  and 


Many  healthy  persons  are  so  constituted  tW  .  \  wiu,  advance  ot  years,  being  greatest  after  fifty  an< 

or,  more  correct,  exeitement  as  he  rlsn  t  of  ne'  VOl'S"eSS  ^  fbls  “-rtion  is  very  misleading  as  ap- 

.ion,  will  cause  an  increase  of  fifteen  or  .  ,  TT'  P  T  °T ““P110”'  A"  aUth°ritieS  aSree  that  pMhM. 

minute.  f  Ve"  y  be  a  18  Pecullar'y  a  disease  of  young  adults  and  early  middle 

of  the^examinatiem  to  th"  ^T*”’  by  leaving  this  Part  oorroborate  tbis-  0f  1.531  deaths  between  sixty^nd  sevcm 

-  day,  xr  zs : :::  zzr* the  pu,so  tbe  ms4*  **  ■*  ^  «* 


Strange  to  onv  thQ  +i  "  V  ,  I  year  1887,  but  123  were  from  consumption, 

by  medical  examiners  .  tlZZ Z  “  ,  If  «™Pa»-  generally  would  use  one  half  of 

in  the  so-called  nretubercular  .  s"dil‘:""1  0  ever,  as  the  care  in  selecting  their  local  medical  examiners  that  they 

much  greater  imonrt  .1  !,*  ’  T  temPerature  is  of  do  in  preparing  their  examination  blanks,  and,  after  ap- 

juent  pulse  with  ,  o  “  T™  ‘f  A  S'lghtly  fr6'  P°'DtinS  m  honorable,  conscientious,  scientific  physician  as 


ungs,  or  kidneys,  has  no  pathological  significance.  The 
uune  may  be  said  of  functional  slow  pulse,  within  certain 
imits.  A  pulse  below  sixty-five  is  generally  regarded  as 

It  has  been  said  that  longevity  depends  far  less  on  race, 
u unate,  profession,  mode  of  life,  or  food,  than  on  heredi¬ 
ty  transmission.  This  is  a  sweeping  assertion  and  should 
>ot  be  made  unqualifiedly.  That  tendencies  or  proclivities 
o  certain  diseases  exist  no  one  will  deny;  but,  with  the 
xception  of  phthisis,  epilepsy,  cancer,  rheumatism,  and  gout 
n  its  fullest  sense,  we  do  not  see  the  effects  of  hereditary 
niiuence  so  markedly  in  this  country  as  they  are  observed 
njlurope,  where  generation  after  generation  live  under  the 

#  Perhaps  I  should  modify  this  statement  slightly  as  to  physical 
o  oms  Didactic  lectures  were  giyen  on  this  subject  in  my  student 
J  ’  .  the  Practlcal  courses  as  now  understood  were  special  and  ex- 
d'  As  to  microscopy,  it  needs  no  qualification. 


ject,  of  course,  to  the  rules  and  regulations  of  each  particu¬ 
lar  company — in  all  doubtful  cases,  there  would  be  fewer 
death  losses  to  pay.  Some  examiners  like  to  put  the  re¬ 
sponsibility  on  the  home  office  in  these  cases,  but  this  is 
unfair  to  both  the  applicant  and  the  company. 

That  accomplished  author  and  physician,  Oliver  Wen¬ 
dell  Holmes,  says  that  “a  diagnosis  which  maps  out  the 
physical  condition  ever  so  accurately  is,  in  a  large  propor¬ 
tion  ot  cases,  of  less  consequence  than  the  opinion  of  a 
sensible  man  of  experience,  founded  on  the  history  of  the 
disease.”  We  should  be  careful  neither  to  overestimate 
nor  to  undervalue  the  information  obtained  by  phvsical  ex¬ 
ploration,  and  in  giving  our  final  opinion  we  should  strive 
to  be  just  to  the  applicant  and  honorable  to  the  company. 


Statistics  collected  in  Europe  with  reference  to  the  hereditary 
transmission  of  disease  should  never  be  considered  as  equal  in  value  to 
those  of  this  country,  for  the  reasons  set  forth  above. 


208 


SULLIVAN:  ON  STOMATITIS  GANGRENOSA. 


[N.  Y.  Med.  Joub., 


ON  STOMATITIS  GANGRENOSA, 

WITH  SPECIAL  REFERENCE  TO 
ITS  TREATMENT  WITH  LIQUOR  FERRI  SUBSULPHATIS. 


By  J.  D.  SULLIVAN,  M.  D., 

BROOKLYN. 


The  majority  of  diseases  of  the  mouth  in  children  are 
attended  by  little  danger  and  respond  very  readily  to  treat¬ 
ment,  but  the  disease  to  which  I  desire  to  direct  your  atten¬ 
tion  in  this  paper  is  one  of  the  most  fatal  affections  of  eailv 


as  it  advances  the  gums  become  swollen,  soft,  and  livid; 
the  teeth  loosen  and  fall  out;  and  as  the  gangrene  pro¬ 
gresses,  the  maxillary  bones  become  involved  in  the  necrotic 
process.  Although  the  suffering  is  not  proportionate  to  the 
gravity  of  the  disease,  and  liquid  nourishment  can  be  taken 
very  well,  prostration  becomes  more  and  more  profound 
and  the  appearance  of  the  child  is  melancholy  in  the  ex¬ 
treme. 

The  peculiar  gangrenous  <>dor  from  the  mouth  is  pies- 
ent  in  every  case,  and  as  the  disease  advances  the  fcetor  be- 


tion  in  tnis  paper  is  one  oi  tue  iuwou  -  „  cut  m  , -  #  . 

life  if  allowed  to  take  its  usual  course,  unchecked  by  treat-  comes  extremely  offensive.  A  microscopical  examination 

ment  •  and  yet  it  is  quite  easily  curable  if  recognized  early  0f  the  gangrenous  tissue  shows  that  it  contains  large  co  o- 

_ !•  j  •  c  i t. : „  onnaar  in  Lfi  infiltrated  all  through 


and  the  proper  treatment  is  promptly  applied. 

Fortunately,  the  disease  is  exceedingly  rare  in  private 


nies  of  bacteria  which  appear  to  be  infiltrated  all  through 
the  diseased  portions. 


Fortunately,  me  uisease  is  -  r  uuc  —  r 

practice,  but  is  quite  frequently  met  with  in  public  institu-  in  the  cases  which  came  under  my  observation  over- 

tions  where  large  numbers  of  children  are  housed  together,  crowding  or  insufficient  ventilation  appeared  to  be  the  chief 

.  .  -  .  1 _ _ * - -  nnmAO  no  I  (*  i  •  _ _ _  fl\U  illCPHQP 


It  is  described  by  different  writers  under  various  names,  as  factor  in  the  causation  of  the  disease. 


It  is  descriDea  oy  aineieiiL  wntcio  «  7  ArtVjlul  #  ,  * 

cancrum  oris,  noma,  necrosis  infantilis,  gangrene  of  the  With  this  brief  sketch  relating  to  the  character  of  this 
mouth  buccal  anthrax,  aqueous  cancer  of  infants,  scorbutic  distressing  affection,  we  will  now  consider  its  treatment, 

.  .  i  i  C  j  1  _ „  iL  rr  L  a  rl  i  I  1  •  1  •  ^  M  1X7D  ITT  PqIIiTKT  V  OUT*  Jit  t  filltlOD  tO 


111  O II  L  H  Ullvvwl  (UIVUIUAJ  -  - - -  ,  I  —  —  —  --  — - 0  '  # 

cancer’  and  sloughing  phagedsena  of  the  mouth.  The  dis-  which  is  my  principal  motive  in  calling  your  attention  to 


ease  appears  to  be  more  frequent  in  Europe  than  in  the  this  subject. 


United  States. 


Both  local  and  constitutional  treatment  are  urgently  de- 


Many  elaborate  essays  have  been  written  on  the  subject  I  manded.  Stimulants,  tonics,  and  the  most  easily  digested 

bv  English  French,  and  German  physicians,  but  outside  f00d  should  be  given  as  liberally  as  the  patient  will  bear. 
*  &  ’  _  ,  ,  _ i„  i;+tlQ  .  i  i  .  _ olr-  I c  aliartlntfilv  necessary  to 


by  EnglisD,  Frencn,  aim  ueimau  —  ---  ivmu  -  * 

the  medical  text-books  there  has  been  comparatively  little  An  abundant  supply  of  fresh  air  is  absolutely  necessary  o 
written  in  this  country.  The  only  article  which  has  come  the  proper  management  of  these  cases.  Although  this  point 

i  1  •  1  • ^  n  o  ormi'  K  \7  I  •  a  _ +  In  TY1  Q  TT  T7  til  P  t,  P  X  t“b  O  O  1a  S .  it  i-S  V  0  TV 


written  in  tins  couimy.  iuc  rlvyrw  ^  .  .  . 

to  my  notice  through  our  medical  journals  is  a  paper  by  j8  not  even  mentioned  in  many  of  the  text-books,  it  is  very 

Dr.  Constantine  J.  Macguire,  of  New  York,  read  before  the  essential  that  the  entire  premises  should  be  thoroughly  ven- 

_  .  i  •  .  •  i  Li!  ,.L  /vd  J  +li  a  IT n  rl  •?  _  I  <  •  1  i  i  t  «  nnf  10  a  f  nQrfi  tyi  GUTlti  1  m  HOI  tHllC6«  RD(i 


jjr.  (Jonstantine  j.  uiauguuo,  ^  > -  - * 

Yorkville  Medical  Association  and  published  in  the  Medi-  tilated.  Local  treatment  is  of  paramount  importance,  and 
cal  Record  of  February  3,  1883.  The  disease  is  limited  al-  aione  is  capable  of  arresting  the  progress  of  the  disease. 

,  ,,  • _ 4.  i* _ _ _  Anlln  if  _ _ nr Afl1lt.pri7fl.ti on  With  the 


cat  Jxecora  oi  rcurudi^  o,  ±000.  j.  aiuuc  l  0  .  .  .  ,  , 

most  exclusively  to  childhood,  occurring  most  frequently  in  Many  authors  recommend  energetic  cauterization  witn  me 

children  of  from  two  to  six  years  of  age,  and  with  dimin-  raost  powerful  agents— nitric  acid,  hydrochloric  acid,  car- 

i/vi  _ j  it:.* — +n  Tt.  1  i-  onrl  pvpn  the  actual  cautery. 


cnnaren  01  num  «<«  —  --  o  7  - r-  —  ° 

ishincr  frequency  to  the  twelfth  and  thirteenth  years.  It  boiic  acid,  nitrate  of  mercury,  and  even  the  actual  cautery. 

*  -  .  -11*  i  I  li.1. I  —  •  T  A.  ♦  Iwi  +  /trviAfl1  GTinii- 


lshing  frequency  to  me  twcmu  —  j  uvnb  . 

generally  attacks  children  who  are  in  delicate  health  or  From  my  experience,  I  can  not  approve  ot  the  topical  appn- 

those  who  are  debilitated  by  other  diseases,  especially  cation  0f  such  strong  caustics. 

I  Til  _  __  1 _ nnC 


measles,  whooping-cough,  and  pneumonia. 


In  the  paper  heretofore  referred  to,  Dr.  C.  J.  Macguire 


asies,  wnooping-cuugu,  auu  rv-uluv -  *■“  t'-t'  — -  •  .  „  f  f 

The  majority  of  authors  maintain  that  the  disease  is  not  reported  twenty-four  cases  of  cancrum  oris,  the  tirst  tour  01 

contagious  but  my  experience  leads  me  to  believe  that  it  is  which  were  treated  in  accordance  with  the  orthodox  meth- 

°  r  .  mi  1  •  • _  .  J?  ,  ,  .  .  •  .1  1 _ _ .A  oflll  +1.P  rranarrPTlP  r.nn- 


contagious,  UUl  Illy  cApcucuuu  . — -  "  -  - 

certainly  infectious  if  not  contagious.  The  beginning  of  0ds  laid  down  in  the  text-books,  and  still  the  gangrene  con 
the  disease  is  usually  manifested  by  an  extremely  offensive  tinued  to  extend  until  finally  the  patients  died.  V  hen  his 

.  1  .  _  J? _ 2.1 _ _  V  nli/vnlr  I  OCil  _ li  /%  t.rn  o  in  rlocnQ  1  r  QHfl  P.OT1P 


the  disease  is  usuany  luaimwi™  ,  ,  A  A  a 

odor  to  the  breath,  with  a  tense  tumefaction  of  one  cheek  fifth  case  appeared  he  was  m  despair,  and  concluded 
or  lip  and  a  pale’ and  glistening  appearance  of  the  skin,  following  in  the  old  rut  of  treatment  was  almost  useless,  1 

.  .  .  .  .  •  i*  a _  „  L  „ i-  1  A  1  ^  T?  I  i  *  j.  .  .  .  TT  ^  +L  f  ll  P  1  fl  PQ  t  il*  1  Vlflff  10" 


Or  lip,  diiu  a  cviivj.  &  rr  I  ©  i  •  iA 

There  is  but  slight  elevation  of  temperature — about  101  F.  not  quite  so.”  He  then  conceived  the  idea  of  appl)in& 

_  .  .  i  ill..,  ^  r  1  • _ AIVa..  rrT»  1\7  aIpATIR- 


liiere  is  out  sugut  eicvatiun  u  —  *  . 

The  pulse  is  soft  and  feeble.  The  expression  is  melancholy  Cally  the  subnitrate  of  bismuth.  After  thorougnly  cleans- 

and  the  patient  is  indifferent  to  surroundiug  circumstances.  ing  the  mouth  with  a  disinfectant  solution,  he  covered  t  e 


ana  tne  paueui  luuuiaciu  ^  oul4VUU  &  #  ,  ,,  ,  ioX7  fup 

On  examining  the  mouth,  a  small,  black,  dry  eschar,  circular  ulcerated  surface  with  the  bismuth,  and  the  next  day 

or  oval  in  shape,  will  be  found  on  the  buccal  surface  oppo-  progress  of  the  disease  appeared  to  be  arrested  and  t  e 

•  ,  j  *  C  ll _ 1K«a.  <17  rv  4-  n  T»  ll  I  _ I.AW.A  i  mnrAVPil  IT  P.  tllftB  had  tllC  UlOUth 


site  the  most  prominent  portion  of  the  swelling,  whether  it  I  symptoms  were'much  improved.  He  then  had  the  mouth 
be  on  the  cheek  or  lip.  If  not  checked  by  treatment,  this  washed  with  a  solution  of  carbolic  acid  and  the  bismut  ap- 

*  -  •  I  TTT!iL  i.L!  _  i-AA*»«At<f  nnrl  flip  ftfl' 


be  on  tne  cneeK  ui  up.  n  wv  -j -  -  7  j, 

swelling  gradually  increases  in  circumference,  sometimes  in  plied  every  three  hours.  With  this  treatment  and  the  - 

a  few  days  •  at  other  times  more  slowly,  taking  in  the  entire  ministration  of  the  syrup  of  the  iodide  of  iron,  cod-liver  01 , 
*  5  T  1  •  A  ii _ Tl,„  I  1  _  lUfln  T-.n+iA»vf  was  nnrpd  i n  loss  than 


a  tew  days;  SI  UlUCl  uuira  mwtv  - - » -  I  -  .  .  .  ,  .  ,  tL 

side  of  the  face  or  even  extending  down  into  the  neck.  The  and  a  generous  diet,  his  little  patient  was  cured  m  e&s 

ii  ii.  _  . 4. _ _ i  i  _  _ a  A- ™  nrUnA^oinrf  +lio  ltQnnv  ATiamyft  effected  by 


siae  oi  me  ui  even  — . .  * - & -  '  .  *  ,  ^  ,  i  uv 

internal  eschar  extends  equally  with  the  external  swelling,  two  weeks.  After  witnessing  the  happy  change  effected  ) 

<  <  i  .  I  _  i  *  *  1  _  _ _ _ _  «  ^  £  +«AnIrrvnnt  in  M 1 S 


internal  escuai  cNtcnvAa  - . . . .  07  -  -  .  °  .  .  •  v,;a 

and  eventually  it  becomes  more  or  less  detached,  leaving  a  the  bismuth  he  pursued  a  similar  course  ot  treatment  in  >. 

hole  in  the  cheek,  and  the  adjacent  tissues  change  as  the  following  nineteen  cases,  and,  although  some  of  these  seeme 

.1  i  _  .  i _ i _ +Lo<7  all  rpcovered. 


o-angrenous  process  advances. 

In  other  cases  the -disease  begins  on  the  alveolar  border 


to  be  almost  hopeless  in  the  beginning,  they  all  recovered. 
It  is  evident,  from  the  accurate  description  given  bv  Dr. 


ill  Oiuex  oases  mcuwcaoi,  ~  — - -  - - » -  ... 

of  the  gums,  frequently  at  the  seat  of  a  decayed  tooth,  and  |  Macguire  of  his  cases,  that  he  was  dealing  with  gcDU|n 
- -  “  cases  of  stomatitis  gangrsenosa,  and  that  he  instituted  t 


*  Read  before  the  Kings  County  Medical  Association,  May  9,  1890. 


August  23,  1890.] 


SULLIVAN:  ON  STOMATITIS  GANGRENOSA. 


20£ 


course  of  treatment  that  proved  remarkably  efficacious  un¬ 
der  his  direction. 

In  one  of  the  largest  orphan  asylums  in  this  city,  to 
which  I  have  been  the  medical  attendant  during  the  last 
twenty  years,  we  have  had  about  thirty-five  cases  of  stoma¬ 
titis  gangrsenosai  Of  these  patients,  two  died  from  the 
effects  of  the  disease;  the  remainder  recovered.  Of  the 
latter,  two  lost  a  portion  of  the  lower  jaw  bone  from  ne¬ 
crosis  caused  by  the  gangrene,  but  there  is  no  apparent 
deformity  as  the  result. 

My  experience  with  the  disease  began  in  1878,  when  a 
boy  who  had  just  recovered  from  measles  contracted  scar¬ 
let  fever,  and  during  convalescence  from  the  latter  disease 
was  attacked  by  gangrene  of  the  mouth.  He  was  treated 
according  to  the  usual  method,  but  a  portion  of  one  cheek 
was  destroyed  before  the  disease  was  arrested.  After  a 
great  deal  of  care  and  constant  attention,  during  a  period 
of  about  three  months,  he  was  restored  to  health,  with  but 
little  deformity. 

In  September,  1884,  Eddie  S.  was  admitted.  He  was  about 
three  years  of  age  and  in  very  poor  physical  condition,  and 
shortly  after  he  developed  gangrenous  stomatitis.  Notwith¬ 
standing  the  most  vigorous  and  diligent  treatment  the  gan¬ 
grene  continued  to  extend  until  one  entire  side  of  his  face  and 
a  portion  of  his  tongue  sloughed  away.  In  this  most  deplor¬ 
able  condition  he  lived  for  about  two  weeks,  during  a  portion 
of  which  time  it  was  necessary  to  carry  his  food  into  the 
pharynx  with  a  tube  or  spoon  to  enable  him  to  swallow  it. 

During  the  year  1888  we  had  seventeen  cases  of  can- 
crum  oris.  Many  of  these  followed  an  epidemic  of  whoop¬ 
ing-cough.  Of  these,  sixteen  patients  recovered  and  one 
died.  Many  remedies  were  tried  during  the  progress  of  these 
cases — subnitrate  of  bismuth,  naphthalin,  hydronaphthol, 
salol,  listerine,  permanganate  of  potassium,  tincture  of  iodine, 
and  various  disinfectant  solutions  at  different  times,  and 
still  recovery  was  very  slow,  extending  over  periods  of 
from  one  to  three  months. 

The  application  of  naphthalin  gave  as  good  satisfaction 
as  any  other  agent  used,  if  not  better. 

During  the  year  1889  six  cases  came  under  my  obser¬ 
vation.  All  the  patients  recovered  more  rapidly.  It  was 
during  the  progress  of  these  cases  that  I  conceived  the  idea 
of  applying  liq.  ferri  subsulphatis,  diluted  with  an  equal 
part  of  glycerin,  and  the  result  was  much  more  satisfactory 
than  with  any  remedy  heretofore  used. 

»  On  the  evening  of  April  1st  of  this  year,  while  hastily  mak- 
ing  my  usual  visit  through  the  infirmary,  my  attention  was 
called  to  a  boy  about  six  years  of  age  with  a  swollen  face  and 
8  most  horribly  foetid  odor  to  his  breath.  On  examining  his 
mouth,  I  found  the  gums  of  a  dark-purple  color,  soft,  pulpy, 
and  very  much  swollen,  and  the  teeth  loosened.  I  instantly 
recognized  the  same  old  enemy  which  had  given  us  so  much 
^rouble  in  former  years.  A  moment’s  reflection  satisfied  me 
lhat  the  proper  thiDg  to  do  was  to  remove  the  dead  tissue  and 
endeavor  to  arrest  the  gangrene.  Graspihg  the  gums  between 
my  forefinger  and  thumb,  and  pressing  upon  them,  I  found  that 
the  dead  parts  easily  separated  from  the  living  tissue.  In  this 
way  I  removed  the  greater  portion  of  the  gums  on  both  sides, 
with  several  of  the  teeth.  Then,  with  a  large  camel’s  hair 
brush,  I  copiously  applied  a  mixture  of  equal  parts  of  liq.  ferri 


subsulphatis  and  glycerin.  This  arrested  the  slight  haemor¬ 
rhage  and  contracted  the  remaining  diseased  portions  into 
firm  shreds.  Now,  with  pledgets  of  absorbent  cotton  held  in 
the  grasp  of  a  foroeps,  I  cleaned  out  the  mouth  and  made 
another  application  of  the  iron  solution.  This  was  all  done 
in  a  few  moments,  with  very  little  pain  to  the  patient  and 
with  but  slight  resistance  on  his  part.  The  next  day  the  boy 
presented  a  much  brighter  appearance,  and  the  disease  had 
evidently  made  no  further  progress.  Apprehending  that  the 
gangrene  might  still  be  lurkiag  where  it  was  so  active  on  the 
previous  day,  I  gently  curetted  the  alveolar  processes  and  tooth 
sockets,  removing  all  the  diseased  tissue,  and  washed  ont  the 
mouth  with  a  solution  of  sulphate  of  copper,  half  a  drachm  to 
the  ounce  of  water,  and  then  thoroughly  applied  the  solution 
of  iron  and  glycerin.  I  then  gave  instructions  to  have  this  re¬ 
peated  four  times  daily.  On  the  following  day  the"  parts  pre¬ 
sented  a  healthy,  granulating  appearance,  and  there  was  but 
very  little  of  the  offensive  odor  remaining.  The  applications 
were  continued  for  eight  or  ten  days,  and  at  the  end  of  two 
weeks  the  parts  were  healed  over  and  the  boy  was  in  good 
health  minus  his  molar  teeth. 

Within  the  next  nine  days  five  more  cases  of  cancrum 
oris  were  developed  in  boys  whose  ages  ranged  from  three 
to  six  years.  These  were  all  treated  in  the  same  way  as 
the  last  case,  excepting  that  two,  which  were  seen  in  the 
incipient  stage,  were  not  curetted.  In  these  two  cases  the 
mouths  were  simply  washed  with  the  solution  of  sulphate 
of  copper,  and  the  iron  mixture  applied  as  in  the  other 
cases.  In  each  case  the  gangrene  was  arrested  within 
three  days  after  the  first  application,  and  their  recovery 
was  complete  within  two  weeks.  Whisky  and  good  nour¬ 
ishment  were  diligently  administered  to  every  case,  and 
ample  ventilation  was  provided  for  them. 

In  carefully  considering  the  action  of  the  many  reme¬ 
dies  which  I  have  used  in  the  treatment  of  this  destructive 
disease,  I  am  satisfied  that,  so  far  as  my  observation  ex¬ 
tends*,  the  solution  of  the  subsulphate  of  iron  is  the  most 
efficacious.  Diluted  with  an  equal  part  of  glycerin,  it 
appears  to  combine  with  the  diseased  tissue,  and  either 
dissolves  it  or  converts  it  into  an  inert,  odorless  substance, 
without  irritating  the  healthy  parts.  It  is  powerfully  de¬ 
structive  to  organisms  of  a  low  vitality,  therefore  serving 
as  a  good  germicide  and  antiseptic,  and  consequently  we 
might  infer  that  it  would  be  a  valuable  agent  in  arresting 
a  septic  disease  like  gangrene.  Even  after  the  eschar  has 
been  dissolved  or  removed  by  the  application  of  this  solu¬ 
tion,  it  appears  to  promote  a  healthy  granulation  of  the 
parts,  and  hastens  their  restoration  to  a  sound  condition. 

If  time  would  permit,  I  might  extend  these  remarks 
by  reciting  the  details  of  each  case  more  minutely,  but  it 
would  simply  be  a  repetition  of  what  I  have  endeavored  to 
picture  to  your  minds,  and  would  be  unnecessary,  as  this 
paper  has  been  hastily  prepared  with  the  special  purpose 
of  bringing  before  the  profession  the  treatment  of  this 
affection  by  the  removal  of  the  diseased  portions,  and  the 
topical  application  of  the  solution  of  the  subsulphate  of 
iron  diluted  with  an  equal  part  of  glycerin. 

If  others  try  it  and  obtain  the  same  results  that  have 
attended  my  experience,  many  innocent  children  will  be 
saved  from  a  revolting  deformity  or  death,  and  my  efforts 
will  be  richly  rewarded. 


210 


WILLIAMS:  A  VAPORIZER ,  SUBLIMER ,  AND  AIR-STERILIZER.  [N.  Y.  Med.  Jock., 


A  VAPORIZER,  SUBLIMER,  AND  AIR-STERILIZER, 
By  HERBERT  F.  WILLIAMS,  M.  D., 

BROOKLYN. 

I  deem  the  followiug  propositions  to  be  common  ground 
of  belief : 

1.  Tbe  respiratory  avenues  are  influenced  by  various 
atmospheric  conditions. 

2.  Systemic  infection  can  be  produced  by  tbe  inhalation 
of  germs  or  their  spores. 

3.  Various  gases  and  vapors  are  readily  absorbed  by 
pulmonary  tissue. 

4.  The  pulmonary  tissue  is  capable  of  response  to  natu¬ 
ral  methods  of  antagonism  to  agencies  which  seek  its  dis- 
integration. 

5.  Artificial  means  to  produce  Nature’s  methods  must 
imitate  her.  In  these  propositions  are  the  conception,  birth, 
and  elaboration  of  the  instrument  I  now  describe. 

The  cut  shows  the  vaporizer 
on  its  permanent  shelf,  which  is 
sixteen  inches  long  and  ten  inches 
high.  It  shows  the  vaporizer  adapt¬ 
ed  to  the  left  window  casing,  where  it  may  be  connected 
with  the  outside  air  by  extending  tube  1  through  the  win¬ 
dow  sash.  With  it  thus  arranged,  or  having  been  placed 
upon  a  suitable  stand  or  table,  a  patient  in  breathing  impels 
the  air  in  the  direction  shown  by  the  arrows.  First  the 
air  enters  the  drying  tube  2,  2,  in  which  are  placed  such 
agents  as  have  great  affinity  for  atmospheric  moisture,  such 
as  pentoxide  of  phosphorus  or  anhydrous  chloride  of  cal¬ 
cium  (absorbent  cotton  in  either  arm  of  the  U-tube  will 
arrest  all  optical  impurities)  ;  passing  into  the  drying  tube 
3,  3,  the  air  may  be  made  more  dry,  and  any  chemical  im¬ 
purity  of  the  lime  or  the  acid  can  be  neutralized  by  making 
it  pass  through  broken  sticks  of  caustic  soda.  It  now  passes 
into  the  hot-air  drum,  in  which  it  receives  a  sterilizing  tem¬ 
perature,  which,  of  course,  expands  it ;  from  the  hot-air 
drum  it  passes  in  divided  currents  into  tjie  vaporizing  glass, 
in  which  may  be  placed  the  agent  that  may  be  deemed  of 
service  in  any  special  case  ;  passing  over  this,  the  air  enters 
directly  into  the  respiratory  current  through  the  breathing 
tube. 

The  mechanism,  then,  is  briefly  this :  Air  strained  and 
dried,  sterilized  and  expanded,  is  submitted  to  agents  from 
which  it  will  resaturate  itself  according  to  natural  law.  Air 
thus  holding  its  full  complement  of  moisture  for  these  con¬ 
ditions  in  tbe  form  of  gas  becomes  the  respiratory  medium. 

The  changes  in  density  of  intrapulmonary  air,  made  by 
forcible  expiratory  effort,  can  be  theoretically  shown  to  be 
sufficiently  great  to  recondense  saturated  intrapulmonary 
air.  This  can  not  be  shown  practically,  but  the  inevitable  me¬ 
chanical  effect  is  to  make  the  saturated  air  impinge  against 
its  surroundings,  causing  it  to  permeate  unused  areas,  and 
thereby  utilizing  well-recognized  forms  of  pulmonary  gym¬ 
nastics.  Such  a  device  seems  to  me  to  be  an  imitation  of 
Nature’s  way  in  preparing  volatile  products  (for  she  uses  no 
other)  for  rendering  air  serviceable  for  diseased  conditions  ; 
and,  after  over  two  years  of  experience  with  its  principles, 
I  am  convinced  that  whatever  of  good  can  be  gained  by 


voluntary  inhalation  can  be  afforded  by  its  use,  and  my  con¬ 
stant  and  increasing  experience  teaches  me  that  this  good 
may  be  not  a  little.  The  fault  with  our  management  of 
phthisis,  other  than  climatic  (which  to  the  masses  is  de¬ 
nied),  is  that  radical  treatment  is  not  instituted  at  once. 

It  will  not  do  for  one  to  admit  that  a  catarrhal  bronchi¬ 
tis  can  be  inoculated  into  a  tubercular  process,  and  deny  the 
value  of  antiseptic  air  to  prevent  such  inoculation,  if  coin- 
stantaneously  employed,  and  if  the  focus  of  absorption  is 
in  a  remote  portion  of  the  body.  What  more  conservative 
and  honest  effort  can  be  made  than  to  secure,  by  the  best 
means,  a  continuous  asepticism  of  the  lungs?  There  is  a 
theoretical  instant  of  septic  absorption.  To  discover  it  may 
be  impossible;  to  expect  and  guard  against  it  is  our  bound- 
en  duty. 

Nutrition,  begotten  of  healthy  appetite  and  digestion, 
furnishes  a  barrier  of  germicidal  blood  serum.  Should  this 
be  regarded  as  of  more  importance  than  anything  else,  let 


1,  tube  to  connect  with  outside  air ;  2,  2  and  3,  3,  U-tubes  for  holding  drying 
agents  ;  4,  diaphragm  in  hot-air  drum  to  compel  a  free  circulation  of  the  air ; 
5,  drum  to  hold  vaporizing  glass  ;  6,  vaporizing  glass  ;  7,  gravity  valve,  un¬ 
screwing  at  center,  with  valve  inside ;  8,  mouth-piece  ;  9,  opening  in  mouth¬ 
piece  with  adjustable  cover  to  regulate  expiratory  force  ;  10,  lamp  for  ster¬ 
ilizing  drum  ;  11,  lamp  for  vaporizing  drum  ;  12  and  13,  connections. 

it  be  remembered  that  it  is  ouly  one  of  Nature’s  ways  of 
protection,  and  that  it  certainly  does  not  interfere  with  other 
necessary  precautions. 

There  are  fourteen  hundred  and  forty  minutes  in  each 
day,  and  any  means,  however  potent  for  good,  which  can  be 
brought  to  bear  but  a  small  fraction  of  this  time  is  applied 
at  a  great  disadvantage.  Such  is  a  practical  difficulty  with 
the  pneumatic  cabinet,  with  which  initial  energy  can  be  de¬ 
veloped  in  the  air  cell,  and  a  thoroughness  of  intrapulmo¬ 
nary  medication  absolutely  impossible  by  any  other  known 
means.  Vicissitudes  in  the  weather,  even  in  a  climate  for¬ 
tunately  adapted  to  a  given  case,  are  such  that  a  serious  in¬ 
terruption  in  a  progress  toward  health  can  be  made.  I  have 
endeavored  to  make  this  instrument  a  practical  and  compre¬ 
hensive  means  for  home  use,  where  nothing  but  the  judg¬ 
ment  of  the  physician  or  the  indifference  of  the  patient  can 
prevent  its  frequent,  and,  if  necessary,  prolonged  applica¬ 
tion. 

My  patients  easily  understand  its  principles  and  experi¬ 
ence  no  difficulty  in  its  operation,  and  this  has  been  the  ex¬ 
perience  of  a  number  of  personal  professional  friends  who 
have  used  it  in  their  practice. 


August  23,  1890.]  CHEATHAM:  DIPHTHERIA  AND  SCARLET-FEVER  THROAT. 


211 


Indications  for  its  application  can  be  inferred  from  what 


has  been  said;  and  I  bespeak  for  its  clinical  work  only  such 
accomplishment  as  is  made  possible  by  therapeutic  acumen 
and  the  judgment  which  shall  direct  its  use  in  acute  and 
chronic  conditions. 

As  represented  in  the  cut,  it  may  be  used  simply  as  an 
air  diier  and  sterilizer,  for  the  delivery  of  warm  or  cold  air 
or  with  such  agents  as  benzoic  acid,  camphor,  calomel,  etc., 
it  may  be  used  as  a  sublimer.  Experiments  with  hot  air 
per  se  began  over  three  years  ago  ;  first,  by  slaking  lime  in 
a  convenient  apparatus  for  delivery  to  the  patient’s  mouth. 
Then  a  central  attachment  was  made  to  the  present  instru¬ 
ment,  which  would  deliver  air  at  nearly  400°  F. ;  but  the 
relative  proportions  of  the  instrument  now  shown  are  such 
that  the  maximum  temperature  of  the  air  for  the  vaporizing 
glass  is  about  212°  F.,  and  in  its  transit  through  the  breath¬ 
ing  tube  it  becomes  lowered  to  within  a  few  degrees  above 
the  temperature  of  the  mouth.  A  higher  temperature  can 
be  gained  by  using  lamp  11  in  connection  with  lamp  10, 
and  for  aqueous  solutions  or  for  sublimation  it  will  be  ne¬ 
cessary  to  use  it. 

The  degree  of  air  saturation  with  more  pungent  agents 
can  at  all  times  be  regulated  to  the  point  of  toleration  by 
adjusting  the  flames  of  one  or  both  lamps. 

An  increased  scope  for  the  principles  here  shown  can  be 
gained  by  multiplying  the  drying  tubes  and  allowing  com¬ 
pressed  air  from  a  condenser  to  flow  through  an  intermedi¬ 
ate  elastic  air  chamber,  so  as  to  avoid  interference  with  the 
gravity-valve,  V  ;•  moreover,  such  a  device  is  necessary  to  as¬ 
sist  in  the  increased  inspiratory  effort  thereby  produced. 
Air  under  such  conditions  will  resaturate  itself  to  the  degree 
of  toleration  with  little  or  no  heat.  Such  a  device  I  use  in 
my  office  in  connection  with  the  pneumatic  cabinet,  and 
nothing,  excepting  the  increased  expense,  need  prevent  its 
general  domestic  use  ;  but  the  instrument  here  shown  has 
proved  itself  of  great  clinical  value,  and,  I  think,  must  be 
regarded  as  an  advance  in  the  field  already  occupied  by  kin¬ 
dred  devices. 

From  the  encouragement  I  have  thus  far  received  from 
)rofessional  friends,  I  judge  it  may  possibly  find  a  more 
general  use.  In  anticipation  of  this  rather  presumptuous 
orecast,  I  wish  to  forestall  any  accusation  of  egotism,  and 
it  the  same  time  satisfy  truth  and  parentage  and  certainly 
upbony,  by  giving  it  that  portion  of  my  name  at  once 
ustorical— viz.,  Franklin.  Such  manipulation  of  the  air 
iS  I  llave  here  described  can  not  require  any  further  ex- 
ilanation,  and  any  suggestion  with  reference  to  the  use 
f  agents  seems  superfluous;  still  it  may  save  some  little 
rouble  if  I  mention  the  agents  I  have  thus  far  used,  and 
bis  I  will  do.  I  am  quite  sure  that  some  new  questions 
nil  arise  if  inquiry  is  pushed  in  the  direction  of  the 
ydrocarbon  series,  especially  the  aldehydes,  ethyls,  and 
lethyls. 

Ten  drops  of  the  following  agents  or  combination  of  any 
t  them  is  the  ordinary  dose  employed  :  Tincture  of  cam- 
hor,  tincture  of  iodine,  creasote,  carbolic  acid, -eucalyptus 
il,  Sylvester  oil,  terebene,  benzoic  ether,  salicylic  ether, 
araldehyde,  balsams,  guaiacol,  volatile  oils,  alcohol,  chloro- 
>rm,  etc. 


I  beg  herewith  to  acknowledge  valued  assistance  in  the 
mechanical  construction  from  my  friend  and  patient  Mr. 
Walter  C.  Harlow; 


THE  LOCAL  TREATMENT  OF 
DIPHTHERIA  AND  SCARLET-FEVER  THROAT. 

By  W.  CHEATHAM,  M.  D., 

LOUISVILLE,  KT. 

I  have  lately  had  much  experience  with  the  treatment 
of  these  affections,  and  have  found  that  hvdrogen  peroxide, 
fifteen  volumes  strength,  alone  or  combined  with  bichloride 
of  mercury,  gr.  j  to  §  j,  gives  me  better  satisfaction  than  any 
other  remedy.  Hydrogen  peroxide  is  a  thorough  antiseptic, 
besides  acting  mechanically  in  getting  rid  of  the  membrane  ; 
it  does  the  latter  in  the  later  or  most  dangerous  stage,  for  it 
is  at  this  time  that  septic  infection  is  more  liable  to  occur. 
TV  hen  the  membrane  begins  to  slough,  the  peroxide  will, 
when  applied  with  a  mop  or  in  spray  or  as  a  gargle,  get  behind 
it,  and,  by  its  action  on  the  pus,  free  oxygen  and  carbonic- 
acid  gas,  thus  displacing  it ;  the  membrane  appears  under  its 
action  to  lose  all  its  toughness  and  crumble.  If  used  in  the 
nose — and  it  is  here  where  we  get  wonderful  effect— the 
peroxide  had  better  be  made  of  about  ten  volumes  strength, 
and  it  the  bichloride  is  combined  with  it,  make  it  only  gr.  ^ 
to  l  j,  or  in  very  young  children  still  weaker.  Before  clos- 
ing,  I  must  add  that  but  a  small  quantity  of  the  medicine 
should  be  bought  at  a  time,  as  it  degenerates  rapidly  unless 
kept  on  ice  in  a  dark  place,  and  not  agitated.  The  hydro¬ 
gen  peroxide  losing  strength  so  rapidly  makes  it  very  dif¬ 
ficult  to  get  pure,  so  any  one  who  should  be  disappointed 
in  its  action  should  not  give  up  the  use  of  it  until  he  has 
surely  tried  the  pure  article.  It  will  not,  of  course,  cure  all 
cases.  Another  point  in  its  favor  is,  that  when  used  in  the 
throat  it  causes  no  pain.  The  action  of  the  hydrogen  per¬ 
oxide,  its  thorough  antisepsis,  and  the  beautiful  mechanical 
action  in  forcing  pus  from  cavities,  is  well  known.  It  should 
never  be  used  in  a  cavity  unless  there  is  free  vent,  and  es¬ 
pecially  when  this  cavity  is  about  the  neck  ;  as  such  a  vol¬ 
ume  of  gas  is  liberated,  such  an  accident  as  I  came  very  near 
having  is  quite  possible.  An  abscess  of  the  parotid  gland 
following  scarlet  fever  had  been  opened  by  a  small  incis¬ 
ion.  I  thought  I  would  wash  it  out  with  a  little  hydrogen 
peroxide,  which  I  proceeded  to  do.  As  a  result,  I  had  a 
tremendously  distended  sac,  the  child  blue  in  the  face,  and 
nearly  suffocated.  A  large,  free  incision  set  matters  right 
in  a  moment.  As  an  application,  and,  when  the  patient  is 
old  enough,  as  a  gargle,  pure  or  half  and  half  with  lister- 
ine,  it  is  the  best  application  in  scarlet  fever  and  follicular 
amygdalitis  I  know  of. 


Thiol  in  Skin  Diseases. — “  Thiol  has  been  used  by  Professor 
Schwimmer,  of  Buda  Pesth,  in  a  large  number  of  skin  diseases  with 
remarkable  success.  In  herpes  zoster,  acne  simplex,  and  rosacea,  in 
moist  eczema  and  in  burns,  he  paints  the  affected  part  with  a  solution 
in  distilled  water,  of  the  strength  of  1  in  4,  twice  a  day,  not  washing 
off  the  application  for  two  or  three  days.  In  some  long-standing  cases 
the  washing  is  still  longer  delayed.  In  some  instances  an  ointment  (1 
in  3)  was  employed,  and  in  other  cases  the  dry  powder  itself.” — British 
|  and  Colonial  Druggist. 


212 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jocr., 


the 


NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 


Published  by 
D.  Appleton  &  Co. 


Edited  by 
Frank  P.  Foster,  M.  D. 


mentioned  for  anticipating  peritonitis  after  abdominal  section 
and  in  childbed,  also  the  erysipelas  which  is  so  destructive  to 
puerperal  women. _ 


THE  PRESIDENT’S  NOMINEE  FOR  THE  SURGEON-GENERAL¬ 
SHIP  OF  THE  ARMY. 


NEW  YORK,  SATURDAY,  AUGUST  23,  1890. 


THE  ETIOLOGY  OF  PERITONITIS. 


The  President  has  sent  to  the  Senate  the  nomination  of 
Colonel  Jedediah  H.  Baxter  to  be  surgeon-general  of  the  army, 
to  fill  the  vacancy  caused  by  the  retirement  of  Surgeon-General 
John  Moore.  Colonel  Baxter  entered  the  volunteer  service  in 


This  subject  has  recently  been  studied  by  Frankel,  and  a  June,  1861,  as  surgeon  of  the  Twelfth  Massachusetts  Infantry, 
summary  of  his  investigation  has  been  published  in  the  Cen-  was  appointed  surgeon  of  United  States  V  olunteers  in  April, 

.  ■  I  I  1  * 1  A  A  A-  K  a  .. 1-F-  n  -t-  1  v  TC  A  Tt  AT 


D  U  IU  IAI  J  V/  ‘  ‘  - - H -  A  I  *  • 

tralblatt  fur  Gynakologie.  The  following  results  were  obtained  1862,  and  was  promoted  successively  to  the  ranks  of  brevet 
from  the  investigation  of  fifteen  cases  of  exudative  purulent  lieutenant- colonel  and  brevet  colonel,  the  latter  m  March,  1865, 


11  ULU  UiJV  IU  >  ”  — - 

peritonitis.  Spaltpihe  were  demonstrable  in  all  cases  of  puru-  his  promotions  having  been  made  on  account  of  faithful  and 
lent  peritonitis.  In  ten  cases  chain  cocci  were  found,  the  same  meritorious  services  in  the  field.  In  July,  1867,  he  was  ap- 


variety  of  streptococcus  being  found  in  nine  of  them,  and  more  pointed  Assistant  Medical  Purveyor  in  the  regular  army  with 
than  one  variety  in  two  of  them.  The  summary  of  the  investi-  the  rank  of  Lieutenant-Colonel,  and  was  made  Chief  Medical 


gations  contains  the  list  of  the  different  varieties  of  micro-  Purveyor  in  March,  1872,  being  promoted  to  the  rank  of  colo- 
organisms  found,  from  which  it  appears  that  a  streptococcus  nel  in  June,  1874.  The  experience  of  twenty- three  years  which 


which  is  well  known  as  an  exciter  of  inflammation  was  found  Colonel  Baxter  has  had  in  the  administrative  bureau  of  the 
in  all  the  cases  but  one,  and  was  probably  an  important  ele-  medical  department  of  the  array  has  given  him  an  exceptional 

I  —  /%  •  i  1  •  /*  1  *  1  J x  n  —  .1  A.  L  -v  lr  a  nv  I 


ment  in  producing  the  disease.  After  the  peritonaeum  has  been  fitness  for  the  office  of  its  chief  administrator,  and  the  knowl- 
infected  by  the  micro-organism  which  excites  inflammation,  the  edge  that  he  has  acquired  of  the  medical  needs  of  the  army 


morbid  process  proceeds  rapidly  and  reaches  its  end  quickly,  in  will,  if  his  nomination  is  confirmed  by  the  Senate,  be  of  ines- 
which  case  pure  cultures  of  streptococci  are  found.  If  the  case  |  timable  value  to  that  arm  ot  the  service.  It  is  true  that  other 


should  not  terminate  quickly  and  fatally,  other  bacteria  will  medical  officers  have  a  strong  claim  to  the  office  of  surgeon- 
wander  from  the  intestine  to  the  peritoneum,  and,  by  means  general  by  reason  of  their  longer  term  of  service;  for,  although 

T~v  *  .  d  !  .  .  _  _  L  x  « 


of  the  products  of  tissue  change  which  are  developed  through  the  ranking  colonel,  Dr.  Baxter’s  term  of  service  lias  been 
their  influence,  will  either  cause  destruction  of  the  streptococci  much  shorter  than  the  terms  of  several  of  the  officers  now  in 


or  else  so  influence  their  further  development  that  there  will  that  corps.  Nevertheless,  with  a  view  only  to  the  fitness  of 
be  need  of  the  most  favorable  conditions  of  nutrition  in  the  a  candidate  for  the  office  to  which  he  is  nominated,  we  be- 


bacteriological  investigation  of  the  streptococci  contained  in  the  lieve  that  Colonel  Baxter  far  outranks  all  others,  and  tor  the 
exudate  in  order  to  produce  any  results  by  artificial  nourish-  good  of  the  service  we  hope  to  see  his  appointment  confirmed. 


ment  outside  the  body.  The  author  has  always  succeeded  in 
cultivating  the  streptococci  in  a  medium  of  glycerin-agar  at  an 
incubation  temperature,  and  thinks  that  the  failures  of  other 


MEDICAL  AFFAIRS  IN  CONSTANTINOPLE, 
investigators  may  have  been  due  to  insufficient  precautions.  It  I  The  city  of  Constantinople  has  always  been  a  tempting  field 


therefore  follows  that  they  were  not  in  all  cases  justified  in  say-  for  the  illegal  practice  of  medicine,  although  there  exists  a  code 
ing  that  the  streptococci  were  absent  because  they  failed  to  of  regulations  which,  if  faithfully  executed,  would  greatly  re¬ 


find  them. 


duce  the  number  of  unqualified  practitioners.  Under  the  Su- 


The  streptococcus  which  has  been  referred  to  is  considered  preme  Board  of  Health  an  official  list  has  been  drawn  up,  con 


identical  writh  the  streptococcus  of  erysipelas,  and  the  author 
succeeded  in  producing  erysipelas  upon  a  dog’s  ear  with  it. 
The  other  varieties  of  bacilli  which  were  found  had  the  prop¬ 
erty  of  destroying  albuminoid  bodies,  many  of  them  also  pro¬ 
ducing  toxic  substances  which,  even  after  the  death  of  the  bac¬ 
teria,  were  very  virulent  to  the  organisms  of  animals,  while 
cultures  of  streptococci  which  had  been  subjected  to  high  tem¬ 
perature  were  harmless.  Experiments  were  also  made  with 
chemical  agents  which  produce  peritonitis,  including  solution 
of  iron  and  tincture  of  iodine.  The  resulting  peritonitis  was 
sero-fibrinous  in  character  and  free  from  bacteria.  If  the  ani¬ 
mals  survived  some  time,  gangrene  of  the  intestines  resulted 
with  an  invasion  of  bacteria.  Prophylactic  precautions  are 


taining  the  names  of  all  legal  practitioners,  and  the  pharmacists 
are  forbidden  to  dispense  the  prescriptions  of  any  persons  not 
named  in  that  list.  As  a  further  precaution,  the  physicians  are 
directed  to  write  their  prescriptions  on  an  officially  stamped 
form  or  paper,  which  is  issued  to  them  by  the  Imperial  School 
of  Medicine,  and  which  should  bear  the  printed  name  and  ad¬ 
dress  of  the  prescriber.  According  to  the  Chemist  and  Drug¬ 
gist,  from  which  the  foregoing  has  been  abstracted,  there  b 
probably  no  town  on  earth  where  patent  medicines  are  con¬ 
sumed  to  such  an  enormous  extent  as  in  Constantinople;  tin 
nostrums  coming  from  France  take  the  lead  of  all  others,  tlier 
follow"  English,  Italian,  and  German  proprietary  articles.  Street 
venders  dispose  of  considerable  quantities  of  quinine  confee 


August  23,  1890.] 


Ml  NOB  PARAGRAPHS. 


213 


tions  and  pastilles  of  santonin,  and  in  the  bazaars  a  lively  trade 
is  done  in  drugs  for  producing  abortion,  which  are  used  to  a 
large  extent  by  the  Turkish  and  Armenian  women.  The  pur¬ 
chase  of  opium  and  hasheesh  is  almost  unknown  for  private 
consumption,  the  trade  being  exclusively  in  the  hands  of  whole 
sale  merchants,  and  it  may  be  observed  that,  whereas  in  the 
seventeenth  and  eighteenth  centuries  opium-smoking,  in  spite 
of  strong  prohibitive  laws,  was  very  common  in  Constanti¬ 
nople,  very  little  of  that  vice  is  known  to  exist  at  the  present 
time. 

The  Imperial  School  of  Medicine  has  a  strongly  patriarchal 
character,  and  the  tuition  is  almost  entirely  free.  There  are 
about  three  hundred  students,  the  majority  of  whom  are 
clothed  and  boarded  at  the  expense  of  the  government,  but  are 
bound,  after  the  completion  of  their  studies  and  examinations, 
to  serve  for  a  time  in  the  army,  either  as  pharmacists  or  as  sur¬ 
geons.  The  buildings  now  temporarily  occupied  by  the  rnedi 
cal  school  were  formerly  used  as  barracks,  but  they  are  beau¬ 
tifully  situated  in  the  center  of  a  park,  under  the  direction  of  a 
division  general.  The  anatomical  collections  are  exceptionally 
fine  and  the  school  might  be  described  as  well  appointed  and 
turnished,  except  for  the  neglect  that  is  observed  in  the  branch 
of  chemistry,  which  appears  to  be  the  special  care  or  concern 
of  nobody.  The  chemical  laboratory  is  hardly  more  than  a 
nominal  one,  and  nearly  all  the  pharmaceutical  students  have 
to  depend  upon  private  resources  for  the  prosecution  of  the 
practical  part  of  their  studies.  The  chemical  department  is 
under  the  direction  of  a  brigadier  general. 


the  stomach,  the  Strongylus  armatus  from  aneurysms,  and  the 
Gastrophilus  equi  from  the  stomach;  from  the  cow  the  Acti¬ 
nomyces  bovis  from  tumors,  the  Cysticercus  tcenice  mediocanel- 
lata,  from  the  heart  muscle,  the  Strongylus  micrurus  from  the 
lungs,  and  the  A ilaria  labiato-papillosa  troin  the  peritonaeum  ■ 
from  the  hog  an  Echinococcus  from  the  liver,  the  Cysticercua 
cellulose*}  from  the  muscles,  the  Echinorrhynchus  gigas  from  the 
small  intestine,  the  Trichocephalus  crenatus  from  the  ciecum 
the  Ascaris  suilla  from  the  intestines,  the  Sclerostoma  bingui- 
colum  from  the  liver  and  abdominal  fat,  and  the  Strongylus 
paradoxus  from  the  bronchi ;  from  the  dog  the  Tania  cucu- 
merina,  Tania  serrata ,  and  Tania  echinococcus  from  the  intes¬ 
tines,  the  Eustrongylus  gigas  from  the  peritonaeum,  the  Stron¬ 
gylus  or  Dochmius  trigonocephalies  from  the  small  intestines 
the  Trichocephalus  depressiusculus  from  the  caecum,  the  Ascaris 
marginata  from  the  stomach,  and  the  Filaria  immitis  from  the 
blood;  and  from  the  rabbit  the  Coccidium  oviforme  from  the 
liver  and  the  Cysticercus pisiformis  from  the  peritonaeum. 


MINOR  PARAGRAPHS. 

TELEPHONE  INSANITY. 

A  tale  is  told  by  the  Paris  correspondent  of  the  London 
Daily  Telegraph  that  may  suggest  Mark  Twain’s  account  of  how 
Hank  Morgan’s  sixth-century  wife  came  to  bestow  the  name  of 
Hello  Central  on  her  first-born  child.  The  Paris  story  is  as  fol¬ 
lows:  A  lady,  about  twenty-six  years  of  age,  employed  in  the 
chorus  of  one  of  the  theatres,  suddenly  stopped  in  the  middle  of 
the  rue  des  Petits-Carreaux  and  shouted  at  the  top  of  her  voice, 
‘Hallo!  hallo!”  A  crowd  at  once  gathered  around  the  young 
lady,  who  put  her  hands  to  her  mouth  and  ears  in  telephonic 
fashion.  ‘-Is  that  you,  Saint  Peter?”  continued  she,  as  if 
speaking  into  a  tube.  “  Right,  give  me  my  keys?  What?  You 
:  an  not  be  bothered  ?  Then  send  your  commissionaire.  I  must 
get  home !  ”  She  repeated  this  several  times,  and  at  last  the 
spectators  came  to  the  conclusion  that  she  was  wrong  in  her 
mind.  A  constable  took  her  to  the  police  station,  where  she 
went  on  in  the  same  way,  declaring  that  she  heard  distinctly 
hrough  the  telephone  the  celestial  music  of  Paradise,  that  she 
iould  hear  Saint  Cecilia  playing  the  piano,  and  that  the  chorus 
was  composed  of  cherubim.  She  was  sent  into  a  hospital. 


OBSERVATIONS  ON  THE  SECRETION  OF  BILE  IN  A  CASE 
OF  BILIARY  FISTULA. 

In  the  Proceedings  of  the  Royal  Society  Mr.  A.  W.  Mavo 
Robson  makes  a  careful  report  on  the  analysis  and  daily  secre¬ 
tion  of  bile  in  a  case  of  biliary  fistula.  He  concludes  that  bile 
is  probably  excrementitious  ;  that,  while  it  may  assist  in  the  di¬ 
gestion  of  fat,  it  is  not  necessary  to  digest  such  an  amount  as  is 
capable  of  supporting  life  and  nutrition  ;  that  increase  of  body 
weight  and  good  health  are  compatible  with  the  absence  of  bile 
from  the  intestines ;  that  its  antiseptic  properties  are  unimpor¬ 
tant;  that  its  supposed  stimulating  effect  on  the  intestinal  walls 
is  not  necessary  for  regular  defecation  ;  that  more  bile  is  se¬ 
creted  during  the  night  than  during  the  day  ;  that  the  excretion 
is  regular  and  unaffected  by  diet ;  that  the  pigment  of  fresh  bile 
is  biliverdin;  and  that  supposed  cholagogues  (calomel,  euony- 
min,  rhubarb,  podophvllin,  iridin,  turpentine,  and  benzoate  of 
sodium)  do  not  increase  the  excretion  of  bile,  though  carbonate 
of  sodium  in  aerated  water  produces  an  increased  flow. 


DISINFECTION  BY  SULPHUR  FUMIGATION. 

Dr.  Henry  B.  Baker,  the  secretary  of  the  Michigan  State 
Board  of  Health,  has  written  to  the  health  officer  of  Detroit  a 
letter  called  forth  by  a  rumor  that  the  latter  was  about  to  dis¬ 
pense  with  the  use  of.  burning  sulphur  in  the  disinfection  of  the 
rooms  and  appurtenances  of  persons  affected  with  diphtheria. 
It  will  be  remembered  that  the  efficacy  of  such  fumigation  has 
lately  been  denied  in  case  the  sulphur  fumes  are  not  mingled 
with  the  vapor  of  water.  Dr.  Baker  maintains  that  the  few 
laboratory  experiments  on  which  this  contention  is  founded 
should  not  be  held  to  outweigh  the  experience  of  health  officers 
in  the  restriction  of  diphtheria.  He  states,  moreover,  that  it  is 
not  necessary  to  use  water  with  the  sulphur,  but  that  the  essen¬ 
tial  thing  is  to  use  enough  sulphur— three  pounds  for  each 
thousand  cubic  feet  of  space. 


ENTOZOA  IN  DOMESTIC  ANIMALS. 

Dr.  "William  II.  Welch,  in  the  Johns  Hopkins  Hospital  Bul- 
ttin  for  July,  says  that  entozoa  are  of  great  interest  and  im- 
»ortance,  although  they  have  been  overshadowed  by  the  study 
>f  pathogenic  bacteria,  and  deserve  careful  attention.  In  the 
ourse  of  his  examination  of  animals  during  the  past  two  years 
ie  ^as  obtained  from  the  horse  the  Spiroptera  megastoma  from 


THE  NEW  JERSEY  LAW  REGULATING  THE  PRACTICE  OF 

MEDICINE. 

We  have  heard  considerable  comment  recently  on  the  law 
of  New  Jersey  regulating  the  practice  of  medicine  that  requires 
all  physicians  to  pass  an  examination  before  a  State  board  of 
examiners  before  they  can  be  licensed,  and  imposes  a  fine  of 
from  fifty  to  a  hundred  dollars,  or  imprisonment  for  from  ten 
to  ninety  days,  or  both,  for  practicing  in  the  State  without  a 
license.  The  law  is  virtually  the  same  as  that  regulating  prac- 


214 


MIJSW R  PARA  G RA PHS.— ITEMS. 


[N.  Y.  Med.  Joub., 


tice  in  this  State,  and  to  us  it  seems  as  fair  as  could  be  desired. 
Certainly  it  is  not  surprising  that  the  citizens  and  physicians  of 
New  Jersey  should  desire  the  same  protection  that  we  have 
sought  for  for  so  many  years. 


THE  DAILY  BULLETIN  OF  THE  BERLIN  CONGRESS. 

Under  the  general  title  of  Journal ,  with  the  subtitles  Tag- 
licJie  Mittheilungen ,  Daily  Bulletin ,  and  Bulletin  quotidien ,  a 
sort  of  daily  programme  of  the  Congress — for  it  was  little  else 
—was  published  for  the  use  of  the  members  during  the  session. 
The  matter  was  arranged  in  three  parallel  columns,  in  German, 
English,  and  French.  The  English  is  somewhat  peculiar,  but 
it  is  intelligible.  The  publication  is  certainly  interesting,  and 
not  the  least  charming  in  its  advertising  pages,  in  which  “  Oberst 
W.  F.  Cody”  (Buffalo  Bill)  closes  his  announcement  as  follows  : 
“  Die  Herren  Mediciner  und  Anthropologen  seien  auf  das  bedeu- 
tende  ethnographisclie  und  anthropologische  Interesse  aufmerk- 
sam  gemacht,  das  diese  Schanstellung  w&hrend  des  Anthropolo- 
gen-Congresses  in  New  Y’ork  und  Paris  liervorrief.” 


A  MEDICAL  COLLEGE  AT  MARSEILLES. 

It  may  seem  singular  to  us  that  Marseilles,  with  its  popula¬ 
tion  of  about  four  hundred  thousand,  has  no  medical  college. 
It  has  awakened  to  a  realization  of  its  deficiency,  and  has  peti¬ 
tioned  the  Minister  of  Public  Instruction  to  authorize  the  estab¬ 
lishment  of  a  medical  faculty— a  preliminary  step  toward  a 
university — at  the  expense  of  the  municipality.  The  consum¬ 
mation  of  the  desire  is  being  thwarted  by  the  vigorous  opposi¬ 
tion  of  Montpellier,  that  fears  for  the  prestige  of  its  ancient 
university.  _ 

THE  COLOR-SENSE  AMONG  THE  CHINESE. 

In  the  China  Medical  Missionary  Journal  Adele  M.  Fielde 
reports  an  examination  of  twelve  hundred  Chinese  for  the 
color-sense.  Of  six  hundred  women,  only  one  was  color-blind 

_ for  green;  of  six  hundred  men,  nineteen  were  color-blind, 

and  four  of  these  were  sons  of  the  green-blind  woman.  The 
examinations  were  made  with  Thomson’s  arrangement  of  Holm¬ 
gren’s  test.  The  results  obtained  among  the  men  give  the  pro¬ 
portion  usually  ascertained  in  such  examinations. 


BUBONIC  PLAGUE  IN  TURKEY. 

The  British  Medical  Journal  announces  that  the  Imperial 
Sanitary  Board  of  Turkey  has  information  of  an  outbreak  of 
the  plague  at  Kale-Daragehan,  a  village  of  two  hundred  and 
eighty  inhabitants,  and  that  forty-two  persons  have  been  at¬ 
tacked,  with  twenty-six  deaths  already.  The  reporter  of  the 
cases,  Dr.  Constantinides,  personally  observed  many  of  the 
patients.  He  states  that  the  disease  is  marked  by  inguinal,  ax¬ 
illary,  and  retro-auricular  buboes,  with  a  temperature  of  104° 
F.  and  a  bluish  cutaneous  rash. 


THE  BRUNSWICK  HOME  FOR  NERVOUS  DISEASES. 

A  private  institution  at  Amityville,  Suffolk  County,  Long 
Island,  named  the  Brunswick  Home,  is  carried  on  under  State 
license.  It  is  distant  from  New  York  about  thirty-two  miles. 
It  is  constructed  on  the  cottage  plan.  Persons  with  nervous 
or  mental  disease,  acute  or  chronic,  or  addicted  to  alcohol  or 
opium,  can  be  accommodated  at  relatively  low  charges.  The 
circular  states  that  $8  to  $12  a  week  are  the  regular  terms  for 
individual  rooms.  A  school  for  idiotic  and  feeble-minded  per¬ 
sons  is  embraced  in  the  scope  of  the  Home. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  August  19,  1890; 


DISEASES. 

Week  ending  Aug.  12. 

Week  ending  Aug.  19. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

40 

5 

40 

12 

Scarlet  fever . 

28 

2 

18 

3 

Cerebro-spinal  meningitis . 

3 

2 

2 

0 

Measles . 

109 

8 

104 

13 

Diphtheria . 

36 

11 

34 

16 

The  American  Climatological  Association  will  hold  its  seventh  an¬ 
nual  meeting  in  Denver,  Col.,  on  Tuesday,  Wednesday,  and  Thursday, 
September  2d,  3d,  and  4th,  under  the  presidency  of  Dr.  Charles  Deni- 
son,  of  Denver.  Besides  the  president’s  address,  on  Abnormal  Intra- 
Ihoracic  Air-pressures  and  their  Treatment,  the  programme  includes  the 
following  items :  Remarks  on  the  Pneumatic  Treatment  of  Disease,  with 
Cases,  by  Dr.  D.  M.  Cammann,  of  New  York ;  Bilateral  Pleurisy,  by  Dr. 
John  H.  Musser,  of  Philadelphia ;  The  Physiology  and  Pathology  of 
Breathing,  by  Dr.  B.  F.  Westbrook,  of  Brooklyn;  Exhibition  of  the 
Pneumograph  and  Graphic  Methods  for  recording  Diseased  Conditions, 
by  Dr.  J.  H.  Kellogg,  of  Battle  Creek,  Mich. ;  A  Comparative  Study  of 
the  Climate  of  those  Regions  of  Europe  and  America  which  are  now  in 
Vogue  in  the  Treatment  of  Pulmonary  and  Nervous  Diseases,  by  Dr. 
Leonard  Weber,  of  New  York  ;  The  Climate  of  Ajaccio,  Corsica,  by  Dr. 
A.  Tucker  Wise,  of  Maloja,  Switzerland ;  The  Climate  of  the  Hawaiian 
Islands,  by  Dr.  Titus  Munson  Coan,  of  New  York  ;  Is  Herpes  Zoster  a 
Cause  of  Pleurisy  and  Peritonitis  ?  by  Dr.  R.  G.  Curtin,  of  Philadelphia; 
Report  of  Cases  of  Phthisis  treated  in  Colorado,  by  Dr.  S.  E.  Solly,  of 
Colorado  Springs  ;  The  Preferable  Attributes  of  Climate  for  Consumption 
as  applied  to  the  Winters  in  Southern  New  Mexico,  Southern  Arizona, 
and  Western  Texas,  by  Dr.  W.  M.  Yandell,  of  El  Paso,  Texas ;  Informa¬ 
tion  about  Desirable  Localities  for  Winter  Health  Stations  in  Southern 
Arizona,  by  Dr.  Thomas  Darlington,  of  Bisbee,  Arizona  ;  The  Climate 
of  New  Mexico  as  viewed  by  the  Medical  Fraternity  there,  by  Dr.  James 
H.  Wroth,  of  Albuquerque;  The  Climate  of  the  Great  Salt  Lake  Basin, 
by  Dr.  A.  C.  Standart,  of  Salt  Lake  City;  The  Thermal  Springs  of  Salt 
Lake  City,  by  Dr.  George  W.  Fosffer,  of  Salt  Lake  City ;  Mtental  and 
Nervous  Diseases  observed  in  Colorado,  by  Dr.  J.  T.  Eskridge,  of  Den¬ 
ver;  Mode  of  Life  of  the  Consumptive  Patient  in  High  Altitudes,  by 
Dr.  P.  B.  Anderson,  of  Colorado  Springs ;  The  Relation  of  Climate  tr 
Pulmonary  Haemorrhage  in  Colorado,  by  Dr.  Jacob  Reed,  of  Colorado 
Springs  ;  Practical  Suggestions  with  Reference  to  Exercise  of  Consump¬ 
tive  Patients  in  Colorado,  by  Dr.  S.  A.  Fisk,  of  Denver ;  The  Injurious 
Effects  of  Over-exertion  in  Pulmonary  Phthisis,  by  Dr.  Karl  von  Ruck, 
of  Ashville,  N.  C. ;  The  Preferable  Climate  for  Consumption  as  applied 
to  Northern  New  Mexico,  by  Dr.  W.  R.  Tipton,  of  Las  Vegas,  N.  M. ; 
Climate  by  Exclusion,  by  Dr.  Francis  H.  Atkins,  of  Las  Vegas,  N.  M. ; 
Acclimation  of  the  Consumptive  to  the  Colorado  Climate,  by  Dr.  H.  0. 
Dodge,  of  Boulder,  Col. ;  The  Influence  of  High  Altitude  Climates  upon 
Youth,  as  determined  by  an  Acquaintance  with  the  Public-School  Sys¬ 
tem  of  Denver,  by  Dr.  A.  Stedman,  of  Denver ;  How  to  select  a  Proper 
Climate  for  Individual  Cases  of  Phthisis  Pulmonalis,  by  Dr.  John  W. 
Robinson,  of  Chicago ;  Fifteen  Aphorisms  embodying  the  Present 
Status  of  Pulmonary  Consumption,  by  Dr.  J.  H.  Tindale,  of  New  \  ork ; 
Can  Patients  in  whom  Tubercular  Disease  of  the  Lungs  has  been  ar¬ 
rested  in  High  Altitudes  return  with  Safety  to  a  Low  One  ?  by  Dr. 
Frederick  I.  Knight,  of  Boston ;  Study  of  Tuberculosis  in  the  Criminal 
Classes,  by  Dr.  William  Duffield  Robinson,  of  Philadelphia;  Ocean 
Climate,  by  Dr.  M.  Charteris,  of  Glasgow,  Scotland ;  The  Climate  of 
our  Homes,  Public  Buildings,  and  Railroad  Coaches,  a  Leading  Factor 
in  the  Production  of  the  Annual  Crop  of  Pulmonary  Diseases,  by  Dr. 
R.  Harvey  Reed,  of  Mansfield,  Ohio ;  Relations  of  Certain  Meteorologi¬ 
cal  Conditions  to  Diseases  of  the  Lungs  and  Air-passages  in  Colorado, 
by  Dr.  Henry  B.  Baker,  of  Lansing,  Mich. ;  How  far  does  Dryness  of 
Atmosphere  influence  the  Course  or  Treatment  of  Inflammatory  Dis¬ 
eases  of  the  Nasal  and  Pharyngeal  Mucous  Membranes  ?  by  Dr.  E. 
Fletcher  Ingals,  of  Chicago ;  The  Essentials  for  a  Successful  “  Closed 


August  23,  1890.]  ITEMS.  LETTERS  TO  THE  EDITOR-PROCEEDINGS  OF  SOCIETIES. 


215 


Sanitarium  in  Colorado,  by  Dr.  J.  II.  Kellogg,  of  Battle  Creek,  Mich. ; 
and  Selected  Cases  with  Reference  to  Climatic  Treatment,  by  Dr.  H.  A. 

Johnson,  of  Chicago. 


to  %  (Sbitor. 


The  New  Jersey  Board  of  Medical  Examiners,  recently  authorized 
by  the  Legislature,  is  announced  as  consisting  of  Dr.  William  P.  Wat¬ 
son,  of  Jersey  City ;  Dr.  W.  L.  Newell,  of  Salem ;  Dr.  Henry  S.  Wag¬ 
ner,  of  Somerset ;  Dr.  George  W.  Brown,  of  Monmouth  ;  Dr.  Hugh  C. 
Hendry,  of  Essex ;  Dr.  A.  Aebalacker  (homoeopathic),  of  Morristown ; 
and  Dr.  Eugene  Tiesler  (eclectic),  of  Essex.  It  is  stated  that  the  board 
will  meet  for  organization  on  the  first  Tuesday  in  September. 

Naval  Intelligence.  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  August  16 ,  1890 : 

Wales,  P.  S.,  Medical  Director.  Detached  from  the  Medical  Examin¬ 
ing  Board  and  will  resume  present  duty  at  the  Museum  of  Hygiene. 
Ames,  H.  E.,  Passed  Assistant  Surgeon.  Ordered  as  member  of  Medi¬ 
cal  Examining  Board  in  addition  to  present  duty. 

Sayre,  J.  S.,  Passed  Assistant  Surgeon.  Detached  from  the  Navy  Yard 
New  York,  and  ordered  to  the  U.  S.  Steamer  Ranger. 

North,  J.  H.,  Jr.,  Assistant  Surgeon.  Ordered  to  the  Navy  Yard  New 
York. 

Barber,  George  H.,  Assistant  Surgeon.  Detached  from  the  U.  S.  Re¬ 
ceiving-ship  Vermont  and  ordered  to  the  Pensacola. 

Yedekind,  L.  L.  von,  Assistant  Surgeon.  Detached  from  the  Pensa¬ 
cola  and  ordered  to  the  Vermont. 

Vnzal,  E.  W.,  Passed  Assistant  Surgeon.  Assigned  to  temporary  duty 
at  Naval  Academy  to  examine  candidates. 

*  itts,  H.  B.,  Passed  Assistant  Surgeon.  Detached  from  the  U.  S. 

Steamer  Pinta  and  to  proceed  home  and  wait  orders. 

'Tone,  E.  P.,  Passed  Assistant  Surgeon.  Detached  from  the  U.  S. 

Steamer  Independence  and  ordered  to  the  Pinta. 

Vhitfield,  J.  M.,  Assistant  Surgeon.  Detached  from  the  Monitor  and 
ordered  to  the  Naval  Hospital,  Norfolk. 
lyers,  Joseph,  Surgeon.  Ordered  to  the  Naval  Academy  to  examine 
candidates  for  admission. 

■right,  George  H.,  Surgeon.  Ordered  to  the  Naval  Academy  to  ex¬ 
amine  candidates  for  admission. 

mith,  George  T.,  Assistant  Surgeon.  Detached  from  the  Naval  Hos¬ 
pital,  Norfolk,  and  ordered  to  the  U.  S.  Steamer  Independence. 

'"hite,  S.  S.,  Passed  Assistant  Surgeon.  Detached  from  the  Marine 
and  ordered  to  the  Naval  Rendezvous,  San  Francisco,  Cal. 

Marine-Hospital  Service.—  Official  List  of  Changes  of  Stations  and 
hities  of  Medical  Officers  of  the  United  States  Marine-Hospital  Service 
■om  July  26 ,  1890,  to  August  1$,  1890  : 

awtelle,  H.  W.,  Surgeon.  Granted  leave  of  absence  for  fifteen  days. 
August  8,  1890. 

'heeler,  W.  A.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  thirty  days.  August  5,  1890. 

armichael,  D.  A.,  Passed  Assistant  Surgeon.  Granted  leave  of  ab¬ 
sence  for  thirty  days.  August  2,  1890. 
eckham,  C.  T.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  thirty  days.  July  28,  1890. 

mes,  R.  P.  M.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  fourteen  days.  August—,  1890.  To  proceed  to  Shreveport 
La.,  as  inspector.  August  5,  1890.  ’ 

alloch,  P.  C.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  seven  days.  July  — ,  1890. 

:rry,  J.  C.,  Assistant  Surgeon.  To  proceed  to  Wilmington,  N.  C., 
for  temporary  duty.  July  31,  1890. 
hth,  A.  0.,  Assistant  Surgeon.  Granted  leave  of  absence  for  thirty 
days.  August  11,  1890. 

•png,  G.  B.,  Assistant  Surgeon.  Leave  of  absence  extended  twenty 
days  on  account  of  sickness.  August  2,  1890.  Upon  expiration  of 
leave,  to  proceed  to  New  Orleans,  La.,  for  temporary  duty.  August 

8,  1890. 

impson,  W.  G.,  Assistant  Surgeon.  When  relieved  at  Buffalo, 

K.  \  .,  to  proceed  to  Norfolk,  Va.,  for  temporary  duty.  August  5, 

1890. 


BLINDNESS  AFTER  CEREBRO-SPINAL  MENINGITIS. 

Cuba,  N.  Y.,  August  15,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir.  The  case  of  blindness  following  cerebro-spinal  menin¬ 
gitis  with  recovery  after  two  years,  reported  by  Dr.  W.  L. 
Stowel),  is  very  similar  to  a  case,  that  of  ray  own  brother.  Some 
fifteen  years  ago  he  had  a  severe  attack  of  cerebro-spinal  men¬ 
ingitis.  After  he  recovered  sufficiently  to  get  about  it  was 
found  that  he  was  ataxic,  and  that  his  sight  and  hearing  were 
much  involved. 

He  continued  in  that  state  without  much  change  for  about 
three  years. 

At  that  time  he  ran  against  a  dipper  of  boiling  water  which 
was  being  dipped  from  a  boiler  into  a  tub. 

All  of  the  breast  above  the  nipples  was  severely  scalded. 
The  scald  healed  without  any  unusual  symptoms,  and  with  the 
healing  all  the  former  troubles  were  cured. 

He  has  since  grown  to  be  a  strong  and  vigorous  man. 

H.  F.  Gillette,  M.  D. 


rocetbinp  o{  Sorietus. 


NEW  YORK  SURGICAL  SOCIETY. 

Meeting  of  April  9,  1890. 

The  President,  Dr.  C.  K.  Briddon,  in  the  Chair. 

Appendicitis. — Dr.  F.  W.  Murray  presented  a  young  man 
whose  case  had  been  diagnosticated  by  a  dispensary  physician 
as  perityphlitic  abscess.  The  patient  had  come  to  St.  Luke’s 
Hospital,  where  a  similar  diagnosis  was  made.  An  operation 
was  urged,  but  declined  ;  on  the  following  day  the  patient  had 
changed  his  mind  and  his  abdomen  was  opened  by  an  incision 
three  inches  in  length  on  the  outer  side  of  the  right  rectus  mus¬ 
cle.  The  abdominal  tissues  were  found  matted  together  and 
thickened.  The  abscess  wall  was  opened  and  a  quantity  of  very 
foetid  pus  was  discharged.  The  inner  wall  of  the  abscess,  which 
was  intra-peritoneal,  was  formed  by  a  coil  of  intestine.  A 
smaller  cavity  was  found,  from  which  a  fsecal  concretion  was 
extracted.  It  was  also  seen  that  the  end  of  the  appendix  had 
sloughed  away.  A  counter-opening  was  made  in  the  loin  above 
the  ilium,  through  which  a  large  drainage-tube  was  passed  into 
the  abscess  cavity,  which  was  then  packed  with  gauze.  The 
general  peritoneal  cavity  was  washed  out  and  a  glass  drainage- 
tube  was  inserted  and  secured  in  the  lower  angle  of  the  abdomi¬ 
nal  wound.  Iodoform  gauze  and  two  sutures  were  used  in 
closing  the  wound.  The  patient  had  done  very  well.  In  three 
weeks  lie  was  out  of  bed.  Now  he  was  perfectly  well  and  had 
gone  back  to  work.  The  speaker  was  rather  glad  he  had  made 
the  error  of  making  the  incision  somewhat  too  far  outside  the 
muscle;  but  for  this  he  might  have  opened  directly  into  the 
abscess  and  thereby  have  enhanced  the  danger  of  infection  of 
the  peritoneal  cavity.  Another  point  of  note  was  the  good 
condition  of  the  patient,  considering  the  state  of  things,  and  it 
went  to  show  that  it  was  impossible  to  predict  exactly  what 
would  be  found  until  the  dissection  was  made. 

Cancer  of  the  Lip. — Dr.  Willy  Meyer  presented  a  patient, 
sixty-five  years  of  age,  upon  whom  he  had  recently  operated  for 
cancer  of  the  lip.  The  growth  was  very  extensive  and  nearly 
the  whole  lip  had  to  be  removed  except  at  either  corner.  Fol¬ 
low  ing  the  method  of  Dieffenbach,  he  had  taken  two  flaps  from 


216 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Joub., 


the  cheeks,  cutting  through  the  mucous  membrane  a  quarter  of 
an  inch  above,  so  that  he  could  approximate  both  flaps  perfect¬ 
ly.  It  was  now  ten  weeks  since  the  operation,  and  it  would  be 
seen  that  when  the  man’s  beard  grew  he  would  present  a  very 
good  appearance. 

Extensive  Penetrating  Wound  of  the  Thorax ;  Disloca¬ 
tion  of  a  Rib;  Non-coHapse.of  the  Lung;  Recovery.— The 

President  presented  a  patient  whose  case,  as  reported  by  Dr 
W.  H.  Ross,  was  as  follows :  A  man,  nineteen  years  old,  a  truck¬ 
man,  was  brought  into  the  Presbyterian  Hospital,  in  the  service 
of  Dr.  Briddon,  on  February  19, 1890.  The  patient  was  stand 
ing  by  a  horse’s  head,  urging  the  animal  to  start  with  a  load  of 
manure,  when  suddenly  the  horse  turned,  forcing  the  man 
against  a  fence,  where  he  received  the  driving  force  of  the  end 
of  the  shaft  in  his  chest.  The  shaft  was  somewhat  pointed,  but 
almost  at  once  its  diameter  increased  to  two  inches.  It  was 
thought  that  the  shaft  had  penetrated  the  thorax  about  three 
inches. 

On  examination,  it  was  found  that  the  patient  had  sustained 
a  wound  in  the  skin  two  inches  and  a  half  by  three,  with  its 
center  over  the  fourth  intercostal  space,  midway  between  the 
nipple  and  the  axilla  on  the  right  side.  The  fourth  and  fifth 
ribs  were  separated  to  the  extent  of  two  inches  and  a  half  at 
the  widest  point,  and  the  fourth  rib  was  denuded  of  periosteum 
for  three  inches  opposite  the  wound  in  the  skin  and  displaced 
upward  at  the  vertebral  end.  The  intercostal  muscles  were 
torn  asunder  for  a  distance  of  six  inches  and  the  skin  and  fascia 
separated  from  the  muscles  for  a  distance  of  eight  inches.  The 
wound  of  the  muscles  must  have  been  produced  by  the  forcible 
separation  of  the  ribs  by  the  cart  shaft.  There  was  only  partial 
collapse  of  the  lung.  During  quiet  respiration  the  lung  did  not 
-  quite  come  up  to  the  opening,  but  during  violent  respiration  it 
protruded  through  the  opening  from  two  to  three  inches.  Dur¬ 
ing  inspiration  the  lung  would  sink  back,  and  during  expiration 
come  up  to  the  opening  or  protrude  from  it.  The  action,  there 
fore,  was  exactly  the  reverse  of  the  normal  movement.  The 
lung  had  remained  of  a  pink  color.  The  wound  was  occluded 
with  iodoform  gauze,  the  ordinary  dressing  being  put  on,  then 
covered  with  rubber  tissue  and  firmly  bandaged.  Y ery  little 
reaction  followed  this  serious  injury.  The  temperature  never 
rose  above  101°  F.  There  was  no  suppuration.  The  wound 
contracted  rapidly  and  healed  kindly  by  primary  union  and 
granulation.  On  the  morning  following  the  injury  there  was 
cracked-pot  resonance,  with  many  creaking  sounds,  gurgling 
rales,  and  a  feeble  respiratory  murmur  over  the  lung  of  the  af¬ 
fected  side.  There  was  a  moderate  blood-stained  expectora 
tion.  This  ceased  in  a  few  days.  The  respiratory  murmur 
steadily  improved  and  the  creaking  and  crepitant  rales  became 
less  marked.  The  patient  was  able  to  leave  his  bed  in  three 
weeks,  and  since  then  had  been  about  the  ward.  Physical  ex 
amination,  made  six  weeks  from  the  date  of  injury,  showed  the 
percussion  resonance  slightly  sonorous  over  a  space  three  inches 
in  diameter  corresponding  to  the  wound  in  the  chest.  The 
breathing  was  somewhat  sibilant  there.  The  difference  in  ex¬ 
pansion  of  the  sides  of  the  chest  was  only  a  quarter  of  an  inch. 
In  all  other  respects  the  physical  examination  was  negative. 

Dr.  A.  G.  Gerster  had  observed  in  a  case  of  sarcoma  of  the 
rib  in  which  he  had  seen  the  pleural  cavity  opened  that  when 
this  was  done  the  lung  had  collapsed  and  curled  up  at  its  edges. 
A  very  considerable  portion  of  the  pleural  cavity  had  re 
mained  full  of  air.  There  had  been  no  wound  of  the  lung  in 
that  case. 

Dr.  Gerster,  referring  to  Dr.  Murray’s  case  of  appendicitis, 
said  he  had  lately  paid  a  good  deal  of  attention  to  the  distribu¬ 
tion  of  the  abscesses  which  were  most  frequently  met  with  in 
this  region.  In  most  cases  the  classical  site  of  selection  was 


near  Poupart’s  ligament,  close  to  the  parietal  peritonaeum.  Then 
the  abscess  was  apt  to  become  subcutaneous,  and  the  opening 
and  drainage  was  a  simple  matter.  The  next  most  frequent 
place  he  had  found  to  be  a  point  corresponding  to  the  right 
rectus  muscle,  within  the  peritoneal  cavity  and  beneath  the 
muscle  itself.  He  had  three  times  made  a  median  incision 
for  exploratory  purposes.  This  incision  would  tell  the  sur¬ 
geon  where  to  attack  the  abscess  so  as  to  avoid  opening  into 
the  peritoneal  cavity.  He  had  not  learned  to  regard  with 
indifference  an  interference  with  the  peritoneal  cavity,  and 
thought  that  good  surgery  required  that  one  should  try  to  get 
at  such  abscesses  without  involving  it,  if  possible.  To  ascertain 
whether  this  could  be  done  he  had  made  the  exploratory  open¬ 
ings,  as  stated.  He  believed  that  the  technique  of  operating 
properly  in  perityphlitic  abscess  was  not  yet  developed,  and 
that  this  could  only  follow  very  careful  study  of  the  history  of 
such  cases,  especially  as  to  the  locations  most  commonly  the 
site  of  the  abscess  and  the  directions  in  which  they  tended  to 
spread.  The  appendix  was  a  very  movable  body,  and  certain 
variations  must  be  expected,  but  still  there  were  rules  which 
would  govern  these  cases  which  ought  to  be  studied. 

Dr.  Robert  Abbe  thought  it  was  a  question  as  to  whether 
the  entire  vermiform  appendix  should  be  removed  in  every 
case.  In  the  event  of  existing  perforation  of  the  distal  end 
only,  he  should  be  inclined  to  leave  the  stump. 

Dr.  Murray  said  he  should  certainly  have  removed  the  en¬ 
tire  organ  in  his  case  if  he  could  have  done  so,  as  he  considered 
it  increased  the  chances  of  recurrence  to  leave  any  of  the  dis¬ 
eased  organ  behind. 

Dr.  Gerster  thought  that  recurrence  of  true  perityphlitic 
abscesses  was  not  common.  Many  of  the  so-called  relapses 
really  resulted  from  imperfect  drainage  at  the  first  operation 
and  the  establishment  of  sinuses  and  pockets  which  favored 
the  redevelopment  of  abscesses  in  the  presence  of  any  exciting 
cause.  Cases  of  true  relapse  did,  however,  undoubtedly  exist. 

The  President  thought  the  treatment  followed  by  Dr.  Mur 
ray  was  the  best  which  could  have  been  adopted.  He  should 
hesitate  very  much  to  make  any  dissection  in  searching  for  th< 
appendix,  lest  he  might  infect  the  general  peritonaeum.  H< 
would  rather  risk  the  recurrence  of  the  disease.  It  was  ver] 
important  to  avoid,  if  possible,  opening  into  the  peritoneal  cav 
ity  in  these  abscesses. 

Colotomy. — A  discussion  oh  this  subject  having  beei 
started,  Dr.  George  A.  Peters  agreed  that  the  operatic*) 
should  be  done  as  early  as  possible.  He  had  had  more  experi 
ence  with  the  lumbar  operation  than  with  the  anterior  one 
The  benefit  derived  was  often  very  marked.  In  a  case  whici 
he  recalled,  the  patient,  until  he  had  submitted  to  it,  had  beei 
a  great  sufferer.  From  that  time  on,  during  the  three  or  fou 
months  that  he  had  lived,  his  existence  was  fairly  comfortabh 
During  this  period  the  bladder  had  become  involved  and  faeci 
matter  had  found  its  way  into  the  urine  occasionally.  Still  th 
man  had  been  relieved  from  all  his  great  distress. 

Dr.  Abbe  suggested  the  employment  of  cocaine  anassthe>i 
in  these  operations,  believing  that  its  use  would  obviate  the  to 
frequent  fatal  results  traceable  to  shock.  He  had  made  use  « 
this  method  in  a  case  some  two  years  before,  and  with  the  ha| 
piest  results.  The  patient  had  watched  the  removal  of  a  larg 
quantity  of  faecal  matter.  Relief  from  distention  had  beeu  ir. 
mediate,  and  the  young  man  had  made  a  perfect  recovery.  T 
patient  could  not  have  withstood  general  anaesthesia  and  shoe 
It  might  not  be  a  suitable  method  when  a  great  deal  of  mamp 
lation  was  necessary.  He  had  employed  cocaine  three  times 
opening  the  abdomen,  and  in  one  case  in  extremis. 

Dr.  B.  F.  Curtis  thought  that  surgeons  were  apt  to  err 
the  direction  of  refinements  of  technique  in  this  operation. 


August  23,  1890.J 


PROCEEDINGS  OR  SOCIETIES. 


217 


was  not  necessary  to  put  in  many  stitches  if  the  opening  into 
the  intestine  was  not  made  at  the  time.  Two  or  three  would 
hold  the  gut  in  position  with  the  aid  of  a  stout  thread  passed 
through  the  mesentery. 

The  President  thought  it  was  of  decided  advantage  to  mak 
an  opening  through  the  muscular  tissue.  There  was  less  likely 
to  be  prolapse,  as  it  acted  as  a  sphincter. 

Dr.  Meyer  said  he  had  performed  a  similar  operation  in 
babies  who  had  been  born  with  imperforate  anus.  In  such  cases 
it  was  necessary  to  decide  between  anterior  and  posterior  co- 
lotoiny.  If  the  children  recovered  they  were  better  off  with  the 
inguinal  opening,  as  a  pad  could  he  more  readily  applied.  Still, 
the  face*  could  be  better  retained  after  the  lumbar  incision. 

The  President  said  he  had  never  had  any  trouble  after 
lumbar  colotomy.  Patients  had  no  trouble  in  retaining  faeces 
except  after  some  error  of  diet.  Some  of  his  patients  were 
living  who  had  undergone  this  operation  eight  or  ten  years  ago. 

Dr.  Gerster  said  he  bad  done  the  operation  quite  a  number 
of  times  and  had  found  it  to  be  a  very  excellent  one.  The  sev 
eral  steps  were  comparatively  easy  under  all  circumstances, 
lie  was  one  of  those  who  had  once  incised  the  small  intestine 
instead  of  the  large  one,  through  the  lumbar  opening.  Since 
then  he  had  always  preferred  inguinal  colotomy.  It  put  every 
thing  in  the  hands  of  the  op  rat*»r.  As  to  complications  ant! 
(lifficulth s.  he  thought  the  majority  of  the  cases  in  which  colot 
omy  was  done  were  not  those  in  which  the  patients  were  in 
extremis.  He  thought  the  operation  at  one  sittiug  gave  the 
better  technical  results.  The  incision  should  always  be  trans¬ 
verse.  He  had  had  some  cases  of  prolapse  and  they  were  verv 
lisagreeable.  To  avoid  this,  care  should  be  taken  to  select  a 
piece  of  mesentery  of  proper  length.  If  it  was  too  large,  the 
gut  should  be  dragged  back  and  another  section  of  intestine 
sought  for  with  a  mesentery  of  suitable  length. 

Tumor  of  the  Bladder  diagnosticated  with  the  Cysto- 
3C0pe. — Dr.  Meyer  presented  a  tumor  which  he  had  removed 
from  the  bladder  of  a  patient  tifty-five  years  of  age.  In  this 
•ase  the  diagnosis  had  been  made  by  means  of  the  cyst  iscope. 
The  patient  had  suffered  for  a  long  time  from  hsematuria. 
When  consulted,  the  speaker,  instead  of  using  a  sound  to  search 
'or  stone,  had  at  once  tried  to  introduce  the  cystoscope  under 
;ocaine  anaesthesia.  This  he  had  found  impracticable,  and  three 
lays  subsequently  had  given  the  patient  chloroform.  He  had 
;hen  made  out  with  the  utmost  certainty  the  growth  on  the  left 
wall  of  the  bladder.  He  could  also  see  the  blood  oozing  from 
t.  The  result  of  the  operation  had  been  to  confirm  the  diag- 
losis  so  made.  The  tumor,  on  being  removed,  was  found  to  be 
nalignant. 


RICHMOND,  VA.,  ACADEMY  OF  MEDICINE  AND 

SURGERY. 

Meeting  of  July  8,  1890. 

The  President,  Dr.  W.  W.  Parker,  in  the  Chair. 

( Reported  l>y  Dr.  J.  W.  Ilenson ,  Richmond.) 

Speech  and  Locomotion  Absent  in  a  Child  Three  Years 

md  a  Half  of  Age. — Dr.  J.  N.  Upshur  reported  the  history  of 
i  case  of  a  child  unable  to  walk  or  talk  at  the  age  of  three  years 
md  a  half,  although  apparently  perfectly  developed  physically 
nd  to  a  casual  observer  as  bright  mentally  as  any  child— in 
eality,  however,  being  several  months  or  a  year  behind  the 
verage.  The  expression  of  its  face  was  a  little  more  childish 
ban  the  age  demanded. 

_  There  was,  he  said,  a  remarkable  suppleness  about  the  hip 
oints,  the  child  being  able  to  abduct  the  lower  limbs  until  at 
>ght  angles  with  the  trunk,  or  flex  them  until  flat  upon  the  ab¬ 


domen.  It  possessed  a  good  appetite,  was  perfectly  well  nour¬ 
ished,  though  constipated,  and  had  resisted  well  two  or  three 
severe  attacks  of  sickness.  It  had  a  remarkable  aptitude  for  the 
appreciation  of  musical  sounds.  The  child’s  teeth  exhibited 
great  irregularity  in  their  manner  of  eruption,  appearing  here 
and  there  at  haphazard  around  the  dental  arch. 

The  speaker  knew'  of  no  cause  for  the  state  of  affairs,  except 
that  the  mother,  when  pregnant  with  this  child,  was  subjected 
to  considerable  mental  and  physical  worry  on  account  of  the  ill¬ 
ness  of  an  older  one.  He  would  like  to  know  the  chances  of  its 
attaining  the  power  of  speech  and  locomotion.  Was  the  condi¬ 
tion  the  result  of  lack  of  nervous  power,  and  would  benefit  ac¬ 
crue  from  the  use  of  electricity  and  massage? 

Dr.  J.  Miohaux  asked  if  there  had  been  any  convulsions. 

Dr.  Upshur  replied  that  there  had  been  none. 

Dr.  0.  L.  Oudlipp  asked  if  all  the  pelvic  bones  were  normal. 

Dr.  Upshur  replied  that  they  were. 

Dr.  Miciiaux  thought  the  caje  one  of  arrest  of  development 
from  lack  <>f  brain  or  nervous  organization,  and  that  there  was 
ittle  chance  for  mental  development  under  such  conditions. 

The  President  thought  that  a  child  of  three  years  would 
learn  to  talk. 

Dr.  George  Ben  Johnston  believed  the  case,  from  the  his¬ 
tory,  to  be  one  of  mi kl  rickets,  and  he  was  sure  that  by  an  active 
tonic  treatment  in  which  the  by pophosphites  were  involved, 
massage  (particularly),  electricity,  and  strict  attention  to  hy¬ 
gienic  surroundings,  much  good  could  be  done  for  the  child’s 
bones.  He  thought  it  would  walk,  and  did  not  believe  the  in¬ 
ability  to  speak  necessarily  serious. 

Veratrum  Viride  in  Puerperal  Convulsions.— The  Presi¬ 
dent  reported  having  used  in  a  case  of  puerperal  convulsions, 
occurring  two  or  three  weeks  before  the  expected  time  of  labor 
(besides  the  usual  plan  of  venesection  and  chloroform),  tincture 
of  veratrum  viride,  administering  fourteen  drops  early,  and 
afterward  five  drops  every  two  hours.  Dr.  Hugh  M.  Taylor,  in 
consultation,  had  recommended  enemata  of  bromide  of  potas¬ 
sium  and  hydrate  of  chloral  in  large  doses.  The  patient  was 
successfully  relieved,  but  labor  commenced  two  or  three  days 
afterward,  and  under  chloroform  the  patient  gave  birth  to  a 
live  child  of  eight  months’  gestation,  large  but  feeble.  The 
speaker  had  great  faith  in  veratrum  viride  for  the  relief  of  con¬ 
vulsions. 

Dr.  Albert  Sneed  had  recommended  it  in  ten-drop  doses 
every  two  hours. 

Cholera  Morbus  rapidly  Fatal. — The  President  stated  that 
a  Mr.  V.  had  summoned  medical  aid  about  2  a.  m.  on  Wednes¬ 
day.  By  3  p.  m.  on  Thursday  he  was  dead.  Before  death  the 
vomiting  and  purging  became  excessive,  and  a  convulsive  move¬ 
ment  of  the  lower  extremities  manifested  itself.  The  victim 
had  been  robust  and  perfectly  healthy  all  of  his  life,  except  for 
an  anal  fistqla  some  years  ago.  The  speaker  had  been  the 
family  physician,  but,  being  out  of  town,  another  doctor  was 
called,  who  reported  the  case  to  him.  He  thought  the  action 
of  the  vagus  had  been  inhibited  by  the  intense  heat,  the  man’s 
work  keeping  him  much  in  the  sun. 

Chloroform  vs.  Opium  in  Intestinal  Inflammations.— A 
short  time  after  V.’s  death,  continued  the  President,  his  son 
was  stricken  down.  After  the  first  day  or  two  of  illness  he 
complained  of  very  little  pain.  The  speaker,  accepting  the  case 
only  the  day  before  death  occurred,  found  him  quiet,  pulse 
120,  and  temperature  101°  ;  but,  though  there  was  no  pain,  ex¬ 
cept  upon  deep  pressure,  it  was  then  severe  and  the  abdomen 
was  retracted — two  bad  features.  Late  the  next  day  the  boy 
was  in  collapse,  death  soon  following.  A  post-mortem  exami¬ 
nation  revealed  the  ascending  colon  pushed  obliquely  across  the 
abdomen  by  the  greatly  distended  and  inflamed  small  intestines, 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Joub., 


218 

which  here  and  there  showed  adhesions  and  exudations  (some 
as  large  as  a  fifty-cent  piece)  about  to  undergo  organization.  In 
fact,  a  severe  general  peritonitis  had  existed,  a  pint  of  pus  being 
in  the  cavity  of  the  peritoneum. 

The  speaker  believed  the  lack  of  pain  due  to  the  amount  of 
morphine  given  by  the  physician  first  in  charge.  He  objected 
to  such  large  doses  of  the  drug,  and  mentioned  in  connection  a 
fatal  case  of  intestinal  inflammation  to  which  he  had  been 
called  at  Old  Point.  The  phssicians  called  in  before  him  had 
probably  administered  large  doses  of  morphine.  He  found  the 
man  in  collapse,  perfectly  quiet  and  indifferent.  No  amount  of 
stimulation  or  other  means  used  produced  any  reaction.  He 
believed  large  doses  of  opium  would  not  only  prevent  reaction, 
but  increase  congestion.  He  thought  the  pain  of  these  cases 
very  largely  due  to  spasm  of  the  muscular  layer  of  the  bowel, 
and  therefore  would  just  as  readily  and  much  more  safely  be 
relieved  by  chloroform  (by  inhalation  and  internally),  together 
with  stimulants. 

Dr.  Johnston  asked  if  there  was  any  debris  of  food  in  the 
colon,  particularly  about  the  caecum,  in  the  post-mortem  case 
mentioned. 

The  President  replied  that  there  was  none. 

Irritation  from  Calomel  and  Castor-oil. — Dr.  Upshur 
believed  there  was  something  back  of  the  opium  in  the  presi¬ 
dent’s  case.  He  thought  the  purgative  act;on  from  large  doses 
of  calomel  (such  as  fifteen  grains)  and  the  castor-oil  following 
it  would  add  to  the  irritation  and  congestion.  The  kind  of 
congestion  referred  to  by  the  president  would  be  aggravated  by 
opium,  but  lie  considered  the  drug  beneficial  in  passive  conges¬ 
tions,  such  as  occurred  in  the  latter  stages  of  typhoid  fever. 
He  had  been  interested  in  the  president’s  case  of  puerperal 
convulsions,  because  the  child  was  born  alive.  He  always  ex¬ 
pected  a  dead  child  after  convulsions.  The  speaker  believed  it 
the  imperative  duty  of  every  physician  to  make  periodical  ex¬ 
aminations  of  the  urine  of  pregnant  womtn  in  his  charge,  and 
to  inquire  into  the  amount  of  water  passed  per  diem  and  the 
condition  of  head  and  vision.  There  might  be  double  vision, 
intense  headache,  and  scanty  urine  without  albumin,  and  yet 
convulsions.  He  remembered  a  patient  of  his  who  complained 
of  severe  headache  two  weeks  before  confinement,  no  albumin 
being  present  and  no  impairment  of  vision.  Just  alter  comple¬ 
tion  of  labor  she  had  been  threatened  with  convulsions.  The 
prompt  and  continued  use  of  chloroform,  however,  had  warded 
off  the  attack.  The  skin  had  been  hot  and  dry.  Bromide  of 
potassium  and  pilocarpine  were  administered  in  repeated  doses, 
until  a  profuse  perspiration  was  induced,  with  relief  of  heac 
symptoms.  Examination  of  the  urine  now  showed  thirty-three 
percent,  of  albumin.  The  patient  had  made  a  complete  recovery. 
He  mentioned  another  case  in  which  he  had  had  the  same  ex¬ 
perience  with  pilocarpine.  He  knew  the  objection  to  it — that 
it  was  depressing;  but  why  object  to  it,  and  recommend  vera- 
trum  viride  ?  For  the  immediate  relief  of  convulsions  he  usee 
morphine  and  atropine  hypodermically,  besides  the  lancet  anc 
chloroform. 

Dr.  Landon  B.  Edwards  thought  that  Dr.  Upshur  had  given 
the  true  cause  why  some  physicians  had  so  many  cases  of  puer¬ 
peral  convulsions.  The  maxim  of  Dr.  Owen,  of  Lynchburg,  was: 
“Watch  the  woman  as  you  would  the  training  of  a  child.” 
Though  convulsions  did  not  always  follow  the  symptoms,  yet 
they  should  be  accepted  as  warnings. 

As  a  prominent  symptom  he  mentioned  the  morbid  appetite 
in  the  latter  stages  of  pregnancy.  First  quiet  the  alarm  of  the 
patient,  then  direct  attention  to  the  kidneys.  He,  too,  highly 
recommended  pilocarpine  if  the  patient  was  strong  enough  to 
cough  up  or  call  attention  to  the  accumulation  that  would  oc¬ 
cur  in  the  bronchial  tubes. 


Erratic  Pain  in  Labor.— Dr.  Johnston  had  been  called,  fif¬ 
teen  or  twenty  days  before  her  expected  delivery,  to  a  woman, 
the  mother  of  four  children  (good  labor  each  time),  who  com¬ 
plained  of  a  severe  pain,  paroxysmal  in  character,  occurring  on 
the  right  side  of  the  neck  and  extending  down  upon  her  chest 
to  the  margin  of  the  axilla.  The  speaker,  suspecting  the  ap¬ 
proach  of  labor,  asked  an  examination,  but  was  refused.  Early 
the  next  morning  he  was  called  again,  and  found  the  child  born. 
The  pains  had  increased  in  length  and  intensity,  the  intervals 
growing  shorter  until  there  was  suddenly  a  gush  of  waters,  the 
>irth  of  the  child  immediately  following.  The  woman  had  not 
a  single  uterine  or  abdominal  pain,  and  did  not  in  the  least  sus¬ 
pect  the  real  condition  of  affairs. 

Scirrhus  of  the  Rectum  in  a  Child  of  Thirteen  Years.— 
Dr.  Miohatjx  had  been  treating  a  child  of  thirteen  years  lor 
ulcerated  rectum  for  some  time  with  no  benefit.  He  had  de¬ 
cided  upon  an  examination  of  the  parts,  which  he  had  made  with 
the  patient  under  chloroform.  About  two  inches  above  the 
anus  he  had  found  a  band  two  inches  and  a  half  in  width 
nearly  closing  the  caliber  of  the  bowel.  It  was  hard  to  the 
touch,  but  tore  upon  pressing  the  finger  through  it.  There  was 
some  inguinal  enlargement.  Every  motion  of  the  bowelscausid 
violent  pain,  and  this  examination  induced  so  much  as  to  render 
the  use  of  opiates  necessary.  The  general  appearance  of  the 
boy  suggested  malignancy,  and  the  doctor  believed  it  such, 
though  he  had  never  seen  or  known  of  a  case  in  so  young  a  sub¬ 
ject 

Dr.  Upshur,  refusing  to  believe  in  malignancy  at  that  age, 
thought  Dr.  Michaux  would  find  that  some  previous  proctitis 
had  produced  the  band  of  lymph  present,  or  that  there  was 
some  history  of  syphilis  back  of  the  trouble,  lie  had  seen  such 
a  case  in  a  woman  of  decided  syphilitic  history,  there  bung 
acute  pain  upon  defecation.  He  had  performed  repeated  cut¬ 
tings  and  dilatations.  Her  health  had  ultimately  given  "in, 
death  following  soon.  He  would  suggest  alteratives,  such  as 
iodide  of  iron,  etc.;  and  nutritious  but  fluid  diet.  The  rectum 
might  be  washed  out  with  warm  water  and  boric  acid.  The 
pain  could  be  relieved  by  suppositories  medicated  with  cocaine 
or  enemata  of  glycerin  and  cocaine. 

Dr.  Wheat  thought  Dr.  Michaux  had  better  look  after  a 
probable  syphilitic  history.  He  related  the  histories  ot  two 
cases  of  his  own.  He  found  that  a  constitutional  treatment 
involving  potassium  iodide  particularly  gave  decided  relief. 
Though  the  trouble  returned,  this  treatment  relieved  each  time. 
He  had  no  faith  in  operative  measures  in  such  cases.  Had  tested 
that  plan. 

Dr.  Mioiiaux  had  neglected  to  say  that  the  child’s  grandfa¬ 
ther  had  died  of  cancer.  He  would,  however,  take  advantage 
of  the  encouraging  suggestions.  He  would  obtain  some  of  the 
growth  for  microscopic  examination. 

[Since  the  meeting  Dr.  Upshur  has  found,  upon  stripping  the 
little  girl  of  three  years  and  a  half  whose  condition  he  reported, 
that  there  was  a  uniform  atrophy  of  the  muscular  system.  He 
has  given  her  the  benefit  of  massage  and  electricity  for  ten 
days.  Improvement  has  manifested  itself  by  the  more  ruddy 
appearance  generally,  and  the  toning  up  of  the  muscles.] 


ROYAL  ACADEMY  OF  MEDICINE  IN  IRELAND. 

SECTION  IN  PATHOLOGY. 

Meeting  of  May  2,  1890. 

The  President,  Dr.  E.  II.  Bennett,  in  the  Chair. 

Diphtheritic  Micro-organisms. — Dr.  McWeeny  show-ed  a 
section  through  the  epiglottis  of  a  child  who  had  died  in  the 


August  23,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


Muter  Misericord iaa  Hospital  from  post-scarlatinal  diphtheria. 
The  patient  had  been  admitted  in  the  desquamation  stage 
of  scarlatina  suffering  from  a  bad  throat  and  albuminuria. 
After  death  the  mucous  membrane  of  the  upper  part  of  the 
larynx  was  found  coated  with  a  thin  layer  of  greenish-grav 
exudation. 

The  sections  exhibited  showed  numerous  micro-organisms 
in  irregular  masses,  and  also  scattered  through  the  almost 
structureless  membranous  exudation.  Some  of  these  were  cocci, 
others  bacilli;  the  cocci  were  scattered  or  in  pairs,  the  bacilli 
were  smaller  in  size  than  the  Klebs-Loppler  diphtheria  bacillus, 
and  were  certainly  not  the  same  species,  as,  in  addition  to  the 
difference  in  size,  they  also  differed  in  the  fact  that  the  bacillus 
found  by  Dr.  McWeeny  stained  readily  by  Gram’s  method, 
whereas  the  Klebs-Loppler  organisms  was  at  once  decolorized 
by  iodide  of  potassium.  Oornil  and  Babes  also  described  organ 
isms  found  in  cases  of  pseudo-diphtheritic  laryngitis  after  scar¬ 
latina,  but  they  seemed  to  have  found  chiefly  cocci. 

Dr.  McWeeny  also  showed  a  cover-glass  preparation  of  a 
pure  culture  of  the  Klebs-Loppler  diphtheria-bacillus  showing 
the  so-called  “  involution  forms,”  and  referred  to  the  recent  re* 
searches  of  Spronck  into  the  subject,  which  had  quite  estab¬ 
lished  its  pathogenicity.  A  sterile  filtrate  of  a  pure  culture 
would  cause  paralysis  closely  resembling  the  metadiphtheritic 
in  the  human  subject,  and  also  albuminuria  in  rabbits. 

Multiple  Abscesses  of  the  Liver. —Dr.  Joseph  Redmond 
submitted  a  case  of  multiple  small  abscesses  of  the  liver. 

Mrs.  E.,  a  married  woman,  was  admitted  into  the  Mater 
Misericordise  Hospital  on  the  27th  of  February,  1890.  The  pa¬ 
tient  was  anaemic,  wasted,  and  somewhat  jaundiced  in  appear¬ 
ance.  She  complained  of  severe  pain  over  the  liver,  and  stated 
that  she  suffered  from  gall-stones.  Her  stomach  was  irritable, 
no  food  having  been  retained  for  some  days,  the  vomited  mat' 
ters  yellow  and  bitter  to  the  taste.  The  bowels  were  consti 
pated,  and  the  last  motions  observed  were  somewhat  light  in 
color.  Her  tongue  was  furred;  temperature,  98°;  pulse,  100; 
respirations,  24.  The  liver  was  enlarged  and  tender  on  percus 
sion.  The  spleen  was  also  enlarged,  and  could  be  felt  below  the 
ribs.  Some  days  after  admission  she  suffered  from  rigors :  tern 
perature,  103°  ;  pulse,  148 ;  respirations,  36  ;  signs  of  pleuritis 
)eing  detected  over  left  bases.  The  patient  died  on  the  12th  of 
March. 

The  post-mortem  was  made  by  Dr.  McWeeny.  The  right  and 
eft  pleural  cavities  showed  evidence  of  acute  inflammation 
the  liver  was  enlarged;  numerous  small  abscesses  were  de 
ected,  m<>re  especially  in  the  left  lobe.  The  gall-bladder 
vas  full  of  small  angular  calculi.  The  cystic  duct  was  thick- 
med  but  patent.  The  common  bile  duct  was  blocked  by  a 
•aleulus  lying  immediately  behind  the  duodenal  mucous  mem¬ 
brane. 

Dr.  McWeeny  said  that  he  suggested  the  somewhat  wild 
ivpothesis  that  the  gall-stones  might  have  caused  ulceration  of 
he  common  bile  duct,  and  that  micro-organisms  might  have 
nade  their  way  up,  in  spite  of  the  supposed  antiseptic  action  of 
e  bile,  and  spread  into  the  ordinary  liver  substance;  but  his 
lehef  was  that  the  case  was  pyaemia. 

The  President  said  he  regarded  the  abscesses  in  question  as 

ysemic. 

Dr.  Redmond,  in  reply,  said  he  had  no  remark  to  make  save 
hat  the  gall-bladder  contained  no  pus. 

Round-celled  Sarcoma  of  the  Testis.  — Dr.  McWeeny 
lowed  a  tumor  of  the  testis  removed  at  the  Mater  Misericordite 
ospital  in  January  last  by  Mr.  Chance.  The  patient,  aged 
ut  thirty,  had  first  noticed  the  swelling  about  two  years 
eviously ,  and  it  had  since  increased  gradually  and  painlessly 
ith  absence  of  testicular  sensation.  No  tubercular  or  syphi¬ 


219 


litic  history  of  patient  or  family;  no  history  of  injury.  The 
testis  was  enlarged  to  the  size  of  a  medium-sized  orange;  its 
shape  was  globular;  its  consistency  hard.  On  section,  the  sub¬ 
stance  was  white,  mottled  with  yellowish  patches,' which  looked 
to  the  naked  eye  like  caseated  portions,  and  which  on  micro¬ 
scopic  examination  were  fatty  degenerated  and  almost  devoid 
of  structure.  There  was  no  trace  of  tubercular  new  growth. 
The  white  tissue  consisted  of  cells  and  a  stroma.  The  cells  were 
largish,  oval,  uni-nucleated,  and  offered  little  or  no  variation  in 
size  or  shape.  They  did  not  lie  in  actual  contact,  but  each  was 
separated  from  its  neighbor  by  a  small  quantity  of  homogeneous 
intercellular  substance.  Their  characteristics  were,  on  the 

whole,  those  of  the  connective  tissue  rather  than  of  the  epithe¬ 
lial  type. 

. Tlie  stroma  was  trabecular  in  character,  the  main  trabecula 
being  comparatively  thick  and  running  a  straight  course 
through  a  considerable  part  of  the  sections.  From  them  were 
given  off  more  delicate  bands,  which  in  their  turn  gave  origin 
to  s'  ill  more  delicate  ones  —  the  same  structure  prevailing 
throughout— viz.,  round  and  spindle-shaped  nuclei  of  various 
sizes,  with  little  or  no  approach  to  the  formation  of  fibrous  tis¬ 
sue.  The  ultimate  trabecula  consisted  of  but  one  or  two  rows 
of  spindle  cells  placed  side  by  side  and  end  to  end.  They  were 
clearly  distinguishable  from  the  oval  cellular  elements  above 
mentioned,  which  lay  in  groups  of  varying  size— about  a  dozen 
together  as  a  rule— in  the  ultimate  meshes  of  the  stroma.  He 
was  in  some  doubt  as  to  whether  the  stroma  did  not  represent 
that  which,  in  the  normal  testis,  starting  from  the  mediastinum, 
runs  between  the  lobules— in  which  case  it  would  seem  to  have 
increased  pari  passu  with  the  tumor,  or  whither  it  was  of  en¬ 
tirely  new  formation,  in  which  case  the  specimen  would  have 
to  be  looked  upon  as  one  of  alveolar  sarcoma— a  neoplasm  of 
some  rarity  in  that  situation. 

Dr.  Patteson  said  that,  judging  from  the  general  distribu¬ 
tion  of  the  stroma  and  the  character  of  the  cells,  this  disease 
was  much  more  distinctly  a  carcinoma  than  a  sarcoma. 


SECTION  IN  SURGERY. 

Meeting  of  May  9 ,  1890. 

Mr.  Edward  Hamilton,  F.  R.  C.  S.,  in  the  Chair. 

The  Surgery  of  the  Brain. — Mr.  Thornley  Stoker  read  a 
paper  on  two  cases  of  brain  disease  on  which  he  had  operated 
during  the  session. 

The  first  he  detailed  was  treated  jointly  by  Dr.  O’Carroll 
and  himself.  It  was  a  case  of  abscess  in  the  right  temporal  lobe, 
depending  on  disease  of  the  ear.  Pain,  retraction  of  the  head, 
and  right  anosmia  were  the  leading  brain  symptoms.  The  pa¬ 
tient,  a  girl  of  eighteen,  was  dying  from  pain,  and  operation 
was  determined  on,  although  symptoms  did  not  show  clearly 
whether  the  temporal  lobe  or  the  cerebellum  was  the  seat  of 
disease.  On  March  9,  1890,  the  brain  was  exposed  with  the 
view  of  exploring  the  cerebellum,  if  pus  should  not  be  found  in 
the  temporal  lobe. 

The  trephine  opening  was  placed,  with  the  purpose  of  ex¬ 
posing  the  second  temporal  convolution,  with  its  center  an  inch 
and  a  quarter  behind  the  external  meatus  and  an  inch  and  a 
half  above  this  base  line.  Mr.  Thornley  Stoker  spoke  of  the 
mistake  made  by  Mr.  Barker  in  placing  the  point  to  expose  the 
second  convolution  too  low  down — viz.,  an  inch  and  a  quarter 
above  the  base  line — and  he  demonstrated,  by  a  number  of  Pro¬ 
fessor  Cunningham’s  models  and  drawings,  kindly  lent  for  the 
occasion,  that  the  point  indicated  by  Mr.  Barker  could  only  ex¬ 
pose  at  the  highest  the  inferior  convolution,  and  might  even 
endanger  the  lateral  sinus.  He  expressed  his  intention  in  future 
of  operating  an  inch  and  three  quarters  above  the  base  line,  at 


220 


‘ proceedings  of  societies. 


[N.  Y.  Med.  Jodr. 


whicli  height  only  there  would  be  reasonable  certaiuty  of  expos 
ing  the  second  convolution. 

Nine  exploratory  punctures  were  made  in  different  direc¬ 
tions,  and  on  the  ninth,  at  a  distance  of  an  inch  and  a  half  from 
the  surface  of  the  brain,  pus  was  found,  to  the  amount  of  two 
to  three  drachms,  lying  above  the  tentorium,  in  a  direction 
downward,  inward,  and  backward  from  the  trephine  opening, 
at  the  junction  of  the  under  surfaces  of  the  temporal  and  occipi¬ 
tal  lobes. 

The  patient,  who  bad  passed  through  several  dangerous  and 
interesting  periods  since  operation,  was  now,  three  months  after 
the  trephining,  alive  and  doing  well.  And,  although  she  had 
lost  several  drachms  of  brain  matter  by  sloughing  and  by  the  le 
moval  of  a  hernia  cerebri,  she  suffered  no  paralysis  or  impair¬ 
ment  of  any  kind,  the  sense  of  smell  being  restored  and  all  her 
symptoms  relieved. 

The  second  case,  treated  jointly  by  Dr.  Nugent  and  Mr. 
Tliornley  Stoker,  was  one  of  a  spindle-celled  sarcoma  of  small 
size  situated  in  the  superior  and  back  part  of  the  right  parietal 

lobe  of  a  man  aged  forty-two. 

It  had  given  rise  to  tonic  spasms  of  the  left  side,  commenc¬ 
ing  in  the  leg  and  gradually  invading  the  trunk,  upper  extremi¬ 
ty,  and  face.  Spasm  was  followed  by  paralysis,  occurring  in 

the  same  order  from  below  upward. 

The  patient  was  operated  on,  the  leg  and  arm  centers  being 
exposed,  but  the  tumor  was  not  discovered,  as  it  lay  at  the  ex¬ 
treme  back  of  the  leg  center,  and  was  of  the  same  consistence 
as  the  brain  substance,  so  that  instruments  passed  through 
it  without  resistance.  The  removal  of  pressure  afforded 
by  the  operation  gave  temporary  relief.  I  he  patient,  who 
was  nearly  comatose  and  quite  hemiplegic,  recovered  con¬ 
sciousness  and  partial  power  in  the  side,  but  died  three  weeks 
afterward. 

The  chief  points  of  interest  in  the  case  were:  1.  The  irregu¬ 
lar  position  of  the  spasms,  which  sometimes  engaged  the  upper 
extremity  without  the  lower,  although  the  tumor  proved  to  be 
remote  from  the  arm  center.  Mr.  Stoker  dwelt  on  the  matter 
of  what  he  termed  “referred”  pressure  as  an  important  and 
confusing  factor  in  such  cases.  2.  That  the  position  of  the 
tumor  pointed  to  the  extension  backward  of  the  leg  center  into 
what  had  been  regarded  as  a  doubtful  region.  3.  That  the 
case  showed  the  leg  center  to  be  behind  that  for  the  thigh.  4. 
The  absence  in  this  instance  of  three  of  the  four  classical  symp¬ 
toms  of  brain  tumor— viz.,  optic  neuritis,  fixed  headache,  and 
vomiting;  only  the  fourth,  hemispasm,  being  present. 

Dr.  Birmingham  communicated  a  preliminary  report  of  an 
investigation  which  he  was  carrying  on  into  the  surgical  anato 
my  of  the  parts  engaged  in  the  operations  of  trephining  in 
mastoid  and  tympanic  disease.  The  following  were  the  chief 
objects  kept  in  view  in  the  investigation:  1.  The  anatomy  of 
Mr.  "Wheeler’s  operation,  which  opened  the  cranial  cavity  and 
the  mastoid  cells  at  the  same  time  by  one  trephine  hole.  2. 
The  exact  relation  of  the  mastoid  autrum  to  the  surface.  3. 
The  position  of  the  lateral  sinus,  how  to  find  and  how  avoid  it. 
4.  Whether  there  was  (anatomically)  any  danger  in  opening  the 
mastoid  cells  immediately  behind  the  meatus.  Many  specimens 
were  shown  illustrating  the  points  considered,  and  a  full  report 
was  promised  in  a  short  time. 

The  Chairman  observed  that  before  brain  surgery  could 
make  any  steady,  useful  advance  there  must  be  something 
like  anatomical  certainty;  and  he  regarded  the  contribu- 
tions  of  Mr.  Stoker  and  Dr.  Birmingham  as  valuable  anatomical 

data. 

Mr.  Patterson  said  he  had  himself,  like  Mr.  Stoker,  proved 
the  unreliability  of  Barker’s  lines.  lie  had  had  a  case  in  St 
Vincent’s  Hospital  in  which  it  was  decided  to  trephine  the 


temporal  lobe  of  the  brain;  and  taking  a  quarter  of  an  inch 
higher  than  Barker’s  line  in  order  to  make  perfectly  sure,  he 
had  had  great  difficulty  in  removing  the  disc  of  bone,  and  when 
he  succeeded  he  found  that  the  lateral  sinus  was  exposed  and 
occupying  one  third  of  the  available  space,  thus  showing  clearly 
that  Barker’s  lines  were  unreliable.  A  limited  post-mortem 
examination  proved  that  the  diagnosis  was  unfortunately  incor¬ 
rect,  and  that  the  case  was  one  of  long-standing  otorrhcea;  but 
the  course  adopted  seemed  to  be  the  only  possible  one  of  saving 
life.  However,  as  applicable  to  the  surgery  of  the  brain,  the 
point  was  that  the  lines  of  demarkation  chosen  resulted  in  ex¬ 
posing  about  half  an  inch  of  the  upper  border  of  the  inferior 
temporo- sphenoidal  convolution. 

Mr.  Tobin,  referring  to  Dr.  Birmingham’s  observations,  re¬ 
called  Mr.  Wheeler’s  remark  on  reading  his  communication  to 
the  section  as  being  to  the  eftect  that  the  opening  which  he 
made  was  one  from  which  the  tympanum  might  be  reached,  and 
not  one  for  the  purpose  of  exposing  the  tympanum.  As  re¬ 
garded  Mr.  Stoker's  communication,  he  asked,  assuming  in  the 
first  case  detailed  that  the  abscess  was  secondary  to  caries  of  the 
temporal  bone,  whether  it  would  not  have  been  advisable,  after 
reaching  the  abscess,  to  adopt  means  for  getting  rid  of  the  pri¬ 
mary  disease,  so  that  further  secondary  abscesses  might  not 
form.  Thus,  a  secondary  trephining  operation  might  be  adopt¬ 
ed  for  the  primary  disease.  Another  moot  point  was  as  to  the 
advisability  of  using  the  aspirator  to  empty  a  pus  cavity  of  the 
brain,  the  tendency  of  the  structure  being  to  break  down  and, 
from  the  use  of  the  aspirator,  to  give  rise  to  more  pus. 

Mr.  Stoker,  in  reply,  was  glad  to  find  that  his  obseivations 
had  been  indorsed  by  Mr.  Patterson’s  experience.  There  could 
be  no  doubt  that  an  examination  of  Professor  Cunningham’s 
diagrams  and  casts  would  show  that,  instead  of  going  an  inch 
and  a  quarter  above  the  horizontal  line,  as  Barker  recommend¬ 
ed,  or  an  inch  and  a  half,  as  he  himself  had  gone  in  one  of  the 
cases  under  consideration,  the  operator  might  go  an  inch  and 
three  quarters.  He  cordially  agreed  with  Mr.  Tobin  s  view  as 
to  the  desirability  of  treating  the  primary  disease ;  and  in  op¬ 
erating  in  the  case  of  the  temporal  abscess,  he  was  prepared  to 
trephine  the  mastoid  process  with  that  object,  but  he  did  not 
find  it  desirable  for  several  reasons.  He  looked  forward  to  do¬ 
ing  if,  as  at  present  the  ear  was  suppurating,  and  required  to  he 
washed  out  twice  daily  with  corrosive-sublimate  solution.  It 
was  obviously  proper  to  remove  the  cause  of  the  disease,  as  well 
as  the  secondary  evidence  of  it.  As  regarded  the  use  of  the  as¬ 
pirator,  the  case  was  one  of  the  first  in  which  he  operated  for 
an  abscess  in  the  brain,  and  he  used  the  aspirator,  but  with  the 
result  that  he  made  up  his  mind  that  he  ought  not  to  use  it 
again  ;  that  it  was  calculated  to  do  violence  to  structures,  and 
that  it  was  totally  unnecessary.  The  brain  exercised  such  press¬ 
ure  that  as  soon  as  the  abscess  was  opened  it  closed  the  walls 
together,  and  the  pus  was  pushed  out  with  as  much  force  as  was 
desirable.  So  that  the  aspirator  was  unnecessary  and  might  he 
injurious. 

Dr.  Birmingham,  in  reply  to  Mr.  Tobin’s  remark,  said  he 
adopted  Mr.  Wheeler’s  published  description  as  the  basis  of  hie 
observations. 

SECTION  IN  MEDICINE. 

Meeting  of  May  16 ,  1890. 


Dr.  JonN  William  Moore  in  the  Chair. 

Acute  Confusional  Insanity.— Dr.  Conolly  Norman  rea< 
a  paper  on  acute  confusional  insanity.  He  pointed  out  that  thi: 
form  of  psychoneurosis  occupied  an  intermediate  place  betweei 
acute  mania  and  the  acute  dementia  of  the  older  classificator; 
schemes,  and  contained  a  very  large  number  of  cases.  It  wa 
characterized  by  engagement  of  consciousness  in  the  form  o 


August  23,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


221 


lream-like  confusion,  together  with  hallucinatory  disturbance, 
t  was  interesting  to  others  than  specialists,  because  it  was  the 
orm  of  mental  disturbance  most  often  associated  with  diseases 
lot  primarily  affecting  the  nervous  system.  Puerperal,  post- 
ebrile,  rheumatic,  phthisical,  and  other  varieties  of  insanity 
lepending  on  general  diseases  commonly  took  this  form.  Dr. 
Borman  dwelt  upon  its  frequency  in  alcoholic  cases,  and  pointed 
>ut  that  the  peculiar  mental  disturbance  described  byKorsakow, 
loss,  and  Viglesworth  as  accompanying  alcoholic  neuritis  was 
i  variety  of  acute  confusional  insanity.  He  detailed  a  number 
if  illustrative  cases,  including  several  alcoholic  ones,  and  de 
ended  the  differentiation  of  this  affection  on  etiological  and 
.rognostic  grounds,  as  well  as  because  the  distinction  tended  to 
Qore  accurate  clinical  description. 

Dr.  Moloney  inquired  whether,  firstly,  in  the  younger  per 
ons  whose  cases  had  been  detailed,  the  state  of  the  heart  and 
idneys  had  been  examined  ;  and,  secondly,  in  the  older  persons, 
articularly  in  the  case  of  the  woman  who  fancied  a  black  man 
arae  into  her  room  at  night,  whether  there  had  been  any  uter- 
ae  trouble,  or  the  climacteric  time  had  been  reached.  He  hac 
imself  observed  a  considerable  number  of  cases  in  which,  at 
climacteric  time  of  life,  there  was  confusion  as  to  dates  anc 
laces,  and  also,  most  commonly  in  cases  of  the  melancholic 
ppe,  delusion  of  persecution  by  unseen  agents.  One  woman’s 
isanity  commenced  with  the  hallucination  that  somebody  was 
utside  at  the  gate  shouting  that  she  was  too  fond  of  going  into 
er  father’s  bedroom  (her  father  was  suffering  from  bladder 
•ouble)  and  that  such  conduct  was  indecent.  At  the  outset  she 
xhibited  maniacal  excitement,  and  for  several  months  she  was 
ither  confused  in  identifying  those  about  her,  being  doubtful 
hether  her  nurse  of  to-day  was  the  nurse  in  charge  of  her  the 
revious  day,  and  doubtful  also  of  his  (Dr.  Moloney’s)  name, 
hile  identifying  him  sometimes  by  his  boots  and  at  other 
mes  by  his  hat. 

Dr.  Norman,  in  reply,  said  there  was  no  heart  or  kidney 
fection  in  the  younger  patients;  at  least,  though  anxiously 
arched  for,  none  was  discovered.  The  woman  who  came  to 
u’olin  to  consult  her  lawyer  was  aged  fifty,  and  had  ceased  to 
enstruate  at  forty-seven;  but  there  was  no  indication  of  uter- 
e  trouble.  He  was  inclined  to  think  that  to  the  type  which 
>  had  described  belonged  the  case  mentioned  by  Dr.  Moloney, 
ises  of  the  kind  seemed  to  vary  in  character  between  mania 
id  melancholia,  giving  rise  to  difficulty  of  classification;  but 
the  asylum  such  classification  was  not  so  important  for  pur¬ 
ges  of  treatment  as  to  comply  with  the  desire  of  the  Psycho- 
gical  Society,  there  being  what  was  called  in  asylum  slang  a 
refractory  ward,”  into  which  cases  that  would  not  go  any- 
here  else  were  inevitably  put. 

Medicated  Soaps. — Dr.  Walter  G.  Smith  made  a  coinmn- 
cation  upon  medicated  soaps.  He  drew  attention  to  the  dif- 
•ences  in  preparation  and  properties  of  soda  and  potash 
3ps,  and.  pointed  out  the  injurious  effects  upon  the  skin  of  an 
cess  of  alkali,  which  not  only  removed  the  greasy  dirt  but 

•  o  robbed  the  skin  of  its  natural  fat.  This  was  derived  from 
0  sources  (a)  the  glands,  sebaceous  and  coil  glands  ;  (J)  the 

"idin  of  the  epidermis.  Over-fatty  (super-fatted)  soaps — i.  e ., 
•ataining  some  unsaponified  fat — represented  a  real  advance 
1  the  preparation  of  good  soaps  for  medicinal  use.  The  com- 
! sition  of  “Grundseife”  (basis-soap)  was:  Beef  suet,  59'3  per 
<rJt.;  olive-oil,  7-4  per  cent. ;  soda  lye,  38°  Beaumd,  22-2  per 
( ‘f  ;  potash  lye,  11 -1  per  cent.  This  could  be  medicated  by  a 
■iety  of  drugs — e.  g.,  resorcin,  ichtbyol,  sulphur,  mercurials, 

*  •  The  detergent  action  of  soap  was  explained,  and  the 
'ales  of  using  medicinal  soaps  were  commented  upon. 

Hr.  Mc\  eagh  said  that  to  dermatologists  medicated  soaps 
^  1  many  recommendations  for  the  treatment  of  parasitic  dis¬ 


eases;  and  he  expressed  great  faith  in  corrosive-sublimate  soap 
for  eczema  in  children,  rubbing  it  in  and  then  putting  on  a  thin 
gauze. 

Dr.  S.  M.  Thompson  inquired  whether  salicylic  acid  might 
be  used  in  soap  tor  eczema  of  the  head  in  children  without 
causing  irritation. 

Dr.  William  Stoicer,  having  regard  to  the  limitation  of  the 
medicated  soaps  chiefly  to  the  soaps  composed  of  the  fatty 
acids  in  which  the  alkali  had  replaced  the  glycerin,  inquired  as 
to  lithium  soap ;  secondly,  in  view  of  the  explanation  of  the 
action  of  soap  on  the  hands  in  the  ordinary  method  of  use, 
whether  it  was  equally  true  of  the  super-fatty  soaps  that  there 
was  free  alkali  in  free  dilution;  and  thirdly,  whether  it  was 
competent  in  the  glycerin  soap  to  retain  much  of  the  glycerin 
as  used  in  commerce,  or  was  it  only  “glycerin  ”  so  called  on  the 
lucus  a  non  lueendo  principle.  He  had  been  informed  by  a 
Dublin  manufacturer,  on  the  surface  of  whose  soap  he  noticed 
globules,  that  almost  all  the  glycerin  was  retained  in  the  soap. 

The  Chairman  3aid  he  had  seen  an  ointment  containing  ten 
grains  of  salicylate  to  the  ounce  used  even  on  children  with¬ 
out  deleterious  effect.  As  regarded  the  question  whether  gly¬ 
cerin  was  really  present  in  so-called  “glycerin  soap,”  the  sweet 
taste  of  that  soap  was  conclusive  evidence  of  its  presence. 

Dr.  Smith,  in  reply,  said,  as  regarded  Dr.  Thompson’s  in¬ 
quiry,  that  the  question  was  one  for  the  practitioner’s  judg¬ 
ment.  As  to  Dr.  Stoker’s  questions,  he  had  no  knowledge  of 
lithium  soap.  The  transparent  glycerin  soap  contained  a  large 
amount  of  glycerin.  He  had  not  had  time  to  make  an  analysis 
of  the  vinola  soap.  There  was  no  doubt  that  the  use  of  medi¬ 
cated  soaps  represented  a  distinct  advance  in  the  methods  of 
treatment. 

Old  Fallacies  revived  under  New  Names.— Dr.  T.  More 
Madden  read  a  paper  on  the  recent  revival  under  new  names 
of  some  old  fallacies  bearing  on  medicine. 

A  recurrence  of  epidemic  empiricisms  widely  affecting  the 
practice  of  physic  had  been  often  observed  in  the  history  of  our 
art.  These  popular  beliefs,  however  fallacious  their  foundation, 
generally  died  hard,  and,  after  a  period  of  oblivion,  were  not  in¬ 
frequently  resuscitated.  Thus  at  present  we  had  at  least  “  three 
Richmonds  in  the  field,”  where  medical  science  and  its  counter¬ 
feits  were  in  close  competition,  and  where  the  prize  of  epheme¬ 
ral  success  was  perhaps  most  frequently  awarded  to  the  latter. 
These  rival  popular  therapeutic  theories,  methods,  or  “  fads  ” 
included  hypnotism,  massage,  aud  faith-healing,  each  of  which 
might  be  considered  as  being  in  some  measure  illustrative  of  the 
revivalism  just  referred  to,  with  the  exception  of  the  latter. 
Faith-healing  rested  on  religious  belief,  and  therefore,  however 
erroneous  or  fanatical  it  might  be,  it  could  not  be  properly 
classified  in  the  medical  journal.  Hypnotism  and  massage  could 
claim  no  such  exemption  from  full  discussion  and  criticism,  al¬ 
though  in  some  respects  it  might  perhaps  be  difficult  to  treat 
their  pretensions  seriously.  First,  with  regard  to  hypnotism. 
Jnder  that  terra  had  apparently  been  recently  confounded  and 
intermixed  the  resuscitated  phenomena  of  two  essentially  dis¬ 
tinct  conditions — namely,  that  modification  of  animal  magnetism 
with  which  the  name  of  the  late  Mr.  Braid,  of  Manchester,  was 
formerly  associated — i.  e.,  Braidism  ;  and,  secondly,  with  this, 
in  some  instances,  were  now  conjoined  the  revival  in  a  new 
guise  of  the  older  illusions  of  mesmerism.  Of  the  possibility, 
in  many  cases,  of  producing  by  tbe  former  a  state  of  concentra¬ 
tion  or  anaesthesia  in  which  surgical  operations  might  be  pain¬ 
lessly  performed  there  could  be  no  question.  The  expediency 
or  prudence  of  availing  ourselves  of  this  power,  especially  in  the 
cases  in  which  it  might  most  commonly  be  exercised — namely, 
in  the  case  of  patients  of  abnormal  mental  or  nervous  constitu¬ 
tion,  such  as  those  of  hysterical  temperament,  of  whom  the 


proceedings  of  societies. 


[N.  Y.  Mtcr>.  Joor., 


222 


number,  male  as  well  as  female,  was  larger  than  was  generally 
supposed— was  another  question,  and  one  which  Dr.  Madden 
thought  should  be  unhesitatingly  answered  in  the  negative,  for 
various  reasons,  physical  and  moral,  which  he  assigned.  With 
regard  to  the  still  more  objectionable  and  more  remarkable  al¬ 
leged  powers  by  which,  as  had  been  again  recently  asserted,  the 
skilled  operator  in  this  occult  art  might,  at  his  will  or  by  his 
mental  suggestion,  or  induction  of  a  subtile  nerve  force,  some¬ 
what  akin  in  its  supposed  action  to  the  magnetic  influence,  con¬ 
trol  the  thoughts  and  acts  of  the  hypnotized  subject,  and  even 
thus  modify  the  course  or  arrest  the  progress  of  disease— these, 
although,  as  just  said,  very  commonly  confounded  with  Braid- 
ism,  were  obviously  traceable  to  the  older  illusions  of  animal 
magnetism  or  of  mesmerism,  of  which  they  were  substantially 
the  resuscitation  in  a  new  guise.  The  real  marvel  connected 
with  such  assertions  appeared  to  be  the  fact  that  at  the  present 
day  some  men  of  whose  sincerity  and  sanity  there  could  be  no 
possible  question  should  claim  these  powers,  and  that  others 
similarly  circumstanced  should  admit  the  possibility  of  theii  in¬ 
fluencing  any  persons  save  those  of  abnormal  nervous  or  mental 
constitution,  more  especially  the  oftentimes  semi-insane  victims 
of  hysteria.  A  priori ,  it  might  well  seem  incredible  that  pre¬ 
tensions  of  this  kind  should  be  gravely  advanced  and  accepted 
in  the  last  decade  of  the  nineteenth  century,  were  it  not  that 
this  age,  so  often  skeptical  of  the  truths  of  Divine  Revelation, 
had  afforded  so  many  illustrations  of  its  credulity  in  the  illusions 
of  pseudo-scientific  enthusiasm;  and  that  at  the  present  time 
we  had  abundant  contemporaneous  evidence  of  a  widespread 
credence  in  the  alleged  and  incomprehensible  powers  of  animal 
magnetism,  as  asserted,  under  the  name  of  hypnotism. 

To  deny  in  toto  the  possibility  of  phenomena  to  the  actuality 
of  which  so  many  witnesses  had  testified,  merely  because  they 
were  apparently  at  variance  with  common  sense  and  wholly  inex¬ 
plicable  in  the  present  state  of  our  knowledge,  might  perhaps  be 
thought  unphilosophieal.  Hence,  whatever  our  own  opinion 
might  be  on  this  subject,  we  must  be  content  to  leave  its  final 
decision  for  the  eventual  judgment  founded  on  the  better  know  1- 
edge  and  experience  of  the  profession.  Whatever  that  verdict 
might  be,  it  could  not  be  very  long  delayed. 

The  painful  exhibitions  of  so-called  hypnotic  influence  de¬ 
scribed  in  recently-published  reports  of  certain  proceedings  on 
the  Continent,  as  well  as  the  spectacles  of  either  fanatical  en¬ 
thusiasm  or  else  of  charlatanism  acting  on  acquiescent  imbe¬ 
cility  which  he  had  himself  more  than  once  witnessed  in  the 
performances  of  professors  of  animal  magnetism,  could  haidly 
be  spoken  of  from  any  point  of  view  save  in  terms  that  might 
perhaps  be  deemed  offensive  by  those  who  were  believers  in 
these  powers.  Hence  he  would  forbear  any  further  reference 
to  them.  For,  as  the  learned  Fuller  had  long  since  observed: 

“  I  meddle  not  with  these  Bedlam  phancies,  all  whose  conceits 
are  antiques,  but  leave  them  for  the  physician  to  purge  with 
hellebore.” 

Dr.  Madden  then  discussed  the  pretensions  of  massage  to 
novelty,  and  entered  at  considerable  length  into  the  history  of 
some  persons  whose  methods  of  cure,  as  successfully  employed 
in  Ireland  so  far  back  as  the  days  of  the  Commonwealth,  and 
subsequently  in  the  time  of  Charles  II,  were,  he  thought,  largely 
anticipatory  of  the  present  practices  of  massage,  as  well  as 
those  of  animal  magnetism  or  hypnotism. 

Whether  such  phenomena,  ancient  or  modern,  had  any 
foundation  in  actuality  it  would  be  difficult  as  yet  to  pronounce. 
There  were  more  things  in  heaven  and  earth  than  were  dreamed 
of  in  our  philosophy,  and  these  might  be  of  them.  At  any  rate 
it  might  be  interesting  to  bear  in  mind  the  success,  in  one  re¬ 
spect  at  least,  that  rewarded  the  original  professor  of  animal 
magnetism,  whose  career  might  possibly  be  some  encourage- 


ment^to  the  modern  practitioners  of  hypnotism,  and  to  remind 
them  that  upward  of  a  century  ago  somewhat  similar  preten¬ 
sions  were  made  by  Mesmer,  whose  thesis  On  the  Influence  of 
the  Planets  on  Human  Bodies  was  published  in  Vienna  in  1776. 
Whether  Mesmer  appropriated  the  views  previously  held  on 
this  subject  by  the  Viennese  astronomer,  Hehl,  as  the  latter 
maintained,  or  not,  now  mattered  little.  The  conti oversy  be¬ 
tween  the  learned  professor  of  unsavory  name  and  the  reputed 
father  of  animal  magnetism  was  a  very  animated  one,  and  con¬ 
tained  some  curious  matter.  1  he  result  of  the  discussion  was 
Mesmer’s  retirement  from  Vienna  to  Paris,  where,  two  years 
later,  in  1778,  he  reappeared  on  the  stage  as  the  then  reigning 
lion  of  Parisian  society  as  well  as  the  most  successful  practi¬ 
tioner  of  his  occult  art— from  both  of  which  positions  his  fall 
was  as  signal  and  as  rapid  as  his  rise  thereto  had  been.  W  bile 
the  brief  sunshine  of  his  popularity  lasted,  however,  Mesmer, 
who  apparently  had  always  a  shrewd  eye  to  the  main  chance, 
acted  on  the  old  adage  so  successfully  that  within  a  couple  of 
years  he  realized  by  his  practice  in  Paris  a  fottune  of  some 
340,000  livres,  and  before  the  publication  of  the  adverse  report 
of  the  commission  appointed  to  investigate  this  question  man¬ 
aged  to  sell  the  secret  of  his  method  for  a  sum  equivalent  to 
fourteen  thousand  pounds.  The  modern  professor  of  animal 
magnetism  might  well  regret  the  palmy  days  of  the  V  illo 
Cour. 

Dr.  A.  N.  Montgomery  said,  with  reference  to  massage,  that 
it  was  a  pity  Dr.  Madden  had  not  attended  the  previous  meet¬ 
ing  of  the  Section,  at  which  an  exhaustive  paper  on  the  subject 
was  read  by  Dr.  Kendal  Franks,  who  traced  its  origin  to  many 
years  prior  to  the  Christian  era,  and  advocated  taking  the  treat¬ 
ment  out  of  the  hands  of  quacks  and  charlatans  and  putting  it 
on  a  scientific  basis,  which  he  had  explained.  It  was  also  to  be 
regretted  that  Dr.  Madden,  in  sending  in  the  title  of  his  paper, 
had  not  specified  the  fallacies  which  he  intended  to  discuss. 

Dr.  Norman  said  that  about  massage  he  knew  little :  but 
since  it  had  been  prescribed  by  some  enthusiasts  in  late  years 
as  a  universal  remedy  in  mental  diseases,  he  fully  shared  in  the 
terms  of  contempt  and  scorn  with  which  Dr.  Clinton,  of  Edin¬ 
burgh,  had  referred  to  the  curative  powers  alleged  for  it  in 
mental  disease.  That  mesmerism  had  taken  the  course  it  did 
was  unfortunately  due  to  the  attitude  adopted  toward  it  by  the 
medical  profession  in  the  time  of  Mesmer — denying  the  truth  of 
certain  things  which  were  undoubted  facts.  But  since  the  day? 
of  Heidenheim,  and  since  Charcot’s  investigations,  the  faculty 
looked  upon  what  was  now  generally  called  hypnotism  in  s 
more  serious  way.  That  there  was  some  truth  in  the  phenome¬ 
non  everybody  knew,  but  that  hypnotism  had  the  therapeutic 
effects  ascribed  to  it,  he  agreed  with  Dr.  Madden  was  incredible 
and  absurd.  He  had  learned  that  Charcot  was  now  withdraw¬ 
ing  from  the  practice  of  hypnotism,  conceding  that  its  certaii 
evil  effects  counterbalanced  any  good  that  might  be  expected 
Voisin,  the  author  of  a  famous  treatise  on  several  diseases  com 
mon  to  the  insane — amenorrhoea,  epilepsy,  masturbation,  lying 
thieving,  and  moral  insanity— was  under  the  delusion  that  the* 
diseases  could  be  cured  by  its  means.  It  was  almost  enough  t< 
overturn  one’s  mental  balance  to  broach  the  idea  that  moral  de¬ 
pravity  could  be  cured  through  the  agency  of  hypnotism.  A 
a  warning  of  the  danger  of  hypnotism,  Heidenheim’s  first  am 
favorite  subject  was  his  own  brother — a  fine,  active,  health 
young  man,  who,  under  the  constant  strain  of  hypnotic  exper 
ments,  fell  into  a  state  of  neuro-anaemia,  became  incapable  c 
following  his  profession,  and  had  to  take  a  holiday  of  two  yeai 
duration  before  he  recovered  his  mental  tone.  He  had  read 
recent  case  in  a  German  medical  journal  recording  the  detai 
of  a  woman  who  fell  into  the  hands  of  a  hypnotic  quack  an 
was  hypnotized  into  a  state  of  acute  confusional  insanity. 


August  23,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


223 


geporis  on  tire  progress  of  Ulcbirine. 


ANATOMY. 

Bt  MATTHIAS  L.  FOSTER,.  M.  D. 

Congenital  Sacculations  and  Cystic  Dilatations  of  Veins. _ These 

conditions  have  from  ancient  times  been  generally  recognized  in  con¬ 
nection  with  varicose  disease,  but  have  received  very  little  attention  as 
distinct  affections.  The  reason  for  this  is  twofold:  First,  because  they 
frequently  give  rise  to  no  trouble  of  any  kind ;  and  second,  because 
when  symptoms  demanding  treatment  arise  their  existence  is  masked 
by  the  general  varicosity  which  coexists  in  many  cases. 

Mr.  Bennett  ( Lancet ,  April  12, 1890)  describes  three  classes  of  these 
venous  sacs  and  dilatations.  The  first  and  rarest  form  consists  of  a  dis¬ 
tinct  sac  springing  from  one  side  of  a  vein,  with  which  it  communicates 
through  a  small  opening.  This  condition  may  or  may  not  be  associated 
with  a  varicose  condition  of  the  surrounding  veins,  but  some  evidence 
of  venous  abnormity  in  the  form  of  naevus  or  varix  is  to  be  found  in 
near  or  distant  parts.  Clinically  it  presents  the  form  of  a  softish,  com¬ 
pressible  tumor,  the  connection  of  which  with  a  vein  may  more  or  less 
easily  be  demonstrated.  When  this  occurs  in  the  neck  the  patient  has 
the  power,  by  mean^  of  holding  the  breath,  to  cause  the  tumor  to  be¬ 
come  large  and  tense. 

The  second  class  consists  of  a  dilatation  at  the  point  of  entry  of  a 
tributary  vein  into  the  parent  vessel.  In  part  of  these  cases  the  proxi¬ 
mal  end  of  the  tributary  and  the  neighboring  part  of  the  recipient  are 
about  equally  involved,  and  in  part  the  tributary  is  the  more  affected, 
and  a  globular  swelling  is  produced  which  seems  to  project  from  the 
main  vessel.  This  class  seems  to  be  almost  invariably  associated  with 
varicosity  of  the  veins  in  the  immediate  neighborhood.  The  tendency 
to  dilatation  seems  to  be  congenital ;  its  development  seems  to  depend 
on  the  same  conditions  which  promote  the  development  of  ordinary 
varicosity. 

The  third  and  most  common  class  is  local  dilatation  involving  the 
whole  circumference  of  the  vein.  This  may  occur  in  any  valved  vein 
and  invariably  involves  the  portion  of  the  vein  in  the  immediate  neigh¬ 
borhood  of  a  valve  which  generally  formfT  the  distal  boundary  of  the 
tumor.  At  first  it  is  pyriform,  afterward  spherical,  but  rarely  attains 
any  great  sizd.  This  form  is  often  found  associated  with  extensive 
rarix,  but  it  does  not  occur  as  frequently  in  the  midst  of  masses  of 
raricose  veins  as  is  sometimes  supposed. 

The  only  conditions  which  render  active  treatment  necessary  are 
rapid  distention  causing  pain  and  possible  hasmorrhage  through  rupture 
)f  the  cyst  wall,  rapid  coagulation  in  the  sac  from  injury,  inflammation 
)r  other  cause,  and  suppurative  inflammation  in  dilatations  packed  with 
■lot.  In  these  cases  the  clot-packed  sac  should  be  removed  together 
vith  the  portion  of  the  vein  from  which  it  springs.  When  the  sac 
wrings  from  a  deep,  important  vein,  like  the  femoral,  operative  treat- 
nent  is  contra-indicated  unless  the  sac  be  pedunculated  sufficiently  to 
idmit  of  ligation.  When  removal  is  impracticable  in  a  superficial  vein, 
livision  of  the  distal  portion  of  the  vein  between  two  ligatures  is  rec- 
immended.  The  pain  from  distention  may  be  controlled  by  pressure, 
f  suppuration  appear,  it  should  be  treated  as  an  abscess,  opened  anti- 
leptically  and  cleaned  out. 

Gastroschisis. — Dr.  Brown  (Brit.  Med.  Jour.,  Jan.  4,  1890)  gives 
he  following  description  of  a  monster  which  breathed  only  once  or 

wice  : 

The  liver  and  part  of  the  small  intestine  were  projecting  through 
he  umbilical  opening,  which  also  admitted  the  insertion  of  two  fingers, 
he  abdominal  wall  below  the  umbilicus  was  covered  with  serous  mem- 
uane  only,  the  skin  and  muscle  being  absent  from  the  anterior  aspect 
'f  the  abdomen.  In  both  groins  was  a  diminutive  penis — without  the 
‘cihra  and  the  scrotum.  There  "was  no  anal  opening.  The  legs  were 
'Oth  abducted  from  arrested  development  and  displacement  of  the  pel- 
ic  bones.  There  was  also  talipes  varus.” 

Development  of  the  Ciliary  or  Motor  Oculi  Ganglion. — Dr.  Ewart 
resents  some  investigations  of  the  cranial  nerves  of  sharks  and  skates 
Proceedings  of  the  Royal  Society ,  March  6,  1890),  from  which  it  appears 


that  the  ciliary  ganglion  stands  in  the  same  relation  to  one  of  the 
cranial  nerves,  the  ophthalmicus  profundus,  as  the  sympathetic  ganglia 
of  the  trunk  stand  to  the  spinal  nerves,  and  that  this  ganglion  may 
henceforth  be  considered  a  sympathetic  ganglion. 

The  most  conflicting  views  have  for  some  time  been  held  as  to  the 
origin,  relations,  and  homology  of  this  ganglion,  which  is  known  as  the 
ciliary,  motor  oculi,  ophthalmic,  and  lenticular.  Some  observers  have 
confused  it  with  the  ganglion  of  the  ophthalmicus  profundus,  and  con¬ 
sidered  it  homologous  with  the  Casserian  and  other  cranial  ganglia,  but 
within  the  past  few  years  the  ciliary  ganglion  and  the  ganglion  of  the 
ophthalmicus  profundus  have  been  shown  to  be  distinct,  and  the  old 
view  of  Arnold,  that  the  ciliary  was  a  sympathetic  ganglion,  has  been 
revived.  The  researches  of  Dr.  Ewart  go  to  strengthen  this  view,  and 
he  thinks  that  perhaps  further  investigations  may  show  that  the  gan¬ 
glia  in  connection  with  the  branches  of  the  trigeminus  nerve  may  also 
be  considered  as  belonging  to  the  sympathetic  system.  He  professes  to 
have  found  the  vestiges  of  the  ophthalmicus  profundus  ganglion  in  a 
five  months’  human  embryo,  lying  under  cover  of  the  inner  portion  of 
the  Casserian  ganglion,  and  has  satisfied  himself  that  the  ophthalmicus 
profundus  of  the  elasmobranch  is  represented  in  man  by  the  nasal 
branch  of  the  ophthalmic  division  of  the  fifth  nerve. 

Supernumerary  Tonsils.— Donelan  (Brit.  Med.  Jour.,  May  17,  1890) 
reports  a  case  in  which  there  were  two  pairs  of  symmetrically  placed 
tonsils.  One  pair  was  in  the  normal  position,  the  other  was  situ¬ 
ated  low  down  in  the  pharynx.  All  four  tonsils  were  hypertro¬ 
phied  and  were  removed.  A  microscopic  examination  showed  that 
they  all  presented  the  usual  characteristics  seen  in  hypertrophied 
tonsils. 

This  case  is  a  very  unusual  one  in  that  the  supernumerary  tonsils 
were  bilateral  and  symmetrically  placed  below  the  normal  glands,  from 
which  they  were  separated  by  the  posterior  palatine  fold  by  an  interval 
of  half  an  inch. 

Development  of  the  Hymen. — Schaeffer  (Arch,  fur  Gyn.  ;  Am. 
Jour,  of  the  Med.  Sci.,  June  1890)  has  made  a  careful  study  of  this  sub¬ 
ject,  based  upon  the  examination  of  the  genitalia  in  nearly  tw-o  hundred 
foetuses.  He  found  that  in  every  instance  the  hymen,  as  early  as  the 
fifth  month,  was  composed  of  two  lamellae,  the  inner  being  derived 
from  the  vagina,  the  outer  from  the  folding  in  of  the  vulva;  in  many 
cases  the  two  layers  coalesced,  but  they  sometimes  remained  distinct 
until  birth,  though  seldom  later.  The  foetal  hymen  had  on  its  inner 
(upper)  surface  transverse  folds  similar  to  those  in  the'vagina;  between 
the  folds  small  pockets  were  often  formed,  from  which  cysts  of  the 
hymen  might  form.  Certain  anomalies  in  the  hymen — the  hymen  crene- 
latus,  dentatus,  carinatus,  falciformis,  etc. — may  be  accounted  for  by 
irregularities  in  the  distribution  of  these  folds.  On  the  outer  surface 
of  the  foetal  hymen  numerous  folds  were  found,  which  extended  from 
the  fossa  navicularis,  nymphae,  -clitoris,  and  meatus.  The  writer  gives 
this  summary  of  the  arguments  in  favor  of  the  bilamellar  origin  of  the 
hymen :  1.  In  over  one  fourth  of  the  specimens  the  lamellae  were  clearly 
demonstrated.  2.  The  outer  lamella  was  proved  to  be  developed  from 
the  folds  which  radiated  from  the  region  of  the  vestibule.  3.  Various 
stages  in  the  union  of  the  tw-o  lamellae  were  observed.  4.  The  outer 
lamella  had  the  same  color  and  epithelial  covering  as  the  vestibule,  the 
inner  that  of  the  vaginal  mucosa. 

The  Nerves  of  the  Back  of  the  Hand. — Zander  (ForUchritte  der 
Medicin,  No.  9,  1890)  gives  these  results  of  his  investigations  : 

The  dorsal  finger  anastomosis  supplies  not  only  the  nail  of  the 
thumb,  but  also  of  the  little  finger,  occasionally  of  the  fore  and  ring 
fingers,  and  rarely  of  the  middle  finger.  There  is  an  interchange  of 
filaments  between  the  anastomoses  on  the  dorsal  and  volar  surfaces  of 
the  fingers,  and  wherever  the  dorsal  nerves  fail  to  supply  the  nail  the 
palmar  nerves  supply  the  deficiency. 

Upon  the  back  of  the  hand  proper  the  areas  of  distribution  of  the 
radial  and  ulnar  are  not  sharply  divided  along  the  middle  line,  but  the 
branches  of  each  nerve  anastomose  with  those  of  the  other.  Fre¬ 
quently  the  skin  of  the  entire  dorsal  surface  of  the  hand  is  supplied 
by  both  nerves,  and  it  is  quite  common  that  the  middle  portion  is  sup¬ 
plied  with  sensitive  filaments  from  both  sources.  On  the  ground  of 
this  observation  it  can  be  affirmed,  in  cases  where  section  of  one  of 
these  nerves  has  produced  no  marked  loss  of  sensibility,  that  a  very 


224 


MISCELLANY. 


[N.  Y.  Mkd.  Jodh. 


extensive  interchange  of  the  nerve  fibers  exists;  the  less  extensive 
this  is,  the  more  clearly  will  the  loss  of  sensibility  appear. 

But  the  integument  of  the  dorsum  of  the  hand  receives  its  nerves 
of  sensation  not  only  from  the  superficial  branch  of  the  radial  and 
the  dorsal  branch  of  the  ulnar,  but  also  from  other  sources.  The 
musculo-cutaneous  unites  with  the  radial  and  innervates  the  integu¬ 
ment  of  the  thumb  and  the  radial  part  of  the  back  of  the  hand.  The  J 
posterior  inferior  cutaneous  nerve  the  writer  has  found  in  several  cases 
to  supply  the  entire  middle  part  of  the  back  of  the  hand.  Turner  once 
saw  the  external  interosseous  branch  of  the  radial  continue  to  the 
fingers,  and  innervate  the  adjacent  sides  of  the  fore  and  middle  fingeis. 
A  more  important  source  of  innervation  is  found  in  the  anastomosis 
between  the  dorsal  branch  of  the  ulnar  and  the  median  cutaneous. 
Twigs  from  the  palmar  nerves  also  rise  between  the  fingers  and  spread 
over  the  neighboring  surfaces. 

On  account  of  these  facts  Zander  maintains  that  in  any  given  case 
it  is  very  difficult,  if  not  impossible,  to  diagnosticate  the  section  of  the 
involved  nerve  trunk  by  means  of  the  degree  and  extent  of  loss  of  sen¬ 
sation  on  the  dorsal  surface  of  the  hand. 


JgxsrdUttg. 


Mortality  in  Cities  in  the  United  States.— The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  August  15th: 


DEATHS  FROM — 


CITIES. 

Week  ending- 

©  , 

li 

.5 

a 

Total  deaths  f 
all  causes. 

|  Cholera. 

|  Yellow  fever. 

o 

p- 

IsS 

e 

|  Varioloid. 

cj 

<U 

a 

a 

> 

|  Typhus  lever. 

|  Enteric  lever. 

|  Scarlet  lever. 

|  Diphtheria. 

|  Measles. 

Whooping- 
cough  . 

1,636,598 

815 

8 

4  12 

10 

13 

1,200,000 

597 

32 

2  14 

2 

8 

lj 064/277 

414 

13 

1  7 

11 

871,852 

475 

7 

4  18 

i 

11 

500,343 

208 

11 

..  5 

1 

450,000 

163 

4 

2  6 

450,000 

192 

5 

2  2 

437’245 

278 

. 

3 

1  3 

2 

325’000 

111 

12 

..  2 

i 

Washington,  D.  C  .. . 

Aug.  9. 

250,000 

102 

6 

..  2 

• . 

240-COi  i 

*1 

4 

i 

240,000 

128 

11 

..  4 

2 

230'000 

108 

1 

. .  8 

200,000 

68 

1 

..  6 

190,000 

63 

9 

1  2 

An?.  2. 

150^000 

40 

i  i 

2 

130j000 

66 

130,000 

80 

..  2 

An?.  8. 

129,346 

39 

4 

1  .. 

Aug.  9. 

100^000 

43 

2 

1 

Aug.  8. 

81,650 

34 

1 

1 

Aug.  9. 

80^000 

34 

3 

An?.  9. 

69,000 

46 

Aug.  9. 

60,145 

29 

2 

Aug.  9. 

4400C 

. 

Aug.  9. 

42,00C 

16 

.... 

1 

July  25. 

40.00C 

14 

1 

1  Aug.  1. 

40,000 

6 

Yrnilrprs  N  Y . 

1  Aug.  8. 

32,000 

13 

Aug.  2. 

26,000 

10 

r 

I  Aug.  9. 

26,000 

13 

.J.. 

Aug.  9. 

22,01 

9 

.. 

. 

1  Aug.  7. 

19,56 

3  14 

1 

1  Aug.  3. 

16,00 

1  8 

Pensacola,  Fla . 

|  Aug.  2. 

i5;oo 

)  5 

. 

• 

l..|. 

... 

The  Treatment  of  Cystitis  in  Women.— Dr.  T.  M.  Madden  presented 
the  following  note  at  the  recent  International  Medical  Congress : 

Of  all  the  diseases  which  come  before  us  in  gynaecological  practice 
there  is  none  more  frequently  met  with,  more  distressing  in  its  effects, 
or  more  intractable  to  the  means  generally  relied  on  for  its  relief  than 
cystitis  in  women.  I  therefore  desire  to  bring  under  the  notice  of  the 
International  Medical  Congress  a  method  of  treatment  which  I  have 
found,  by  clinical  experience,  to  be  generally  successful  in  the  rapid 
curative  treatment  of  this  condition.  The  measures  most  commonly 
employed  in  such  cases  are  merely  palliative,  and  may  relieve,  but  per 
se  can  never  cure,  well-established  cystitis  in  women.  Nor  am  I  aware 


of  any  method  by  which  that  can  be  accomplished  save  by  giving  the 
bladder  absolute  physiological  rest.  For  this  purpose  Dr.  Emmet’s 
operation—/,  e.,  the  establishment  of  an  artificial  vesico-vaginal  fistula 

_ may  be  successfully  employed  in  some  instances,  but  the  practical 

objections  to  it  are  so  great  and  obvious  that  for  several  years  past  I 
have  abandoned  this  procedure  in  favor  of  another  which  I  have  found 
more  generally  effectual  and  quite  free  from  the  disadvantages  of  the 
operation  referred  to.  The  plan  which  I  have  now  employed  in  a  very 
large  number  of  cases  of  cystitis  in  the  gynaecological  wards  of  the 
Mater  Misericordiae  Hospital,  Dublin,  consists  firstly  in  the  full  dilata¬ 
tion  of  the  uretheral  canal  with  the  instrument  exhibited,  so  as  to 
paralyze  the  contractility  of  the  sphincter  vesicae,  and  thus  produce  a 
temporary  incontinence  of  urine ;  and,  secondly,  in  the  direct  applica¬ 
tion  through  the  same  instrument  of  glycerin  of  carbolic  acid  to  the 
diseased  endovesical  mucous  membrane.  I  may  add  that  any  pain  thus 
caused  may  be  prevented  by  the  previous  topical  application  of  a  solu¬ 
tion  of  cocaine,  and  that  the  procedure  recommended  seldom  requires 
to  be  repeated  more  than  once  or  twice  at  intervals  of  a  week  or  ten 
days ;  and,  combined  with  the  internal  use  of  boric  acid,  rarely  fails  to 
effect  a  rapid  cure  in  any  ordinary  case  of  cystitis. 


To  Contributors  and  Correspondents.—  The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow - 

ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles,  we  alivays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of— we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (2)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  pat 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  oj 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

j  All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal ,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  If ''  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  hi  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  August  30,  1890. 


tctures  anil  lUirrtsses. 


CLINICAL  LECTURES 

ON  SOME  COMMONLY  OBSERVED  FORMS  OF 

PULMONARY  DISEASE. 

DELIVERED  AT 

THE  NEW  YORK  POST-GRADUATE  MEDICAL  SCHOOL. 

By  JAMES  K.  CROOK,  M.  IX, 

INSTRUCTOR  IN  CLINICAL  MEDICINE  AND  PHTSICAL  DIAGNOSIS,  ETC. 

Lecture  I. 

Simple  Acute  and  Chronic  Bronchitis  of  the  Larger 
Tubes, — This  morning,  gentlemen,  we  have  a  number  of 
ases  representing  the  most  common  form  of  disease  of  the 
espiratory  organs,  viz.,  inflammation  involving  the  larger 
.ronchial  tubes.  Fully  two  thirds  of  all  the  cases  observed 
,t  our  chest  clinics  are  of  this  nature,  and  you  will  find  it 
very  frequent  affection  in  almost  every  part  of  the  tern 
ierate  zone  the  world  over.  We  will  examine  these  cases 
eriatim ,  and  endeavor  to  learn  what  features  of  interest 
bey  present.  No.  1  is  that  of  a  young  man,  aged  twenty- 
our,  by  occupation  a  truck-driver.  He  informs  us  that  he 
eceived  a  severe  wetting,  while  engaged  in  his  work,  three 
ays  ago.  On  the  following  morning  he  experienced  some 
hilly  sensations,  with  a  sense  of  malaise  and  lassitude,  and 
uring  the  day  was  seized  with  a  harsh,  painful,  dry  cough, 
ie  also  felt  a  sensation  of  oppression  and  obtuse  pain  and 
i w ness  in  the  front  of  his  chest,  more  particularly  behind 
ie  breast  bone.  All  these  symptoms  he  has  this  morning, 
ut  now  a  small  quantity  of  glairy  mucus  is  raised  occa- 
onally,  and  he  also  feels  sensations  of  soreness  and  pain 
long  the  false  ribs.  These  are  undoubtedly  due  to  the 
were  muscular  contractions  caused  by  the  coughing 
forts.  We  find  his  temperature  to  be  99-5°  F.,  and  his 
ulse  rate  94  to  the  minute.  A  careful  physical  exami- 
ation  reveals  no  physical  signs  whatever  save  a  slight 
bilance  of  the  inspiratory  and  expiratory  notes.  We  are 
ius  led  to  a  plain  and  unequivocal  diagnosis  of  simple 
:ute  bronchitis  in  the  first  or  dry  stage.  To  use  a  lay 
cpression,  our  patient  has  caught  a  “  bad  cold.”  We  base 
iis  diagnosis  on  the  history  of  the  case,  and  on  the  ab- 
nce  of  all  signs  or  symptoms  of  other  pulmonary  troubles, 
here  is  no  pain  in  the  side,  no  high  temperature,  no 
illness  on  percussion,  and  no  bronchial  breathing.  No 
>rtion  of  the  lung  is  withdrawn  from  the  exercise  of  its 
action.  The  signs  are  negative,  and  that  is  what  we 
pect  to  find  in  almost  every  case  of  simple  acute  bron- 
utis  in  the  first  stage,  unless  the  attack  is  exceptionally 
\ere,  when  we  may  have  harsh  breathing  or  sonorous  and 
Want  rales.  The  pathological  basis  of  this  patient’s 
auble  consists  at  this  time  simply  in  a  certain  amount  of 
ddening  and  tumefaction  of  the  mucous  membrane  of 
c  primary  bronchi,  and  probably  of  the  nasal  passages 
d  trachea.  The  membrane  is  very  dry  and  irritable. 
iere  is  probably  also  more  or  less  hypersemia  and  per- 
'•ps  inflammation  of  the  bronchial  glands.  The  prognosis 
good.  Our  patient  is  young  and  strong,  and,  with  proper 


care,  ought  to  be  well  in  a  few  days.  If  he  were  a  weak 
and  puny  subject,  or  else  a  little  child,  or  an  old  person 
above  sixty,  we  would  be  more  guarded  in  the  prognosis. 
In  such  cases  the  disease  is  liable  to  dangerous  sequelaj. 
as  we  shall  see  in  referring  to  chronic  bronchitis.  The  in¬ 
dications  for  treatment  here  are:  1,  to  observe  care  against 
further  exposure,  as  in  sitting  in  a  draft,  going  suddenly 
from  a  warm  to  a  cold  atmosphere,  wearing  insufficient 
clothing,  etc. ;  2,  to  relieve  the  irritable  cough  and  the 
soreness  and  oppression  of  which  he  complains.  The  dis¬ 
ease  is  not  so  far  advanced  but  that  we  may  still  hope  to 
abort  it.  For  this  purpose  I  am  in  favor  of  the  old-fash¬ 
ioned  treatment  of  a  strong  mustard  foot-bath  at  bedtime. 
The  feet  and  legs  should  be  bathed  up  to  the  knees,  and 
should  remain  in  the  hot  water  at  least  ten  minutes.  They 
must  then  be  wiped  dry  with  a  coarse  towel,  and  the  pa¬ 
tient  must  go  to  bed  at  once.  He  should  then  take  a 
powder  consisting  of  one  grain  each  of  ipecac  and  opium 
and  ten  grains  of  antipyrine.  This  formula  is  similar  to 
the  time-honored  Dover’s  powder,  except  that  the  sulphate 
of  potassium  is  replaced  by  antipyrine.  I  have  never  been 
able  to  see  the  value  of  the  sulphate  of  potassium  in  the  Do¬ 
ver’s  powder,  while  I  am  well  convinced  of  the  good  effects 
of  the  antipyrine.  This  dose  will  cause  profuse  diaphoresis, 
but  is  quite  sure  to  give  the  patient  a  good  night’s  rest! 
free  from  coughing.  A  vigorous  friction  of  the  chest 
with  the  hartshorn  or  soap  liniment  will  aid  its  action. 
To-morrow  morning  on  rising  he  should  take  a  good  saline 
purgative  in  the  shape  of  a  glass  of  Villacabras  or  Rubinat 
mineral  water,  or  a  couple  of  heaping  teaspoonfuls  of  Spru- 
del  salt.  By  this  treatment  we  may  reasonably  expect  a 
modification  of  his  symptoms,  possibly  a  complete  cessa¬ 
tion.  It  will  at  least  greatly  ameliorate  the  severity  of  the 
trouble.  However,  there  is  apt  to  be  more  or  less  bron¬ 
chial  irritation  and  cough  for  several  days,  which  may  be 
severe  enough  to  require  treatment.  Our  object  will  then 
be  to  promote  the  secretion  of  the  bronchial  membrane  so 
as  to  allay  the  dryness  and  irritation  which  produce  the 
cough.  Our  subsequent  measures  need  not  be  specially 
active,  as  the  tendency  of  the  trouble  is  toward  recovery 
Probably  ninety-five  per  cent,  of  cases  in  such  subjects  as 
this  young  man  would  end  in  recovery  without  treatment. 
To  hasten  this  end,  and  to  promote  his  comfort,  we  should 
prescribe  a  mild,  stimulating  expectorant.  There  are  a 
large  number  of  these  remedies,  but  I  know  of  none  more 
reliable  than  the  chloride  of  ammonium.  It  has  been  justly 
said,  however,  that  this  compound,  when  mixed  with  a 
syiuP>  is  uot  pleasing  to  the  palate.  To  obviate  this  bad 
taste,  and  also  to  gain  the  benefit  of  its  sedative  action,  I 
have  been  in  the  habit  of  adding  the  spirit  of  chloroform, 
a  favorite  formula  being  as  follows  : 

I£  Ammon,  cblorid .  3  jj . 

Spt.  chloroform.,  ) 

Tinct.  opii  camph.,  V . aa  f  3  iij ; 

Syr.  ipecac.,  ) 

Syr.  tolut.  vel  syr.  prun.  Virginian..  . .  ad  f  3  iij. 

M.  Sig. :  Dose,  a  teaspoonful  as  required. 

This  is  not  a  bad-tasting  mixture,  and  I  have  found  few 


people  object  to  it.  A  little  chloride  of  aporaorpbine  (one 
fifteenth  to  one  sixth  of  a  grain  two  or  three  times  a  day) 

is  sometimes  equally  efficacious, 

Patient  No.  2  is  a  man  aged  thirty,  who  is  in  the  sec 
ond  stage  of  bronchitis.  His  case  might  be  called  sub¬ 
acute,  as  his  symptoms  have  been  very  mild  from  the  be 


slate-colored  or  grayish.  There  is,  no  doubt,  an  abundance 
of  mucus,  and  probably  pus,  covering  the  membrane  in 
places,  which  gives  rise  to  the  dyspnoea  of  which  he  com¬ 
plains.  There  are  elements  of  gravity  in  this  case  which 
did  not  exist  in  the  others.  The  patient  is  already  con¬ 
siderably  run  down  and  he  is  progressively  getting  worse, 


I'irx? ;:t  . .™  ;  /;».« «.. ■»>■  »-  -  *  ;•  •-»  * * 


half  a  teaspoonful  on  retiring  and  on  rising  in  the  morn- 


cases 


ins  The  iougl,  is  loose  and  not  at  all  irritating.  The  the  smaller  bronehi,  giving  rise  to  bronchiolitis  or  the  so- 

expectoration  has  been  quite  copious  for  several  days,  but  called  capillary  bronchitis,  and  eventually  to  collapse  of  the 
expectoration  mis  4  '  _  _  ,  alveoli  and  lobular  pneumonia.  Such  ternnna- 


is  now  becoming  less.  TtTsTaLT  thicil  and'  exposed  I  pulmonary  alveoli  and  lobular  pneumonia.  Such  termina 

n  WrT„  With  a  little  pus  During  the  first  two  tions  of  bronchitis  are  not  uncommon  in  infants  and  old 

mostly  of  mucus,  P  *.  ,  +  nf  blood  Lersons  but  they  also  occur  in  debilitated  persons  of  adult 

or  throe  davs  he  observed  an  occasional  streak  ot  blood,  persons,  out  tu^  1 

or  turee  uays  There  is  even  a  possibility  that  the  per- 

but  this  was  not  an  alarming  occurrence,  as  it  is  quite  com-  I  or  middle  .  P 


raon  iu  tlie  first  stage  of  bronchitis.  The  lining  mem¬ 
brane  of  the  bronchi  is  now  moist,  and  probably  only  a 
little  congested.  We  need  not  subject  this  patient  to 
needless  precautionary  measures.  He  is  doing  well  now, 
and  with  ordinary  care  will  recover  his  health  in  a  few 

days. 

Patient  No.  3,  however,  shows  us  that  all  cases  do  not 
progress  so  favorably.  He  is  a  tailor,  forty  years  of  age, 


sistent  bronchial  inflammation  may  light  up  a  latent  tuber¬ 
culosis.  We  can  thus  see  that  we  have  a  case  of  great  im¬ 
portance  on  our  hands.  Should  he  escape  the  foregoing 
evils,  the  disease  may  still  continue  for  years  and  lead  to 
bronchiectasis  from  loss  of  elasticity  of  the  bronchial  walls. 
We  hope  for  a  more  favorable  termination,  however,  and 
with  proper  management  ought  to  be  able  to  achieie  it. 
The  indications  for  treatment  here  are  clearly  of  the 


P7 :n  rather°delicate  physique.  Early  iu  January  (about  touic  and  supportive  order.  We  should  regulate  the  pa- 

“ Llth since  he fell a Sn  to  tie  morbific  atmos-  tient’s  dal),  habits  and  regimen.  Ho  should  wear  want 
six  months  si  j  r  L _ i„  cVin  and  avoid  undue  exposure.  However, 


OXA  i**v»*w -  /  n 

pheric  influences  prevailing  at  that  time,  from  the  effects  of 
which  he  has  never  recovered.  After  a  week  or  two  of 
sneezing,  headache,  pain  in  the  back,  rigors,  etc.,  he  settled 
down  to  a  steady  cough,  which  has  not  left  him  since.  But 
he  has  developed  other  symptoms  which  somewhat  augment 
the  gravity  of  the  case.  His  appetite  has  failed  and  he  is 
losing  flesh  lately  ;  he  also  finds  himself  somewhat  short  of 
breath  on  exertion.  He  complains  of  irregular  thoracic 


flannels  next  his  skin  and  avoid  undue  exposure.  However, 
on  all  pleasant  days,  he  should  spend  as  much  time  as  pos¬ 
sible  out  of  doors.  Moderate  stimulation  is  advisable  to 
sustain  bis  strength.  If  the  patient  can  afford  it,  he  may 
take  a  glass  or  two  of  claret  with  his  meals,  and  the  latter 
should  be  composed  of  as  nourishing  food  as  possible,  espe¬ 
cially  meats  and  farinaceous  articles  of  diet.  We  may  find 
it  necessary  to  administer  a  bitter  tonic  for  his  appetite,  and 


pains  and* there  isLome  tenderness  on  pressure  at  different  for  this  purpose  I  know  of  nothing  superior  to  the  old-fash- 
un  ts  of  the  chest.  The  cough  is  attended  by  a  profuse  ioned  formula  known  as  South’s  bitters,  consist, ng  of  half 
1  .  „  _ _  „ ,  .  4.  a  •  a  drachm  each  of  the  compound  tinctures  of  gentian  and 


s -i... ..a v- » ... -w -r rr  ;  t 


and  tenacious  ana  nara  to  get  up.  ~  w  be  reasonably  sure 

cially  early  in  the  morning  on  rising,  he  gets  a  coughing  fore  meals  m  a  little  vate  *  , 

spell  which  lasts  for  ten  or  fifteen  minutes,  and  even  leads  that  a  little  good  exercise  in  e  a  ern  ,  « • 

:oPevio.ent  retching  and  vomiting.  These  spells  almost  al-  of  this  prepay  w  1  f  ™  ^ " 


xvaysset  upasev^-e^eadache.  The  patient  has  taken  sev-  dinner.  It  would  not  be  a  bad  plan  to  administer  also  a 

z — : .... «... .. «...  - «-,  «• ...  -  ••  /Si1 


oral  rpinpdies  from  time  to  time,  Dut  tuey  uu  nut  seem  w  -  *  1  1  *  ,  . 

have  helped  him  much.  On  physical  examination,  we  find  bedtime  Art .mnlating  * 


have  helped  him  muen.  ua  pnya.oa.  —  -  ...  ---  “ductg  bronohial  exudation  in  as 

all  the  methods  to  yield  negative  results,  except  percussion  We  wish  to  keep  the  p 

and  auscultation.  On  percussion,  in  the  lower  and  posterior  ^  the  cLe of  Lute 


Darts  of” the  lungs  we  find  a  certain  degree  of  dullness  on  1  pulsion.  The  formula  recommended  in  the  ease  of  acute 
both8 sides.  In  fhese  same  regions,  on  auscultation,  we  find  bronchitis  would  be  use*  ta.  as  t ene,  ^ * 


both  sides,  in  tnese  same  regions,  on  ausouuawuu,  we  uuu  — .  . 

an  abundance  of  large  and  small  moist  rales.  These  phys-  adynamia  here  I  won  d  rep  ace .  e  c  or,  e ,j, ■ 


ical  signs  are  undoubtedly  due  to  a  gravitation  of  the  fluid 
secretions  of  the  bronchial  tubes  to  the  dependent  poi  tions 
of  the  lungs.  Higher  up  we  still  find  rales,  hut  they  are 
more  dry  in  character,  being  chiefly  sibilant  and  sonorous. 
There  is  no  circumscribed  area  of  dullness  or  bronchial 
breathing.  AVe  need  feel  no  hesitation  in  pronouncing  this 
a  case  of  chronic  bronchitis.  There  are  not  sufficient  ele 
ments  in  the  history  or  physical  signs  to  warrant  any  other 


nate  of  ammonium.  The  addition  of  a  few  grains  of  the 
iodide  of  potassium  would  also  increase  its  efficiency.  But 
we  can  not  undertake  to  enumerate  the  many  remedies 
which  have  been  found  useful  in  bronchitis.  The  last  edi¬ 
tion  of  the  National  Dispensatory  gives  a  list  of  more  than 
one  hundred  and  twenty.  We  can  only  say  that,  whateyei 
remedy  we  choose  for  the  cough  symptoms,  we  should  give 
as  little  of  and  at  as  long  intervals  as  is  consistent  with  the 


Z  aTd  le  I  PUL  aJ  fumZtLn  ;a„  i.  Caie  I.  administered  for  a  long  time,  and  such  drugs  are  very  ap, 
The  membrane  is  probably  of  a  bluish-red  tin,,  or  it  may  be  1  to  upset  the  appetite  and  digest, on,  1  have  very  little  fa,.! 


August  30,  1890.] 


AULDE:  STUDIES  IN’  THERAPEUTICS. 


227 


in  local  measures  in  the  treatment  of  chronic  bronchitis, 
■ind  rarely  employ  them.  If  our  patient  were  In  a  position 
to  afford  the  expense,  we  should  advise  him  to  get  away 
'rom  the  seaboard  for  a  while  at  this  season  (summer),  and 
?pend  a  few  weeks  in  the  Catskill  or  Adirondack  Mount¬ 


ains. 


#rt0tiral  Commtwmtftons. 

STUDIES  IN  THERAPEUTICS. 
ASSAYED  GALENICAL  PREPARATIONS. 

By  JOHN  AULDE,  M.  D., 

PHILADELPHIA, 

MEMBER  OF  THE  AMERICAN  MEDICAL  ASSOCIATION, 

OF  THE  MEDICAL  SOCIETY  OF  THE  STATE  OF  PENNSYLVANIA,  ETC. 

Soon  after  the  publication  of  my  lectures  upon  The 
linical  Applications  of  Drugs,  which  appeared  in  this  Jour- 
al  during  the  month  of  April  last,  I  received  a  number  of 
ommunications  asking  for  further  information  upon  various 
)pics  ;  but  the  question  which  I  deemed  of  greatest  impor- 
ince  was  in  regard  to  the  assayed  fluid  extracts  mentioned, 
hose  who  read  the  lectures  will  remember  that  I  insisted 
pon  the  need  of  giving  attention  to  the  character  of  the 
uid  extracts  employed,  and  I  desire  again  to  emphasize 
lat  need,  and  to  point  out  that  such  preparations  are  in 
any  instances  superior  to  alkaloids  in  the  treatment  of 
isease. 

To  some,  the  foregoing  statement  may  appear  absurd, 
it  a  few  words  will  suffice  to  show  that  the  position  is 
ell  taken.  It  is  well  known  among  clinicians  that  many 
ilenical  preparations  are  not  truly  represented  by  the  al- 
iloids  they  contain  ;  but  we  depend  upon  the  presence  of 
e  alkaloid  for  the  activity  of  the  drug,  as  without  it  our 
erapeutical  applications  must  be  to  a  great  extent  tenta- 
.'e.  No  better  illustration  of  this  point  can  be  given  than 
the  use  of  cinchona.  There  are  times  when  the  salts  of 
e  alkaloids  will  answer  our  purpose  admirably,  but  at 
her  times  an  infusion  will  do  as  well  ;  then,  again,  it  be- 
mes  necessary,  in  order  to  obtain  all  the  virtues  of  the 
rk,  to  employ  the  extract.  Occasionally  it  has  been  found 
at  the  combination  of  one  or  more  of  the  salts  with  the 
id  extract  will  act  more  efficiently  than  either  of  these 
eparations  alone.  It  must  be  borne  in  mind,  however, 
iat  these  conclusions  were  determined  upon  at  a  time  when 
J  scare  was  given  to  the  manufacture  of  fluid  extracts  than 
igiven  at  present,  and  there  can  be  no  doubt  in  the  minds 
1  practical  pharmacists  that  fluid  extracts  were  often  pre¬ 
yed  from  inferior  qualities  of  bark.  It  is  not  reasonable 
t  suppose  that  inexperienced  young  men  are  competent  to 
' ect  and  pass  upon  the  quality  of  a  product  so  simple  as 
1  Tuvian  bark;  and  if  there  is  difficulty  here,  what  must 
t  the  dilemma  of  those  who  have  to  decide  upon  the  char- 
•  er  ot  crude  drugs  where  great  experience  is  required, 

'  !n&  to  ^eir  peculiar  delicacy  and  liability  to  sophistica¬ 
te?  1  lants  like  aconite,  cannabis  indica,  digitalis,  and 
-semium  require  experienced  operators  to  determine  the 
t  e  from  the  false ;  but  in  addition,  they  demand  the  skill 


of  the  chemist  to  ascertain  the  presence  of  the  proper  pro- 
poition  ot  active  constituents.  Chemical  analysis  alone 
serves  to  demonstrate  their  value,  just  as  an  assay  process 
determines  the  presence  and  percentage  of  precious  metals, 
and  enables  the  purchaser  to  set  a  proper  value  upon  the 
ore  which  is  offered  for  sale. 

The  advantages  of  assayed  galenical  preparations  must 
be  apparent  to  the  most  obtuse  observer  ;  if  not  from  the 
foregoing  remarks,  his  own  experience  has  convinced  him 
that  certain  preparations  are  better  than  others,  owing  to 
their  certainty  ot  physiological  action.  The  committee  now 
engaged  in  a  revision  of  the  United  States  Pharmacopoeia 
will  doubtless  be  guided  to  the  conclusion  that  the  advance 
of  scientific  medicine  and  the  success  of  the  practitioner 
alike  depend  upon  the  early  adoption  of  processes  for  the 
determination  of  the  active  constituents  of  all  galenical 
preparations,  where  those  constituents  occur  in  the  form 
of  an  alkaloid,  a  glucoside,  or  a  neutral  substance.  Until 
such  rules  become  obligatory  upon  the  pharmacist,  the  work 
of  the  physician  must  to  a  great  extent  be  a  matter  of  guess¬ 
work  ;  otherwise,  the  results  which  he  desires  from  the  ex¬ 
hibition  of  certain  drugs  of  this  class,  when  they  are  as  ex¬ 
pected,  will  be  mere  accidents,  and  in  general  anything  but 
mathematically  exact. 

The  rapid  advances  in  other  departments  of  science  are 
sufficient  to  warrant  us  in  insisting  that  the  noble  science 
of  medicine  shall  not  lag  behind.  The  progressive  spirit 
of  the  nineteenth  century  invites  the  medical  man  to  take 
a  step  in  advance,  just  as  it  has  brought  the  surgeon  from 
the  darkness  of  ignorance  and  superstition  into  the  light 
of  truth  and  opened  a  new  era  in  this  department  of  medi¬ 
cal  science.  Let  this  be  the  beacon  which  shall  guide  us 
to  an  advanced  position  in  the  use  of  drugs.  Possessing 
medicaments  which  are  exact  and  reliable  in  alkaloidal 
strength,  the  physician  will  attain  greater  skill  in  their  ad¬ 
ministration,  and  the  temptation  to  make  combinations  will 
gradually  disappear.  Too  often  combinations  mean  io-nor- 
ance  on  the  part  of  the  practitioner,  and  unfortunately  they 
are  used  at  the  expense  of  the  patients’  strength. 

No  physician  can  fail  to  appreciate  the  benefits  which 
must  accrue  to  his  patients  through  the  influence  of  reliable 
medicines.  When  called  to  see  a  patient  in  a  distant  coun¬ 
try  town,  the  first  inquiry  of  the  physician  should  be  in  re¬ 
gard  to  the  reliability  of  the  druggist ;  and  when  prescrib¬ 
ing  for  a  patient  in  a  dilapidated  portion  of  a  large  city,  he 
should  be  particular  to  instruct  his  patient  as  to  the  drug¬ 
gist  he  ought  to  patronize.  Happily,  his  selfish  disposition 
and  the  welfare  of  his  patient  run  in  parallel  lines.  So  long 
as  the  patient  remains  in  bed,  the  doctor  knows  that  his 
professional  ability  is  not  very  highly  rated  ;  and  besides, 
when  the  patient  again  goes  on  the  street,  he  becomes  at 
once  a  moving  and  talking  monument  of  the  professional 
skill  of  his  physician  ;  the  eclat  which  follows  a  rapid  re¬ 
covery  of  an  exceptionally  interesting  or  exceptionally 
prominent  patient  is  more  to  the  physician  than  great 
riches.  For  these  reasons,  if  not  for  those  higher  and 
holier  motives  which  prompt  men  to  face  death  for  their 
fellow-men  in  times  of  sickness,  the  doctor  is  prompted  to 
seek  remedies  that  he  can  depend  upon  in  the  hour  of  need. 


228 


ATJLDE:  STUDIES  IN  THERAPEUTICS. 


The  objections  urged  against  the  plan  suggested  are  not 
so  formidable  as  its  opponents  would  have  us  believe,  nor 
are  they  insuperable.  They  are  such  as  serve  to  break  the 
force  of  the  arguments  against  the  method  proposed,  be¬ 
cause  they  show  beyond  question  the  fallacy  of  the  premises, 
and  prove  the  uselessness  of  a  system  which  is  inefficient 
because  of  its  irregularities.  The  opposition  comes  from 
sources  least  suspected,  and,  owing  to  the  under-current  of 
antagonism,  the  necessities  of  the  physician  must  be  more 
strenuously  insisted  upon  than  the  overwhelming  evidence 
in  its  favor  would  appear  to  require. 

For  example,  it  is  alleged  that  no  pharmacist  of  ordi¬ 
nary  ability  is  capable  of  undertaking  these  delicate  opera¬ 
tions,  and  it  is  said  also  that,  had  he  the  capacity,  it  would 
require  too  much  time  and  an  unnecessary  outlay  for  appa¬ 
ratus  ;  but  these  are  flimsy  excuses  where  life  is  at  stake. 
On  the  contrary,  it  is  stated  on  the  authority  of  Professor 
Mew,  of  Washington,  D.  C.,  analytical  chemist  to  the  pur¬ 
veying  department,  U.  S.  Army,  that  any  well-qualified 
druggist  can,  in  the  course  of  a  few  weeks,  be  thoroughly 
educated  to  do  this  work,  and  that  the  expenses  of  the  outfit 
are  comparatively  trifling  when  compared  with  the  increased 
advantages  which  would  attend  the  introduction  of  assayed 
products.  Again,  it  has  been  suggested  that  it  would  be 
an  easy  matter  to  prepare  a  finished  product  which  would 
meet  all  the  requirements  in  respect  to  alkaloidal  strength 
by  any  known  chemical  process,  through  the  addition  of 
foreign  substances  which  possess  no  medicinal  value  what¬ 
ever;  but,  as  no  reputable  pharmacist  would  be  guilty  of 
such  sophistication,  only  a  short  time  would  elapse  before 
the  source  of  the  spurious  preparations  would  be  discovered. 
The  notion  that  such  counterfeits  could  be  placed  in  the 
hands  of  an  innocent  druggist,  who  should  be  held  respon¬ 
sible  unless  he  could  show  the  preparation  in  the  original 
package,  is  too  absurd  to  be  entertained  for  a  moment. 

Finally,  it  is  strongly  urged  that  if  we  are  coming  to 
alkaloidal  therapy,  it  would  be  far  better  to  discard  the  other 
products  entirely  ;  but  there  are  several  valid  reasons  why 
this  plan  can  not  be  adopted  at  the  present  time.  First,  the 
physiological  actions  of  alkaloids  in  many  instances  are  not 
fully  understood ;  consequently,  further  investigation  is  re¬ 
quired.  Secondly,  quite  a  number  of  alkaloids  do  not,  as 
previously  stated,  represent  the  physiological  action  of  the 
crude  drug,  owing  to  the  presence  of  principles  which  neu¬ 
tralize  one  another ;  while  some  alkaloids,  like  cannabine, 
are  too  expensive  even  for  physiological  investigation.  Pos¬ 
sibly  they  may  in  the  future  be  produced  synthetically  at  a 
cost  low  enough  to  permit  their  general  employment.  Some 
alkaloids,  such  as  those  belonging  to  the  Solanacece,  can  not 
be  used  continuously  for  any  length  of  time,  owing  to  their 
tendency  to  accumulate  in  the  liver  and  obstruct  its  func¬ 
tions.  While  admitting  that  many  of  the  active  principles 
of  vegetable  origin  are  used  with  satisfaction,  and  that  there 
is  no  doubt  of  their  safety,  I  must  insist  that  such  usage 
can  have  no  direct  bearing  upon  the  question,  where  these 
principles  do  not  represent  the  physiological  actions  of  the 
crude  drug,  or  where  they  can  not  be  produced  in  such 
quantity,  and  at  an  outlay  which  will  enable  their  use  to 
become  general. 


[NT  Y.  Med.  Joub., 

Clinical  experience  is,  therefore,  the  final  and  crucial  test 
which  must^uide  us  in  determining  whether  or  not  we  art 
to  use  galenical  preparations  which  have  been  submitted  to 
an  assay  process.  Those  opposed  to  the  method  must  be 
regarded  as  opposed  to  progress;  they  are  entitled  to  be 
classed  wifh  a  large  number  of  physicians,  now  passing  from 
the  stage,  who  knew  but  little  of  the  possibilities  of  drugs 
from  a  scientific  standpoint,  who  practiced  wholly  on  an 
empirical  basis,  firing  shot-gun  prescriptions  into  their  pa¬ 
tients  from  day  to  day. 

We  are  not  in  a  position  to  estimate  with  any  degree  ol 
accuracy  what  a  great  blessing  physiological  investigation 
has  been  to  mankind,  nor  can  we  appreciate  how  human 
life  has  been  prolonged  through  this  apparently  insignificanl 
agency ;  but  the  time  is  approaching  when  the  practice  oi 
physic  will  be  conducted  upon  a  surer  footing,  when  the 
physician  will  be  able  to  calculate  with  a  reasonable  degree 
of  certainty  the  effect  which  any  particular  drug  will  pro¬ 
duce;  and  he  can  give  the  nurse  instructions  which  wil 
enable  her  to  discontinue  one  preparation  and  replace  it 
by  another  at  the  proper  time,  just  as  we  do  now  in  con¬ 
trolling  the  temperature  and  pulse  in  typhoid,  scarlatina 
and  in  acute  forms  of  disease.  The  stepping  stone  towarc 
accomplishing  this  achievement  is  to  be  found  in  the  use  o 
galenical  preparations  made  to  conform  to  a  regulatec 
standard  of  alkaloidal  strength. 

Almost  daily-recurring  incidents  might  be  recordec 
which  illustrate  the  truth  of  the  propositions  here  advanced 
but  a  few  will  be  quite  sufficient.  Some  time  ago,  a  pro 
fessional  friend  complained  to  me  that,  even  when  following 
my  directions  to  the  letter,  he  could  get  no  satisfactory  re 
suits  from  the  use  of  cannabis  indica  for  the  relief  of  supra 
orbital  neuralgia  and  certain  forms  of  dysmenorrhoea.  AVhei 
asked  whose  manufacture  of  the  drug  he  had  employed,  h< 
could  not  tell.  I  advised  him  to  use  the  so-called  “  norma 
liquid,”  and  since  that  time  the  treatment  of  these  affcc 
tions,  where  this  drug  was  indicated,  has  been  invariable 
successful.  Quite  recently  I  read  some  suggestions  regard 
ing  the  use  of  gelsemium  in  the  form  of  a  fluid  extract,  th< 
dose  being  given  at  from  ten  to  twenty  drops,  and  came  t< 
the  conclusion  that  the  preparation  used  in  this  manne 
must  be  practically  inert,  and  that  a  teaspoonful  might  b 
taken  with  safety.  With  the  use  of  “normal  liquid’ 
gelsemium  the  cases  are  rare  indeed  where  ptosis  can  no 
be  produced  in  two  hours  by  the  judicious  employment  o 
ten  drops.  Within  the  past  few  weeks  I  had,  with  an  ex 
ceptionally  practical  and  reliable  druggist,  a  conversatioi 
which  turned  upon  the  subject  of  ergot.  Taking  down  tin 
shelf-bottle,  I  pointed  to  a  precipitate  in  the  form  of  a  poul 
tice,  when  he  informed  me  that  it  was  impossible  to  keej 
this  preparation  any  length  of  time  without  precipitation 
Personal  observation  enables  me  to  contradict  this  state 
ment,  as  I  have  kept  for  more  than  a  year  a  small  bottle  o 
the  normal  liquid,  and  there  are  no  indications  of  a  precipi 
tate. 

About  two  months  ago  a  physician  wrote  me  that  h 
had  used  rhus  toxicodendron,  in  both  large  and  small  doset 
in  nearly  all  the  disorders  for  which  I  had  recommende< 
it,  and  had  utterly  failed  to  notice  any  result  whatever,  but 


229 


August  30,  1890.]  DONALDSON:  THE  LARYNGOLOGY  OF  TROUSSEAU  AND  HORACE  GREEN. 


like  ray  friend  with  the  cannabis  indica,  he  did  not  know 
whether  the  preparation  used  was  the  fluid  extract  made 
from  the  dried  leaves  or  the  tincture  made  from  the  fresh 
leaves  growing  in  the  shade  and  gathered  during  the  period 
of  efflorescence.  A  sample  which  I  immediately  sent  him 
relieved  in  every  case,  including  a  rheumatic  trouble  from 
which  he  had  long  suffered  himself,  and  he  was  therefore 
prepared  to  champion  the  drug.  This  preparation,  it  should 
be  remembered,  is  one  which  depends  for  its  activity  upon 
the  presence  of  a  volatile  substance,  toxicodendric  acid, 
and  the  subject  is  introduced  here  as  an  illustration  of  the 
facts  already  pointed  out — viz.,  that  the  preparation  of 
drugs  for  the  relief  of  disease  can  not  receive  too  much 
care.  It  shows,  too,  that  drugs,  to  be  efficient,  must  be  pre¬ 
pared  according  to  certain  recognized  methods;  hence  it  is 
extremely  doubtful  if  in  their  preparation  inexperienced 
clerks  can  be  depended  upon. 

Both  aconite  and  belladonna  are  drugs  which  are  exten¬ 
sively  used  in  general  practice,  but,  as  usually  found  in  the 
shops,  they  are  the  most  uncertain  of  all  in  the  Pharma¬ 
copoeia,  with  the  possible  exception  of  the  tincture  of  opium. 
The  first  of  these  is  a  remedy  of  prime  importance  in  the 
early  stages  of  all  inflammatory  affections  in  which  mucous 
surfaces  are  involved,  and  the  failure  to  obtain  promptly 
the  physiological  effects  of  the  drug  means  an  attack  of 
pneumonia,  amygdalitis,  or  other  serious  disorder.  The 
physician  prescribing  this  drug  especially  desires  a  reliable 
preparation,  because,  after  the  first  twenty-four  hours,  when 
his  patient  is  seen  on  the  second  day,  the  period  for  its  ad¬ 
ministration  may  have  passed,  when  efforts  must  be  made  to 
conduct  the  disease  to  a  favorable  termination  rather  than 
control  it.  With  the  exhibition  of  reliable  preparations, 
attacks  of  this  character  in  the  acute  stage  may  frequently 
be  aborted. 

What  is  true  of  aconite  is  notably  applicable  to  prepa¬ 
rations  of  ergot.  With  his  hand  upon  the  uncontracted 
uterus,  when  every  throb  of  the  heart  means  a  gush  of 
blood  which  may  possibly  be  the  last,  when  the  vision  fails, 
and  the  recently  delivered  woman  raises  a  feeble  but  pierc¬ 
ing  cry  that  she  is  dying,  then  it  is  that  the  physician  thinks 
of  the  quality  of  his  ergot.  It  is  his  sheet-anchor.  The 
movements  of  the  nurse  in  procuring  it  may  be  slow,  the 
patient  may  hesitate,  but  the  physician  knows  that,  if  once 
the  drug  is  taken,  the  danger  is  averted.  "There  are  other 
instances  in  which  the  necessity  for  reliable  medication  is 
quite  as  great,  and,  when  those  who  oppose  the  method  as¬ 
sert  that  such  work  as  I  have  suggested  is  unnecessary  be¬ 
cause  it  takes  too  much  time,  that  it  will  require  the  phar¬ 
macist  to  increase  his  stock  of  intelligence  and  increase  by 
a  few  dollars  his  outlay  for  apparatus,  I  most  respectfully 
submit  that  it  is  a  sad  commentary  upon  the  boasts  we  are 
accustomed  to  make  regarding  our  modern  civilization. 

In  conclusion ,  therefore,  I  desire  to  offer  my  plea  for 
the  employment  of  assayed  galenical  preparations,  and,  as 
the  normal  liquids  have  served  me  well,  I  commend  them 
to  the  attention  of  my  brethren  in  the  field,  believing  that 
they  will  be  instrumental  in  guiding  them  to  a  more  scien¬ 
tific  use  of  drugs.  By  their  use  for  several  years  past  I  have 
been  able  to  conduct  the  administration  of  medicines  with 


greater  precision,  and  at  the  same  time  have  learned  to  em¬ 
ploy  drugs  of  this  class  with  due  regard  to  their  physio¬ 
logical  actions.  As  a  consequence  it  seems  to  me  that  my 
medical  horizon  has  gradually  widened,  and,  as  my  knowl¬ 
edge  of  diseased  conditions  increases,  my  respect  for  drugs 
improves.  As  a  result  of  clinical  observation,  I  recom¬ 
mend  the  use  of  small  doses,  because  the  small  doses,  given 
at  short  intervals,  at  least  in  acute  cases,  more  quickly  bring 
the  disease  under  the  control  of  the  physician,  while,  with 
medicines  which  are  unreliable,  the  results  are  always  un¬ 
certain.  If  the  attendant  is  interested  in  prolonging  the 
patient’s  illness,  haphazard  medicaments  are  a  desideratum ; 
but  if  he  desires  the  recovery  of  the  patient,  and  possesses 
selfish  motives  which  prompt  him  to  add  laurels  to  his  pro¬ 
fessional  reputation,  the  remedies  which  have  been  sub¬ 
mitted  to  a  chemical  or  physiological  test  to  determine 
their  activity  are  the  only  ones  he  will  be  willing  to  accept. 

It  would  be  interesting  to  say  a  word  in  regard  to  the 
precautions  to  be  observed  in  the  preparation  of  assayed 
galenical  products,  but  it  is  believed  that  enough  has  been 
said  to  establish  a  good  case,  as  the  evidence  is  substantial 
and  complete. 

1910  Arch  Street. 


THE  LARYNGOLOGY  OF 
TROUSSEAU  AND  HORACE  GREEN. 

AN  HISTORICAL  REVIEW* 

By  FRANK  DONALDSON,  M.  D., 

BALTIMORE. 

Nearly  all  the  prominent  and  valuable  discoveries  in 
science  and  the  arts  have  reached  completion  gradually. 
Thoughtful  minds  at  different  epochs  have  been  occupied 
with  attempts  to  overcome  the  same  difficulties  and  to  solve 
identical  problems.  Not  aware  how  near  they  have  been 
sometimes  to  success  in  their  attempts,  they  have  often  aban¬ 
doned  their  work  when  perseverance  would  have  rewarded 
them  with  brilliant  results. 

We  are  all  familiar  with  the  history  of  the  discovery  of 
the  little  instrument  which  has  furnished  us  with  a  name  as 
well  as  a  science  and  a  practical,  invaluable  art.  Starting 
from  the  middle  of  the  last  century  (1743)  with  the  ingeni¬ 
ous  device  of  M.  Levret,  the  laryngoscope  had  nearly  been 
reached  several  times  by  Bozzini,  by  Senn,  and  others,  but 
never  so  nearly  as  by  Babington  in  1829.  It  was  left  for 
Garcia,  in  1854,  to  demonstrate  in  his  own  person  auto¬ 
laryngoscopy,  and  to  present  to  the  profession  his  simple 
mirror  and  reflector  enabling  all  to  illuminate  and  inspect 
the  hitherto  darkened  chambers  of  the  larynx  and  nares. 

The  imperfect  and  unsatisfactory  art  of  laryngology 
yielded  to  the  exact  science  of  laryngoscopy. 

The  feat  was  accomplished.  When  once  the  discovery 
had  been  made,  there  was  no  difficulty  in  the  future. 

The  history  of  the  invention  and  of  the  futile  preceding 
efforts  it  is  unnecessary  to  mention. 

The  object  of  this  brief  paper  is  to  inquire  into  that 
period  of  the  history  of  laryngology  immediately  anterior 

*  Read  before  the  American  Larvngological  Association  at  its 
twelfth  annual  congress. 


230 


DONALDSON:  THE  LARYNGOLOGY  OF  TROUSSEAU  AND  HORACE  GREEN.  [N.  Y.  Med.  Jour., 


to  Garcia’s  successful  inspection  of  the  larynx,  and  more 
particularly  of  the  part  played  by  Trousseau,  of  Paris,  and  by 
Horace  Green,  of  New  York.  The  French  give  great  credit 
to  the  former,  and  the  American  has  had  his  appreciative 
friends  and  also  his  detractors.  I  thought  it  might  not  be 
uninteresting  to  endeavor  to  take  an  impartial  view  of  both, 
the  writer  having  had  as  a  student  the  privilege  of  follow¬ 
ing  Trousseau  in  1850-’51,  and  of  closely  watching  his 
practice.  All  acknowledge  that  he  was  a  very  able  clini¬ 
cian.  He  was  particularly  interested  in  the  study  of  dis¬ 
eases  of  the  mouth,  oro-pharynx,  and  larynx — all  of  which 
are  generally  included  in  the  designation  of  laryngology. 
His  wards  contributed  abundant  material  for  lectures  upon 
common  membranous  sore  throat,  gangrenous  and  inflam¬ 
matory  pharyngitis,  diphtheria,  and  tubercular  laryngitis. 

Trousseau  popularized  the  operation  of  tracheotomy  for 
membranous  croup,  which  he  regarded  in  many  cases  as 
diphtheritic.  He  was  very  successful.  He  insisted  that  the 
operation  should  be  performed  early  in  the  disease,  and  he 
used  strong  solutions  of  nitrate  of  silver  freely  in  the  orifice 
after  opening  the  trachea. 

His  limited  knowledge  of  the  pathology  of  the  larynx 
was  that  of  his  day.  He  taught  his  classes  that  tuberculo¬ 
sis  and  syphilis  were  the  almost  exclusive  causes  of  aphonia 
and  dysphonia.  For  these  his  treatment  was  by  the  appli¬ 
cation  of  nitrate  of  silver  in  the  form  of  the  solid  stick  to 
the  pharynx,  or  by  solution  injected  through  perforated 
silver  curved  tubes  passed  behind  the  epiglottis.  The 
shower  from  these  was  thrown  over  the  epiglottis  and  the 
supraglottis.  If  it  touched  any  diseased  points,  it  also  irri¬ 
tated  the  healthy  surfaces.  The  oro-pharynx  was  really 
the  only  part  that  he  could  illuminate  sufficiently  to  be  able 
to  apply  the  medicaments  accurately.  The  diseases  of  the 
upper  pharynx  and  posterior  nares  he  overlooked,  for  the 
rhinoscope  had  not  then  been  applied.  These  were  the 
points  of  his  practice  in  1850  in  connection  with  laryn¬ 
gology.  A  set  of  silver  tubes  I  brought  home  with  me, 
and  used  for  some  years  as  I  had  seen  him  apply  them,  but 
I  soon  ceased  to  use  them,  as  they  were  unsatisfactory. 

Let  us  for  a  moment  see  what  Trousseau  did  after  the 
laryngoscope  had  been  used  by  others. 

In  the  last  edition  of  Trousseau’s  Clinical  Medicine ,  pub¬ 
lished  in  1867,  edited  by  M.  Michel  Peter,  his  pupil,  and 
translated  by  Sir  John  Rose  Cormack  and  Bazire,  it  is 
maintained  that  Trousseau  and  Belloc,  long  before  the 
publication  of  their  work  on  laryngeal  phthisis  (in  1837), 
felt  that  the  examination  of  the  larynx  by  a  suitable  specu¬ 
lum  was  a  likely  means  of  attaining  accurate  diagnosis; 
further,  that  at  the  date  of  their  publication  they  were  oc¬ 
cupied  with  the  construction  of  such  a  speculum  laryngis. 
At  that  time,  likewise,  M.  Sellique,  an  ingenious  mechanic, 
who  was  also  a  sufferer  from  laryngeal  phthisis,  made  for 
his  physician  an  apparatus  consisting  of  two  tubes — one  for 
throwing  light  on  the  glottis,  and  the  other  for  affording  a 
view  of  the  image  of  the  glottis,  as  reflected  in  a  mirror 
placed  at  the  guttural  extremity  of  the  instrument.  There 
were  serious  defects  in  this  instrument ;  we  are  told  that 
the  difficulties  in  applying  it  were  so  great  that  Trousseau 
ceased  to  try  to  use  it.  It  is  a  curious  fact  that  neither 


Trousseau  nor  others  took  any  notice  of  an  instrument  pro¬ 
posed  and  presented  in  1825  to  the  Institute  by  M.  Caguiard 
de  Latour,  especially  as  Fournie  affirms  that  it  was  the  first 
discovery  of  the  laryngoscope.  It  consisted  of  a  small 
mirror,  which  was  to  be  introduced  into  the  fauces  and,  by 
the  aid  of  another  as  a  reflector,  to  catch  the  solar  rays  and 
reflect  them  and  illuminate  the  epiglottis  and  the  glottis. 
Its  practical  application  allowed  only  the  inspection  of  the 
epiglottis.  M.  Latour  lacked  perseverance,  or  he  might 
have  been  the  successful  discoverer.  Benniti,  of  Paris,  in 
1832,  had  asserted  his  ability  to  see  the  vocal  cords  with 
Sellique’s  instrument — his  double-tubed  speculum,  of  which 
one  tube  served  to  carry  the  light  to  the  glottis,  and  the 
other  to  bring  back  the  image  to  the  eye.  Trousseau  dis¬ 
credited  this  statement,  and  undertook,  in  his  work  on 
laryngeal  phthisis,  to  prove  that  the  epiglottis  formed  an 
insuperable  impediment  to  a  view  of  the  interior  of  the 
larynx.  Trousseau’s  rejection  of  Sellique’s  and  Benniti’s 
instruments,  by  the  weight  of  his  name  and  position,  was 
calculated  to  defer  the  discovery  of  the  laryngoscope. 

In  bis  clinic  on  oedema  of  the  larynx,  as  reported  in  the 
last  edition,  Trousseau,  or  his  editor,  says:  “The  laryngo¬ 
scope  has  been  carefully  studied  in  England  and  Germany; 
when  it  has  attained  a  greater  degree  of  perfection  it  will, 
no  doubt,  render  service  not  only  in  the  diagnosis,  but  also 
jn  the  treatment,  of  laryngeal  affections.” 

If  he  were  living,  how  cordially  should  we  welcome  him 
to  witness  the  perfection  its  application  has  reached!  He 
would  be  as  dazed  as  Rip  Yan  Winkle  was  when  he  awoke 
from  his  prolonged  sleep. 

Dr.  Horace  Green,  as  a  very  young  man,  was  impressed, 
in  several  cases  of  follicular  disease  of  the  throat  in  which  he 
had  become  interested,  with  the  uncertainty  attending  their 
treatment.  He  went  abroad  to  visit  the  hospitals  of  Europe 
to  see  if  there  had  been  any  discoveries  in  connection  with 
the  pathology  and  treatment  of  the  diseases  of  the  larynx 
and  the  adjacent  organs.  In  a  casual  conversation  he  had 
with  Dr.  James  Johnson,  the  editor  of  the  British  and 
Foreign  Medical  Review,  in  alluding  to  the  difficulties  and 
uncertainty  which  attended  the  treatment  of  laryngeal  dis¬ 
ease,  Dr.  Johnson  intimated  that  all  modes  of  treatment 
would  fail  us  until  appropriate  therapeutic  agents  could  be 
applied  directly  to  the  lining  membrane.  This  remark,  in 
connection  with  Green’s  past  experience  of  the  nature  of 
the  disease,  and  especially  of  its  local  character,  made  an 
abiding  impression  on  his  mind,  and  suggested  the  idea  of 
the  possibility  of  medicating  the  cavity  of  the  larynx  by 
catheterization.  This  was  in  1838. 

He  made  for  himself  a  probang,  with  which  he  com¬ 
menced  introducing  a  solution  of  nitrate  of  silver  into  the 
pharynx  and  into  the  larynx.  He  found  at  first  some  diffi¬ 
culty,  but  he  gradually  made  himself  very  expert  in  cathe- 
terizing  the  larynx  and  the  bronchi.  He  met  with  such 
success  that  he  soon  made  a  reputation  and  enjoyed  an  in¬ 
creasingly  large  practice. 

His  first  work  wTas  a  treatise  on  Bronchitis,  published  in 
1846.  In  this  he  advocated  strongly,  amidst  much  oppo¬ 
sition,  topical  applications  of  nitrate  of  silver  to  the  interior 
of  the  larynx  and  catheterization.  He  gave  numerous  cases 


August  80,  1890.]  DONALDSON:  THE  LARYNGOLOGY  OF  TROUSSEAU  AND  HORACE  GREEN. 


where  he  had  succeeded.  These  were  in  addition  to  the  cases 
previously,  in  1841,  reported  to  the  Medical  and  Surgical 
Society  of  New  York.  A  committee  of  this  society,  ap¬ 
pointed  in  1847,  condemned  his  practice.  The  members 
repeatedly  and  publicly  denied  the  possibility  of  cauteriz¬ 
ing  the  interior  of  the  larynx.  Why  is  it  that  there  are 
always  persons  who  are  persistently  incredulous  and  cavil 
at  new  things  ? 

A  resolution  was  offered  asking  Dr.  Green  to  withdraw 
from  the  society.  His  offense  was  that  he  had  repeatedly 
performed  an  operation  which  even  a  professor  of  anatomy 
declared  impossible,  although  accidentally  in  many  cases 
particles  of  food,  besides  bits  of  coin  and  other  foreign 
bodies,  had  passed  unhindered  through  the  glottis.  Others 
accused  Dr.  Green  of  imitating  Trousseau  and  Belloc. 
Dr.  Green  warmly  defended  himself  against  the  charge  of 
having  imitated  Trousseau  and  Belloc.  He  stated  that 
he  had  commenced  his  method  of  cauterizing  two  years  be¬ 
fore  he  knew  of  the  writings  of  Trousseau  and  Belloc.  He 
admitted  that  to  them  belonged  the  credit  of  having  been 
the  first  to  prescribe  and  employ  topical  medication  in 
chronic  diseases  of  the  larynx.  He  maintained  that  he  was 
the  first  to  pass  a  sponge-probang  loaded  with  a  strong  so¬ 
lution  of  nitrate  of  silver  below  the  epiglottis,  through  the 
larynx  and  rima  glottis,  down  into  the  trachea,  thus  reach¬ 
ing  disease  of  these  parts  with  more  certainty. 

Trousseau’s  method  was  to  saturate  the  sponge  with  the 
solution  of  nitrate  of  silver;  next,  the  mouth  being  open,  to 
depress  the  tongue  with  the  handle  of  a  spoon  and  intro¬ 
duce  the  porte-caustique.  As  it  is  passed  over  the  isthmus 
of  the  gullet,  it  produces  an  effort  of  deglutition  which  raises 
the  larynx.  This  moment  is  seized  upon  for  bringing  for¬ 
ward  the  sponge,  which,  in  the  first  part  of  the  operation, 
had  been  carried  to  the  entrance  of  the  oesophagus.  By  this 
means  he  reached  the  opening  of  the  larynx  by  elevating 
the  epiglottis;  and  then,  by  pressure,  it  was  easy  to  pass 
the  caustic  solution  into  the  larynx.  Dr.  Green  deserves  the 
honor  of  having  been  the  first  to  persist  in  this  treatment, 
and  practically  he  was  the  inventor,  but  he  was  not  the  dis¬ 
coverer.  Sir  Charles  Bell  made  applications  of  caustic  to 
the  respiratory  mucous  membrane  as  early  as  1816.  In  his 
work,  Surgical  Observations ,  will  be  found  a  record  of  these 
cases.  In  one  case  of  extensive  ulcerations  of  the  glottis 
lie  says:  “I  made  a  small  pad  of  lint,  and  attached  it  to  the 
ring  of  a  catheter  wire  after  bending  it  so  as  to  pass  it  over 
the  tongue  and  epiglottis.  I  dipped  the  lint  in  a  twenty- 
grain  solution  of  caustic,  and  touched  the  glottis  with  it  in 
this  manner  :  With  the  finger  of  my  hand  I  pressed  down 
the  tongue  and  stretched  the  forefinger  over  the  epiglottis; 
then  directing  the  wire  along  my  finger,  I  removed  the  point 
of  my  finger  from  the  glottis,  introduced  the  pad  of  lint 
into  the  opening,  and  pressed  it  with  my  finger.” 

This  treatment  was  considered  hazardous  and  was  aban¬ 
doned.  Mr.  Vance,  a  naval  surgeon  of  eminence,  was  in  the 
habit  of  employing  topically  a  solution  of  nitrate  of  silver  in 
the  treatment  of  laryngeal  diseases.  Dr.  Stokes  mentions 
Mr.  Cusack  as  having  introduced  nitrate  of  silver  by  satu¬ 
rating  a  piece  of  lint  sewed  on  the  end  of  his  index  finger; 
bv  these  means  the  solution  was  carried  with  great  facilitv 


23L 

to  paits  of  the  pharynx  and  even  to  the  rima.  Trousseau 
contends  that  his  master,  Bretonneau,  as  early  as  1818,  car¬ 
ried  over  the  arytaeno-epiglottic  ligaments  a  sponge  wet  with 
lunar  caustic  to  the  entrance  of  the  larynx  ;  yet  Trousseau 
denied  that  Dr.  Green  or  any  one  else  could  introduce  in¬ 
struments  below  the  vocal  cords;  indeed,  he  maintained 
that  the  operation  was  impossible. 

Dr.  Green  lived  to  see  the  best  men  abroad  and  in  this 
country  candidly  admit  that  he  had  done  as  he  reported 
that  he  had.  Dr.  Cotton,  Dr.  Hughes  Bennett,  Dr.  Fordyce 
Barker,  Dr.  Sayre,  Dr.  Carnochan,  Dr.  Sims,  Dr.  Praslee 
Davis,  Dr.  Bowditch,  of  Boston,  and  Professor  Davis,  of  the 
University  of  Virginia,  had  seen  Dr.  Green  demonstrate  the 
entrance  of  instruments  into  the  larynx  and  trachea.  They 
had  all  seen  the  passage  of  air  coming  through  the  catheter 
blow  out  the  candle.  Dr.  Sayre,  always  fearless  and  truth¬ 
ful,  so  testified  before  the  New  York  Academy  of  Medicine. 
An  overwhelming  demonstration  was  made  at  the  request 
of  Dr.  Carnochan.  Dr.  Green  introduced  the  probang 
through  the  larynx  of  a  man  who  had  attempted  suicide  by 
cutting  his  throat,  and  in  whom  the  orifice  in  the  trachea 
had  never  healed.  Dr.  Green  passed  the  probang  until  it 
made  its  appearance  at  the  opening  in  the  trachea.  This 
proved  that  there  was  no  anatomical  impossibility,  as  Trous¬ 
seau  had  contended,  of  catheterism  of  the  larynx. 

Dr.  Green  wrote  vigorously  on  the  Local  Origin  of  Con¬ 
stitutional  Diseases ,  the  converse  of  Mr.  Abernethy’s  work 
on  the  Constitutional  Origin  of  Local  Disease.  He  advo¬ 
cated  topical  medication  as  of  vast  importance.  This 
showed  his  independence  of  thought  and  his  boldness  in 
expressing  his  views  at  a  period  in  the  history  of  medicine 
when  there  existed  sucb  superstitious  over-confidence  in 
drugs  administered  internally  for  all  the  ills  of  life.  He 
cared  not  for  the  unpopularity  of  thus  combating  poly¬ 
pharmacy.  He  had,  it  must  be  admitted,  too  implicit  faith 

in  the  topical  application  of  his  favorite  local  application _ 

nitrate  of  silver — for  follicular  disease,  croup,  spasmodic 
asthma,  laryngitis,  chronic  bronchitis,  and  other  diseases  of 
the  respiratory  organs. 

Dr.  Green’s  work  on  Polypi  of  the  Larynx  and  (Edema 
of  the  Glottis  (1859)  shows  that  the  thoughtful  observation 
of  the  author  was  turned  toward  the  interior  of  the  larynx, 
and  that  he  was  not  to  be  led  by  traditional  teaching, 
either  in  his  views  of  laryngeal  pathology  or  in  his  practice. 
Dr.  Green  did  not  hesitate  to  express  the  opinion,  and  to 
leave  it  for  future  experience  to  confirm  or  invalidate,  that 
foreign  growths  occurred  in  the  opening  of  the  air-passages 
in  many  instances  where  their  presence  was  neither  sus¬ 
pected  nor  discovered;  and  that,  if  the  attention  of  the 
profession  should  by  any  means  be  directed  to  this  subject, 
it  would  be  found  that  the  existence  of  polypi  and  other 
excrescences  in  these  passages  was  an  occurrence  much  more 
frequent  than  had  been  supposed.  On  this  point  of  pathol¬ 
ogy  Dr.  Green  was  far  in  advance  of  his  day. 

He  diagnosticated  the  presence  of  these  neoplasms  by 
close  and  careful  inspection,  together  with  the  subjective 
symptoms;  heoperated  for  their  removal  by  laryngo-trache- 
otomy,  and  he  healed  cases  of  oedema  of  the  glottis  by  scari¬ 
fications  and  strong  solutions  of  nitrate  of  silver. 


232 


DONALDSON:  THE  LARYNGOLOGY  OF  TROUSSEAU  AND  HORACE  GREEN.  [N.  Y.  Med.  Jour., 


In  Dr.  Green’s  article,  published  in  1857,  on  Lesions  of 
the  Epiglottis,  there  is  a  careful  description  of  the  minute 


anatomy  of  the  cartilage,  showing  that  its  mucous  membrane 
adheres  closely  to  the  cartilage  on  the  laryngeal  face,  there 
bein£  no  areolar  tissue  interposed  between  the  lining  mem¬ 
brane  and  the  cartilage,  whereas  beneath  the  mucous  mem¬ 
brane  on  its  anterior  or  lingual  surface  considerable  areolar 
tissue  is  deposited.  Disease,  therefore,  affecting  this  fibro- 
eartilage  must  have  its  seat  either  in  the  mucous  membrane 
or  its  follicles  or  in  the  subjacent  areolar  tissue. 

He  reviews  the  physiology  of  the  epiglottis,  calling  at¬ 
tention  to  its  very  slight  sensibility  in  health.  While  in 
its  normal  condition  it  is  almost  insensible — for  it  may  be 
touched  by  the  finger  or  with  the  handle  of  an  instrument 
without  producing  any  irritation — yet  when  it  is  inflamed 
it  becomes  much  more  sensitive  and  causes  pain.  When 
the  lips  of  the  glottis  are  reached  a  convulsive  cough  is  pro¬ 
duced.  Dr.  Green  dwells  on  the  function  of  this  cartilage, 
together  with  other  parts,  in  the  protection  of  the  larynx, 
as  also  of  the  supraglottic  space.  He  writes,  tirst,  of  the 
erosions  or  abrasions  of  its  mucous  membrane  ;  secondly, 
of  ulcerations  of  the  membrane  and  of  the  glands  ;  thirdly, 
of  oedema  or  infiltrations  of  its  areolar  tissue. 

These  lesions  of  the  epiglottis  he  justly  maintains  are  of 
much  greater  frequency  than  has  been  generally  supposed. 
Persistent  coughs  have  been  kept  up  by  the  presence  of  un¬ 
detected  erosions  of  the  epiglottis.  These  he  had  greatly 
benefited  by  applications  of  lunar  caustic.  Dr.  Green  con¬ 
tended  that  the  direct  medication  of  the  lungs  by  means 
of  catheterism  of  the  air  tubes,  an  operation  not  before  per¬ 
formed  by  any  one,  he  had  repeatedly  accomplished,  that 
the  operation  might  be  performed  by  the  dexterous  surgeon 
with  ease  and  facility  and  with  perfect  safety  to  the  patient, 
and  that  the  results  of  this  method  of  treating  disease, 
whether  it  had  been  employed  in  bronchial  affections  or  in 
the  commencement  of  tuberculosis,  had  been  very  encour¬ 
aging.  Dr.  Green  reported  one  hundred  and  six  cases  of 
tuberculosis  and  chronic  bronchitis  treated  by  him,  espe¬ 
cially  by  catheterism  of  the  air-passages,  with  great  suc¬ 
cess.  Following  Dr.  Green,  Professor  Hughes  Bennett  re¬ 
ported  that  he  had  repeatedly  acted  upon  Dr.  Green’s  sug¬ 
gestion  with  success.  In  Green’s  report  (1859)  on  the 

o 

Difficulties  and  Advantages  of  Catheterism  of  the  Air-pass¬ 
age,  he  quotes  freely  from  Bennett,  Trousseau,  Loiseau, 
Blondeau,  and  others— all  strongly  in  favor,  from  their  per¬ 
sonal  experience,  of  injecting  the  air-passages.  The  death 
of  Mr.  Whitney  fourteen  days  after  Dr.  Green  had  passed 
an  instrument  into  his  throat  prejudiced  many  against  him  ; 
he  had  pushed  the  instrument  with  some  force  through  an 
obstruction.  In  operating,  he  felt  something  give  way— an 
abscess  probably.  Mr.  Whitney’s  death  created  a  great  sen¬ 
sation.  Trousseau,  Bennett,  and  Rokitansky  wrote  letters 
•after  receiving  the  details,  stating  that  they  did  not  think 
the  operation  had  anything  to  do  with  it.  Irousseau  said 
the  abscess  existed  before  the  operation. 

Dr.  Horace  Green  encountered  great  opposition  through¬ 
out  his  professional  life.  His  originality  and  his  persistent 
maintenance  of  his  views,  which  he  knew  were  founded 
upon  close  observation,  attracted  much  attention  and  caused 


no  little  jealousy.  I  may  be  allowed  to  say  that,  after  hav¬ 
ing  practiced  in  1854  upon  Dr.  Green’s  views,  and  subse¬ 
quently  (1859)  with  M.  Buchnt’s  suggestion  in  catheteriz- 
ing  the  larynx,  I  determined  to  go  to  New  York  to  see  Dr. 
Green  and  to  get  some  practical  points  from  him.  I  did 
so,  but,  after  reaching  New  Yrork,  1  was  dissuaded  by  promi¬ 
nent  New  York  physicians  from  calling  on  him.  Some  of 
them  said  he  was  a  charlatan  who  was  guilty  of  pretending 
to  do  what  he  could  not  do.  I  now  regret  that  1  left  the 
city  without  seeing  him. 

This  occurred  when  the  feeling  against  Dr.  Green  had 
culminated' and  a  committee  of  the  New  York  Academy  of 
Medicine  had  been  appointed  to  investigate  Dr.  Green’s 
views.  So  great  was  the  feeling  against  Dr.  Green  in  New 
York  that  the  Academy  of  Medicine,  after  their  committee 
had  made  their  report,  which  was  a  divided  one,  although 
they  could  not  convict  him,  yet  they  did  him  the  injury  of 
allowing  no  vote  to  be  taken,  and  the  report  remained  for 
over  five  years  on  their  table  unacted  upou.  Afterward, 
although  men  of  the  highest  character  indorsed  him  and  his 
statements,  they  did  not,  as  far  as  I  can  ascertain,  withdraw 
the  charges  against  him. 

Why  was  Dr.  Green  so  unpopular  with  his  professional 
brethren  ?  He  certainly  was  a  gentleman  of  high  culture 
and  great  ability,  very  laborious,  conscientious,  and  perse¬ 
vering.  His  great  success  made  him  a  mark  for  jealousy. 
His  studies  and  his  taste  led  him  to  carve  out  for  himself 
a  specialty  when  specialties  were  not  considered  allowable. 
All  specialism,  particularly  ours,  was  considered  question¬ 
able  from  an  ethical  point  of  view. 

Dr.  Green  was  calculated  to  be  a  leader  in  medical 
thought.  Had  his  health  permitted,  he  would  have  availed 
himself  in  his  declining  years  of  Garcia’s  discovery,  and  no 
doubt  would  have  enriched  the  new  science  of  laryngoscopy 
by  his  accurate  observations. 

Time  and  justice  have  rescued  his  reputation.  As 
Americans  we  are  proud  of  him.  AYe  gratefully  acknowl¬ 
edge  that  his  works  revolutionized  the  pathology  and  treat¬ 
ment  of  laryngeal  disease.  “His  researches,”  says  our  emi¬ 
nent  president,  “formed  an  epoch  in  the  study  of  laryngeal 
inflammation.”  They  dissipated  the  clouds  that  surrounded 
laryngology  and  assisted  at  the  dawn  of  laryngoscopy. 

Our  former  secretary,  in  his  wonderfully  accurate  pho¬ 
tograph  of  our  fellows,  appropriately  placed  Dr.  Horace 
Green  as  the  central  figure. 


Action  of  Cod-liver  Oil.— “MM.  Gautier  and  Mourgnes,  in  a  re¬ 
cent  communication  to  the  Academy  of  Sciences,  discuss  at  some  length 
the  reasons  why  cod-liver  oil  is  superior  to  other  fats  as  a  therapeutical 
agent,  and  arrive  at  the  following  conclusions  :  1.  It  is  more  easily  as¬ 
similated,  owing  to  its  containing  free  fatty  acids  and  some  biliary  mat¬ 
ters  which  render  its  emulsion  specially  easy  when  it  comes  in  contact 
with  the  pancreatic  juice.  2.  It  is  rich  in  phosphates,  phosphoric  acid, 
lecithin,  and  phosphorus  in  organic  combination  ;  the  phosphorus,  espe¬ 
cially  in  the  last-mentioned  form,  is  very  readily  assimilated  to  form 
protoplasm,  and  thus  nutrition  is  greatly  stimulated.  The  small 
amounts  of  bromine  and  iodine  being  also  present  as  organic  compounds 
exercise  a  beneficial  influence  on  the  general  metabolism.  3.  The  alka¬ 
loids  present — butylamine,  amylamine,  morrhuine — and  morrhuic  acid 
stimulate  the  nervous  system,  increase  the  amount  of  sweat  and  urine, 
and  act  as  nervine  tonics.” — British  Medical  Journal. 


August  30,  1890.]  WILMER:  OCULAR  DEFECTS  A S  A  FREQUENT  CAUSE  OF  HEADACHE. 


233 


OCULAR  DEFECTS 

AS  A  FREQUENT  CAUSE  OF  HEADACHE  * 

By  WILLIAM  HOLLAND  WILMER,  M.  D., 

WASHINGTON,  D.  0. 

If  there  is  one  malady  more  than  all  others  that  has 
taxed  the  ingenuity  of  the  physician  in  regard  to  alleviation 
or  cure,  that  one  is  headache.  The  brain,  with  its  cover¬ 
ings,  as  a  part  of  the  body,  and  not  an  isolated  organ,  has 
a  more  or  less  close  connection  by  nerves  and  blood  current 
with  other  organs  ;  and  experience  has  established  the  fact 
that  disorders  existing  in  distant  portions  of  the  body, 
among  other  manifestations,  may  exhibit  themselves  in  the 
form  of  headache.  Therefore,  a  symptom  aetiologically  and 
pathologically  so  complex  can  not  be  relieved  by  any  single 
remedy.  It  is  only  by  tracing  the  symptom  to  its  cause, 
and  by  removing  or  correcting  it,  that  we  can  hope  to  afford 
relief.  A  very  frequent  cause  of  head  pain  is  some  defect 
in  the  visual  apparatus,  but  the  causal  relation  between  the 
two  has  only  of  late  obtained  due  recognition.  Recently, 
not  a  little  has  been  written  upon  this  subject,  but  it  is  not 
the  writer’s  object  to  give  the  literature,  but  simply  his  per¬ 
sonal  experience  with  this  class  of  cases. 

Here  let  me  say  parenthetically  that  I  do  not  intend  to 
exclude  other  causes  of  headache.  Our  confreres  the  gen¬ 
eral  practitioners  are  prone  to  believe  that  the  specialist 
has  become  so  warped  by  specialism  that  he  can  behold 
only  the  mote  in  the  eye,  while  the  beam  in  other  organs  is 
not  recognized.  I  must  admit  that  there  has  been  ground 
for  this  opinion.  Some  of  us,  like  the  birds  and  species  of 
reptiles,  seem  to  have  developed  a  mental  membrana  nicti- 
tans  by  which  we  exclude  from  our  sight  all  portions  of  our 
patients’  bodies  except  their  eyes.  For  the  past  few  years 
the  writer  has  carefully  noted  the  clinical  features  of  the 
cases  as  well  as  corrected  the  ocular  defects. 

The  headaches  which  the  ophthalmologist  meets  with 
fall  under  two  classes  :  One,  in  which  the  symptom  is  di¬ 
rectly  traceable  to  the  use  of  the  eyes  and  is  accompanied 
by  other  signs  of  asthenopia — such  as  weak  feeling  of  the 
eyes,  watering,  strained  sensation,  and  inability  to  use  them 
for  any  length  of  time'.  In  the  other  class,  the  vision  is  ap¬ 
parently  perfect  and  the  eyes  themselves  free  from  pain, 
yet  headache  is  often  severe.  I  do  not  recall  a  single  case 
coming  under  the  first  classification  in  which  the  headache 
was  not  cured,  or  relieved,  by  the  proper  glasses.  , 

Cases  under  the  second  category  generally  come  to  the 
oculist  after  previous  medical  treatment,  and  frequently  by 
the  advice  of  the  family  physician,  or,  as  a  dernier  ressort, 
at  the  suggestion  of  a  friend.  Such  patients  attribute  their 
headache  to  some  other  organ  than  the  eye  ;  for  it  is  diffi¬ 
cult  for  them  to  understand  how  headache  can  result  from 
eye  strain  when  the  vision  is  good  and  the  eyes  themselves 
free  from  pain. 

In  cases  of  this  division  a  goodly  proportion  of  head¬ 
aches  were  relieved  or  cured  by  the  systematic  use  of  glasses 
—often  to  the  joy  and  surprise  of  the  patient.  However, 
nothing  can  bring  out  the  point  so  well  as  a  recital  of  a  few 

*  Abstract  of  a  paper  read  before  the  Medical  Society  of  the  District 
of  Columbia,  May  28,  1890. 


of  the  most  interesting  cases,  which  I  will  give  in  some  lit¬ 
tle  detail  even  at  the  risk  of  becoming  tedious. 

I  select  at  random  a  few  cases  in  which  the  age  of  the 
patient,  the  refraction  error,  and  the  length  of  duration  of 
the  headache  vary.  I  am  indebted  to  my  friend  Dr.  Grue- 
ning,  of  IS  ew  A  ork,  for  the  use  of  his  case  books,  from  which 
these  cases  were  taken  : 

Case  I.  Hyperopia.— E.  M.,  aged  nine,  came  to  the  office 
with  the  following  history  :  Vision  had  been  apparently  perfect 
until  three  days  before,  when  he  noticed  that  figures  on  the  black¬ 
board,  which  were  previously  clearly  seen,  could  no  longer  he 
recognized.  He  had  suffered  from  frequent  headache  since  he 
first  started  to  school,  but  during  the  past  three  days  has  had 
constant  dull  pain  in  forehead  and  temples.  Sight  in  either  eye 
one  fifth  of  normal.  Tested  by  glasses,  there  was  an  apparent 
myopia  of  A-  With  this  correction,  the  vision  for  distance  was 
normal.  One  hour  after  the  instillation  of  a  one-per-cent,  so¬ 
lution  of  atropine  the  pupils  were  fully  dilated  and  patient  said 
that  his  head  felt  better  than  it  had  for  three  days.  At  this  time  a 
hyperopia  of  A  was  found.  Three  days  later  patient  returned, 
after  the  systematic  use  of  atropine,  with  the  statement  that  he 
had  had  no  return  of  the  headache  since  last  visit.  He  showed 
a  total  hyperopia  ol  -fa  at  this  visit,  and  glasses  correcting  the 
full  defect  were  given.  There  has  been  no  return  of  the  head¬ 
ache. 

Case  II.  Compound  Myopic  Astigmatism. — V.  M.,  aged  fifty- 
two,  was  seen  in  November,  1888.  He  complained  of  great  dif¬ 
ficulty  in  reading,  especially  by  artificial  light.  Upon  being 
questioned,  he  said  that  he  had  more  or  less  constant  dull  pain 
in  the  head,  principally  at  the  back  part.  He  added  that  he  did 
not  expect  to  be  relieved  of  that.  He  had  never  worn  glasses, 
bight  in  either  eye  =  f;  with  the  proper  correction,  normal. 
A  combined  concave  cylindrical  and  spherical  glass  was  pre¬ 
scribed  for  the  distance,  while  for  reading  the  astigmatism  and 
presbyopia  were  corrected  by  another  glass.  The  headache, 
with  the  other  symptoms  of  asthenopia,  disappeared  after  the 
use  of  the  glasses. 

Case  III.  Mixed  Astigmatism. — J.  F.,  aged  thirty-five  is  the 
last  that  I  will  recite.  The  patient,  a  Wall  Street  broker,  came 
to  the  office  in  April  of  the  past  year.  He  suffered  from  in¬ 
somnia  and  from  headache  which  extended  from  the  top  to  the 
back  of  the  head.  Prolonged  medical  treatment  had  given  no 
lelief  other  than  the  production  of  sleep  by  hypnotics.  Sight 
=  f  5  wi.th  the  correction,  =  f  + .  The  hyperopic  element  of  the 
astigmatism,  which  was  predominant,  was  corrected  temporari¬ 
ly,  and  the  patient  informed  that  it  would  probably  be  neces¬ 
sary  to  re-examine  the  eyes  under  a  mydriatic,  when  other 
glasses  could  be  prescribed.  The  patient  received  his  glasses 
the  same  afternoon,  and  returned  three  days  later  to  report  that 
during  the  past  few  days  he  had  been  free  from  headache,  and 
had  slept  without  a  hypnotic  better  than  he  had  done  for 
years.  The  relief  was  so  great  that  another  examination  has 
been  thus  far  not  imperative. 

In  the  first  case  the  constant  headache  was  of  only  three 
days’  duration  and  came  on  at  the  same  time  as  the  ocular 
symptom  of  near-sight.  Owing  to  the  spasm  of  the  ciliary 
muscle,  not  only  was  the  existing  hyperopia  masked,  but 
apparent  myopia  produced.  The  headache  was  relieved 
when  the  ciliary  muscle  was  put  at  rest  by  atropine. 

The  headache  in  the  next  case  had  lasted  through  the 
patient’s  lifetime,  but  had  not  been  attributed  to  the  eyes ; 
in  fact,  it  was  only  the  other  symptoms  of  asthenopia  that 
brought  him  to  an  oculist. 


234 


WRIOET:  HEMORRHAGE  AFTER  AMY GDALOTOMY. 


[N.  Y.  Med.  Joub., 


The  third  case  is  interesting  on  account  of  the  reflex 
nervous  symptoms  that  accompanied  the  headache.  The 
glasses  relieved  him  when  three  years  of  medical  treatment 
and  traveling  had  failed. 

As  the  correction  of  an  ocular  error  can  relieve  head¬ 
ache,  so  the  production  of  such  a  defect  artificially  may 
cause  it.  This  fact  is  exemplified  in  the  writer’s  experience 
with  dark  curved  glasses.  All  glasses  of  this  description 
brought  by  patients  to  the  office  during  the  two  years  fol¬ 
lowing  September,  1887,  were  examined  and  their  refrac¬ 
tion  noted.  They,  without  exception,  possessed  the  action 
of  a  concave  glass  in  one  or  all  meridians.  There  were  con¬ 
cave  sphericals,  the  same  with  concave  cylinders,  and,  with 
these,  a  variety  of  combinations  with  prisms.  In  the  ma¬ 
jority  of  cases  the  glasses  were  irregularly  concave.  The 
cheaper  grade  of  glasses  worn  by  dispensary  patients  pre¬ 
sented  the  same  defects  to  a  greater  degree.  The  writer 
has  had  some  personal  experience  with  headaches  from  this 
cause.  Some  years  ago  I  purchased  colored  glasses  to  wear 
while  traveling.  For  a  short  while  they  were  agreeable,  but 
in  the  course  of  half  an  hour  pain  extending  from  forehead 
to  occiput  supervened.  A  slight  amount  of  hyperopic  astig¬ 
matism  in  my  case  will  account  for  the  pain  caused  by  the 
irregularly  concave  glasses. 

Not  by  any  means  can  every  headache  be  cured  by 
glasses.  It  may  require  the  care  of  the  general  physician, 
the  gynaecologist,  the  rhinologist,  the  neurologist,  or  even 
the  surgeon. 

The  headaches  that  belong  to  the  domain  of  the  general 
practitioner  are  legion,  e.  g.,  the  various  toxaemic  headaches 
and  those  dependent  upon  other  general  disorders.  Again, 
we  all  know  of  frontal  headaches  due  to  disease  of  the 
frontal  sinuses  or  to  nasal  occlusion. 

In  conclusion,  I  think  we  may  safely  say  tbat  headaches, 
even  where  the  eyes  seem  perfect,  can  frequently  be  cured 
by  properly  adjusted  glasses. 

At  times,  the  true  condition  of  the  eyes  can  only  be 
found  under  the  influence  of  a  mydriatic.  Especially  is  this 
the  case  with  children. 

The  fact  that  headache  disappears  under  the  influence 
of  a  mydriatic  gives  ground  for  prognosticating  relief  by 
glasses. 

Flat  smoked  glasses  should  be  worn,  if  a  colored  glass 
is  necessary,  when  the  patient  is  not  myopic  or  when  the 
accommodation  is  not  completely  paralyzed. 

Finally,  the  existence  or  non-existence  of  eye  strain 
should  at  least  be  known  in  cases  of  obstinate  cephalalgia 
before  any  course  of  treatment  can  be  intelligently  adopted. 


Antipyrine  for  Erysipelas. — “  Dr.  Favre,  of  Fribourg,  relates  an  un¬ 
usually  severe  case  of  erysipelas,  showing  the  high  curative  value  of 
antipyrine.  A  woman,  aged  thirty,  suffered  from  facial  erysipelas  ac¬ 
companied  by  somnolence,  vomiting,  constipation,  and  high  fever.  In 
spite  of  the  local  application  of  cold,  carbolic  acid,  ichthyol,  corrosive 
sublimate,  strips  of  adhesive  plaster,  etc.,  the  morbid  process  gradually 
spread  over  the  scalp,  neck,  chest,  upper  extremities,  abdomen,  and 
buttocks.  On  the  tenth  day  the  administration  of  antipyrine  was  com¬ 
menced,  with  the  result  that  fever  at  once  markedly  decreased,  the  pa¬ 
tient’s  subjective  state  greatly  improved,  and  the  erysipelas  soon  ceased 
to  spread.” — British  and  Colonial  Druggist. 


HAEMORRHAGE  AFTER  AMYGDALOTOMY. 

WITH  A  DESCRIPTION  OF 
A  GALVANO-CAUTERY  AMYGDALOTOME. 

By  JONATHAN  WRIGHT,  M.  D., 

BROOKLYN. 


The  question  of  haemorrhage  after  amygdalotomy  has 
been  the  theme  of  many  animated  discussions  in  various 
society  meetings.  The  symptoms  for  which  amygdalotomy 
is  usually  performed  are,  as  a  rule,  so  little  threatening  to 
life  and  to  comparatively  good  health  that  it  has  seemed 
to  many  that  even  the  few  cases  reported  of  serious  htemor- 
rhage  form  a  contra-indication  to  the  operation.  On  the 
other  hand,  the  less  conservative  are  disposed  to  disregard 
the  danger,  estimating  it  as  infinitely  small,  pointing  both 
to  the  extremely  small  percentage  of  cases  of  dangerous 
haemorrhage  when  all  amygdalotomies  are  considered,  and  to 
the  assertion*  that  no  case  of  fatal  haemorrhage  with  mod¬ 
ern  methods  has  ever  been  reported.  These  are  two  ex¬ 
tremes  of  opinion,  much  of  it  expressed  in  the  heat  of 
debate.  This  is  one  of  the  many  questions  where  a  mean 
position  is  probably  the  more  tenable. 

It  has  never  been  my  misfortune  to  have  any  case  of 
considerable  haemorrhage  following  amygdalotomy,  neither 
has  any  such  case  come  under  my  direct  observation  in  the 
practice  of  others  5  but  in  looking  over  the  literature  of  the 
subject,  as  well  as  in  considering  the  cases  which  have  come 
to  my  knowledge,  the  fact  has  been  very  apparent,  and  the 
remark  has  frequently  been  made  before  by  others,  that  in 
the  very  large  majority  of  cases  the  patients  were  adults. 
The  fibroid  elements  in  a  hypertrophied  tonsil,  which  always 
increase  relatively  as  age  advances,  and  often  absolutely, 
form  a  less  favorable  tissue  for  the  retraction  and  closure  of 
cut  vessels  than  the  soft,  spongy  mass  of  a  young  tonsil 
made  up  largely  of  lymphoid  tissue. 

In  order  to  ascertain  how  many  of  the  cases  of  haemor¬ 
rhage  reported  after  amygdalotomy  were  in  adult  patients,  I 
have  requested  Dr.  R.  Lorini,  of  Washington,  to  search  the 
records  of  the  last  twenty-five  years  in  the  Surgeon-Gen¬ 
eral’s  office.  Dr.  Lorini  has  not  been  able  to  find  the  arti¬ 
cles  denoted  by  the  following  references :  De  Blois,  Boston 
Med.  and  Surg.  Jour.,  Mar.,  1887,  p.  309  ;  Billroth,  Aerztl. 


Intell.-Blatt ,  1870,  No.  31,  and  Wien.  mad.  Woch.,  1870, 
No.  49.  The  following-named  journals  were  not  accessible 
at  the  time  of  making  the  search,  the  volumes  being  at  the 
Government  bindery:  Med.  Record ,  xxiii,  1883;  N.  Y. 
Med.  Jour.,  1,  1889.  Dr.  Lorini  remarks  that  Ricordeau. 
in  his  thesis,  states  that  Cheselden  reported  two  cases  of 


death  from  haemorrhage  after  removal  of  the  tonsils  with 
the  bistoury,  no  details  being  given.  I  insert  herewith  the 
report  as  he  made  it  to  me. 

Several  facts  are  especially  noteworthy. 

It  will  be  seen  that  the  total  number  of  cases  reported 
is  not  so  large  as  might  be  expected.  It  will  also  be  seen 
that  in  the  list  are  two  fatal  cases,  one  in  an  adult  of  twentj- 
four  or  twenty-five,  in  which  no  mention  is  made  of  the  in¬ 
strument  used.  The  other  fatal  case  was  in  a  boy  of  eight 


*  Delavan,  Trans,  of  the  Am.  Laryng.  Assoc.,  1888. 


August  30,  1890.] 


WRIQHT :  HEMORRHAGE  At  TER  A  MY ODALOTOMY. 


235 


CASES  OF  ALARMING 

HAEMORRHAGES  AFTER  AMYGDALOTOMY* 

Sex. 

Age. 

Disease  or  con- 

dition  requiring  Instrument  used, 

operation. 

Ultimate 

result. 

Operator,  reporter,  reference,  and  other  remarks. 

United  States. — 17  cases. 

Male. 


Male. 


Female. . 

Middle.. 

Hypertrophy  of 

Amygdalotorae  (no 

right  tonsil. 

pattern  ment’ned). 

Male.... 

18 . 

Hypertrophied 

Tonsillo-guillotine. 

tonsil. 

Male. . . . 

25 . 

Hypertrophied 

Tonsil  bistoury. 

tonsil. 

Male. . . . 

35 . 

Hypertrophied 

Mackenzie’s  amyg- 

tonsil. 

dalotome. 

Female. . 

Young. . 

Amygdalotome. 

Hypertrophy  of 
right  tonsil. 

Male.  .  . . 

Amygdalotome. 

Female. . 

30 . 

Enlargement  of 

Mackenzie’s  modifi- 

left  tonsil, 

cation  of  Physick’s 

acute  inflam. 

guillotine. 

Male .... 

25 . 

Hypertrophy  of 

Mathieu’s  amygdalo- 

tonsil. 

tome. 

Male. . .  . 

21 . 

Quinsy. 

Mathieu’s  amygdalo¬ 
tome. 

Male. . . . 

27 . 

Amygdalitis. 

Mathieu’s  amygd’lot. 

Male. . . . 

22 . 

Hypertrophy  of 

Volsella  and  angu- 

both  tonsils. 

lar  scissors. 

Male. . .  . 

Young. . 

Physick’s  amygdalo¬ 
tome. 

Male. . . . 

34 . 

Amygdalotome  (no 
pattern  ment’ned). 

Female. . 

7 . 

Fahnestock’s. 

Male. . . . 

Adult. .  . 

Guillotine  (no  make 
mentioned). 

Male. . .  . 

Male.  . .  . 

48..  . .  . 

Tonsillar  hy- 

Mathieu’s  amygdalo- 

pertrophy. 

tome. 

Dr.  A.  M.  Fauntleroy,  Amer.  Med.  Weekly ,  Louisville,  ii,  1875,  p.  498. 
Patient  was  very  full  blooded;  ice-packing  upon  neck  employed. 

Dr.  L.  D.  Kastenbine,  Louisville  Med.  News ,  i,  1876,  280,  281.  Haemor¬ 
rhage  stopped  by  patient  walking  home  with  mouth  open. 

Dr.  G.  M.  Lefferts,  Arch,  of  Laryngol.,  New  York,  iii,  1882,  37.  Press¬ 
ure  applied  directly  upon  surface. 

Do.  Haemorrhage  from  artery  at  right  stump ;  artery  twisted,  haemor¬ 
rhage  stopped. 

Do.  Artery  twisted. 

Do.  Do. 

Dr.  Clinton  Wagner,  Tr.  of  the  Am.  Laryngol.  Assoc.,  1886,  New  York, 
1887,  viii,  185.  Artery  twisted  with  artery  forceps. 

Dr.  S.  E.  Fuller,  Amer.  Jour,  of  the  Med.  Sci.,  Phila.,  xcv,  1888,  357.  Caro- 
tis  commun.  ligated ;  saline  solution  (12  oz.)  transfused  into  radial  vein. 

Dr.  L.  E.  Blair,  Albany  Med.  Ann.,  ix,  1888,  41-47.  Haemorrhage  from 
left  tonsil ;  ice  and  compress. 

Do.  Haemorrhage  from  right  tonsil ;  stopped  by  compress. 

Dr.  E.  W.  Clarke  reported  and  performed  ligation ;  Dr.  T.  M.  Markoe, 
operator,  N.  Y.  M.  J.,  xlviii,  1888,  7.  Haemorrhage  stopped  by  liga¬ 
tion  of  stump. 

Dr.  Daly,  Tr.  of  the  Am.  Laryngol.  Assoc.,  1888.  N.  Y.,  1889.  Haemor¬ 
rhage  stopped  by  compress. 

Dr.  D.  Bryson  Delavan,  Tr.  of  the  Am.  Laryngol.  Assoc.,  x,  1888,  N.  Y., 
1889,  153-163. 

Do.  Patient  was  a  haomophile. 

Dr.  R.  J.  Lewis,  Med.  News,  Phila.,  liii,  1888,  640.  Haemorrhage  stopped 
by  application  of  a  tenaculum  through  base  of  tonsil  and  twisting  it. 

Dr.  A.  Yander  Veer,  reporter;  Dr.  Alden  March,  operator;  Albany  Med. 
Ann.,  ix,  1888,  41-47.  No  details  given. 

Dr.  F.  Park  Lewis,  J.  of  Ophtli.,  Otol.,  and  Laryngol.,  N.  Y.,  i,  1889, 
115-117.  Haemorrhage,  4  qts.  in  17  hours  from  left  tonsil. 


Austria. — 1  case. 


31. 


Syphilitic  en¬ 
largement  of 
right  tonsil. 


Recovery.  Dr.  Giintner,  Oesterr.  Zeitschr.  f.  prakt.  Heilk.,  Wien,  1872,  xviii,  No.  62, 
p.  839.  Patient  a  haemophile,  syphilitic,  common  carotid  ligated. 


Hook  and  bistoury. 

France. — 8  cases :  6  recoveries,  2  fatal 


Male .... 

Male. . . . 

Male. . . . 

Female. . 
Bov . 

21 . 

Hypertrophy  of 
tonsils. 

Hypertrophy  of 
tonsils. 

Young. . 

35 . 

Amygdalot. ;  operat’n 
by  patient  himself. 

20 . 

Male. . . . 
Male. . . . 

Male. . . . 

24-25. . . 

8h . 

Double  tonsill’r 
angina ;  hy¬ 
pertrophy. 

Amygdalotome  (no 
pattern  ment’ned). 

20 . 

Recovery. 


Fatal. 

U 


Recovery. 

Germany. — 1  case. 


Gayat,  These,  Paris,  1868,  No.  275,  p.  52.  Jarjavay  operated,  right 
tonsil  removed. 

Mary,  These,  Paris,  1875,  No.  29,  Verneuil,  operator.  Haemorrhage 
stopped  by  perchloride  of  iron. 

Do.  Broca,  operator,  1869.  Both  tonsils  removed;  patient  a  haemo- 
phile ;  haemorrhage  stopped  in  two  hours  by  direct  application  of  ice. 

Do.  Do.  No  details. 

Ricordeau,  Thbse,  Paris,  1886;  Reclus,  operator.  Both  tonsils  removed. 

Do.  Broca,  operator,  1879.  No  details. 

Do.  Nov.,  1879.  Cause  of  haemorrhage,  anomalous  internal  carotid. 


Dr.  Saint-Germain.  No  details;  haemorrhage  stopped  by  ice  applied 
around  throat. 


31. 


Cautery  (probably 
thermo-cautery). 


Dr.  Werner,  Oct.  11,  1887,  Med.  Cor. -LI,  d,  wurtemb.  drztl.  Ver .,  Stutt., 
lviii,  1888,  241.  Manual  compression  of  carotis  for  10  days. 


Recovery. 

Great  Britain. — 3  cases. 


Male. . . . 

Hypertrophy  of 
left  tonsil. 

Bistoury. 

Recovery. 

U 

Male. 

Male .... 

34 . 

Chron.  follicul’r 
amygdalitis. 

Mackenzie’s  for  right 
tonsil  and  tonsil- 
sickle  for  left  ton. 

U 

Sweden 

Female. . 

Hypertrophy  of 
tonsils. 

Forceps  and  blunt 
bistoury. 

Recovery. 

Dr.  Wharton  P.  Hood,  Lancet,  1870,  vol.  ii,  600.  Small  calculus  within 
tonsil ;  vomiting  stopped  haemorrhage. 

Do.  No  details ;  both  tonsils  excised ;  sulph.  of  zinc  administered ; 
vomiting,  haemorrhage  stopped. 

Dr.  J.  Walker  Dounie,  Edinb.  M.  J.,  xxxii,  1886-  87,  116.  Haemorrhage 
stopped  by  actual  cautery. 


Dr.  Lidon,  1880,  Hygeia,  Stockholm,  xlii,  1881,  p.  256.  Ligation  of 
common  carotid. 


*  Since  this  table  was  compiled  I  note  the  report  of  a  case  of  haemorrhage  after  amygdalotomy,  in  a  child  seven  years  old,  during  active  in¬ 
flammation  of  the  tonsils.  (Moure,  reference  in  Jour,  of  Laryng .,  1890,  No.  8.) 


236 


WEIGHT:  HEMORRHAGE  AFTER  AMYGDALOTOMY. 


[N.  Y.  Med.  Joub., 


years  and  a  half,  in  which  the  operation  was  performed 
with  an  amygdalotome.  The  cause  of  death  in  the  latter 
instance  was  the  wounding  of  the  internal  carotid  artery, 
which  pursued  an  anomalous  course,  so  that  no  precaution 
could  have  averted  the  catastrophe.* 

Delavan’s  case  of  haemophilia  is  the  only  other  one  in 
which  the  age  is  given  where  the  patient  was  a  child. 

It  is,  of  course,  impossible  to  say  how  many  unreported 
instances  of  haemorrhage  have  occurred.  There  is  hardly 
a  physician  who  has  not  heard  of  or  observed  one  or  more. 
When  we  consider  how  comparatively  few  amygdalotomies 
are  done  after  the  age  of  eighteen  or  twenty,  the  chances 
of  the  occurrence  of  a  very  undesirable  amount  of  haemor¬ 
rhage  in  any  given  adult  case  are  not  so  few  as  to  be  dis¬ 
regarded  if  there  is  any  way  of  lessening  the  danger.  The 
question  of  fatality  or  recovery  from  the  immediate  effects 
of  the  haemorrhage  is  not  the  only  one  to  be  considered. 
The  loss  of  a  large  quantity  of  blood  may  often  cause  se¬ 
rious  impairment  of  the  general  health  for  many  months. 
It  is  a  common  cause  of  chronic  anaemia,  an  affection  which 
most  frequently  baffles  the  skill  of  the  physician  and  ex¬ 
hausts  the  patience  of  friends.  Although  the  operator 
himself  may  not  be  unduly  alarmed,  unless,  as  in  one  case 
in  the  list,  he  himself  happens  to  be  the  victim,  the  patient 
and  his  friends  are  always,  in  spite  of  the  most  positive 
assurances,  greatly  agitated. 

When  all  these  facts  are  considered,  I  can  not  see  how 
amygdalotomy  under  ordinary  indications  is  a  justifiable  op¬ 
eration  in  adults  when  there  is  a  safer  and  quite  as  efficient 
method  of  procedure.  On  the  other  hand,  I  am  unable 
to  perceive  why  any  other  than  the  cutting  operation 
should  be  done  in  children,  since  the  danger  is  practically 
nil  and  the  difficulties  of  other  procedures  are  very  much 
greater. 

Ignipuncture  has  been  extensively  used  as  a  substitute 
for  amygdalotomy.  I  have  employed  it  in  a  large  number 
of  cases,  and  a  year  or  two  ago  gave  a  short  account  of  my 
experience  in  a  letter  to  the  Medical  News ,  March  24,  1888. 
In  children  it  is  only  of  value  in  my  experience  where  the 
tonsillar  tissue  is  diffuse  and  does  not  project  beyond  the 
faucial  pillars.  In  these  cases  a  cutting  operation  is  in¬ 
effectual  and  usually  impossible.  If  the  child  is  tractable 
and  cocaine  is  applied,  the  platinum  point  of  the  galvano- 
cautery  can  frequently  be  used  advantageously  to  burn 
down  the  irregular  nodules  of  lymphoid  tissue  between  the 
pillars.  In  burning  adult  tonsils,  eight  to  twelve  sittings 
are  often  necessary,  the  number,  of  course,  depending  upon 
the  size  and  extent  of  the  hypertrophy.  There  must  be  a 
week  or  ten  days  between  each  sitting.  Occasionally,  in 
spite  of  cocaine,  the  applications  are  disagreeably  painful, 
especially  toward  the  last,  when  the  hot  wire  is  used  in 
close  proximity  to  the  mucous  membrane.  In  the  above¬ 
given  table  a  case  of  haemorrhage  after  the  cautery  has  been 
reported.  It  is  a  little  hard  to  understand  how  such  a  thing 
could  occur  to  any  sensible  operator  or  with  any  reasonable 
procedure  unless  a  vessel  of  very  large  size  (internal  ca- 


*  Dr.  Lorini  assures  me  that  no  mention  of  these  cases  can  be 
found  outside  of  Ricordeau’s  thesis. 


rotid)  was  wounded  by  the  penetration  of  the  hot  point. 
Nevertheless,  the  case  should  be  kept  in  mind. 

Notwithstanding  these  disadvantages,  I  believe  igni¬ 
puncture  in  adults  preferable  to  amygdalotomy.  Preferable 
to  both,  however,  is  the  removal  by  the  galvano-cautery 
snare  as  recommended  by  Dr.  Knight.*  I  have  used  it 
several  times,  both  before  and  since  the  appearance  of  the 
paper.  The  principal  objection  to  it  is  the  extreme  diffi¬ 
culty  frequently  encountered  in  the  satisfactory  adjustment 
of  the  platinum  or  irido-platinum  loop.  The  reflex  move¬ 
ments  of  the  patient’s  throat  are  often  so  pronounced  as  to 
render  the  procedure  almost  impossible.  After  my  clothing 
had  formed  the  repository  of  the  contents  of  one  patient’s 
stomach,  I  began  to  cast  about  me  for  some  pleasanter 
method  of  accomplishing  my  purpose.  The  instrument 
figured  here  has  been  the  result. 


As  will  be  seen  at  a  glance,  it  is  the  adaptation  of  an 
ordinary  Mackenzie  amygdalotome  to  galvano-cautery  pur¬ 
poses.  Instead  of  the  steel  blade  with  the  convex  cutting 
edge,  a  non-conducting  material  (compressed  paper)  is  used, 
and  one  end  hollowed  out  into  a  crescent.  Across  this  is 
stretched  a  platinum  wire  which  represents  the  sharp  edge 
of  the  cutting  instrument.  This  is  connected  by  means  of 
copper  wires,  inlaid  along  the  sides  of  the  blade,  with  the 
binding  screws  at  the  other  end.  Here,  by  means  of  the 
ordinary  spring,  the  circuit  from  a  cautery  battery  is  closed 
by  the  pressure  of  the  thumb  as  the  blade  is  driven  against 
the  mass  included  in  the  loop  of  the  instrument  when  ad¬ 
justed.  The  frame  of  the  instrument  is  the  same  as  that  of 
the  Mackenzie.  The  platinum  and  copper  wires  are  so  ar¬ 
ranged  that  the  former  can  be  cheaply  and  easily  replaced 
when  by  accident  it  is  burned  through. 

Of  course  this  instrument  can  be  as  easily  adjusted  as 
the  ordinary  amygdalotome.  The  tonsil  can  be  severed  as 
quickly  as  with  a  knife  if  the  wire  is  heated  white  hot,  but 
by  regulating  the  current  the  operation  can  be  done  as  slowly 
as  may  be  thought  desirable.  It  must  be  remembered  that 
more  of  the  tonsil  is  destroyed  than  is  represented  by  the 
part  cut  away,  the  cauterization  of  the  stump  causing 
marked  retraction  after  healing.  With  the  galvano-cautery 
snare  the  edges  of  the  faucial  pillars  are  apt  to  be  severely 
cauterized,  often  causing  great  pain  for  several  days  after 
the  operation.  This  is  entirely  avoided  by  the  galvano- 
cautery  amygdalotome.  I  can  not  say  that  the  device  will 

*  Tram,  of  the  Am.  Laryngol.  Assoc.,  1889,  p.  79. 


August  30,  1890.]  MARSHALL:  A  PRACTITIONER'S  EXPERIENCE  IN  INFANT-FEEDINQ. 


237 


entirely  abolish  all  danger  of  secondary  limmorrhage,  but  it 
must  be  apparent  to  every  one  that  it  will  greatly  diminish 
the  risk.  I  have  not  as  yet  had  an  opportunity  of  using  the 
instrument  extensively,  but  I  present  it  because  I  can  not, 
theoretically,  see  why  it  should  not  do  the  work  required 
with  a  great  diminution  of  the  risk. 

In  one  case  of  large,  flat  fibrous  tonsils,  it  removed 
them  on  both  sides  with  very  little  pain  (the  patient  com¬ 
plained  of  none)  and  no  haemorrhage  whatever.  The  retrac¬ 
tion  of  the  stumps  has  been  more  marked  than  usual  where 
they  are  adherent  to  the  pillars  on  all  sides. 

I  atn  indebted  to  the  surgical-instrument  department  of 
Hazard,  Hazard,  &  Co.  for  the  execution  of  the  idea. 


A  PRACTITIONER’S  EXPERIENCE  IN 
INFANT-FEEDING. 

By  CUVIER  R.  MARSHALL,  A.  M.,  M.  D., 

PHILADELPHIA. 

It  may  seem  to  be  almost  a  useless  waste  of  time  to 
attempt  to  add  anything  to  the  volumes  of  matter  which 
have  been  written  upon  the  subject  of  infant-feeding,  and 
the  only  excuse  the  writer  has  to  offer  for  the  present  in¬ 
trusion  upon  the  time  and  patience  of  the  busy  readers  of 
the  New  York  Medical  Journal  is  a  desire  to  present  the 
results  of  a  summer’s  experience  in  the  management  of  arti¬ 
ficially  fed  infants.  I  am  of  the  number  of  those  who  be¬ 
lieve  that  cow’s  milk  is  the  best  substitute  for  the  mother’s 
milk  in  the  vast  majority  of  cases.  I  have  met  with  in¬ 
stances  among  the  poor  where  children  of  from  two  to  four 
months  of  age  have  been  fed  on  cold  cow’s  milk,  undiluted, 
except  when  that  precaution  had  been  kindly  taken  by  the 
milkman  before  delivery.  In  many  of  these  cases  apparent¬ 
ly  no  evil  results  were  noticeable.  I  have  frequently  seen 
upon  the  streets  of  our  cities  infants  being  wheeled  about 
with  the  omnipresent  nursing-bottle  conveniently  arranged 
in  such  a  position  as  to  enable  the  child  to  feed  at  pleasure 
without  any  regard  to  proper  periods  of  digestion,  and  yet 
those  children  seemed  to  thrive.  These  facts  are  not  offered 
in  support  of  such  improper  methods,  for  they  can  not  be 
too  strongly  condemned ;  and  we  all  know  how,  on  the 
other  hand,  a  very  slight  departure  from  the  strictest  clean¬ 
liness  or  the  greatest  care  in  the  preparation  of  the  milk 
will  bring  on,  in  many  infants,  various  types  of  gastric  and 
intestinal  derangement.  I  was  once  very  favorably  im¬ 
pressed  with  the  possible  value  of  some  of  the  artificially 
prepared  foods  of  the  Liebig  class,  the  so-called  malted 
foods,  but,  after  having  given  them  a  fair  trial,  I  was  led  to 
conclude  that  they  would  give  satisfactory  results  in  excep¬ 
tional  cases  only.  The  class  of  infants  with  which  we,  as 
general  practitioners,  have  to  deal  with  reference  to  the 
regulation  of  the  diet  is  that  large  number  of  puny,  sickly 
children  possessed  of  very  feeble  digestive  powers,  with 
which  class  I  have  found  the  malted  foods  to  disagree,  pro¬ 
ducing  vomiting,  and,  on  account  of  their  laxative  proper¬ 
ties,  diarrhoea.  In  my  experience,  the  wheat  foods  should 
not  be  given  to  young  infants  unless  everything  in  the 
milk  line  has  been  proved  to  be  impracticable;  young  in¬ 


fants  can  not  digest  starch,  and,  although  some  very  able 
writers  and  teachers  advise  the  use  of  starch  in  these  cases, 

I  am  unable  to  obtain  the  results  alleged  for  this  class  of 
foods.  One  leading  authority  has  asserted  that  the  addition 
of  a  small  quantity  of  barley  water  or  oat-meal  water  to 
cow’s  milk  will  prevent  the  curdling  of  the  casein  in  large 
masses;  but  I  have  failed  to  obtain  any  such  much-desired 
result  from  that  procedure.  Starch  is  digested  in  the  in¬ 
fant  by  the  saliva;  the  young  infant  does  not  secrete  a  large 
quantity  of  that  fluid,  and,  even  if  it  did,  it  does  not  mas¬ 
ticate  the  food  and  incorporate  with  it  the  saliva  as  the 
adult  does;  but  the  starchy  food  being  received  immediate¬ 
ly  into  the  stomach  ferments  there,  and  is  apt  to  give  rise 
to  unpleasant  results. 

The  most  efficient  agent  for  the  artificial  digestion  of 
milk  which  has  been  brought  out  by  modern  enterprise  is 
the  extract  of  pancreas,  as  prepared  by  several  well-known 
firms.  By  its  use  the  casein  may  be  completely  converted 
into  peptone  for  use  in  cases  of  children  of  very  feeble  con¬ 
stitution,  or  it  may  be  only  partially  digested  for  stronger 
infants,  in  which  condition,  on  the  addition  of  a  few  drops 
of  anv  acid,  the  casein  will  precipitate  in  fine  flakes,  the 
effect  resembling  that  produced  by  the  action  of  the  gastric 
juice  on  human  milk.  Any  one  can  make  this  experiment 
for  himself,  and  it  will  show  at  once  the  great  value  of  this 
agent  in  the  preparation  of  infant  food  :  Warm  a  small  quan¬ 
tity  of  fresh  milk,  and  pour  an  equal  portion  into  each  of 
two  test  tubes  ;  note  the  reaction  of  both  specimens,  and, 
if  not  alkaline,  add  a  few'  grains  of  bicarbonate  of  sodium ; 
and  into  one  test  tube  drop  a  grain  of  a  good  extract  of 
pancreas ;  shake  both  tubes  and  allow  them  to  stand  for 
eight  or  ten  minutes ;  at  the  expiration  of  that  time,  add  to 
each  sample  a  few  drops  of  nitric  acid  and  observe  the  re¬ 
sult.  The  casein  in  the  sample  treated  with  pancreatin 
will  precipitate  in  fine  flakes,  while  that  in  the  other  tube 
will  be  curdled  in  dense,  ropy  masses,  just  as  the  same  re¬ 
sult  is  produced  in  the  stomach  of  the  infant  by  the  acid 
gastric  juice.  The  method  of  artificial  feeding  which  I  have 
adopted  after  much  study  and  careful  reading  and  observa¬ 
tion  is  the  following:  Care  is  taken  to  obtain  the  milk  from 
a  reliable  dealer.  The  milk  supply  of  the  city  of  Philadel¬ 
phia  is  derived  chiefly  from  the  adjoining  counties,  and  it 
is  not  difficult  to  obtain  a  very  fair  quality  of  milk.  A 
number  of  ordinary  prescription  bottles  are  obtained,  vary¬ 
ing  in  size  according  to  the  age  and  weight  of  the  child  ; 
these  bottles  are  thoroughly  cleansed  and  sterilized  by  boil¬ 
ing  them  for  twenty  minutes.  While  this  is  going  on  the 
milk  is  also  sterilized  by  boiling,  in  the  absence  of  the 
modern  sterilizer,  and  at  the  end  of  the  period  of  twenty 
minutes  the  bottles  are  immediately  tilled  and  tightly 
corked,  the  corks  also  having  been  boiled  with  the  bottles. 
After  cooling,  the  bottles  are  laid  on  ice  until  required  for 
use.  When  the  time  for  feeding  has  come,  one  bottle  is 
opened  and  the  contents  are  mixed  with  an  equal  quantity 
of  boiling  water;  the  temperature  of  this  mixture  will  be 
about  right  for  feeding,  and  in  many  cases  it  may  be  given 
without  further  treatment.  When  the  stomach  of  the  in¬ 
fant  is  in  such  an  irritable  condition  that  even  sterilized 
milk  will  not  agree  with  it,  I  am  in  the  habit  of  using  the 


238 


WEED:  HYPERTROPHY  OF  THE  TURBINATED  BODIES. 


[N.  Y.  Med.  Jour., 


pancreatic  extract  of  the  Fairchilds  to  partially  or  completely 
predigest  the  milk  for  administration.  The  mixture  of 
milk  and  boiling  water  having  been  prepared  as  above,  a 
few  drops  of  a  saturated  solution  of  sodium  bicarbonate  are 
added  (sufficient  to  render  the  reaction  alkaline),  and  this  is 
followed  by  the  addition  of  a  small  quantity  of  extractum 
pancreatis,  from  one  to  three  grains  being  used,  according 
to  the  quantity  of  milk  to  be  treated.  The  mixture  is  well 
shaken  and  allowed  to  stand  at  a  uniform  temperature  of 
about  100°  for  from  six  to  twenty  minutes,  when  it  is 
ready  for  use,  the  amount  of  undigested  casein,  of  course, 
decreasing  as  the  process  is  prolonged.  My  rule  is  to  feed 
about  every  two  hours  in  very  young  infants,  about  once  in 
three  hours  being  often  enough  after  the  second  month. 

I  am  sure  that  I  have  succeeded  in  saving  the  lives  of 
infants  in  hot  weather  by  the  above-described  process  when 
every  other  method  or  article  tried  proved  useless.  The 
extra  trouble  involved  is  more  than  is  ordinarily  required  to 
prepare  the  food,  but  after  a  few  trials  the  process  becomes 
quite  simple.  The  articles  required  are  from  six  to  ten 
bottles  (varying  in  size  from  two  ounces  to  six  in  capacity), 
a  few  corks,  a  bottle  of  a  saturated  solution  of  sodium  bi¬ 
carbonate,  and  a  quantity  of  a  good  extract  of  pancreas. 
1  he  peptogenic  milk  powder  of  the  Fairchilds  is  a  very  ex¬ 
cellent  article,  and  it  probably  enables  us  to  so  modify  cow’s 
milk  as  to  obtain  as  perfect  an  imitation  of  human  milk  as 
it  is  possible  to  produce  in  the  laboratory.  I  have  used  it 
with  success,  and  the  only  objection  which  I  have  to  it  is 
the  fact  that,  on  account  of  the  alkaline  salts  which  it  con¬ 
tains,  the  kidneys  are  powerfully  stimulated  and  the  urine 
is  rendered  alkaline,  offensive,  and  abundant.  The  use  of 
any  artificially  digested  food  is  not  to  be  continued  for  a 
longer  time  than  is  necessary  to  bridge  over  a  critical  period 
in  the  life  of  the  infant,  and  as  soon  as  the  cool  weather  of 
the  fall  mouths  returns,  an  attempt  should  be  made  to  sub¬ 
stitute  for  it  pure  cow’s  milk,  properly  diluted  with  water, 
according  to  the  age  of  the  child. 

‘2243  North  Seventeenth  Street. 


HYPERTROPHY  OF  THE  TURBINATED  BODIES, 

AND  THE  EVILS  RESULTING  THEREFROM* 

By  CHARLES  R.  WEED,  M.  D., 

UTICA,  N.  Y. 

In  presenting  for  your  consideration  my  subject  to-day, 
I  shall  endeavor  to  be  as  brief  as  possible,  refraining  from 
lengthy  anatomical  and  physiological  details  and  descrip¬ 
tions,  assuming  that  with  these  branches  you  are  all  famil¬ 
iar.  Medical  literature  teems  with  the  various  diseases 
originating  from  turbinated  hypertrophies,  and  to  their 
cause,  prognosis,  and  treatment  I  shall  confine  myself. 

To  the  specialist  I  think  I  am  justified  in  saying  that, 
of  the  major  number  of  nasal  troubles  that  come  within  his 
province  and  that  he  is  called  upon  to  treat,  anterior  and 
posterior  hypertrophic  rhinitis  stand  pre-eminently  first. 
During  my  residence  here  I  have  found  that  many  so-called 

*  Read  before  the  Medical  Society  of  the  County  of  Oneida,  July  8, 
1890. 


simple  catarrhs  arise  solely  from  these  hypertrophic  condi¬ 
tions,  which,  unfortunately,  have  not  been  recognized  early 
enough  to  have  effected  the  relief  sought  for. 

To  simplify  my  subject  I  will  divide  the  nasal  cavity 
into  its  two  regions  :  First,  the  olfactory,  which  includes 
the  superior  and  the  upper  half  of  the  middle  turbinated 
bones.  The  membrane  in  this  situation  is  more  closely  ad¬ 
herent  to  the  periosteum  and  relatively  thinner  than  in  the 
second  or  respiratory  area,  is  less  vascular,  and  but  moder¬ 
ately  supplied  with  serous  glands.  Its  nerve  supply  comes 
from  the  terminal  branches  of  the  olfactory,  which,  with 
nerves  of  sensation,  are  distributed  solely  to  this  region 
after  passing  through  the  apertures  of  the  cribriform  plate 
of  the  ethmoid.  The  superficial  lining  of  this  area  of  spe¬ 
cial  sense  is  freely  provided  with  cells  (the  olfactory  cells 
of  Schultz),  and  if  these  are  destroyed  the  sense  of  smell  is 
lost  as  completely  as  though  the  lobes  or  nerves  had  been 
divided. 

The  second,  or  respiratory  region,  includes  the  inferior 
turbinated  bodies  as  supplied  by  the  nerves  of  the  fifth  pair. 
The  glands  in  this  location  are  both  mucous  and  serous,  and 
considerably  larger  than  those  of  the  olfactory  region. 
Their  alveoli  are  filled  with  globules  of  fatty  matter;  hence 
in  ozsena  the  crusts  and  discharges  always  contain  decom¬ 
posing  fatty  globules,  which  give  rise  to  its  characteristic 
offensive  odor.  So  much  for  the  regional  structures;  and 
now  for  the  changes  in  them. 

First,  the  most  frequent  cause  of  hypertrophy  is  the  de¬ 
struction  of  the  vibrissae,  or  hairs  in  the  nostrils,  they  act¬ 
ing  as  the  sentinels  that  guard  the  entrance  to  the  respira¬ 
tory  tract  from  floating  dust  and  coarse  particles.  The 
moist  and  ciliated  mucosa,  by  its  irregular  contour  and 
vibratile  cilia,  is  specially  adapted  to  hold  the  finer  parti¬ 
cles.  These,  on  being  deposited,  act  by  stimulating  the 
glands.  Then  a  secretion  is  poured  out,  and  this  cleans  the 
nostrils.  Now,  in  connection  with  the  hairs,  if  these  cilia 
are  destroyed,  the  above  function  necessarily  ceases,  and 
an  inflammation  begins  whicb,  if  not  treated  at  once,  will 
result  in  hypertrophy.  I  always  warn  my  male  patients 
(for  the  habit  I  am  about  to  mention  is  fortunately  confined 
to  our  sex)  against  pulling  the  hairs  from  the  nostrils — a 
habit  not  only  pernicious  in  the  extreme,  but  disgusting  as 
well.  The  membrane  covering  the  bones  is  first  affected, 
becoming  thickened  in  its  three  layers  by  constant  irritation, 
and  presents  to  the  rhinoscopist  a  turgid,  swollen  appear¬ 
ance.  Anteriorly  the  surface  of  the  inferior  turbinated  bones 
is  most  prominent,  and  at  times  the  membrane  is  so  thick¬ 
ened  as  to  cause  complete  stenosis  by  pressure  against  the 
septum.  The  middle  turbinated,  where  the  hypertrophy  is 
great,  takes  more  of  a  horizontal  position ;  the  membrane 
is  more  or  less  red  according  to  the  intensity  of  the  inflam¬ 
mation  present.  This  condition,  if  allowed  to  increase,  re¬ 
sults  finally  in  the  bony  structures  becoming  hypertrophied, 
the  posterior  ends  showing  the  condition,  which  requires  a 
careful  rhinoscopic  examination  to  determine. 

Of  the  varieties  of  hypertrophy  there  are  two,  the  white 
and  purple,  the  former  being  far  more  commonly  met  with 
than  the  latter.  In  shape  they  are  rounded,  their  surface 
irregular,  and  their  location  posterior,  often  compressing  the 


August  30,  1890.] 


WEED:  HYPERTROPHY  OF  THE  TURBINATED  BODIES. 


239 


Eustachian  orifices.  This  is  particularly  the  case  with  the 
inferior  turbinated  bodies.  The  above  conditions  constitute 
the  diseases  known  as  hypertrophic  rhinitis,  anterior  and 
posterior.  Resulting  from  these  conditions  and  the  most 
frequent  of  all  troubles  is,  first,  deafness  from  pressure  upon 
and  occlusion  of  the  Eustachian  apertures ;  next,  neo¬ 
plasms  of  various  kinds,  polypi,  ulcers,  etc ;  pharyngeal 
disease,  with  its  various  conditions;  laryngeal  disease,  re¬ 
sulting  from  the  constant  irritation  produced  by  the  drop¬ 
ping  into  the  throat  of  the  retained  post-nasal  secretions 
and  the  hawking  process  to  dislodge  them,  often  resulting 
in  a  catarrhal  laryngitis  and  ultimately  in  consumption. 
Asthma  is  a  very  frequent  sequela.  Schmiegelow,  of  Co¬ 
penhagen,  in  an  essay  published  in  London  this  year,  places 
the  cases  of  asthma  caused  by  nasal  diseases  at  about  ten 
per  cent,  in  males  and  six  per  cent,  in  females,  and  the 
cases  tabulated,  without  exception,  were  cured  by  the  result 
of  proper  treatment  of  the  nasal  passages.  Hack,  in  his 
work  published  in  1884,  although  exaggerating  the  reflex 
conditions  arising  from  hypertrophies,  is  nevertheless  en¬ 
titled  to  the  credit  of  being  really  the  first  rhinologist  to 
establish  that  asthma  resulting  from  the  hypertrophy  of  the 
turbinated  bodies  is  a  fact.  Woolen  says  that  asthma 
is  especially  due  to  hypertrophy  of  the  posterior  tips  of  the 
inferior  turbinated  bones  and  occasionally  of' the  middle 
ones,  which  either  touch  the  septum  or  curl  on  themselves 
and  touch  the  outer  wall  of  the  nose.  This  same  writer  con¬ 
siders  hypertrophy  of  the  anterior  tips  the  essential  local 
factor  of  hay  fever ;  while  in  our  own  country  such  men  as 
Roe,  of  Rochester,  Daly,  of  Pittsburgh,  Sajous,  of  Philadel¬ 
phia,  and  Bosworth,  of  New  York,  all  agree  with  the  for¬ 
eign  authorities  just  quoted.  Hay  fever,  with  its  distressing 
symptoms,  and  even  aphonia,  caused,  in  my  opinion,  bv  a 
nervous  reflex  condition  in  persons  of  a  highly  sensitive 
nature,  is  another  of  the  ills  following  these  hypertrophic 
conditions.  Cough  in  some  cases  is  certainly  from  the  same 
source.  Vertigo  is  often  present,  and  even  epileptiform 
convulsions  have  been  reported,  though  rarely,  as  arising 
from  these  hypertrophic  conditions,  while  supra-orbital 
neuralgia,  diffuse  headache,  and  migraine  almost  invariably 
have  their  origin  from  nasal  obstruction.  I  mention  these 
diseases  as  being  those  most  commonly  complained  of  by 
patients  suffering  from  hypertrophies.  Of  course,  there  are 
probably  others  more  complex  in  character  that  we  may  be 
able  to  trace  to  the  same  origin,  but,  beinsf  rare,  are  natu¬ 
rally  overlooked,  and  my  time  forbids  a  more  extended  re¬ 
search  into  them.  I  might  add  that  Guye,  of  Amsterdam, 
Holland,  finds  aprosexia  (inability  to  fix  the  attention)  oc¬ 
curring  mostly  in  young  persons  and  especially  would-be 
students — a  condition  due  to  nasal  obstruction  and  hyper¬ 
trophy;  while  Hill,  of  London,  also  tabulates  a  number  of 
cases  from  this  cause. 

As  to  the  treatment  of  these  hypertrophies,  it  varies 
with  different  practitioners,  as  the  cases  present  themselves, 
and  according  to  the  amount  of  thickening  present.  Of 
course,  to  relieve  the  hypertrophy  is  their  first  object,  and 
for  this  purpose,  if  the  membrane  alone  is  diseased,  the  ap¬ 
plication  of  the  galvano-cautery  and  the  acids — nitric,  chro- 
unc,  and  glacial  acetic — may  be  tried.  For  myself  I  prefer 


the  galvano-cautery  as  being  more  thorough  and  giving  a 
quicker  result.  The  almost  universal  treatment  of  spray 
ing  the  nasal  cavities  with  a  two-  or  four-per-cent,  solution 
of  cocaine  daily  is  to  be  condemned  for  two  reasons :  First, 
the  relief  is  only  temporary  and  simply  tends  to  lessen 
any  congestion  of  the  membrane  that  may  be  present, 
while  ultimately  increasing  the  turgescence  by  causing  an 
increased  vascularity,  and  by,  in  many  persons,  setting  up 
the  cocaine  habit.  Lennox  Browne,  of  London,  freely  con¬ 
demns  its  indiscriminate  use,  showing  that  where  there  is 
a  temporary  relief  from  capillaty  engorgement  of  the  turbi¬ 
nated  bone,  it  results,  if  unduly  prolonged,  in  anaemia  with 
atrophy,  or  in  an  increase  in  the  chronicity  of  the  hypersemia. 

As  regards  the  habit,  I  have  had  patients  who,  before 
consulting  me,  commencing  with  a  two-per-cent,  solution* 
have  gradually  increased  it  until  a  ten-  or  even  a  twelve- 
per-cent.  solution  has  beeu  used,  showing  how  easily  ac¬ 
quired  this  habit  is. 

Of  course,  where  operations  are  necessary,  either  by  the 
cautery,  acids,  or  the  cold  snare,  which  may  be  used,  then  a 
six-per-cent,  solution  of  cocaine  thoroughly  applied  to  the 
seat  of  the  operation  and  solely  for  its  anaesthetic  effect  is 
proper. 

The  next  important  step  in  the  treatment  is  to  see  that 
the  parts  are  kept  clean  by  spraying  with  any  of  the  mild 
and  efficient  alkaline  solutions.  Seiler’s  tablets  are  a  very 
elegant  preparation  for  this  purpose,  and  for  cleansing 
a  coarse  spray  should  be  used,  this  to  be  followed  by  a 
nebulous  spray  of  warm  vaseline,  which  acts  as  a  protective 
to  the  parts  and  hastens  the  cure. 

Of  course,  while  treating  these  cases  it  is  necessary  that 
your  patients  observe  strict  hygienic  laws.  I  find  it  is  a 
very  good  plan,  where  patients  are  able,  to  have  them  visit 
localities  by  the  sea,  for  we  are  all  aware  how  beneficial 
salt  air  is  for  those  suffering  from  nasal  troubles.  The  diet 
should  be  generous,  bathing  frequent,  a  fair  amount  of 
open-air  exercise,  and  respiration  through  the  nose. 

Of  course,  should  your  patients  be  of  a  strumous  di¬ 
athesis,  alteratives,  with  the  different  preparations  of  cod- 
liver  oil,  malt,  etc.,  should  be  used. 

S 

A  word  in  regard  to  the  specula  to  be  used  in  making 
examinations  of  the  nose.  The  lighter  and  more  delicate  the 
better.  The  “ G*oodwillie ”  and  “Folsom”  are  both  to  be 
commended,  being  light  and  very  delicately  made. 

Meyrowitch  has  introduced  a  set  of  three  that  are  ad¬ 
mirable,  being  very  light  and  self-sustaining. 

Finally,  I  wish  to  add  a  few  words  of  warning  regarding 
the  too  frequent  and  indiscriminate  cutting  and  gouging  of 
the  turbinated  bones.  Nasal  plows,  up-and-down  saws, 
bone-gnawing  forceps  in  the  hands  of  the  unskillful,  inex¬ 
perienced,  and  ambitious  practitioner  frequently  cause  great 
trouble,  leading  to  more  serious  results  than  originally  ex¬ 
isted  ;  whereas  careful  and  delicate  manipulation  with  the 
cautery  or  acids,  though  taking  longer  time,  will,  I  am 
positive,  repay  you  by  the  marked  improvement  following 
their  use,  and  this,  too,  without  submitting  your  patient  to 
the  torture  of  the  cutting  operations  or  to  the  dangers  fol¬ 
lowing  them. 

226  Genesee  Street. 


240 


BARR:  AN  EARLY  EXTRACTION  OF  CATARACT. 


[N.  Y.  Med.  Jouh., 


AN  EARLY  EXTRACTION  OF  CATARACT. 

By  S.  DICKSON  BARR,  M.  D., 

YORK,  PA., 

MEMBER  OP  THE  MEDICAL  SOCIETY  OF  THE  STATE  OF  PENNSYLVANIA. 

Mbs.  S.  S.,  a  farmer’s  wife,  sixty-five  years  of  age,  came  to 
me  complaining  of  indistinct  vision.  Objects  appeared  as  in  a 
mist,  while  in  picking  up  anything  like  pieces  of  money  she 
would  miss  some  of  them.  This  dimness  began  last  winter  and 
was  gradually  growing  worse. 

She  had  always  been  myopic,  a  minus-five-dioptre  glass  be¬ 
ing  necessary  to  give  a  good  sight  of  the  optic  nerve — that  is, 
as  good  as  could  he  had  through  the  lens,  which  was  growing 
opaque. 

I  found  beginning  cataracts  in  both  eyes,  that  of  the  right 
one  being  further  advanced  than  the  left. 

With  the  right  eye  she  could  count  fingers  at  three  feet, 
while  with  the  left  eye  she  was  able  to  recognize  people  at 
about  ten  feet. 

In  the  lens  of  the  right  eye  I  found  a  central  opacity  not 
implicating  the  entire  thickness  of  the  lens,  while  at  the  periph¬ 
ery  was  a  semi-opaque  rim. 

The  striae  showed  clearly,  the  red  reflection  of  the  retina 
showing  between,  giving  the  whole  lens  the  appearance  of  a 
wheel. 

The  left  eye  was  in  a  like  condition,  but  not  so  far  advanced. 

Usually  we  advise  patients  who  have  as  much  vision 
as  this  to  wait  for  some  time  until  there  is  no  more  vision 
than  is  necessary  to  distinguish  light  in  a  dark  room.  In 
this  case  the  patient  was  anxious  to  have  the  operation  per¬ 
formed,  and  I,  believing  that  the  lens  was  in  a  condition 
to  be  extracted  (although  not  nearly  in  the  stage  of  opacity 
generally  thought  necessary  before  an  attempt  to  remove 
is  made),  agreed  to  operate. 

My  belief  was  based  on  the  following  ideas,  and  the  re¬ 
sults  seem  to  verify  them. 

Donders  represents  that  the  refractive  power  of  the  eye 
is  at  its  maximum  in  a  child  aged  ten  years,  and  that  from 
that  age  it  decreases  until  at  the  age  of  sixty  it  is  lost  en¬ 
tirely.  Certainly  the  ciliary  muscle  does  not  begin  to  de¬ 
generate  at  this  early  age,  for  this  would  be  incompatible 
with  the  state  of  the  general  muscular  system.  If  it  is  not 
the  ciliary  muscle,  then  it  must  be  the  crystalline  lens  which 
changes,  since  the  accommodation  is  due  entirely  to  these 
two.  So,  at  the  age  of  sixty  years  we  h£ve  the  lens  in  a 
condition  of  solidity  that  can  not  be  changed  by  any  amount 
of  action  of  the  ciliary  muscle. 

Is  not  this  lens  iu  a  condition  solid  enough  to  admit  of 
removal  if  it  were  necessary  ?  Why  should  we  wait  until 
the  lens  becomes  entirely  opaque  and  retrograde  metamor¬ 
phosis  takes  place  before  operating  ?  I  believe  that  the 
lens  is  in  a  better  condition  for  extraction  when  the  patient 
begins  to  complain  of  the  appearance  of  a  web  over  the  eye, 
and  the  lens  shows  the  characteristic  milky  appearance  suf¬ 
ficient  to  satisfy  the  examiner  that  it  is  a  cataract  that  he  is 
dealing  with,  than  it  will  be  in  if  allowed  to  remain  until  the 
patient  is  totally  blind.  In  the  first  case,  the  lens  being  solid 
at  the  age  of  sixty  years  from  natural  causes,  has  not  be¬ 
come  atrophied  as  yet,  nor  brittle  or  scaly,  but  is  a  solid 
mass  of  almost  the  consistence  of  gum  ;  the  corticle  having 
still  adhesive  power  enough  to  hold  well  together,  and  the 


milky  appearance  being  indicative  of  the  separation  of  the 
lens  substance  from  the  capsule,  the  cataract  can,  by  slight 
pressure,  be  forced  out  without  any  of  the  particles  scaling 
off.  But  when  the  lens  is  allowed  to  remain  until  it  is  en¬ 
tirely  opaque,  so  that  there  is  no  red  reflection,  it  becomes 
brittle  and  changes  into  “  molecular  detritus.” 

Then,  when  an  attempt  is  made  to  remove  this  lens,  in 
breaking  the  capsule  with  the  cystotome,  these  brittle  par¬ 
ticles  or  scales  are  disturbed  at  the  same  time  and  fall  away 
from  the  lens,  and  so  create  a  great  deal  of  after-trouble. 
Another  objection  to  making  the  patient  wait  until  the  eye 
is  entirely  blind  is  the  great  inconvenience  which  the  pa¬ 
tient  will  have  to  put  up  with.  One  may  have  to  wait  for 
a  year  or  more  (generally  more)  before  the  eye  attains  the 
so-called  ripeness.  These  are  my  ideas  based  on  the  result 
of  observation  in  a  number  of  cases  of  different  stages  of 
growth. 

In  the  case  noted  at  the  beginning  of  this  article  I 
operated  on  the  right  eye,  making  a  von  Oraefe  linear  in¬ 
cision  in  the  superior  portion  at  the  corneo-scleral  margin, 
about  three  millimetres  below  a  tangent  drawn  to  the  supe¬ 
rior  margin,  making  a  corneal  flap.  An  average-size  iridec¬ 
tomy  was  done  and  the  capsule  opened  by  inserting  the 
cystotome  first  on  the  left  side  of  the  pupil  and  moving  it 
up  and  down,  then  across  in  the  inferior  portion  several 
times,  then  up  and  down  at  the  right  side  and  several 
times  across  the  superior  portion  of  the  capsule,  in  this  way 
cutting  a  square  piece  out  of  it.  While  doing  this  I  was 
careful  to  catch  the  capsule  with  just  the  tip  of  the  hook, 
and,  to  do  this  right,  I  had  an  assistant  with  a  strong 
convex  glass  focus  the  light  from  a  lamp  held  near  the 
patient's  head  on  the  capsule  and  lens.  Now,  by  very 
slight  pressure  on  the  inferior  portion  of  the  cornea,  the 
lens  came  out  without  the  slightest  trouble,  not  a  particle 
temaining. 

The  eye  was  cleansed  thoroughly  after  making  sure 
that  the  iris  was  clear  of  the  edges  of  the  wound,  and,  in¬ 
stilling  a  few  drops  of  atropine  solution,  I  bandaged  the 
eye  carefully  and  allowed  it  to  remain  so  until  the  next 
day.  When  I  examined  the  eye  the  next  day  I  found  the 
pupil  clear  with  the  exception  of  an  almost  imperceptible 
web  in  the  inferior  portion  of  the  pupil.  This  disappeared 
by  the  next  day,  leaving  a  beautiful  black  pupil. 

The  patient  did  not  have  the  slightest  pain,  although  no 
opiates  were  given.  Her  vision  is  excellent.  I  shall  op¬ 
erate  in  a  week  or  so  on  the  left  eye,  which  will  allow 
enough  time  for  all  inflammation  to  subside  in  the  right 
eye.  In  this  case,  although  the  patient  was  highly  myopic, 
not  a  drop  of  vitreous  was  lost;  whether  this  was  due  to 
the  early  operation  or  not  I  am  unable  to  say. 

In  performing  any  cataract  operation  I  always  provide 
myself  with  a  small  syringe  to  flush  the  anterior  chamber 
and  wash  out  any  particles  which  might  remain  there,  but 
I  found  it  entirely  unnecessary  in  this  case. 

One  of  the  best  syringes  for  this  use  is  one  made  by 
Dr.  Lippincott,  of  Pittsburgh,  in  which  one  can  regulate  the 
force  of  the  flow. 

I  should  like  very  much  to  get  the  opinions  of  other 
men  on  this  subject. 


August  30,  1890.] 


PETERSON:  HOMONYMOUS  HEMIOPIG  HALLUCINATIONS. 


241 


homonymous  hemiopic  hallucinations. 

By  FREDERICK  PETERSON",  M.  D., 

CHIEF  OF  CLINIC,  NERVOUS  DEPARTMENT,  VANDERBILT  CLINIC. 

The  following  history  of  a  case  of  paranoia  presents 
something  unique  in  the  way  of  visual  hallucinations: 

H.  K.,  aged  twenty,  single,  came  to  the  Vanderbilt  Clinic, 
June  10,  1890,  complaining  of  persecution  by  unknown  persons. 
He  had  noticed  since  January  last  that  “  mesmeric  influences  ” 
were  being  used  upon  him,  and  the  conspirators,  three  in  num¬ 
ber,  have  been  redoubling  their  annoyances  as  time  went  on. 
He  has  unilateral  hallucinations  of  hearing.  There  are  three 
voices  in  his  right  ear,  all  talking  to  him  and  not  to  each  other. 
They  tease  him,  swear  at  him,  curse  him,  and  call  him  names. 
In  addition  to  these  uni-aural  polyphonic  hallucinations,  be  is 
tortured  by  disagreeable  odors  and  by  peculiar  tastes  in  his 
water  and  food. 

His  visual  hallucinations  are  singularly  limited  to  the  right 
visual  areas  of  each  eye,  so  that  we  may  in  fact  speak  of  them 
as  homonymous  hemiopic  hallucinations.  He  sees  at  times 
skeletons  and  various  people,  but  always  moving  about  and  upon 
his  right  side,  and  this  is  true  if  either  eye  is  shut.  They  never 
appear  upon  bis  left  side.  If  he  directs  his  eyes  toward  his  right 
side,  where  the  visions  appear,  they  move  still  farther  toward 
the  right. 

He  complains  of  parassthesise,  flashes  of  heat  and  waves  of 
cold  through  his  body,  jerkings  of  his  muscles  and  viscera,  and 
pains  in  his  trunk  and  limbs,  all  of  which  he  ascribes  to  electri¬ 
cal  devices.  Most  of  the  pains  in  his  trunk  are  restricted  to  the 
right  side,  but  there  is  no  unilateral  distinction  with  regard  to 
those  of  the  limbs. 


His  hallucinations  are  conjoined  with  the  delusions  of  perse¬ 
cution  already  mentioned.  He  thinks  there  are  several  persons, 
certainly  three,  who  control  him  by  mesmerism  and  annoy  him 
by  telephony  and  electricity.  He  has  purchased  a  dozen  books 
ou  mesmerism  and  clairvoyance,  hoping  to  gain  sufficient  knowl¬ 
edge  of  the  subject  to  be  able  to  counteract  the  schemes  of  his 


enemies.  Latterly  his  attention  has  been  called  to  hypnotism 
and  suggestion,  and  to  the  ease  with  which  people  may  be  in¬ 
fluenced  to  commit  theft  and  murder  under  such  control,  by 
reading  the  newspaper  interviews  with  some  of  our  leading 
specialists.  He  had  copies  of  these  interviews  in  his  pocket  and 
showed  some  of  the  illustrations,  among  which  was  that  of  a 
man,  under  hypnotic  influence,  plunging  a  dagger  into  another. 
The  patient  intimated  that  he  had  some  fear  of  being  made  to 
carry  out  some  nefarious  undertaking  by  his  imaginary  hypno- 
tizers. 

Although  no  heredity  could  be  ascertained,  he  exhibits 
marked  facial  asymmetry,  and  in  particular  a  remarkable  mal¬ 
formation  of  the  hard  palate,  showing  that  be  belongs  to  the 
superior  degenerate  classes.  His  is  in  fact  a  typical  case  of 
paranoia  with  systematized  delusions  of  persecution  which  have 
been  evolved  from  a  degenerative  soil. 

Tbe  case  is  related,  however,  merely  on  account  of  the 
very  remarkable  character  of  the  visual  hallucinations. 
Their  limitation  to  the  right  visual  fields  of  both  eyes  is  ab¬ 
solute  proof  of  their  central  origin,  and  they  doubtless  arise 
through  irritation  in  the  cortical  visual  area  of  the  left  oc¬ 
cipital  lobe.  It  would  seem  as  if  the  cortex  of  the  left 
hemisphere  were  the  chief  seat  of  disturbance  in  this  case. 

Unilateral  hallucinations  of  one  eye  alone,  or  uni-ocular 
hallucinations,  have  been  described  by  several  authors  as 
occurring  in  the  insane,  but,  so  far  as  I  know,  this  is  the 
first  reference  that  has  been  made  to  visual  hallucinations 
of  the  character  herein  mentioned,  and  for  which  I  can  find 
no  simpler  name  than  that  which  forms  the  title  of  this 
article. 

201  West  Fifty-fourth  Street. 


THE  SURGICAL  TREATMENT 
OF  POST-TURBINATED  HYPERTROPHY.* 
By  A.  E.  PRINCE,  M.  D., 

JACKSONVILLE,  ILL. 

The  little  that  I  have  to  say  on  the  removal  of  the  hy¬ 
pertrophied  tissue  which  is  found  at  the  posterior  extremity 
of  the  inferior  turbinated  bone  is  particularly  addressed  to 
those  who  have  found  difficulty  in  the  successful  removal  of 
these  enlargements  with  the  time-honored  snare  and  the  va¬ 
rious  methods  of  cauterization.  That  they  may  be  removed 
with  the  snare  or  destroyed  by  the  galvano-  or  chemical 
cautery  is  not  brought  into  question,  but  that  the  difficul¬ 
ties  attending  either  of  these  methods  in  the  majority  of 
cases  is  not  small  I  am  convinced  both  by  personal  experi¬ 
ence  and  by  valid  testimony  of  men  who  are  not  unskilled 
in  the  inspection  and  manipulation  of  these  parts. 

Nothing  sounds  easier  than  the  operation  as  described 
by  Bosworth  in  his  recent  volume  on  the  Nose  and  Throat , 
page  151.  “The  loop,  having  been  bent  slightly  to  one  side 
before  entering  the  nares,  will  by  its  own  elasticity  slip  over 
the  mass,  when  it  can  easily  be  drawn  into  place  and  the 
tumefaction  cut  through.”  “  Of  course  there  is  liability  to 
be  considerable  haemorrhage  as  the  result  of  this  procedure, 
but  if  the  operation  be  done  slowly,  a  half-hour  or  even  an 

*  Read  before  the  Illinois  State  Medical  Society,  May  6,  1890. 


242 


PRINCE:  POST-TURBINATED  HYPERTROPHY. 


[N.  Y.  Med.  Jour., 


hour  being  consumed,  it  may  often  be  done  without  loss  of 
blood.  If,  however,  haemorrhage  does  occur,  a  plug  of  cot¬ 
ton  can  easily  be  passed  back  and  wedged  between  the  cut 
surface  and  the  septum  and  allowed  to  remain  until  the  next 
day  if  necessary.” 

The  operation  as  above  described  is  the  standard  opera¬ 
tion  for  the  removal  of  the  posterior  turbinated  hypertro¬ 
phy,  and  though  it  is  usually  efficient  in  the  hands  of  a  pa¬ 
tient  surgeon  and  has  served  the  purpose  in  the  past,  there 
are,  nevertheless,  certain  disadvantages,  more  or  less  real, 
which  it  may  seem  worth  while  to  attempt  to  overcome. 

The  introduction  of  the  wire  and  its  adjustment  over 
the  tumor,  so  as  to  get  the  entire  tumor  into  the  loop,  is 
not  always  easy.  While  tightening  the  loop  over  the  growth, 
more  or  less  of  it  may  escape,  often  resulting  in  the  removal 
of  small  portions  and  necessitating  a  repetition  of  the  op¬ 
eration  which  is  thereby  made  more  difficult.  In  many  of 
these  cases  the  tumor  consists  more  of  dilated  blood-vessels 
than  actual  hypertrophy,  and  in  these  cases  it  is  almost  im¬ 
possible  to  apply  the  snare  on  account  of  its  escape  with  the 
closure  of  the  loop,  in  which  case  the  removal  of  but  a  small 
portion  of  the  mucous  membrane  may  be  the  result.  This 
difficulty  is  increased  by  the  use  of  cocaine.  The  tedious 
nature  of  the  operation,  when  attempt  is  made  to  avoid  haem¬ 
orrhage,  exhausts  the  patience  of  both  patient  and  physi¬ 
cian  ;  besides,  with  the  greatest  prudence,  haemorrhage  will 
rarely  be  avoided,  and,  when  it  occurs,  the  difficulty  of  as¬ 
certaining  the  result  by  ocular  inspection  is  increased  to  such 
an  extent  that  little  is  gained  by  an  attempt  at  its  preven¬ 
tion.  Bosworth’s  procedure  as  recommended  to  arrest  ar¬ 
terial  haemorrhage  by  “  passing  a  plug  of  cotton  back,  and 
wedging  it  between  the  cut  surface  and  the  septum,”  will 
seldom  succeed,  because  this  space  is  wider  than  the  ante¬ 
rior  passage,  and,  besides,  the  haemorrhage  may  not  come 
from  the  lateral  face  but  from  the  posterior  end  of  the  bone. 
Except  in  the  purpuric  state,  I  regard  haemorrhage  as  of  no 
moment,  because  in  the  rare  cases  in  which  it  does  not  spon 
taneously  cease  it  may  effectually  be  controlled  at  any  loca¬ 


tion  by  the  use  of  a  posterior  plug,  which  can  be  introduced 
at  a  moment’s  warning  with  the  aid  of  a  soft  catheter.  With 
confidence  in  one’s  ability  to  execute  this  manoeuvre  all 
danger  vanishes. 

The  substitute  which  is  here  offered  for  the  snare  is 
the  curved  turbiuated  forceps,  which  has  served  me  in  this 
class  of  cases  for  about  two  years.  In  its  construction  the 
excellent  septum  gouge  of  Weir  has  been  taken  as  a  model, 
and  it  has  been  made  with  sufficient  length  to  reach  into 
the  pharynx.  To  it  has  been  given  the  curve  of  the  convex 
surface  of  the  inferior  turbinated  bone.  The  handles  are 
so  curved  and  the  pivot  is  so  placed  that  it  can  be  easily 
.opened  after  it  is  introduced  into  position.  The  size  is  such 


that  it  can  be  readily  passed  through  the  inferior  meatus. 
The  blades  are  so  made  that  while  the  biting  edges  come 
into  exact  contact,  the  edges  on  the  convexity  of  the  blades 
are  cut  away  so  as  to  prevent  the  material  in  the  grasp  of 
the  blades  from  interfering  with  their  perfect  closure. 

Experience  commends  the  following  method  of  proced¬ 
ure  :  The  patient  is  placed  in  a  recumbent  position  and 
O’Dwyer’s  gag  is  applied  on  the  right  side  of  the  mouth. 
A  canvas  cone  is  placed  over  the  mouth  and  the  patient  in¬ 
structed  to  breathe  deeply  and  rapidly  with  emphasis  on 
the  exhalation.  Two  drachms  of  ethyl  bromide  are  now 
poured  on  the  cone  and  the  respiration  is  continued  in  the 
same  artificial,  rapid,  deep  manner.  If  we  are  successful 
in  controlling  the  manner  of  breathing,  the  patient  will  be 
anaesthetized  in  thirty  to  forty  seconds,  when  the  forced 
respiration  will  be  changed  to  natural  slow  breathing. 

If  from  any  cause  this  manner  of  breathing  is  not  main¬ 
tained,  the  ethyl  anaesthesia  is  not  certain  to  be  profound, 
when  chloroform  or  ether  may  be  added.  The  next  step  is 
the  introduction  of  the  left  index  finger  back  of  the  palate, 
bringing  it  in  contact  with  the  posterior  end  of  the  inferior 
turbinated  bone,  where  the  tissue  in  question  will  be  dis¬ 
tinctly  felt  as  a  soft,  yielding  mass.  The  forceps  is  then 
introduced  with  the  concavity  downward  and  will  be  found 
to  glide  easily  along  the  floor  of  the  inferior  meatus  until  it 
can  be  felt  by  the  finger.  The  cutting  edge  is  then  rotated 
outward  and  the  blades  are  separated.  This  movement  will 
bring  the  tumor  between  the  tips  of  the  blades,  the  position 
of  each  of  which  can  be  precisely  determined  by  the  sense 
of  touch.  The  blades  are  now  closed  on  the  tumor  and  the 
concavity  is  rotated  downward  and  inward  through  a  semi¬ 
circle  while  being  withdrawn,  the  effect  of  which  is  partly  to 
cut  and  partly  to  tear  the  mucous  tissues  and  vessels,  thus 
favoring  the  early  arrest  of  the  inevitable  hemorrhage. 
The  operation  is  repeated  on  the  opposite  side  without  re¬ 
moving  the  finger  from  the  mouth.  The  patient  is  then 
placed  in  a  position  favorable  to  the  escape  of  the  blood,  a 
portion  of  which  is  always  swallowed.  The  hemorrhage, 
though  seemingly  profuse  at  the  time,  does  not  continue 
more  than  a  few  minutes,  and  but  little  blood  is  actually 
lost.  In  but  one  case  out  of  about  fifty  have  I  found  it 
necessary  to  introduce  a  plug  to  control  the  hemorrhage. 

My  excuse  for  detailing  this  procedure  so  minutely  is 
found  in  the  desire  that  some  may  be  led  to  practice  the 
bimanual  manipulation,  which  will  be  found  invaluable  in 
the  removal  of  the  pharyngeal  tonsil  and  other  forms  of 
nasal  polypi  as  well  as  this.  The  form  of  the  blades  of  the 
instrument,  aided  by  the  sense  of  touch,  often  enables  one  to 
reach  the  origin  of  a  pedunculated  polypus,  and  in  some 
cases  a  small  portion  of  bone  has  been  removed  with  the 
pedicle,  thus  demonstrating  the  efficiency  of  the  operation. 

Trusting  that  the  procedure  may  find  favor  at  the  hands 
of  those  who  may  see  fit  to  give  it  a  trial,  I  submit  it  for 
your  criticism  and  consideration. 


Anomalous  Outlet  of  the  Coronary  Artery. — Meigs  reports  an  au¬ 
topsy  ( Univ.  Med.  Mag.,  May,  1890)  in  which  the  opening  of  the  right 
coronary  artery  was  found  to  lie  directly  in  the  angle  between  the  right 
coronary  and  intercoronary  flaps. 


August  30,  1890.] 


LEADING  ARTICLES. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Prank  P.  Foster,  M  D. 


NEW  YORK,  SATURDAY,  AUGUST  30,  1890. 


HYPNOTISM  BEFORE  THE  BRITISH  MEDICAL  ASSOCIATION. 

The  obscure  phenomena  of  hypnotism  were  made  the  sub¬ 
ject  of  serious  attention  at  the  recent  meeting  of  the  British 
Medical  Association  at  Birmingham,  when  a  paper  on  the  sub¬ 
ject  was  read  by  Dr.  Norman  Kerr,  which  was  followed  by  a 
discussion  that  occupied  the  time  of  the  Psychological  Section 
for  two  days.  The  reader  of  the  paper  accepted  practically  all 
the  alleged  hypnotic  phenomena  as  facts,  but  in  hypnosis,  after 
close  watching,  he  saw  only  a  distorted  cerebral  state,  a  condi¬ 
tion  with  exaltation  of  receptivity  and  energy  which  was  ab¬ 
normal.  Several  questions  had  to  be  answered  when  we  came 
to  consider  the  applicability  of  hypnosis  to  therapeutics.  Only 
a  limited  number  of  persons  were  susceptible,  and  even  in 
these  the  after-effect  was  a  disturbed  mental  balance  and  nerve 
exhaustion.  Deterioration  of  brain  and  nerve  function,  with 
intellectual  decadence  and  moral  perversion,  was  apt  to  follow 
frequent  repetition.  Dr.  Kerr,  moreover,  maintained  that  hyp¬ 
nosis  itself  was  a  departure  from  health,  a  diseased  state,  a  true 
neurosis,  embracing  the  lethargic,  cataleptic,  and  somnambu¬ 
listic  states,  and  that,  if  a  disease  was  cured  by  hypnotism,  it 
would  merely  be  by  the  substitution  of  another  disease.  Hyp¬ 
notic  suggestion  might  sometimes  temporarily  assuage  suffering, 
but  the  underlying  disease  was  not  necessarily  cured,  though 
evanescent  oblivion  might  be  secured,  and  the  lethal  power  of 
the  morbid  disorder  was  in  most  cases  increased.  The  few  pa¬ 
tients  he  had  seen  apparently  benefited  had  in  no  way  been 
beyond  the  reach  of  ordinary  treatment,  but  they  resisted  or 
were  passive  to  that,  while  they  gave  themselves  up  to  the  mes- 
merizer.  and  became  the  subjects  of  what  he  called  a  jelly¬ 
fish  slavery,  which  was  worse  than  days  and  nights  of  pain  and 
rendered  their  lives  total  wrecks.  In  the  somnambulistic  state 
subjects  had  been  compelled  by  the  operator’s  behest  to  com¬ 
mit  crime.  So  serious  were  the  evils  that  French  surgeons  had 
been  prohibited  from  practicing  hypnotism  in  the  army  and 
navy. 

The  gauntlet  was  taken  up  by  Dr.  Kingsbury,  of  Blackpool, 
who  has  adopted  hypnotism  in  his  practice  and  professes  to 
have  effected  many  cures  by  its  agency.  After  describing  the 
peculiarities  of  the  two  schools  of  Paris  and  Nancy,  he  entered 
into  a  discussion  of  the  dangers  of  hypnotism  and  the  range 
of  its  applicability,  and  detailed  the  clinical  histories  of  cases 
treated  by  him  by  hypnotic  suggestion.  In  one  instance  a  pa¬ 
tient  suffered  from  sleeplessness,  the  result  of  a  neuralgia.  He 
hypnotized  the  subject,  and  left  a  paper  with  him  on  which 
was  written  :  “  Go  to  sleep  at  once  and  wake  up  to-morrow 
morning  at  7.30.  You  will  have  no  pain  when  you  awake.” 


243 

And  the  experiment  answered  admirably.  Seven  out  of  ten 
persons  were  susceptible  to  the  influence.  He  maintained  that 
hypnotism  was  a  useful  adjunct  to  regular  treatment,  and  said 
that  it  behooved  medical  men  to  become  familiar  with  it,  so  as 
to  be  able  to  use  it  in  special  cases.  Demonstrations  were  then 
given  by  Dr.  Kingsbury  and  Dr.  Tuckey  on  two  subjects  brought 
for  the  purpose  from  Manchester.  The  usual  performances  were 
gone  through  with,  in  no  way  differing  from  those  commonly 
seen  on  the  public  platform. 

A  general  discussion  of  the  subject  then  took  place,  in  the 
course  of  which  Dr.  Gairdner,  of  Glasgow,  said  he  should  leave 
the  meeting  in  a  somewhat  different  state  of  mind  from  that  in 
which  he  entered  it,  and  had  not  the  smallest  doubt  that  many 
other  persons  present  would  be  in  a  similar  state  to  his  own. 
A  great  many  years  ago  he  had  been  disgusted  by  an  exhibition 
of  hypnotism  in  the  drawing-room.  While  he  did  not  doubt 
that  there  was  a  great  psychic  force  involved  in  it,  still,  he  had 
the  strongest  feeling  that  there  was  something,  to  use  a  Scotch 
expression,  “no  canny”  about  it,  and  that  it  was  not  for  physi¬ 
cians  to  tamper  with.  Dr.  Clifford  Allbutt  sided  with  the  hvp- 
notizers  in  the  discussion,  and  referred  to  Dr.  Norman  Kerr’s 
brilliant  rhetoric,  but  failed  to  find  in  his  discourse  mention  of 
any  facts.  If  the  profession  did  not  take  up  the  subject,  it  was 
sure  to  fall  into  the  hands  of  quacks.  He  did  not  think  that 
medical  men  were  justified  in  throwing  the  whole  thing  over¬ 
board.  Dr.  Hack  Tuke  had  been  much  interested  in  the  phe¬ 
nomena,  and  thought  the  subject  had  a  direct  medico-legal 
bearing.  He  gave  instances  of  patients  who  had  been  directly 
benefited  by  it.  Another  speaker,  alluding  to  the  moral  aspect 
of  the  question,  asked  very  pertinently  whether  any  of  those 
present  would  allow  their  wives  or  their  daughters  to  be  hyp¬ 
notized  except  on  the  strongest  possible  grounds.  If  not,  they 
had  no  right  to  hypnotize  others.  The  opinion  was  very  gen¬ 
erally  expressed  that  it  was  time  for  the  government  to  put  a 
stop  to  the  disgusting  public  exhibitions  of  hypnotism  which 
were  becoming  very  prevalent,  and  that  it  would  be  well  for 
the  British  Medical  Association  to  appoint  a  committee  to  in¬ 
vestigate  the  whole  question  of  hypnotism  and  to  give  facilities 
for  experiments  upon  lower  animals  as  well  as  upon  human 
beings. 

On  the  whole,  this  discussion,  which  is  the  first  occasion  on 
which  the  subject  has  of  late  years  gained  the  •serious  attention 
of  the  profession,  will  yield  good  results.  The  matter  has  been 
carefully  considered.  Evidence  pro  and  con  has  been  weighed 
and  both  sides  have  had  a  fair  hearing.  To  whatever  length 
the  friends  of  hypnotism  may  go  in  France,  it  is  certain  that  in 
England  its  title  to  be  considered  a  therapeutic  agent  of  utility 
must  be  fully  proved  before  it  is  accepted. 


REMOVAL  OF  THE  PUERPERAL  SEPTIC  UTERUS. 

In  the  Deutsche  Medizinal-Zeitung  we  find  the  history  of  a 
case  in  which  this  procedure  was  resorted  to  by  Dr.  Stahl : 

The  patient  was  a  primipara,  thirty-five  years  of  age,  suffer¬ 
ing  with  a  subserous  fibroma  of  the  raterus.  Her  labor  was 


244 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Jouk., 


spontaneous,  but  the  membranes  were  completely  torn  away  at 
the  border  of  the  placenta,  and  remained  in  utero.  Puerperal 
septic  endometritis  resulted,  for  which  curetting,  with  disin¬ 
fection  of  the  uterine  cavity,  was  done.  Notwithstanding, 
puerperal  sepsis  resulted,  with  thrombosis  of  the  pelvic  veins 
and  threatening  general  symptoms.  Softening  of  the  nodes  of 
the  fibroma  was  apparent,  and  the  author  performed  supra¬ 
vaginal  amputation  of  the  uterus  and  employed  extraperito- 
neal  treatment  of  the  stump.  The  conclusion  from  this  case  is 
that  the  membranes  should  be  removed,  if  possible,  immediate¬ 
ly  after  the  removal  of  the  placenta,  or  they  may  bring  about 
serious  disaster  to  the  patient. 

Let  us  hope  the  conclusion  may  not  be  drawn  that,  if  the 
membranes  are  not  removed  and  sepsis  takes  place,  amputation 
of  the  uterus  will  be  the  proper  thing  to  do.  It  would  be 
obviously  unfair  to  say  it  should  not  have  been  done  in  this 
case,  for  the  gentleman  in  charge  of  the  case  was  probably  a 
better  judge  as  to  its  gravity  than  one  could  possibly  be  from 
the  reading  of  a  brief  history.  The  moral  that  must  always  be 
drawn  from  the  record  of  such  cases  is  that  it  may  furnish  an 
excuse  for  many  a  similar  operation  when  other  means  would 
be  more  suitable.  Certainly,  in  puerperal  endometritis,  as 
cases  go,  even  when  complicated  with  subserous  myomata,  he 
would  be  a  dangerous  man  who  would  counsel  extirpation  of 
the  uterus  as  a  means  of  treatment.  In  the  balance,  which 
would  weigh  the  heavier — we  mean  in  the  average,  yes,  the 
majority  of  cases — a  puerperal  septic  endometritis,  or  the  dan¬ 
gers  of  the  supravaginal  extirpation  added  to  the  enfeebled 
condition  resulting  from  sepsis?  We  leave  out  of  considera¬ 
tion  the  questiou  of  removal  of  an  important  organ  in  a  state 
of  full  functional  power.  The  recent  words  of  Greig  Smith 
are  golden  words,  that  to  sweep  away  the  reproductive  organs 
is  retrograde  surgery,  unless  it  is  necessary  to  save  life. 


MINOR  PARAGRAPHS. 

THE  PROTEIDS  IN  THE  URINE  IN  VARIOUS  FORMS  OF 

ALBUMINURIA. 

Dr.  D.  Noel  Patton,  Mr.  John  Douglas,  and  Mr.  Ronald 
Mackenzie  publish  in  the  British  Medical  Journal  the  results 
of  numerous  observations  on  albuminuria  in  acute  and  chronic 
parenchymatous  nephritis,  in  amyloid  disease  of  the  kidney, 
and  in  heart  disease,  on  functional  albuminuria,  and  on  the 
causes  that  increase  or  diminish  albuminuria.  They  consider 
that  Senator  was  right  in  the  conclusion  that,  in  all  cases  of 
albuminuria,  both  serum  albumin  and  serum-globulin  are  pres¬ 
ent,  though  their  proportions  vary  within  wide  limits,  the 
quotient  of  the  amount  of  serum-albumin  divided  by  the  amount 
of  serum-globulin  being  sometimes  as  low  as  0-6  and  sometimes 
as  high  even  as  39.  The  quotient  is  high  in  acute  nephritis 
when  blood  is  absent,  though  globulin  is  in  excess  when  haemo¬ 
globin  is  present;  the  quotient  sinks  as  low  as  06  when  the 
disease  becomes  chronic,  the  alteration  depending  on  the  condi¬ 
tion  of  the  patient.  Amyloid  disease  can  not  be  distinguished 
from  the  ordinary  forms  of  chronic  nephritis  by  the  high  pro¬ 
portion  of  serum-globulin,  as  maintained  by  Senator;  and  func¬ 
tional  albuminuria  is  not  characterized  by  the  high  proportion 
of  serum-globulin,  as  suggested  by  Maguire.  The  proportion 
of  the  proteids  to  one  another  varies  much  in  the  course  of  the 


day,  serum-globulin  being  always  highest  during  the  night  and 
reaching  its  lowest  point  after  breakfast,  the  amount  of  pro¬ 
teids  passed  bearing  a  tolerably  direct  proportion  to  the  amount 
of  the  proteids  taken,  though  a  milk  diet  increases  the  propor¬ 
tion  of  serum-albumin.  Apparently,  high  arterial  pressure 
favors  the  transudation  of  serum  albumin,  while  a  low  pressure 
increases  the  proportion  of  globulin  transuded. 


'  NEW  TESTS  FOR  ALBUMIN. 

The  Pharmaceutical  Era  states  that  a  new  reagent  to  detect 
albumin,  even  in  infinitesimal  quantities,  is  said  to  exist  in  sali- 
cylsulphonic  acid.  This  reagent  is  a  body  formed  by  the  actioD 
of  sulphuric  acid  on  salicylic  acid.  It  will  affect  as  little  as 
of  a  grain  of  albumin,  making  the  urine  turbid,  but  not  affecting 
the  other  constituents,  such  as  sugar,  peptone,  etc.  In  the  Johns 
Hopkins  Hospital  Bulletin  there  is  a  report,  by  Dr.  D.  Meredith 
Reese,  on  trichloracetic  acid  as  a  test  for  albumin  in  urine.  An 
editorial  note  in  the  British  Medical  Journal  had  called  atten¬ 
tion  to  this  new  test,  which  Boymond  professes  to  have  first 
brought  into  notice.  This  reagent  precipitates  albumin  in  cold 
solution,  and  is  considered  to  rank  among  the  most  delicate  tests. 
Under  Dr.  Reese’s  observation  eighty-seven  specimens  of  urine 
were  examined.  In  twenty-five  cases  there  was  no  reaction  of 
any  kind.  In  fourteen  cases  where  there  was  no  reaction  in 
check-experiments  the  trichloracetic  acid  gave  a  precipitate. 
In  eleven  of  these,  granular,  epithelial,  and  hyaline  casts  were 
found,  and  in  three  of  these  eleven  cases  the  post-mortem  showed 
distinct  changes  in  the  kidneys.  In  three  cases  where  heat, 
acetic  acid,  and  nitric  acid  gave  no  precipitate  of  albumin,  a 
precipitate  was  obtained  with  picric  and  trichloracetic  acids; 
and  casts  were  found  in  these  three  instances.  Trichloracetic 
acid  is  a  delicate  test,  is  prompt  and  easily  applied,  and  gives 
no  discoloration  or  colored  zone. 


CHRONIC  INDURATION  OF  SUPERFICIAL  VEINS. 

According  to  the  Mercredi  medical,  M.  Duponehel  has  re¬ 
cently  presented  to  the  Societe  medicale  des  hopitaux  a  patient 
suffering  from  a  rare  condition  of  the  superficial  veins.  They 
were  indurated  and  felt  to  the  finger  like  atheromatous  arteries. 
The  condition  was  a  chronic  one,  with  subacute  exacerbations 
now  and  then.  The  cephalic  veins  of  both  upper  extremities 
and  the  left  internal  saphenous  gave  the  sensation  of  a  hard, 
resisting  cord.  A  few  days  before,  these  same  veins  had  felt 
like  pipe- stems.  Though  rare,  the  trouble  is  of  practical  inter¬ 
est.  It  exists  without  varices  or  haemorrhoids.  Only  once  has 
the  observer  found  cyanosis  of  the  extremities.  The  hypothe¬ 
sis  of  chronic  periphlebitis  explains  the  venous  induration ;  at 
the  same  time  a  morbid  process  similar  to  atheroma  also  sug¬ 
gests  itself.  When  soldiers  complain  of  vague  pains  without 
objective  signs  or  painful  points  at  intervals,  such  as  charac¬ 
terize  neuralgia,  it  is  natural  to  suppose  that  the  cases  are  simu¬ 
lated.  Duponehel  has  frequently  found  an  explanation  of  the 
alleged  pain  by  a  careful  examination  of  the  veins. 


/  f* 

HYPNAL  IN  THE  TREATMENT  OF  NEURALGIC  INSOMNIA 

Dr.  Fraenkel  reports,  in  Nouveaux  remedes,  that  he  has 
prescribed  hypnal  in  various  cases  at  his  clinic,  and  that  sleep 
resulted  as  with  chloral  and  with  the  characteristics  of  tbe 
sleep  produced  by  the  latter  drug — that  is,  a  calm  and  refresh¬ 
ing  sleep,  without  nausea  or  disagreeable  sensations  on  awak¬ 
ening — and  that  the  painful  symptoms  improved  as  they  im¬ 
prove  after  the  administration  of  antipyrine.  Hypnal,  or  mono- 


August  30,  1890.] 


MINOR  PARAGRAPHS.— ITEMS. 


chloralantipyrine,  is  a  chemically  well-defined  compound  that 
is  less  soluble  than  either  chloral  or  antipyrine ;  in  the  presence 
of  a  feeble  alkali  it  is  resolved  into  these  substances,  and  this 
decomposition  occurs  in  the  blood  or  in  the  intestine.  It  has 
only  a  slight  taste  and  odor,  and  is  easily  administered  to  chil¬ 
dren.  It  produces  the  hypnotic  effect  of  chloral  augmented  by 
(he  analgesic  action  of  antipyrine,  and  is  especially  valuable  in 
insomnia  caused  by  pain.  It  may  be  administered  in  capsules 
or  powders,  in  doses  of  fifteen  grains,  to  an  adult,  that  may  be 
repeated  if  necessary.  For  a  child  the  dose  is  from  a  grain  to 
ten  grains. 

FATAL  POISONING  WITH  SALOL. 

Dr.  IIessei.bach  reports,  in  the  Fortschritte  der  Medicin ,  the 
case  of  a  young  man  suffering  with  rheumatism,  who  took  by 
mistake  two  drachms  of  salol.  Coma  resulted,  with  great  dry¬ 
ness  of  the  tongue,  anuria,  and  death  on  the  second  day.  At 
the  necropsy  the  kidneys  were  found  to  be  soft,  anaemic,  and  of 
a  pale-yellow  color ;  microscopically,  the  glomeruli  were  full  of 
embryonic  cells  and  leucocytes,  the  convoluted  tubes  were 
tumefied,  and  fatty  degeneration  had  begun.  The  tubuli  were 
filled  with  degenerated  epithelium.  There  were  no  other 
lesions  attributable  to  the  drug.  The  toxic  principle  was  the 
carbolic  acid  that  is  generated  from  salol  in  the  system;  and 
the  author  believes  that  it  should  be  prescribed  carefully,  and 
the  condition  of  the  kidneys,  as  indicated  by  the  urine,  carefully 
watched. 


THE  CREMATION  CONGRESS. 

An  International  Congress  on  Cremation  was  opened  at  Ber¬ 
lin  on  August  4th.  There  were  many  foreign  delegates  pres¬ 
ent,  and  a  resolution  was  passed  expressing  the  hope  that  the 
governments  that  had  hitherto  opposed  cremation  would  recog¬ 
nize  the  pernicious  effects  of  inhumation  and  make  cremation 
optional.  Considering  that  the  Roman  Catholic  Church  has 
taken  a  position  adverse  to  cremation,  the  acceptance  of  this 
proposition  in  Catholic  countries  is  very  doubtful. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  August  26,  1890 : 


DISEASES. 

Week  ending  Aug.  19. 

Week  ending  Aug.  26. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

40 

12 

37 

11 

Scarlet  fever . 

18 

3 

14 

3 

Cerebro-spinal  meningitis . 

2 

0 

0 

0 

Measles . 

104 

13 

79 

12 

Diphtheria . 

34 

16 

51 

16 

Government  Measures  against  Hypnotism. — As  an  outcome  of  the 
expression  of  opinion  at  the  Birmingham  meeting  of  the  British  Medi¬ 
cal  Association  a  bill  will  be  introduced  at  the  next  session  of  Parlia¬ 
ment  to  restrict  the  public  performances  of  hypnotic  experiments  which 
are  now  so  much  the  fashion.  There  is  no  reason  to  doubt  medical 
testimony  to  the  effect  that  much  injury  is  done  to  the  health  of  the 
subjects  of  these  public  experiments. 

Dr.  Jonathan  Adams  Allen,  of  Chicago,  died  August  15th,  at  the 
age  of  sixty-five.  He  was  identified  with  Rush  Medical  College  for 
more  than  thirty  years,  having  held  the  chair  of  theory  and  practice 
since  1859,  and  was  president  or  dean  for  many -years.  He  was  one  of 
the  editors  of  the  Chicago  Medical  Journal  for  several  years.  He  wrote 
a  book  on  life-insurance  examinations  which  sold  to  the  extent  of  thirty 
thousand  copies.  His  contributions  to  medical  literature  were  numer¬ 
ous,  and  his  favorite  subjects  were  nervous  pathology,  medical  jurispru- 


^45 

dence,  mental  capacity  and  alienation.  He  was  for  over  twenty  years 
the  chief  surgeon  of  a  large  system  of  railways  in  Illinois.  As  a 
teacher,  he  was  eloquent,  persuasive,  and  instructive,  well  prepared 
both  by  extensive  reading  and  original  research. 

The  American  Association  of  Obstetricians  and  Gynaecologists 
will  hold  its  next  annual  meeting  in  the  hall  of  the  College  of  Physi¬ 
cians,  Philadelphia,  on  Tuesday,  Wednesday,  and  Thursday,  September 
16th,  17th,  and  18th.  An  invitation  to  attend  the  sessions  is  extended 
to  all  physicians  who  are  interested. 

The  American  Rhinological  Association  will  hold  its  eighth  annual 
meeting  in  Louisville,  on  the  6th,  7th,  and  8th  of  October,  under  the 
presidency  of  Dr.  A.  G.  Hobbs,  of  Atlanta. 

Change  of  Address. — Dr.  Gustav  A.  Pohl,  to  No.  96  Lemon  Street, 
Buffalo,  N.  Y. 

Army  Intelligence. —  Official  Inst  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army ,  from  August  3  to  August  23,  1890  : 

By  direction  of  the  Secretary  of  War,  the  ordinary  leave  of  absence 
granted  Kimball,  James  P.,  Major  and  Surgeon,  in  S.  0.  152,  July 
1,  1890,  from  this  office,  is  changed  to  leave  of  absence  on  sur¬ 
geon’s  certificate  of  disability,  with  permission  to  leave  the  Division 
of  the  Missouri.  Par.  7,  S.  O.  182,  A.  G.  0.,  August  6,  1890. 
Caldwell,  Daniel  G.,  Major  and  Surgeon,  is,  by  direction  of  the  Act¬ 
ing  Secretary  of  War,  granted  leave  of  absence  for  one  month  and 
fifteen  days,  to  take  effect  about  August  15,  1890.  Par.  1,  S.  0. 
176,  A.  G.  0.,  July  30,  1890,  Washington,  D.  C. 

Stephenson,  William,  Captain  and  Assistant  Surgeon,  now  on  duty  at 
Columbus  Barracks,  Ohio,  is,  by  direction  of  the  Acting  Secretary 
of  War,  assigned  to  temporary  duty  at  Jefferson  Barracks,  Missouri, 
during  the  absence  on  leave  of  Major  Daniel  G.  Caldwell,  Surgeon, 
and  will  report  accordingly.  On  the  return  to  duty  of  Major  Cald¬ 
well,  Captain  Stephenson  will  rejoin  his  proper  station.  Par.  2, 
S.  0.  176,  A.  G.  0.,  July  30,  1890,  Washington,  D.  C. 

Retirement. 

Moore,  John,  Brigadier-General  and  Surgeon-General,  August  16,  1890 
(Act  June  30,  1882).  Headquarters  of  the  Army,  A.  G.  0.,  Wash¬ 
ington,  August  18,  1890. 

Promotions. 

Ives,  Francis  J.,  Assistant  Surgeon,  July  25,  1890.  To  be  assistant 
surgeon  with  the  rank  of  captain,  after  five  years’  service,  in  ac¬ 
cordance  with  the  act  of  June  23,  1874.  Headquarters  of  the  Army, 
A.  G.  0.,  Washington,  August  11,  1890. 

Kendall,  William  P.,  First  Lieutenant  and  Assistant  Surgeon,  to  be 
assistant  surgeon  with  rank  of  captain,  after  five  years’  service, 
from  August  12,  1890.  Headquarters  of  the  Army,  A.  G.  0.,  Wash¬ 
ington,  August  18,  1890. 

Reed,  Walter,  Captain  and  Assistant  Surgeon,  is,  with  the  approval 
of  the  Acting  Secretary  of  War,  granted  leave  of  absence  for  four 
months,  to  take  effect  about  September  1,  1890.  Par.  17,  S.  0. 
192,  A.  G.  0.,  Washington,  D.  C.,  August  18,  1890. 

By  direction  of  the  Acting  Secretary  of  War,  a  board  of  medical  officers, 
to  consist  of  Middleton,  Joseph  Y.  D.,  Major  and  Surgeon ;  Ewen, 
Clarence,  Major  and  Surgeon;  Hopkins,  William  E.,  Captain  and 
Assistant  Surgeon,  will  assemble  at  the  U.  S.  Military  Academy, 
West  Point,  N.  Y.,.at  11  o’clock,  a.  m.,  August  27,  1890,  or  as  soon 
thereafter  as  practicable,  to  examine  into  the  physical  qualifications 
of  the  candidates  for  admission  to  the  Academy.  Par  1,  S.  0.  192, 
Washington,  D.  C.,  A.  G.  0.,  August  18,  1890. 

Mason,  Charles  F.,  First  Lieutenant  and  Assistant  Surgeon,  is,  by  di¬ 
rection  of  the  Acting  Secretary  of  War,  relieved  from  further  tem¬ 
porary  duty  at  Fort  Logan,  Colorado,  and  will  report  for  duty  at  his 
proper  station  (Fort  Washakie,  Wyoming).  Par.  3,  S.  0.  191, 
A.  G.  0.,  Washington,  D.  C.,  August  16,  1890. 

By  direction  of  the  Acting  Secretary  of  War,  the  retirement  from  active 
service  this  date,  by  operation  of  law,  of  Moore,  John,  Brigadier- 
General  and  Surgeon-General,  under  the  provisions  of  the  act  of 


246 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jook., 


Congress  approved  June  30,  18(52,  is  announced.  General  Moore 
will  repair  to  his  home,  Bloomington,  Indiana.  Par.  2,  S.  0.  191, 
A.  G.  0.,  Washington,  D.  C.,  August  16,  1890. 

McCreery,  George,  Captain  and  Assistant  Surgeon.  The  leave  of  ab¬ 
sence  for  seven  days,  granted  by  Orders  No.  84,  Fort  Warren,  Massa¬ 
chusetts,  August  13,  1890,  is  hereby  extended  fifteen  days.  S.  0. 
193,  Headquarters  Division  of  the  Atlantic,  Governor’s  Island,  New 
York  city,  August  15,  1890. 


JJrocetbiwfs  of  jfontlus. 


NEW  YORK  SURGICAL  SOCIETY. 

Meeting  of  April  23,  1890. 

The  President,  Dr.  C.  K.  Briddon,  in  the  Chair. 

Removal  of  Diseased  Appendices.— Dr.  L.  A.  Stimson 
detailed  the  histories  of  several  cases  of  appendicitis  in  which 
he  had  recently  operated,  and  presented  the  diseased  organs  re¬ 
moved. 

The  first  case  was  that  of  a  young  man  from  Middletown, 
N.  Y.  This  patient  had  suffered  from  four  attacks  within  a 
year,  the  last  one  about  six  weeks  before  the  operation.  The 
history  was  clearly  that  of  appendicitis,  and  the  second  and 
fourth  attacks  had  not  been  quite  so  severe  as  the  first  and 
third.  The  usual  incision  was  made  and  the  appendix  exposed. 
It  was  lying  free  in  the  abdominal  cavity,  its  base  being  directed 
forward  and  in  contact  with  the  anterior  abdominal  wall,  so 
that  it  presented  in  the  wound.  The  apex  of  the  organ,  which 
he  exhibited,  was  adherent  to  the  omentum  and  slightly  so  to 
the  caecum.  It  was  dissected  out  from  the  mesentery,  ligated 
with  catgut  close  to  its  origin,  and  removed.  The  case  was  a 
typical  one.  The  wound  had  healed  almost  without  suppura¬ 
tion  within  three  weeks,  and  the  patient  had  only  remained  in 
the  city  in  order  that  he  might  be  presented  to  the  society.  Dr. 
Ferguson,  pathologist  to  the  New  York  Hospital,  had  examined 
the  appendix  after  removal,  and  had  found  that  its  mucous 
membrane  was  entirely  destroyed  by  catarrhal  inflammatory 
process.  There  was  no  pus  or  foreign  body  within  its  cavity. 
The  muscular  coat  of  the  organ  was  thickened  and  intiltrated 
with  round  cells. 

The  second  case  was  that  of  a  patient,  sixteen  years  old, 
whom  the  records  of  the  hospital  described  as  having  been 
three  years  previously  under  treatment  for  general  peritonitis 
due  to  trauma.  Since  that  time  the  lad  had  suffered  from  many 
attacks  of  pain  in  the  right  iliac  fossa.  When  seen  on  admis¬ 
sion  to  the  hospital,  about  two  weeks  before  the  meeting,  he 
had  come  complaining  of  a  pain  in  his  abdomen  of  ever-in¬ 
creasing  severity.  There  was  a  temperature  of  102°  F.,  and 
there  was  marked  tenderness  in  the  right  iliac  region.  The  op¬ 
eration  revealed  the  appendix  as  occupying  a  similar  position 
to  that  in  the  previous  case.  The  distal  end  was  directed  for¬ 
ward  and  was  in  contact  with  the  anterior  abdominal  wall. 
The  caecum  was  above  it,  while  a  small  pocket  was  found  formed 
by  the  adhesion  of  a  knot  of  small  intestines  to  the  caecum  and 
the  abdominal  parietes,  and  within  this  the  appendix  lay.  This 
made  the  dissection  quite  difficult,  and  there  was  free  bleeding. 
After  dissecting  out  about  two  inches  of  the  appendix  and 
ligating  it  with  catgut  it  was  cut  away,  and  there  escaped  from 
its  cavity  about  a  drachm  of  turbid,  non-purulent  liquid.  The 
interior  of  the  appendix  was  deeply  congested  and  seemed  to 
be  in  a  sloughing  condition.  At  the  apex  the  wall  of  the  organ 
was  reduced  to  a  thin  membrane  and  seemed  to  be  on  the  point 
of  rupturing.  A  slight  amount  of  turbid  fluid  was  found  free 


in  the  abdominal  cavity.  This  patient  had  made  a  rapid  and 
uneventful  recovery. 

The  third  specimen  presented  was  that  of  an  appendix  taken 
post  mortem  from  a  man  who  had  been  brought  into  the  hos¬ 
pital  in  a  moribund  condition.  The  patient  was  a  Norwegian, 
thirty  years  of  age.  He  gave  a  history  of  previous  attacks  of 
peritonitis.  His  abdomen  was  distended,  his  temperature  104°, 
and  his  general  appearance  that  of  a  man  about  to  die.  There 
had  been  no  movement  of  the  bowels  since  this  la>t  attack  catue 
on,  nearly  a  week  before.  The  case  was  clearly  one  in  which 
operative  interference  would  be  useless;  indeed,  the  speaker 
had  some  doubt  as  to  the  real  character  of  the  trouble.  An 
artificial  anus  was  made  with  the  view  of  relieving  the  disten¬ 
tion.  The  man  died,  and  upon  removing  the  appendix  it  was 
found  to  present  an  appearance  similar  to  that  in  the  other  two 
cases.  There  was  no  foreign  body  within  it,  but  its  mucous 
membrane  was  found  to  be  in  a  condition  of  catarrhal  inflam¬ 
mation.  The  abdominal  viscera  were  in  a  state  of  general  peri¬ 
tonitis  without  exudation. 

The  speaker  narrated  as  a  fourth  case  that  of  a  physician  of 
this  city  who  had  suffered  five  previous  attacks  within  three 
years,  each  of  which  was  said  to  have  been  cut  short  by  a  dose 
of  castor-oil.  The  last  attack  had  commenced  on  Thursday, 
three  weeks  before.  The  speaker  had  seen  the  case  first  on  Fri¬ 
day,  at  which  time  the  patient  had  described  himself  as  getting 
well  fast.  On  the  following  Sunday,  however,  he  had  come  to 
the  New  York  Hospital  and  sent  for  the  speaker,  stating  that 
he  had  felt  something  give  way  in  the  abdomen,  and  this  was 
followed  by  great  rectal  tenesmus.  Introduction  of  the  finger 
revealed  a  soft  mass  depressing  the  anterior  rectal  wall  behind 
the  bladder.  There  was  tenderness  in  the  right  iliac  fossa,  to¬ 
gether  with  some  resistance  on  deep  pressure.  Aspiration  of 
the  mass  pressing  upon  the  rectum  with  an  exploring  needle  re¬ 
vealed  the  presence  of  foetid  pus.  The  sphincter  was  then 
stretched  and  the  abscess  opened  through  the  rectum.  This 
was  found  to  he  in  the  peritoneal  cavity  and  behind  the  blad¬ 
der,  the  latter  fact  being  ascertained  with  a  sound  in  the  blad¬ 
der.  Evacuation  of  the  abscess  contents  was  followed  by  a  rapid 
fall  in  the  patient’s  temperature  and  such  general  improvement 
that  in  a  few  days  he  was  able  to  leave  the  hospital. 

The  speaker  said  he  had  presented  these  four  cases  because 
he  thought  they  all  represented  instances  of  catarrhal  inflamma¬ 
tion  of  the  appendix  with  non-perforation,  and  had  all  been  of 
the  recurrent  type.  In  one  case  it  had  been  demonstrated  that 
non-perforative  appendicitis  was  capable  of  destroying  life, 
while  another  had  shown  that  an  abscess  of  considerable  size 
might  form  and  rupture  in  such  a  way  that  its  contents  would 
determine  to  the  lower  part  of  the  abdominal  cavity.  The  con¬ 
ditions  in  each  case  had  been  such  that  the  patients  might  well 
have  died.  He  thought  that  when,  on  the  one  hand,  one  con¬ 
sidered  the  excellent  results  that  had  thus  far  followed  t lie  re¬ 
moval  of  the  diseased  appendices  through  the  abdominal  cav  ity, 
and,  on  the  other,  the  very  dangerous  character  of  the  processes 
to  which  these  inflammations  could  give  rise,  one  was  justified 
in  advocating  early  operative  interference. 

Suprapubic  Lithotomy.— Dr.  A.  J.  MoCosh  presented  a 
patient  from  whose  bladder  he  had  removed  nine  calculi  weigh¬ 
ing  in  all  four  hundred  and  sixty  grains.  The  wound  in  the 
bladder  had  been  about  an  inch  in  length  and  through  this  the 
stones  had  been  removed.  This  opening  had  then  been  sewed 
up,  except  a  slit  left  for  a  drainage-tube.  A  perineal  opening 
was  then  made,  and  after  some  difficulty,  on  account  of  an  en¬ 
larged  prostate,  a  tube  was  introduced  into  the  bladder  for  peri¬ 
neal  drainage.  Some  trouble  had  been  caused  by  occlusion  of 
this  latter  tube  by  mucus  during  the  first  few  days,  and  during 
this  time  the  urine  had  come  entirely  through  the  suprapubic 


August  30,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


247 


opening.  A  large  perineal  tube  was  introduced  and  perfect 
drainage  thereby  established.  Thirteen  days  after  the  opera¬ 
tion  the  suprapubic  wound  had  closed.  The  perineal  wound 
was  now  almost  healed,  and  most  of  the  urine  now  came  through 
the  penis.  The  speaker  had  reported  the  case  to  emphasize  his 
appreciation  of  the  advantages  of  the  perineal  opening.  It  had 
been  very  noticeable  that  whenever  the  drainage  through  the 
perineal  opening  was  insufficient  and  the  urine  was  forced  to 
find  outlet  through  the  suprapubic  incision,  the  patient’s  general 
condition  had  changed  for  the  worse.  His  temperature  went 
up  a  degree  or  more,  his  pulse  increased  in  frequency,  and  his 
appetite  failed.  When  the  perineal  drainage  was  re-established, 
the  man  became  himself  again.  The  speaker  was  much  im¬ 
pressed  with  the  result,  and  in  operating  upon  other  old  patients, 
this  one  being  seventy-two  years  of  age,  he  should  certainly 
make  the  perineal  opening,  while  in  younger  ones  he  would 
also  favor  this  opening  and  the  suturing  of  the  bladder  wound 
as  recently  advocated  before  the  society  by  Dr.  McBurney. 

Recurrent  Appendicitis. — Dr.  J.  A.  Wyeth  presented  a  pa¬ 
tient,  sixteen  years  old,  who  had  been  sent  to  him  by  Dr. 
Ground,  with  the  following  history:  The  first  trouble  had  be¬ 
gun  in  June,  1887,  when  he  had  vomiting  and  felt  severe  pain 
in  the  right  iliac  fossa.  Previous  to  this  attack  bis  bowels  had 
been  regular.  The  attack  lasted  very  nearly  two  days  and  was 
attended  with  no  fever.  About  two  months  later  he  had  his 
•econd  attack,  when  he  experienced  symptoms  similar  to  those 
present  in  the  first  one.  The  third  attack  occurred  in  January, 
1888,  and  was  quite  severe.  The  greatest  amount  of  pain  was 
midway  between  the  umbilicus  and  the  right  anterior  superior 
spinous  process.  The  temperature  in  this  third  attack  ran  as 
aigb  as  103°  F.,  and  a  tumor  was  found  in  the  right  iliac  fossa 
which  was  quite  firm.  This  attack  had  lasted  about  two  weeks. 
In  May,  1888,  he  had  his  fourth  attack,  which  was  the  severest 
>f  all,  the  vomiting  and  abdominal  pains  being  very  distressing. 
A.bout  the  fifth  day  a  tumor  was  found  in  the  right  inguinal 
ossa.  Peritonitis  had  then  developed  and  extended  over  a  con¬ 
siderable  portion  of  the  abdomen.  There  wTas  marked  tym- 
>anites  and  the  temperature  ran  as  high  as  104°.  In  this  attack 
le  failed  rapidly  and  had  chills,  and  about  the  twelfth  day  the 
umor  was  aspirated  and  some  pus  was  obtained.  This  fourth 
ittack  lasted  four  weeks.  Up  to  the  time  of  his  entering  the 
3oly clinic  Hospital,  in  February,  1890,  he  had  had  sixteen  at- 
acks,  which  had  recurred  at  intervals  of  a  month  or  two  and 
vere  similar  to  those  already  described.  During  the  attacks  be 
vas  constipated,  but  in  the  intervals  his  bowels  were  regular 
md  his  appetite  was  good.  Vomiting  was  present  in  almost 
wery  attack  and  a  tumor  of  pronounced  character  was  to  be 
nade  out  in  about  half  of  the  attacks,  but  when  it  was  absent  a 
narked  sense  of  resistance  could  be  noticed. 

On  March  11th,  while  in  the  hospital  being  prepared  for  an 
•peration,  he  had  another  attack,  which  lasted  about  a  week 
md  caused  the  operation  to  be  postponed. 

On  March  27th  the  boy  was  operated  on  by  the  speaker. 
Considerable  difficulty  was  experienced  in  finding  the  appendix, 
m  account  of  extensive  adhesions.  At  last  a  very  small,  firm 
ppendix  was  found,  about  two  inches  in  length  and  of  about 
he  diameter  of  the  little  finger.  It  was  adherent  to  the  perito- 
laeuin  and  was  bound  down  beneath  and  parallel  with  the  iliac 
rtery.  It  was  tied  off  and  found  to  contain  no  foreign  body. 
Vlthough  the  boy  had  had  sixteen  attacks  of  localized  perito- 
itis.  there  did  not  seem  to  be  any  active  inflammation  present, 
mt  the  appearance  was  that  of  a  catarrhal  condition.  The 
peaker  was  by  no  means  certain  that  the  appendix  had  been 
lone  responsible  for  the  trouble.  The  patient  had  made  an  un- 
lterrupted  recovery  and  was  now  quite  restored  to  a  condition 
t  normal  good  health. 


Dr.  Robert  Abbe  asked  if  there  had  been  any  relief  in  Dr. 
Stimson’s  case  where  an  opening  had  been  made  to  lessen  the 
pain  of  pressure  by  gas.  He  understood  that  the  gas  liberated 
was  only  for  a  distance  of  twelve  inches  from  the  point  of  the 
pain. 

Dr.  Stimson  replied  that  there  had  been  an  immediate  and 
abundant  discharge  of  faeces  through  the  opening. 

Dr.  V  yeth  mentioned  a  case  in  which  the  patient  was  in  a 
moribund  condition  from  obstruction.  To  relieve  the  disten¬ 
tion  he  had  opened  the  abdominal  cavity,  taken  the  first  loop 
of  intestine  that  presented,  and  cut  a  hole  in  it.  There  had 
been  a  copious  discharge  of  gas,  the  patient  had  begun  to 
breathe,  the  obstruction  was  removed,  and  the  woman  had  re¬ 
covered. 

The  President  mentioned  a  case  in  which  laparotomy  was 
done  for  a  wound  of  a  large  artery  in  the  abdominal  cavity, 
and  in  which  there  was  paresis  of  the  intestinal  canal.  In  the 
search  for  the  vessel  almost  all  the  intestines  were  turned  out 
of  the  abdominal  cavity.  They  were  bound  and  bunched  to¬ 
gether  by  the  exudations  of  a  former  peritonitis  and  dilated  to 
their  fullest  extent.  He  bad  found  it  necessary  to  make  four 
or  five  short  incisions  at  various  points  before  he  could  reduce 
them.  Of  course,  these  incisions  were  sutured  when  the  gases 
had  escaped. 

Dr.  J.  D.  Bryant  said  that,  although  the  fact  appeared  to 
be  well  established  that  the  escape  of  gas  in  these  cases  was 
somewhat  limited,  he  would  add  two  more  cases  in  support  of 
that  fact.  In  these  cases  a  small  aspirating  needle  was  passed 
obliquely  through  the  intestinal  wall.  Only  a  limited  portion 
of  the  intestine  was  emptied  of  gas,  and  that  mainly  by  the  in¬ 
fluence  of  external  pressure  on  the  intestine  at  either  side  of 
the  point  of  puncture.  In  one  of  these  cases  great  difficulty 
was  experienced  in  closing  the  puncture  properly  with  sutures. 
The  speaker’s  experience  thus  far  led  him  to  consider  intestinal 
puncture  under  these  circumstances  as  of  doubtful  expediency 
from  all  standpoints. 

Dr.  Wyeth,  in  reply  to  a  question  by  Dr.  Murray,  said  he 
had  not  operated  in  his  case  of  appendicitis  during  the  acute 
stage  of  the  sixteenth  attack,  as  the  boy  had  already  recovered 
from  all  the  previous  ones,  and  he  thought  it  advisable  under 
the  circumstances  to  let  him  alone  rather  than  risk  interference 
in  the  acute  stage. 

Paranephric  Cysts.— Dr.  R.  Abbe  read  a  paper  with  this 
title.  (See  page  147.) 

Dr.  Stimson  referred  to  a  case  which  seemed  analogous  to 
those  of  Dr.  Abbe’s.  The  patient,  a  man,  had  a  large  tumor 
apparently  connected  with  the  left  kidney.  This  was  reduced 
by  multiple  aspirations,  three  in  all  being  made  in  the  course  of 
six  weeks.  Since  that  time  there  had  been  no  return  of  the 
.fluid. 

Ovarian  Fibroid  and  Tubal  Pregnancy.— Dr.  McCosh 
narrated  the  case  of  a  woman  admitted  into  the  Presbyterian 
Hospital  with  the  following  history  :  She  had  always  menstru¬ 
ated  irregularly,  both  profusely  and  painfully,  and  for  many 
years  her  periods  had  been  delayed  or  were  too  frequent,  inter¬ 
changeably.  She  had  been  married  two  years  and  bad  never 
been  pregnant  to  her  knowledge.  Five  months  ago  her  periods 
had  ceased  altogether  and  had  not  recurred.  For  fifteen  years 
she  had  had  abdominal  pain  and  tenderness,  with  bearing-down 
sensations,  especially  at  her  menstrual  epochs.  Seven  years 
ago  she  had  noticed  a  swelling  in  the  right  side,  appearing  after 
severe  exertion.  It  had  seemed  larger  during  menstruation. 
Five  months  ago  a  swelling  on  the  left  side  appeared  which 
grew  rapidly,  and  menstruation  had  ceased.  According  to  the 
patient’s  observations,  there  were  no  breast  changes.  She  had 
lost  flesh  and  strength. 


248 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jouk., 


Examination  revealed  a  solid  tumor  growing  out  of  the  pel¬ 
vis  and  occupying  the  middle  of  the  abdomen  as  high  as  the 
umbilicus.  On  the  left  side,  at  a  point  on  a  level  with  and  above 
the  umbilicus,  there  was  felt  a  fluctuating  tumor  adherent  to  or 
forming  a  part  of  the  mass  just  mentioned.  The  diagnosis  was 
made  of  uterine  fibroid  complicated  by  a  cyst.  On  opening 
the  abdomen,  the  body  of  the  uterus  was  found  occupied  by  a 
fibromyoma  somewhat  larger  than  an  adult  head.  Springing 
from  near  its  upper  border  on  the  left  side  was  a  thin-walled 
cyst  almost  as  large  as  the  solid  tumor,  to  which  it  was  closely 
adherent.  At  the  time  the  speaker  thought  that  it  might  be  a 
tubal  gestation-sac.  Even  subsequently,  on  opening  the  sac, 
which  contained  a  four-and-a-half-months  foetus,  he  could  not 
tell  whether  it  was  a  Falloppian  tube  or  the  left  cornu  of  the 
uterus.  On  account  of  a  firm  adhesion  of  the  sigmoid  flexure 
to  the  upper  part  of  the  cervix  uteri,  it  was  deemed  best  not  to 
remove  the  entire  uterus,  and  hence  the  pedicle  was  fastened  in 
the  abdominal  wound.  The  patient  made  an  uninterrupted  re¬ 
covery.  An  examination  of  the  tumor  showed  that  the  entire 
body  of  the  uterus  was  occupied  by  a  fibromyoma,  and  after 
shrinkage  of  the  foetal  sac  it  was  evident  that  it  was  the  dilated 
left  uterine  cornu.  The  uterine  canal  could  not  be  traced  higher 
than  the  internal  os,  and  careful  dissection  failed  to  find  any 
communication  between  this  canal  and  the  sac  in  which  the 
foetus  lay.  It  was  evident  that  delivery  per  vias  naturales  would 
have  been  impossible,  and  that,  had  the  patient  been  allowed  to 
goto  term  without  rupture  taking  place,  a  Porro  operation  must 
have  resulted. 

The  pathologist’s  description  of  the  mass  removed  was  as 
follows:  A  nearly  spherical  mass  about  5  inches  in  diameter, 
very  firm  and  resembling  a  fibroid ;  on  section,  for  the  most 
part  white,  over  a  considerable  portion  a  grayish  discoloration. 
About  one  third  of  its  surface  is  covered  with  peritonaeum. 
Attached  to  this  tumor,  over  an  area  about  4  inches  in  diam¬ 
eter,  is  a  second  mass,  hollow,  with  a  cavity  about  3  inches  in 
diameter,  with  a  smooth  lining,  pinkish  gray,  and  showing  some 
yellowish  patches  resembling  atheromatous  tissue;  walls  about 
1  inch  thick,  resembling  loose  uterine  tissue.  It  is  covered  ex¬ 
ternally  by  peritonaeum,  has  a  pedunculated  fibroid  attached  to 
it  1  inch  in  diameter,  also  the  left  tube  and  ovary  and  the  be¬ 
ginning  of  the  right  tube.  Inside  this  cavity,  which  has  been 
opened,  all  along  one  side  is  a  foetus  4f-  inches  long,  from  ver¬ 
tex  to  tube#  ischii,  with  its  membranes,  cord,  and  placenta. 
The  left  ovary  shows  a  corpus  luteum  4  inch  in  its  longest 
diameter.  The  ovary  is  If  inch  long,  somewhat  fibrous,  and 
contains  several  minute  cysts.  The  whole  tumor,  without  the 
foetus,  weighs  5  pounds. 

Osteo-chondromata. — -Dr.  A.  G.  Gerster  presented  two 
specimens  of  this  condition  taken  from  two  patients  in  whom 
the  clinical  histories  were  for  the  most  part  similar.  The  first 
specimen  had  been  removed  from  the  right  popliteal  space  of  a 
woman  between  thirty  and  forty  years  of  age,  where  it  had 
existed  for  many  years  as  a  painless  tumor,  causing  no  incon¬ 
venience  except  that  it  had  impeded  the  function  of  the  joint. 
Six  weeks  before  she  bad  come  under  the  speaker’s  notice, 
sharp,  shooting  pains  had  commenced  along  the  course  of  the 
popliteal  nerve.  The  tumor  was  apparently  attached  to  the 
lower  end  of  the  femur  near  the  epiphyseal  line,  and  projected 
backward  and  inward.  It  had  seemed  to  be  pedunculated.  The 
vessels  and  nerves  were  displaced  outward.  He  had  told  the 
patient  that  he  could  not  be  positive  as  to  the  exact  nature  of 
the  growth.  His  diagnosis  had  been  either  osteo-chondroma  or 
sarcoma  of  the  lower  end  of  the  epiphysis  of  the  femur.  On 
cutting  down,  he  had  found  the  growth  invested  by  a  membrane 
resembling  periosteum.  Keeping  well  out  of  the  way  of  the 
vessels  and  nerves,  he  was  able  to  expose  the  pedicle  of  the 


growth  and  to  remove  the  mass  easily  with  a  chisel  and  mallet. 
The  patient  had  made  an  uneventful  recovery. 

The  second  and  larger  specimen  had  been  removed  from  a 
young  man  twenty-one  years  of  age.  The  general  details  of  the 
case  were  in  effect  similar  to  those  of  the  previous  case.  The 
speaker  would  remind  the  meeting  of  the  ease  with  which  this 
operation  could  now  be  undertaken  as  compared  with  fourteen 
years  ago.  Then  a  small  incision  was  made  and  a  chain-saw 
used.  Now,  by  ample  incision  and  the  use  of  the  chisel,  there 
was  no  difficulty  and  no  danger  of  lacerating  the  surrounding 
tissues. 


ROYAL  ACADEMY  OF  MEDICINE  IN  IRELAND. 

SECTION  IN  OBSTETRICS. 

Meeting  of  May  23 ,  1890. 

The  President,  Mr.  S.  R.  Mason,  in  the  Chair. 

Fibromyoma  of  the  Ovary.— Dr.  Bagot  showed  a  fibro¬ 
myoma  of  the  ovary,  and  stated  that  the  tumor  was  of  great 
interest  and  importance  from  a  pathological  point  of  view,  be¬ 
cause  there  seemed  to  exist  a  great  difference  of  opinion  as  to 
the  nature  of  that  rare  class  of  tumor — namely,  the  solid  non- 
malignant  tumors  of  the  ovary.  Some  observers  stated  that 
they  were  fibromata,  others  that  they  were  chiefly  fibromyo- 
mata.  Spencer  Wells  had  met  with  but  six  examples,  which 
he  considered  to  be  fibromata.  Dr.  Alban  Doran,  however,  in 
his  book  on  Tumors  of  the  Ovary ,  Falloppian  Tube ,  and  Broad 
Ligament ,  published  in  1884,  stated  that  he  had  examined  one 
of  these  tumors,  which  had  been  presented  by  Spencer  Wells 
to  the  museum  of  the  Royal  College  of  Surgeons,  London,  and 
that  it  was  a  leiomyoma,  containing  but  little  true  connective 
tissue.  All  the  solid  tumors  that  he  himself  had  seen,  removed 
at  operations,  were  either  carcinomata  or  sarcomata.  ODhausen 
had  described  them  as  consisting  of  connective  tissue,  some¬ 
times  with  a  few  muscular  fibers ;  but  the  latter  were  always 
scanty.  Martin  agreed  with  him.  Winkel  stated  that  they 
were  chiefly  connective-tissue  growths.  Waldeyer  found  no 
trace  of  smooth  muscular  tissue.  Leopold  and  Wyder’s  obser¬ 
vations  coincided  with  Waldeyer’s,  but  Klebs  and  Tucke  found 
muscular  tissue,  as  did  also  Hartmann  and  Terrier. 

Dr.  Bagot’s  case  was  as  follows:  J.  D.,  aged  forty-four 
years,  married  twenty  years,  had  given  birth  to  eight  children. 
Eight  years  had  elapsed  since  her  last  pregnancy.  In  Decem¬ 
ber,  1889,  she  came  to  the  Rotunda  Hospital  to  have  a  pessary 
changed,  as  she  had  been  wearing  it  for  some  time.  The  fol¬ 
lowing  conditions  were  found  on  examination  :  Perineal  lacera¬ 
tion  of  the  first  degree;  the  external  os  patulous;  the  cervix 
fissured;  slight  ectropion;  the  uterus  normal  in  size ;  the  fun¬ 
dus  retroverted  toward  the  left;  the  left  ovary  normal.  There 
was  a  tumor  of  the  right  ovary,  somewhat  larger  than  a  wal¬ 
nut.  Nothing  else  abnormal  could  be  made  out.  The  woman 
had  been  in  bad  health  and  was  complaining  of  various  nervous 
symptoms,  but,  as  none  of  these  could  he  distinctly  traced  tc 
the  ovary,  and  as  it  did  not  seem  to  be  injuring  her  in  any  way, 
it  was  not  interfered  with.  The  patient  had  been  under  Dr. 
Macan’s  care  since  1884,  when  the  same  diagnosis  and  prognosis 
had  evidently  been  adopted.  In  March,  1890,  however,  the 
tumor  was  very  much  larger,  and,  as  it  grew  so  rapidly,  it  wa> 
thought  advisable  to  remove  it.  Accordingly,  on  March  27 
1890,  the  speaker  removed  it  by  an  abdominal  section.  Tbt 
patient  made  a  perfect  recovery,  and  all  her  former  symptoms 
disappeared. 

Dr.  Earl  had  kindly  made  a  microscopical  examination  o 
the  tumor  and  found  the  following :  The  tumor  consisted  tnainfi 
of  unstriped  muscle,  arranged  in  bundles.  Adjoining  bundle 


August  30,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


249 


ran  at  right  angles  to  one  another.  Traversing  this  tissue  were 
numerous  tracts  of  fibrous  connective  tissue,  rather  dense. 
They  presented  a  somewhat  insular  appearance  as  seen  in  the 
sections.  Small  blood-vessels  could  be  seen  here  and  there,  and 
there  appeared  to  be  very  thick  external  coats  to  these  vessels. 

Observations  on  a  New  Speculum  Illuminator.— Dr.  T. 
More  Madden  said  that  the  importance  of  sufficient  illumina¬ 
tion  as  an  essential  element  in  the  diagnosis  and  treatment  of 
the  various  morbid  conditions  of  the  vaginal  portion  of  the 
uterus  or  of  the  vagina  in  which  the  speculum  was  resorted  to 
was  obvious.  And  yet  to  the  neglect  of  due  attention  to  this 
consideration  must  be  largely  ascribed  some  of  the  erroneous 
views  and  practices  which  for  many  years  had  retarded  the 
progress  of  gynaecology.  This  point  he  illustrated  by  a  reference 
to  the  very  opposite  opinions  at  different  periods  held  by  au¬ 
thorities  of  equal  accuracy  and  of  equal  experience  with  regard 
to  the  aspect  and  character  of  the  most  common  forms  of  dis¬ 
ease  discernible  through  the  vaginal  speculum.  Had,  however, 
those  who  thus  differed  as  to  the  nature  and  treatment  of  the 
pathological  conditions  presented  to  visual  examination  by  the 
speculum  possessed  instruments  such  as  those  now  available  for 
this  purpose,  and  enjoyed  the  advantage  of  the  methods  of  il¬ 
lumination  by  which,  when  necessary,  the  best  of  all  lights — 
namely,  that  of  direct  sunlight — might  be  replaced,  the  heated 
controversies  and  fallacious  practices  of  former  days  might  prob¬ 
ably  have  been  avoided.  Much  as  had  been  done  in  this  way, 
there  still  remained,  however,  some  room  for  further  improve¬ 
ment,  as  even  yet,  among  the  every-day  troubles  of  gynaeco¬ 
logical  work,  not  the  least  frequent  or  least  annoying  of  its  kind 
was  the  difficulty  occasionally  experienced  in  making  a  satisfac¬ 
tory  visual  examination  of  the  vagina  or  vaginal  portion  of  the 
uterus  in  many  cases  where  it  was  required  for  diagnostic  or 
therapeutic  purposes.  In  regions  wherein  sunshine  was  so  ex¬ 
ceptional  as  was  unfortunately  the  case  under  the  leaden  skies 
and  murky  atmosphere  of  the  British  Isles,  this  difficulty  fre¬ 
quently  presented  itself  even  in  the  physician’s  best- arranged  con¬ 
sulting  room,  where  the  couch  was  most  advantageously  placed 
with  reference  to  light.  And,  a  fortiori ,  it  occurred  still  more 
commonly  in  the  patient’s  chamber,  where  the  bed  was  often  so 
situated  as  to  preclude  full  access  of  natural  light  into  the  specu¬ 
lum.  And,  in  his  opinion,  the  deficiency  was  not  supplied  by 
any  of  the  electric  lamps  which,  so  far  at  least,  he  had  himself 
employed.  These,  he  had  found,  were  apt  to  fail  at  the  moment 
their  assistance  was  needed,  as,  owing  to  some  one  or  other  of 
the  defects,  either  in  battery,  connections,  or  lamp,  that  were 
of  such  frequent  occurrence  in  electrical  apparatus,  on  pressing 
the  button,  instead  of  the  brilliant  flood  of  electric  light  expect¬ 
ed,  the  result  obtained  might  be  either  nil  or  else  merely  the 
dull-red  glow  of  the  incandescent  carbon  filament.  On  the  other 
hand,  if  we  contented  ourselves  with  the  more  reliable  if  less 
elegant  “bit  of  candle  end,”  still  recommended  by  some  au¬ 
thorities,  the  necessity  for  holding  it  so  as  to  throw  some  light 
into  the  speculum  must  interfere  with  any  manipulation  required 
by  the  case.  Therefore  the  speaker  desired  to  suggest  to  other 
practitioners  who  were  likely  to  meet  with  the  difficulty  he  had 
often  thus  encountered,  a  trial  of  the  little  contrivance  now  ex¬ 
hibited,  which  he  had  found  serviceable  under  such  circum¬ 
stances.  This  consisted  of  a  very  portable,  many-jointed  illumi¬ 
nator,  capable  of  rotation  in  every  possible  direction,  which  could 
be  instantly  and  securely  affixed  to  any  form  of  speculum,  so  as 
not  to  be  in  the  surgeon’s  way,  while  affording  sufficient  and  re¬ 
liable  light  for  all  examinations  or  operations  in  the  vaginal  pas¬ 
sage.  This  instrument,  he  added,  had  been  very  carefully  made, 
in  accordance  with  his  directions,  by  Messrs.  Lynch  &  Co.,  Al- 
dersgate  Street,  London. 

Dr.  McVeigh  was  of  opinion  that  the  illuminator  would 


prove  of  the  greatest  use,  especially  in  making  examinations  in 
the  evening. 

Dr.  Macan  remarked  that  probably  every  gynaecologist  had 
his  own  plan  for  getting  through  his  work  in  the  dark.  For  his 
own  part,  he  did  not  find  any  difficulty  in  working  with  an  or¬ 
dinary  lamp  and  reflector;  and  he  did  not  know  that  the  instru¬ 
ment  now  exhibited  would  prove  much  better.  He  had  also 
used  the  ordinary  electric  light;  but  the  objection  to  it  was 
that  the  operator  had  to  use  one  hand  in  holding  it,  while  he 
manipulated  with  the  other.  He  had  not  found  any  difficulty 
in  working  with  an  ordinary  gas  lamp.  He  was  sure  that  the 
present  instrument  was  a  very  capable  one,  but  he  did  not  think 
it  a  necessity. 

Dr.  Byrne  said  he  considered  Dr.  Madden’s  invention  very 
ngenious  and  simple. 

Dr.  Bagot  said  the  present  instrument  was  liable  to  the 
same  fault  that  existed  in  the  case  of  others  also,  namely,  that 
the  light  was  between  the  operator  and  his  work.  For  the  pur¬ 
pose  of  an  operation  he  thought  that  a  lamp  or  electric  light, 
with  a  reflector  on  the  forehead,  would  be  more  effectual  and 
less  in  the  way. 

Dr.  Madden  said  he  had  found  this  instrument  useful  not 
only  in  cases  in  the  hospital  with  which  he  was  connected,  but 
still  more  so  in  private  practice,  inasmuch  as  some  of  the  elec¬ 
tric  and  other  lights  relied  on  for  utero-vaginal  examinations 
were  very  troublesome  to  carry  about,  and  were  apt  to  go  out 
at  a  moment’s  notice. 

section  in  pathology. 

Meeting  of  May  30 ,  1890. 

The  President,  Dr.  E.  H.  Bennett,  in  the  Chair. 

Porencephaly. — Dr.  Conolly  Norman  read  a  paper  on  por¬ 
encephaly.  He  briefly  traced  the  history  of  this  affection  in 
medical  literature  from  the  days  of  Heschl,  who  first  described 
it  under  this  name,  to  Andry,  who  had  recently  written  a  valu¬ 
able  memoir.  Dr.  Norman  described  a  case  which  had  occurred 
{n  his  own  practice.  The  patient  was  not  an  idiot.  The  his¬ 
tory  was  very  defective,  but  he  was  known  to  have  been  a 
criminal.  When  under  Dr.  Norman’s  care  he  suffered  from 
paranoia,  with  persecutory  delusions.  He  exhibited  partial  right 
hemiplegia  without  aphasia.  He  died  of  phthisis.  The  brain 
showed  a  large  opening  on  the  left  side  leading  directly  into  the 
lateral  ventricle,  the  insula,  the  operculum,  and  the  internal 
capsule  being  absent.  The  optic  thalamus  and  optic  tract  on 
the  left  side  were  diminutive.  Having  described  the  conditions 
found  in  some  detail,  and  exhibited  some  beautiful  photographs 
of  the  brain  made  by  Professor  Fraser,  Dr.  Norman  dwelt  upon 
the  various  theories  of  the  causation  of  porencephaly.  He  in¬ 
clined  to  believe  that  a  case  like  this  was  probably  a  condition 
of  arrested  development,  and  regarded  the  membrane  which 
closed  the  opening  in  these  cases  as  the  altered  wall  of  the  sec¬ 
ondary  anterior  cerebral  vesicle  which  had  not  developed  nerv¬ 
ous  matter.  The  most  interesting  points  were :  1.  The  aetiology. 
2.  How  the  functions  of  the  internal  capsule  were  even  imper¬ 
fectly  performed  in  the  absence  of  that  structure. 

Dr.  0.  J.  Nixon  remarked  that  Dr.  Norman  had  discussed 
porencephaly  as  if  it  invariably  had  a  congenital  origin;  but  it 
was  equally  true  that  porencephaly  was  acquired ;  for  instance, 
from  injuries  several  months  after  birth,  or  from  acute,  ex¬ 
hausting  diarrhoea,  or  from  a  bad  form  of  measles  or  scarlatina, 
resulting  in  infantile  hemiplegia  or  in  total  paralysis. 

Dr.  T.  Myles  said  the  photogi’aph  shown  by  Dr.  Norman 
seemed  to  be  one  of  the  brain  of  an  orang-outang  or  of  a  South 
African  bushman  rather  than  of  an  ordinary  human  brain;  for 
the  Sylvian  fissure,  instead  of  being  horizontal,  was  nearly  ver- 


250 


BOOK  NOTICES. — NEW  INVENTIONS. 


[N.  Y.  Mkd.  Joub., 


tical ;  the  fissure  of  Rolando  was  invisible;  the  parietooccipital 
fissure  extended  to  the  temporo-sphenoidal  bone,  and  the  tip  of 
that  bone,  instead  of  reaching  out  to  the  frontal  lobe,  was  un¬ 
developed,  extending  only  as  far  as  the  Sylvian  fissure. 

Dr.  Norman  said  the  conditions  described  by  Dr.  Myles  wrere 
attributable  to  the  fact  that  the  brain  had  been  allowed  to  lie  a 
little  crooked  and  was  badly  hardened ;  but  the  fissure  of  Ro¬ 
lando  was  specially  marked  and  recognizable,  while  the  temporo- 
sphenoidal  lobe  had  got  squeezed  up.  There  was  no  trace  of 
destruction  of  tissue  or  of  any  lesion  from  thrombosis  or  other 
cause.  The  chief  problem  was,  from  what  had  taken  place  to 
the  fibers  of  the  internal  capsule,  how  any  movement  remained 
in  the  limbs,  which  were  entirely  cut  otf  from  what  were  re¬ 
garded  as  the  motor  centers  of  the  cerebral  cortex. 

Dr.  Nixon  asked  if  there  was  volitional  movement  in  the 
limbs,  notwithstanding  the  destruction  or  absence  of  the  inter¬ 
nal  capsule. 

Dr.  Norman  said  there  was  volitional  movement,  limited  in 
extent  and  impaired,  but  undoubtedly  existent. 


00k  Uoftres. 


BOOKS  AND  PAMPHLETS  RECEIVED. 

The  Throat  and  Nose  and  their  Diseases.  With  One  Hundred  and 
Twenty  Illustrations  in  Color,  and  Two  Hundred  and  Thirty-five  En¬ 
gravings,  designed  and  executed  by  the  Author.  By  Lennox  Browne, 
F.  R.  C.  S.  E.,  Senior  Surgeon  to  the  Central  London  Throat  and  Ear 
Hospital,  etc.  Third  Edition,  revised  and  enlarged.  Philadelphia : 
Lea  Brothers  &  Co.,  1890.  Pp.  xxii-716.  [Price,  $6.50.] 

Hysteropexie  abdominale  ant^rieure  et  operations  sus-pubiennes 
dans  les  retrodeviations  de  l’uterus.  Par  Marcel  Baudouin.  Avec  vingt- 
deux  figures  dans  le  texte.  Paris:  Lecrosnier  et  Babe,  1890.  Pp. 
x~414.  [Publications  du  Progres  medical .] 

Ruptures  des  tendons  sus  et  sousrotuliens.  Traitement  par  la  su¬ 
ture.  Par  Herve,  Docteur  en  medecine  de  la  Faculte  de  Paris.  Paris : 
Henri  Jouve,  1890.  Pp.  5  to  88. 

Nine  Months’  Work  in  Abdominal  Surgery.  Bv  Clinton  Cushing, 
M.  D.  [Reprinted  from  the  Pacific  Medical  Journal.'] 

Electricity  in  Gynaecology;  the  Galvanic  Apparatus.  By  C.  N. 
Smith,  M.  D.,  Toledo,  Ohio.  [Reprinted  from  the  Toledo  Medical  and 
Surgical  Reporter.] 

On  the  Toxic,  Pathogenetic,  and  Therapeutic  Qualities  of  the  Cac- 
taceae.  By  Edwin  M.  Hale,  M.  D.,  Chicago,  Ill.  [Reprinted  from  the 
North  American  Journal  of  Homoeopathy.] 

The  Use  of  Commercial  Milk  Sugar  in  Infant-Feeding.  Bv  E.  F. 
Brush,  M.  D.,  Mount  Vernon,  N.  Y.  [Reprinted  from  the  Journal  of 
the  American  Medical  Association. 

Abortion  and  its  Effects.  By  Joseph  Taber  Johnson,  A.  M.,  M.  D., 
Washington,  D.  C.  [Reprinted  from  the  Maryland  Medical  Journal.] 

What  is  the'  Present  Medico-legal  Status  of  the  Abdominal  Sur¬ 
geon  ?  By  William  Warren  Potter,  M.  D.,  Buffalo,  N.  Y.  [Reprinted 
from  the  American  Journal  of  Obstetrics  and,  Diseases  of  Women  and 
Children.] 

The  Seborrhoeic  Wart,  Verruca  seborrhoica,  Verruca  senilis,  Ver¬ 
ruca  plana  seniorum,  Keratosis  pigmentosa.  By  S.  Pollitzer,  A.  M., 
M.  D.,  New  York.  [Reprinted  from  the  British  Journal  of  Derma¬ 
tology.] 

Functional  Nervous  Diseases  of  Reflex  Origin.  By  Albert  Rufus 
Baker,  M.  D.,  Cleveland,  Ohio.  [Reprinted  from  the  Journal  of  the 
American  Medical  Association.] 

The  New  Treatment  of  Peritonitis.  By  Emory  Lanphear,  M.  D., 
Kansas  City,  Mo.  [Reprinted  from  the  Kansas  City  Medical  Index.] 

Reformation  in  the  Practice  of  Medicine  by  the  Dosimetric  Method 
of  Practice  ;  or,  the  Method  of  Small  Doses  of  the  Active  Principles  of 


Plants,  mathematically  measured  and  scientifically  adapted  to  the 
Varied  Abnormal  Conditions ;  with  Biographical  Sketch  of  Dr.  Ad. 
Burggrave.  By  J.  E.  MacNeill,  M.  D.,  Denver,  Col.  [Revised  and  re¬ 
printed  from  the  Dosimetric  Medical  Review.] 

Dosimetry  in  Colorado.  By  Dr.  J.  E.  MacNeill,  Denver,  Col. 

Report  on  Alcohol  and  Longevity.  By  E.  Macdowel  Cosgrave, 
M.  D.,  Ch.  M.,  Univ.  Dubl.  [Reprinted  from  the  Dublin  Journal  of 
Medical  Science.] 

The  Anniversary  Address  before  the  Medical  Society  of  the  State  of 
New  York.  By  Daniel  Lewis,  A.  M.,  M.  D.,  New  York.  [Reprinted 
from  the  Transactions.] 

The  Limits  of  Vaginal  Hysterectomy  for  Cancer  of  the  Uterus.  Bv 
Henry  C.  Coe,  M.  D.,  New  York.  [Reprinted  from  the  American  Jour- 
7101  of  Obstetrics  and  Diseases  of  Women  and  Children.] 

The  Use  and  Abuse  of  Soap  and  Water.  By  B.  Merrill  Ricketts, 
M.  D.  [Reprinted  from  the  Journal  of  Cutaneous  and  Genito-ur inary 
Diseases.] 

External  Surgery  of  the  Nose.  By  B.  Merrill  Ricketts,  M.  D.,  Cin¬ 
cinnati,  Ohio.  [Reprinted  from  the  Journal  of  the  American  Medical 
Association.] 

Cholecystotomy.  By  Edward  Ricketts,  M.  D.,  of  Cincinnati,  Ohio. 
[Reprinted  from  the  Pittsburgh  Medical  Review.] 

Five  Cases  of  Vaginal  Hysterectomy  for  Malignant  Disease  of  the 
Uterus.  All  recovered.  By  W.  F.  McNutt,  M.  D.,  etc.  [Reprinted 
from  the  Transactions  of  the  Medical  Society  of  the  State  of  California.] 
Varicocele.  By  Thomas  W.  Kay,  M.  D.,  Scranton,  Pa.  [Reprinted 
from  the  Cleveland  Medical  Gazette.] 

A  New  Operation  for  Prolapsus  of  the  Anterior  Vaginal  Wall.  By 
Andrew  F.  Currier,  M.  D.,  New  York.  [Reprinted  from  the  Annals  of 
Gyncecology  and  Peediatry.] 

Scheme  of  the  Antiseptic  Method  of  Wound  Treatment.  By  Dr. 
Albert  Hoffa,  Privat  Docent  of  Surgery  in  the  University  of  Wurz¬ 
burg.  Translated  from  the  German,  with  Additions,  by  special  Per¬ 
mission  of  the  Author,  by  Aug.  Schachner,  M.  D.,  Ph.  G.,  Louisville,  Ky. 

Ueber  die  Natur  der  von  Zander  im  embryonalen  Nagel  gefundenen 
Kornerzellen.  Von  S.  Pollitzer,  A.  M.,  M.  D.  [Sonder-Abdruck  aus 
Monatshefte  fur  praktische  Dermatologie.] 

Die  Resultate  der  aseptischen  Laparotomien.  Von  Heinrich  Fritsch. 
[Sonder-Abdruck  aus  dem  Centralblatt  fur  Gynakologie.] 

Due  casi  di  paralisi  motoria  della  laringe.  Pel  Dott.  A.  Damieno. 
[Estratto  dalle  Gozzetta  delle  Cliniche.] 

Tenth  Annual  Report  of  the  State  Board  of  Health  of  New  York. 
Transmitted  to  the  Legislature,  February  20,  1890. 

Twenty-ninth  Annual  Report  of  the  Cincinnati  Hospital  to  the 
Mayor  of  Cincinnati  for  the  Fiscal  Year  ending  December  31,  1889. 


fteto  Jfnbenttons,  etc. 


NEW  NASO-PHARYNGEAL  SCISSORS. 

By  F.  C.  Raynor,  M.  D., 

ASSISTANT  SURGEON  TO  SKIN  AND  THROAT  DEPARTMENT,  BROOKLYN  EYE 

AND  EAR  HOSPITAL. 

The  instrument  which  is  illustrated  herewith  was  designed  for  the 
removal  of  adenoid  vegetations  from  the  vault  of  the  pharynx  by  sub¬ 
stituting  a  clean  cut  for  the  older  and  more  common  methods  of 
crushing,  scraping,  and  tearing,  and,  as  it  has  proved  so  satisfactory  in 
my  hands  and  in  those  of  others  to  whom  I  have  submitted  it  for  trial, 
I  venture  to  bring  it  before  the  profession.  It  is  believed  to  be  the 
only  instrument  for  this  purpose  working  on  scissors  principle,  all  other 
cutting  instruments  with  which  I  am  familiar  being  variously  formed 
punches.  Its  shape  can  be  well  appreciated  by  referring  to  the  cuts, 
a  representing  the  instrument  closed,  b  open  for  use.  Its  form  in  gen¬ 
eral  resembles  the  letter  f  the  female  blade  terminating  in  a  rounded 
point,  the  male  blade  being  prolonged  to  make  a  fenestra  for  bring¬ 
ing  away  the  portion  excised.  In  size  it  corresponds  closely  with 


August  30,  1890.J 


MISCELLANY. 


Hooper’s  forceps,  and  is  therefore  adapted  for  use  in  small  children 
As  the  cutting  surface  extends  from  the  joint  to  the  tip  of  the  fe¬ 
male  blade,  it  may  be  employed  for  removing  hypertrophied  follicles 
from  the  posterior  pharyngeal  wall,  trimming  ragged  tonsils,  etc.  The 


instrument,  being  small  and  delicately  made,  should  only  be  used  in 
operating  on  soft  tissues.  Both  Dr.  Sherwell  and  myself  have  oper¬ 
ated  without  general  or  local  anaesthesia,  and  the  pain  produced  was 
very  slight.  The  instrument  was  made  for  me  by  George  Tiemann 

&  Co. 

169  State  Street. 


J£l  i:  g  c  1 1 1  a  n  g. 


The  American  Orthopaedic  Association  will  hold  its  fourth  annual 
neeting  at  the  College  of  Physicians,  Philadelphia,  on  Tuesday,  Wednes- 
lay,  and  Thursday,  September  16th,  17th,  and  18th,  under  the  presi- 
iencv  of  Dr.  DeForest  Willard,  of  Philadelphia.  The  programme  in- 
•ludes  the  following  papers  :  Spinal  Distortions  and  their  Treatment  by 
he  Straightened  Leather  Jacket,  by  Dr.  Bernard  Bartow,  of  Buffalo  ; 
Treatment  of  Deformities  of  Spastic  Paralysis,  by  Dr.  E.  H.  Bradford, 
>f  Boston  ;  Tenotomy  for  Relief  of  Deformity  in  Spastic  Paralysis,  by 
Jr.  Arthur  J.  Gillette,  of  St.  Paul;  Amputation  as  an  Orthopaedic  Meas- 
ire,  by  Dr.  Ap  Morgan  Vance,  of  Louisville  ;  A  Ready  Method  of  Coun- 
er-traction  of  the  Knee,  by  Dr.  Henry  Ling  Taylor,  of  New  York; 
Treatment  of  Infantile  Club-foot  preliminary  to  Operation,  by  Dr.  F.  H. 
dilliken,  of  New  York  ;  Paralytic  Club-foot,  by  Dr.  W.  R.  Townsend, 
>f  New  York  ;  Ten  Years’  Experience  in  the  Management  of  Knee-joint 
fisease,  by  Dr.  V.  P.  Gibney,  of  New  York ;  The  Inefficiency  of  Me- 
hanical  Treatment  in  Spasmodic  Wryneck,  with  a  Report  of  Three 
lases,  by  Dr.  G.  W.  Ryan,  of  Cincinnati ;  Sacro-iliac  Disease,  by  Dr. 
lenjamin  Lee,  of  Philadelphia  ;  Instantaneous  Photograph,  illustrating 
he  Gait  of  a  Child  from  whom  both  Hips  had  been  removed,  by  Dr.  H. 
I.  Sherman,  of  San  Francisco  ;  a  discussion  on  the  subject  of  Rotary 
.ateral  Curvature  of  the  Spine,  in  which  the  following  papers  will  be 
ead  :  The  Nervous  and  Muscular  Elements  in  the  Causation  of  Idio- 
lathic  Curvature,  by  Dr.  Benjamin  Lee  ;  the  Muscular  Element  in  the 
Etiology,  by  Dr.  Charles  L.  Scudder ;  ^Etiology,  by  Dr.  R.  W.  Lovett ; 
lechanism  of  Rotation,  by  Dr.  A.  B.  Judson  ;  the  Mechanical  Theory, 
•y  Dr.  0.  H.  Allis  ;  Causes,  by  Dr.  M.  T.  Bissel ;  Pathogeny,  by  Dr. 
Tewton  M.  Shaffer  ;  Treatment  especially  Applicable  to  Poor  and  Dis- 
■ensarv  Patients,  by  Dr.  V.  P.  Gibney,  and  papers  on  Treatment  by  Dr. 
1.  H.  Bradford,  Dr.  B.  E.  McKenzie,  and  Dr.  Henry  Ling  Taylor ;  The 
igDificance  and  Value  of  Involuntary  Muscular  Protection  and  the  Limp 
f  the  First  Apparent  Stage  of  Hip  Disease,  by  Dr.  Newton  M.  Shaffer; 
Teatment  of  Hip  Disease,  by  Dr.  B.  E.  McKenzie,  of  Toronto ;  A  Re- 
ort  of  Sixty-two  Cases  of  Hip  Disease  observed  in  the  Practice  of  Hugh 
'wen  Thomas,  by  Dr.  John  Ridlon,  of  New  York  ;  Diseases  of  the  Eye 
ssociated  with  Spinal  Caries,  by  Dr.  James  K.  Young,  of  Philadelphia; 
’osterior  Rhachitic  Curvature  of  the  Spine,  by  Dr.  Samuel  Ketch,  of 
>ew  York  ;  Lateral  Deviation  of  the  Spinal  Column  in  Pott’s  Disease) 
v  Dr.  R.  W.  Lovett,  of  Boston  ;  Relief  of  Paraplegia,  by  Dr.  A.  J. 
teele,  of  St.  Louis  ;  Prognosis  of  Pressure  Paralysis,  by  Dr.  T.  Halsted 
lyers,  of  New  York  ;  Do  Orthopaedic  Surgeons  operate  as  frequently 
,s  they  should?  by  Dr.  J.  E.  Moore,  of  Minneapolis;  Joint  Diseases, 
y  Dr.  John  Ridlon,  of  New  York  ;  and  papers  by  Dr.  T.  G.  Moton,  Dr. 
ioswell  Park,  Dr.  R.  H.  Sayre,  and  Dr.  H.  A.  Wilson. 


251 

Sulphurous  Disinfection. — Dr.  Henry  B.  Baker,  Secretary  of  the 
Michigan  State  Board  of  Health,  has  addressed  a  letter  to  Dr.  E.  B. 
Frazer,  Secretary  of  the  State  Board  of  Health  of  Delaware,  of  which 
the  following  is  a  copy  : 

Dear  Doctor:  Your  letter  of  August  18th,  acknowledging 
the  receipt  of  a  copy  of  my  letter  to  Dr.  Duffield  (giving  results 
of  experience  of  health  officers  in  Michigan,  and  an  account  of 
experiments  by  Pasteur,  Roux,  Dujardin-Beaumetz,  and  others 
relative  to  sulphurous  disinfection),  is  before  me.  You  ask 
me  for  further  opinion,  and  refer  to  the  Report  of  the  Maine 
State  Board  of  Health  for  1889,  page  251,  and  Dr.  T.  Mitchell 
Prudden’s  estimate  of  the  want  of  value  of  sulphurous  disin¬ 
fection.* 

There  are  at  least  two  valid  objections  to  the  acceptance  of 
Dr.  Prudden’s  conclusions  to  which  you  refer  :  1.  His  experiments  dealt 
with  a  micro-organism  which  seems  to  be  different  from  the  one  most 
generally  accepted  as  the  probable  cause  of  diphtheria.  Therefore  he 
may  or  may  not  have  been  dealing  with  a  micro-organism  causing  diph¬ 
theria.  2.  The  quantity  of  sulphur  burned,  the  strength  of  the  sul¬ 
phurous-acid  fumes  which  he  employed,  is  not  stated.  It  having  been 
proved  by  actual  experience  with  disease,  and  by  other  laboratory  ex¬ 
perimenters  (Pasteur,  Roux,  Dujardin-Beaumetz,  Vallin,  Legouest,  Pol- 
li,  Pettenkofer,  Dougall,  Fatio,  Pietra  Santa),  that  sulphurous-acid  gas 
is  not  always  a  disinfectant  when  employed  in  small  proportions,  and 
that  it  is  a  disinfectant  when  employed  in  large  proportions,  such  as 
result  from  the  burning  of  three  pounds  of  sulphur  to  each  thousand 
cubic  feet  of  air-space,  no  different  conclusion  should  be  reached  from 
Dr.  Prudden’s  experiments  as  published,  f 

You  mention  that  Dr.  W.  H.  Welch,  of  Baltimore,  “enters  his  pro¬ 
test  against  ”  disinfection  by  sulphurous-acid  gas.  I  respectfully  submit 
that  entering  a  protest  should  count  for  very  little  in  science  as  against 
results  of  actual  practical  experience  in  the  restriction  of  diphtheria  ; 
it  should  not  even  take  rank  with  definite  statements  of  results  of 
laboratory  experiments. 

Laboratory  experiments  are  very  valuable,  but  they  need  to  be  re¬ 
peated,  by  the  same  observer  and  by  other  observers,  in  order  to  elimi¬ 
nate  errors  due  to  accidental  and  incidental  conditions. 

It  is  not  easy  to  make  laboratory  experiments  which  shall  conform- 
to  or  correctly  represent  average  conditions  in  actual  outbreaks  of  dis¬ 
ease.  That  is  probably  one  reason  for  the  discrepancies  in  laboratory 
experiments,  and  for  the  disagreement  of  some  laboratory  experiments 
with  practical  experience  with  disease.  One  reason  for  this  last  dis¬ 
agreement  may  be  that  micro-organisms  which,  after  subjection  to  a 
disinfectant,  may  yet  have  sufficient  vitality  to  reproduce  in  a  labora¬ 
tory  where  the  most  favorable  conditions  are  supplied,  could  not  possibly 
do  so  in  the  human  throat,  or  elsewhere  in  the  human  body,  because 
of  the  well-known  power  of  the  fluids  of  the  body  to  destroy  micro¬ 
organisms,  as  proved  by  Dr.  Prudden’s  and  other  laboratory  experi¬ 
ments  following,  but  not  confirming,  Metschnikoff’s  doctrine  of  the 
phagocytes. 

Progress  would  be  easier,  more  rapid,  and  the  backward  and  for¬ 
ward  movements  less  frequent,  if  experimenters  in  laboratories  would 
be  more  careful  in  stating  the  details  of  their  work. 

The  interpretation  of  the  results  of  laboratory  experiments  and  the 
determination  of  the  bearing  which  they  should  have  upon  practical 
affairs  is  an  extremely  difficult  work,  and  one  in  which  there  is  very 
great  liability  to  error. 

Practical  health  officers  need  to  employ  a  gaseous  disinfectant  that 
shall  at  once  reach  all  surfaces,  ledges,  cracks,  drawers,  and  receptacles 
of  dust  wherever  it  may  be  in  a  room,  that  shall  permeate  all  articles 
sufficiently  permeable  to  admit  disease-causing  micro-organisms,  that 
will  not  necessitate  too  much  labor  in  the  removal  of  furniture  or 
other  articles,  and  that  shall  have  power  to  destroy  or  sufficiently  weaken 
the  vitality  of  the  “  germs  ”  of  such  diseases  as  diphtheria  and  scarlet 
fever,  and  occasionally  small-pox,  as  they  are  usually  distributed  in  the 
sick-room,  and  that  shall  not  destroy  family  portraits  and  similar  arti- 


*  American  Journal  of  the  Medical  Sciences,  May,  1890,  p.  470. 

f  Ibid. 


252 


MIS  CELL  A  N  Y. 


[N.  Y.  Med.  Jodr. 


cles.  Only  two  such  disinfectants  are  prominently  before  us  for  choice 
—chlorine  and  sulphurous-acid  pas.  Of  these  two,  sulphurous-acid 
gas  is  made,  in  proper  quantity,  with  more  certainty  and  less  trouble 
than  is  chlorine  gas ;  and  at  present  I  regard  the  weight  of  evidence  in 
its  favor  as  equal  to  that  relative  to  chlorine  gas,  concerning  which  not 
so  much  evidence  has  been  published.  Practical  experience  in  Michi¬ 
gan  proves  that  by  isolation  of  first  cases  of  diphtheria,  and  disinfec¬ 
tion  of  premises  after  death  or  recovery  therefrom  by  fumes  of  burning 
sulphur,  etc.,  four  fifths  of  the  cases  and  deaths  which  would  otherwise 
occur  from  that  disease  are  prevented.  If  there  is  any  other  method 
of  disinfection  or  any  other  procedure  that  can  be  shown  to  reduce  the 
cases  and  deaths  more  than  the  four  fifths  and  down  to  less  than  an 
average  of  two  and  one  third  cases  and  six  tenths  of  one  death  to  each 
outbreak,  I  am  exceedingly  desirous  of  knowing  what  it  is.  But,  inas¬ 
much  as  that  is  the  recent  experience  in  Michigan  (outside  of  the  great 
cities),  it  does  not  seem  best  to  give  up  the  methods  employed  until 
evidence  of  a  better  method  is  produced. 

Meantime  I  would  advise  a  continuance  of  sulphurous  disinfection, 
for  the  purposes  for  which  it  is  applicable,  and  for  which  it  is  greatly 
needed  as  stated  above,  not  including  the  disinfection  of  excretions 
from  the  patient,  for  which  chlorinated  lime  or  liquid  is  applicable,  nor 
of  bits  of  diphtheritic  membrane,  which  should  be  destroyed  by  fire,  as 
should  also  all  rags  and  everything  else  not  too  valuable  used  about  a 
patient ;  and  all  clothing,  bed-clothes,  etc.,  that  can  profitably  be  boiled 
should  be  so  treated. 

Mortality  in  Cities  in  the  United  States.— The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  August  22d : 


CITIES. 

Week  ending- 

Estimated  pop 
lation. 

Total  deaths  f 
all  causes. 

|  Cholera. 

|  Yellow  fever. 

|  Small-pox. 

|  Varioloid. 

|  Varicella. 

|  Typhus  fever.  | 

|  Enteric  fever. 

|  Scarlet  fever. 

|  Diphtheria. 

|  Measles. 

Whooping- 

cough. 

1,637,548 

732 

10 

5 

12 

9 

15 

fi064,277 

430 

23 

3 

5 

10 

i,ioo|ooo 

512 

25 

4 

8 

1 

10 

500,343 

175 

4 

2 

1 

5 

437^245 

242 

3 

1 

3 

325^000 

96 

4 

3 

July  26. 

260^000 

102 

2 

2 

i 

260 j  000 

132 

8 

1 

254^000 

116 

2 

A  lie1.  9. 

254,000 

120 

1 

1 

1 

250,000 

72 

4 

Aug.  16. 

240 ’  000 

91 

8 

6 

l 

Aug.  9. 

230,000 

101 

3 

Aug.  16. 

227,000 

53 

4 

Aug.  16. 

220,000 

85 

1 

2 

l 

Aug.  9. 

132, 000 

50 

1 

1 

Aug.  16. 

132’neo 

36 

O 

1 

Aug.  16. 

130,000 

63 

1 

2 

Aug.  15. 

129^346 

32 

2 

Aug.  15. 

81,650 

24 

1 

Aug.  16. 

75v5?5 

38 

2 

1 

Aug.  16. 

69^000 

40 

1 

Aug.  16. 

35,000 

7 

July  19. 

34,397 

13 

July  26. 

34,397 

14 

Aug.  16. 

26.000 

9 

Aug.  16. 

22,011 

10 

Aug.  10. 

16,000 

1 

Aug.  9. 

15,000 

7 

Successful  Operation  for  Actinomycosis. — “Dr.  Matlakowski,  of 
Warsaw,  reports  an  interesting  case  of  actinomycosis  in  a  man  which 
was  successfully  eradicated  by  operative  measures.  The  patient,  who 
was  engaged  in  agricultural  pursuits,  was  forty-six  years  of  age,  and 
had  noticed  for  six  weeks  a  rounded,  movable  tumor,  which  did  not 
cause  him  any  pain,  under  the  angle  of  the  jaw  on  the  right  side.  He 
had  been  losing  the  teeth  for  the  last  fourteen  years,  they  having  fallen 
out  without  being  carious.  The  last  tooth  in  the  right  lower  jaw  had 
fallen  out  a  year  before.  The  tumor  kept  on  increasing,  and  a  week 
before  admission  a  small  abscess  had  broken.  Not  only  was  there  no 
pain,  but  there  was  no  difficulty  in  opening  the  mouth  or  in  swallow¬ 
ing.  When  first  examined  there  were  two  fistulous  openings  near  the 
angle  of  the  jaw,  but  a  probe  passed  into  them  did  not  penetrate  at  all 
deeply,  and  could  not  be  made  to  reach  the  bone ;  a  considerable  quan¬ 


tity  of  blood  exuded  in  consequence  of  the  probing.  The  discharge 
was  scanty  and  looked  like  boiled  sago  mingled  with  bloody  serum. 
The  molars  and  canines  were  all  wanting  in  the  lower  jaw  on  the 
affected  side,  the  gum,  which  was  healthy  enough,  having  grown  over 
their  alveoli  The  ray  fungus  having  been  found  on  microscopical  ex¬ 
amination,  and  there  being  a  complete  absence  of  any  signs  of  disease 
elsewhere,  an  operation  was  decided  on.  Ample  incisions  having  been 
made,  parts  of  the  masseter,  digastric  and  sternomastoid,  and  the  whole 
of  the  mylo-hyoid  muscles  were  excised,  together  with  the  entire  sub¬ 
maxillary  gland  and  the  lower  part  of  the  parotid,  also  the  bridge  of 
salivary  gland  substance  connecting  the  two  glands.  A  large  number 
of  arteries  and  veins  had  to  be  ligatured.  At  first  the  patient  experi¬ 
enced  some  difficulty  in  swallowing,  and  in  expectorating  a  quantity  of 
tenacious  and  somewhat  sanguinolent  mucus,  for  the  existence  of  which 
no  physical  cause  could  be  found  by  examination  of  the  lungs.  How¬ 
ever,  after  a  time  all  these  difficulties  passed  off,  and  the  wound,  which 
was,  of  course,  a  large  gaping  cavity  in  consequence  of  the  quantity 
of  tissue  that  had  been  extirpated,  granulated  up  and  healed  over. 
Two  years  and  a  half  afterward  Dr.  Matlakowski  obtained  information 
that  the  patient  continued  in  good  health.” — Lancet. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “ original 
contributions  ”  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (I)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and-  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters ,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter ,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number ,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential,  li  e  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  not  if  - 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  jterson 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  prof  cssion  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and , 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  m 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  HEW  YORK  MEDICAL 


lectures  anb  ^bbrcsses. 


CLINICAL  LECTURES 

ON  SOME  COMMONLY  OBSERVED  FORMS  OF 

PULMONARY  DISEASE. 

DELIVERED  AT 

THE  NEW  YORK  POST-GRADUATE  MEDICAL  SCHOOL. 

By  JAMES  K.  CROOK,  M.  D., 

INSTRUCTOR  IN  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS,  ETC. 

Lecture  II. 

Bronchial  Asthma. — We  have  to-day,  gentlemen,  sev¬ 
eral  patients  with  chest  trouble  who  complain  principally 
)f  one  symptom — viz.,  shortness  of  breath.  Ask  any  one 
>f  these  what  he  or  she  is  suffering  from,  and  the  answer 
vill  probably  be  “  asthma.”  To  the  laity  all  these  troubles 
nvolving  difficulty  of  breathing  are  known  by  that  name. 
This  was  formerly  true  among  physicians  also,  until  the 
esearches  of  pathology  taught  us  the  vastly  different  con- 
litions  which  produce  this  symptom.  On  investigation, 
ve  find  that  only  one  of  these  cases  is  entitled  to  the  name 
>f  asthma  as  we  understand  it  at  the  present  day.  Patient 
^o.  1  has  a  well-marked  case  of  mitral  regurgitation  ;  No. 
!  has  dropsy  of  the  lower  extremities  and  ascites,  with  a  di- 
ated  heart,  and  probably  is  in  an  advanced  stage  of  Bright’s 
lisease ;  No.  3  is  suffering  from  chronic  pleurisy  with  a  mod- 
rate  effusion;  No.  4  is  a  case  of  pronounced  emphysema; 
vhile  No.  5  is  undoubtedly  a  bona-fide  case  of  spasmodic 
ironchial  asthma.  The  patient  is  a  stout  old  woman  of 
eventy,  and  she  informs  us  that  she  has  a  cough  almost  all 
he  year  round,  being  worse  in  the  winter  months.  Some- 
imes  it  will  cease  for  a  little  while  during  the  summer. 
Ier  breathing,  as  you  will  see,  is  perfectly  free  and  easy  at 
'resent,  but  she  states  that  several  times  during  the  week, 
nd  often  when  in  bed,  she  is  seized  with  a  severe  spell  of 
hortness  of  breath.  During  the  attacks  she  is  obliged  to  sit 
erfectly  quiet  bv  an  open  window  and  in  a  position  lean- 
ng  forward.  A  loud  wheezing  occurs,  which  may  be  heard 
11  over  the  room.  The  spells  last  from  a  few  minutes 
o  several  hours.  Last  night  she  had  an  unusually  severe 
eizure,  which  extended  over  most  of  the  night.  She  has 
ome  shortness  of  breath  also  whenever  she  takes  unusual 
xercise,  but  it  is  not  attended  by  wheezing,  and  may  be 
ue  to  her  stoutness  and  advanced  age.  On  physical  ex- 
mination  we  find  no  signs  except  an  occasional  moist  rale, 
f  we  could  see  the  patient  during  a  paroxysm  of  dyspnoea 
re  should  undoubtedly  find  a  large  number  of  sibilant  and 
:>norous  rales  on  auscultation,  with  probably  a  great  pro¬ 
rogation  of  the  expiration.  We  have  here,  then,  a  very 
'ell  marked  case  of  asthma  attended  by  bronchitis.  Be- 
ond  the  slight  lesions  produced  by  the  latter  trouble  there 
re  no  anatomical  lesions  in  this  disease.  It  is  essentially 
neurosis — according  to  Biermer,  whose  classical  definition 
i  commonly  accepted,  a  neurosis  depending  upon  tonic 
pasm  of  the  bronchial  muscles  and  caused  by  faulty  inner- 
ation  of  the  pneumogastric  nerve.  It  is  probable  that 
uring  the  seizures  the  bronchial  membrane  is  very  much 


JOURNAL,  September  6,  1890. 

congested  from  distention  of  the  small  vessels  in  the  bron¬ 
chial  walls.  This  has,  in  fact,  been  proved  by  the  tra- 
cheoscopic  researches  of  Stoerck,  and  has  been  said  by 
Theodor  Weber  and  others  to  be  the  true  anatomical  basis 
of  the  disease.  Some  authorities,  led  by  Wintrich,  main¬ 
tain  that  there  is  no  spasm  of  the  bronchial  tubes  during 
the  attacks,  but  a  spasmodic  fixation  of  the  diaphragm  and 
other  muscles  of  respiration.  The  fact  of  bronchial  con¬ 
traction,  however,  is  abundantly  shown  by  the  presence  of 
sibilant  and  sonorous  rales  and  loud  wheezing.  There  are 
even  other  theories  of  the  pathology  of  asthma,  but  that  of 
Biermer  before  mentioned  is  most  satisfactory.  The  asthma 
crystals  discovered  by  Leyden  about  twenty  years  ago  are 
not  believed  to  be  concerned  in  the  causation  of  the  parox¬ 
ysms.  As  before  stated,  there  is  usually,  hut  not  always,  a 
certain  amount  of  bronchitis  in  asthma.  This  bronchial 
inflammation  doubtless  greatly  increases  the  tendency  to 
the  disease,  and  probably  in  many  cases  is  directly  respon¬ 
sible  for  it  by  increasing  the  irritability  of  the  respiratory 
mucous  membrane.  The  setiological  relations  of  asthma 
are  not,  however,  perfectly  understood.  There  is,  no  doubt, 
an  important  hereditary  influence  in  some  cases,  hut  the 
great  majority  are  not  referable  to  this  cause.  Among  the 
causative  factors  besides  bronchitis  may  be  mentioned  en¬ 
larged  and  inflamed  bronchial  glands,  nasal  catarrh,  amyg¬ 
dalitis,  the  inhalation  of  irritants,  such  as  dust,  the  pollen 
of  certain  plants,  etc.  Reflex  disorders  of  the  alimentary 
tract,  uterus,  and  ovaries  are  also  probably  concerned  in 
some  instances.  The  diagnosis  of  bronchial  asthma  is  easily 
made  (1)  by  the  paroxysmal  nature  of  the  attacks,  and  (2) 
by  the  absence  of  the  physical  signs  of  other  pulmonary  or 
of  cardiac  troubles.  The  differential  points  between  asthma 
and  emphysema  will  be  discussed  in  speaking  of  the  latter 
disease. 

With  reference  to  the  prognosis,  we  can  not  speak  very 
hopefully  in  onr  present  case.  In  youth  the  tendency  is 
toward  recovery,  but  in  a  person  of  this  old  lady’s  age  there 
is  a  great  probability  that  it  will  continue  during  life.  The 
persistence  of  the  disease  may  possibly  lead  to  the  develop¬ 
ment  of  other  pulmonary  troubles,  more  especially  to  em¬ 
physema.  There  is  always  a  transitory  emphysema  during 
the  asthmatic  paroxysms.  The  alveoli  become  very  much 
distended,  and  with  repeated  attacks  are  liable  to  lose  their 
elasticity  and  remain  permanently  dilated.  This  leads  to 
an  extreme  attenuation  of  the  interalveolar  walls  and 
finally  to  rupture,  two  or  more  cells  becoming  merged  into 
one  emphysematous  bleb.  Lobular  pneumonia  or  pulmo¬ 
nary  oedema  may  also  result  from  the  frequent  congestion  of 
the  small  bronchi  involved  in  the  asthmatic  attacks.  During 
the  paroxysms  the  right  side  of  the  heart  has  a  much  greater 
amount  of  work  to  do  than  usual,  in  order  to  drive  the 
blood  through  the  distended  and  congested  vessels.  This 
may  lead  to  enlargement  and  dilatation  of  the  right  cavi¬ 
ties,  and  eventually  to  renal  disease  and  dropsy.  However, 
these  terminations  of  asthma  are  rather  the  exception  than 
the  rule,  and,  though  we  should  make  no  promise  to  cure 
the  disease,  we  can  do  much  to  allay  its  severity  and  in¬ 
crease  the  patient’s  comfort.  The  treatment  resolves  itself 


CROOK:  rULMONART  DISEASE . 


[N.  Y.  Med.  Jocb., 


254 

natarally  into  measures  to  mitigate  the  intensity  of  the 
paroxysms  and  to  prevent  their  recurrence.  During  the 
seizure  the  patient  intuitively  seeks  relief  by  going  to  an 
open  window  and  sitting  in  a  bending  position,  with  the 
elbows  on  a  table  or  on  the  knees.  This  natural  instinct 
should  be  encouraged  by  having  the  clothing  about  the 
chest  and  abdomen  loose  and  free  from  constrictions.  If 
the  weather  will  permit,  all  the  windows  of  the  apartment 
should  be  raised.  Any  exciting  cause  which  may  be  dis¬ 
covered  should  be  removed  as  speedily  as  possible.  I  have 
seen  severe  asthmatic  attacks  relieved  by  a  hot  rectal  in¬ 
jection  or  an  ipecac  emetic.  The  remedial  agent  I  employ 
most  largely  for  the  paroxysms  is  Hoffmann’s  anodyne. 
Thirty  drops  of  this  preparation  may  be  given  at  the  out¬ 
set  (to  adults),  and  repeated  two  or  three  times  at  half-hour 
intervals  if  required.  It  acts  well  in  conjunction  with 
strong  black  coffee  given  ad  libitum.  These  measures  will 
relieve  many  cases,  but  they  are  not  always  efficient,  and 
we  shall  not  infrequently  find  it  necessary  to  run  the  gamut 
of  remedies  without  finding  one  that  is.  A  hypodermic  in¬ 
jection  of  eight  or  ten  minims  of  Magendie’s  solution  of 
morphine  with  about  one  eightieth  of  a  grain  of  atropine 
will  sometimes  abort  an  attack,  although  I  am  aware  that 
so  distinguished  an  authority  as  Salter  declaims  against 
the  use  of  opiates  as  being  rather  harmful  than  of  any 
benefit  in  the  treatment  of  asthma.  In  a  severe  case  at 
the  Bellevue  chest  clinic  a  few  days  ago  this  dose  cut  short 
an  attack  in  a  few  minutes.  A  combination  of  Hoffmann’s 
anodyne  and  the  U.  S.  P.  (1870)  solution  of  morphine,  con¬ 
stituting  the  mistura  asthmatica  of  the  Bellevue  formulary, 
will  often  prove  efficacious.  I  have  seen  good  results  from 
the  inhalation  of  a  few  whiffs  of  chloroform,  but  the  inha¬ 
lation  of  nitrite  of  amyl  as  well  as  the  internal  administra¬ 
tion  of  nitroglycerin  has  not  been  successful  in  my' hands. 
Various  other  remedies,  including  brandy,  stramonium,  ar¬ 
senic,  eucalyptus,  lobelia,  musk,  valerian,  niter  paper,  etc., 
have  been  recommended,  but  it  is  beyond  our  province  to 
attempt  a  discussion  of  all  these  agents.  In  the  case  before 
us,  as  in  the  majority  of  asthmatics,  the  treatment  of  the 
intervals  is  to  be  directed  to  the  accompanying  bronchitis. 
This  may  be  treated  in  accordance  with  the  directions  men¬ 
tioned  in  our  remarks  on  chronic  bronchitis,  but  here  we 
should  not  fail  to  add  the  iodide  of  potassium  to  the  cough 
mixture  in  doses  of  five,  ten,  fifteen,  or  twenty  grains  three 
or  four  times  a  day.  If  we  find  that  the  bronchitis  is  not 
amenable  to  treatment,  or  the  attacks  are  purely  neurotic  in 
character,  we  can  hardly  hope  to  cure  the  disease  with 
medicines.  A  change  of  surroundings  or  climate  is  then 
advisable.  Generally  speaking,  persons  with  asthma  are 
more  comfortable  in  the  pure  fresh  air  of  mountainous  or 
hill v  country  districts,  but  it  sometimes  happens  that  per¬ 
sons  living  in  the  country  escape  their  asthmatic  paroxysms 
by  coming  to  the  city.  The  climatic  part  of  the  treatment 
is,  therefore,  in  a  great  degree  experimental. 

Lecture  III. 

Chronic  Vesicular  Emphysema. — Our  first  patient  this 
morning,  gentlemen,  is  J.  L.,  a  ’longshoreman,  aged  fifty- 
three.  lie  is  a  rather  stout,  strongly-built  man,  and  does 


not  appear  to  be  out  of  health,  yet  we  shall  find  that  his  dis¬ 
ease  almost  destroys  his  power  to  earn  his  living.  Several 
years  ago — he  does  not  remember  how  many — his  trouble 
came  on  with  a  great  cough.  This  cough  did  not  leave 
him  entirely,  and,  after  a  winter  or  two,  he  commenced  to 
suffer  from  shortness  of  breath,  which  came  on  especially 
after  some  unusual  exertion,  and  did  not  seem  to  trouble 
him  much  as  long  as  he  was  quiet.  The  dyspnoea  has  con¬ 
tinued  to  increase  gradually  until  now  he  is  unable  to  walk 
half  a  dozen  blocks  without  feeling  it.  As  his  work  is  very 
heavy,  he  finds  this  symptom  a  great  hindrance  to  him.  If 
you  examine  his  skin  closely,  especially  about  his  chest, 
you  will  notice  that  it  is  traversed  by  numerous  minute 
blood-vessels,  which  give  it  a  rather  congested  appearance. 
The  veins  about  the  neck  are  also  abnormally  prominent. 
The  breathing  movements,  too,  are  not  natural.  There 
seems  to  be  considerable  motion  about  the  chest  and  neck, 
but  it  is  to  a  great  extent  produced  by  the  voluntary  mus¬ 
cles  of  respiration.  It  is  not  expansive  in  character,  but 
almost  entirely  of  the  up-and-down  variety.  A  close  in¬ 
spection  will  show  you  that  the  ribs  rotate  very  little,  and 
tfiere  is  but  a  slight  increase  in  the  size  of  the  intercostal 
spaces  during  a  deep  inspiration.  The  lower  part  of  the 
chest  has  the  appearance  of  being  too  prominent  in  front, 
although  there  is  no  decided  bulging.  V  hen  I  lay  iny 
hand  on  the  chest,  I  find  that  palpation  confirms  inspection 
so  far  as  the  chest  movements  are  concerned,  but  I  am  not 
sure  that  the  vocal  fremitus  is  at  all  modified.  Mensuration 
we  find  to  be  an  important  method  of  examination  in  this 
case.  On  a  level  with  the  sixth  rib  in  front  I  find  the  chest 
to  measure,  at  the  end  of  a  deep  inspiration,  thirty-nine 
inches,  while  at  the  end  of  a  prolonged  expiration  it  is 
thirty-seven  inches  and  a  half.  This  shows  a  variation  of 
only  an  inch  and  a  half,  which  is  much  less  than  it  should 
be  in  a  person  of  this  man’s  physique  and  laborious  manual 
occupation.  An  expansion  of  three  or  four  inches  would 
be  nearer  normal.  When  I  percuss  the  chest,  I  find  reso¬ 
nance  all  over  the  lungs  on  both  sides;  but  what  kind  of 
resonance  is  it  ?  You  will  observe  that  it  exists  in  situa¬ 
tions  where  we  find  dullness  or  flatness  normally,  as  over 
the  precordial  region,  low  down  over  the  liver,  etc.,  and 
you  will  observe  also  that  the  quality  differs  somewhat  from 
ordinary  healthy  resonance,  having  here  something  of  a 
metallic  character.  It  is  a  good  example  of  the  vesiculo¬ 
tympanitic  resonance  first  described  by  Professor  Flint.  On 
auscultation,  I  find  an  occasional  mucous  rale,  and  I  find 
also  a  great  change  in  the  respiratory  rhythm.  The  ex¬ 
piration  is  very  long,  indeed  twice  as  long  as  inspiration, 
whereas  in  health  it  should  be  shorter,  the  proportion  being 
about  as  ten  to  eight.  In  addition,  the  expiration  is  very 
low-pitched,  being  almost  inaudible  low  down  posteriorly. 
I  can  make  out  no  appreciable  change  in  the  vocal  sounds. 
On  examining  the  heart,  I  find  the  signs  of  an  hypertrophied 
right  ventricle. 

From  this  man’s  history  and  the  physical  signs  which 
are  present,  we  make  out  a  very  well  marked  case  of  vesicu¬ 
lar  pulmonary  emphysema;  not  one  of  those  exaggerated 
cases,  with  a  barrel  chest,  a  displaced  heart,  and  oedema- 
tous  extremities,  but  still  sufficiently  developed  to  leave 


3ept.  6,  1890.] 


CROOK:  PULMONARY  DISEASE. 


255 


io  reasonable  doubt  as  to  the  diagnosis.  If  we  could 
<ee  his  lungs,  I  feel  no  doubt  that  we  would  find  them 
n larged  and  extending  tyeyond  their  natural  limits.  We 
hould  find  numerous  air-blebs  caused  by  overdistention 
ind  coalescence  of  the  pulmonary  alveoli.  This  condition 
.vould  be  most  marked  along  the  free  margins  and  at  the 
ipices  of  the  lungs.  If  we  were  very  careful,  we  should 
■Jso  see  traces  of  atelectasis  or  collapse  of  the  air-vesicles  in 
ome  portions  of  the  lungs.  Adjacent  to  the  dilatations 
here  would  doubtless  be  certain  pigmentary  changes  ow- 
ng  to  a  transudation  of  coloring  matter  from  the  small 
ilveolar  blood-vessels  These  vessels,  by  . the  distention  of 
he  alveolar  walls,  become  so  compressed  as  to  allow  the 
>assage  of  the  watery  elements  only  ;  hence  the  pigmentary 
leposits.  When  this  condition  continues  long,  as  it  doubt- 
ess  has  done  here,  some  of  the  little  vessels  become  obliter- 
ted,  and,  the  pulmonary  circulation  being  thus  impeded,  a 
tackward  pressure  is  extended  through  the  pulmonary  ar- 
ery  upon  the  right  ventricle,  which  soon  yields  to  dilata- 
ion  and  enlargement.  We  have  already  discovered  the 
•hysical  evidences  of  right  ventricular  enlargement  in  this 
ase.  The  usual  lesions  of  chronic  bronchitis  are  no  doubt 
resent  here,  and  there  is  probably  also  a  hypertrophic  tbick- 
ning  of  the  muscular  coats  of  the  bronchial  walls.  In  the 
iagnosis  of  the  case  we  can  readily  exclude  phthisis  and 
leurisy  with  effusion  by  the  absence  of  the  physical  signs 
f  those  diseases.  Pneumothorax  is  excluded  by  its  great 
irity,  by  its  absolutely  tympanitic  percussion  note,  by  its 
usually)  sudden  onset,  and  by  the  fact  of  its  being  almost 
Iways  unilateral.  The  case  differs  from  spasmodic  asthma, 
ure  and  simple,  in  the  fact  that  the  dyspnoea  is  brought 
n  by  exertion  and  is  not  paroxysmal.  He  thinks  he  has 
ad  asthmatic  attacks,  however,  and  this  does  not  surprise 
ie,  as  there  is  undoubtedly  a  very  close  relationship  be- 
•veen  the  two  diseases.  All  asthmatics  do  not  become  em- 
hysematous;  but  you  will  find,  on  careful  inquiry,  that 
[most  every  case  of  pulmonary  emphysema  begins  with  or 
preceded  by  spasmodic  asthma.  As  to  the  exact  mode 
f  development  of  vesicular  emphysema,  two  principal  theo- 
es,  known  as  the  inspiratory  and  expiratory  theory,  have 
eld  sway.  The  former  was  advanced  by  Laennec,  who 
■garded  the  presence  of  bronchitis  as  an  essential  factor, 
id  on  this  point  authorities  do  not  differ.  This  bronchial 
iflammation  leads  to  a  certain  amount  of  exudation  in  the 
ibes,  causing  more  or  less  obstruction  to  the  ingress  and 
ijress  of  air.  But  expiration,  according  to  Laennec,  being 
ss  powerful  than  inspiration,  is  unable  to  expel  the  air 
rawn  in  by  inspiration,  on  account  of  this  mucous  accu- 
ulation.  The  air-cells  in  consequence  continue  to  distend 
ffil  rupture  takes  place.  This  explanation  of  Laennec’s 
as  accepted  for  many  years,  but  is  rejected  by  a  majority 
modern  authorities.  According  to  the  observations  of 
utchinson,  Gairdner,  Mendelssohn,  and  Traubc,  Laennec 
as  mistaken  in  his  view  that  inspiration  was  more  power- 
1  than  expiration.  They  have  shown  that  more  air  was 
pelled  through  the  tubes  involved  in  the  mucous  obstrue¬ 
nt  than  was  admitted  by  inspiration.  The  conformation 
the  tubes,  according  to  Gairdner,  also  facilitates  the 
:ress  while  retarding  the  ingress  of  air.  This  consists 


in  the  fact  that  the  tubes  are  smaller  as  they  approach  the 
air-cells,  and,  of  course,  larger  as  they  go  out.  On  this  ac¬ 
count  the  exudation  may  act  in  the  nature  of  a  ball-valve, 
being  easily  displaced  by  expiration  in  the  direction  of  the 
larger  diameter  and  allowing  free  exit,  but  at  once  closiug 
the  tube  on  inspiration  and  effectually  cutting  off  the  en¬ 
trance  of  air.  In  this  way  the  small  amount  of  air  remain¬ 
ing  in  the  air-cells  becomes  so  rarefied  that  collapse  of  their 
walls  inevitably  ensues.  Neighboring  air-vesicles  receive 
too  much  air  in  consequence,  and  a  vicarious  or  supplement¬ 
ary  emphysema  is  thus  established. 

The  prognosis  in  the  present  case,  as  in  most  cases  of 
pulmonary  emphysema,  is  not  favorable.  There  is  no  con¬ 
siderable  danger  to  life  from  the  affection,  but,  on  the  other 
hand,  there  is  no  probability  that  the  patient  will  ever  be 
entirely  well  again.  The  cells  which  are  only  dilated  may 
be  restored,  but  the  ruptured  ones  do  not  admit  of  repara¬ 
tion.  Emphysema  increases  the  danger  from  intercurrent 
diseases.  It  also  causes  dilatation  and  hypertrophy  of  the 
right  side  of  the  heart,  which  increases  the  danger.  It  may 
even  threaten  life  from  the  liability  of  bronchorrhcea,  with 
profuse  umco-purulent  expectoration  occurring  and  filling 
the  tubes,  and  thus  bring  about  death  from  asphyxia. 
Some  authors  have  taught  that  the  presence  of  emphysema 
affords  more  or  less  immunity  from  pneumonia,  pulmonary 
oedema,  and  consumption.  There  may  be  a  grain  of  truth 
in  this,  as  emphysema  diminishes  the  amount  of  blood  in 
the  lungs — a  condition  which,  as  we  know,  is  not  conducive 
to  the  development  of  these  troubles. 

The  first  indication  in  the  treatment  of  pulmonary  em¬ 
physema  consists  in  the  employment  of  measures  to  prevent 
the  extension  of  the  disease  and  so  far  as  possible  to  re¬ 
store  the  pulmonary  structure  to  a  condition  of  health. 
This  indication  is  best  carried  out  by  means  of  nourishing 
food,  fresh  air,  careful  habits,  avoidance  of  strains,  etc., 
and  the  administration  of  tonics,  more  especially  some  of 
the  preparations  of  strychnine.  One  of  the  most  valuable 
of  these  is  an  elixir  of  the  phosphate  of  iron,  quinine,  and 
strychnine,  a  teaspoonful  of  which  represents  :  of  the  phos¬ 
phate  of  strychnine,  one  sixtieth  to  one  one-hundredth  of 
a  grain;  phosphate  of  iron,  two  grains;  and  phosphate  of 
quinine,  one  grain.  This  dose  should  be  taken  three  times 
a  day  before  meals.  If  it  fails  to  agree,  as  is  not  often 
the  case,  recourse  must  be  had  to  other  preparations.  I 
do  not  believe  strychnine  to  possess  any  peculiar  value  in 
restoring  the  diseased  lung  tissue,  and  prescribe  it  only  for 
its  tonic  effects.  Certain  mechanical  means,  to  which  we 
can  only  allude  in  the  briefest  possible  manner  this  morn¬ 
ing,  have  been  devised  to  facilitate  resolution  of  the  in¬ 
volved  air-vesicles.  They  mostly  involve  the  principle  of 
pneumatic  aspiration,  the  patient  inhaling  condensed  air 
and  exhaling  into  rarefied  air.  The  idea  involved  is  that 
the  inhalation  of  condensed  air  retards  the  respiration,  al¬ 
lowing  more  oxygen  to  be  consumed,  and  thus  causes  a 
more  complete  tissue  metamorphosis;  while  exhaling  into 
rarefied  air  facilitates  the  withdrawal  of  the  abnormal 
amount  of  residual  air  in  the  distended  alveoli.  The  most 
satisfactory  apparatus  with  which  I  am  acquainted  is  that  of 
Waldenburg,  as  modified  by  Tobold  and  manufactured  by 


256 


COWL:  THE  RESPIRATORY  RHYTHM. 


[N.  Y.  Mbd.  Joob, 


Messrs.  J.  Reynders  &  Co.,  of  this  city.  A  second  indica¬ 
tion  in  the  treatment  of  emphysema  consists  in  the  relief 
of  the  complications,  chronic  bronchitis  being,  as  a  rule, 
the  most  important.  The  measures  involved  in  the  treat¬ 
ment  of  this  affection  have  been  sufficiently  outlined  in  our 
remarks  on  bronchitis.  But  here,  as  in  bronchial  asthma, 
we  shall  find  the  iodide  of  potassium  to  be  of  great  advan¬ 
tage.  It  must  be  given  in  considerable  doses  and  long  con¬ 
tinued.  I  usually  combine  it  with  the  compound  spirit  of 
ether  for  the  relief  of  the  dyspnoea.  In  advanced  cases  a 
dilated  heart  and  oedematous  lower  extremities  are  apt  to 
demand  attention.  A  favorite  formula  under  these  circum¬ 
stances  is  as  follows :  Spt.  seth.  co.,  §  j ;  ammon.  carb., 

3  iij ;  inf.  digital.,  ad  §  iv.  M.  Sig. :  A  teaspoonful  in  a  lit¬ 
tle  water  every  two,  three,  or  four  hours.  We  can  not 
hope  to  cure  many  cases  of  this  disease,  but  it  is  remarka¬ 
ble  how  even  in  apparently  the  most  unfavorable  examples 
the  patients  will  rally  and  attain  a  degree  of  comparative 
comfort  under  proper  management. 


#rt0tital  Cffmmutwattons. 


THE  FACTORS  OF  THE  RESPIRATORY  RHYTHM 
AND  THE  REGULATION  OF  RESPIRATION.* 

By  W.  Y.  COWL,  M.  D. 

In  an  article  entitled  The  Self-regulation  of  Respiration, 
read  before  the  American  Physiological  Society  in  New 
York,  December  28,  1889,  and  published  in  the  issue  of 
this  Journal  for  January  18,  1890,  Dr.  S.  J.  Meltzer,  of  this 
city,  brings  forward  a  new  theory  of  respiratory  rhythm,  or, 
more  precisely,  a  revival,  under  a  new  hypothesis,  of  the 
idea  of  the  peripheral  incitation  of  the  inspiration  in  ordi¬ 
nary  respiration,  which  for  several  reasons — but  chiefly  be¬ 
cause  of  a  disregard  therein  of  the  mass  of  facts  that  show 
a  central  origin  for  inspiration,  and  already  furnish  indeed 
sufficient  and  simple  explanation  of  the  respiratory  rhythm 
— deserves  further  attention. 

Instead,  namely,  of  referring  the  impulse  to  inspiration 
to  the  respiratory  center,  as  is  usual  at  the  present  time,f 
he  supposes  an  incitation  of  this  center  by  the  vagus  to 
occasion  each  inspiratory  effort,  and  in  the  following  lines, 
which  I  regret  to  have  to  repeat,  he  gives  the  only  refer¬ 
ence  in  his  paper  to  the  facts  that  are  acknowledged  to 
show  the  non-pulmonic  incitation  of  inspiration. \ 

“  For  the  production  of  inspiration,  Gad  (1)  seeks  the 
cause  in  a  center  in  which  a  constant  inspiratory  stimulus 
resides.  Thus  the  inspiration  is  said  to  start  from  the  cen¬ 
ter,  and  the  inhibition  of  this  inspiration  is  to  be  effected 
by  reflex  from  the  lungs.  Hence  the  inspiratory  nerve  fibers 
which  undoubtedly  exist  in  the  vagus  find  no  application  in 
Gad’s  theory,  and  this  alone  speaks  sufficiently  against  this 
hypothesis.” 

*  Manuscript  received  from  the  author  July  30,  1890. — Editor. 

\  Flint,  Text-book  of  Physiology.  New  York,  1888. 

\  Hermann,  Lehrbuch  der  Physiologie ,  Berlin,  1889. 


But  to  give  an  idea  of  the  general  contents  of  Dr. 
Meltzer’s  paper. 

After  briefly  stating  the  results  of  a  series  of  electrical 
stimulations  of  the  vagus  largely  stronger  than  those  used 
by  other  observers  in  this  field,  and  accepting  the  theory  (2) 
of  the  induction  of  expiration  by  the  inspiratory  expansion 
of  the  lung,  and  the  excitation  thereby  of  pulmonary  vagus 
fibers  reflex-inhibitory  of  inspiration,  the  author  puts  forth 
the  supposition,  upon  the  basis  of  his  experiments,  that  in¬ 
spiration  arises  by  a  similarly  and  in  fact  simultaneously 
effected  excitation  of  pulmonary  vagus  fibers  reflex-in  cita- 
tory  of  the  inspiration,  the  excitation  of  the  respiratory  cen¬ 
ter  by  which,  at  first  hidden  under  the  predominating  inhi¬ 
bition,  outlasts  the  same  and  causes  then  a  new  inspira¬ 
tion. 

In  the  research  itself  he  obtained,  upon  using  weak  or 
medium  strong  electrical  excitation,  like  previous  experi¬ 
menters,  a  varied  effect  upon  the  respiration — namely,  as 
stated,  of  an  inspiratory  or  of  an  expiratory  character,  while 
upon  using  very  strong  stimulation  he  found  the  effect  uni¬ 
formly  expiratory,  consisting  “  partly  in  passive,  partly  in 
active  expirations.” 

The  course  of  these  expirations — in  fact,  their  number 
and  frequency,  if  repeated  during  any  one  stimulation  of 
the  nerve — is  not  stated  ;  but  in  another  place  it  is  left  to 
be  inferred  that,  at  least  in  the  main,  there  was  an  arrest 
of  respiration — namely  :  “  But  we  can  also  conclude,  wher¬ 
ever  we  find  after  an  expiratory  arrest  an  inspiratory  after¬ 
effect,  that  inspiratory  fibers  are  present  in  the  trunk  and 
have  been  likewise  stimulated  in  a  latent  manner.  But,  as 
we  have  demonstrated  in  all  animals  under  strong  stimula¬ 
tion,  such  an  inspiratory  after-effect  following  an  expiratory 
inhibition,  we  may  conclude  that  both  kinds  of  nerves  exist 
in  the  vagus  of  all  animals.” 

In  the  case  of  his  stimulations  of  the  vagus  the  author 
was  able  to  exclude  the  occurrence  of  a  coexcitation  of  the 
superior  laryngeal  nerve  in  that,  as  he  had  previously 
shown  (3),  such  excitation  always  produces  a  succession  of 
swallowing  acts,  which  were  absent  in  his  experiments,  and 
he  therefore  used  stronger  currents  than  previous  observers 
without  fear  that  the  recorded  effects  were  due  to  such  co¬ 
excitation. 

The  direct  ground  adduced  by  Dr.  Meltzer  for  his  new 
and  ingenious  hypothesis,  above  given,  is  not,  then,  the  im¬ 
mediate  effects  of  these  strong  excitations  of  the  vagus  dur¬ 
ing  the  time  of  the  same,  but  the  character  of  the  respiration 
after  their  cessation — namely,  a  notably  increased  inspira¬ 
tory  activity  over  that  before  the  excitation,  which  the  au¬ 
thor  assumes  to  be  a  specific  effect  of  such  excitation  of  the 
so-called  inspiratory  fibers  in  question,  outlasting  the  ef¬ 
fects  of  the  excitation  of  the  inhibitory  fibers.  He  also 
draws  an  analogy  between  his  experiments  and  those  of 
Head  (4)  upon  the  intact  animal,  wherein  a  prolonged  in¬ 
sufflation  of  the  lungs  occasioned  an  inhibition  of  respira¬ 
tory  effort  during  the  time  of  the  same,  and  a  marked  inspi¬ 
ratory  effect  after  its  cessation. 

In  bringing  forward  this  hypothesis,  the  author  makes 
no  mention,  on  the  one  hand,  of  the  assumptions  concern¬ 
ing  such  experimentation  upon  the  vagus,  which  form  a  pre- 


Sept.  6,  1890.] 


COWL:  THE  RESPIRATORY  RHYTHM. 


257 


requisite  to  this  use  of  its  results,  nor  does  he,  on  the  other, 
bring  evidence  to  show  that  this  inspiratory  after-effect  is 
not  dyspnoea  from  non-aeration  of  blood  coursing  through 
the  respiratory  center,  such  as  indeed  is  to  be  awaited  upon 
arresting  respiration  in  expiration. 

The  conclusions,  tacit  or  expressed,  from  simple  electri¬ 
cal  excitation  of  the  vagus,  which  are  necessary  to  form  a 
hypothesis  thereon  concerning  the  ordinary  respiration,  are 
the  following — namely,  first,  that  the  fibers  of  the  vagus, 
the  excitation  of  which  causes  the  changes  in  respiration, 
are  pulmonary  fibers  and  not  sensory  fibers  from  the  lower 
part  of  the  larynx  (deriving  its  sensibility  in  part  from  the 
inferior  laryngeal  nerve  [5]),  the  trachea,  oesophagus,  stom¬ 
ach,  or  intestine,  not  to  include  the  bronchi;  and, secondly, 
that  they  are  fibers  which  exercise  their  function  in  ordinary 
breathing,  and  not  fibers  either  from  the  alveolar  walls,  the 
pulmonary  pleura,  or  the  bronchioles  or  bronchi,  which 
merely  come  into  play  under  extraordinary  circumstances 
of  the  respiration — e.  (/.,  in  coughing. 

That  extraordinary  circumstances  do  call  forth  special 
action  in  a  reflex  manner  is  shown  quite  conclusively  by 
one  experiment. 

Berns  (6)  under  Donders,  and  M.  Rosenthal  (V)  under 
Gad,  have  induced  dyspnoeic  breathing  immediately  by  the 
first  of  a  series  of  inhalations  or  by  a  single  inhalation  of 
carbonic-acid  gas.  In  the  latter’s  experiments  the  gas  was 
purified  and  the  gas-holder  so  arranged  that,  upon  the  first 
inspiration  after  opening  the  communication  with  the 
trachea,  the  gas  was  inhaled.  Hydrogen  respired  in  the 
same  way  produced  only  a  secondary,  i.  e.,  a  later-ap¬ 
pearing  dyspnoea,  dependent,  upon  deficient  arterialization 
of  the  blood.  A  secondary  dyspnoea  alone  was  produced 
by  the  carbonic  acid  when  the  vagi  were  previously 
cut.  The  immediate  dyspnoea  excited  then  is  of  peripheral 
origin. 

That  the  vagus  fibers,  the  terminations  of  which  become 
excited  in  this  instance,  are  pulmonary,  is  open  to  a  certain 
slight  doubt,  which  is  lent  strength  by  the  known  excitant 
action  of  carbonic  acid  on  the  dermal  surface  (9),  for  it  is 
impossible  to  ascertain  what  part  if  any  of  the  immediate 
dyspnoea  is  due  to  excitation  of  the  sensory  nerve  fibers  dis¬ 
tributed  to  the  lower  part  of  the  trachea,  below  the  point 
at  which  the  tracheal  cannula  may  be  introduced.  That 
this  portion  of  the  respiratory  tract  is  much  less  sensitive 
than  the  pulmonary  parenchyma,  however,  is  to  be  inferred 
from  an  experiment  respecting  such  excitation  of  the  tra¬ 
cheal  surface,  directly  to  be  mentioned. 

Other  facts  indicating  the  existence  of  special  nervous 
provision  for  extraordinary  circumstances  of  the  respiration 
are  that  the  inhalation  of  chloroform  (through  a  tracheal 
cannula)  causes  at  once  inspiratory  dyspnoea,  as  found  by 
Knoll  (5),  who  also  passed  the  vapor  through  the  length  of 
the  trachea  alone  without  effect  upon  the  respiration,  like¬ 
wise  that  vapor  of  ammonia  causes  immediate  expiration, 
and,  furthermore,  the  peculiarity  noted  by  Head,  that,  after 
interrupting  the  impulses  coursing  through  the  vagi  by  the 
method  of  Gad  (by  local  freezing  of  the  nerves),  at  the  be¬ 
ginning  of  their  resumption  of  power,  upon  thawing,  an 
insufflation  of  the  lungs  will  cause  an  inspiratory  effort  of 


the  diaphragm,  instead  of  an  expiratory  effort  as  in  the  in¬ 
tact  animal. 

But,  in  addition  to  the  doubts  above  expressed,  which 
arise  in  the  present  state  of  knowledge  concerning  the  va¬ 
gus,  whenever  the  effects  upon  the  respiration  of  simple 
electrical  excitation  of  the  nerve  be  boldly  referred  to  its 
pulmonary  fibers,  and  indeed  obtrude  themselves  when  the 
assumption  be  made  that  these  fibers  thus  act  continually 
in  ordinary  respiration,  there  are  positive  reasons  which  re¬ 
enforce  them. 

First,  the  expiratory  effect,  with  stoppage  of  respiration, 
upon  electrical  excitation  of  other  nerves  than  the  vagus, 
or  indeed  upon  natural  excitation  of  their  endings,  and  the 
marked  increase  in  the  inspiratory  activity  thereafter.  Evi¬ 
dence  of  such  is  to  be  found  in  the  graphic  tracings  of 
the  respiration  upon  stimulation,  notably  of  the  splanchnic 
and  infra-orbital  nerves,  published  by  Knoll  (10),  who  also 
calls  attention  to  the  signs  in  the  tracheotomized  animal  of 
crying  efforts  occasioned  by  strong  excitation,  and  gives 
tracings  of  the  respiration,  showing  it  to  be  very  much  in¬ 
creased  and  remarkably  regular. 

Again,  the  fact  observed  by  the  same  author  that  strong 
excitation  of  the  inferior  laryngeal  nerve  causes  expiratory 
effects  (5),  while  excitation  in  the  same  manner  of  the  va¬ 
gus  beyond  this  branch — namely,  in  the  chest — produced, 
as  a  rule,  inspiratory  effects.  Thus  we  perceive  that,  by  ex¬ 
citation  of  the  vagus  in  the  neck,  there  is  a  probability, 
when  obtaining  expiratory  effects,  that  they  come  from  the 
excitation  of  the  sensory  fibers  of  the  recurrent  laryngeal 
nerve,  and  not  from  the  pulmonary  branches  of  the  vagus. 

As  previously  noted,  Dr.  Meltzer  does  not  refer  to 
vitiation  of  the  blood  as  a  possible  cause  of  the  dyspnoea 
after  the  arrest  of  respiration  during  his  excitations  of  the 
vagus,  although  such  is  to  be  expected,  either  upon  simple 
stoppage  of  the  respiration,  or  especially  when  the  arrest 
occurs  in  expiration,  for  dyspnoea  appears  more  quickly  and 
strongly  after  a  cessation  of  breathing  when  the  chest  is 
contracted  than  when  expanded  and  full  of  air — a  fact, 
however,  which,  if,  according  to  the  theory,  the  inspiration 
be  excited  wholly,  nay,  or  even  partially,  by  expansion  of 
the  chest,  is  certainly  difficult  to  explain. 

The  sensitiveness,  on  the  other  hand,  of  the  respiratory 
center  to  changes  in  the  constitution  of  the  blood,  which 
was  long;  since  indubitably  shown  under  various  condi- 
tions  by  the  researches  of  Rosenthal  (11),  Pfliiger  and  Doh- 
men  (12),  and  others,  is  particularly  well  demonstrated  by 
Fredericq  (13),  who  causes  the  blood  to  flow  to  the  brain 
through  only  a  single  artery  in  each  of  two  rabbits,  where¬ 
by,  in  their  quiet  state,  as  shown  by  Gad,  though  in  each 
both  vertebrals  and  one  carotid  be  occluded,  no  changes  in 
respiration  or  general  blood-pressure  are  occasioned,  and 
thereupon,  by  means  of  crossed  cannulas,  so  connects  the 
free  vessels  that  each  animal  serves  the  brain  of  the  other 
with  blood.  Upon  then  partly  obstructing  the  trachea  in 
one  animal,  increased  breathing  appears  in  the  other,  while 
diminished  breathing  is  to  be  observed  in  the  one  supplied 
with  insufficient  air. 

That  the  cause  of  the  changes  in  respiration  here  does  not 
lie  in  the  decrease  and  increase,  respectively,  in  the  amount 


258 


COWL:  THE  RESPIRATORY  RHYTHM. 


[R.  Y.  Mkd.  Jode., 


of  oxygen  inspired,  but  in  the  variation  from  the  normal 
amount  of  carbonic  acid  in  the  blood  circulating  through 
the  respiratory  center  of  each  animal,  is  to  be  concluded 
from  the  researches  especially  of  Gad  and  M.  Rosenthal  (7), 
Miescher  (14),  Kempner  (15),  and  others. 

The  delicate  reaction  of  the  respiratory  center  to  a 
change  in  the  constitution  of  the  blood  in  this  experiment, 
together  with  the  many  current  facts  showing  the  influence 
of  nervous  impressions  reflected  upon  this  center,  convey 
an  idea  of  its  importance  for  the  regulation  of  the  respira¬ 
tion  under  various  circumstances  of  the  individual. 

Two  observations  of  Gad  (1)  and  Sig.  Mayer  (16)  show, 
furthermore,  the  change  in  the  excitability  of  the  respira¬ 
tory  center  which  is  effected  by  considerable  changes  in  the 
blood-supply.  The  former  observer,  on  diminishing  the 
flow  of  blood  to  the  brain  for  a  time  and  then  restoring  the 
current  to  its  previous  amount,  observed  a  stoppage  of  res¬ 
piration.  The  latter  noted  the  same  on  occasioning  a  pause 
in  the  heart’s  action. 

We  have  in  these  experiments  a  demonstration  of  the 
two  ground  factors  in  the  above-mentioned  regulation — 
namely,  the  excitability  of  the  spino-bulbar  respiratory  cen¬ 
ter,  and  the  constantly  present  excitant  of  the  same,  as 
well  as  a  proof  of  the  variability  of  each  of  these  factors 
whereby  this  regulation  becomes  effected. 

In  respect  of  the  experiments  of  Head,  cited  by  Dr. 
Meltzer  in  support  of  his  theory,  it  is  to  be  noted  that  the 
former,  without  expressly  stating  what  he  does  regard  as 
the  causation  of  the  results  obtained  by  him,  refers  to  the 
after-effect  upon  the  action  of  the  diaphragm  of  his  pro¬ 
longed  insufflations  of  the  lungs,  in  the  following  words, 
the  here  Italicized  portions  of  which  alone  concern  us  in 
this  connection  : 

If  the  lungs  are  inflated,  the  expiratory  pause  produced  by 
the  inflation  is  finally  broken  by  an  inspiratory  contraction ,  al¬ 
though  the  lungs  are  still  dilated.  This  contraction  is  strong, 
of  comparatively  short  duration,  and  traces  a  curve  with  an  ex¬ 
tremely  sharp  crest.  But  if  the  lungs  are  allowed  to  return  to 
the  normal  volume  just  before  this  interrupting  inspiration 
would  normally  have  made  its  appearance,  the  breathing  under¬ 
goes  a  very  different  modification. 

At  the  moment  of  collapse  the  inspiratory  muscles  contract 
strongly,  and  produce  a  strong,  flat-topped  curve.  This  con¬ 
traction  is  of  about  the  same  strength  as  the  interrupting  in¬ 
spiration,  but  exceeds  it  greatly  in  duration.  Thus  sudden  re¬ 
turn  of  the  lungs  to  the  normal  volume  after  an  inflation  of 
considerable  duration  produces  a  strong  and  long  inspiratory 
contraction.  It  might  be  objected  that  both  the  interrupting  in¬ 
spiration  and  the  strong  inspiratory  effect  which  follows  collapse 
after  an  inflation  were  due  to  the  dyspnoea  which  must  neces¬ 
sarily  result  during  such  a  long  pause  in  the  breathing.  How¬ 
ever,  I  think  that  this  explanation  will  scarcely  suffice  to  explain 
either  phenomenon  ;  for ,  provided  the  inflations  are  of  the  same 
strength,  the  pause  is  broken  at  almost  exactly  the  same  moment , 
whether  oxygen ,  air ,  or  hydrogen  be  used  to  inflate  the  lungs. 

It  is  true  that  the  strength  of  the  interrupting  contraction  is 
generally  greatest  when  the  lungs  have  been  inflated  with  hydro¬ 
gen,  but  the  time  of  its  appearance  is  the  same  with  all  three 
gases  under  otherwise  similar  conditions. 

Again,  the  fact  that  the  animal  is  breathing  oxygen  during 
and  after  the  inflation  does  not  diminish  the  strength  of  the 
inspiratory  contraction,  which  is  produced  by  the  sudden  return 


of  the  lungs  to  their  normal  volume  after  the  inflation.  Indeed , 
it  is  rather  favorable  than  otherwise  to  its  appearance,  far,  if 
the  animal  is  dyspnceic ,  this  inspiratory  contraction  is  of  much 
shorter  duration  and  is  much  more  difficult  to  produce  than  when 
the  ungs  have  been  inflated  with  air  or  oxygen. 

It  will  be  noticed  in  the  above  that  the  author,  with¬ 
out  leaving  the  question  an  open  one,  does  not  distinctly 
hold  these  inspirations,  during  or  after  prolonged  insuffla¬ 
tions  of  the  lungs,  to  be  due  to  central  (direct)  or  to  pe¬ 
ripheral  (reflex)  incitation  ;  namely,  to  vitiated  blood  in  the 
medulla,  or  to  excitation  of  the  vagus  in  the  lungs;  but  it 
is  evident  that  the  latter  is  his  view. 

This  conclusion  does  not  seem  to  me  to  follow,  how¬ 
ever,  from  the  simple  circumstance  stated,  that  the  inter¬ 
rupting  inspiratory  effort  was  stronger  on  the  use  of  hydro¬ 
gen  than  of  air  or  oxygen. 

Exception  may  also  be  taken  here  to  the  author’s  use 
of  the  word  dyspnoea,  whereby  he  wrests  it  from  its  univer¬ 
sal  clear  and  symptomatic  meaning  of  increased  respiratory 
effort  with  want  of  air,  and  devotes  it  to  a  condition  of  the 
respiratory  center,  due  to  vitiation  of  blood,  for  the  reason, 
namely,  that  neither  of  these  definitions  includes  the  other; 
for  we  may  have,  on  the  one  hand,  as  already  detailed,  a 
peripherally  arising  dyspnoea,  and  on  the  other,  as  iu  the 
experiments  of  Gad  and  of  Sig.  Mayer,  already  cited,  a 
vitiation  of  the  blood  with  diminished  rather  than  increased 
breathing;  or,  as  in  the  author’s  case,  a  diminished  respiratory 
effort  with  increasing  vitiation  of  the  blood,  until  finally 
the  inhibition  of  the  respiration  is  broken  through  by  the 
increased  excitation  of  the  center;  or,  again,  a  stoppage  of 
the  breathing  after  a  dyspnoeic  patient  draws  the  first  long 
breath  or  two  upon  a  tracheotomy,  or  the  same  when,  after 
a  severe  haemorrhage,  a  transfusion  is  quickly  made ;  and 
yet  in  all  these  cases  the  center  contain  vitiated  blood  and 
tissue  fluid,  the  condition  of  which  has  only  begun  to  be¬ 
come  normal. 

The  difficulties,  moreover,  to  which  such  a  conception 
of  dyspnoea  are  apt  to  lead  is  illustrated  in  the  last  sen¬ 
tence  of  the  quotation,  in  which  the  animal  is  spoken  of 
as  “dyspnceic,”  when  in  reality  it  is  apnoeic  (17). 

That  the  above-mentioned  experiment,  as  given  to  us,  is, 
furthermore,  of  altogether  too  complicated  a  nature  to  be 
more  than  food  for  controversy,  or  better,  perhaps,  for  further 
investigation,  is  indicated  by  the  following  considerations, 
as  well  as  by  the  description  itself: 

1.  It  has  been  shown,  especially  by  the  above-cited  ex¬ 
periments  of  Gad  and  M.  Rosenthal,  which  covered  the 
use  of  both  gases  concerned,  that  dyspnoea  unmistakably 
appears  upon  a  slight  increase  of  the  carbonic  acid  in  the 
inspired  air,  while  a  much  greater  corresponding  decrease 
of  oxygen  in  an  atmosphere  breathed  is  requisite  for  a 
similar  effect ;  in  fact,  they  consider  that  in  respiration 
from  a  limited  air  space  the  dyspnoea  is  in  reality  occa¬ 
sioned  by  the  carbonic  acid. 

2.  In  the  above-cited  experiments  of  Head,  the  condi¬ 
tions  for  the  diffusion  of  carbonic  acid  from  the  blood  into 
the  pulmonary  alveoli  were  apparently  the  same  in  all  three 
cases. 

3.  By  reason  of  the  quietude  of  the  animal,  which,  in 


Sept.  6,  1890.] 


COWL:  THE  RESPIRATORY  RHYTHM. 


the  first  place,  narcotized,  in  the  second  made  no  respira¬ 
tory  effort,  the  general  consumption  of  oxygen  was  un¬ 
doubtedly  small ;  the  vitiation  of  the  blood  in  general  was, 
therefore,  reduced  to  a  minimum  from  the  beginning  of  the 

experiment  on. 

4.  As  the  respiratory  center  had  ceased  its  respiratory 
activity,  we  may  assume  both  its  call  for  oxygen  and  the 
vitiation  of  the  blood  and  tissue  fluid  within  it  to  have 
been  abnormal — to  have  been  abnormally  small. 

5.  In  that  the  insufflations  with  hydrogen,  commencing 
during  normal  respiration,  were  superimposed  upon  the 
residual  plus  the  reserve  atmospheric  air  then  in  the  chest, 
there  was  merely  less  oxygen  available  therein  than  when 
air  or  oxygen  was  injected. 

6.  By  their  considerable  duration  (some  twenty  sec¬ 
onds),  and  the  continually  lessening  hsematosis,  especially 
in  the  case  of  the  hydrogen  insufflations,  the  excitability 
of  the  respiratory  center  would  by  this  of  itself  be  reduced— 
would  not,  therefore,  respond  so  quickly  or  so  well  (l,  16). 
That  this  was  the  case  is  to  be  seen  from  the  last  sentence 
of  the  quotation,  which  seems  to  contradict  the  previous 
statement  concerning  the  effect  of  hydrogen. 

7.  Where  less  oxygen  is  furnished  to  the  organism,  less 
?arbonic  acid  is  formed  (15). 

8.  The  data  given  are  insufficient  for  estimating  the 
wo  variable  factors  at  the  center — namely,  its  excitability, 
ind  the  amount  of  excitant  offered  to  it. 

As  indicated  at  the  beginning  of  this  paper,  an  inhibi¬ 
tory  function  of  the  pulmonary  vagus  in  ordinary  respira- 
ion  has  been  established  and  without  recourse  to  excita- 
ion  of  the  nerve  stem — namely,  the  power  of  cutting  off 
nspi ration  and  inducing  expiration,  which  was  maintained 
n  the  first  part  of  the  theory  of  Hering  and  Breuer. 

This  fact  was  rendered  probable  by  the  experiments  of 
hese  observers  (2),  who  noted  the  effect  on  the  respiratory 
fforts  of  pulmonary  insufflations  in  the  intact  animal  and 
he  absence  of  such  effect  after  the  vagus  was  cut.  The 
onclusive  proof  of  the  same  was  brought  by  Gad  (1),  who, 
■y  using  chloral  instead  of  opium  as  a  narcotic,  by  a  means 
t  precisely  and  continuously  registering  the  changes  in  the 
olume  of  the  lungs  with  inspiration  and  expiration  (18), 
ut  chiefly  by  the  employment  of  a  new  and  trustworthy 
lethod  of  suddenly  interrupting  the  nervous  impulses 
oursing  through  the  vagus  without  exciting  the  nerve 
hereby  namely,  by  locally  freezing-  it— was  enabled  to 
bserve,  so  soon  as  this  latter  was  done,  that  the  inspira- 
10ns  were  deepened  and  their  frequency  reduced,  just  as 
s  found  some  time  after  cutting  the  vagi,  and  also  that  the 
aspiration  was  carried  on  with  a  much  greater  distention 
f  the  chest,  while  a  new  pause,  relative  or  absolute,  ap- 
eared  at  the  end  of  inspiration,  and  the  normal  one  at  the 
nd  of  expiration  in  ordinary  quiet  respiration  disappeared, 

that  the  tracing  of  the  latter  appeared  inversed  and 
magnified  from  the  moment  on  when  both  nerves  were 
ozen  through,  although  the  animal  often  breathed  less  air 
lereafter  than  before. 

From  this  alteration  of  the  type  of  respiration  it  is  evi- 
ent  that  a  restraining,  an  inhibitory  influence  has  been  re- 


259 

moved;  for,  as  above  said,  not  only  were  the  individual 
inspirations  now  deeper,  but  the  inspiratory  muscles  con¬ 
tinued  each  time  in  a  state  of  contraction  after  the  inflow 
of  air  had  ceased,  while  the  expirations  were  cut  short  by 
a  new  inspiration,  so  that  altogether  the  mean  expansion  of 
the  chest  remained  by  a  considerable  amount  above  its  for¬ 
mer  level. 

We  are  also  furnished,  however,  by  the  above  experi¬ 
ment  with  the  presumption  of  the  sufficiency  of  the  direct 
action  of  the  respiratory  center  in  iuciting  inspiration,  for 
the  respiratory  activity  upon  eliminating  the  influence  of 
the  vagi,  instead  of  decreasing,  has  markedly  increased.  We 
find,  moreover,  in  the  following  experiments  of  Flint  (19), 
to  which  we  would  call  especial  attention  by  reason  of  their 
obvious  incompatibility  with  the  theory  of  Dr.  Meltzer,  a 
further  evidence  of  the  sufficiency  of  the  action  of  the  res¬ 
piratory  centei  for  the  incitation  of  ordinary  respiration. 
This  observer  noted  in  an  animal  abundantly  and  regularly 
supplied  with  air  by  a  bellows,  and  which  in  consequence 
thereof  had  ceased  respiratory  effort,  that  the  latter  would 
begin  upon  letting  arterial  blood,  and  that  the  same  would 
occur  whether  the  vagi  were  intact  or  cut.  The  conclusion  of 
the  author  therefrom — that  the  incitation  to  inspiration  did 
not  flow  from  the*  lungs— was  the  first  emancipation  from 
the  confusion  that  seems  to  have  been  stamped  upon  the 
subject  by  the  various  memoirs  of  Marshall  Hall  (20).  The 
complement  to  this  was  furnished  by  Rosenthal  (11a),  who 
showed,  by  cutting  the  various  cerebral  and  sensory  paths  to 
the  medulla  oblongata,  that  respiration  was  not  a  reflex  act. 

Hermann  and  Escher  (21), 'by  occluding  the  veins  lead¬ 
ing  from  the  brain  and  cervical  cord,  showed  that  it  was 
merely  lack  of  circulation  and  not  the  emptiness  of  the 
blood-vessels  by  which,  in  Rosenthal’s  researches  on  this 
point,  the  dyspnoea  was  caused,  and  that  therefore  the  con¬ 
clusion  of  the  latter — that  occlusion  of  the  cerebral  arteries 
acted  by  disturbing  the  tissue  changes  in  the  center— was 
justified. 

As  pointed  out  by  Gad,  the  pause  following  normal 
quiet  expiration  indicates  that  the  inhibitory  influence  from 
the  vagus,  which  cuts  off  the  inspiration,  overlasts  the  lat- 
G1’*  The  existence  of  this  pause  at  the  end  of  expiration 
and  the  absence  of  such  at  the  end  of  normal  inspiration 
are  adduced  by  him,  in  addition  to  the  presumable  suffi¬ 
ciency  of  the  central  incitation  to  inspiration,  against  the 
second  part  of  the  theory  of  Hering  and  Breuer,  according 
to  which  the  inspiration  is  incited  by  reflex  from  the  dimin¬ 
ishing  lung,  just  as  expiration  is  induced  by  inhibitory  re¬ 
flex  from  the  expanding  lung. 

As  this  view  still  remains  undemonstrated,  notwithstand¬ 
ing  extended  researches  directed  to  the  same  (4),  we  may 
regard  the  causation  of  the  respiratory  rhythm  in  the  fol¬ 
lowing  manner,  substantially  as  formulated  by  Gad,  who 
divides  it  into  three  factors,  namely  : 

1.  To  incite  inspiration:  The  constant  presence  in  the 
respiratory  center  of  an  excitant,  probably  carbonic  acid. 

2.  To  occasion  expiration :  The  lowering  of  the  excita¬ 
bility  of  the  center  below  the  point  of  response  to  the 
amount  of  excitant  present  through  mechanical  excitation 
of  the  vagus  in  the  lung  in  inspiration. 


260 


COWL:  TEE  RESPIRATORY  RHYTHM. 


[N.  Y.  Med.  Joub., 


3.  For  the  continuance  of  expiration :  A  persistence  of 
this  effect  until  the  excitability  of  the  center  has  again 
become  sufficiently  great  to  determine  reaction  to  the  ex¬ 
citant. 

Upon  this  basis  a  regulation  of  the  respiration — namely, 
of  the  depth  and  frequency  of  the  respiratory  efforts  and  of 
the  mean  distention  of  the  chest,  according  to  the  position, 
condition,  and  activity  of  the  individual — would  depend  (1) 
upon  the  constituency  of  the  blood  furnished  to  the  respira¬ 
tory  center,  and  (2)  upon  the  nervous  impulses  of  various 
kinds  which,  reflected  upon  the  respiratory  center,  raise  or 
diminish  its  excitability,  the  latter  acting  to  supplement  the 
former,  just  as  at  birth  a  cold  shock  assists  the  stoppage  of 
the  placental  circulation  in  occasioning  the  first  respiratory 
efforts. 

With  reference  to  the  constant  influence  of  the  vagus 
upon  respiration,  which  we  have  already  noted  in  the  re¬ 
searches  of  Gad  on  the  normally  breathing  animal,  the 
following  experiment  by  Hering  and  Breuer  (2),  which 
demonstrated  the  presence  of  such  an  influence  under  the 
conditions  specified  and  showed  it  to  be  independent  of  the 
motions  of  the  lungs,  concerns  us  respecting  the  theory  of 
Dr.  Meltzer  at  this  point.  Upon  sending  a  constant,  even 
current  of  air  through  the  thereby  distended  and  multiply- 
punctured  lungs,  the  rhythmic  respiratory  efforts  continue, 
and  they  at  once  diminish  in  frequency  upon  cutting  the 
vagi,  just  as  in  the  normally  breathing  animal. 

Recently  it  has  been  found  by  Loewy  (22)  that,  by  ren¬ 
dering  one  lung  airless,  impulses  cease  to  flow  therefrom  to 
the  respiratory  center  through  the  vagus,  which  was  shown 
by  cutting  the  vagus  of  the  other  lung,  when  the  respira¬ 
tion  changes,  just  as  after  section  of  both  vagi  in  the  nor¬ 
mal  animal,  while  section  of  the  nerve  on  the  side  of  the 
atelectatic  lung  causes  no  change  in  the  respiration ;  and  it 
has  been  confirmed  by  inflating  the  airless  lung,  when,  if  its 
vagus  be  intact,  the  former  frequency,  and  we  may  allow 
ourselves  to  believe  also  the  former  type  of  respiration,  is 
restored. 

These  experiments,  as  well  as  the  simple  pulmonary  in¬ 
sufflations  of  Hering  and  Breuer  and  of  Head,  have  been 
considered  to  show  that  it  is  the  expansion  of  the  lung  that 
excites  the  fibers  inhibitory  of  inspiration  in  the  vagus,  and 
Dr.  Meltzer  has  founded  his  theory  of  respiratory  rhythm, 
as  before  stated,  on  this  idea. 

Without  going  further  into  the  question  in  this  place, 
I  wish,  however,  to  call  attention  to  the  fact  that  this  is 
only  an  inference  ;  for  in  the  experiments  of  the  above- 
named  observers  there  was,  besides  expansion,  also  pressure 
present,  and,  in  fact,  considerable  pressure,  the  influence  of 
which,  if  it  have  an  influence,  was  not  excluded  or  con¬ 
sidered  by  them. 

The  researches  of  Loewy,  in  the  absence  of  such  exclu¬ 
sion,  simply  show  that  the  constant  normal  inhibitory  in¬ 
fluence  of  the  vagus  on  the  respiration  may  be  due  to  the 
state  of  expansion  of  the  lungs,  or  to  their  intermittent 
active  expansions,  or  to  the  intermittent  pressure  or  rise  of 
pressure  in  the  alveoli,  or  to  some  two  or  all  of  these. 

But  another  supposition  in  this  theory  deserves  atten¬ 
tion,  in  that  it  could  have  been  readily  avoided  by  leaving 


the  question  an  open  one — namely*  the  assumption  of  two 
kinds  of  pulmonary  fibers  in  the  vagus  for  ordinary  respira¬ 
tion  ;  the  one  for  inspiration,  the  other  for  inhibition  of 
the  same;  for  it  is  possible  that,  by  reason  of  the  nature  of 
their  connections  with  the  central  ganglia,  or  of  their  end¬ 
ings  in  the  lungs,  one  set  of  fibers  suffices  for  all  functional 
purposes,  so  that  one  degree  or  kind  of  excitation  effects 
ordinary  incitations  or  inhibitions  ;  other  degrees  or  kinds 
of  excitation,  extraordinary  incitations  or  inhibitions.  This 
is  an  alternative,  mentioned  indeed  by  Hering  and  Breuer 
in  connection  with  their  own  experiments,  and  were  still 
more  worthy  of  regard  in  building  upon  the  effects  of  arti¬ 
ficial  excitation  of  the  nerve  stem. 

In  conclusion,  it  remains  only  to  note  that  the  communi¬ 
cation  of  Dr.  Meltzer  is  restricted  to  his  explanation  of  the 
respiratory  rhythm,  and  does  not  concern  itself  with  the 
regulation  of  respiration ;  indeed,  the  question  that  very 
naturally  suggests  itself — namely,  what  self-regulation  of 
the  respiration  can,  under  any  normal  circumstances,  be 
exerted  alone  by  an  expanding  lung,  which  by  one  and  the 
same  process  excites  both  inhibiters  and  exciters  of  the 
respiration — is  not  even  alluded  to. 

References. 

1.  Gad.  Die  Regulirung  der  normalen  Athmung.  Du  Bois- 
Reymond’s  Archiv,  1880,  p.  1. 

2.  Hering  and  Breuer.  Die  Selbststeuerung  der  Athimiog 
durch  denNervus  Vagus.  Herichte  d.  ATcad.  d.  Wissenschaften 
zu  Wien,  1868,  II.  Abthl.,  Band  58. 

3.  Kronecker  und  Meltzer.  Ueber  den  Scbluckact  uDd  die 
Rolle  der  Cardia  bei  demselben.  Du  Bois-Reymond’s  Archiv , 
1881,  p.  465. 

4.  Head.  On  the  Regulation  of  Respiration.  Journal  oj 
Physiology ,  1869,  vol.  x,  p.  1. 

5.  Knoll.  Athmung  bei  Erregung  der  Vagu9zweige.  Ber. 
Akad.  Wiss.  Wien,  1883,  Band  88,  III.  Abthl. 

6.  Berns.  Over  den  invloed  van  verschillende  Gassen  op  de 
Adembeweging.  Onderzookingen  gedaan  in  het  Physiol.  Labor, 
der  Utrechtsche  Hoogschool,  1870,  2°,  Reeks  III. 

7.  M.  Rosenthal.  Ueber  die  Form  der  Kohlensaure-  und 
Sauerstoff-dyspnoe.  Du  Bois-Reymond’s  Archiv,  1886,  p.  248. 

8.  Gad.  Ueber  automatische  und  reflectorische  Athemcen- 
tren.  Verhandlungen  der  physiolog.  Gesellschaft  zu  Berlin. 
Du  Bois-Reymond’s  Archiv,  1886. 

9.  Goldscheider.  Ueber  der  Einwirkung  der  Kohlensaure 
auf  die  seusiblen  Nerven  der  Haut.  Verh.  physiol.  Geselisch. 
zu  Berlin.  Du  Bois-Reymond’s  Archiv ,  1887,  p.  575. 

10.  Knoll.  Athmung  bei  Erregung  sensibler  NerveD.  Ber. 
Wiener  Akad.,  1885,  Band  92,  III.  Abthl. 

11.  Rosenthal.  Die  Athembewegungenund  ihre  Beziehungen 
zum  Nervus  Vagus ,  Berlin,  1862. 

11a.  Rosenthal.  Studien  uber  Athembewegungen.  Zwei- 
ten  Artikel.  Du  Bois-Reymond’s  Archiv,  1865,  p.  192. 

12.  Dohmen.  Untersuchungen  uber  den  Einfluss  der  die 
Blutgase  auf  die  Athembewegung  ausuben.  Enters,  aus  dem 
physiol.  Labor,  in  Bonn ,  1875. 

13.  Fredericq.  Proc6d6  opdratoire  nouveau  pour  l’6tude 
physiologique  des  organes  thoraciques.  Bulletin  de  Vacad.  roy. 
d.  Belgique,  3  Serie,  t.  13,  N.  4,  p.  417. 

14.  Miescher-Rlisch.  Bemerkungen  zur  Lehre  von  den  Ath- 
embewegungeu.  Du  Bois-Reymond’s  Archiv ,  1885,  p.  355. 

15.  Kempner.  Neue  Versuche  liber  den  Einfluss  des  Bauer 
stoff  gebaltes  der  Einatbmungsluft  auf  dem  der  Oxydationspro 


iept  6,  1890.] 


BULL:  EXTRACTION  OF  LENSES  FROM  THE  VITREOUS. 


261 


■esse  in  tbierischen  Organismus.  Du  Bois-Reymond’s  Archiv, 

884,  p.  396. 

16.  See  Langendorff.  Ueber  die  automatische  Thatigkeit 
les  Athmungs-centrums.  Du  Bois-Reymond’s  Archiv ,  1888,  p. 

>83. 

17.  Gad.  Ueber  Apnoe,  Wurzburg,  1880.  Gad  und  Wegele. 
Ueber  die  centrale  Natur  rejiectorischer  Athmungshemmung , 

vVftrzburg,  1882. 

18.  Gad.  Ueber  einen  neuen  Pneumatographen.  Verb, 
(hysiol.  Ges.  Berlin.  Du  Bois-Reymond’s  Archiv ,  1879,  p.  181. 

19.  Flint.  Experimental  Researches  on  Points  connected 
vitb  Respiration.  Amer.  Jour,  of  the  Med.  Sciences ,  New  Se- 

ies,  42,  1861,  vol.  ii,  p.  841. 

20.  Marshall  Hall.  Memoirs  on  the  Nervous  System ,  Lon- 

lon,  1837. 

21.  Hermann  und  Escher.  Ueber  die  Krampfe  bei  Circula- 
ionsstorungen  im  Gebirn.  Pfliiger’s  Archiv  d.  Physioloqie , 

land  3,  p.  3. 

22.  A.  Loewy.  Ueber  den  Tonus  des  Lungen-vagus.  Pdu- 
;er’s  Archiv ,  1888,  Band  42,  p.  273. 


THE  EXTRACTION  OF  LENSES 
DISLOCATED  INTO  THE  VITREOUS* 

By  CHARLES  STEDMAN  BULL,  M.  D., 

ROFESSOR  OF  OPHTHALMOLOGY  IN  THE  UNIVERSITY  OP  THE  CITY  OF  NEW  YORK ' 
SURGEON  TO  THE  NEW  YORK  EYE  AND  EAR  INFIRMARY  ; 

CONSULTING  OPHTHALMIC  SURGEON  TO  ST.  LUKE’S  HOSPITAL  AND  TO 
ST.  MARY’S  HOSPITAL  FOR  CHILDREN. 

Since  the  publication  of  the  recent  papers  by  Dr.  Ag- 
icw,  Dr.  Webster,  Dr.  Pomeroy,  and  Dr.  Knapp  upon  the 
ubject  of  the  extraction  of  lenses  dislocated  into  the  vit- 
eous,  the  writer  has  collected  a  number  of  cases  of  dislo- 
ation  of  the  lens  into  the  vitreous,  due  to  traumatism, 
yhich  have  been  operated  upon  by  himself  during  a  period 
'f  several  years,  and  now  presents  the  histories  of  the  fol- 
owing  thirteen  cases,  with  some  remarks  upon  the  method 
I  operating,  for  the  consideration  of  the  society.  The  in- 
erest  excited  by  a  description  of  the  method  devised  by 
)r.  Agnew,  with  an  instrument — the  bident — invented  by 
limself,  has  not  sufficed  to  conceal  from  the  mind  of  the 
vriter  the  real  value  of  the  objections  raised  against  the  use 
I  this  instrument.  None  of  the  cases  described  in  detail 
Q  this  paper  were  operated  upon  with  the  bident,  and  the 
writer  has  had  no  personal  experience  with  the  instrument, 
so  very  great  difficulty  has  ever  been  experienced  in  at- 
empting  to  remove  lenses  dislocated  into  the  vitreous  by 
he  methods  hitherto  in  general  use,  and  in  none  of  the 
ases  here  reported  have  any  bad  results  followed.  The  ex- 
raction  of  a  lens  from  the  vitreous  is  a  more  or  less  diffi- 
ult  operation,  and  any  case  may  very  well  differ  from  all 
t’ners  in  some  minor  points.  The  more  serious  the  trau- 
latism  has  been,  and  the  greater  the  resulting  disorganiza- 
ion  of  the  eye,  the  more  difficult  will  be  the  operation  for 
he  removal  of  such  a  dislocated  lens,  and  the  more  serious 
he  possible  accidents  during  the  operation. 

The  writer’s  experience  is  in  accord  with  that  of  Dr. 
Liapp,  who  believes  it  possible,  “  by  external  manipulation, 
o  extract  lenses  dislocated  and  swimming  in  the  vitreous 
■’ithout  accident  and  with  preservation  of  the  natural  pu¬ 

*  Read  before  the  American  Ophthalmological  Society,  July  16,  1890. 


pil.  Not  only  is  this  true  with  regard  to  lenses  entirely 
dislocated  and  floating  freely  in  the  vitreous,  but  the  same 
remark  may  be  applied  to  partially  dislocated  lenses,  and  to 
lenses  floating  in  the  vitreous,  but  attached  at  one  point  to 
the  ciliary  processes.  The  writer  believes  it  possible  in 
many  cases,  perhaps  in  the  great  majority,  to  extract  the 
lens  by  external  pressure,  and  to  confine  the  use  of  instru¬ 
ments  to  assisting  in  the  removal  of  the  lens  after  it  has 
presented  in  the  wound, *or  at  least  in  the  field  of  the  pupil.. 
Ot  course,  in  each  case  the  possible  difficulties  are  an  un¬ 
known  quantity,  and  the  blunt  hook,  the  delicate  wire  spoon 
or  the  broad  silver  spoon  should  be  ready  at  hand  to  use  in 
case  of  necessity. 

The  manipulation  which  the  writer  has  found  useful  in 
this  operation  may  be  described  as  follows:  The  eyelids 
are  held  open  by  the  ordinary  wire  speculum,  and  the 
corneal  section  is  made  upward  with  the  narrow  knife, 
the  ends  of  the  incision  being  in  the  limbus,  and  the  apex 
in  clear  cornea,  just  below  the  limbus.  The  speculum 
is  then  removed,  and  the  upper  lid  is  lifted  up  and  away 
from  the  eyeball  by  the  finger  of  an  assistant,  or,  better,  by 
a  wire  elevator  held  by  an  assistant.  Pressure  is  then  made 
upon  the  lower  part  of  the  eyeball  with  the  thumb  or  finger 
of  the  operator,  by  pressing  the  lower  lid  against  the  eye 
directly  backward.  Almost  immediately  the  lens  will  be 
seen  to  rise  and  appear  in  the  field  of  the  pupil,  and,  in 
not  a  few  instances,  comes  partially  through  the  pupil  and 
engages  in  the  wound.  Sometimes  the  assistance  of  a  blunt 
hook  or  the  wire  spoon  becomes  necessary  to  complete  the 
removal  of  the  lens  at  this  stage  of  the  operation.  If  con¬ 
tinued  pressure  backward  fails  to  push  the  lens  through  the 
pupil,  or  causes  a  prolapse  of  the  vitreous,  it  should  be  dis¬ 
continued,  and  the  lens  removed  at  once  by  hook  or  spoon. 
It  is  surprising  to  see  how  often  a  dislocated  lens  is  removed 
by  this  simple  pressure  backward,  without  the  introduction 
of  any  instrument  into  the  eye.  If  a  criticism  may  be 
passed  upon  the  use  of  the  bident  by  one  who  has  never 
used  it,  it  would  seem  to  the  writer  that  the  objections  to 
its  use  raised  by  Dr.  Knapp  are  just.  The  sclerotic  and 
ciliary  regions  are  pierced  in  four  places  by  the  teeth  of  the 
bident,  and  after  the  lens  is  extracted,  both  aqueous  and 
vitreous  chambers  being  open,  this  instrument  must  then  be 
withdrawn.  Another  objection  to  its  use  is  that  it  decid¬ 
edly  complicates  the  operation  by  adding  one  more  to  the 
number  of  instruments  necessary  for  it,  and  by  the  intro¬ 
duction  of  this  instrument  inside  the  eye,  where  it  must 
remain  until  the  lens  has  been  extracted. 

Case  I. — Patrick  McD.,  aged  seventy-five,  June  3,  1878. 
Has  had  gradually  failing  vision  in  both  eyes  for  several  years. 
One  month  ago  he  received  a  severe  blow  on  the  left  eye  and 
lost  the  sight  in  this  eye  at  once,  and  since  then  has  had  only 
perception  of  light.  There  have  been  occasional  attacks  of 
pain. 

R-  Em  ta)  partial  opacity  of  the  lens;  sluggish  iris;  senile 
degenerative  chorioiditis. 

L.  E.,  Y.  =  perception  of  light;  pupil  irregularly  dilated 
and  immovable  ;  iris  discolored  and  fluttering  ;  lens  dislocated 
downward-  into  the  vitreous,  entirely  opaque  and  floating  free. 

T.  +  1. 

It  was  determined  to  attempt  the  removal  of  the  dislocated 


262 


BULL:  EXTRACTION  OF  LENSES  FROM  THE  VITREOUS. 


[N.  Y*  Med.  Jocr., 


lens.  This  was  before  the  days  of  cocaine,  and  the  patient  de¬ 
clined  to  take  ether.  The  patient  was  placed  on  his  back  in 
bed,  and  a  wire  speculum  was  introduced  to  hold  the  lids  open. 
The  eye  and  culde-sac  were  carefully  washed  with  a  warm 
saturated  solution  of  boric  acid.  The  eyeball  was  then  steadied 
by  fixation  forceps,  and  an  upper  corneal  section  made  with  a 
narrow  Graefe  knife,  the  ends  of  the  section  being  in  the 
limbus  and  the  apex  in  clear  cornea.  The  speculum  was 
then  removed,  in  the  course  of  which  the  lens  presented  in  the 
pupil,  which  was  a  fortunate  accidenf.  A  blunt  hook  was  then 
carefully  introduced  through  the  corneal  wound,  hugging  the 
upper  segment  of  the  iris,  and  passed  slowly  behind  the  upper 
presenting  margin  of  the  lens.  By  a  sudden  delicate  twist  the 
blunt  point  of  the  hook  penetrated  the  lens  capsule,  and  the 
lens  was  at  once  lifted  through  the  pupil  and  corneal  wound 
arid  removed  from  the  eye,  followed  by  a  small  amount  of  vitre¬ 
ous.  The  cornea  at  once  collapsed,  and,  as  a  consequence,  the 
wound  gaped.  Atropine  was  instilled  and  a  bandage  carefully 
applied.  Much  of  the  success  of  this  operation  was  due  to  the 
extraordinary  self-control  of  the  patient,  who  lay  perfectly 
still,  with  an  immovable  eye,  until  all  was  over.  The  eye 
was  dressed  daily,  but  the  wound  remained  open  for  a  long 
time,  and  did  not  entirely  close  for  nearly  a  month.  The  iris, 
which  had  partially  prolapsed  at  the  time  of  the  passage  of  the 
lens  through  the  wound,  replaced  itself  and  gave  no  further 
trouble.  There  was  no  improvement  of  vision  in  the  left  eye, 
probably  owing  to  the  effects  of  the  contusion.  This  patient 
subsequently  underwent  an  operation  for  extraction  of  cataract 
in  the  right  eye  three  years  later,  and  recovered  useful  vision 

so 

or  T7r. 

Case  II. — Henry  H.,  aged  sixty-five,  December  16,  1878. 
Twenty  years  before,  this  patient  had  received  a  violent  blow 
on  the  right  eye,  which  caused  complete  dislocation  of  the  lens 
into  the  vitreous.  The  blow  destroyed  the  sight  at  once,  and 
nothing  more  than  perception  of  light  has  ever  been  regained. 
Attacks  of  intra-ocular  irritation  have  appeared  at  irregular  in¬ 
tervals,  but  subsided  after  a  few  days  of  treatment.  Two 
weeks  ago  an  unusually  severe  attack  began,  and  has  continued 
ever  since,  with  much  pain. 

R.  E.,  perception  of  light.  Signs  of  ciliary  irritation,  with 
injection  of  the  eye  and  photophobia.  Large,  opaque  lens 
floating  in  the  vitreous. 

L.  E.,  2Y<G  cataract;  field  and  projection  normal. 

This  patient  was  etherized,  a  speculum  was  introduced,  and 
the  eye  and  cul-de  sac  were  carefully  irrigated  with  a  saturated 
solution  of  boric  acid.  The  eye  was  then  held  by  fixation  for¬ 
ceps  and  an  upward  corneal  section  made  with  a  narrow  knife, 
entirely  in  the  limbus.  The  speculum  was  then  removed  and  an 
attempt  made  by  pressure  on  the  eyeball  through  the  lower  lid 
to  bring  the  lens  into  the  pupil.  This  partially  succeeded,  but 
vitreous  presented  in  the  wound  before  the  lens.  A  wire  spoon 
was  then  introduced  through  the  wound  and  through  the  pupil 
into  the  vitreous  behind  the  partially  presenting  lens,  and  at 
the  first  attempt  the  lens  was  extracted  intact  in  its  capsule. 
Very  little  vitreous  was  lost  in  the  operation.  The  prolapsed 
iris  was  stroked  into  place  in  the  anterior  chamber  with  a 
spatula,  a  drop  of  eserine  was  introduced,  and  the  eye  was  care¬ 
fully  bandaged.  This  patient  was  operated  upon  while  lying  on 
his  back  in  bed.  The  eye  made  an  excellent  recovery,  and  the 
signs  of  ciliary  irritation  soon  subsided. 

Case  III. — Jane  K.,  aged  twenty-three,  October  6,  1880. 
Patient  has  had  defective  vision  from  birth,  with  nystagmus 
.and  great  intolerance  of  light.  Repeated  attacks  of  inflamma¬ 
tion  in  both  eyes.  For  the  past  two  months  the  right  eye  has 
been  extremely  painful  and  continually  inflamed. 

R.  E.,  whs-  Hazy  cornea,  with  numerous  depressions  from 


old  ulcers.  Congenital  aniridia.  Lens  dislocated  downward 
and  inward  into  the  vitreous,  but  still  attached  by  two  bands 
to  the  ciliary  processes  downward  and  inward,  the  remains  of 
the  suspensory  ligament.  Lens  opaque. 

L.  E.,  ;  congenital  aniridia ;  opacities  in  lens  and  cap¬ 

sule  ;  no  dislocation  of  lens.  Owing  to  the  dangerously  inflamed 
condition  of  the  right  eye,  the  patient  was  advised  to  have  an 
enucleation  done,  but  this  she  refused,  and  it  was  then  decided 
to  attempt  the  removal  of  the  lens.  The  patient  was  etherized 
and  an  upward  corneal  section  was  made,  the  ends  being  in  the 
limbus  and  the  apex  in  clear  cornea.  Much  to  my  surprise,  the 
lens  presented  at  once  in  the  wound,  accompanied  by  a  little 
vitreous,  and  was  readily  removed  by  the  wire  spoon,  with  a 
slight  loss  of  vitreous.  The  eye  and  lids  were  then  carefully  and 
gently  irrigated  with  a  solution  of  mercuric  bichloride  (1  to 
5,000)  and  an  antiseptic  bandage  was  applied.  This  bandage  was 
left  undisturbed  for  three  days  and  was  then  removed.  The  lids 
looked  well  and  there  was  no  discharge  of  any  kind,  so  the  eye 
was  not  opened,  and  the  bandage  was  reapplied  and  left  on  for 
forty-eight  hours  longer.  At  the  end  of  this  period  it  was  re¬ 
moved,  the  eye  was  examined,  and  the  corneal  wound  was  found 
entirely  closed.  There  was  still  considerable  ciliary  injection 
and  irritation,  which  was  treated  by  atropine  and  dark  glasses 
and  soon  subsided.  At  no  time  was  there  any  irritation  of  the 
fellow  eye. 

Case  IV. — James  B.,  aged  sixty-eight,  January  28,  1884. 
Patient  has  had  failing  vision  in  both  eyes  for  some  years. 
Three  months  before  he  had  received  a  violent  blow  on  the 
right  eye  from  a  potato,  which  for  the  time  completely  abol¬ 
ished  the  vision  in  this  eye.  After  about  a  week  he  began  to 
regain  the  sight,  and  it  has  steadily  improved  since. 

R.  E.,  -g-fj,  with  sph.  +  D.  12  =  ;  widely  dilated  pupil ; 

lens  opaque  and  floating  freely  at  the  bottom  of  the  vitreous; 
tension  -f  1. 

L.  E.,  ;  cataract. 

On  February  13th  it  was  decided  to  attempt  the  removal 
of  the  lens,  which  remained  in  the  vitreous  and  could  not  he 
induced  to  fall  into  the  anterior  chamber  by  any  position  or 
manoeuvre.  The  patient  refused  to  be  anaesthetized,  and  the 
operation  was  performed  while  he  was  seated  in  a  chair.  The 
eyeball  was  opened  by  a  corneal  section  upward,  the  apex  in 
clear  cornea,  and  made  with  a  narrow  knife.  Pressure  was 
then  made  upon  the  lower  portion  of  the  eyeball  with  the  thumb 
and  index  finger  alternately  through  the  lower  lid  directly  back¬ 
ward.  This  caused  a  lifting  upward  and  forward  of  the  lens, 
and  at  the  same  time  caused  a  slight  gaping  of  the  lips  of  the 
wound.  As  this  pressure  was  continued  its  direction  was 
changed  from  backward  to  backward  and  upward,  and  as  the 
lens  rose  and  came  forward  through  the  pupil,  a  blunt  hook  was 
introduced  through  the  lips  of  the  wound,  engaged  in  the  lens, 
and  the  latter  was  lifted  out  in  its  capsule  without  the  slightest 
difficulty.  It  was  followed  by  some  fluid  vitreous.  The  cornea 
collapsed,  but  there  was  no  pain  complained  of  by  the  patient. 
The  usual  antiseptic  dressings  and  bandage  were  applied  and 
remained  unchanged  for  two  days.  The  case  did  well,  there  be¬ 
ing  no  adverse  symptoms,  but  the  wound  healed  very  slowly, 
and  it  was  nearly  a  month  before  the  anterior  chamber  was  es¬ 
tablished.  The  ultimate  vision  in  this  eye  was  f$,  with  sph. 
+  D.  12. 

Case  V. — Margaret  W.,  aged  twenty-two,  May  5,  1884.  Pa¬ 
tient  was  struck  a  violent  blow  with  a  fist  on  the  left  eye  six 
days  before,  and  vision  was  lost  at  once.  Since  then  there  has 

been  at  times  severe  pain. 

RE  so 

rt-  ftp 

L.  E.,  perception  of  light ;  small  amount  of  blood  in  anterior 
chamber;  iridodonesis ;  traumatic  iridochorioiditis;  lens  dis- 


Sept.  6,  1890.] 

located  downward  and  backward  into  the  vitreous;  blood  in 
the  vitreous  ;  tension  +  2. 

On  May  28th  all  the  blood  was  gone  from  the  anterior 
diaraber,  and  most  of  the  signs  of  acute  inflammation  had  sub¬ 
sided  under  the  influence  of  cold  applications  and  atropine.  But 
:he  tension  remained  above  normal  and  there  was  at  times  con¬ 
siderable  pain,  and  the  removal  of  the  lens  was  deemed  advisa- 
jle.  The  patient  was  operated  upon  on  her  back  in  bed,  the 
ncision  being  the  usual  corneal  section  upward  made  with  the 
larrow  knife,  the  apex  being  in  clear  cornea.  A  small  bead  of 
atreous  presented  in  the  wound  on  the  withdrawal  of  the  knife, 
ind  the  speculum  was  removed  at  once  and  the  lids  closed. 
\fter  a  lapse  of  five  minutes  the  lids  were  opened  and  the  up- 
ier  lid  raised  by  a  wire  elevator.  Gentle  pressure  directly 
jack  ward  was  then  made  on  the  lower  portion  of  the  eyeball 
hrougb  the  lower  lid,  and  this  soon  brought  the  lens  into  the 
ield  of  the  pupil;  but  any  attempt  to  force  it  through  the  pupil 
oward  the  wound  increased  the  prolapse  of  the  vitreous.  The 
levator  was  then  given  to  an  assistant  to  hold,  and  a  wire 
poon  was  introduced  through  the  wound,  then  through  the 
>upil  and  behind  the  presenting  upper  margin  of  the  lens,  and 
be  latter  was  then  easily  removed  without  any  further  loss  of 
itreous.  The  eyeball  and  cul-de-sac  were  gently  irrigated,  and 
be  lids  closed  under  the  usual  antiseptic  dressings.  The  case 
:id  extremely  well,  no  unusual  reaction  of  any  kind  occurred, 
nd  the  patient  was  discharged  at  the  end  of  the  third  week 
nth  a  perfectly  quiet,  unirritated  eye.  The  vision,  however, 
ras  not  improved. 

Case  VI. — Moses  G.,  aged  forty-five,  June  22,  1885.  Patient 
as  always  been  very  myopic.  He  lost  the  sight  in  the  left  eye 
lxteen  years  before  by  a  blow  from  a  stick,  and  the  eye  was  in- 
amed  and  painful  for  several  months  after  the  injury.  Since 
hen  there  have  been  repeated  attacks  of  inflammation  in  the 
3ft  eye,  the  present  one  having  begun  one  week  ago,  and  the 
ight  of  the  fellow  eye  has  steadily  failed. 

R.  E.,  fingers  at  six  feet;  myopia;  cataract. 

L.  E.,  perception  of  light.  Lens  opaque,  dislocated  down¬ 
ward  and  backward  completely,  and  floating  freely  in  the 
itreous.  Divergent  squint;  marked  ciliary  injection;  ten- 
ion  +  1. 

The  patient  was  advised  to  have  the  eye  enucleated,  but 
ositively  refused  to  allow  it.  It  was  then  proposed  to  him 
bat  an  attempt  should  be  made  to  remove  the  lens,  and  to  this 
e  consented.  Owing  to  the  existence  of  pronounced  valvular 
nd  hypertrophic  disease  of  the  heart,  it  was  thought  unwise  to 
^minister  any  anaesthetic,  and  the  operation  was  done  with 
le  patient  seated  in  the  operating  chair.  The  usual  upward 
sction  was  made  in  the  cornea,  the  apex  being  in  clear  cornea, 
he  iris  prolapsed  at  once,  and  this  apparently  prevented  pro- 
ipse  of  the  vitreous.  Owing  to  the  complete  disorganization 
f  the  vitreous,  it  would  seem  as  if  any  pressure  from  below 
'ould  cause  extensive  prolapse  of  the  fluid  vitreous.  The  pro- 
ipsed  iris  was  therefore  carefully  replaced,  and  a  wire  spoon 
'as  then  gently  introduced  through  the  wound  and  pupil  and 
ehind  the  lens.  Slight  pressure  backward  against  the  lower 
art  of  the  eyeball  brought  the  lens  into  the  hollow  of  the  spoon, 
nd  it  was  then  readily  removed,  followed  by  a  prolapse  of  the 
is.  Gentle  irrigation  of  the  iris  and  eyeball  was  then  done; 
ie  iris  was  replaced,  and  a  pressure  bandage  applied  for.twenty- 
>ur  hours.  The  ciliary  irritation  and  injection  in  this  case  re- 
lained  for  nineteen  days  without  any  visible  improvement, 
fter  which  date  the  case  healed  in  the  usual  manner,  but  with 
icarceration  of  the  iris.  There  was,  of  course,  no  improve- 
lent  in  vision. 

Case  VII. — Francis  E.  R.,  aged  twenty-three,  November  2, 
885.  Patient  had  lost  the  sight  of  the  right  eye  twelve  years 


263 

before  by  a  blow  from  a  ball,  but  since  then  it  had  given  him 
no  trouble,  except  for  the  cosmetic  defect.  He  had  been  ad¬ 
vised  to  have  the  eye  removed,  but  his  father  was  unwilling  to 
permit  it.  At  times  the  opaque,  dense  white  lens  would  ap¬ 
pear  in  the  pupil  and  caused  an  unsightly  appearance. 

R.  E.,  perception  of  light;  cornea  somewhat  cloudy;  irido- 
donesis.  Lens  opaque,  dense  white  in  color,  and  floating  in  the 
clear  vitreous,  but  attached  at  one  point  downward  and  outward 
to  the  ciliary  processes.  Tension  normal ;  no  irritation. 

L.  E.,  §£ ;  normal  in  every  respect. 

The  operation  was  done  on  the  patient  while  seated  in  the 
operating  chair.  The  usual  upward  corneal  section  was  made 
with  the  narrow  knife,  the  apex  in  clear  cornea.  The  specu¬ 
lum  was  then  removed  and  the  upper  lid  lifted  away  from  the 
eye  by  a  wire  elevator.  Pressure  was  then  made  with  the  in¬ 
dex  finger  through  the  lower  lid  on  the  lower  part  of  the  eye¬ 
ball,  directly  backward,  and  the  lens  at  once  rose  and  came  for¬ 
ward  into  the  pupillary  area.  As  the  pressure  backward  was 
continued,  the  point  of  adhesion  downward  and  outward  rupt¬ 
ured,  and  the  lens  at  once  came  almost  entirely  out  of  the  cor¬ 
neal  wound  and  was  received  in  a  small  silver  spoon.  The  iiis, 
of  course,  prolapsed,  and  several  drops  of  vitreous  followed. 
The  iris  was  then  replaced  and  the  eye  antiseptically  treated 
and  bandaged.  There  was  no  reaction  and  the  wound  healed 
in  three  days  throughout,  without  any  prolapse  or  incarceration 
of  the  iris.  The  loss  of  vision,  of  course,  remained  unchanged. 

Case  VIII. — Nicholas  E.,  aged  fifty-six,  February  18,  1886. 
Patient  was  struck  in  the  right  eye  by  a  ball  three  weeks 
before. 

R.  E.,  ^-§-5- ;  irregular  and  immovable  pupil.  Partial  disloca¬ 
tion  of  the  lens  upward  and  inward;  lens  entirely  opaque; 
zonule  only  partially  ruptured  ;  iridodonesis. 

L.  E.,  t270^  ;  senile  chorioiditis  and  beginning  cataract. 

The  irritation  caused  by  the  blow  was  still  intense,  and,  as 
the  lens  was  entirely  opaque  and  partially  displaced,  it  was  de¬ 
cided  to  remove  it.  An  upward  section  was  made  entirely  in 
the  limbus,  and  then  an  iridectomy  was  made  upward  in  the 
usual  manner.  The  pressure  made  upon  the  eyeball  by  the 
fixation  forceps  had  caused  a  partial  rotation  of  the  displaced 
lens  upon  its  vertical  axis,  and  it  was  thought  that  it  might  be 
removed  in  its  capsule.  A  small  wire  spoon  was  introduced 
through  the  wound  and  coloboma  of  the  iris  on  the  temporal 
side  of  the  lens,  a  slight  lifting  motion  brought  the  lens  away 
in  its  capsule,  and  it  was  removed  from  the  eye  without  the  loss 
of  any  vitreous.  This  may  be  considered  a  fortunate  termina¬ 
tion  to  a  rather  dangerous  operation.  The  ultimate  vision  was 
somewhat  improved,  having  risen  from  to 

Case  IX. — Mrs.  Catharine  S.,  aged  forty-four,  July  12, 1886. 
This  patient  was  struck  on  the  right  eye  four  days  before  bj  a 
piece  of  wood,  and  had  lost  her  sight  at  once.  She  had  had 
failing  vision  in  both  eyes  for  some  years. 

R.  E.,  fingers  at  six  inches.  Iridodonesis  ;  blood  in  anterior 
chamber  and  vitreous;  lens  opaque  and  dislocated  into  the  vit¬ 
reous. 

L.  E.,  ^0T;  °ld  chorioiditis  and  opacities  in  lens  and  vit¬ 
reous. 

Nearly  three  months  later  the  right  eye  was  still  injected 
and  painful,  and,  as  she  refused  to  have  an  enucleation  done,  it 
was  thought  best  to  remove  the  lens. 

October  11th. — The  usual  upward  corneal  section  was  made, 
but,  owing  to  the  ciliary  injection,  an  iridectomy  was  not  done, 
on  account  of  the  possible  profuse  hfemorrhage.  Pressure  upon 
the  lower  portion  of  the  eye  directly  backward  threw  the  lens 
at  once  into  the  pupil,  and  at  the  same  time  caused  prolapse  of 
the  iris  and  the  loss  of  some  fluid  vitreous.  As  the  pressure, 
however,  kept  the  lens  presenting  in  the  pupil,  a  blunt  hook 


BULL ;  EXTRACTION  OF  LENSES  FROM  THE  VITREOUS. 


264 


HARDIE  AND  WOOD:  TWO  CASES  OF  NASAL  HYDRORRHEA.  [N.  Y.  Med.  Jouk., 


was  introduced  through  the  wound  and  behind  the  lens,  thrust 
into  the  lens,  and  the  latter  was  then  readily  removed  in  its  cap¬ 
sule,  without  any  more  vitreous  being  lost.  The  iris  was  then 
replaced  and  the  eye  dressed  and  bandaged  in  the  usual  way. 
The  irritation  and  injection  began  to  subside  on  the  fifth  day, 
and  the  patient  was  discharged  on  the  thirty-first  day,  with  a 
sound  central  pupil  and  vision  ^5,  with  some  prospect  of  still 
further  improvement. 

Case  X. — John  S.,  aged  twenty-seven,  February  7,  1887. 
This  patient  was  struck  on  his  left  eye  three  years  before  by  a 
clod  of  earth  and  lost  his  sight  at  once.  The  eye  was  inflamed 
and  painful  for  nearly  two  months,  but  since  then  has  given  him 
no  trouble. 

R.  E.,  +  ;  faint  corneal  macula. 

L.  E.,  V.  =  0.  Tension  —  1.  Discolored  and  fluttering  iris; 
pupil  central ;  lens  opaque  and  floating  freely  in  vitreous,  at¬ 
tached  by  a  single  narrow  band  downward  to  the  ciliary  pro¬ 
cesses. 

March  If,  1887. — The  usual  upward  corneal  section  was  made, 
the  patient  being  seated  in  the  operating  chair.  As  the  knife 
completed  the  section  and  the  aqueous  escaped,  the  lens  pre¬ 
sented  in  the  pupil,  the  upper  margin  nearly  touching  the  cor¬ 
nea.  A  blunt  hook  was  at  once  introduced,  engaged  in  the 
lens,  and  the  latter  was  removed  in  its  capsule  without  the 
slightest  difficulty.  The  prolapsed  iris  replaced  itself  at  once, 
and  not  a  single  untoward  symptom  appeared  in  the  course  of 
the  case,  the  patient  being  discharged  on  the  fifteenth  day. 

Case  XI. — Daniel  F.,  aged  sixty-four,  April  4,  1887.  This 
patient  was  struck  one  month  ago  on  the  right  side  of  the  nose 
and  superior  orbital  margin  of  the  right  eye  with  a  stone.  The 
right  eye  became  inflamed  at  once  and  has  remained  so  ever 
since,  with  frequent  attacks  of  very  severe  pain. 

R.  E.,  ;  marked  ciliary  injection ;  tension  +  1 ;  iris  di¬ 

lated  and  discolored;  very  shallow  anterior  chamber;  lens 
opaque  and  dislocated  into  the  vitreous;  condition  glaucoma¬ 
tous. 

L.  E.,  f $  ;  slight  opacity  at  periphery  of  lens;  normal  fun¬ 
dus. 

April  6th. — Operation  for  removal  of  the  lens.  Corneal  sec¬ 
tion  upward  entirely  in  limbus.  Broad  iridectomy  upward,  fol¬ 
lowed  by  profuse  haemorrhage,  which  filled  the  anterior  chamber 
and  checked  the  further  steps  of  the  operation  for  a  time.  After 
the  haemorrhage  had  been  stopped  by  cold  applications  and  part 
of  the  blood  had  been  removed  from  the  anterior  chamber,  the 
lens  was  found  tilted  forward,  its  upper  margin  lying  in  the 
pupil  and  resting  against  the  cornea.  It  was  at  once  removed 
in  its  capsule  with  a  small  spoon  and  with  no  loss  of  vitreous. 
The  healing  process  in  this  case  was  very  slow,  and,  although 
the  wound  was  clean  and  there  was  no  prolapse  of  the  vitreous, 
the  wound  did  not  close  for  nearly  three  weeks.  Vision  im¬ 
proved  somewhat,  having  risen  to 

Case  XII. — Frederick  G.,  aged  fifty-six,  February  19,  1888. 
This  patient  received  a  blow  on  the  right  eye  from  a  hard  rub¬ 
ber  ball  in  October,  1887,  and  lost  the  sight  of  this  eye  at  once. 
The  sight  of  the  other  eye  had  previously  markedly  failed  from 
the  growth  of  a  cataract. 

R.  E.,  perception  of  light ;  iridodonesis ;  lens  dislocated  en¬ 
tirely  into  the  vitreous  and  lay  tilted  forward,  its  upper  margin 
resting  on  the  iris  and  just  appearing  at  the  pupillary  edge;  eye 
quiet ;  tension  normal. 

L.  E.,  ;  cataract. 

February  21+th. — The  patient  was  seated  in  the  operating 
chair  and  the  usual  upward  corneal  section  made,  the  apex  in 
clear  cornea.  There  being  no  prolapse  of  the  vitreous,  a  delicate 
blunt  hook  was  introduced  through  the  wound,  passed  through 
.the  pupil  and  behind  the  lens,  and  by  a  single  twist  penetrated 


the  capsule  and  caught  the  lens.  The  lens  was  then  drawn 
through  the  pupil  and  out  of  the  lips  of  the  wound,  inclosed  in 
its  capsule,  and  without  any  loss  of  vitreous.  The  wound  healed 
readily  under  the  usual  antiseptic  dressings,  and  without  either 
prolapse  or  incarceration  of  the  iris.  There  was  no  improve¬ 
ment  of  the  vision,  and  the  vitreous  remained  cloudy  as  long  as 
the  patient  wTas  under  observation. 

Case  XIII. — Mary  O’B.,  aged  thirty,  February  25,  1889. 
Patient  was  struck  on  the  right  eye  six  months  ago  by  a  blow 
from  a  fist  and  lost  the  sight  at  once.  She  had  always  been 
quite  myopic,  but  had  never  worn  glasses. 

R.  E.,  perception  of  light;  pupil  irregularly  oval  in  shape 
and  displaced  inward  toward  the  nose  ;  iridodonesis;  lens  dis¬ 
located  downward  into  the  vitreous;  tags  of  broken  adhesions 
on  the  posterior  surface  of  sphincter  margin  of  iris ;  floating 
opacities  in  vitreous  ;  tension  normal. 

L.  E.,  -gfo,  with  sph.  —  D.  2‘50  =  ;  large  annular  poste¬ 

rior  staphyloma  and  patches  of  chorio-retinitis  disseminata. 

An  upward  corneal  section  was  made,  the  apex  in  clear  cor¬ 
nea.  The  speculum  was  then  withdrawn  and  the  upper  lid  held 
away  from  the  eye  by  an  elevator.  Pressure  was  then  made 
on  the  lower  part  of  the  sclera  directly  backward  by  the  finger 
against  the  lower  lid.  The  iris  prolapsed  at  once,  and  the  lens 
appeared  in  the  field  of  the  pupil.  Every  attempt  at  further 
pressure  caused  prolapse  of  the  vitreous  without  advancing  the 
lensin  the  slightest  degree,  and  this  method  was  therefore  aban¬ 
doned.  Keeping  the  lens  in  the  field  of  the  pupil  by  moderate 
pressure  below,  a  delicate  wTire  spoon  was  introduced  through 
the  corneal  wound  and  behind  the  plane  of  the  iris,  gently  in¬ 
sinuated  behind  the  lens,  and  then  withdrawn,  bringing  the  lens 
in  its  capsule  with  it.  The  iris  was  then  replaced  and  a  drop  of 
a  solution  of  eserine  was  instilled,  and  the  eye  dressed  and  ban¬ 
daged  in  the  usual  way.  There  was  but  little  vitreous  lost,  and 
the  eye  healed  with  very  little  reaction,  but  with  a  rather  ex¬ 
tensive  incarceration  of  iris  in  the  inner  lips  of  the  wound. 
There  was  no  improvement  in  vision. 


TWO  CASES  OF  NASAL  HYDRORRHCEA  * 

By  T.  MELVILLE  HARDIE,  B.  A.,  M.  B., 

PROFESSOR  OF  RIIINOLOGY  AND  LARYN OOLOGY  IN  THE  POST-GRADUATE 
MEDICAL  SCHOOL  OF  CHICAGO. 

WITH  A  REPORT  ON  THE  EYE  SYMPTOMS , 

By  CASEY  A.  WOOD,  M.  D.,  C.  M., 

INSTRUCTOE  IN  OPHTHALMOLOGY  AND  OTOLOGY  IN  THE  SCHOOL. 

Case  I. — Mary  S.,  aged  forty-three,  German,  married,  has  one 
child,  aged  fourteen,  healthy.  Until  nine  years  ago,  when  she 
came  to  America,  she  had  always  enjoyed  good  health.  After 
living  for  two  weeks  in  a  basement,  in  February,  1881,  she  devel¬ 
oped  a  cough,  which  became  asthmatic  some  time  between  March 
and  July.  She  had  had  occasional  attacks  of  asthma  ever  since, 
particularly  in  cold,  damp  weather.  In  July  she  received  what 
her  medical  attendant  told  her  was  a  sunstroke,  which  confined 
her  to  bed  for  some  time.  Some  pills  prescribed  caused  a  buzz¬ 
ing  in  the  ears  with  deafness  for  several  days  (quinine  ?),  and 
during  the  severe  headaches,  usually  vertical,  from  which  she 
has  suffered  at  intervals  since  that  time  the  deafness  occasion¬ 
ally  recurs.  In  August  or  September,  1881,  a  watery  discharge 
from  the  nose  commenced,  the  conjunctiva  being  reddened  and 
lacrymation  profuse  at  the  same  time.  The  discharge  lasted 
for  three  or  four  days,  stopped  for  a  mdnth,  came  on  again  for 
a  few  days,  and  again  intermitted.  Similar  periods  of  discharge 


*  Read  before  the  Chicago  Medical  Society,  July  7,  1890. 


Sept.  6,  1890.] 


BARDIE  AND  WOOD:  TWO  CASES  OF  NASAL  BYDRORRHOEA. 


265 


and  absence  of  discharge  alternated  continuously  until  about 
two  years  and  a  half  ago,  since  which  time  the  discharge  has 
occurred  daily,  usually  for  three  or  four  hours  in  the  morning. 
The  patient  reports  that  it  begins  just  as  soon  as  she  rises  in 
the  morning,  whether  that  be  at  4.30  or  6.30.  Excepting  on 
one  or  two  occasions,  no  discharge  has  been  noticed  at  night. 
She  can  not  remember  whether  the  discharge  occurred  on  days 
on  which  she  was  confined  to  bed.  Has  never  attempted  to 
stop  the  discharge  by  lying  down  in  the  morning  after  the  com¬ 
mencement  of  the  flow.  As  a  usual  thing  the  fluid  comes  from 
both  nostrils  (sometimes  from  one),  and  drop  by  drop.  Shortly 
before  stopping  for  the  day  the  clear  water,  whitish  and  opal¬ 
escent  when  in  quantity,  becomes  thicker  and  viscid,  resem¬ 
bling  ordinary  mucus.  Sneezing  and  formication  are  somewhat 
frequent  accompaniments  of  the  discharge,  but  they  are  by  no 
means  constant,  nor  does  the  formication  appear  to  precede  the 
discharge,  as  one  might  expect.  It  quite  as  frequently  follows. 
The  patient  avers  that  this  symptom  has  been  more  annoying 
since  treatment  was  begun.  While  the  asthma  is  ordinarily 
troublesome  only  in  cold  and  damp  weather,  she  is  not  sure  that 
the  hydrorrhcea  is  appreciably  influenced  by  matters  meteoro¬ 
logical.  Has  not  noticed  that  it  is  worse  on  damp  days.  Thinks 
it  is  as  bad  in  July  as  in  November.  It  varies  in  amount  from 
time  to  time,  but  without  reason,  so  far  as  the  patient  could  de¬ 
termine. 

Bistory  since  coming  under  Observation. — In  October,  1889, 
“  could  not  see  to  sew,”  and  attended.  Dr.  Coleman’s  eye  clinic, 
where  glasses  were  prescribed.  She  was  then  referred  to  me. 
Examination  of  her  nose  showed  slight  posterior  hypertrophy 
of  the  right  inferior  turbinated  and  a  dropsical  condition  of  the 
middle  turbinated  bodies  right  and  left.  Ridge  on  septum  high 
up  on  left  side.  No  polypi.  Sense  of  smell  unimpaired.  No 
marked  departure  from  normal  sensibility  of  nasal  mucous  mem¬ 
brane  as  tested  by  probe.  Satisfactory  posterior  rhinoscopic 
view  not  obtainable,  tongue  depressor  causing  gagging.  Pa¬ 
tient  says  this  is  produced  by  holding  anything  ( e .  g.,  candy)  in 
the  mouth  for  a  minute  even,  but  she  has  no  such  sensation 
when  masticating  and  eating  ordinary  food. 

General  health  not  very  good.  Burning  pain  in  epigastrium 
after  eating  not  infrequent.  Painful  and  hyperaesthetic  spot 
over  the  left  eighth  rib  in  front,  which  first  became  painful  five 
-years  ago.  No  neuralgias.  Is  being  treated  in  gynaecological 
clinic  for  laceration  of  the  cervix.  The  patient  has  been  treated 
during  the  past  ten  years  by  a  sufficient  number  of  regular 
practitioners  and  quacks,  but  without  marked  benefit.  The  re¬ 
moval  by  snare  of  portions  of  the  middle  turbinated  bodies, 
with  the  internal  administration  of  zinc  oxide  (gr.  |)  and  bella¬ 
donna  extract  (gr.  £),  markedly  diminished  the  flow  for  a  time. 
Treatment  was  begun  on  the  10th  of  April,  with  good  results 
until  the  6th  of  May,  when  a  day  and  night  discharge  com¬ 
menced.  This  lasted  until  the  9th  of  May,  the  patient  getting 
but  little  sleep  in  the  interval.  The  nasal  discharge  was  ac¬ 
companied  by  a  flow  from  the  eyes  and  a  severe  headache.  On 
the  10th  and  11th  of  May  she  had  asthma;  there  was  no  dis¬ 
charge  or  headache.  She  w'as  then  almost  free  from  any  un¬ 
pleasant  symptoms  until  the  3d  of  June,  since  which  time  she 
has  had  an  almost  daily  recurrence  of  the  discharge  until  the 
present  time  (7th  of  July),  with  asthma  and  headache  from  time 
to  time.  Patient’s  attendance  has  been  very  irregular  since  the 
beginning  of  June. 

In  view  of  the  not  infrequent  association  of  optic-nerve 
atrophy  with  nasal  hydrorrhoea  (seven  cases  are  recorded), 
a  careful  examination  of  the  eyes  was  made  at  my  request 
by  Dr.  Casey  Wood,  whose  report  is  appended. 

The  fluid  had  a  specific  gravity  of  l-006,  contained 


chlorides,  traces  of  mucin,  a  few  cells  from  the  olfactory 
region,  and  an  occasional  flat  epithelial  cell.  It  was  feebly 
alkaline  in  reaction. 

Case  II. — I  am  indebted  to  Dr.  Lackner  for  the  discovery  of 
the  case  whose  history  I  shall  now  give. 

Mrs.  K.  K.,  German,  aged  forty-two,  married,  two  children, 
gave  a  history  of  profuse  watery  discharge  from  the  nose  which 
has  lasted  for  ten  years.  Six  months  before  the  discharge 
began  the  patient  suffered  from  “malaria”  when  living  in  a 
basement  tenement.  The  flow  was  at  the  beginning  not  very 
profuse,  but  in  a  short  time  was  troublesome  throughout  the 
day  and  frequently  all  night  as  well.  She  was  often  wakened 
by  it,  and  it  was  occasionally  so  profuse  as  to  prevent  sleep  alto¬ 
gether.  The  intermissions  have  been  rare  and  of  short  dura¬ 
tion.  Patient  asserts  that  the  dropping  has  never  ceased  for 
twenty-four  hours  during  the  ten  years,  the  amount  of  the 
discharge  being  about  the  same  summer  and  winter.  Upper 
lip  swollen  and  excoriated.  Watery  discharge  from  eyes  with 
occasional  conjunctival  injection.  Fundus  normal,  no  optic- 
nerve  atrophy,  and  no  contraction  of  visual  fields.  Dr.  Wood 
kindly  made  the  examination  of  the  eyes  in  this  case  also.  A 
troublesome  and  prominent  symptom  was  sneezing,  “  forty  or 
fifty  times  a  day  ”  being  the  usual  thing.  Unfortunately,  the 
fluid  was  not  examined,  the  discharge  ceasing  before  the  patient 
followed  instructions  in  the  matter  of  collecting  it.  The  patient 
does  not  know  the  amount  of  the  daily  discharge,  as  she  never 
collected  it,  but  the  constant  dropping  interfered  very  much 
with  her  work.  Examination  of  the  nose  showed  polypi  right 
and  left,  and  polypoid  thickening  of  both  middle  turbinated 
bodies. 

Treatment  was  begun  February  25th.  Polypi  removed. 

March  8th. — -Marked  lessening  of  discharge  reported.  Re¬ 
maining  polypi  removed. 

12th. — Discharge  very  slight.  No  sneezing. 

May  6th. — The  same.  Hypertrophy  of  right  middle  turbi¬ 
nated  snared. 

17th. — No  discharge.  No  sneezing.  Snaring  left  middle 
turbinated.  Patient  reported  absence  of  nasal  symptoms  on 
May  22d,  June  5th,  12th,  and  19th.  To  report  again  in  one 
month. 

The  chief  interest  in  the  discussion  of  hydrorrhoea  cen¬ 
ters  in  its  aetiology  and  in  the  fact  of  the  occasional  pres¬ 
ence  of  marked  eye  complications.  The  literature  of  the 
subject  is  by  no  means  extensive ;  about  twenty-five  cases 
are  reported,  and,  as  in  a  number  of  instances  for  some 
reason  or  other  an  examination  of  the  nose  was  not  made, 
it  is  perhaps  hardly  possible  as  yet  to  formulate  a  theory 
applicable  to  all  cases.  In  fact,  a  perusal  of  the  histories 
of  cases  in  which  a  continuous  discharge  of  water  from  the 
nose  was  a  symptom  will  compel  one  to  conclude  that  it 
may,  like  atrophy  of  the  optic  nerve,  be  produced  by  a 
great  many  different  conditions.  One  was  evidently  due 
to  fracture  of  the  base  of  the  skull  (Vieusse’s  case  *)  ;  it  is 
an  occasional  accompaniment  of  general  anasarca  (Rees  f ) ; 
of  meningitis  (Paget  J);  of  trifacial  paralysis  (Altliaus  #) ; 
of  hydrocephalus  internus  (Leber,  ||  who  thought  there 
had  been  bone  absorption  from  pressure  with  escape  of  the 

*  Gaz.  hebd.,  1879,  No.  19,  p.  298. 

|  London  Med.  and  Sury.  Journal ,  1834,  vol.  iv,  p.  823. 

\  Transactions  of  the  Clinical  Society  of  London,  1879,  p.  43. 

#  British  Medical  Journal ,  1878,  vol.  ii,  p.  831. 

|  Graefe’s  Archiv,  vol.  xxix,  i,  273. 


266 _ HARD  IE  AND  WOOD:  TWO  CASES  OF  NASAL  HYDRORRHOEA.  [N.  Y.  Med.  Jouh., 

cerebrospinal  fluid  from  tbe  opening  thus  formed) ;  while 


in  some  cases  (Priestley  Smith’s,*  Nettlesliip’s  f)  the  brain 
symptoms  appear  to  have  been  very  marked.  In  two  cases, 
on  the  other  hand,  reported  by  Bosworth,  J  to  whose  valua¬ 
ble  paper  on  the  subject  I  have  to  acknowledge  my  indebt¬ 
edness,  there  was  at  the  beginning  apparently  no  visible  nasal 
or  other  disease,  and,  presuming  the  examinations  to  have 
been  accurate,  the  affection  can  not  very  well  have  been 
anything  but  a  paresis  of  the  sympathetic  vaso-motor  nerves, 
as  Bosworth  concludes.  A  somewhat  novel  idea  as  to  the 
aetiology  of  this  affection  has  been  suggested  by  Mules,* 
who  reports  three  cases  in  support  of  his  theory  that  “the 
dropping  is  due  to  overdistended  lymph  vessels  of  the 
pituitary  membrane,  which  by  their  bursting  cause  fistulous 
openings.”  Briefly  they  were  :  1.  A  girl  who  suffered  from 
a  discharge  of  fluid  from  the  umbilicus  for  six  months;  no 
fistula,  this  discharge  being  followed  by  a  similar  flow  for 
four  weeks  from  under  right  upper  eyelid  at  frequent,  though 
irregular,  intervals  during  day  and  night.  Stimulation  of 
the  lacrymal  gland  produced  no  effect.  2.  A  boy  who  had 
congenital  lympho-angeioma  of  conjunctiva.  3.  A  woman 
in  whom  a  lympho-angeioma  just  inside  sphincter  ani 
caused  diarrhoea,  which  alternated  with  watery  discharge 
from  fistulous  openings  in  tumor.  In  six  weeks  after  liga¬ 
tion  of  the  tumor  an  apoplectoid  attack  occurred  which 
caused  permanent  paresis  of  one  side. 

We  have  not  far  to  look  to  see  Mules’s  explanation  of  the 
discharge  from  eye  and  nose,  but  are  as  far  as  ever  from  know¬ 
ing  the  cause  of  the  enlarged  lymph  tubes.  As  a  corollary 
to  his  theory,  Mules  concludes  that  the  coexistence  of  optic- 
nerve  atrophy  with  an  abnormal  watery  secretion  from  eye 
and  nose  is  merely  a  coincidence.  He  explains  the  occur¬ 
rence  of  the  atrophy  by  suggesting  that  it  may  sometimes 
be  due  to  the  wasting  character  of  the  general  disease,  of 
which  it  and  hydrorrhoea  happen  to  be  symptoms.  In 
some  cases  of  hydrorrhoea  there  is  no  atrophy,  just  as  in 
other  cases  of  atrophy  there  is  no  hydrorrhoea.  Before, 
however,  any  conclusion  can  be  arrived  at  respecting 
Mules’s  theory,  more  exact  knowledge  with  regard  to  the 
distribution  of  the  nasal  lymphatic  system  is  required.  In 
my  opinion  the  affection  is,  with  few  exceptions,  immedi¬ 
ately  dependent  upon  a  vaso-motor  paresis,  however  that 
may  be  brought  about.  For  this  Bosworth  has  made  out 
a  good  case.  With  some  of  his  conclusions,  however,  it  is 
difficult  to  coincide.  I  fail  to  see,  for  example,  why  the 
general  resemblance  of  nasal  hydrorrhoea  in  many  particulars 
to  hay  fever  should  lead  us  to  assert  an  atmospheric  factor 
in  its  causation.  In  my  first  case  the  appearance  of  the 
interior  of  the  nose  would  have  been  consistent  with  the 
hypothesis  that  there  was  a  distention  of  the  mucous 
membrane  by  lymph,  or  that  we  had  to  do  with  a  lymph- 
angeioma.  The  fluid  could  be  seen  to  ooze  from  the  mu¬ 
cous  membrane  of  the  upper  part  of  the  septum,  and  from 
the  swollen  opalescent  middle  turbinated  body  opposite. 

*  Ophthalmic  Review ,  London,  vol.  ii,  p.  4. 

f  Ibid .,  p.  1. 

%  Treatise  on  Diseases  of  the  Nose  and  Throat ,  New  York,  1889 
vol.  i,  pp.  261,  262. 

*  Transactions  of  the  Ophthalmic  Congress,  Heidelberg,  1888. 


The  discharge  did  not  come  from  a  polypus,  so  far,  at  any 
rate,  as  concerned  that  oozing  from  the  septum  ;  nor  was 
the  opalescent  polypoid-looking  middle  turbinated  a  poly¬ 
pus.  It  became  much  smaller  upon  use  of  cocaine  and 
pressure  with  a  probe.  The  theory  that  the  discharge  is 
invariably  connected  with  polypi  has  been  several  times 
shown  to  be  incorrect.  Cerebral  symptoms  likewise  are 
frequently  absent,  as  in  Case  II. 

An  interesting  occasional  accompaniment  is  asthma,  as 
in  Case  I.  So  far  as  I  have  seen,  it  has  not  been  noted  as 
a  complication  of  other  cases  of  nasal  hydrorrhoea,  but  the 
frequency  of  its  association  with  hay  fever,  and  the  general 
resemblance  between  the  latter  and  such  apparently  un¬ 
complicated  cases  of  nasal  hydrorrhoea  as  the  two  reported 
by  Bosworth,  would  at  any  rate  prevent  our  surprise  at 
such  a  complication.  It  will  be  noticed  that  the  patient 
reports  that  the  asthma  had  troubled  her  chiefly  during  the 
winter  months,  and  that  its  onset  did  not,  so  far  as  she  had 
noticed,  affect  the  nasal  discharge.  My  notes  of  the  case 
since  it  came  under  my  observation  do  not  exactly  cor¬ 
roborate  the  patient’s  statement;  for  instance,  during  the 
latter  half  of  April  the  discharge  was  very  slight  and  asthma 
absent,  although  headache  was,  perhaps,  worse  than  usual 
during  a  part  of  the  time,  but  on  May  6th  (when  the  dis¬ 
charge  had  been  absent  for  ten  days)  began  one  of  the 
worst  of  her  attacks,  which  was  accompanied  by  headache. 
This  gave  way  on  the  10th  and  11th  of  May  to  asthma; 
then,  on  the  12th  to  the  15th  of  May,  a  very  slight  discharge 
occurred  in  the  mornings,  followed  again  on  the  16th  by 
slight  asthmatic  attacks.  After  that,  as  reported  before, 
there  was  absence  of  both  unpleasant  symptoms  until  the 
3d  of  June.  There  was  then  apparently  an  alternation 
between  the  attacks  of  hydrorrhoea  and  of  asthma,  but  as 
this  does  not  correspond  exactly  with  the  patient’s  recol¬ 
lection  of  the  previous  course  of  the  disease,  and  as  the 
number  of  the  observations  is  so  small,  I  shall  merely 
record  the  fact  without  further  comment.  I  may  say  that 
I  have  in  the  present  history  neglected  to  discuss  the  re¬ 
lation  which  the  so-called  neurotic  temperament  bears  to 
the  disease.  One  reason  for  my  omission  may  be  found  in 
the  following  facts:  (1)  Case  I  was  that  of  an  individual 
who  would  nowadays  be  denominated  neurotic ;  (2)  Case  II 
would  not  in  my  opinion  be  so  named.  The  deduction  is 
obvious. 

W  hile  the  presence  of  asthma  was  perhaps  the  most 
noteworthy  feature  of  the  first  case,  the  second  is  worthy 
of  record  for  a  different  reason.  In  it  we  had  the  two 
facts  (1)  that  polypi  were  present  along  with  the  discharge, 
which  is  by  no  means  unusual ;  and  (2)  that  treatment 
directed  to  the  removal  of  these  polypi,  and  of  those  por¬ 
tions  of  the  middle  turbinated  in  which  there  was  poly¬ 
poid  degeneration,  was  efficient  in  stopping  the  discharge, 
and  that,  too,  in  cold  and  wet  weather — a  very  unusual 
termination  to  a  long-standing  case  of  nasal  hydrorrhoea. 

I  think  we  may  conclude,  from  a  careful  reading  of  the 
cases  recorded,  that  nasal  hydrorrhoea  is  not  a  disease  per 
se,  but  a  symptom  of  many  pathological  lesions,  and  that 
the  prognosis  and  treatment  of  each  case  must  be  deter¬ 
mined  by  conditions  aside  in  the  majority  of  instances 


Sept.  6,  1890.] 


HARD  IE  AND  WOOD:  TWO  OASES  OF  NASAL  H  YD  R  ORRHCEA . 


267 


from  the  mere  fact  that  there  is  a  flow  of  water  from  the 

nose. 

M.  S.  has  complained  of  weakness  of  sight,  chiefly  during 
the  pest  eight  months.  Last  November  glasses  were  pre¬ 
scribed  for  her,  which,  however,  she  did  not  think  enabled  her 
to  see  any  better.  She  suffers  from  bilateral  epiphora,  which 
is  usually,  though  not  always,  worse  in  the  morning.  It  then 
amounts  to  a  continual  flow  from  both  eyes  of  a  fluid  resem¬ 
bling  tears,  and,  generally  speaking,  is  worse  when  the  discharge 
from  the  nose  is  worse.  During  the  daytime,  also,  when  the 
nasal  flow  is  lessened  or  stops  altogether,  there  is  very  little 
lacrymation.  The  flow  of  tears  has  never  produced  excori¬ 
ation  of  the  lids.  In  November  last  V.  R.  =  ;  V.  L.  =  if. 

She  was  then  wearing  R.  +  3  D.,  and  L.  +  1‘75  D.,  which  on 
trial  wrere  found  not  to  improve  the  visual  acuity.  Both 
adduction  and  abduction  were  weak,  the  former  showing  at 
one  trial  a  strength  of  4°,  at  another  8°.  The  interni  muscles 
could  overcome  a  prism  of  19°-23°  only.  At  that  time  she 
complained  of  photophobia,  and  of  dark  spots  in  front  of  her 
eyes— in  front  of  the  right  eye  especially — and  she  thinks  that 
for  a  time  at  least  she  was  so  blind  that  she  could  barely  dis¬ 
cern  large  objects.  Then,  for  a  while,  her  vision  improved, 
but  it  has  never  since  been  normal,  nor  is  it  possible  by  cor¬ 
recting  her  refractive  erro’r  (compound  hyperopic  astigmatism) 
to  greatly  improve  the  visual  acuity.  The  conjunctivas,  both 
ocular  and  palpebral,  are  injected,  but  there  is  no  purulent  or 
muco-purulent  secretion  from  the  lids,  and  they  do  not  adhere 
in  the  mornings.  The  last  examination  made  shows  a  marked 
improvement  (in  the  right  eye  particularly),  as  V.  R.  =  f-g-, 
and  V.  L.  =  f-g,  both  with  correction.  The  puncta  lacrimalia 
are  patent  and  in  normal  position.  There  is  no  affection  of 
either  lacrymal  sac,  and  no  indication  of  obstruction  of  the 
nasal  duct.  The  ocular  excursions  are  of  normal  extent  on 
both  sides  and  in  all  directions.  Pupils  are  both  active  to 
light  and  accommodation.  Tension  normal  in  both  eyes.  The 


RIGHT  EYE. 


>atient  does  not  now  complain  of  scotomata,  only  of  weakness 
>f  vision  and  of  inability  to  read  or  to  do  near  work  with  com- 
ort.  These,  and  the  other  ocular  symptoms,  have  not  to  any 
ippreciable  degree  been  relieved  by  atropine  or  by  a  full  cor- 
ection  of  her  refractive  error.  A  further  examination  of  the 
a8e  reveals  the  fact  that  she  is  not  color-blind,  and  that  she 


has  no  color  scotomata.  Both  fields  of  vision  for  white,  taken 
by  means  of  a  McHardy  perimeter  with  a  5  mm.  square  object, 
are  shown  in  the  charts.  These  charts  were  carefully  worked 
out  several  times,  and  the  contractions  were  found  to  be  fairly 
regular  and  symmetrical.  This  regularity  is  especially  seen  in 
the  left  eye,  as  the  right  field  is  more  restricted  toward  the 
nasal  side  than  was  found  to  be  the  case  in  the  left  eye.  The 
field  for  red  is  correspondingly  limited  in  both  eyes. 


75  90  105 


LEFT  EYE. 


The  fundus  appearances  are  interesting,  although  there  is 
nothing  abnormal  outside  of  the  papillae.  The  right  disc  is 
deeply  and  centrally  excavated,  and  the  blood-vessels  come  for¬ 
ward  in  a  normal  manner,  but  the  whole  papilla  is  very  slightly 
paler  than  it  should  be.  On  the  nasal  border  of  the  nerve  there 
is  a  narrow,  yellowish-white  band,  forming  in  that  situation 
the  rim  of  the  physiological  cup,  and  occupying  about  one  third 
of  its  circumference.  A  somewhat  similar  appearance  is  to  be 
seen  in  the  left  disc.  Here  there  is  no  general  pallor,  and  the 


DIAGRAMS  OF  OPTIC  DISCS. 


normal  cupping  is  shallow.  At  its  bottom,  however,  the  stip¬ 
pling  of  the  cribriform  fascia  is  to  be  seen.  A  band,  yellow¬ 
ish-white  in  appearance,  longer  than  but  quite  as  narrow  as 
i;hat  visible  in  the  right  disc,  occupies  the  lower  outer  aspect  of 
the  left  papilla.  It  does  not  extend,  as  in  the  former  case,  to 
the  edge  of  the  excavation  toward  the  nerve  center,  nor  does 
it  reach  in  part  of  its  course  the  outer  rim  of  the  disc.  I  have 
endeavored  to  illustrate  this  condition  of  things  by  the  above 
rough  diagrams. 


268 


VAKDER  POEL:  MYXOMA  OF  THE  EPIGLOTTIS. 


[N.  Y.  Med.  Joub., 


I  have  seen  a  number  of  similar  whitish  areas  in  pa¬ 
pillae  of  eyes  otherwise  normal  which  were  not  accompanied 
by  deterioration  of  vision  or  contraction  of  the  field  of 
vision,  and  I  consequently  hesitate  to  regard  this  picture  as 
•evidence  of  atrophic  changes,  however  limited,  of  the  optic 
nerve  itself,  and  yet  they  are  certainly  not  the  pale  spots 
on  the  surface  of  the  disc  which  one  sometimes  sees  due 
to  variations  in  the  light  reflex  from  an  uneven  papillary 
surface. 

Whether  the  limited  decolorization  of  the  discs  is  evi¬ 
dence  of  a  retro-bulbar  neuritic  process  it  would  be  difficult 
to  say.  The  history  of  an  attack,  occurring  six  months 
before  and  accompanied  by  absolute  central  scotomata  and 
great  loss  of  visual  acuity,  certainly  points  in  that  direc¬ 
tion,  but,  in  the  absence  of  more  positive  proof,  one  can 
not  very  well  decide.  If  such  has  been  the  case,  it  is  not 
easy  to  say  why,  with  some  remaining  impairment  of  vision, 
there  are  no  central  scotomata,  not  even  for  colors. 

Notwithstanding  all  treatment,  the  ocular  symptoms 
since  the  date  of  writing  the  foregoing,  the  epiphora  espe¬ 
cially,  are  as  pronounced  as  ever. 


A  CASE  OF  MYXOMA  OF  THE  EPIGLOTTIS.* 
By  S.  O.  VANDER  POEL,  M.  D. 

The  rarity  with  which  myxomata  present  themselves  in 
the  neighborbood  of  the  larynx,  and  the  fact  that  but  few 
cases  have  been  placed  on  record,  have  induced  me  to  bring 
before  you  for  consideration  the  study  of  this  form  of  be¬ 
nign  growth,  and  the  recital  of  a  case  which  has  recently 
come  under  my  observation. 

The  patient,  a  German,  fifty-four  years  of  age,  by  occupa¬ 
tion  a  blacksmith,  was  perfectly  well  until  seven  months  ago, 
when  he  began  to  notice  failing  strength  and  loss  of  flesh. 
Some  wreeks  later  his  throat  commenced  to  annoy  him  ;  there 
was  difficulty  in  deglutition,  with  the  sensation  of  a  foreign  body 
in  the  throat.  As  he  expressed  it,  “an  obstruction  to  the  pas¬ 
sage  of  food,  and  a  tendency  for  it  to  go  the  wrong  way.”  _At 
no  time  was  any  actual  pain  complained  of.  Talking  was  an 
effort  and  was  carried  on  with  fatigue,  amounting  at  times  to 
actual  distress.  Only  occasionally  was  there  hoarseness,  and 
then  after  prolonged  use  of  the  voice.  It  then  might  more 
properly  be  described  as  a  feeble  whisper  which  it  was  difficult 
to  understand.  Occasionally  the  peculiar  staccato  inflection  was 
noticeable.  At  night  there  were  suffocative  attacks,  when  he 
would  awaken  suddenly  from  his  sleep  with  the  feeling  of  great 
apprehension  and  the  sensation  of  strangling.  Of  late  these 
attacks  have  been  more  frequent,  and  would  seem  to  be  pro¬ 
duced  by  some  mechanical  obstruction  to  the  entrance  of  air. 
When  he  first  came  under  observation  at  the  Throat  Depart¬ 
ment  of  the  Manhattan  Eye  and  Ear  Hospital  on  the  17th  of 
March  last  he  was  emaciated,  and,  from  a  large  and  powerful 
man,  had  become  a  weakly  invalid,  who  walked  with  effort 
and  apparent  distress.  This  condition  he  ascribed  to  the  small 
amount  of  nourishment  he  had  been  able  to  take  of  late,  as  he 
could  swallow  but  liquid  food,  and  that  in  small  quantities.  A 
harassing  cough  had  been  present  for  some  months,  and  consid¬ 


*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


erable  difficulty  was  experienced  in  expectorating  the  mucus 
which  gathered  in  the  throat.  He  complained  of  an  intermit¬ 
tent  pain  in  the  cardiac  region.  Physical  examination  disclosed 
a  loud  blowing  mitral  murmur  heard  over  the  entire  sternum, 
with  dilatation  of  the  left  ventricle.  The  lungs  were  emphy¬ 
sematous,  with  evidence  of  chronic  bronchitis.  Respirations,  28 
to  30  ;  pulse,  90.  Rhinoscopic  examination  revealed  some  slight 
hypertrophic  rhinitis,  the  left  middle  turbinated  body  being  in 
contact  with  the  septum,  together  with  an  ecchondroma  of  the 
septum  of  the  right  side,  but  nasal  respiration  was  not  mate¬ 
rially  interfered  with.  With  the  laryngeal  mirror  a  tumor  of 
a  yellowish-red  color,  translucent,  of  about  the  size  of  a  horse- 
chestnut,  was  seen  springing  from  the  lingual  side  of  the  epi¬ 
glottis;  the  surface  was  glistening,  lobulated,  and  traversed  by 
numerous  small  vessels.  It  was  attached  by  a  broad  base  to  the 
glosso-epiglottic  fossa  of  the  left  side.  It  occupied  so  much 
space  in  the  pharynx  and  pressed  the  epiglottis  to  such  an  ex¬ 
tent  that  only  a  small  portion  of  the  laryngeal  image  could  be 
seen.  Palpation  with  the  laryngeal  probe  and  finger  showed  it 
to  be  of  soft  consistency,  and  imparted  the  sensation  of  fluctua¬ 
tion.  By  elevating  the  neoplasm,  the  right  free  margin  of  the 
epiglottis  could  be  distinguished  with  the  finger,  but,  in  passing 
over  to  the  left  border,  the  free  edge  of  the  epiglottis  was  lost 
in  the  growth.  From  its  consistency,  color,  and  general  con¬ 
formation,  an  epiglottic  cyst  was  diagnosticated,  but  aspiration 
failed  to  withdraw  any  fluid.  It  was  accordingly  decided  to  re¬ 
move  the  growth  with  the  galvano-cautery  snare.  This  was 
done  under  cocaine  anaesthesia  the  following  day.  Twenty-five 
minutes  were  occupied  in  the  operation,  which  was  accom¬ 
plished  with  little  difficulty  and  no  haemorrhage.  It  was  found 
to  have  been  attached  by  a  broad  base  to  the  entire  left  lateral 
half  of  the  lingual  side  of  the  epiglottis.  It  resembled  an  ade¬ 
noma,  its  surface  being  lobulated  and  traversed  by  fine  capillary 
blood-vessels  and  inclosed  in  a  fibrous  capsule.  It  was  sub¬ 
mitted  for  microscopic  examination  to  the  pathologist  of  the 
hospital,  to  whom  I  am  indebted  for  the  following  report: 
The  capsule  inclosing  the  tumor  is  about  1  mm.  in  thickness, 
and  is  composed  of  mucous  membrane  that  in  no  way  differs 
from  the  ordinary  membrane  covering  the  epiglottis.  This  en¬ 
velope,  which  can  be  readily  stripped  from  the  tumor,  is  cov¬ 
ered  by  stratified  pavement  epithelium,  the  underlying  mem¬ 
brane  being  fibrous  tissue  of  loose  texture,  containing  a  network 
of  numerous  and  wide  lymphatics.  The  mucosa  is  dense,  and 
projects,  in  the  form  of  numerous  small  papillae,  into  the  epi¬ 
thelium.  A  network  of  cap¬ 
illary  blood-vessels  is  dis¬ 
tributed  in  the  superficial 
portion  of  the  mucous  mem¬ 
brane.  The  substance  of 
the  tumor  proper  conforms 
to  the  description  of  hya¬ 
line  myxomatous  tissue.  In 
the  hyaline  ground  sub¬ 
stance,  which  is  composed 
of  a  fibrillary  connective- 
tissue  network  of  extreme 
delicacy,  are  imbedded  the  characteristic  stellate  cells,  some 
of  which  anastomose  by  their  prolongations,  while  others 
again  are  without  any  processes,  being  nearly  round.  Pure 
myxoma  is  so  uncommon  that  several  sections  were  made  m 
different  portions  of  the  tumor  to  ascertain  if  some  sarcoma¬ 
tous  tissue  might  not  be  present.  They  all,  however,  presented 
the  same  structure  as  described  above.  The  growth  is  there¬ 
fore  a  pure  hyaline  myxoma.  [Signed:  Ira  Van  Giesen,  M.  D., 
Laboratory  of  the  Alumni  of  the  College  of  Physicians  and  Sur¬ 
geons,  New  York.] 


Fig.  1. 


Sept.  6,  1890.] 


VAN  DEE  POEL:  MYXOMA  OF  THE  EPIGLOTTIS. 


269 


Fig.  2. 


There  were  no  inflammatory  symptoms  in  the  throat  follow¬ 
ing  the  operation,  and  in  the  course  of  two  days  the  patient 
could  swallow  without  pain  or  discomfort.  His  appetite  and 
strength,  however,  failed  to  return,  and,  there  being  a  lurking 

suspicion  of  some  ma¬ 
lignant  trouble  else¬ 
where,  he  was  advised 
to  place  himself  in  the 
German  Hospital,  where 
he  came  under  the  care 
of  Dr.  Isaac  Adler. 
From  the  notes  taken 
after  his  admission  to 
the  hospital,  we  find 
that  several  examina¬ 
tions  of  the  blood  were 
made  which  showed  a 
marked  degree  of  anaemia;  in  one  cubic  millimetre  of  blood 
there  were  but  1,000,000  red  corpuscles  and  400,000  white. 
The  corpuscles  were  of  normal  size  and  shape.  The  spleen 
was  normal  and  there  were  no  glandular  swellings,  except 
some  slight  cervical  enlargements.  In  the  washings  of  the 
stomach  after  a  test  meal  no  hydrochloric  acid  was  found, 
which  tended  to  confirm  the  diagnosis  of  cancer.  The  urine 
contained  traces  of  albumin  but  no  casts.  After  the  lapse  of 
several  weeks  a  slight  recurrence  of  the  growth  on  the  epi¬ 
glottis  was  noticed  ;  it  occupied  the  seat  of  the  original  tumor, 
was  slightly  elevated  above  the  surface,  and  of  a  dark  color. 

The  patient  gradually  sank,  and  died  in  the  first  part  of  May. 
On  autopsy,  all  the  organs  were  markedly  anaemic ;  the  lungs 
were  found  to  be  emphysematous,  with  evidences  of  chronic 
pleurisy.  The  heart  muscle  was  anaemic  and  fatty.  Endocar¬ 
ditis  existed  which  had  resulted  in  mitral  stenosis,  the  left  ven¬ 
tricle  being  dilated.  Slight  parenchymatous  nephritis,  one  kid¬ 
ney  being  red  and  the  other  white.  The  mucous  membrane  of 
the  stomach  was  atrophied  and  the  organ  slightly  dilated.  The 
liver  was  somewhat  shrunken  and  anaemic,  but  otherwise  nor¬ 
mal.  Spleen  normal.  In  no  organ  was  there  found  any  evi¬ 
dence  of  cancerous  disease. 


The  fatal  termination  of  this  case  would  seem  to  be  only 
indirectly  due  to  the  throat  lesion,  for,  as  the  growth  was 
surely  of  a  benign  nature,  it  could  only  have  affected  the 
issue  by  the  inanition  it  caused  previous  to  its  removal. 
The  cause  of  death,  then,  should  be  ascribed  to  pernicious 
anaemia,  as  this  was  undoubtedly  present,  as  is  evidenced 
by  the  diminution  in  the  number  of  red  corpuscles  from 
5,000,000,  the  normal  number,  to  1,000,000 — while  the 
white  corpuscles  were  present  in  their  normal  proportion, 
about  400,000;  also  by  the  fatty  degeneration  of  the  heart 
muscle,  the  endocarditis,  and  dilatation  of  the  left  ventricle, 
and  finally  the  atrophic  changes  found  in  the  mucous  lining 
of  the  stomach.  Although  pernicious  anaemia  has  no  symp¬ 
toms  that  may  not  occur  in  other  forms  of  anaemia,  there 
are,  nevertheless,  certain  symptoms  which,  especially  in 
combination  with  each  other,  are  more  frequent  in  the  per¬ 
nicious  than  in  the  secondary  or  symptomatic  anaemias. 
These  symptoms,  which,  therefore,  are  in  a  degree  charac¬ 
teristic,  although  not  pathognomonic,  of  pernicious  anaemia, 
are  an  excessive  degree  of  anaemia;  the  preponderance  of 
the  anaemia  over  all  other  symptoms;  the  progressive  and 
malignant  course,  often  uncontrolled  by  therapeutical  agents; 
the  absence  in  many  cases  of  emaciation,  the  intensity  of 
heart  murmurs  without  valvular  lesions,  and  the  frequent 


prominence  of  digestive  disturbances.  Upon  post-mortem 
examination,  fatty  degeneration  of  the  heart,  and  at  times 
certain  changes  in  the  marrow  of  the  bones,  are  observed 
with  a  greater  degree  of  constancy  and  of  intensity  in  per¬ 
nicious  than  in  symptomatic  anaemia.  The  clinical  history 
of  our  case  taken  in  its  entirety  is  therefore  sufficiently  char¬ 
acteristic  to  justify  us  in  making  the  diagnosis  of  pernicious 
anaemia. 

Pernicious  anaemia  and  pseudo-leucocythaemia  are  fre¬ 
quently  associated  with,  or  rather  accompanied  by,  new 
growths  located  in  different  portions  of  the  body.  These 
vary  greatly  in  their  size,  location,  and  anatomical  charac¬ 
teristics.  Mosler,  in  the  course  of  an  article  on  Pseudo- 
leucocythaemia  in  Ziemssen’s  Encyclopaedia ,  calls  attention 
to  them  :  “  The  follicles  of  the  tongue  and  tonsils  are  some¬ 
times  much  enlarged,  which  are  whitish  and  pulpy  on  sec¬ 
tion  ;  also  upon  the  surface  of  the  epiglottis  soft,  shiny, 
and  translucent  nodules,  varying  in  size  from  a  pea  to  a 
hazel-nut,  at  times  single  and  again  multiple,  have  been 
found.”  They  project  above  the  surface  and  interfere  more 
or  less  with  the  function  of  the  part,  according  to  their  size 
and  location.  Thus  pressure  upon  the  larynx  or  trachea 
may  obstruct  respiration,  and  death  in  pseudo-leucocythse- 
mia  is  sometimes  due  to  suffocation  from  this  cause.  So 
also  paralysis  of  the  laryngeal  muscles  may  be  caused  by 
pressure  of  one  of  the  growths  on  the  laryngeal  nerve. 
These  growths  are  by  no  means  confined  to  the  respiratory 
tract,  but  are  scattered  through  the  body  in  various  situa¬ 
tions;  for  instance,  the  pneumogastric  nerve  may  be  involved 
in  a  tumor  and  the  action  of  the  heart  be  retarded ;  the 
femoral  vein  may  be  compressed  and  oedema  of  the  lower 
limb  follow  ;  jaundice  has  been  attributed  to  pressure  on 
the  bile  duct,  etc.  It  is,  then,  to  this  class  of  tumors  that 
our  case  properly  belongs.  It  differs  in  some  respects  from 
those  cases  of  laryngeal  myomata  already  reported — in  the 
first  place,  by  being  associated  with  pernicious  anaemia  and 
terminating  fatally,  and  in  the  second  by  the  recurrence 
that  took  place.  In  a  review  of  the  literature  of  the  sub¬ 
ject  we  have  been  able  to  find  but  few  cases  of  this  form  of 
benign  tumor  recorded,  if  we  exclude  those  in  which  no 
microscopic  examination  was  made.  Sir  Morell  Mackenzie 
observed  one  on  the  right  vocal  cord  that  also  had  certain 
mucous  characteristics.  Bruns  reports  a  case  of  pure  hya¬ 
line  myxoma  which  was  attached  to  the  right  wall  of  the 
larynx,  was  of  an  irregular  pear-shape,  yellowish-red  in 
color,  dense  but  elastic  in  consistency,  and  almost  com¬ 
pletely  occluded  the  entrance  to  the  larynx.  J.  Solis-Gohen, 
in  the  Transactions  of  the  Pathological  Society  of  Philadel¬ 
phia  for  1873,  mentions  a  myxomatous  growth  which  he 
removed  with  forceps.  It  was  multiple  and  pedunculated, 
attached  apparently  to  the  anterior  portion  of  the  thyreoid 
cartilage  just  below  the  glottis  and  to  the  left  of  the  middle 
line.  The  growth  was  distinctly  lobulated.  The  character¬ 
istic  stellate  cells,  some  anastomosing,  imbedded  in  a  hyaline 
ground  substance,  were  shown  upon  microscopic  examina¬ 
tion.  Tauber  has  operated  upon  one  case  of  hyaline  myxo¬ 
ma  which  was  attached  by  a  broad  base  to  the  entire  ante" 
rior  or  lingual  surface  of  the  epiglottis.  Thompson  and  M. 
Schmidt  have  had  similar  cases.  Eemann,  in  the  Revue  de 


270 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jock., 


larynyologie  for  February,  1889,  reports  two  cases,  both  of 
which  were  located  on  the  vocal  cords.  These  cases,  to¬ 
gether  with  the  one  here  related,  make  a  total  of  nine — 
certainly  a  small  showing  when  we  consider  the  immense 
number  of  laryngeal  neoplasms  yearly  recorded.  The  dif¬ 
ferential  diagnosis  of  these  growths  in  situ  from  cystic 
tumors,  and  at  times  from  fibroma,  is  most  difficult  if  not 
impossible.  Eemann  states  that  he  made  an  error  in  diag¬ 
nosis  in  both  of  his  cases.  Basing  his  diagnosis  on  the  con¬ 
sistence,  color,  and  transparency  of  the  growths,  he  thought 
they  were  cysts  until  the  microscope  showed  them  to  be 
hyaline  myxomata.  This  fact  would  seem  to  arouse  the 
suspicion  that  perhaps  many  cases  that  have  heretofore 
been  classed  as  cysts  in  reality,  if  microscopic  examination 
had  been  made,  would  properly  have  come  under  the  head 
of  myxoma.  YVould  it  not,  therefore,  be  fair  to  assume 
with  Eemann  that  it  has  not  been  scientifically  proved  that 
hyaline  myxomata  are  so  uncommon  as  we  have  hitherto 
been  led  to  suppose  ? 


Acute  Yellow  Atrophy  of  the  Liver. — “Dr.  Rosenheim  reports  a 
case  of  aoute  yellow  atrophy  of  the  liver  in  a  child  of  ten  in  which  crys¬ 
tals  of  bilirubin  were  found  in  the  urinary  deposit.  These  crystals  have 
never,  as  far  as  Dr.  Rosenheim  is  aware,  been  found  before,  except  in 
the  urinary  tubules  in  icterus  neonatorum.  There  was  no  albumin  in 
the  urine,  only  traces  of  propeptone  and  no  peptone.  Evidence  was 
found  of  a  considerable  amount  of  degenerative  change  in  the  kidney 
parenchyma  by  the  existence  in  the  urine  of  granular  casts.  Epithelial 
remains  and  globules  of  fat  were  also  found.  As  regards  the  aetiology 
of  the  disease,  Dr.  Rosenheim  is  not  inclined  to  share  in  the  view  of 
Klebs  and  Eppinger,  by  whom  acute  yellow  atrophy  is  looked  upon  as 
an  infectious  disease  produced  by  special  microbes,  because  he  was  un¬ 
able  to  detect  any  micro-organisms  in  sections  of  the  liver,  and  his  en¬ 
deavors  to  obtain  cultures  failed.  He  is  much  disposed  to  ascribe  im¬ 
portance  to  the  finding  of  masses  of  bacteria  in  the  blood  circulation, 
in  consequence  of  which  pathological  changes  in  the  liver  may  be  set 
up.  He  is  himself  inclined  to  think  that  bacteria  whose  habitat  is  un¬ 
known  produce  some  chemical  body  which  exerts  a  deleterious  effect 
on  the  parenchyma  of  the  liver,  and  produces  the  characteristic  morbid 
changes  of  acute  yellow  atrophy.” — Lancet. 

The  Microbes  of  Pneumonia. — “  Dr.  Queisner  has  examined  the  lungs 
of  a  number  of  children  and  adults  dying  from  pneumonia,  his  results 
showing  that  the  pneumonia  coccus  of  Frankel  and  Weichselbaum  is  the 
usual  bacterial  cause  of  true  croupcus  pneumonia.  This  coccus  was 
also  found  in  the  majority  of  cases  of  broncho-pneumonia.  In  both 
children  and  grown-up  people  the  sputum  contained  the  coccus  at  the 
very  commencement  of  the  lung  affection,  and  its  existence  appeared 
to  form  a  very  good  sign  of  the  invasion  of  pneumonia  of  one  kind  or 
another.  In  the  lungs  of  ten  children  who  had  died  of  various  forms 
of  pneumonia,  primary  as  well  as  secondary  to  measles,  diphtheria,  and 
tuberculosis,  Friedlander’s  pneumonia  bacillus  was  not  once  found,  but 
the  coccus  was  found  in  eight  cases.  In  several  instances  it  was  im¬ 
possible  to  distinguish  between  the  catarrhal  and  the  croupous  form,  as 
even  in  undoubted  catarrhal  cases  a  very  perceptible  quantity  of  fibrin¬ 
ous  exudation  was  found.” — Lancet. 

Glucose  as  a  Diuretic. — “  According  to  Mile.  Sophie  Meslach,  lac¬ 
tose  is  not  the  only  diuretic  sugar.  Glucose  acts  in  the  same  way.  Lac¬ 
tose  is  only  absorbed  in  the  form  of  glucose ;  it  acts  solely  on  the  kid¬ 
neys,  but  does  not  pass  into  the  urine.  Its  effect  is  to  raise  the  quan¬ 
tity  of  urine  higher  than  the  quantity  of  fluid  swallowed.  It  gives  good 
results  when  the  kidneys  are  healthy  or  nearly  so ;  in  dropsy  of  cardiac 
origin  also,  when  there  is  only  a  small  proportion  of  albumin  in  the 
urine.  The  dose  is  200  grammes  of  syrup  at  V5  per  cent,  a  day.  The 
grape  cure  so  general  in  Switzerland  and  Germany  acts  in  virtue  of  the 
glucose.” — British  and  Colonial  Druggist. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  SEPTEMBER  6,  1890. 


THE  CONNECTION  BETWEEN  GASTRIC  DISEASE  AND 
DISORDERS  OF  THE  NERVOUS  SYSTEM. 

According  to  the  opinions  of  M.  Cuffer,  expressed  in  a  re¬ 
cent  number  of  the  Revue  de  medecine ,  reflex  action  can  not  ex¬ 
plain  the  persistency  with  -which  nervous  disorders  appear  in 
connection  with  diseases  of  the  stomach.  In  chronic  gastric 
cases,  notably  in  those  of  cancer,  he  has  observed  the  presence 
of  these  disturbances,  and  he  considers  it  possible  that  they 
may  depend  upon  an  ascending  inflammation  of  the  pneumo- 
gastric  nerve,  extending  to  the  bulb,  and  on  this  supposition  he 
explains  the  bulbar  symptoms  which  he  has  found  present  in 
his  cases  during  life,  and  which  post-mortem  examination  has 
enabled  him  to  verify.  In  the  early  stage  of  disease  such  mani¬ 
festations  have,  no  doubt,  a  reflex  origin,  but  the  researches 
carried  on  by  the  writer  in  connection  with  tabes  dorsualis 
have  led  him  to  observe  the  fact  that  reflex  disturbances  have 
great  prognostic  value  and  that  they  indicate  the  direction 
which  will  eventually  be  taken  by  the  concomitant  nervous 
lesion. 

Nervous  disorders  of  gastric  origin  may  be  divided  into  two 
classes :  1.  Transient  disturbances  of  variable  intensity,  some¬ 
times  intense,  but  leaving  no  permanent  trace  behind  them.  2. 
Permanent  affections,  always  grave,  bringing  about  disease  of 
sufficient  gravity  to  cause  death.  Of  the  first  class  stomachal 
vertigo  is  a  frequently  observed  instance,  but  it  is  found  more 
commonly  in  cases  in  which  the  mucous  membrane  of  the 
stomach  is  alone  concerned,  and  not  in  those  in  which  the 
whole  thickness  of  the  gastric  wall  is  involved,  as  is  particular¬ 
ly  the  case  in  cancer.  But  it  is  grave  structural  lesions  that 
are  dealt  with  in  M.  Ouffer’s  paper.  Ooincidently  with  the  be¬ 
ginnings  of  disease,  reflex  disturbances  occur,  and  respiration 
and  cardiac  action  are  disturbed,  but  after  a  certain  period  the 
right  heart  becomes  permanently  dilated,  and  the  signs  of  tri¬ 
cuspid  regurgitation  with  intermittence  become  apparent.  Vis¬ 
ceral  congestions  and  oedema  of  the  extremities  also  occur,  and 
in  this  way  patients  whose  disease  is  in  the  stomach  may  die 
of  a  cardiac  cause. 

These  phenomena  are  thus  explained  by  M.  Potain,  who  has 
given  special  attention  to  their  production.  At  the  moment 
that  the  gastric  mucous  membrane  undergoes  congestion  a 
reflex  influence  is  developed  which  brings  about  a  spasm  of  the 
branches  of  the  pulmonary  artery ;  hence  tension  is  increased 
throughout  this  arterial  distribution  and  the  emptying  of  the 
right  heart  is  interfered  with,  so  that  at  first  it  undergoes  tran¬ 
sient  dilatation  and  later  on  manifests  the  signs  of  tricuspid 
regurgitation  and  asystole.  A  reflex  action  may  thus  give  rise 
to  grave  structural  disease,  and  even  to  fatal  effects.  Further, 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


Sept.  6,  1890.] 

the  tendency  to  bulbar  changes  in  gastric  disease  was  long  ago 
pointed  out  by  Peter,  who  described,  in  connection  with  these 
effects,  pain  in  the  upper  part  of  the  vertebral  column.  Saliva¬ 
tion  is  often  present  in  such  cases,  a  symptom  essentially 

bulbar. 

Cuffer  relates  four  cases  in  support  of  bis  statements,  in  all 
of  which  there  were  stomach  symptoms  with  evidence  of 
organic  disease,  and  subsequently  signs  of  bulbar  paralysis,  but 
he  was  not  able  to  prove  bis  explanation  of  these  coincidences 
until  November,  1889,  when  he  was  enabled  thoroughly  to 
convince  himself  of  its  correctness  at  the  autopsy  of  a  man, 
aged  forty -five,  who  had  died  in  his  wards  at  the  Hdpital  Tenon. 
A  well-marked  inflammation  of  the  peripheral  parts  of  the 
vagus  was  demonstrated.  M.  Cuffer  brings  his  communication 
to  a  close  by  asserting  the  existence  of  the  two  kinds  of  nerv¬ 
ous  disturbance  due  to  disease,  functional  disturbance  and  or¬ 
ganic  lesion  which  is  of  the  nature  of  a  bulbar  myelitis  con¬ 
secutive  to  an  ascending  inflammation  of  the  vagus,  the  latter 
taking  its  origin  at  the  level  of  the  gastric  lesion,  and  which  is 
accompanied  by  the  symptoms,  more  or  less  complete,  of  labio- 
glosso-laryngeal  paralysis.  As  to  prognosis,  the  transient  nerv¬ 
ous  manifestations  do  not  increase  the  gravity  of  the  situation, 
except  in  those  rare  cases  where  cardiac  dilatation  and  asystole 
are  present,  while  the  permanent  nervous  changes  indicate  a 
rapidly  fatal  termination. 


FALSE  WEIGHTS  IN  PHARMACEUTICAL  PREPARATIONS. 

In  the  Tenth  Annual  Report  of  the  Board  of  Health  of  the 
State  of  New  York  there  is  an  interesting  report  by  Professor 
G.  C.  Caldwell,  the  public  analyst,  on  the  examination  of  two 
hundred  and  seventy-five  samples  of  alkaloidal  preparations 
made  by  various  manufacturers,  sold  by  various  dealers,  and 
purchased  at  different  times  in  different  localities.  Of  these, 
he  classed  one  hundred  and  seventy-seven  as  good,  thirteen 
as  passable,  and  eighty-five  as  deficient. 

A  review  of  the  appended  tables  gives  some  interesting 
information.  For  instance,  in  fifteen  samples  of  sulphate  of 
quinine,  foreign  alkaloids  were  found  in  excess  in  nine  speci¬ 
mens;  and  this  excess  is  found  in  a  manufacturer’s  quinine 
that  in  other  specimens  shows  an  absence  of  any  foreign  alka¬ 
loids.  Of  forty-two  samples  of  capsules  of  quinine,  twenty-two 
exhibited  a  deficiency  of  quiuine  varying  from  one  two-hun¬ 
dredth  to  four  fifths  of  a  grain  in  each  capsule;  in  twenty 
samples  there  was  an  excess  varying  from  one  fiftieth  to 
one  third  of  a  grain  in  each  capsule.  In  ninety-eight  samples 
of  quinine  pills,  seventy-one  exhibited  a  deficiency  of  from 
one  two-hundredth  to  one  half  a  grain,  and  in  twenty-seven 
specimens  there  was  an  excess  attaining  one  tenth  of  a  grain. 
Here,  again,  we  find  the  pills  of  the  same  manufacturer  show¬ 
ing  a  deficiency  as  great  as  one  sixth  of  a  grain  and  an  ex¬ 
cess  as  high  as  one  twenty-fifth;  with  the  products  of  one 
firm  an  excess  was  found  three  times  and  a  deficiency  twenty 
times,  and,  while  the  amount  is  insignificant  in  each  pill,  it 
makes  considerable  difference  in  the  total  quantity  of  quinine 
in,  say,  a  hundred  pills.  So  with  pills  of  sulphate  of  morphine, 


271 

a  deficiency  was  found  twenty-nine  times  and  an  excess  five 
times,  the  former  varying  from  one  two-hundredth  to  one 
tenth  of  a  grain,  while  the  excess  was  inappreciable.  All  hypo¬ 
dermic  tablets  of  morphine  were  short  from  one  one-hundredth 
to  one  fourteenth  of  a  grain. 

These  average  variations  were  found  in  the  products  of 
well-known  manufacturers,  as  well  as  in  those  of  local  pharma¬ 
ceutists  ;  and  it  is  not  unreasonable  to  question  the  care  with 
which  manufacturing  processes  are  conducted,  as  well  as  the 
indifference  to  any  examination  of  either  the  alkaloids  used  in 
the  manufacture  or  the  product  after  being  manufactured,  if 
such  wide  ranges  of  variation  in  the  dosage  of  preparations 
from  the  same  manufacturer  can  be  found.  We  have  our  ther¬ 
mometers  tested  and  corrected  ;  will  the  competition  of  manu¬ 
facturers  render  the  same  procedure  necessary  with  our  drugs? 
The  work  that  is  done  by  the  State  board  in  this  line  is  excel¬ 
lent,  and  we  hope  that  its  publicity  may  lead  to  greater  care  in 
manufacturing  processes. 


MINOR  PARAGRAPHS. 

THE  “WILD  MELON”  OF  AUSTRALIA. 

In  the  Australasian  Medical  Gazette ,  Mr.  J.  F.  Souter,  of 
Lake  Cudgellico,  New  South  Wales,  records  a  case  of  poisoning 
with  a  cucurbitaceous  plant  indigenous  to  Australia,  known  as 
the  “wild  melon.”  The  patient  was  a  child,  three  years  old. 
The  symptoms  were  nausea  followed  by  vomiting  of  a  watery 
fluid;  five  hours  later,  a  convulsion  with  opisthotonos,  upward 
rotation  of  the  eyeballs,  and  foaming  at  the  mouth  ;  and  finally 
a  comatose  state  with  great  contraction  of  the  pupils,  pallor  of 
the  face,  and  labored  breathing,  the  pulse  being  140  and  the 
temperature  98°  F.  After  further  vomiting  and  the  adminis¬ 
tration  of  a  warm  bath  the  pupils  suddenly  regained  their  nor¬ 
mal  size,  and  the  child  cried.  Pupillary  contraction  came  on 
again,  and  the  pulse  fell  to  100.  Two  grains  of  calomel  were 
then  given,  also  frequent  teaspoonful  doses  of  brandy.  This 
was  followed  by  profuse  sweating  of  short  duration  and  by 
sleep,  after  which  there  was  nothing  noticeable  about  the  child, 
except  slight  yellowness  of  the  sclerotics. 


NERVOUS  DERANGEMENTS  AFTER  CASTRATION. 

In  the  Wiener  medicinische  Presse  Dr.  Weiss  relates  the  case 
of  a  man,  forty-eight  years  old,  both  of  whose  testicles  were 
removed  for  tubercular  disease.  The  operation  was  shortly  fol¬ 
lowed  by  certain  psychical  and  nervous  derangements,  some  of 
which  lasted  for  six  years.  The  attacks  were  generally  pre¬ 
ceded  by  an  aura  ot  a  sensation  of  oppression,  and  consisted  of 
flashes  of  heat  about  the  head  and  trunk,  accompanied  with 
profuse  sweating.  At  the  same  time  there  were  neurasthenic 
phenomena,  such  as  headache,  vertigo,  palpitation,  and  melan¬ 
choly,  and  the  memory  and  the  will  were  notably  enfeebled. 
After  a  short  time  there  were  attacks  of  gastro-intestinal  neu¬ 
ralgia.  The  author  likens  these  troubles  to  those  observed  after 
oophorectomy  or  in  connection  with  the  menopause.  It  is  to  be 
noted  that  the  patient  was  of  neurotic  antecedents  of  an  heredi¬ 
tary  nature. 

THE  TOXICITY  OF  THE  URINE  IN  INTERMITTENT  FEVERS. 

According  to  the  Revue  generate  de  clinique  et  de  thera- 
peutique,  Dr.  Brousse  has  experimented  on  rabbits  to  deter¬ 
mine :  1.  The  modifications  of  the  toxicity  of  urine  during  a 


272 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Jour., 


paroxysm  of  intermittent  fever.  2.  The  relations  between  the 
toxicity  during  the  paroxysm  and  during  convalescence.  He 
has  demonstrated  that  the  urotoxic  coefficient,  calculated  by- 
Bouchard’s  formula,  is  elevated  during  the  paroxysm.  The 
physiological  effects  observed  are  those  usually  noted  after  the 
injection  of  urine :  dyspnoea,  myosis,  fall  of  temperature,  ex¬ 
ophthalmia,  and  convulsions.  The  toxicity  is  diminished  during 
convalescence,  being  much  less  than  during  the  paroxysm  and 
less  than  that  of  normal  urine.  It  is  yet  to  be  determined 
whether  the  toxicity  depends  upon  the  febrile  state  solely,  and 
also  whether  there  is  a  difference  in  the  toxicity  of  the  urine 
during  and  at  the  end  of  the  paroxysm. 


DEDUCTIONS  FROM  EXPERIMENTS  WITH  DRUGS. 

TnE  Progres  medical  states  that  Dr.  Huchard  recently  read 
a  paper  on  The  Physiological  and  Therapeutical  Action  of  Drugs 
before  the  Societe  de  therapeutique,  calling  attention  anew  to 
significant  differences  in  the  action  of  certain  drugs  in  the  well 
and  in  the  sick  and  in  various  forms  of  disease.  For  example, 
it  was  stated  that  quinine  lowered  the  temperature  in  typhoid 
fever,  but  had  no  such  effect  in  erysipelas.  The  lesson  to  be 
drawn  from  such  facts  is  that  it  is  not  safe  to  make  sweeping 
therapeutic  deductions  from  observations  of  the  physiological 
action  of  drugs;  to  use  the  author’s  words,  physiology  should 
not  enslave  medicine. 


A  MODIFICATION  OF  ROMBERG’S  TEST  IN  THE  DIAGNOSIS 
OF  LOCOMOTOR  ATAXIA. 

In  a  recent  Bordeaux  thesis,  summarized  in  the  Gazette 
hehdomadaire  de  medecine  et  de  chirurgie,  Dr.  Perron  describes 
a  modification  of  Romberg’s  test  by  which  he  has  been  enabled 
to  diagnosticate  locomotor  ataxia  in  its  incipiency.  The  patient 
is  directed  to  stand  on  one  leg  and  close  his  eyes;  if  he  can  not 
keep  his  balance,  the  inference  is  that  he  is  affected  with  a 
spinal  lesion  that  will  ultimately  give  rise  to  locomotor  ataxia. 
As  ordinarily  employed,  Romberg’s  test  often  fails  in  cases  that 
are  not  far  advanced. 


PERSONAL  UNCLEANLINESS  AS  A  FACTOR  IN  THE  CAUSA¬ 
TION  OF  CHOLERA. 

In  the  Gazette  medicate  d'  Orient  Dr.  Gabuzzi  cites  Boche- 
fontaine’s  experiments  going  to  show  that  the  microphyte  of 
cholera  is  sterile  within  the  patient’s  organism,  and  that,  in 
order  to  be  rendered  capable  of  conveying  the  disease,  it  must 
find  a  nutritive  soil  on  being  cast  off  from  the  system.  The 
urine,  he  thinks,  often  constitutes  a  medium  in  which  it  may 
attain  pathogenic  powers,  and  uncleanliness,  which  favors  the 
mixture  of  urine  with  the  bacillus,  may  therefore  be  regarded 
as  a  predisposing  cause  of  cholera. 


EPILEPSY  AND  ANKYLOSIS  OF  THE  ATLAS. 

Epilepsy  has  often  been  observed  in  cases  of  ankylosis  of 
the  atlas,  and  the  epilepsy  has  been  regarded  in  such  cases  as 
the  result  of  the  encroachment  of  the  bone  on  the  vertebral 
canal.  In  an  article  published  in  the  Archiv  fur  pathologische 
Anatomie  und  Physiologie  und  fur  Jclinische  Mediein,  Dr.  W. 
Sommer  gives  it  as  his  opinion  that  such  encroachment  should 
not  be  considered  as  a  cause  of  epilepsy  unless  it  is  accompanied 
by  signs  of  compression  of  the  spinal  cord.  He  founds  this 
opinion  on  the  absence  of  epilepsy  in  the  case  of  an  anaemic  old 
man  who  had  ankylosis  and  forward  subluxation  of  the  atlas, 
apparently  in  consequence  of  arthritis  deformans. 


SIMULTANEOUS  DISLOCATION  OF  BOTH  ENDS  OF  THE 

CLAVICLE. 

In  Guy's  Hospital  Reports,  for  1889,  Mr.  Clement  Lucas  re¬ 
lates  a  case  of  this  rare  injury.  The  patient,  a  man,  thirty-two 
years  old,  was  standing  between  the  wheels  of  two  vehicles  that 
were  close  together,  when  a  third  vehicle  came  into  collision 
with  one  of  them  and  gave  it  an  impetus  by  which  the  man’s 
chest  was  partially  crushed  between  the  wheels.  The  outer  end 
of  the  right  clavicle  was  forced  over  the  acromion,  and  its  inner 
end  was  driven  backward  and  downward,  and  lodged  beneath 
the  sternum,  the  first  costal  cartilage  on  each  side  being  at  the 
same  time  dislocated  backward. 


A  MEDICO-LEGAL  VIEW  OF  PAINLESS  LABOR. 

Dr.  Brunon  recently  reported  to  the  Societe  de  medecine  of 
Rouen  the  case  of  a  primipara  whose  labor  was  so  nearly  pain¬ 
less  that  she  herself  mistook  it  for  difficult  defecation  and  would 
have  been  delivered  in  the  water-closet  if  she  had  not  been  re¬ 
moved  from  it.  According  to  the  abstract  published  in  La 
Normandie  medicate,  she  felt  only  lumbar  pains  and  a  sense  of 
weight  in  the  rectum,  and  was  not  aware  of  the  flow  of  liquor 
amnii.  The  author  infers  from  this  case  that  the  discovery  of 
a  new-born  infant  in  a  water-closet  pan  does  not  necessarily 
raise  the  presumption  of  premeditated  infanticide. 


THE  PHYSICIAN  AS  A  PREFERRED  CREDITOR. 

According  to  French  practice,  the  physician  is  a  preferred 
creditor  only  in  case  of  the  patient’s  death,  and  then  only  to  the 
extent  of  his  fees  for  attendance  during  the  last  illness;  but,  as 
we  learn  from  Lyon  medical,  a  French  court  has  recently  de¬ 
cided  in  favor  of  the  claim  of  a  Dr.  Benoist  as  a  preferred 
creditor  of  a  patient  who  recovered,  but  became  insolvent.  The 
decision  overruled  that  of  the  assignee,  and  the  costs  fell  upon 
the  estate. 

THE  MEDICAL  CORPS  OF  THE  ARMY. 

We  would  call  the  attention  of  our  younger  readers  to  the 
notice,  given  elsewhere  in  this  issue,  of  the  session  of  an  array 
medical  board  in  New  York  during  the  month  of  October. 
There  is  no  more  honorable  office  for  a  physician  to  bear  than 
that  of  a  medical  officer  of  the  United  States  Army,  and  there 
are  few  that  afford  him  greater  opportunities  for  entering  upon 
a  career  of  distinction. 

THE  NEW  SURGEON-GENERAL  OF  THE  ARMY. 

The  hope  expressed  by  us  last  week  has  been  fulfilled  by 
the  confirmation  of  Dr.  Baxter’s  nomination  as  surgeon-general 
of  the  army,  which  took  place  at  about  the  time  our  last  issue 
went  to  press.  Surgeon-General  Baxter  is  very  much  esteemed 
by  the  profession,  and  we  feel  confident  that  his  administration 
of  the  affairs  of  his  high  office  will  prove  gratifying  to  them. 


A  REMEDY  FOR  PHTHEIRIASIS  PUBIS. 

According  to  La  Medecine  moderne,  M.  Brocq  uses  a  solu¬ 
tion  of  one  part  of  corrosive  sublimate  in  five  hundred  parts  of 
vinegar  as  a  lotion  for  destroying  crab-lice.  It  is  said  that  it 
not  only  kills  the  pediculi,  but  also  detaches  the  nits. 


ITEMS,  ETC. 

An  Army  Medical  Board  will  be  in  session  in  New  York  city,  dur¬ 
ing  October,  1890,  for  the  examination  of  candidates  for  appointment 
in  the  Medical  Corps  of  the  United  States  Army  to  fill  existing  vacan- 


Sept.  6,  1890.] 


ITEMS.— LETTERS  TO  THE  EDITOR. 


273 


cies.  Persons  desiring  to  present  themselves  for  examination  by  the 
Board  will  make  application  to  the  Secretary  of  War,  before  October  1 
1890,  for  the  necessary  invitation,  stating  the  date  and  place  of  birth, 
the  place  and  State  of  permanent  residence,  the  fact  of  American  citi¬ 
zenship,  the  name  of  the  medical  college  from  whence  they  were  gradu¬ 
ated,  and  a  record  of  service  in  hospital,  if  any,  from  the  authorities 
thereof.  The  application  should  be  accompanied  by  certificates  based 
on  personal  knowledge,  from  at  least  two  physicians  of  repute,  as  to 
professional  standing,  character,  and  moral  habits.  The  candidate 
must  be  between  twenty-one  and  twenty-eight  years  of  age,  and  a  gradu¬ 
ate  from  a  regular  medical  college,  as  evidence  of  which,  his  diploma 
must  be  submitted  to  the  Board.  Further  information  regarding  the 
examinations  may  be  obtained  by  addressing  the  Surgeon-General,  U.  S. 
Army,  Washington,  D.  C. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  September  2,  1890 : 


DISEASES. 

Week  ending  Aug.  26. 

Week  ending  Sept.  2. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

37 

11 

42 

11 

■Scarlet  fever . 

14 

3 

17 

1 

Cerebro-spinal  meningitis . 

0 

0 

1 

0 

Measles . 

79 

12 

62 

10 

Diphtheria . 

61 

16 

62 

16  . 

The  New  York  Institute  for  Eye  and  Ear  Diseases  is  the  title  of  a 
recently  incorporated  institution  under  the  medical  management  of  Dr. 
J.  L.  Campbell,  Dr.  W.  C.  Campbell,  Dr.  Charles  Simmons,  Dr.  George 
P.  Shirmer,  and  Dr.  C.  J.  Dumond.  Its  object  is  to  maintain  a  free 
hospital  and  dispensary  for  the  treatment  of  diseases  of  the  eye,  ear, 
and  throat,  and  to  establish  a  school  of  instruction  in  the  treatment  of 
these  diseases. 

The  Mississippi  Valley  Medical  Association  will  hold  its  sixteenth 
annual  meeting  at  Louisville,  Ky.,  on  Wednesday,  Thursday,  and  Fri¬ 
day,  October  8th,  9th,  and  10th,  under  the  presidency  of  Dr.  Joseph  M. 
Mathews  of  that  city. 

The  German  Medical  Society  of  Brooklyn  will  hold  its  regular 
monthly  meeting  on  Friday,  the  1 2th  inst. 

Bromide  of  Ethyl  as  an  Anaesthetic. — “  Dr.  Thomas  Frank,  of  To- 
rontal-Szegcsany,  in  Hungary,  has  employed,  it  is  stated,  with  great 
success  the  inhalation  of  bromide  of  ethyl  for  anaesthesia  during  opera¬ 
tions  on  the  mouth.  In  one  case  the  patient,  though  he  felt  no  pain 
during  the  removal  of  a  sarcomatous  epulis,  did  not  entirely  lose  con¬ 
sciousness,  as  he  spat  some  blood  when  requested  to  do  so,  and  when 
at  the  commencement  the  breathing  stopped,  he  resumed  it  in  reply  to 
directions .  ” — Lancet. 

Change  of  Address. — Dr.  Charles  W.  Brown,  from  Elmira,  N.  Y.,  to 
902  Fourteenth  Street,  N.  W.,  Washington,  D.  C. 

Marine-Hospital  Service. —  Official  List  of  Changes  of  Stations  and 
Duties  of  Medical  Officers  of  the  United  States  Marine-Hospital  Service 
for  the  two  weeks  ending  July  5,  1890 : 

( Previously  omitted.) 

Hutton,  W.  H.  H.,  Surgeon.  Ordered  to  Washington,  D.  C.,  for  special 
duty.  June  23,  1890. 

Long,  W.  H.,  Surgeon.  Granted  leave  of  absence  for  thirty  days.  July 

2,  1890. 

Austin,  II.  W.,  Surgeon.  When  relieved  at  Chicago,  Ill.,  to  report  in 
person  to  the  Supervising  Surgeon-General.  July  5,  1890. 

Irwin,  Fairfax,  Surgeon.  To  proceed  to  Biloxi,  Miss.,  on  special  duty. 
July  2,  1890. 

Mead,  F.  W.,  Surgeon.  Relieved  from  duty  at  St.  Louis,  Mo.,  to  assume 
command  of  the  Service  at  Chicago,  Ill.  July  5,  1890. 

Armstrong,  S.  T.,  Passed  Assistant  Surgeon.  Granted  leave  of  ab. 

sence  until  August  7,  1890.  June  24,  1890. 

Kalloch,  P.  C.,  Passed  Assistant  Surgeon.  Relieved  from  duty  at  San 


Francisco,  Cal.,  to  assume  command  of  the  Service  at  St.  Louis, 
Mo.  July  5,  1890. 

Perry,  T.  B.,  Assistant  Surgeon.  Granted  leave  of  absence  for  ten 
days,  July  2,  1890.  Upon  expiration  of  leave  to  proceed  to  Nor¬ 
folk,  Va.,  for  temporary  duty.  July  5,  1890. 

Cobb,  J.  O.,  Assistant  Surgeon.  To  proceed  to  St.  Louis,  Mo.,  for  tem¬ 
porary  duty.  July  5,  1890. 

Brown,  B.  W.,  Assistant  Surgeon.  To  proceed  to  San  Francisco,  Cal., 
for  temporary  duty.  June  23,  1890. 

Resignation. 

Armstrong,  S.  T.,  Passed  Assistant  Surgeon.  Resignation  accepted, 
by  direction  of  the  President,  to  take  effect  August  7,  1890.  June 
24,  1890. 

Appointment. 

Brown,  B.  W.,  Assistant  Surgeon.  Commissioned  as  an  assistant  sur¬ 
geon  by  the  President.  June  23,  1890. 

(Omitted  from  previous  list.) 

Bailhache,  P.  H.,  Surgeon.  To  proceed  to  Eureka,  Col.,  and  Astoria, 
Oregon,  as  inspector.  June  5,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 

of  the  United  States  Navy  for  the  week  ending  August  30 ,  1890 : 

Hoehling,  A.  A.,  Medical  Inspector.  In  addition  to  present  duties, 
ordered  as  President  of  Medical  Examining  Board  at  Philadelphia 
convened  by  Department  Order,  June  9,  1890. 

Kennedy,  R.  M.,  Assistant  Surgeon.  In  addition  to  present  duty,  or¬ 
dered  as  member  of  the  above-named  Board. 

Ogden,  F.  N.,  Passed  Assistant  Surgeon.  In  addition  to  present  duty, 
ordered  as  member  of  the  above-named  Board. 

McClurg,  Walter  A.,  Surgeon.  Granted  a  month’s  leave  of  absence 
from  September  1st. 

Kershner,  Edward,  Surgeon.  Granted  two  weeks’  leave  of  absence 
from  September  1,  1890. 


letters  to  %  (Stottur. 


“  PINK-EYE.” 

London,  August  20,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  In  your  issue  for  June  28,  1890,  an  article  entitled 
“  Pink-Eye  ”  appears,  which  refers  to  articles  by  the  under¬ 
signed  which  appeared  in  the  Arch,  of  Ophth .,  vol.  xv,  No.  4, 
1886,  and  in  the  Medical  Record  for  May  21,  1887.  I  wish  to 
notice  the  article  in  your  Journal  only  to  correct  some  errors. 

Quoting  from  the  paper  referred  to  :  “  No  one  has,  so  far  as 
I  am  aware,  repeated  his  experiments  ”  (meaning  my  experi¬ 
ments),  “  nor  has  any  one  essayed  to  make  an  analysis  of  the 
evidence  he  has  furnished.” 

The  writer  is  referred  to  an  article  by  Kartulis  ( Ctrlbl.f. '. 
Bacteriologie  u.  Parasitenk .,  page  289, 1887),  where  he  will  find 
full  confirmation  of  the  results  previously  arrived  at  by  me. 

“A  pure  cultivation  of  the  small  bacillus  could  not  be  ob¬ 
tained.” 

Since  writing  the  articles  referred  to  above,  I  have  produced 
a  pure  cultivation  of  the  bacillus,  photographs  of  which  have 
been  made.  These  were  shown  at  the  Tenth  International 
Medical  Congress  in  Berlin.  Their  existence  was  known  to  the 
writer  of  the  article  which  appeared  in  your  Journal  before  that 
article  was  published.  “  The  small  bacillus  (together  with  the 
clubbed  bacillus)  was  found  in  the  secretion  in  every  case.” 

There  is  no  authority  whatever  in  my  article  for  the  clause 
included  in  parenthesis  in  this  quotation. 

John  E.  Weeks,  M.  D. 


274 


PROCEEDINGS  OF  SOCIETIES.— SPECIAL  ARTICLES. 


[N.  Y.  Med.  Joub., 


JJrocecbinjgs  of  ^octettes* 


AMERICAN  LARYNGOLOGICAL  ASSOCIATION. 

Twelfth  Annual  Congress,  held  at  Baltimore ,  on  Thursday , 
Friday ,  and  Saturday ,  May  29 ,  30,  and  31,  1890. 

The  President,  Dr.  John  N.  Mackenzie,  of  Baltimore, 
in  the  Chair. 

( Continued  from  page  187.) 

A  Case  of  Myxoma  of  the  Epiglottis  was  the  title  of  a 
paper  read  by  Dr.  Vander  Poel.  (See  page  268.) 

The  President:  We  ofteD  draw  incorrect  inferences  with 
regard  to  the  rarity  of  diseases  by  the  infrequency  of  reports 
of  such  cases  in  medical  literature.  I  think  that,  whereas  this 
growth  in  the  locality  described  by  Dr.  YanderPoel  is  rare, 
the  same  growths,  occurring  lower  down  in  the  larynx,  are 
not  of  such  rarity  as  might  be  inferred  from  the  published 
records. 

Dr.  Swain  :  I  remember  removing  such  a  growth  from  the 
fossa  glosso-epiglottidea,  just  at  the  junction  of  the  epiglottis  and 
the  tongue,  which  was  a  simple  polypus,  strictly  a  mucous  polyp, 
resembling  those  of  the  nose  in  every  respect,  except  it  was 
more  consistent. 

Dr.  Vander  Poel:  In  reply  to  the  chairman  I  would  sim¬ 
ply  say  that  myxomata  are  essentially  embryonic  tissue  tumors, 
as  myxomatous  tissue  is  only  present  in  the  normal  adult  in  a 
very  imperfect  and  atypical  form — as  in  the  vitreous  of  the  eye 
— and  in  small  amount  in  the  medulla  of  bone.  It  is,  however, 
a  tissue  which  readily  undergoes  transformation,  and  pure  myxo¬ 
mata  are  not  common.  They  are  apt  to  be  combined  with  fibril¬ 
lar  connective  tissue,  as  fibro-myxoma;  or  with  fat  tissue,  lipo- 
myxoma;  and  they  frequently  become  sarcomatous,  or  take 
part  in  the  formation  of  complex  tumors.  It  is  therefore  to  this 
class  of  tumor,  this  degenerated  or  transformed  myxoma,  that 
I  believe  the  chairman  refers  when  he  says  that  he  has  fre¬ 
quently  seen  them.  What  I  referred  to  was  a  pure  gelatinous 
growth,  characterized  by  stellate  fusiform  cells,  often  anasto¬ 
mosing,  imbedded  in  a  homogeneous  or  finely  fibrillated,  soft, 
gelatinous  basement  substance.  The  case  mentioned  by  Dr. 
Swain  is  undoubtedly  analogous  to  the  one  I  have  reported. 
Probably  in  most  cases  the  diagnosis  is  made  from  the  macro¬ 
scopic  appearances,  and  is  not  confirmed  by  microscopic  exami¬ 
nation.  I  think  that  originally  the  growth  may  be  a  hyaline 
myxoma,  but  subsequently  undergoes  a  change  such  as  I  have 
referred  to. 


Social  ^rtkks. 


LETTERS  TO  MY  HOUSE  PHYSICIANS. 

By  WILLIAM  OSLER,  M.  D., 

BALTIMORE. 

Letter  IY. 

Erlangen  and  Wurzburg. 

Dear  S. :  The  university  is  Erlangen — practically  there  is  nothing 
else  in  the  little  Bavarian  town,  which  forcibly  illustrates  the  great 
truth  that  men  make  a  seat  of  learning,  and,  if  given  proper  facilities, 
will  attract  students.  It  is  surprising,  however,  in  a  place  of  this  size 
to  find  so  large  a  hospital ;  but  many  patients  come  from  the  surround¬ 


ing  country,  and  there  is  ample  teaching  material  in  medicine  and  sur¬ 
gery,  and  even  in  the  special  branches. 

Striimpell,  who  has  charge  of  the  medical  clinic  (whose  text-book, 
edited  by  Shattuck,  has  made  his  name  well  known  in  America),  is  one 
of  the  most  industrious  and  progressive  of  the  younger  generation  of 
German  professors.  His  contributions  to  neurology  have  been  most 
important.  The  medical  wards  are  well  arranged,  and  we  were  shown 
a  series  of  instructive  cases,  several  of  great  rarity.  One  in  particular, 
of  acromegalia,  attracted  our  attention,  as  it  was  a  most  typical  in. 
stance — a  woman,  aged  twenty-eight,  looking  over  fifty,  with  large, 
coarse  features,  apathetic  expression,  and  enormous  hands  and  feet, 
which  had  been,  with  the  face,  progressively  enlarging  for  years.  The 
remarkable  affection  seems  rare  in  Germany,  as  it  is  with  us.  Ever 
since  the  publication  of  Marie’s  paper  I  have  been  on  the  lookout  for 
cases,  and  searched  in  vain  the  chronic  wards  at  the  Philadelphia  Hos¬ 
pital.  I  have  known  of  one  case  in  Toronto  for  several  years,  and  saw 
a  second  in  the  same  town  with  Dr.  Burritt ;  both  of  these  have  re¬ 
cently  been  described  by  Dr.  I.  E.  Graham.  I  see  that  a  special  mono¬ 
graph  has  just  been  published  in  Paris  on  the  disease. 

A  case  of  rhythmical  spasm  of  the  psoas  muscles  in  a  middle-aged 
man,  which  came  on  after  a  sudden  paraplegia  two  years  ago,  was 
rather  a  puzzler  for  diagnosis.  The  thighs  were  lifted  with  each  con- 
traction,  and  there  was  a  slight  spastic  condition  of  the  legs.  There  was 
evidently  organic  disease,  but  the  case  simulated  hysterical  rhythmical 
spasm,  an  instance  of  which  I  remember  was  shown  by  Dr.  George 
Ross  at  the  Medico-chirurgical  Society  of  Montreal.  Speaking  of  hys¬ 
teria,  Professor  Striimpell  sent  for  photographs  of  a  remarkable  case 
which  had  recently  been  under  his  care,  in  which  the  girl  had  produced 
extensive  lesions  of  the  extremities  by  cauterization,  leaving  sloughs 
resembling  somewhat  those  of  symmetrical  gangrene.  In  my  last  letter 
I  referred  to  the  heart  disease  induced  by  the  combination  of  heavy 
drinking  and  heavy  work,  and  we  found  here  in  one  of  the  wards  a 
most  characteristic  example :  A  man,  aged  about  thirty-six,  employed 
in  a  brewery  and  accustomed  for  years  to  drink  from  twenty  to  thirty 
litres  of  beer  daily,  began  to  suffer  with  shortness  of  breath,  then  oedema 
of  the  feet,  and  finally  anasarca  of  the  lower  part  of  the  body ;  in  this 
condition  he  was  admitted  to  hospital.  The  heart  was  much  dilated 
and  a  loud  apex  systolic  murmur  was  heard.  Under  treatment  and 
rest  the  dropsy  was  subsiding  and  the  heart’s  impulse  was  much  more 
distinct,  about  two  inches  outside  the  nipple  line.  This,  Striimpell  said, 
was  a  common  history  in  the  workers  in  the  large  Erlangen  breweries. 
At  about  the  age  of  forty  the  breakdown  occurred,  and  usually  with 
heart  failure,  which  proved  fatal  after  two  or  three  attacks.  We  ques¬ 
tioned  this  patient — a  most  intelligent  fellow — as  to  the  quantity  of 
beer  consumed  daily  by  the  men,  and  the  figures  I  mention  above  repre¬ 
sent,  he  assured  us,  an  average  allowance.  As  might  have  been  ex¬ 
pected  from  the  good  work  which  has  been  done  here,  there  was  an  ex¬ 
cellent  collection  of  cases  of  diseases  of  the  cord,  including  one  of 
syringomyelia,  and  of  cases  of  muscular  atrophy,  and  in  the  clinical 
laboratory  we  were  shown  many  beautiful  microscopical  sections,  par¬ 
ticularly  of  the  combined  scleroses  of  the  cord.  Unfortunately,  it  was 
not  a  clinic  day,  and  we  did  not  hear  Professor  Striimpell  lecture  (I  had 
had  that  pleasure  in  Leipsic  in  1884),  but  after  the  hospital  visit  we 
spent  a  couple  of  delightful  hours  at  his  house. 

One  of  the  men  I  was  most  anxious  to  meet  in  Erlangen  was  Pro¬ 
fessor  Zenker,  the  describer  of  trichinosis  in  man,  the  discoverer  of  fat 
embolism,  and  the  industrious  worker  at  anthracosis  and  siderosis.  He 
was  busy  at  a  Staats-Examen  and  could  not  give  us  much  time,  but  his 
son  and  assistant  showed  us  the  Pathological  Institute,  which,  though 
small,  is  conveniently  arranged  for  teaching.  In  the  post-mortem  room 
we  saw  a  rare  termination  of  mediastinal  sarcoma.  A  man  of  about 
forty,  with  signs  of  intrathoracic  pressure,  had  died  suddenly  in  the 
wards.  The  entire  mediastinum  was  occupied  by  a  large  sarcoma,  which 
completely  surrounded  the  great  vessels,  covered  over  the  heart,  and 
had  perforated  the  superior  vena  cava,  into  which  masses  of  the  soft 
tumor  projected.  Death  was  no  doubt  due  to  extensive  pulmonary  em¬ 
bolism.  As  is  common  in  these  mediastinal  growths,  there  was  exten¬ 
sive  pleural  effusion  on  one  side,  a  condition  which  often  complicates 
the  diagnosis. 

The  new  building  for  the  general  faculties  and  the  new  biological 


lept.  6,  1890.] 


BOOK  NOTICES. 


275 


iboratory  (in  charge  of  Professor  Selenka)  have  helped  largely  in  the 
ipid  progress  which  Erlangen  has  made  as  an  educational  center  dur- 
ig  the  past  few  years. 

Wurzburg  is  the  second  largest  Bavarian  university,  and  its  medi¬ 
al  school  ranks,  in  number  of  students,  fourth  in  the  empire.  The  at- 
endance  has  increased  enormously  during  the  past  decade,  due  in  part, 
o  doubt,  to  the  attractive  character  of  the  new  laboratories  which  have 
een  provided  by  the  government. 

The  name  of  Kdlliker  is  not  so  familiar  to  English-speaking  stu- 
ents  of  to-day  as  it  was  twenty  years  ago.  The  new  works  on  histolo- 
y  have  displaced  the  old  text-book  upon  which  we,  and  indeed  the 
eneration  before  us,  were  brought  up,  but  the  man  who,  forty-five 
ears  ago,  with  Bowman  and  Goodsir,  stimulated  the  study  of  minute 
natomy,  is  still  vigorous  and  at  work,  thoroughly  abreast  of  the  times, 
nd  a  living  illustration  of  the  fact  that  age,  after  all,  is  a  relative  con- 
ition.  One  who  has  within  a  few  years  brought  out  an  elaborate 
)iiwickelungnge8chichte ,  and  who,  within  a  month  or  so,  has  issued  the 
rst  part  of  a  new  edition  of  his  general  histology,  twenty-five  years 
fter  the  last  edition,  can  not  be  called  old,  though  his  years  may  be 
jachipg  the  Psalmist’s  limit.  I  have  very  pleasant  recollections  of 
rofessor  Kdlliker  in  1872  and  1873,  on  the  occasion  of  his  visits  to 
ear  old  Dr.  Sharpey  at  University  College.  He  then  was  an  elderlv 
ian,  with  snow-white  hair,  and  naturally  eighteen  years  have  left  their 
aces;  but  he  retains  a  bodily  and  a  mental  vigor  which  many  a 
lunger  man  might  envy,  and  an  interest  in  all  departments  of  anatomy 
hich  it  was  delightful  to  see.  The  new  anatomical  institute  is  indeed 
orthy  of  the  distinguished  director,  and  it  was  with  evident  pleasure 
rd  pride  that  he  showed  us  the  various  divisions  devoted  to  human 
latomy,  histology,  embryology,  and  comparative  anatomy.  The  mu- 
■uins  occupy  a  large  space,  as  the  collections  are  very  extensive ;  but 
te  laboratory  and  lecture-room  accommodation  in  this  building  alone 
pials  the  entire  teaching  space  of  an  average  American  medical  school, 
mple  provision  is  made  for  instruction  in  the  specially  practical  de- 
irtments — gynaecological,  surgical,  and  medical — and  we  found  one 
ass-room  occupied  by  a  teacher  of  gynaecology  who  was  lecturing  to 
■nior  men  on  pelvic  anatomy.  The  general  lecture-room  seems  excep- 
onally  well  arranged  for  the  students,  and  is  regarded  by  Professor 
blliker,  and  rightly  I  think,  as  a  model  of  the  kind.  In  the  histo- 
gical  laboratory  it  was  pleasant  to  see  a  son  of  the  late  Max  Schultze, 
ie  founder  of  the  Archiv  fur  mi/croscopische  Anatomic,  whose  mem- 
y  will  always  be  held  in  grateful  remembrance  by  students  of  micros- 

>py- 

The  Julius  Hospital  is  an  ancient  and  wealthy  foundation  dating 
om  the  sixteenth  century,  and  is  in  many  parts  sadly  in  need  of  the 
novation  which  is  in  progress.  The  new  surgical  amphitheatre  is  the 
test  which  we  have  seen — very  spacious,  with  tiled  floor,  glazed  walls, 
on  and  oak,  open  seatings,  so  that  the  entire  room  can  be  flushed  with 
e  hose.  The  arrangements  for  patients  and  assistants  seem  very  per- 
ct  in  the  large  suite  of  rooms  opening  into  the  amphitheatre.  Hospi- 
1  authorities  in  America,  particularly  those  in  connection  with  large 
edical  schools,  might  consult  with  advantage  the  plans  of  this  new 
Aiding,  which  apparently  combines  all  the  modern  antiseptic  require- 
ents  in  a  thorough  yet  plain  manner. 

In  the  medical  clinic  we  found  Professor  Leube  with  a  class  of  at 
ast  three  hundred  students,  who  even  thronged  the  arena  and  the  steps 
the  auditorium.  I  have  already  referred  to  the  system  of  instruction 
hich  appears  uniform  in  the  German  schools.  A  case  of  acute  yellow 
rophy  of  the  liver  was  shown  which  had  previously  been  before  the 
ass  and  very  unexpectedly  had  convalesced.  Every  symptom  of  the 
sease  had  been  present,  and,  in  spite  of  the  great  improvement,  the 
iginal  diagnosis  was  maintained,  and  the  professor  stated  that  he  had 
town  of  one  other  instance  of  recovery.  The  microscopical  and  chem- 
d  examination  of  the  urine  was  demonstrated  by  the  assistants  at 
ry  conveniently  arranged  tables  in  the  arena  and  without  any  eon  tu¬ 
rn  or  disturbance.  Upon  the  next  case — haemorrhage  from  the  stom- 
!i — two  students  were  thoroughly  and  patiently  drilled,  first,  on  the 
neral  aetiology,  and  then  on  the  probable  special  conditions  existing 
the  patient ;  then  followed  a  summing  up,  a  diagnosis,  and  the  treat- 
eut  (which  in  this  case  consisted  in  complete  abstention  from  food, 
th  the  administration  of  ergot  and  opium).  Professor  Leube  is  a  ‘ 


clear,  incisive,  and  most  agreeable  teacher,  and  I  envied  the  students 
who  had  the  privilege  of  his  instruction. 

In  the  Pathological  Institute  we  were  fortunate  enough  to  see  a 
demonstration  in  the  post-mortem  room.  One  of  the  assistants  was  in¬ 
structing  a  tyro  in  the  technique  of  an  autopsy,  while  Professor  Rind- 
fleisch,  with  blackboard  and  chalks  and  coarse  sections,  was  explaining 
the  anatomy  of  stone-workers’  phthisis.  Instead  of  passing  the  entire 
specimen  about,  small  but  characteristic  portions  were  distributed  on 
little  platters.  The  whole  question  of  fibroid  induration  due  to  dust 
inhalation  was  very  thoroughly  discussed.  The  remainder  of  the  hour 
was  occupied  in  the  demonstration  of  the  kidneys  in  a  case  of  acute  ne¬ 
phritis  in  which  macroscopically  there  were  no  changes  visible  in  the 
cortical  part,  but  with  the  microscope  extensive  glomerular  disease  was 
found.  The  post-mortem  room  is  oblong  in  shape,  with  a  large  central 
area,  around  which  are  three  tiers  of  seats  for  about  eighty  men.  A 
good  view  can  be  obtained  from  almost  any  part  of  the  room. 

Wurzburg  has  had  many  notable  professors  in  the  past  three  cent¬ 
uries,  but,  on  leaving  the  Pathological  Institute,  I  could  not  but  think 
of  the  young  Berlin  prosector  who  in  1849  found  it  desirable  to  accept 
a  chair  in  this  university,  and  who  in  the  succeeding  seven  (?)  years,  by 
a  brilliant  series  of  researches,  made  the  name  of  Virchow  imperishable 
in  our  annals  and  gave  the  glory  to  the  Wurzburg  school  of  a  majority 
of  those  epoch-making  works  in  the  Gesammelle  Abhandlunyen . 


00k  Ifafias. 


Syllabus  of  the  Obstetrical  Lectures  in  the  Medical  Department 
of  the  University  of  Pennsylvania.  By  Richard  0.  Norris, 
A.  M.,  M.  D.,  Demonstrator  of  Obstetrics,  University  of 
Pennsylvania.  Philadelphia:  W.  B.  Saunders,  1890.  Pp. 
xv-17  to  154.  [Price,  $2.] 

This  little  book,  prepared  for  the  class  in  obstetrics  at  the 
University  of  Pennsylvania,  presents  in  a  concise  form  an 
analysis  of  the  lectures  which  are  given  at  that  institution  upon 
that  subject.  Its  range  might  be  widened  with  profit,  and  it 
may  be  referred  to  with  advantage  by  students  in  obstetrics 
elsewhere,  not  only  by  those  who  are  still  students  in  theory, 
but  by  those  who  have  been  brought  into  practical  contact 
with  the  all-important  questions  of  the  obstetric  art. 


Hypnotism :  Its  History  and  Present  Development.  By  Fred- 
rik  Bjorxstrom,  M.  D.,  Head  Physician  of  the  Stockholm 
Hospital,  etc.  Authorized  Translation  from  the  Second 
Swedish  Edition.  By  Baron  Nils  Posse,  M.  G.,  Director  of 
the  Boston  School  of  Gymnastics.  New  York:  The  Hum¬ 
boldt  Publishing  Co.  Pp.  126.  [The  Humboldt  Library.] 
The  advantages  and  dangers  of  psycho-therapeutics,  together 
with  a  review  of  hypnotism  from  earlier  times  to  the  present, 
and  the  history  of  clinical  experience  with  this  agent,  form  the 
interesting  contents  of  Dr.  Bjornstroin’s  essay.  It  is  a  valuable 
contribution  to  the  literature  of  the  subject,  which  continues 
to  attract  general  attention.  A  little  learning  is  even  more 
dangerous,  perhaps,  when  it  is  a  question  of  hypnotism  than  in 
some  other  applications  of  medicine.  Hence  the  importance  of 
all  good  books  that  treat  of  this  particular  agent. 

The  Student's  Surgery.  A  Multum  in  Parvo.  By  Frederick 
James  Gant,  F.  R.  0.  S.,  Senior  Surgeon  to  the  Royal  Free 
Hospital.  Philadelphia:  Lea  Brothers  &  Co.,  1890.  Pp. 
xxxv-817.  [Price,  $3.75.] 

This  book  is  written  for  the  use  of  English  students  pre¬ 
paring  for  their  final  examination,  and  seems  to  be  unusually 
well  adapted  to  the  purpose  for  which  it  is  written.  The  ar- 


276 


BOOK  NOTICES.— MISCELLANY. 


[N.  Y.  Med.  Jodb., 


rangeraent  is  good,  it  is  written  very  closely,  and  deserves  its 
title  “  mnltura  in  parvo.”  The  omission  of  such  subjects  as  the 
surgery  erf  the  eye,  ear,  teeth,  skin,  female  genital  organs,  and 
orthopaedic  surgery  will  meet  with  general  approval,  for  these 
special  lines  of  surgery  have  been  developed  to  such  a  degree 
that  an  attempt  to  outline  each  would  require  either  the  omis¬ 
sion  of  much  that  is  valuable  or  a  great  increase  in  the  size  of 
the  book,  and  in  either  case  would  detract  from  its  value  to 
students. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

A  Treatise  on  Massage,  Theoretical  and  Practical ;  its  History,  Mode 
of  Application  and  Effects,  Indications  and  Contra-indications,  with  Re¬ 
sults  in  over  Fifteen  Hundred  Cases.  By  Douglas  Graham,  M.  D.,  Fel¬ 
low  of  the  Massachusetts  Medical  Society,  etc.  Second  Edition,  revised 
and  enlarged.  New  York:  J.  H.  Vail  &  Company,  1890.  Pp.  x-342. 

The  Essentials  of  Medical  Chemistry  and  Urinalysis.  By  Sam  E. 
Woody,  A.  M.,  M.  D.,  Professor  of  Chemistry  and  Public  Hygiene,  and 
Clinical  Lecturer  on  Diseases  of  Children,  in  the  Kentucky  School  of 
Medicine.  Third  Edition,  revised,  enlarged,  and  illustrated.  Philadel¬ 
phia:  P.  Blakiston,  Son,  &  Co.,  1890.  Pp.  viii-9  to  15 7. 

A  Library  of  American  Literature  from  the  Earliest  Settlement  to 
the  Present  Time.  Compiled  and  edited  by  Edmund  Clarence  Stedman 
and  Ellen  Mackay  Hutchinson.  In  Eleven  Volumes.  Vol.  XI.  New 
York:  Charles  L.  Webster  &  Company,  1890.  Pp.  xxvi-648. 

Fifth  Annual  Report  of  the  State  Board  of  Health  of  the  State  of 
Maine.  For  the  Fiscal  Year  ending  December  31,  1889. 

Menstruation  and  the  Removal  of  Both  Ovaries.  By  George  J. 
Engelmann,  A.  M.,  M.  D.,  etc.  [Reprinted  from  the  Transactions  of 
the  Southern  Surgical  and  Gynecological  Association .] 

Stricture  of  the  Rectum  :  a  Study  of  Ninety-six  Cases.  By  Charles 
B.  Kelsey,  M.  D.,  Professor  of  Diseases  of  the  Rectum  at  the  New  York 
Post-graduate  Medical  School  and  Hospital.  Pp.  3  to  41. 

The  Popularization  of  Sanitary  Science.  Annual  Address  before  the 
Third  District  Branch  of  the  New  York  State  Medical  Association  at 
Syracuse,  N.  Y.,  June  19,  1890.  By  J.  G.  Orton,  M.  D.  [Reprinted 
from  the  Sanitarian. \ 

Transactions  of  the  American  Dermatological  Association  at  its 
Thirteenth  Annual  Meeting,  held  at  the  Boston  Medical  Library,  Boston, 
Mass.,  on  the  17  th,  18th,  and  19th  of  September,  1889. 

Report  on  the  Cause  of  the  Recent  Outbreak  of  Typhoid  Fever  in 
Waterbury.  Made  to  the  Connecticut  State  Board  of  Health.  By 
Herbert  E.  Smith,  M.  D. 

Annual  Address  on  Practice  of  Medicine.  The  Mutual  Obligations 
and  Responsibilities  of  the  Physician  and  the  People  in  promoting 
Medical  Science.  By  W.  F.  Breakey,  M.  D.,  Ann  Arbor,  Mich.  [Re¬ 
printed  from  the  Proceedings  of  the  Michigan  State  Medical  < Society. \ 

Kurzer  Abriss  der  Perkussion  und  Auskultation.  Von  Dr.  Her¬ 
mann  Vierordt,  a.  o.  Professor  der  Medizin  an  der  Universitat  Tubingen. 
Dritte  verbesserte  Auflage.  Tubingen:  Franz  Fues,  1890.  Pp.  65. 

De  l’anesthesie  locale  par  injection  de  cocaine  et  du  bon  effet  de 
la  bande  d’Esmarch.  Par  le  Dr.  E.  Kummer,  Chirurgien  4  l’Hopital 
Butini.  [Extrait  de  la  Revue  el  Archives  suisses  d’’odontologie.~\ 

Report  of  the  Provost  of  the  University  of  Pennsylvania.  For  the 
Two  Years  ending  October  1,  1889.  With  Abstracts  from  the  Treas¬ 
urer’s  Annual  Reports. 

Proceedings  of  the  First  Annual  Meeting  of  the  Tri-State  Medical 
Association  of  Alabama,  Georgia,  and  Tennessee.  Held  in  Chatta¬ 
nooga,  Tenn.,  October  15  and  16,  1889. 

Second  Annual  Report  of  the  New  Amsterdam  Eye  and  Ear  Hospi¬ 
tal,  with  Nose  and  Throat  Department.  For  the  Year  ending  May  13, 
1890. 

Report  of  the  Trustees  of  the  Newport  Hospital.  Presented  to  the 
Corporation  at  their  Seventeenth  Annual  Meeting,  July  8,  1890. 

Appeal  for  a  Ward  for  Women  and  Children  at  the  Newport  Hos¬ 
pital. 

Altes  und  Neues  in  der  Therapie.  Akademische  Antrittsrede  gehal- 
ten  in  der  Aula  der  Universitat  Tubingen  am  2V.  Februar,  1890.  Von 
Dr.  Hermann  Vierordt,  a.  o.  Professor  der  Medizin.  Tubingen:  Franz 
Fues,  1890.  Pp.  3  to  26. 


gjtxstell  ann. 


The  Medical  Department  of  the  Army. — The  following  circular  of 

information  is  published  for  the  benefit  of  medical  men  who  may  be 
desirous  of  entering  the  United  States  Army  : 

The  Medical  Department  of  the  Army  consists  of  one  Surgeon-Gen¬ 
eral  with  the  rank  of  Brigadier-General ;  one  Assistant  Surgeon-Gen¬ 
eral,  one  Chief  Medical  Purveyor,  and  four  Surgeons  with  the  rank  of 
Colonel ;  two  Assistant  Medical  Purveyors  and  eight  Surgeons  with  the 
rank  of  Lieutenant-Colonel;  fifty  Surgeons  with  the  rank  of  Major; 
and  one  hundred  and  twenty-five  Assistant  Surgeons  with  the  rank  of 
First  Lieutenant  of  Cavalry  for  the  first  five  years  of  service,  and  of 
Captain  of  Cavalry  subsequently  until  their  promotion  by  seniority  to  a 
majority. 

With  the  rank  stated  in  each  case  the  pay  and  emoluments  of  the 
rank  are  associated.  The  salary  of  each  grade  is  a  fixed  annual  sum 
payable  monthly;  but  at  the  end  of  each  period  of  five  years  of  service 
the  annual  sum  representing  the  pay  of  the  grade  is  increased  by  ten 
per  cent,  until  forty  per  cent,  is  added.  After  twenty  years  of  service 
the  forty  per  cent,  additional  continues  to  be  drawn,  but  the  further 
increase  of  the  pay  by  ten  per  cent,  additions  ceases — i.  e .,  an  officer, 
although  he  may  have  served  twenty-five  or  thirty  or  more  years,  can, 
under  existing  laws,  have  no  more  than  forty  per  cent,  added  to  his  pay 
proper  by  way  of  increase  for  length  of  service.  The  pay  of  a  first 
lieutenant  of  cavalry,  or  of  a  medical  officer  during  the  first  five  years 
of  his  service,  is  $1,600  per  year,  or  $133.33  per  month.  At  the  expi¬ 
ration  of  his  five  years  of  service  he  becomes,  by  virtue  of  that  fact,  a 
captain,  and  his  pay  is  that  of  a  captain  of  cavalry,  $2,000  per  year, 
increased  by  ten  per  cent,  for  his  years  of  service — viz.,  $2,200  annual¬ 
ly,  or  $183.33  monthly.  At  the  end  of  his  tenth  year  of  service  this 
rate  of  pay  is  increased  by  the  service-addition  to  $2,400  annually,  or 
$200  per  month,  and  after  five  years  more  the  service-addition  makes 
his  pay  $2,600  annually,  or  $216.67  per  month.  If  he  continue  in  the 
rank  of  captain,  at  the  end  of  twenty  years  of  service  his  monthly  pay 
becomes  $233.33 ;  but  about  this  time  promotion  to  a  majority  is 
usually  obtained,  and  a  major’s  annual  pay  of  $2,500,  with  forty  per 
cent,  added,  makes  the  monthly  pay  of  the  major  and  surgeon  $291.67. 
Subsequent  promotion,  investing  the  individual  with  the  rank  of  lieu¬ 
tenant-colonel,  colonel,  and  brigadier-general,  augments  the  monthly 
pay  respectively  to  $333.33,  $375.00,  and  $458.33.  Compulsory  re¬ 
tirement  at  the  age  of  sixty-four  years  increases  the  rapidity  of  promo¬ 
tion  to  the  younger  men  ;  and  when  retirement  is  effected  either  by  age 
or  by  the  accidents  of  service  prior  to  reaching  the  retiring  age,  the 
rate  of  pay  subsequently  drawn  is  seventy-five  per  cent,  of  the  total 
salary  and  increases  of  the  rank  held  by  the  individual  at  the  time  of 
his  retirement.  Thus,  a  major  retired  for  broken  health  after  twenty 
years’  service  draws  seventy-five  per  cent,  of  $291.67  per  month;  a 
colonel  retired  for  age,  seventy-five  per  cent,  of  $375.00.  The  medical 
officer  has  the  right  of  selecting  quarters  in  accordance  with  his  rank, 
and  when  stationed  in  a  city  where  there  are  no  Government  quarters, 
commutation  money,  intended  to  cover  the  expense  of  house  rent,  is 
paid  to  him.  The  Government  provides  forage  and  stable  room  for  the 
horses  of  the  medical  officer,  and  when  traveling  under  orders  the  ex¬ 
penses  of  transportation  are  paid  by  the  Quartermaster’s  Department. 

Among  the  privileges  granted  to  medical,  as  to  other  officers  of  the 
army,  is  that  of  leave  of  absence  on  full  pay.  The  authorized  leave 
amounts  to  thirty  days  annually.  This  leave  is  not  forfeited  if  not 
taken  during  the  year,  but  is  credited  to  the  officer,  who  may  thus  ac¬ 
cumulate  a  continuous  leave  of  four  months  on  full  pay.  If  he  desires 
to  be  absent  for  a  longer  period  than  four  months,  and  the  permission 
is  accorded  him,  he  is  reduced  to  half-pay  for  all  time  in  excess  of  the 
four  months  or  maximum  of  cumulated  leaves  of  absence.  Absence 
from  duty  on  account  of  sickness  does  not  affect  the  relations  of  the 
officer  with  the  paymaster ;  he  continues  to  draw  full  pay. 

A  commission  in  the  Medical  Department  of  the  Army  is  an  instru 
ment  which  is  good  for  life,  premising  conduct  consistent  with  its  re¬ 
tention  on  the  part  of  its  possessor  ;  but  it  involves  no  contract  which 
binds  the  individual  to  service  for  any  given  number  of  years.  On  the 


Sept.  6,  1890.] 


MISCELLANY. 


277 


contrary,  should  the  medical  officer  find  on  experience  that  civil  life  has 
greater  attractions  for  him  than  that  of  the  army,  there  is  nothing  to 
prevent  him  from  at  any  time  tendering  the  resignation  of  his  com¬ 
mission. 

A  young  medical  officer  on  appointment  is  usually  assigned  to  duty 
for  a  few  months  at  some  large  post  where  there  are  other  officers  of 
his  department,  to  afford  him  opportunity  of  becoming  acquainted  with 
the  requirements  of  the  Army  Regulations  and  the  routine  duties  of 
military  life.  After  this  he  goes  to  some  post  west  of  the  Mississippi 
River,  where  he  serves  a  tour  of  duty  of  four  years.  An  assignment 
in  the  East  follows  the  leave  of  absence  which  is  usually  taken  at  this 
time ;  and  in  after  years  his  stations  are  selected  so  as  to  give  him  a 
fair  share  of  service  at  what  may  be  called  desirable  posts  as  an  offset 
to  the  time  spent  at  less  desirable  stations. 

Candidates  for  appointment  to  the  Medical  Corps  should  apply  to 
the  Secretary  of  War  for  an  invitation  to  appear  before  the  Army  Medi¬ 
cal  Board  of  Examiners.  The  application  should  be  in  the  handwriting 
of  the  applicant,  should  give  the  date  and  place  of  his  birth,  and  the 
place  and  State  of  which  he  is  a  permanent  resident ;  it  should  be  ac¬ 
companied  by  certificates  based  on  personal  acquaintance  from  at  least 
two  persons  of  repute  as  to  citizenship,  character,  and  moral  habits. 
Candidates  must  be  between  twenty-one  and  twenty-eight  years  of  age 
(without  any  exceptions),  and  graduates  of  a  regular  medical  college, 
evidence  of  which,  the  diploma,  must  be  submitted  to  the  Board.  The 
morals,  habits,  physical  and  mental  qualifications  and  general  aptitude 
for  the  service  of  each  candidate  will  be  subjects  for  careful  investiga¬ 
tion  by  the  Board,  and  a  favorable  report  will  not  be  made  in  any  case 
in  which  there  is  a  reasonable  doubt. 

The  following  is  the  general  plan  of  the  examination  : 

I.  The  physical  examination  will  be  rigid ;  and  each  candidate  will, 
in  addition,  be  required  to  certify  “  that  he  labors  under  no  mental  or 
physical  infirmity,  nor  disability  of  any  kind,  which  can  in  any  way  in¬ 
terfere  with  the  most  efficient  discharge  of  any  duty  which  may  be  re¬ 
quired.” 

II.  Oral  and  written  examinations  on  subjects  of  preliminary  edu¬ 
cation,  general  literature,  and  general  science.  The  Board  will  satisfy 
itself  by  examination  that  each  candidate  possesses  a  thorough  knowl¬ 
edge  of  the  branches  taught  in  the  common  schools,  especially  of  Eng¬ 
lish  grammar,  arithmetic,  and  the  history  and  geography  of  the  United 
States.  Any  candidate  found  deficient  in  these  branches  will  not  be 
examined  further.  The  examination  on  general  science  will  include 
chemistry  and  natural  philosophy,  and  that  on  literature  will  embrace 
English  literature,  Latin,  and  history,  ancient  and  modern.  Candidates 
claiming  proficiency  in  other  branches  of  knowledge,  such  as  the  higher 
mathematics,  ancient  and  modern  languages,  etc.,  will  be  examined 
therein,  and  receive  due  credit  for  their  special  qualifications. 

III.  Oral  and  written  examination  on  anatomy,  physiology,  surgery, 
practice  of  medicine,  general  pathology,  obstetrics  and  diseases  of 
women  and  children,  medical  jurisprudence  and  toxicology,  materia 
medica,  therapeutics,  pharmacy,  and  practical  sanitation. 

IV.  Clinical  examinations,  medical  and  surgical,  at  a  hospital,  and 
the  performance  of  surgical  operations  on  the  cadaver. 

Due  credit  will  be  given  for  hospital  training,  and  practical  expe¬ 
rience  in  surgery,  practice  of  medicine,  and  obstetrics. 

The  Board  is  authorized  to  deviate  from  this  general  plan  when¬ 
ever  necessary,  in  such  manner  as  it  may  deem  best  to  secure  the  in¬ 
terests  of  the  service. 

The  Board  reports  the  merits  of  the  candidates  in  the  several 
branches  of  the  examination,  and  their  relative  merit  in  the  whole, 
according  to  which  the  approved  candidates  receive  appointments 
to  existing  vacancies,  or  to  vacancies  which  may  occur  within 
two  years  thereafter.  At  the  present  time  there  are  three  vacancies  to 
be  filled. 

An  applicant  failing  in  one  examination  may  be  allowed  a  second 
after  one  year,  but  not  a  third. 

No  allowance  is  made  for  the  expenses  of  persons  undergoing  ex¬ 
amination,  but  those  who  are  approved  and  receive  appointments  are 
entitled  to  transportation  in  obeying  their  first  order  assigning  them  to 

duty. 

Copies  of  examination  papers  used  by  the  Board  in  session  in  New 


York  city  in  October  last  are  hereto  appended  as  an  illustration  of  the 
character  of  the  questions  submitted  to  candidates. 

John  Moore,  Surgeon-  General. 

Approved :  Redfield  Proctor,  Secretary  of  War. 

War  Department, 

Surgeon  General’s  Office, 

Washington,  D.  C.,  December  12,  1889. 

Specimens  of  Examination  Papers  used  by  the  Army  Medical  Examin¬ 
ing  Board ,  in  Session  in  New  York  City,  October,  1889. 

ARITHMETIC. 

1.  Change  '194  to  an  equivalent  fraction  whose  denominator  is  432. 

2.  How  many  inches  are  there  in  '0625  of  a  yard? 

3.  What  is  the  percentage  of  mortality  in  pneumonia  when  13 
deaths  occur  in  64  cases  ? 

4.  A  barometer  indicates  29  36  inches;  what  is  its  height  in  milli¬ 
metres  ? 

5.  9-1 1  :  13-83  ::  19-34  :  ? 

6.  What  is  the  cube  and  cube  root  of  3-6  ? 

7.  By  what  principle  of  trigonometry  is  the  distance  of  certain  stars 
ascertained  ?  Illustrate  by  diagram. 

8.  How  do  you  ascertain  the  solid  contents  of  a  cylinder  ? 

GEOGRAPHY. 

1.  Name  eight  rivers  of  the  United  States  that  empty  into  the  Gulf 
of  Mexico. 

2.  What  large  lake  in  the  United  States  is  at  the  greatest  altitude? 
Where  is  it  ?  And  what  is  its  approximate  elevation  ? 

3.  Give  the  boundaries  of  Montana,  and  briefly  mention  its  general 
geographical  features. 

4.  Describe  the  route  you  would  take  in  going  from  St.  Louis,  Mo., 
to  the  City  of  Mexico,  and  name  the  States  through  which  you  would 
pass. 

5.  Mention  two  or  three  cities  of  Europe  that  are  in  nearly  the  same 
latitude  as  New  York. 

6.  Name  the  capital  of  Saxony,  of  Bavaria,  and  of  Switzerland. 

7.  What  do  you  consider  to  be  a  small  and  what  a  large  annual 
rainfall  ? 

8.  A  storm  is  approaching,  passes  to  the  south  of  the  observer  in 
the  Eastern  United  States,  and  out  to  sea.  Describe  the  changes  of  the 
wind  that  would  occur. 

HISTORY  AND  LITERATURE. 

1.  Give  the  names  of  the  principal  Roman  deities,  and  the  corre¬ 
sponding  names  used  by  the  Greeks. 

2.  State  what  you  know  in  regard  to  the  date  and  object  of  the 
Magna  Charta, 

3.  Who  was  Galen  ?  And  in  what  century  did  he  live  ? 

4.  Give  a  brief  account  of  Mohammed.  In  what  century  did  he 
live  ? 

5.  Who  was  Frederick  the  Great  ?  Mention  some  of  his  victories. 

6.  Give  the  particulars  of  General  Arnold’s  treason. 

V.  Mention  the  leading  events  in  the  administration  of  President 
Madison. 

8.  Give  the  names  of  at  least  eight  of  Shakespeare’s  plays,  and  the 
approximate  dates  of  his  birth  and  death. 

9.  Mention  the  principal  works  of  Victor  Hugo. 

10.  Name  the  best-known  works  of  George  Eliot.  State  what  you 
know  about  this  writer. 

PHYSICS. 

1.  What  are  the  differences  between  the  solar  day  and  the  siderea- 
day? 

2.  What  portion  of  the  earth’s  quadrant  does  the  French  metre  rep¬ 
resent  ? 

3.  Does  the  weight  of  a  given  mass  increase  or  diminish  as  you  go 
from  the  equator  to  one  of  the  poles  ?  Give  the  reason. 

4.  Describe  the  Torricellian  vacuum. 

5.  Describe  the  process  of  ebullition. 

6.  What  is  Newton’s  first  law  of  motion  ? 

1.  What  is  osmosis?  What  effects  have  heat  and  electricity  on  it? 

8.  Which  color  of  the  solar  spectrum  is  produced  by  the  slowest  vi¬ 
bration  of  ether  waves  ? 


278 


MISCELLANY. 


[N.  Y.  Mud.  Joub., 


CHEMISTRY. 

1.  Explain  briefly  the  determination  of  atomic  weight  by  means  of 
specific  heat. 

2.  What  other  elements  belong  in  the  same  natural  group  with  sul¬ 
phur  ? 

3.  Describe  briefly  the  chemistry  of  glass-making. 

4.  State  the  physical  and  chemical  properties  of  aluminium. 

5.  Mention  some  of  the  analytical  reactions  of  the  proteids. 

6.  What  are  the  principal  fornls  in  which  nitrogen  enters  into  or¬ 
ganic  compounds  ? 

7.  What  ptomaines  have  been  isolated  ?  What  other  substances 
do  they  resemble  in  physiological  action  and  chemical  reaction  ? 

8.  Mention  some  tests  for  morphine. 

ANATOMY. 

1.  Give  the  origins  and  insertions  of  the  triceps  muscle  of  the  arm. 
State  its  actions,  and  describe  its  relations  to  neighboring  parts. 

2.  Give  the  origin,  course,  and  relations  to  neighboring  parts  of  the 
ophthalmic  artery,  and  name  its  branches  and  the  parts  to  which  they 
are  distributed. 

3.  Mention  the  nerves  that  supply  the  tongue,  and  describe  the  spe¬ 
cial  parts  supplied  by  each,  and  the  kind  of  nervous  supply  in  each  case. 

4.  Describe  the  structure,  location,  attachments,  and  relations  of 
the  ligamentum  denticulatum,  and  state  its  uses. 

5.  Describe  the  structure,  course,  and  relations  of  the  ureter  proper. 

6.  Describe  the  relations  of  the  trachea  in  the  neck. 

PHYSIOLOGY. 

1.  By  what  means  is  the  exchange  of  gases  between  the  blood  of 
the  pulmonary  capillaries  and  the  air  in  the  air  vesicles  effected,  and 
what  is  the  nature  of  the  process  ? 

2.  State  the  differences  between  gastric  and  pancreatic  digestion. 

3.  Describe  the  various  modes  of  origin  of  the  lymphatics  within 
the  different  tissues. 

4.  Describe  the  different  forms  of  reflex  action,  and  give  an  exam¬ 
ple  of  each. 

5.  State  the  changes  that  take  place  in  the  Graafian  follicle,  from 
which  the  ovum  has  been  discharged. 

SURGERY. 

1.  Describe  hospital  gangrene,  its  treatment,  constitutionally  and 
locally.  What  preventive  measures  check  its  spread  ? 

2.  What  are  the  constitutional  manifestations  of  secondary  and  ter¬ 
tiary  syphilis,  and  the  appropriate  treatment? 

3.  When  is  phlebotomy  demanded  ? 

4.  Describe  the  operation  of  exposing  the  inferior  dental  nerve  in 
its  course  in  the  body  of  the  bone. 

5.  What  are  the  indications  for  abdominal  section  or  laparotomy  ? 

6.  What  are  the  four  primary  forms  of  club-foot  ?  Name  the  con¬ 
tracted  muscles  in  each  variety. 

7.  What  pathological  condition  may  follow  ligation  of  veins? 

8.  Describe  the  various  operations  for  stone  in  the  bladder. 

PRACTICE  AND  PATHOLOGY. 

1.  What  are  the  anatomical  characters  of  lymphadenoma  ? 

2.  Give  the  pathology  of  uraemia. 

3.  What  are  the  pathological  results  of  chronic  alcoholism  ? 

4.  What  course  or  courses  of  treatment  would  you  pursue  in  cases 
of  acute  or  chronic  dysentery  ? 

6.  Give  an  account  of  the  treatment  of  acute  pneumonia. 

6.  What  are  the  causes  and  the  usual  location  of  rupture  of  the 
heart  ? 

7.  Give  the  clinical  history  of  chronic  diffuse  nephritis. 

8.  Give  the  symptoms  of  gout,  and  the  differential  diagnosis  of  gout 
and  rheumatism. 

9.  What  is  the  differential  diagnosis  of  the  eruptions  of  scarlatina, 
roseola,  and  measles  ? 

10.  Mention  the  principal  animal  parasites  of  man. 

OBSTETRICS  AND  DISEASES  OF  WOMEN  AND  CHILDREN. 

1.  What  are  the  causes  of  severe  vomiting,  in  pregnancy?  How 
can  it  be  controlled  ? 

2.  What  is  puerperal  eclampsia,  the  means  of  prevention,  and  the 
treatment  in  early  pregnancy  and  during  labor? 


3.  Describe  the  utero-placental  circulation. 

4.  Give  the  signs  of  pregnancy. 

5.  What  are  common  causes  of  abortion  ?  State  the  preventive 
measures,  and  the  treatment  when  it  occurs. 

6.  Give  the  causes  of  tedious  labor ;  mention  two  cases  and  the  ap¬ 
propriate  treatment  for  them. 

7.  What  are  the  most  dangerous  diseases  of  children  ? 

8.  What  are  the  earliest  symptoms  of  tetanus  nascentium  ?  What 
are  the  supposed  causes  of  it  ? 

MATERIA  MEDICA  AND  THERAPEUTICS. 

1.  Give  the  source  and  composition  of  eucalyptus;  name  its  ofti- 
cinal  preparations  and  dose  of  each ;  describe  its  physiological  actions, 
and  state  the  therapeutical  indications  for  its  use. 

2.  Give  the  officinal  preparations  of  the  mineral  acids  and  doses  of 
each ;  describe  their  physiological  actions,  and  mention  the  therapeuti¬ 
cal  indications  for  their  use. 

3.  Give  the  source  and  composition  of  guaiacum ;  name  its  officinal 
preparations  and  doses  of  each,  and  describe  its  physiological  actions 
and  the  therapeutical  indications  for  its  use. 

4.  Give  the  officinal  preparations  of  silver,  with  doses  of  each. 
Describe  its  physiological  actions,  and  mention  the  therapeutical  indi¬ 
cations  for  its  use. 

5.  Give  the  source  and  active  principles  of  ergot ;  name  the  offi¬ 
cinal  preparations,  and  describe  its  physiological  actions,  and  state  the 
therapeutical  indications  for  its  use. 

6.  Give  the  source  and  composition  of  erythroxylon  ;  name  its  offi¬ 
cinal  preparations,  and  describe  its  physiological  actions,  and  state  the 
therapeutical  indications  for  its  use. 

7.  Describe  the  physiological  actions  of  the  bromides. 

8.  Give  the  source  and  composition  of  gelsemium  ;  name  its  offi¬ 
cinal  preparations  and  dose  of  each  and  describe  its  physiological  ac¬ 
tions  and  the  indications  for  its  use. 

9.  Describe  the  physiological  actions  of  salicin  and  its  derivatives. 

HYGIENE. 

1.  What  amount  of  fresh  air  per  minute  should  be  furnished  for 
each  inmate  in  school-rooms,  audience-halls,  etc.  ? 

2.  What  are  the  effects  of  exercise  on  the  lungs  ? 

3.  What  are  the  possible  disadvantages  of  hot-air  furnaces,  and 
how  may  they  be  overcome  ? 

4.  What  is  the  source  and  the  nature  of  organic  impurities  in  drink 
ing-water  ? 

5.  What  can  you  say  of  the  composition  and  of  the  merits  of  rain¬ 
water  for  drinking  purposes  as  ordinarily  stored  ? 

6.  What  are  the  advantages  and  the  disadvantages  of  leavened 
bread  as  an  article  of  diet  ? 

7.  What  is  the  relative  amount  of  potential  energy  in  the  following 
proximate  alimentary  substances :  Dry  albuminate,  starch,  fat,  cane- 
sugar  ? 

8.  By  what  ordinary  means  may  milk  be  preserved  for  a  limited 
time  without  ice  ? 

9.  In  purifying  an  infected  apartment  by  burning  sulphur,  what 
quantity  of  sulphur  in  proportion  to  the  size  of  the  room  would  be 
sufficient  ? 

10.  What,  in  your  opinion,  is  the  best  method  of  disposing  of  ex¬ 
creta  ?  Give  your  reasons. 

Trance  following  Influenza. — In  the  Lancet  for  August  16th  Mr. 
Nathan  Raw,  of  the  Borough  Asylum,  Portsmouth,  England,  quotes 
Gowers  as  follows :  “  Trance  or  lethargy  as  it  occurs  spontaneously  is  a 
peculiar  sleep-like  state  from  which  a  patient  can  not  be  roused,  or  can 
be  roused  only  imperfectly,  and  which  is  not  due  to  organic  disease  of 
the  brain.”  He  then  relates  the  following  case :  Louisa  C.,  aged  thirty- 
nine,  married,  was  admitted  into  this  asylum  on  February  24,  1890. 
She  was  carried  from  the  cab  to  the  reception  room  in  a  helpless  state. 
She  could  not  sit  on  a  chair  unless  held  in  position,  without  which  she 
fell  to  the  ground.  Face  unusually  pale  ;  skin  bedewed  with  cold  per¬ 
spiration.  Eyes  closed ;  pupils  normal.  Limbs  relaxed,  but  when 
placed  in  any  position  remained  for  some  time,  until  overcome  by  gravita¬ 
tion.  She  was  apparently  unconscious,  and  could  not  be  roused.  Phys- 


Sept.  6,  1890.] 


MISCELLANY. 


icallv  she  is  a  stout,  strong  woman,  with  congenital  talipes.  Heart 
sounds  could  hardly  be  detected  even  with  stethoscope ;  pulse  could 
only  be  felt  as  a  minute  thread  at  the  wrist,  and  was  45  to  the  minute. 
Respiration  slow,  shallow,  and  quiet,  and  was  hardly  discernible,  12 
per  minute.  She  was  placed  in  a  warm  bath  and  vigorously  rubbed 
with  towels,  with  a  hope  of  restoring  her  to  consciousness.  Beyond 
slowly  opening  her  eyes  and  leisurely  looking  around,  this  had  no  effect, 
as  she  at  once  relapsed  into  her  former  unconscious  state.  She  as¬ 
sumed  the  dorsal  decubitus  with  her  arms  by  her  side,  and  unless  care¬ 
fully  examined  was  apparently  lifeless. 

March  3d. — For  the  last  seven  days  she  has  remained  in  exactly  the 
same  unconscious  state,  eyes  half  open,  conjunctival  reflex  present. 
Pupils  act  to  light.  Knee-jerks  much  exaggerated,  no  ankle  clonus. 
Apparent  cutaneous  anaesthesia,  as  pins  stuck  into  her  muscles  are  not 
felt.  Urine  and  faeces  passed  in  bed ;  has  refused  food  absolutely,  and 
has  been  fed  three  times  a  day  by  the  stomach  tube  with  milk,  eggs, 
brandy,  etc.  Nothing  seems  to  rouse  her.  Cold  water,  beyond  a  mo¬ 
mentary  reflex  effect,  is  useless ;  an  ice-bag  to  the  spine  and  a  strong 
current  of  electricity  are  of  no  avail.  The  nurse  on  special  duty  with 
her  this  afternoon  thought  she  was  dead.  When  seen  a  few  minutes 
after  she  was  apparently  lifeless,  breathing  almost  imperceptible,  and 
heart  sounds  could  not  be  detected  with  stethoscope.  A  galvanic  bat¬ 
tery  applied  over  the  region  of  the  heart,  artificial  respiration,  and  in¬ 
halation  of  nitrite  of  amyl  had  the  effect  of  restoring  her  vital  functions 
a  little. 

7th. — She  suddenly  opened  her  eyes  and  looked  around  her,  after 
remaining  unconscious  for  ten  days  ;  was  persuaded  to  take  a  cup  of 
tea ;  only  answered  questions  in  a  whisper. 

8th. — This  morning  she  was  cheerful,  talked  quite  rationally,  did 
not  know  where  she  was  or  when  she  came ;  had  no  memory  what¬ 
ever  for  the  events  of  the  last  ten  days ;  took  her  food  well,  and  sat 
up  in  bed. 

May  12th. — Talks  a  good  deal  about  religious  matters,  but  has  no 
delusions ;  went  out  to-day  on  a  month’s  trial. 

June  12th. — Was  discharged  this  day  recovered. 

The  following  is  the  history  as  given  by  the  patient :  She  has  al¬ 
ways  been  hysterical.  No  history  of  intemperance  or  insanity  in  the 
family.  For  several  years  she  has  been  a  diligent  student  of  the  Bible, 
and  thoroughly  believed  everything  therein  regarding  a  future  state. 
One  month  before  admission  two  of  her  children  were  taken  ill  with  in¬ 
fluenza;  after  their  recovery  she  herself  contracted  the  disease,  and  had 
a  most  severe  attack.  The  pain  in  her  head  was  excruciating,  and  she 
was  quite  prostrate  in  mind  and  body  for  two  weeks.  After  spending 
an  anxious  day  she  relapsed  into  a  deep  sleep,  during  which  she  had  a 
dream,  and  was  awakened  by  a  loud  voice,  which  said,  “You  are  dead.” 
She  felt  quite  helpless,  and  lay  in  this  state  for  two  days,  absolutely  re¬ 
fusing  all  food.  When  visited  by  the  doctor  she  informed  him  she  was 
dead,  and  wished  to  be  buried.  She  was  at  once  removed  to  this  asy¬ 
lum  as  insane.  She  remembers  coming  into  the  gates  of  the  grounds, 
which  she  thought  was  the  cemetery.  She  says  that  had  she  been  put 
into  a  grave  she  could  have  offered  no  resistance. 

Remarks. — Some  very  interesting  clinical  points  arise  in  this  most 
unusual  case.  The  condition  of  trance  is  exceedingly  rare  in  this 
country,  Gowers  having  seen  only  four  cases.  Regarding  the  diagnosis 
of  the  case,  I  am  not  yet  satisfied  as  to  the  true  mental  condition.  Here 
is  a  woman  whose  physical  and  mental  powers  are  exhausted  with  the 
care  and  anxiety  of  nursing  her  sick  children ;  then  she  is  herself  pros¬ 
trated  by  a  severe  physical  illness  with  great  mental  depression.  She 
is  not  predisposed  to  insanity  either  by  hereditary  transmission  or 
otherwise,  but  she  is  undoubtedly  hysterical  and  emotional.  Was  the 
woman  insane  ?  The  voice  which  she  heard  was  not  a  true  hallucina¬ 
tion,  as  she  was  unconscious  from  sleep  at  the  time.  Legally,  she  was 
insane  without  a  doubt ;  she  was  not  responsible  for  her  actions,  and 
would  have  probably  died  from  want  of  food,  the  diagnosis  thus  rest¬ 
ing  between  (1)  delusional  insanity,  (2)  hysteria,  (3)  catalepsy,  and  (4) 
trance.  She  was  not  suffering  from  catalepsy,  as  evidenced  by  the  ab¬ 
sence  of  muscular  rigidity  ;  nor  were  the  symptoms  purely  hysterical, 
as  shown  by  the  utter  impossibility  to  restore  her  to  consciousness. 
Then  regarding  insanity  pure  and  simple,  this  is  negatived  by  the  fact 
that  she  has  no  memory  whatever  for  what  occurred  during  those  ten 


279 

days,  and  the  sudden  and  complete  recovery  from  all  the  symptoms.  I 
am  inclined  to  think  that  this  was  a  case  in  which,  from  severe  nervous 
exhaustion  and  with  a  predisposition  to  emotion,  the  patient’s  mind  was 
temporarily  unhinged,  and  that  the  trance  condition  was  due  to  an  in¬ 
hibition  or  arrest  of  action  of  the  nerve  cells,  probably  from  previous 
exhaustion. 

Sea  Voyages. — “A  correspondent  writes:  ‘I  am  glad  to  see  in  the 
Lancet  an  article  saying  so  much  in  favor  of  sea  voyages,  but  I  think 
you  have  omitted  one  very  important  point — viz.,  the  very  great  advan¬ 
tages  of  a  sailing  ship  over  a  steamship,  such  as  the  greater  cleanli¬ 
ness,  freedom  from  smoke,  and  especially  the  freedom  from  that  most 
unpleasant  oily  smell  of  the  engines,  also  the  greater  size  of  the  cabins. 
I  speak  from  experience  of  a  voyage  to  Australia  and  back  in  sailing 
ships,  from  which  I  derived  much  benefit.  I  was  lately  in  a  steamship 
and  was  greatly  surprised  at  the  difference  ;  go  where  I  would  on  the  ship, 
I  could  never  escape  from  that  oily  smell  of  the  engines.  The  food  on 
the  sailing  ship  was  very  good  indeed.’  Exigencies  of  space  forbade  a 
comparison  of  the  merits  of  sailing  vessels  and  steamships  in  the  ar¬ 
ticle  to  which  our  correspondent  refers.  The  point  is,  however,  well 
worthy  of  attention,  and  the  advantages  of  a  sailing  vessel  enumerated 
above  are  real  and  important.  A  sailing  vessel  is  usually  cleaner, 
quieter,  and  roomier  (in  proportion  to  the  number  of  passengers)  than  a 
steamer,  and  on  a  long  sea  voyage  the  importance  of  cleanliness,  quiet, 
and  space  can  hardly  be  overestimated.  If  no  other  considerations 
had  weight,  it  would  not  be  difficult  to  lay  down  the  rule  that  for  in¬ 
valids  a  sailing  vessel  should  always  be  preferred  to  a  steamer.  But 
the  question  is  more  complicated  than  our  correspondent's  letter  would 
seem  to  indicate.  A  sailing  vessel  is  open  to  the  objections  that  the  voyage 
is  sometimes  very  prolonged  and  monotonous,  that  the  detention  in  the 
hot  and  moisture-laden  atmosphere  of  the  Belt  of  Calms  may  extend  to  a 
week  or  a  fortnight,  and  is  a  very  trying  time,  and  that  few  or  no  op¬ 
portunities  are  afforded  for  touching  at  ports  to  obtain  fresh  vegeta¬ 
bles,  fruit,  etc.  Some  animals,  such  as  pigs  and  ducks,  thrive  well  at 
sea,  and  their  flesh  remains  agreeable  and  nutritious ;  but  sheep  and 
bullocks,  not  to  mention  chickens,  turkeys,  etc.,  nearly  always  show 
more  or  less  deterioration  in  the  quality  of  their  meat  after  a  few  weeks 
at  sea.  Steamships  with  their  ice  chambers  can  surmount  this  disad¬ 
vantage,  but  it  is  generally  more  or  less  felt  on  sailing  ships,  above  all 
if  the  voyage  is  very  prolonged.  There  is  another  point  that  must  be 
kept  in  view  in  considering  this  question — viz.,  that  steamships  are 
more  and  more  driving  sailing  ships  out  of  the  trade,  and  that  the 
choice  among  the  former  is  very  much  wider  than  among  the  latter. 
We  mention  these  facts  in  order  that  the  pros  and  cons  of  the  case  may 
be  kept  before  our  readers,  but  we  by  no  means  wish  to  imply  that 
steamships  should  generally,  and  as  a  matter  of  routine,  have  the  pref¬ 
erence  over  sailing  vessels.  .  .  .  Much  will  turn  upon  the  patient’s 
malady,  and  upon  his  general  constitutional  state  and  usual  mode  of 
life.  For  serious  cases  (when  such  can  be  prudently  sent  to  sea  at  all) 
a  sailing  vessel,  always  provided  that  reasonable  comfort  can  be  assured, 
will  generally  be  preferable.  Life  on  a  steamship  is  too  much  like  life 
in  a  hotel  to  suit  such  cases.  Again,  if  the  patient  be  specially  desir¬ 
ous  of  perfect  rest  and  quiet,  a  sailing  vessel  will  best  meet  the  case. 
On  the  other  hand,  if  the  case  be  one  mainly  requiring  change  and 
travel,  if  the  patient  likes  company  and  must  have  variety  and  amuse¬ 
ment,  and  if  he  can  not  be  content  without  a  very  liberal  and  constantly 
varied  dietary,  then  a  first-class  steamship  will  probably  please  him 
best.  Some  patients,  again,  want  ‘  to  see  the  world,’  and  take  great 
delight  in  the  various  calls  made  at  different  ports.  Such  persons 
must  remember  that  sailing  vessels  hardly  call  anywhere,  and  very  com¬ 
monly  make  the  long  voyage  to  the  Antipodes  in  a  single  run.  Proba¬ 
bly  a  well-appointed  yacht  affords  the  best  type  of  what  is  most  desira¬ 
ble  for  travelers  by  sea ;  and,  while  such  is  only  at  the  disposal  of  a 
very  limited  number  of  patients,  it  is  possible  that  ‘  invalid  ships,’ 
which  are  now  becoming  a  recognized  institution,  may  be  gradually  ap¬ 
proximated  in  some  degree  to  this  type.” — Lancet. 

Sugar  in  the  Blood. — “The  condition  known  as  mellitaemia,  or  the 
presence  of  sugar  in  the  blood,  has  long  been  recognized.  Pavy, 
Ewald,  Seegen,  and  Otto  have  demonstrated  beyond  doubt  that  sugar  is 
a  normal  constituent  of  the  blood,  although  it  is  present  only  in  very 


280 


MISCELLANY. 


[N.  Y.  Med.  Jour. 


small  proportions :  the  quantity  is  not  altered  when  the  blood  is  ana¬ 
lyzed  after  death.  The  proportion  of  sugar  in  the  blood  is  considerably 
raised  in  cases  of  diabetes.  In  1885  Freund  examined  the  blood  of 
seventy  patients  suffering  from  carcinoma,  and  found  it  to  contain  a 
large  quantity  of  sugar,  but  he  was  unable  to  detect  it  in  cases  of  sar¬ 
coma.  Freund’s  experiments  have  not  been  fully  verified  by  other  ob¬ 
servers.  In  the  Centralblatt  fur  die  medicinischen  Wissemchaften,  1890, 
No.  25,  Trinkler  gives  an  interesting  account  of  a  series  of  observations 
he  has  made  as  regards  the  amount  of  sugar  contained  in  the  blood  in 
various  diseases.  He  examined  the  blood  of  one  hundred  and  nine  pa¬ 
tients,  and  the  investigation  fell  into  two  classes :  1.  Quantitative  esti¬ 
mation  of  sugar  and  reducing  substances  in  the  blood  during  life,  the 
quantity  of  blood  required  being  obtained  during  the  performance  of 
operations.  2.  In  which  the  greater  number  of  analyses  took  place 
after  death.  The  diseases  from  which  the  patients  were  suffering  were 
carcinoma,  typhoid  fever,  pneumonia,  morbus  cordis,  dysentery,  peri¬ 
tonitis,  nephritis,  uraemia,  etc.  Sugar  was  found  to  be  present  in  all 
the  cases.  In  carcinoma  the  amount  was  very  large ;  next  came  typhoid 
fever  and  pneumonia,  while  nephritis  and  uraemia  exhibited  the  least. 
In  the  case  of  carcinoma  the  following  conclusions  could  be  drawn :  1. 
The  blood  of  patients  suffering  from  carcinoma  always  contained  a  con¬ 
siderable  percentage  of  reducing  substances,  of  which  the  chief  was 
grape  sugar.  2.  The  maximum  percentage  of  sugar  in  the  blood  of 
living  patients  was  less  than  the  maximum  obtained  after  death.  3. 
Carcinoma  affecting  the  internal  organs  produced  a  greater  quantity  of 
sugar  than  when  attacking  superficial  structures  (skin,  mucous  mem¬ 
branes).  4.  The  degree  of  cachexia  stood  in  no  direct  proportion  to 
the  percentage  of  sugar  in  the  blood.  The  quantity  of  sugar  in  acute 
pneumonia,  typhoid  fever,  and  dysentery  was  about  the  same,  and  very 
little  above  the  normal ;  while  in  nephritis,  and  especially  in  uraemic 
conditions,  the  quantity  was  below  the  normal.” — Lancet. 

Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  August  29th : 


CITIES. 

Week  ending — 

Estimated  popu¬ 
lation. 

Total  deaths  from 
all  causes. 

DEATHS 

FROM 

— 

03 

'© 

O 

<a> 

> 

£ 

£ 

© 

13 

r* 

X 

c 

— 

~ 

13 

£ 

o 

03 

> 

03 

13 

*E 

03 

V 

00 

3 

f 

H 

U. 

$ 

> 

£ 

3 

o 

W 

> 

£ 

© 

1 

.2 

’E 

© 

5 

Cl, 

5 

CO 

V 

r. 

<u 

£ 

■ 

be 

^  A 

g.  be 

S  3 
£  8 

£ 

New  York,  N.  Y . 

Aug.  23. 

1,638,498 

751 

12 

4 

u 

12 

16 

Philadelphia,  Pa . 

Aug.  16. 

1,064,277 

337 

11 

9 

9 

16 

Brooklyn,  N.  Y . 

Aug.  16. 

871,852 

386 

1 

9  19 

ID 

Brooklyn,  N.  Y . 

Aug.  23. 

871,852 

369 

1 

2 

6 

4 

7 

Baltimore,  Md . 

Aug.  23. 

500^343 

141 

5 

8 

4 

St.  Louis,  Mo . 

Aug.  16. 

450,000 

169 

4 

1 

3 

St.  Louis,  Mo  . 

Aug.  23. 

450,000 

4 

1 

2 

Boston,  Mass . 

Aug.  23. 

437,245 

200 

6 

5 

Washington,  D.  C  .. . 

Aug.  23. 

250,000 

83 

6 

2 

1 

Cincinnati,  Ohio . 

Aug.  22. 

325,000 

41 

9 

8 

Detroit,  Mich . 

Aug.  16. 

230,000 

86 

1 

5 

Milwaukee,  Wis . 

Aug.  22. 

220,000 

66 

9 

4 

i 

Minneapolis,  Minn... 

Aug.  16. 

200,000 

65 

5 

3 

Minneapolis,  Minn... 

Aug.  23. 

200,000 

53 

3 

O 

2 

Rochester,  N.  Y . 

Aug.  16. 

135,000 

57 

i 

Kansas  City,  Mo . 

Aug.  23. 

132,000 

28 

1 

Providence,  R.  1 . 

Aug.  23. 

130,000 

70 

3 

1 

Indianapolis,  Ind .... 

Aug.  22. 

129,346 

28 

4 

2 

Richmond,  Ya . 

Aug.  16. 

100,000 

40 

4 

2 

Richmond,  Va . 

Aug.  23. 

100,000 

35 

9 

9 

Toledo,  Ohio . 

Aug.  23. 

81,650 

20 

Nashville,  Tenn . 

Aug.  23. 

75,695 

33 

3 

Fall  River,  Mass . 

Aug.  23. 

74,918 

.33 

Charleston,  S.  C . 

Aug.  16. 

60,145 

37 

2 

Charleston,  S.  C . 

Aug.  23. 

60,145 

31 

1 

Manchester,  N.  H. .  . . 

Aug.  23. 

44.000 

Portland,  Me . 

Aug.  23. 

42,000 

15 

“ 

Binghamton,  N.  Yr . . . 

Aug.  23. 

35,000 

13 

Yonkers,  N.  Y . 

Aug.  15. 

32,000 

13 

1 

Yonkers,  N.  Y . 

Aug.  23. 

32,000 

10 

1 

Auburn,  N.  Y . 

Aug.  23. 

26.1X10 

8 

1 

Newton,  Mass . 

Aug.  23. 

22,011 

5 

Rock  Island,  Ill . 

Aug.  17. 

16,000 

2 

Pensacola,  Fla . 

Aug.  16. 

15,000 

4 

1 

Sickness  as  a  Teacher. — “All  the  circumstances  of  life,”  says  the 
Lancet ,  “  are  in  some  sort  educative.  Health  and  happiness  have  their 
lesson  of  active  duty  to  teach  us  if  we  will  receive  it,  and  so,  likewise, 
have  pain,  disease,  and  misfortune,  as  lately  stated  by  Mr.  Spurgeon,  a 
purpose  of  correction,  a  chastening  and  a  mellowing  influence  within 


them.  With  some  natures  and  moods,  perhaps,  it  is  otherwise ;  the 
sharpness  of  the  stroke  touches  no  mental  spring  but  that  of  self-con¬ 
cern,  but  here,  again,  it  is  the  wise  who  learns.  For  him  these  evils, 
for  such  they  still  remain,  are  also  the  seeds  of  sympathy  with  others 
in  like  trouble.  If  he  be  through  any  fault  of  his  own  accountable  for 
them,  they  are  in  true  science  as  in  Scripture  the  natural  recompense  of 
evil,  a  protest  on  behalf  of  needful  self-control  which  he  will  do  well  to 
observe.  There  is  more,  therefore,  than  an  apparent  tendency  to  asceti¬ 
cism  in  this  doctrine  of  disciplinary  suffering.  Of  course,  it  does  not 
follow  that  the  prosperous  and  the  healthy  mu3t  at  some  time  undergo 
this  training  by  reverses.  The  same  lessons  of  patience,  fellow-feeling, 
and  self-restraint  can  be  learned  in  other  ways,  and  it  is  quite  certain 
that  the  daily  round  and  task  abound  in  opportunities  for  such  whole¬ 
some  instruction.  We  are  alike  justified,  therefore,  in  admitting  for 
this  purpose  the  frequent  utility  of  pain,  and  in  seeking,  to  the  best  of 
our  ability,  to  limit  and  to  destroy  by  suitable  remedies  the  influence  of 
this  otherwise  harsh  and  hurtful  instructor.  Health  of  mind  and  body 
and  well-being  of  estate  are  alone  consistent  with  perfect  life  as  or¬ 
dered  by  Nature’s  plan  and  the  Divine  will,  and  every  purpose  of  train¬ 
ing  is  compatible  with  their  full  possession  and  their  proper  use.” 


To  Contributors  and  Correspondents. — The  attenlioiuof  all  who purjme 

favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  ”  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (2)  when  a  manuscript  is  sent  to  this  jour¬ 
nal ,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  ( 3 )  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors,  arc 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  prrofession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


HE  NEW  YORK  MEDICAL  JOURNAL,  September  13,  1890. 


$  e  c  t  xt  r  t  s  anb  ^bbrcsscs. 


THE  BLOOD  AND  BLOOD-YESSELS  IN 
HEALTH  AND  DISEASE. 

r  ADDRESS  DELIVERED  BEFORE  THE  OTTAWA  MEDICAL  SOCIETY, 

May,  1890. 

By  WESLEY  MILLS,  M.  A.,  M.  D., 

PROFESSOR  OF  PHYSIOLOGY  IN  MCGILL  UNIVERSITY,  MONTREAL. 

Gentlemen  :  Our  knowledge  of  any  subject  may  per- 
,ps  be  regarded  as  a  perception  of  relations.  As  these, 
>wever,  are  innumerable,  tbe  great  question  becomes, 
hat  relations  are  of  the  most  importance?  From  what 
>int  of  view  shall  we  look  at  a  subject?  Necessarily  this 
ust  vary  with  the  progress  of  all  knowledge  mid  with  that 
any  department  under  consideration. 

When  the  period  of  derision  and  skepticism  that  fol- 
wed  at  once  the  announcement  of  the  discovery  of  the 
rculation  of  the  blood  by  Harvey  had  passed  away,  and  a 
•dy  of  practitioners  less  prejudiced  than  the  great  man’s 
in  contemporaries  considered  the  subject,  a  reaction  took 
ace.  Undue  attention  was  given  the  blood  in  all  discus- 
in  on  the  {etiology  of  disease. 

In  comparatively  recent  times  the  investigations  of 
ood-pressure  and  kindred  problems  by  Ludwig  and  his 
hool  diverted  attention  unduly  to  that  subject,  and  the 
tluence  of  this  is  evident  in  almost  every  text-book  on 
lysiology  at  present  extant.  Believing  myself  that  physi- 
ogy  has  been  confined  within  extremely  narrow  limits, 
at  it  must  in  consequence  suffer  from  the  intellectual  myo- 
a  of  its  cultivators,  I  have  within  the  past  year  endeav- 
ed  to  present  to  the  student  of  this  science  a  work  *  on 
new  plan,  and  it  is  my  purpose  this  evening  to  ask  your 
nsideration  to  its  advantages,  which  I  shall  endeavor  to 
esent  as  applied  to  the  subject  of  this  address,  and  leave 
>u  to  judge  for  yourselves  whether  this  method  of  view- 
g  the  subject  gives  a  wider  and  truer  view  of  physiological 
iiths  than  the  older  plan  or  not. 

We  all  recognize  the  fact  that  any  individual  can  be  but 
differently  understood  apart  from  his  antecedents;  hence 
e  importance  we  attach  to  biographical  sketches  of  those 
■rsons  that  interest  us.  It  is  really  an  acknowledgment 
the  influence  of  the  environment  on  the  organism,  both 
iring  its  own  life-time  and  that  of  its  ancestors. 

Why,  then,  is  not  the  consideration  of  every  function 
the  body  preceded  by  an  account  of  the  development  of 
e  structures  involved  as  well  as  by  ordinary  anatomical  or 
stological  details? 

No  advanced  morphologist  hopes  to  clear  up  the  rela¬ 
ms  of  any  animal  group  without  taking  its  embryology 
to  consideration.  Up  to  the  present  this  method  has 
ien  almost  wholly  ignored  by  physiologists.  Allow  me  to 
ggest  in  this  connection  a  few  considerations  which  seem 
put  the  student  in  the  possession  of  a  clew  to  otherwise 
‘ry  obscure  relations. 

*  A  Text-book  of  Animal  Physiology.  D.  Appleton  &  Co.,  New 

>rk,  October,  1890. 


All  are  agreed  that  whatever  the  later  history  of  the 
blood-cells,  they  arise  in  the  embryonic  mesoblast  at  the 
same  time  as  the  heart  and  blood-vessels  themselves.  To 
consider,  therefore,'  the  heart,  blood-vessels,  and  blood 
wholly  separately,  or  without  a  perception  of  their  unity,  is 
a  mistake  that  has  practical  as  well  as  theoretical  conse¬ 
quences.  When  we  bear  this  relation  in  mind,  it  is  possi¬ 
ble  to  understand  that  there  may  be  cases  in  which  the 
whole  vascular  system,  including  the  contained  blood,  may 
be  imperfectly  developed,  and  with  all  the  consequences  of 
recurrent  anaemia.  There  can  be  no  doubt  that  any  crop 
of  blood-cells  must  bear  relations  to  the  preceding  one,  and 
if  the  original  ancestors  are  defective,  their  descendants  are 
likely  to  be  similarly  weak,  apart  from  any  unfavorable  cir¬ 
cumstances  in  the  environment. 

Until  recently  the  functions  of  the  white  corpuscles,  if 
considered  at  all  in  works  on  physiology,  were  dismissed 
in  a  very  few  lines.  When  we  remember  that  the  leuco¬ 
cytes  of  the  blood  correspond  to  the  original  indifferen- 
tiated  embryonic  cells,  which  alone  have  made  up  the  entire 
embryo  and  are  preserved  as  floating  organisms  with  a 
latent  capacity  for  further  development,  much  light  is 
thrown  upon  both  physiological  and  pathological  processes. 
Whatever  the  view  that  finally  prevails  as  to  their  relations 
to  invading  micro-organisms,  there  can  be  no  doubt  that  as 
scavengers,  porters,  or  phagocytes  their  function  is  of  great 
importance;  yet,  apart  from  a  consideration  of  their  origin, 
this  can  be  but  indifferently  understood.  It  is  well  known 
that  the  undifferentiated  cells  of  the  embryo  are  more  or 
less  amoeboid  organisms  ;  hence  it  is  perfectly  natural  that 
their  descendants  should,  under  suitable  circumstances,  ex¬ 
hibit  those  qualities  which  recent  investigators  are  showing 
more  and  more  that  they  possess.  The  great  part  they 
play  in  inflammation  is  also  more  readily  comprehended.  In 
this  condition  there  is  a  profound  alteration  in  the  environ¬ 
ment,  as  will  be  shown  later. 

At  present  our  positive  and  clear  knowledge  of  the  red 
cells  of  the  blood  is  confined  to  their  oxygen-carrying  func¬ 
tion  ;  but  I  feel  satisfied  that  this  does  not  include  all  their 
work  and  that  we  must  look  for  a  very  considerable  en¬ 
largement  of  our  knowledge  of  the  range  of  their  duties. 
Indeed,  it  would  seem  that  we  are  in  great  danger  now  of 
going  to  an  extreme  the  opposite  of  that  of  our  ancestors 
and  attributing  too  little  to  the  blood,  especially  its  cells. 
It  is  not  to  be  forgotten  that  the  blood  as  a  whole  is  to  be 
regarded  as  a  tissue,  and  there  is  no  more  reason  why  this 
tissue  should  be  devoid  of  functions  than  any  other. 

Most  of  our  works  on  physiology  so  present  the  subject 
to  the  student  that  he  has  no  clear  ideas  as  to  how  the  blood 
does  minister  to  the  tissues,  though  every  one  is  ready  to 
say  at  once  that  the  function  of  the  blood  is  “  to  nour¬ 
ish  the  tissues.”  In  truth,  some  very  remarkable  doctrines 
have  been  taught  in  regard  to  the  relations  of  the  blood 
and  blood-vessels.  As  a  rule,  students  have  the  most  misty 
notions  of  the  relations  and  importance  of  the  lymph.  They 
know  that  it  flows  in  “the  lymphatics,”  that  it  gets  into 
the  blood-stream  finally,  that  it  is  in  some  way  derived 
from  the  blood,  etc.  But  there  is  no  clear  perception  of 


282 


MILLS:  THE  BLOOD  AND  BLOOD-VESSELS  IN  HEALTH  AND  DISEASE.  [N.  Y,  Mbd.  Jo 


these  relations,  and  it  is  impossible  that  there  should  be 
with  the  teachings  that  are  prevalent. 

The  books  represent  the  lymph  as  passing  through  the 
capillaries  ;  but,  if  any  explanation  of  this  process  is  given 
at  all,  it  is  represented  as  a  filtration — very  much  of  the 
character  of  that  “  filtration  ”  of  urine  through  the  capil¬ 
laries  of  the  Malpighian  capsules  which  has  been  so  com¬ 
monly  taught  up  to  the  present  as  dependent  almost  solely 
on  blood  pressure. 

This  doctrine  has  seemed  to  me  so  utterly  at  variance 
with  all  sound  biological  laws  that  for  three  or  four  years 
I  have  been  accustomed  to  teach  in  my  lectures,  aud  have 
recently  published  in  my  text-book,  a  theory  which  I  must 
present  to  you  with  brevity,  but  which  I  am  sure  you  will 
see  places  the  physiologist,  the  pathologist,  and  the  prac¬ 
titioner  of  medicine  on  an  eminence  from  which  they  can 
view  the  events  of  the  body  in  an  entirely  new  light.  It  is 
simply  this  :  The  capillaries  of  the  body  are  glands.  They 
are  glands  not  only  in  the  glomeruli  of  the  kidney,  but 
everywhere  else.  So  far  as  I  know,  I  have  been  the  first  to 
teach  this  doctrine  ;  I  must  therefore  give  you,  at  least  in  a 
general  way,  the  reasons  for  my  conviction. 

In  the  first  place,  I  should  be  prejudiced  against  any  bi¬ 
ological  doctrine  that  would  represent  a  living  structure  as 
acting  as  a  mere  filter,  or  as  teaching  that  osmosis  played  any 
considerable  part  or,  in  the  strict  sense,  any  part  at  all  when 
living  structures,  “  membranes  ”  or  other,  were  concerned. 
There  seem  to  be  no  facts  that  can  not  be  better  explained 
without  such  an  assumption  ;  and,  even  if  this  were  not 
the  case,  it  is  better  not  to  construct  a  theory  at  all,  but 
simply  confess  ignorance  and  wait,  than  one  which  like 
this  is  radically  opposed  to  all  sound  conception  of  living 
structure. 

To  believe  that  the  lymph  which  bathes  each  tissue  is 
identical  in  composition  is  to  overlook  the  relations  of  the 
blood  and  blood-vessels  to  the  tissues  among  which  they 
have  been  developed.  But  the  lesson  Nature  everywhere 
teaches  is  that  things  do  work  in  relation  to  each  other. 

What  a  crude  conception  of  life  processes  to  suppose 
that  the  capillaries  pour  out  a  fluid  around  the  cells  of  the 
tissues  whose  composition  is  not  specially  related  to  the 
needs  or  peculiarities  of  each  one ! 

But  the  facts  we  do  know  are  opposed  to  such  a 
view. 

All  exudations  or  transudations  are  not  alike  in  chemi¬ 
cal  composition  ;  nor  are  passive  exudations  identical  with 
inflammatory  ones.  Can  osmosis  explain  this?  Can  it  ex¬ 
plain  why  an  inflammatory  exudation  does  not  correspond 
with  the  normal  tissue-lymph  ?  Can  it  give  a  reason  why 
there  are  coagulable  proteids  in  lymph  or  any  of  the  fluids 
that  are  derived  from  the  blood  at  all  ?  While  the  facts 
can  not  be  explained  by  osmosis,  they  are  all  simple  enough 
when  we  view  the  capillaries  as  glands — i.  e.,  as  passing 
from  the  blood  to  the  tissues,  and  the  reverse,  an  elaborated 
fluid  which  varies  with  the  condition  of  the  cells  composing 
the  capillary  and  the  tissue-cells  that  surround  it.  That  the 
condition  of  the  blood  can  modify  the  capillaries,  the  latter 
the  blood  and  the  tissues  both,  is  to  my  mind  clear  enough. 
To  put  it  otherwise:  The  tissue-cells  around  a  capillary,  the 


—  —  ■  —  — ■ 

capillary  cells  themselves,  and  the  blood  are  always  in  asor 
of  balanced  relation.  They  understand  each  other,  so  t 
speak,  and  act  in  harmony.  One  can  not  be  disturbed  witl 
out  affecting  the  other. 

WThen  a  great  derangement  occurs,  what  we  call  inflam 
mation  arises,  and,  sooner  or  later,  all  the  parts  of  this  ir 
separable  trio  become  involved.  In  inflammation  we  hav 
changes  in  the  blood-cells,  changes  in  the  vessel-walls,  an 
changes  in  the  surrounding  tissue-cells.  The  embryologies 
history  should  have  led  us  to  expect  all  this. 

When  this  relation  of  the  capillaries  as  secreting  mechar. 
isms  is  understood,  many  of  the  difficulties  that  surroum 
“  digestion  ”  and  “  absorption  ”  will  be  removed.  Tim 
will  not  allow  of  my  developing  this  part  of  the  subject  a 
length  now.  In  my  opinion,  there  is  no  sharp  line  to  b 
drawn  between  digestion  and  absorption.  They  are  part 
of  one  great  series  of  processes.  Not  only  so,  but  the  ten 
absorption  is  misleading,  as  it  suggests  purely  physical  pr< 
cesses,  which  latter  must  always  be  dealt  with  very  cai 
tiously  by  physiologists. 

If,  for  example,  we  regard  the  capillaries  of  the  alimeni 
ary  tract  as  glands,  it  will  no  longer  be  impossible  to  undei 
stand  that  the  peptones  of  digestion  are  not  represented  b 
peptones  in  the  blood,  the  great  stumbling-block  of  phys 
ologists  for  long  enough. 

Intracellular  digestion  is  not  confined  to  invertebrate- 
The  cells  of  the  digestive  tract,  those  of  the  capillaries  ii 
eluded,  have  not  wholly  forgotten  the  amoeboid  habits  c 
their  embryonic  ancestors.  They  are  specialized,  it  is  tru 
but  not  wholly  altered.  To  suppose  that  digestion  or  tb 
physical  and  chemical  alteration  of  food  ends  within  tb 
cavity  of  the  alimentary  tract  is  to  overlook  a  large  part  c 
the  truth.  Food  is  changed  there  by  virtue  of  the  digestiv 
secretions,  but  all  is  not  thus  done.  In  fact,  what  is  con 
monly  termed  digestion  is  only  the  beginning  of  a  Ion 
series  of  processes  which  go  on  in  the  cells  of  the  structuri 
of  the  tract,  the  capillaries  included,  in  the  blood  itself  1 
some  extent,  and  which  continue  under  the  name  of  met; 
holism  in  the  tissues  themselves.  But  it  is  the  separatio 
and  isolation  in  the  mental  conception  of  the  student  < 
what  must  be  linked  in  one  long  chain  that  is  to  be  esp 
cially  dreaded  in  the  modern  teaching  of  physiology. 

A  student  may  throw  a  great  part  of  the  facts  of  b 
physiology  overboard  after  his  examination,  but  the  inlb 
ence  of  his  teaching  must  last  for  good  or  evil  in  all  b 
thinkings  as  a  practitioner.  That  a  sounder  view  of  tl 
processes  of  digestion,  etc.,  would  greatly  modify  practic 
and  especially  would  explain  present  failures  and  successe 
is  clear  to  myself.  Any  attempt,  however,  to  make  tb 
evident  to  others  must  be  left  for  another  occasion. 

It  may,  without  exaggeration,  be  said  that  the  applic 
tion  of  the  principles  of  evolution  to  morphology  lias  rev 
lutionized  the  teaching  of  that  subject.  But,  strange 
enough,  its  great  doctrines  have  thus  far  made  very  litt 
impression  on  physiology,  especially  the  teaching  of  tl 
subject;  and  my  own  text-book  is  the  first  and  only  one 
which  an  attempt  has  been  made  to  light  up  the  student 
path  with  this  theory,  and  you  will  be  glad  to  hear  that  tb 
effort  has  been  rewarded  by  increased  interest  in  physiolo£ 


Sept.  13,  1890.] 


BRILL:  A  CASE  OF  PSEUDO-HYPERTROPHIC  PARALYSIS. 


283 


in  the  part  of  my  own  classes  during  the  four  years  of 
rial  of  the  new  methods  of  presenting  the  subject. 

But  if  this  is  good  for  students  that  are  undergraduates, 
nay  it  not  also  prove  helpful  to  practitioners  to  regard  dis¬ 
ease  in  the  light  of  evolution  ? 

Physicians  have  given  but  little  attention  to  the  subject. 
To  this  statement,  however,  there  are  at  least  two  notable 
exceptions:  the  late  brilliant  Milner  Fothergill,  and  that 
profound  thinker,  of  whom  we  are  all  so  proud  the  world 
over,  II  ugh  lings  Jackson. 

Turning  to  the  vascular  system  in  the  wider  sense 
(the  blood  and  blood-vessels),  by  the  help  of  evolution  and 
embrvology  not  only  are  many  anomalies  of  vessels  under¬ 
stood,  but  of  the  blood  itself. 

Does  not  a  case  of  extreme  multiplication  of  leucocytes 
in  the  blood  iudicate  a  condition  at  once  embryonic  and 
ancestral  ?  In  other  words,  is  this  not  an  example  of  physi¬ 
ological  or  pathological  reversion  ?  In  the  early  embryo, 
leucocytes  are  very  abundant  everywhere,  and  in  inverte¬ 
brates,  almost  without  exception,  they  or  their  equivalents 
are  alone  found,  while  in  the  lower  vertebrates  they  are 
both  numerous  and  of  very  much  more  pronounced  amoeboid 
character  than  in  the  higher.  Is  not  this  tendency,  then,  on 
the  part  of  the  higher  mammals  and  man,  under  certain  cir¬ 
cumstances,  to  an  excess  of  leucocytes  in  the  blood  better 
understood  than  without  the  explanation  of  evolution? 
Why  this  particular  form  of  derangement,  and  not  some 
other,  if  higher  forms  are  not  related  by  descent  to  the 
lower? 

Again,  in  the  various  forms  of  ansemia  we  find  red 

o  ' 

cells  that  are  nucleated,  cells  smaller  or  larger  than  normal, 
distorted  cells,  corpuscles  resembling  the  genetic  marrow- 

cells,  etc. 

All  these  forms  occur  in  the  embryo,  apparently  nor¬ 
mally  ;  some  of  them  are  certainly  transition  forms.  They 
also  bear  a  resemblance  to  the  red  cells  of  lower  vertebrates. 
Are  these  not  clear  cases  of  reversion  to  an  earlier  condi¬ 
tion,  both  embryonic  and  ancestral  ?  Even  that  form  of 
anaemia  in  which  the  cells  are  fairly  normal,  excepting  a  de¬ 
ficiency  in  haemoglobin,  points  to  the  lower  vertebrate  and 
invertebrate  blood,  which  is,  relatively  to  the  higher  groups 
of  animals,  poor  in  haemoglobin. 

Inflammation  itself,  both  as  regards  the  vascular  system 
and  the  tissues,  becomes  clearer  from  the  standpoint  of  evo¬ 
lution.  The  increased  amoeboid  activity  of  the  leucocytes, 
the  alterations  in  the  latter  and  the  vessel  walls  permitting 
of  the  ready  “  wandering”  of  the  colorless  blood-cells,  point 
to  a  condition  of  things  common  in  lower  vertebrates.  In- 
f.ammation  is  clearly  a  reversion. 

Reference  might  be  made  to  the  resemblance  between 
the  condition  of  things  in  the  young  mammal — in  which, 
after  birth,  the  usual  changes  that  fit  it  to  its  altered  en¬ 
vironment  do  not  take  place — and  the  permanent  state  of  the 
heart  and  vessels  in  lower  vertebrates,  as  reptiles.  However, 
the  illustrations  employed  may  suffice  to  show  that  evolution 
does  concern  the  physiologist,  the  pathologist,  and  the 
physician ;  and,  did  time  permit,  I  think  I  could  demon¬ 
strate  that  such  views  may  be  made  to  have  a  bearing  on 
the  treatment  of  disease  by  the  most  enlightened  methods. 


The  subject  has  been  dealt  with  further  in  its  relations  to 
medicine  elsewhere.* 

I  shall  not  pursue  this  line  of  thought  further  at  present, 
but  leave  you  to  judge  for  yourselves  whether  the  time  has 
come  when  students  and  practitioners  should  be  provided 
with  text-books  of  physiology  in  which  attention  is  paid 
to  general  biology,  comparative  embryology,  and  evolu¬ 
tion,  with  a  view  of  giving  a  wider  and  truer  grasp  of  the 
functions  of  those  organisms  with  which  the  great  art  of 
medicine  is  concerned. 


(Original  Communications. 


A  CASE  OF  PSEUDO-HYPERTROPHIC  PARALYSIS 

COMPLICATED  BY  A 

FRACTURE  OF  THE  LAMINA  OF  THE  FIFTH  CERVICAL  VERTEBRA ; 

A  Contribution  to  the  Physiology  of  the  Spinal  Cord.\ 

By  N.  E.  BRILL,  A.  M.,  M.  D. 

It  is  so  seldom  that  an  opportunity  arises  in  the  human 
species  to  make  an  intra-vitam  experiment  on  the  spinal 
cord,  that  the  following  case  is  of  unusual  interest: 

James  G.  K.,  twenty- six  years  of  age  at  the  present  time. 
No  history  of  neuropathies  in  his  family.  At  the  age  of  eight 
months  made  successful  attempts  to  walk  with  the  supporting 
aid  sometimes  of  a  chair  and  sometimes  of  the  wall.  At  this 
period,  while  being  weighed  in  the  following  manner — he  was 
placed  in  a  blanket,  his  head  and  legs  dangling  over  the  sides, 
the  rest  of  the  blanket  being  tied  into  a  loop  which  was  held 
by  the  hook  of  an  old-fashioned  scales — his  head  was  wrenched 
by  the  violent  oscillations  of  the  spring  of  the  scales.  Although 
the  age  at  which  he  made  his  attempts  at  walking  was  a  remark¬ 
ably  early  one,  there  can  be  no  doubt  as  to  the  fact  that  these 
attempts  were  then  frequently  made  by  him.  They  were  made 
spontaneously  and  without  assistance  on  the  part  of  his  parents. 
After  the  weighing  episode,  however,  he  could  make  no  further 
attempts,  his  failure  to  walk  extending  then  until  the  age  of 
twenty-two  months.  Nothing  unusual  tvas  noticed  by  his  par¬ 
ents  during  the  months  following  the  weighing,  excepting  his 
desisting  in  making  further  trials  at  walking.  These  he  re¬ 
sumed  at  the  last-mentioned  period,  and  progressed  until  he 
walked  without  any  support.  His  walk  was,  however,  peculiar, 
being  attended  by  swaying  motions  which  gave  him  the  name 
of  a  “toddler.”  From  this  time  to  his  tenth  year  nothing  of 
note  occurred.  The  only  fact  remarked  was  his  liability  to 
stumble,  to  stub  his  toe  in  walking,  and  to  fall  whenever  he  en¬ 
countered  any  obstacle  like  a  play-toy  which  might  happen  to 
lie  on  the  floor  in  his  path.  He  could  walk  and  run,  the  latter 
not  as  swiftly  as  his  companions,  but  he  could  keep  up  his  pace 
for  longer  distances  than  they.  He  indulged  in  all  the  sports 
of  childhood,  and  in  the  acrobatic  feats  usually  performed  by 
boys  living  in  the  country.  He  could  turn  handsprings  with 
great  agility.  At  his  tenth  year,  while  indulging  in  the  latter 
exercise  on  a  load  of  hay,  the  hay  not  being  packed  or  com¬ 
pressed,  his  hands  sunk  into  it,  and,  in  throwing  his  legs  over  in 

*  Physiological  and  Pathological  Reversion.  Canada  Hied,  and  Sui  g. 
Journal ,  April,  1888. 

f  Read  before  the  American  Neurological  Association  at  its  six¬ 
teenth  annual  meeting. 


284 


BRILL:  A  CASE  OF  PSEUDO-HYPERTROPHIC  PARALYSIS. 


[N.  Y.  Med.  Jotjb., 


the  accomplishment  of  the  feat,  his  head  was  caught  or  wedged 
in  the  hay.  He  felt  a  sudden  pain  and  shock  in  the  neck,  and 
remarked  to  his  playmates  that  he  thought  he  had  broken  his 
neck.  He  immediately  proceeded  to  the  house,  and,  although 
at  that  time  he  detected  nothing  unusual,  he  dates  all  the  sub¬ 
sequent  trouble  to  that  event.  Besides  pain  and  stiffness  in  the 
,  back  of  the  neck,  he  noticed  a  diminished  amount  of  lateral 
motion  and  difficulty  in  rotating  the  head,  the  movement  being 
more  restricted  in  turning  the  head  to  the  left  than  to  the 
right. 

Shortly  after  the  accident — he  can  not  say  definitely  how 
long  thereafter — he  noticed  that  his  “  ankle  would  move  rapidly 
up  and  down  ”  whenever  he  put  the  ball  of  his  right  foot  in  a 
certain  position  (ankle  clonus).  The  same  symptom  appeared 
in  the  left  foot  about  two  years  afterward.  Until  his  fourteenth 
year,  four  years  after  the  accident,  his  attention  was  directed 
to  no  other  abnormal  phenomenon.  But  at  this  period  of  his 
life  he  found  that  while  walking  his  right  “  knee  would  give 
way,”  that  is,  it  would  suddenly  bend  beneath  his  weight, 
doubling  up  in  flexion,  and,  unless  he  exercised  great  care,  he 
would  fall  to  the  ground.  He  soon  found  his  right  leg  would 
become  tired  and  his  gait  became  different.  This  weakness,  as 
he  describes  it,  in  the  right  leg  increased,  the  knee  would  bend 
more  and  more  frequently,  and  the  same  phenomenon  began  to 
develop  in  the  left  knee.  It  was  exactly  two  years  after  the 
first  sign  in  the  right  knee  showed  itself  that  the  left  knee  be¬ 
came  affected.  The  same  changes  developed  in  this  extremity 
as  in  the  right.  At  the  same  time  that  changes  were  beginning 
to  manifest  themselves  in  the  left  lower  extremity  he  detected 
that  his  right  hand  and  forearm  would  quickly  become  tired 
while  milking  the  cows.  This  was  his  usual  occupation  at 
home,  and  bis  inability  to  continue  it  on  account  of  rapidly  de¬ 
veloping  weakness  in  his  arm  alarmed  him.  The  weakness  of 
the  right  upper  extremity  kept  step  in  development  with  that 
of  the  left  lower,  and  when  they  had  reached  a  high  degree  the 
same  appeared  in  the  left  upper  extremity.  It  was  about  two 
years  after  the  first  sign  of  weakness  showed  itself  in  the  right 
upper  that  he  detected  the  presence  of  it  in  the  left.  The  latter 
underwent  the  same  loss,  and  he  found  himself  unable  to  raise 
his  arms  to  a  level  with  his  shoulders.  It  was  a  difficult  matter 
for  him  to  button  his  collar  to  his  shirt  in  the  back;  he  was 
compelled  to  give  his  arm  a  swing  to  get  his  hand  to  his  head, 
and  it  was  in  this  way  that  he  succeeded  in  accomplishing  that 
part  of  his  toilet.  He  then  sought  medical  advice  and  treat¬ 
ment.  The  latter  embraced  almost  everything  between  the  ex¬ 
tremes  of  “  laying  on  of  hands  ”  and  electricity.  As  to  the 
diagnoses  given,  the  less  said  the  better.  Dr.  Spencer,  of  Water- 
town,  N.  Y.,  w'as  perhaps  the  only  individual  who  appreciated 
a  serious  organic  lesion  of  the  cord.  It  was  he  who  brought 
him  to  New  York  for  the  purpose  of  obtaining  an  authoritative 
opinion,  and  for  treatment.  This  was  the  history  given  by  the 
patient,  and,  being  a  very  intelligent  young  man,  observant  and 
reflective,  the  points  elicited  by  subsequent  examination  were 
very  satisfactory;  many  of  his  spontaneous  descriptions  corre¬ 
sponded  to  the  course  and  distributions  of  the  nerves  and  their 
functions,  although  the  patieut  has  no  knowledge  of  anatomy 
or  physiology.  He  mentioned,  in  addition  to  the  previous  signs, 
an  inability  at  times  to  grasp  objects  on  account  of  a  sudden 
and  spasmodic  retraction  of  the  arm,  forearm,  and  fingers  which 
forcibly  drew  them  away  from  the  desired  object,  these  mem¬ 
bers  of  the  upper  extremity  undergoing  twists  and  turns,  some¬ 
times  being  drawn  to  a  position  behind  his  back.  During  my 
examination  I  had  the  good  fortune  to  observe  one  of  these 
athetotic  movements. 

Status  prcesens. — Patient  is  about  five  feet  six  inches  and  a 
half  high.  Walks  with  the  aid  of  a  cane,  steps  slowly  and  de¬ 


liberately,  each  foot  after  leaving  the  ground  being  forcibly  re¬ 
tracted,  giving  a  good  example  of  the  spastic  gait.  In  ascend¬ 
ing  stairs  he  supports  himself  with  his  right  hand  on  the  wall 
or  balustrade,  puts  his  left  foot  forward,  his  left  hand  on  his  left 
thigh  directly  above  the  knee,  and  lifts  himself  in  this  way  up 
to  each  successive  step.  In  descending  he  uses  the  wall  or  bal¬ 
ustrade  support,  puts  down  his  left  foot  upon  the  step  and  his 
right  foot  is  jerked  after  him,  step  by  step.  This  evidently 
shows  a  greater  loss  of  muscular  power  in  the  right  lower  ex¬ 
tremity  than  in  the  left. 

His  head  assumes  a  peculiar  position,  being  lowered,  as  it 
were,  to  an  abnormal  degree  between  the  shoulders  and  bent 
considerably  forward,  his  chin  approaching  his  chest.  A  trans¬ 
verse  furrow  in  the  muscular  structures  in  the  back  of  the  neck 
is  present,  and,  on  putting  the  finger  therein  and  pressing  upon 
the  spinous  processes,  the  fifth  cervical  spinous  process  can  not 
be  felt.  It  seems  to  have  been  either  destroyed,  perhaps  by 
absorption,  or  undeveloped,  by  reason  of  a  defective  blood  sup¬ 
ply  occasioned  by  the  accident.  When  asked  to  rotate  his  head, 
he  does  so  slowly  and  methodically,  feeling  each  successive  step 
in  the  arc  described  ;  normal  rotation  is  interfered  with  to  the 
extent  that,  on  turning  the  head  to  the  left,  it  describes  an  arc 
of  about  30°  only,  to  the  right  one  of  about  50°.  He  carries  his 
head  stiffly,  avoiding  all  rotatory  motion.  He  likewise  bends 
his  head  forward  and  backward  to  a  limited  extent,  but  flexion 
and  extension  are  more  readily  performed  than  rotation. 

In  speaking,  he  moves  his  lips,  keeping  his  jaws  quiet,  so  that 
his  face  appears  to  be  immobile.  This  is  done  to  avoid  the  fa¬ 
tigue  which  the  muscles  of  the  neck  undergo  in  conjunction  with 
the  facial  muscles  in  this  act.  He  thus  requires  all  the  muscular 
power  he  has  in  supporting  his  head,  avoiding  all  extra  and  un¬ 
necessary  efforts. 

On  stripping  him,  a  remarkable  atrophy  of  certain  muscular 
groups  is  observed,  wasting  being  especially  observed  in  the 
clavicular,  scapular,  humeral,  and  femoral  groups. 

The  clavicles  stand  out  very  prominently,  owing  to  the  atro¬ 
phy  of  the  pectoralis  major,  the  deltoid,  and  subclavius  below  ; 
the  acromial  end,  the  head  of  the  humerus,  and  the  acromion 
of  the  scapula  likewise  appearing  beneath  the  skin  as  distinctly 
as  in  a  dissection. 

The  scapulas  show  the  “  angel-wing”  appearance,  owing  to 
the  wasting  of  their  muscular  groups. 

In  the  arm  the  wasting  is  extreme,  the  forearm  and  hand  ap¬ 
pearing  overdeveloped.  When  questioned  about  the  latter  mus¬ 
cles,  he  stated  that  in  them  the  first  signs  of  weakness  and  wast¬ 
ing  appeared  after  the  legs  had  been  involved,  and  that  he  no¬ 
ticed  these  signs  first  in  the  thenar  and  hypothenar  eminences, 
but  that  these  groups  subsequently,  together  with  the  muscles 
of  the  forearm,  increased  in  size,  so  that  at  the  present  time  they 
are  actually  overgrown,  although  they  present  the  same  weak¬ 
ness.  (See  cuts.) 

On  looking  at  the  lower  extremities  we  are  struck  by  the 
overdevelopment  of  the  legs,  the  circumference  of  each  calf 
being  equal  to  that  of  its  respective  thigh  in  its  middle  third. 
The  thighs,  however,  present  the  same  atrophy  which  was  no¬ 
ticed  in  the  upper  extremity,  all  the  muscles  being  involved. 
Owing  to  this  atrophy,  the  patient  stands  with  his  legs  apart, 
and  presents  a  marked  convexity  in  the  popliteal  region,  which, 
instead  of  showing  a  depression,  bulges  out  to  complete  with 
the  gastrocnemii  a  continuous  convex  curvature.  The  atrophy 
is  greater  on  the  right  than  on  the  left  side.  (Fig.  2.) 

The  gluteal  muscles  appear  to  be  unaffected,  the  buttocks 
standing  out  prominently.  They,  however,  are  the  seat  of  the 
same  changes  as  were  noticed  in  the  calves.  Both  erectores 
spin®  are  also  involved  in  this  hypertrophic  change.  As  a  re¬ 
sult,  the  back  presents  a  marked  concavity  in  the  lumbo-sacral 


BRILL:  A  CASE  OF  PSEUDO-HYPERTROPHIC  PARALYSIS. 


285 


Sept.  13,  1890.] 


region,  the  muscular  masses  of  the  erector  spin®  rising  on 
either  side,  causing  a  deep  longitudinal,  lineal  furrow,  as  is  well 

shown  in  Fig.  2. 

The  position  of  the  patient  is  characteristic  and  shows  the 
involvement  of  the  muscles  which  keep  the  spine  erect.  He 
stands  with  his  feet  widely  separated,  the  upper  part  of  his 
trunk  thrown  far  backward,  his  abdomen  protruding,  so  that  a 
line  let  fall  perpendicularly  from  the  upper  dorsal  spines  clears 
the  sacrum  which  lies  iu  front.  (Fig.  1.) 


On  examining  the  crease  or  furrow  in  the  back  of  the  neck 
more  closely,  on  firm  pressure  over  the  side  of  the  fifth  cervical 
vertebra  while  the  head  is  partly  drawn  back,  the  vertebra  pre¬ 
sents  a  movable  point  corresponding  to  the  junction  of  the  left 
pedicle  and  lamina ;  a  smooth  crepitus  can  be  distinctly  felt. 
There  can  hence  be  no  doubt  that  a  fracture  of  the  lamina  of 
this  vertebra  is  present.  The  origin  of  this  may  be  referred  to 
the  accident  the  boy  met  in  his  tenth  year  while  turning  a  hand¬ 
spring.  It  is  curious,  however,  that  no  callus  can  be  detected 
and  that  Nature  has  not  established  a  reparative  process.  It  is 
hardly  conceivable  to  my  mind  that  motion  of  the  head  has 
failed  to  permit  union.  That  there  may  be  a  ligamentous  union 
is  possible.  It  is  also  possible  that  the  same  cause  which  pro¬ 
duced  the  loss  of  substancein  the  spinous  process  may  have  pre¬ 
vented  the  formation  of  callus  and  bony  union.  However,  there 
can  be  no  doubt  as  to  the  motion  in'.'the  part  of  the  vertebra 
mentioned,  for  as  soon  as  pressure  is  made  the  patient  immedi¬ 
ately  complains  of  a  sensation  as  if  a  “  cold,  damp  wind  passed 
over  his  side.”  This  sensation  is  referred  in  greatest  intensity 
to  the  right  side,  and  is  severe  or  slight  according  to  the  manner 
in  which  the  pressure  is  made  on  the  left  side  of  the  affected 
vertebra.  The  middle  line  of  the  body  dorsad  limits  the  sen¬ 
sation,  which  is  distributed  over  the  back  to  the  vertebral  col¬ 
umn,  the  shoulder,  the  dorsum  of  the  arm,  of  the  forearm,  and 


over  a  finger  and  a  half  on  the  ulnar  side  of  the  hand  ;  the  but¬ 
tocks,  back  of  the  thigh,  outer  part  of  the  leg,  and  the  entire 
foot.  lie  says  there  is  a  distinct  boundary  between  the  affected 
part  (and  pointed  out  this  limit  in  his  description)  and  the  part 
free  from  this  paraesthesia.  In  the  arm  and  forearm  this  bound¬ 
ary  is  well  marked  and  corresponds  to  the  line  a  in  Fig.  5.  The 
limit  of  the  sensation  on  the  trunk  ventrally  is  not  sharp,  and 
extends  but  a  slight  distance  ventrad  of  the  axillary  line.  In 
the  leg  and  thigh  the  limit  is  as  distinct  as  in  the  upper  ex¬ 
tremity.  The  same  panesthesia,  but  to  a  limited  degree,  can 
be  elicited  on  the  left  side  when  pressure  is  made  on  the  oppo¬ 
site  side  of  the  fractured  vertebra,  but  the  limit  of  definition 
and  distribution  is  not  abrupt,  and,  to  use  the  words  of  the 
patient,  the  paraesthesia  “  runs  into  the  normal  sensation,  so  as 
to  leave  no  line  by  which  I  can  say  the  cold  stops  here  and  the 
natural  feeling  begins.  Or,  in  other  words,  the  cold  feeling  on 
the  right  side  is  of  equal  intensity  from  the  spine  out  to  the 
limit  at  the  point  of  the  shoulder,  down  the  side,  taking  in  the 
back  of  the  thigh  and  nearly  all  of  the  calf  of  the  leg  and  the 
foot.  On  the  left  side  the  cold  sensation  seemed  to  fade  and 
become  less  marked  at  the  point  of  the  shoulder,  the  arm,  leg, 
and  foot  showing  a  decrease  in  the  cold  feeling.”  Let  it  be 
borne  in  mind,  therefore,  that  this  partesthesia  may  be  elicited 
on  either  side  by  pressure  on  the  respective  opposite  side  of  the 
vertebra,  but  that  its  greatest  intensity  is  on  the  right  side  of 
the  body,  as  is  its  most  abrupt  limitation. 


Fig.  2. 


Muscular  Movements. — Owing  to  the  atrophy  of  the  pectoral 
groups,  adduction  of  both  arms  is  greatly  interfered  with.  He 
is  unable  to  put  his  hand  to  the  opposite  shoulder.  By  allow¬ 
ing  the  arm  to  hang  to  his  side  and  by  giving  it  a  swing,  he  suc¬ 
ceeds  in  accomplishing  this  act.  The  deltoids  being  involved, 
he  can  not  raise  his  arm  to  a  level  with  his  shoulder,  nor  can 
he  get  his  hand  to  the  back  of  his  neck  to  button  his  collar,  as 


236 


BRILL:  A  CASE  OF  PSEUD O-HYPER TJR OPHIO  PARALYSIS • 


[N.  Y.  Med.  Jo  cm., 


was  previously  remarked.  Opposition  to  extension  of  the  fore¬ 
arm  on  to  the  arm  is  very  weak,  showing  the  triceps  to  be  in¬ 
volved  in  the  atrophy.  Flexion  of  the  arm  on  the  forearm  is 
likewise  affected,  the  brachial  group  being  the  seat  also  of  simi¬ 
lar  changes. 

The  muscles  of  the  forearms  and  hands  show  a  relative  and 
real  overdevelopment,  the  circumference  of  the  lower  part  of 
the  forearm  being  greater  than  that  of  any  part  of  the  lower 
two  thirds  of  the  arm.  The  thenar  and  hypothenar  eminences 
are  very  prominent.  Although  the  forearm  and  band  appear  to 
be  overdeveloped,  the  grasp  of  each  hand  is  very  weak. 

The  changes  in  the  trunk  and  abdominal  muscles  have  been 
already  mentioned,  as  have  those  of  the  thighs  and  legs. 

The  feet  are  likewise  involved  in  the  pseudo-hypertrophy; 
the  sole  is  greatly  arched,  and  the 'first  phalanges,  especially  of 
the  great  toes,  are  quite  strongly  flexed  on  to  the  dorsum,  while 
the  distal  phalanges  are  bent  toward  the  plantar  surface,  owing 
to  the  paretic  condition  of  the  interossei.  This  appearance  of 
the  toes  has  been  named  by  Duchenne  “  griff e  des  orteils .” 
(Fig.  3.)  The  patient  can  not  raise  himself  on  his  toes,  nor  can 
he  flex  his  feet. 


Fig.  3. 


He  can  not  cross  one  leg  over  the  other,  neither  can  he  lift 
his  legs  from  the  ground  while  his  thighs  are  extended. 

When  he  makes  attempts  to  sit  down,  unless  he  uses  the 
support  of  his  arms,  he  falls  quickly  and  spasmodically  into  the 
chair.  This  motion  is  just  like  the  closing  of  the  blade  of  a 
knife,  which  returns  to  the  division  in  its  case  as  soon  as  the 
opposed  force  exerted  by  the  spring  is  released.  In  rising 
from  a  seat  he  lifts  his  body  by  means  of  his  right  arm,  places 
his  left  hand  above  his  left  knee,  and  completes  the  act  by 
throwing  his  body  forward,  using  his  left  hand  and  leg  as  the 
lifting  force. 

Reflexes. — There  is  an  absolute  loss  of  the  patellar  reflex  on 


both  sides.  Ankle  clonus  is  exaggerated  on  both  sides — more 
so,  however,  on  the  right  than  on  the  left.  Triceps  reflex  is 
also  increased  on  both  sides,  but  more  on  the  right  than  on  the 


Fig.  4. 


left.  It  is  remarkable  that  with  the  considerable  atrophy  of  the 
triceps  there  should  be  any  reflex  at  all,  much  less  an  increased 
one.  The  forearm  is  quickly  extended  and  rotated  outward 
when  the  triceps  tendon  is  struck,  and  shows  the  preponder¬ 
ance  of  the  conjoined  action  of  the  supinators. 

Cremasteric  reflex  is  greatly  exaggerated,  the  slightest 
touch  to  the  skin  on  the  inner  surface  of  the  upper  thigh  being 
accompanied  by  a  violent  retraction  of  the  corresponding  testi¬ 
cle.  This  exaggeration  is  equally  marked  on  either  side. 

Sensations. — Tactile  and  general  sensations  are  normal. 
Touch,  pain,  temperature,  and  muscular  and  space  senses  were 
all  examined  and  were  found  to  show  no  deviation  from  the 
normal.  Smell,  taste,  and  hearing  are  likewise  unaffected. 
Vision  is  hypermetropic.  lie  met  with  an  accident  some  years 
ago  to  his  right  eye  which  resulted  in  a  probable  dislocation  of 
the  lens  of  that  organ,  the  iris  being  retracted  strongly  to  the 
right.  Light  and  accommodation  reactions  are  perfect. 

The  functions  of  the  rectum  and  bladder  are  unimpaired. 

He  has  normal  sexual  desires,  and  has  noticed  no  change  in 
his  sexual  functions. 

There  are  no  paraesthesiae,  with  the  exception  of  the  one 
described,  which  is  produced  whenever  pressure  is  made  on  the 
fractured  vertebra. 

No  Romberg  symptom. 

Electrical  Examination  of  Muscles  and  Nerves.  —  All  the 
muscles  and  nerves  examined,  with  the  exception  of  a  few 
which  will  be  soon  mentioned,  showed  similar  reactions  to  the 
respective  currents.  These  reactions  differed  only  in  degree, 
greater  or  less  contraction  being  dependent  upon  the  amount 


Sept.  13,  1890.] 


BRILL:  A  CASE  OF  PSEUDO-HYPERTROPHIC  PARALYSIS . 


287 


of  healthy  muscular  fibers  remaining  in  the  individual  muscles. 
Both  muscle  and  nerve  showed  diminished  faradaic  excitability, 
no  muscle  contracting  under  a  current  whose  strength  meas¬ 


ured  less  than  half  the  distance  of  the  secondary  coil  of  a 
Du  Bois-Reymond  machine. f 

To  the  galvanic  current  both  muscles  and  nerves  responded 
peculiarly,  and  showed  both  quantitative  and  qualitative 
changes.  Anodal  closure  and  anodal  opening  contractions  were 
both  stronger  than  cathodal  closure,  anodal  closure  stronger 
than  anodal  opening.  The  peculiarity,  however,  of  all  the  con¬ 
tractions  produced,  whether  the  electrode  was  applied  to  mus¬ 
cle  or  nerve,  was  this :  In  the  first  place,  it  required  the  strong¬ 
est  currents  to  produce  any  contraction  whatever,  no  muscle 
contracting  under  a  current  less  than  twelve  milliamperes,  ap¬ 
plied  either  to  nerve  or  muscle ;  in  the  second  place,  the  muscle 
was  slow  in  responding,  the  contraction  being  tetanic  and  in¬ 
creasing  in  its  tetanus  after  the  electrode  was  removed,  and 

*  The  shaded  region  should  have  been  on  the  right  side  of  the  body, 
and  not  on  the  left  as  in  the  figure,  the  fault  being  due  to  a  transposi¬ 
tion  of  the  drawing. 

f  This  coil  is  made  of  a  wire  whose  length  is  600  m.  and  whose 
diameter  is  0225  mm.  The  scale  of  this  faradaic  battery  ranges  from 
0  to  100  ;  the  secondary  current  produced  no  contraction  at  a  distance 
less  than  50  in  any  muscle  examined,  with  the  exception  of  the  left 
sterno-cleido-mastoid,  the  upper  half  of  the  trapezius,  and  both  abdomi¬ 
nal  obliques.  These  contracted  with  the  coil  at  10,  13,  and  16,  respect¬ 
ively,  a  normal  irritability. 


remaining  in  increasing  tetanus  for  at  least  two  minutes,  as  timed 
by  the  watch  after  that  removal.  At  the  end  of  this  time  the 
muscle  gradually  and  slowly  returned  to  its  previous  condition. 
Only  in  the  left  sterno-cleido-mastoid,  in  the  upper  half  of  both 
the  trapezii,  and  in  the  abdominal  muscles  was  a  normal  con¬ 
traction  obtained.  Whether  the  electrode  was  applied  to  either 
muscle  or  nerve  made  no  difference  in  the  character  of  the  con¬ 
traction,  which,  with  the  few  exceptions  in  the  muscles  men¬ 
tioned,  was  always  a  tetanus,  but  more  marked  when  the  elec¬ 
trode  was  applied  to  the  muscle  than  to  the  nerve. 

The  facial  muscles  and  nerves  were  also  involved  in  this 
reaction,  and  in  them  the  peculiarity  of  contraction  was  first 
noticed.  The  other  muscles  examined  were  the  pectorals, 
brachials,  triceps,  supinator  longus,  pronator  radii  teres,  the 
flexors  of  the  hand,  the  common  flexors  of  the  fingers,  the  indi¬ 
vidual  flexors,  the  extensors  of  the  hands  and  fingers,  the 
thumb  muscles  and  interossei,  the  serratus  magnus,  the  rhom- 
boidii,  the  levator  anguli  scapuli,  the  trapezius,  and  the  erector 
spinse.  In  the  lower  extremity  the  gluteals,  the  adductors  of 
the  thigh,  the  great  quadriceps,  the  sartorius,  the  flexors  of  the 
leg,  the  gastrocnemii,  the  tibialis  anticus,  and  the  peroneal 
group.  The  apparently  overdeveloped  muscular  groups  in  the 
forearm  and  leg  showed  no  difference  in  their  contractions,  and 
required  strong  currents  to  bring  them  forth.  The  nerves  of 
all  the  muscles  mentioned,  where  they  were  accessible,  were 
also  examined,  either  in  the  nervous  trunk  or  in  the  branches 
thereof. 

Etiology. — This  is,  then,  the  history  of  a  typical  case  of 
pseudo-hypertrophic  paralysis  complicated  by  a  fracture  of  a 
cervical  vertebra.  There  can  be  no  doubt  that  the  trouble  in 
the  cord  began  at  the  early  age  of  eight  months,  for  at  that 
period  the  child  gave  up  its  attempts  at  walking;,  and  did 
not  renew  them  for  fourteen  months  thereafter.  Even  after 
it  could  walk  its  peculiar  gait  gave  it  the  name  of  a  “  tod¬ 
dler,”  and  its  many  falls  can  only  be  explained  on  the 
ground  of  an  affection  involving  the  neuro-muscular  system. 

It  becomes  an  interesting  question  to  determine  whether 
the  accident  in  weighing  acted  as  a  causative  factor  in  the 
production  of  this  disease.  It  is  very  probable  that  the 
stretching  which  the  upper  part  of  the  cord  suffered  in  the 
weighing  process  was  so  extensive  as  to  interfere  with  its 
molecular  integrity.  All  authors  agree  upon  the  hereditary 
neuropathic  factor  in  the  production  of  pseudo-muscular 
hypertrophy,  and  none  has  indicated  any  other  constantly 
defined  setiological  factor.  The  absence  of  a  neuropathic 
history  in  this  case,  and  the  fact  that  attempts  at  walking- 
had  been  given  up  shortly  after  the  cord  suffered  an  injury, 
would  lead  one  to  infer  that  the  injury  which  the  cord  sus¬ 
tained  in  the  weighing  of  the  child  was  an  active  agent  in 
the  production  of  the  disease,  if  it  were  not  solely  respon¬ 
sible.  However,  I  do  not  insist,  on  this  view,  but  simply 
mention  it  as  a  possibility. 

Explanation  of  Symptoms  and  Signs. — The  inconsist¬ 
ency  of  the  various  reflexes  merits  but  a  moment’s  discus¬ 
sion.  The  total  absence  of  the  patellar  phenomenon  can 
only  be  due  to  the  great  atrophy  of  the  quadriceps  extensor. 
And  yet  when  we  regard  the  fact  that,  although  the  atrophy 
in  the  triceps  was  almost  as  extreme  as  in  the  great  exten¬ 
sor  of  the  leg,  the  tendon  reflex  was  exaggerated,  we  are  led 
to  think  that  some  other  factor  is  operative  in  the  abolition 
of  that  of  the  latter.  The  generally  increased  reflexes — ere- 


288 


CORNING:  NATURE  AND  TREATMENT  OF  EXOPHTHALMIC  GOITRE.  [N.  Y.  Med.  Jour., 


that  the  temoerature-sense  tract  follows  the  same  law  as  re¬ 


masteric,  ankle  clonus,  triceps — are  certainly  consistent  with 
the  spastic  gait,  all  of  which  are  probably  due  to  pressure 
on  the  cord  by  the  fractured  vertebra.  However,  it  has 
been  shown,  and  it  has  been  my  own  experience,  that  when 
the  lower  portion  of  the  quadriceps  extensor  is  the  seat  of 
pronounced  atrophy,  especially  the  portion  adjoining  the 
tendon,  it  is  impossible  to  elicit  the  reflex. 

The  athetotic  contractions  in  the  right  upper  extremity 
are  a  little  more  difficult  to  explain.  They  appear  to-  me 
to  be  due  to  the  loss  of  contractile  equilibrium  between  the 
extensor  and  flexor  group,  and  are  elicited  by  the  unequal 
contractions  of  the  various  muscles  employed  in  the  act 
which  called  them  forth,  co-ordinated  action  between  an¬ 
tagonists  being  lost  by  reason  of  the  unequal  atrophic  pro¬ 
cess.  The  pressure  of  the  fractured  vertebra  may  also  be 
an  element  in  the  production  of  this  symptom,  as  it  cer¬ 
tainly  is  in  the  production  of  the  spastic  gait. 

The  electrical  reaction  is  anomalous,  notwithstanding  the 
fact  that  it  adheres  to  the  law  of  degenerative  reaction.  In 
the  entire  literature  that  has  been  accessible  to  me  I  can 
find  no  mention  of  the  fact  as  it  exists  in  this  case ;  that 
ordinary  contractions  can  not  be  elicited  by  any  strength 
of  galvanic  current,  the  very  first  indication  of  contraction 
being  immediately  a  tetanus ,  equally  produced  whether 
nerve  or  muscle  be  galvanized,  but  produced  by  feebler  cur¬ 
rents  in  the  former  than  in  the  latter. 

The  symptom  of  most  importance  to  us  is  the  sensation 
of  cold,  having  a  definite  distribution  and  following  every 
pressure  made  upon  the  posterior  segment  of  the  cord. 

The  course  and  location  of  the  temperature-sense  tract 
are  unknown.  Goldscheider  has  made  experiments  to  test 
them,  and  has  analyzed  the  intrinsic  relations  of  the  tem¬ 
perature  sense  to  the  other  cutaneous  senses.  The  general 
idea  seems  to  be  that  the  temperature-sense  tract  runs  to¬ 
gether  with  the  tracts  transmitting  the  other  cutaneous  sen¬ 
sations.  It  is  a  well-known  fact  that  in  systemic  diseases  of 
the  spinal  cord,  such  as  tabes  dorsalis,  the  involvement  of 
tactile  perceptions  follows  the  distribution  of  the  ulnar  and 
sciatic.  In  this  case  the  subjective  sensation  of  cold  fol¬ 
lows  the  same  distribution,  from  which  we  are  led  to  infer 
that  the  temperature-sense  tract  is  situated  in  the  posterior 
segment  of  the  cord,  and  near,  intermingled  or  identical 
with,  the  tract  for  tactile  impressions.  While  this  conclu¬ 
sion  is  presented  as  a  mere  supposition,  this  peculiar  intra- 
vitam  experiment  proves  one  fact  beyond  doubt — viz.,  that, 
be  the  temperature-sense  tract  identical  with,  or  regionally 
related  to,  or  even  remote  from  other  tactile  transmission 
channels,  it  follows  the  same  laws  in  regard  to  peripheral 
distribution  for  the  same  areas  which  are  exquisitely  in¬ 
volved  in  spinal-system  diseases  causing  anaesthesias  and 
parsesthesias.  In  other  words,  this  case  would  sustain  the 
proposition  that  there  was  a  homology  in  the  distribution 
of  peripheral  sensation  tracts  in  the  cord  whose  general 
laws  can  not  be  formulated  to  cover  all  physiological  con¬ 
tingencies.  The  pain-sense  tract  has  already  been  proved 
to  harmonize  with  this  general  law:  that,  as  in  cutaneous 
space-sense  disturbances,  a  systemic  disease  must  involve  the 
posterior  segment  of  the  cord  in  an  area  which  is  too  famil¬ 
iar  to  you  for  me  to  define ;  and  from  this  case  it  is  evident 


gards  distribution,  the  sciatic  for  the  lower  and  the  ulnar 
for  the  upper  extremity  being  the  weaker  points. 


SOME  CONSIDERATIONS 
ON  THE  NATURE  AND  TREATMENT  OF 
EXOPHTHALMIC  GOITRE* 

By  J.  LEONARD  CORNING,  M.  A.,  M.  D., 

NEW  YORK, 

CONSULTANT  IN  NERVOUS  DISEASES  TO  ST.  FRANCIS’S  HOSPITAL, 
JERSEY  CITY  ;  THE  HACKENSACK  HOSPITAL,  ETC. 

The  salient  features  of  Graves’s  disease— enlargement  of 
the  thyreoid  gland,  protrusion  of  the  eyeball,  and  accelera¬ 
tion  of  the  pulse — are  doubtless  familiar  to  most  physicians 
in  active  practice.  I  sincerely  wish  that  our  knowledge  oi 
the  pathology  of  the  affection  were  equally  accurate.  Un¬ 
fortunately,  post-mortem  research  has  not  done  much  to 
enlighten  us  on  this  point,  so  that  what  little  has  been 
found  is  in  no  respect  decisive,  either  as  regards  the  loca¬ 
tion  or  character  of  the  lesion.  Inasmuch,  therefore,  as  ail 
efforts  to  solve  the  question  by  direct  observation  in  the 
dead-house  have  heretofore  proved  futile,  we  have  been 
forced  to  lay  hold  of  the  less  exact  resources  of  deduction. 
By  comparing  the  three  fundamental  symptoms  of  the  dis¬ 
ease  with  what  has  already  been  ascertained,  or  partially 
ascertained,  regarding  the  physiology  of  the  central  nerv¬ 
ous  system,  we  have  been  enabled  to  construct  a  theory  of 
the  disease  which,  whether  it  be  objectively  true  or  not, 
affords,  at  all  events,  a  hypothesis  which  may  be  car¬ 
ried  to  the  bedside  without  danger  to  the  patient.  The 
theory  to  which  I  refer  is  that  which  ascribes  the  symptoms 
of  the  disease  to  a  functional  disturbance  of  the  sympathetic 
system,  and  it  is  this  theory  which  I  believe  we  must  accept 
until  something  more  plausible  is  forthcoming. 

As  physiological  experiment  has  clearly  shown,  the  func¬ 
tions  of  the  sympathetic  are  manifold  ;  certainly  vaso¬ 
motor,  cardiac,  oculo-pupillary,  trophic,  and  secretory  fibers 
have  been  pretty  clearly  made  out.  While  this  system  of 
nerves  throughout  its  entire  course  is  interesting,  it  is  the 
cervical  portion  which  most  concerns  us  here.  Several 
most  interesting  observations  have  been  made  on  this 
part  of  the  nerve-plexus.  In  the  first  place,  Claude  Ber¬ 
nard  has  shown  that  division  of  the  cervical  sympathetic 
in  animals  is  followed  by  dilatation  of  the  vessels  of  the 
neck  and  head  on  the  same  side.  Conversely,  it  has  been 
shown  that  electrization  of  the  peripheral  end  of  the  di¬ 
vided  sympathetic  causes  contraction  of  the  dilated  vessels 
of  the  neck  and  head,  with  concomitant  lowering  of  the 
temperature  on  the  same  side  and  bulging  of  the  eyeball. 

Another  noteworthy  observation  in  connection  with  the 
sympathetic  is  the  fact  that  the  heart’s  action  is  accelerated 
by  irritation  and  retarded  by  division  of  the  nerve. 

Now,  the  purely  clinical  and  practical  objects  of  this 
paper  do  not  admit  of  further  digression  in  favor  of  physio¬ 
logical  theory ;  nevertheless,  enough  has  been  called  to 
mind,  I  trust,  to  show  with  reasonable  clearness  that  the 

*  Read  by  invitation  before  the  Newark  Medical  and  Surgicai  So¬ 
ciety,  June  19,  1890. 


?ept.  13,  1890.]  CORNING :  NATURE  AND  TREATMENT  OF  EXOPHTHALMIC  GOITRE. 


icceleration  of  the  pulse,  and  possibly  the  exophthalmia, 
nay  be  explained  by  assuming  that  the  sympathetic  is  irri- 
ated  at  its  cervical  part,  or  at  some  point  above  it.  But 
iow  shall  we  account  for  the  goitre  ?  for,  indeed,  some 
vriters  affirm  that  the  theory  of  sympathetic  irritation  is 
.vholly  opposed  to  the  dilated  condition  of  the  vessels  in 
he  enlarged  thyreoid.  To  my  own  mind  the  logical  diffi- 
ulty  is  more  imaginary  than  real,  inasmuch  as  one  may 
)erceive  in  the  enlarged  vessels  of  the  thyreoid  nothing 
nore  nor  less  than  one  of  the  inevitable  results  of  the  in¬ 
creased  vascular  tension.  The  patient  complains  of  pul- 
ation  in  the  head,  and  his  eyeballs  are  driven  forward 
jy  the  distended  vessels  in  the  orbit.  What  wonder, 
hen,  that  compensatory  dilatation  takes  place  in  the  di- 
•ection  of  least  resistance,  and  at  the  point  where  the 
dood-curreut  is  strongest?  Is  there  any  other  point  Avhich 
;o  well  fulfills  these  prerequisites  as  the  thyreoid  ?  Most 
certainly  I  know  of  no  such  locality.  Let  us  conclude  our 
■easoning,  then,  with  the  admission  that  the  theory  which 
ooks  to  irritation  of  the  sympathetic  as  a  prominent,  if  not 
he  most  prominent,  cause  of  exophthalmic  goitre  is  rea¬ 
sonable,  and  certainly  not  to  be  discarded  until  the  evidence 
n  rebuttal  has  been  materially  augmented. 

Symptoms. — Although  exophthalmic  goitre  is  subject 
o  a  certain  amount  of  variation  in  its  mode  of  develop- 
nent,  the  following  account  of  the  disease  is  applicable  in 
i  large  proportion  of  cases  : 

As  a  rule,  the  evolution  of  the  symptoms  is  gradual, 
out  this  is  not  always  the  case,  for  in  some  instances  the 
iffection  pursues  an  exceedingly  rapid  course,  attaining  its 
naximum  degree  of  development  in  forty-eight  hours. 
3ases  of  this  kind  have  been  aptly  characterized  as  “  acute,” 
nasmuchas  recovery  may  take  place  in  a  few  weeks,  or  even 
ess.  The  advent  of  the  disease  is  often  heralded  by  a 
variety  of  nervous  phenomena,  prominent  among  which  are 
sudden  outbreaks  of  anger,  vague  indescribable  sensations 
n  the  head,  and  mental  irritability.  These  manifestations 
nay  persist  for  a  variable  length  of  time,  but,  sooner  or 
ater,  they  are  followed  by  one  of  the  prominent  symptoms 
)f  the  disease.  In  many  instances  the  apprehensions.of  the 
patient  are  first  aroused  by  palpitations  and  a  feeling  of 
ullness  in  the  head.  If  the  pulse  be  examined  at  this  time, 
t  will  be  found  to  average  from  one  hundred  and  ten  to 
)ne  hundred  and  forty-five,  or  more.  The  condition  of 
he  circulation  is  specially  striking  in  the  neck,  where  the 
carotids  are  seen,  even  at  an  early  period,  to  pulsate  with 
?reat  vehemence. 

Simultaneously  with  or  shortly  after  the  advent  of  the 
Jardiac  symptoms  the  thyreoid  gland  begins  to  swell,  and 
soon  the  enlargement — which,  however,  is  never  very  great — 
s  quite  perceptible,  so  that  the  patient  resorts  to  a  high  collar 
3r  cravat,  with  a  view  to  hiding  the  deformity.  When  the 
iiand  is  placed  upon  the  tumor  a  distinct  thrill  is  felt,  and, 
3n  auscultation,  characteristic  murmurs,  emanating  from 
the  distended  vessels,  may  sometimes  be  heard. 

Shortly  after  the  enlargement  of  the  thyreoid  the  eyes 
begin  to  bulge — a  condition  which  gives  rise  to  a  peculiar 
staring  expression.  Sometimes  the  exophthalmia  is  so  great 
that  the  eyes  appear  to  hang  from  the  head,  as  if  about  to 


289 

drop  from  their  sockets.  Such  extreme  protrusion  is,  how¬ 
ever,  exceptional.  In  most  cases  the  deformity  is  about 
equal  on  both  sides;  sometimes,  however,  especially  during 
the  earlier  stages  of  the  disease,  one  eye  may  project  more 
than  the  other. 

Examination  with  the  ophthalmoscope,  after  the  disease 
has  lasted  some  time,  reveals  more  or  less  arterial  pulsation 
and  tortuosity  of  the  veins.  This  at  least  is  true  in  many 
instances.  Again,  while  accommodation  is  rarely  impaired, 
there  may  be  slight  diplopia  when  the  patient  attempts  to 
read  or  to  scrutinize  objects  in  his  immediate  vicinity. 
Conjunctivitis  is  common,  owing  probably  to  the  inadequate 
protection  afforded  by  the  upper  lid,  which,  in  some  cases, 
is  not  depressed  to  the  physiological  limit.  In  this  connec¬ 
tion  it  is  worthy  of  note,  as  first  pointed  out  by  von  Graefe, 
that,  when  the  eyeball  is  moved  up  and  down,  the  upper 
lid  does  not  move  in  concert  with  it.  To  this  phenomenon 
considerable  diagnostic  weight  has  been  assigned  by  vari¬ 
ous  authors,  who  have  sought  to  explain  it  in  different  ways. 
I  am  inclined  to  think,  however,  that  too  much  importance 
has  been  ascribed  to  it,  as,  in  my  experience,  it  is  not  a  very 
constant  symptom. 

Testimony  is  conflicting  with  regard  to  the  temperature 
in  exophthalmic  goitre.  In  my  experience  it  is  normal  or 
nearly  so,  elevations  of  1°  or  2°  F.  being  rather  exceptional. 
Excessive  perspiration  and  a  subjective  sensation  of  extreme 
heat  are,  however,  quite  common. 

The  condition  of  the  heart  is  naturally  a  question  of 
great  importance  ;  in  some  cases,  aside  from  great  vehe¬ 
mence  of  action,  nothing  whatever  of  an  abnormal  nature  is 
discoverable  either  before  or  after  death.  In  others,  how¬ 
ever,  there  may  be  dilatation  of  the  heart,  hypertrophy  of 
the  left  ventricle,  or  disease  of  the  valves. 

Besides  the  symptoms  just  mentioned,  those  who  suffer 
from  exophthalmic  goitre  are  often  the  victims  of  concomi¬ 
tant  nervous  disturbances,  ranging  in  severity  from  tremor, 
headache,  general  nervous  exhaustion,  vertigo,  feebleness  of 
memory,  and  insomnia,  to  epilepsy,  hysteria,  and  insanity. 

A  certain  precipitancy  of  speech,  abruptness  of  manner, 
and  unseemly  haste  are  peculiar  to  almost  all  cases  of 
Graves’s  disease. 

As  previously  remarked,  the  cases  which  run  an  acute 
course  are  exceptional ;  as  a  rule,  the  disease  lasts  a  long 
time.  Periods  of  real  or  apparent  improvement  may  occur, 
but  relapses  are  prone  to  take  place,  though  it  is  a  remarka¬ 
ble  fact  that  the  disease  is  sometimes  arrested,  and  recovery 
attained  in  the  most  unaccountable  manner. 

In  the  fatal  cases  the  patient  loses  flesh  more  or  less 
rapidly  and  dies  of  exhaustion,  or  the  heart  becomes  en¬ 
larged  and  is  ultimately  unable  to  perform  its  functions; 
or,  finally,  death  occurs  as  the  result  of  some  intercurrent 
affection. 

Diagnosis. — When  the  three  principal  symptoms  are 
well  developed,  little  difficulty  will  be  experienced  in  arriv¬ 
ing  at  a  correct  opinion  as  to  the  real  nature  of  the  trouble. 
As  a  matter  of  fact,  however,  it  is  quite  common  to  meet 
with  undoubted  instances  of  Graves’s  disease  in  which  either 
the  goitre,  the  exophthalmus,  or  the  cardiac  disturbance  is 
absent.  In  irregular  cases  of  this  sort  we  must  rely  prin- 


CORNING:  NATURE  AND  TREATMENT  OF  EXOPHTHALMIC  GOITRE.  [N.  Y.  Med.  Jour., 


290 

cipally  upon  a  careful  study  of  the  collateral  symptoms — 
the  profuse  diaphoresis,  the  headache,  the  irritability,  the 
tremulousness,  and  other  nervous  phenomena — in  framing  a 
diagnosis. 

Causes. — Prominent  among  the  exciting  causes  of  ex¬ 
ophthalmic  goitre  may  be  mentioned  prolonged  worry,  sud¬ 
den  fear,  anger,  and,  in  short,  inordinate  emotionality  in 
general.  As  predisposing  factors  are  a  weak  neurotic  con¬ 
dition  of  the  patient  and  a  special  hereditary  predisposi¬ 
tion.  Cases  are  quite  common  in  which  several  members 
of  the  same  family  have  been  affected  by  the  disease  in  the 
same  or  successive  generations. 

I  have  myself  recently  had  a  case  under  treatment  in 
which  I  was  able  to  trace  the  disease  in  the  direct  line  for 
three  generations. 

Finally,  the  disease  is  much  more  frequent  in  women 
than  in  men. 

Morbid  Anatomy. — As  has  already  been  said,  the  au¬ 
topsy  has  not  helped  us  much  in  so  far  as  the  establishment 
of  an  anatomic  basis  for  the  disease  is  concerned.  The 
data  available  are  at  once  meager  and  contradictory,  so 
that  anything  more  than  a  shrewd  surmise  as  to  ultimate 
causation  is  impossible. 

Some  observers,  like  Fournier,  Wilks,  and  Ollivier,  have 
failed  to  find  any  noteworthy  changes  in  the  cord  or  ganglia 
of  the  sympathetic  system,  while,  on  the  other  hand,  Moore, 
Peter,  Trauble,  and  others  have  found  more  or  less  extensive 
alterations  in  these  structures.  The  more  noteworthy 
changes  mentioned  in  literature  are  atrophy  of  the  ganglia, 
proliferation  of  connective  tissue,  and  consequent  oblitera¬ 
tion  of  nerve  elements  and  hypertrophy  of  the  ganglia. 

It  is  quite  useless,  in  the  present  state  of  knowledge,  to 
attempt  to  reconcile  these  two  phases  of  conflicting  opin¬ 
ion,  and  I  shall  therefore  refrain  from  discussing  them  fur¬ 
ther. 

Treatment. — In  view  of  the  chaotic  condition  of  the 
pathology  of  the  disease,  it  is  evident  that  very  little  in¬ 
spiration  of  a  practical  kind  is  to  be  derived  from  that 
source.  But  while  this  is  impossible,  while  the  treatment 
of  the  disease  can  not  be  based  upon  its  real  or  imaginary 
pathology,  valuable  assistance  regarding  its  management 
may  be  derived  from  purely  clinical  sources. 

Looking  at  the  question  from  this  standpoint,  two  facts 
of  commanding  importance  impress  themselves  upon  the 
physician.  First  and  foremost  is  the  phenomenal  disturb¬ 
ance  of  the  circulation,  and,  secondly,  the  profound  consti¬ 
tutional  impairment.  No  system  of  treatment  is  worthy  of 
a  moment’s  consideration  which  does  not  take  cognizance 
of  these. 

With  a  view  to  neutralizing  the  morbid  distribution  of 
the  circulation  and  improving  the  nutrition  of  the  patient, 
I  have  had  resource  to  a  plan  of  treatment  which  may 
briefly  be  described  as  follows : 

In  order  to  prevent  the  excessive  blood-pressure  in  the 
thyreoid,  cranial  cavity,  and  orbit,  I  have  placed  the  patient 
in  a  warm  bath,  at  least  once  a  day,  aud  caused  her  to  re¬ 
main  there  for  three  quarters  of  an  hour  or  more.  When  the 
derivative  action  of  the  bath  has  seemed  inadequate,  I  have 
applied  elastic  straps  around  the  legs  of  the  patient,  either 


above  or  below  the  knee,  according  to  the  amount  of  deri¬ 
vation  which  seemed  admissible  in  each  case.  The  con¬ 
striction  of  the  bandages  is  never  excessive,  since  they  are 
adjusted  in  such  a  way  as  to  interfere  more  or  less  with  the 
venous  circulation,  but  not  with  that  in  the  arteries.  While 
these  precautions  are  observed  below,  the  swollen  thyreoid 
is  treated  with  a  special  preparation  of  styptic  collodion, 
whose  constricting  properties  are  further  enforced  by  a 
carefully  adjusted  elastic  truss.  I  have  also  bandaged  the 
eyes  during  the  emersion  ;  but  I  am  not  certain  that  this 
has  been  efficacious,  in  so  far  as  a  permanent  reduction  of 
the  exophthalmia  is  concerned.  On  the  other  hand,  the 
application  of  elastic  pressure  to  the  thyreoid  certainly 
does  good,  and  this  is  more  especially  the  case  when  such 
pressure  is  combined  with  concomitant  expansion  of  the 
veins  of  the  lower  extremities,  as  in  the  method  just  de¬ 
scribed.  A  case  of  Graves’s  disease,  occurring  in  a  lady  of 
twenty-five  and  referred  to  me  about  three  months  since,  is 
an  illustration  in  point.  At  the  time  of  beginning  treat¬ 
ment  the  circumference  of  her  neck  at  the  most  prominent 
portion  of  the  tumor  was  a  little  more  than  fifteen  inches. 
The  present  measurement  at  the  same  spot  is  a  trifle  over 
thirteen  inches — an  appreciable  reduction  certainly. 

In  addition  to  the  foregoing  measures,  I  am  in  the  habit 
of  submitting  the  tumor  to  daily  applications  of  galvanism, 
employing  for  this  purpose  an  electrode  of  potter’s  clay 
moistened  with  iodine  and  of  sufficient  size  to  envelop  the 
entire  thyreoid.  This  electrode,  which  is  most  serviceable 
for  the  purpose,  is  connected  with  the  positive  pole  of  the 
battery,  while  the  negative,  composed  of  a  large  flat 
sponge,  is  placed  at  the  back  of  the  neck. 

As  regards  the  duration  of  these  applications,  I  may 
say  that  I  continue  them  for  from  ten  to  twenty-five  min¬ 
utes  twice  a  day  at  least.  Not  much  good  is  to  be  antici¬ 
pated  short  of  six  weeks  or  two  months.  The  faradaic  cur¬ 
rent  I  do  not  employ,  or,  to  speak  more  correctly,  I  do  not 
apply  it  to  the  tumor.  However,  it  is  doubtless  of  benefit 
when  used  in  a  general  way. 

The  question  has  often  been  asked,  and  will  doubtless 
continue  to  be  asked  in  future,  What  shall  we  do  to  regu¬ 
late  the  heart’s  action  ?  In  reply  I  would  say  that  our  ac¬ 
tion  in  this  regard  must  be  largely  governed  by  circum¬ 
stances.  When  the  pulse  is  rapid,  say  from  125  to  145, 
and  the  arterial  tension  notably  increased,  especially  at  the 
carotids,  aconitine  may  be  given  with  great  benefit.  On  the 
other  hand,  where  there  is  no  notable  increase  in  the  pulse, 
which  say  at  90  is  lacking  in  fullness,  digitalis,  sparteine,: 
and  strophanthus  are  clearly  indicated. 

We  next  come  to  a  question  of  great  if  not  paramount 
importance — the  diet  of  the  patient.  Nothing  is  more  cer¬ 
tain  than  that  neglect  to  improve  the  general  nutrition  of 
the  subject  will  be  followed  by  disaster.  It  is  incumbent, 
therefore,  upon  the  practitioner  to  pay  due  heed  to  this 
point  as  soon  as  the  character  of  the  disease  has  been  made 
out.  In  my  experience,  a  judiciously  regulated  but  not  ex¬ 
clusive  milk  diet  is  to  be  preferred.  To  the  milk,  which 
should  be  taken  in  quantities  ranging  from  two  to  four 
quarts  a  day,  bread  and  butter,  poultry,  and  game  in  mod¬ 
eration  may  be  added.  A  raw  egg  carefully  beaten  up  with 


HIG  GINS:  THE  TREATMENT  OF  HEMORRHOIDS. 


Sept.  13,  1890.] 

•ugar  and  milk  may  be  given  with  advantage  two  or  even 
liree  times  a  day.  Some  patients,  however,  refuse  to  have 
my  thing  to  do  with  the  mixture  unless  brandy  or  whisky 
s  added;  and  since  alcohol  in  all  its  forms  is  absolutely 
ontra-indicated  in  most  cases  of  Graves’s  disease,  it  is  per- 
iaps  better  to  give  the  eggs  as  an  omelet  or  poached. 

Should  there  be  the  least  falling  off  in  the  appetite  of 
he  patient,  bitter  tonics  may  be  given  without  stint. 

It  is  hardly  necessary  to  add  that  both  iron  and  arsenic 
nay  be  given  with  advantage,  provided  the  stomach  of  the 
.atient  will  bear  them. 

Finally,  it  is  necessary  to  shield  the  patient  from  emo- 
ional  excitement  and  mental  strain  of  all  kinds,  and  to 
livert  her  thoughts  from  herself.  Simple  games,  musical 
entertainments,  and  a  moderate  amount  of  reading  may  be 
described  with  confidence,  as  being  the  best  means  of  pre- 
enting  the  habit  of  morbid  introspection. 

Prolonged  cerebral  rest  I  regard,  too,  as  of  the  utmost 
mportance.  By  this  I  do  not  mean  that  the  patient  should 
>e  kept  in  bed  for  inordinately  long  periods,  but  that  while 
here  she  should  remain  unconscious.  Only  in  this  wray  is 
hat  rest  of  the  higher  nervous  centers  to  be  obtained  which 
s  so  surely  demanded.  In  this  connection  I  would  remark 
hat  in  my  opinion  the  subjection  of  patients  who  are  suf- 
'erers  from  Graves’s  disease  to  what  is  familiarly  known  as 
he  “  Weir  Mitchell  treatment  ”  is  a  great  cruelty.  Patients 
.vho  suffer  in  this  way  are  exceedingly  irritable  and  restless, 
ind  to  demand  of  them  that  they  shall  remain  for  days  or 
.veeks  in  bed,  more  or  less  wakeful  for  a  considerable  por- 
ion  of  the  time,  is  not  good  practice.  I  have  seen  patients 
.vho  have  sustained  great  injury  in  this  way. 

The  best  method  of  affording  necessary  rest  to  the  pa- 
ient  without  irritating  her  is  to  keep  her  asleep  at  night, 
)r  so  long  as  she  maintains  the  recumbent  posture.  This 
nay  readily  be  done  by  the  use  of  a  little  dexterity,  with- 
>ut  excessive  resort  to  drugs.  At  the  present  time,  for  ex- 
iraple,  I  have  a  lady  under  my  care  who  has  suffered  from 
Iraves’s  disease  for  about  a  year  and  a  half,  and  who  is 
ihle  to  sleep  from  ten  to  fourteen  hours  out  of  the  twenty- 
our  without  sedatives.  This  she  was  not  able  to  do  when 
she  first  came  under  my  care  ;  but,  by  the  utilization  of 
labit  and  the  elimination  of  psychical  and  sensory  irrita- 
ion,  she  is  now  able  to  sleep  as  much  or  more  than  she 
;ares  to. 

53  West  Thirty-eighth  Street. 


THE  TREATMENT  OF  HAEMORRHOIDS  * 

By  CARTER  B.  HIGGINS,  M.  D., 

SURGEON  IN  CHARGE,  WABASH  RAILROAD  HOSPITAL,  PERU,  INDIANA. 

From  the  earliest  recorded  period  there  has  cumbered  the 
■arth  a  class  of  humanity  whose  only  object  in  life  has  been 
o  become  possessed  of  the  honest  accumulations  of  thrifty 
md  credulous  people  without  returning  any  adequate  equiva- 
ent.  Individuals  of  this  class  are  usually  characterized  by 
jfight  intellects,  which  they  exercise  exclusively  in  devis- 
ng  schemes  of  trickery  and  fraud.  A  few  years  ago,  im- 

*  Read  before  the  Miami,  Ind.,  County  Medical  Society,  July  18,  1890. 


291 

mediately  following  the  publication  of  numerous  so-called 
Systems  of  Rectal  Treatment,  this  class  almost  in  a  body 
abandoned  their  lightning-rod,  fruit-tree,  grave-yard  insur¬ 
ance,  and  other  schemes,  which  had  frequently  brought  them 
in  contact  with  officers  of  the  law,  and,  arming  themselves 
with  hypodermic  syringes,  “took  the1  road”  as  specialists 
in  the  treatment  of  diseases  of  the  rectum.  By  some  pre- 
«oncerted  arrangement  each  fellow  was  given  a  special  field, 
and,  in  confirmation  of  the  adage  “  there  is  honor  among 
‘professional  purloiners,’ ”  it  seldom  happened  that  one 
trespassed  on  the  territory  of  another.  Not  long  after  the 
ex-pomologist  or  electrician  had  established  his  route  there 
appeared  in  the  public  press  of  the  various  towns  which  he 
honored  with  his  visits  elaborate  and  extended  “  puffs  ” 
proclaiming  the  many  cures  he  had  effected  in  cases  which 
had  previously  baffled  the  skill  of  the  most  eminent  and 
expert  surgeons.  To  these  advertisements  were  attached 
the  uames  of  many  more  or  less  prominent  citizens,  most 
of  whom  had  attained  prominence  by  having  been  made 
victims  of  some  patent  right  or  other  swindle  directed  by  a 
colaborer  of  the  specialist  previous  to  changing  his  voca¬ 
tion.  To  morally  fortify  the  allegation  there  were  in  most 
instances  attached  the  signatures  of  the  “  atrabilious  par¬ 
son  ”  and  the  divinity  student  enfeebled  by  too  frequent 
offerings  at  the  shrine  of  Onan.  The  new  scheme  for  a 
time  proved  very  profitable,  and  for  many  months  at  each 
recurring  visit  the  schematist  would  find  his  rooms  crowded 
with  victims.  But  gradually  the  field  was  exhausted  ;  finally 
his  callers  were  exclusively  those  of  his  early  patrons  who 
came  urging  the  fulfillment  of  his  guarantee  of  “  No  cure, 
no  pay.”  Suddenly  the  impostor  disappeared  ;  but  we  shall 
hear  of  him  again  as  the  originator  of  some  new  project 
“  well  calculated  to  deceive.”  I  wish  here  to  disclaim  any 
intention  to  reflect  disparagingly  on  the  clergy  as  a  body, 
or  on  reputable  people  engaged  in  the  occupations  assumed 
by  confidence  men.  The  clerical  coadjutors  of  quacks  and 
the  rascally  hordes  that  infest  the  country  in  the  guise  of 
honest  tradesmen  sustain  the  same  relation  to  the  honorable 
followers  of  their  respective  callings  that  the  advertising- 
specialists  do  to  the  profession  of  medicine. 

The  conditions  could  not  well  have  been  more  favorable 
to  his  success  than  when  the  peripatetic  pile  doctor  began 
his  rounds.  The  treatment  of  haemorrhoids  had  been  almost 
entirely  neglected  by  the  general  practitioner.  Each  physi¬ 
cian  had  probably  in  the  early  days  of  his  professional 
career  applied  the  treatment  recommended  by  the  authori¬ 
ties,  but  one  trial  was  sufficient  to  convince  him  that  his 
ambition  to  attain  fame  and  wealth  would  not  be  gratified 
in  that  direction.  The  tedious  separation  of  the  slough, 
the  slow  healing  of  the  resulting  sore,  the  tenesmus,  stran¬ 
gury,  and  other  forms  of  suffering  experienced  by  the  pa¬ 
tient,  together  with  the  doctor’s  recollection  of  the  fact 
mentioned  by  all  authorities  that  death  was  a  possible  re¬ 
sult  of  the  operation,  served  to  convince  him  that  rectal 
surgery  was  not  an  attractive  specialty.  In  succeeding 
cases  it  is  not  strange  that  he  should  exhaust  the  list  of 
ointments  and  laxatives  before  advising  operative  interfer¬ 
ence.  In  rural  communities,  where  every  one  is  familiar 
with  his  neighbor’s  affairs,  the  result  of  one  operation  by 


292 


HIGGINS:  THE  TREATMENT  OF  HEMORRHOIDS. 


[N.  Y.  Med.  Jouk., 


ligature  or  clamp  and  cautery  would  excite  such  distrust  in 
the  minds  of  the  people  that  it  would  be  impossible  to  find 
one  courageous  enough  to  submit  to  like  treatment  until 
time  had  obliterated  all  remembrance  of  the  first  case. 

The  treatment  of  piles  popularized  by  the  “  itinerant 
vagabonds”  was  for  a  time  thought  to  be  of  real  value,  and 
some  surgeons  of  national  repute  gave  it  a  place  in  surgery 
by  their  recommendation.  The  talented  author  of  one  of 
the  most  valued  text-books  on  rectal  diseases,  in  the  first 
edition  of  his  work,  gave  the  treatment  by  injection  his  un¬ 
qualified  approval,  and  advised  its  use  in  preference  to  all 
others.  In  a  recent  publication,  however,  he  acknowledges 
that  his  hopes  have  not  been  realized  and  again  recom¬ 
mends  the  clamp  and  cautery.  The  frequent  relapses  oc¬ 
curring  among  cases  treated  by  the  roving  quacks  was  for  a 
while  thought  to  he  owing  to  the  imperfect  and  clumsy 
manner  in  which  the  treatment  was  applied;  but  time  has 
shown  that  relapse  is  the  rule  even  in  the  practice  of  edu¬ 
cated  surgeons.  This  treatment  I  believe  is  no  longer  ad¬ 
vocated  by  any  reputable  authority.  The  instrument-mak¬ 
ers  will  from  time  to  time  send  us  circulars  offering  what 
they  call  “  rectal  sets  ”  at  ruinously  low  prices,  but  after 
they  have  disposed  of  their  dead  stock  the  treatment  of 
haemorrhoids  by  hypodermic  injections  will  sink  into  de¬ 
served  oblivion  in  company  with  its  unsavory  originators. 

The  treatment  of  haemorrhoids  by  forcible  dilatation  of 
the  sphincters  was,  I  think,  first  publicly  advocated  by  the 
eminent  French  surgeon  Verneuil  about  sixteen  years  ago. 
At  that  time  he  professed  to  have  radically  cured  many  cases 
of  the  most  aggravated  character.  Immediately  following 
Yerneuil’s  came  other  statements  emanating  from  French 
surgeons  of  the  highest  standing,  all  confirming  in  the 
most  positive  manner  the  wonderful  effects  of  dilatation  of 
the  sphincters  in  the  treatment  of  piles.  That  treatment  so 
simple,  advocated  with  such  earnestness  by  surgeons  of  un¬ 
questioned  ability  and  integrity  and  of  world-wide  reputa¬ 
tion,  should  attract  so  little  attention  is  indeed  wonderful. 
Our  wonder  grows  when  we  call  to  mind  the  fundamental 
fiasco  of  Bergeon,  which  we  can  not  do,  most  of  us,  without 
feelings  of  shame  and  humiliation.  Upon  the  recommenda¬ 
tion  of  a  comparatively  obscure  French  doctor  the  profes¬ 
sion  of  the  civilized  world  provided  themselves  with  appa¬ 
ratus  to  manufacture  and  force  into  the  intestines  of  their 
tuberculous  patients,  whose  poor  emaciated  bodies  were 
already  tortured  to  the  extreme  of  endurance,  a  putrescent 
gas  which  their  feeble  digestive  powers  had  already  caused 
to  be  present  in  distressful  abundance. 

The  more  recent  testicular  experimentation  following 
Brown-Sequard’s  suggestion  resulted  in  an  epidemic  of 
pyaemia  which  prevailed  in  every  city,  village,  and  hamlet 
of  Christendom.  It  must  not  be  forgotten  that  these  ab¬ 
surdities  developed  subsequent  to  the  publication  by  Ver¬ 
neuil  of  his  success  in  the  treatment  of  piles. 

Allingham’s  is  about  the  only  text-book  on  rectal  sur¬ 
gery  which  gives  the  treatment  by  dilatation  respectful  no¬ 
tice.  He  says  it  may  succeed  in  selected  cases,  but  must  not 
be  thought  of  as  a  general  treatment.  Andrews,  not  having 
given  the  method  a  trial,  says  it  may  be  desirable  in  cases 
of  timid  patients  who  cherish  a  horror  of  ligatures  and  in¬ 


struments.  (I  wonder  if  he  comes  in  contact  with  any  who 
do  not  ?)  Kelsey  barely  mentions  the  treatment  as  not 
worthy  of  consideration.  Since  taking  charge  of  the  Wa¬ 
bash  Railroad  Hospital  I  have  had  in  my  service  six  house 
surgeons,  graduates  from  four  different  medical  colleges,  all 
high-grade  schools.  These  young  gentlemen  received  ap¬ 
pointment  on  account  of  high  standing  in  their  classes.  Not 
one  of  them  previous  to  coming  here  had  ever  heard  dila¬ 
tation  of  the  sphincters  recommended  as  a  curative  method 
in  the  treatment  of  piles.  Three  or  four  articles  have  ap¬ 
peared  in  as  many  different  medical  journals  published  in 
the  United  States  advocating  the  treatment.  With  these 
exceptions  I  have  failed  to  see  it  commended  by  either 
English  or  American  authority.  The  following  quotation 
from  Allingham’s  Diseases  of  the  Rectum  may  account  for 
the  treatment  suggested  by  Verneuil  having  been  so  en¬ 
tirely  ignored  by  rectal  surgeons  : 

“  I  do  not  think  in  the  whole  range  of  surgery  there  is 
any  procedure  worthy  of  the  name  ‘  operation  ’  which  can 
show  greater  amount  of  success  or  smaller  death-rate  than 
the  ligature  of  internal  haemorrhoids.” 

Dilatation  of  the  sphincters  may  not,  in  a  surgical  sense, 
be  worthy  of  the  name  1  operation.’  If  such  is  the  case,  I 
advise  the  “  farnity  doctor  ”  to  appropriate  it,  for,  with  the 
multiplied  and  multiplying  specialties  devoted  to  diseases 
affecting  all  organs  and  tissues  between  the  fields  of  the 
alienist  and  chiropodist,  inclusive,  there  is  very  limited  ter¬ 
ritory  in  which  he  may  practice. 

My  confidence  in  the  superiority  of  the  treatment  by 
dilatation  was  secured  by  the  same  nature  of  accident  which 
convinced  the  French  surgeons — that  is,  by  observing  the 
complete  and  permanent  disappearance  of  a  number  of  large 
internal  pile  tumors  in  the  case  of  a  gentleman  who,  in  con¬ 
nection  with  his  other  trouble,  developed  an  anal  fissure, 
dilatation  for  the  cure  of  which  also  cured  his  haemorrhoids. 
Dr.  Brenton,  of  this  society,  reports  similar  experience,  his 
patient  being  a  lady  who  had  suffered  greatly  both  from 
strangulation  of  the  tumors  and  great  loss  of  blood;  her 
fear  of  any  operation  suggested  for  the  cure  of  the  piles  was 
too  great  to  be  overcome,  but  the  fortunate  intervention 
of  an  anal  fissure  induced  her  to  consent  to  the  procedure 
of  dilatation,  with  the  result  of  curing  both  fissure  and  haem¬ 
orrhoids  and  her  speedy  restoration  to  perfect  health. 

I  have  used  no  other  method  in  effecting  the  radical  cure 
of  piles  for  the  past  eight  years,  and  during  that  time  have 
succeeded  in  curing  many  cases  of  the  most  aggravated  char¬ 
acter.  I  will  not  now  state  the  number  of  cases  nor  the  per¬ 
centage  of  cures,  realizing  that  advocates  of  new  methods  too 
often  excite  distrust  by  alleging  too  much.  I  know  of  no 
condition  that  would  forbid  the  application  of  this  treat¬ 
ment.  I  have  applied  it  at  almost  every  stage  of  pregnancy, 
in  four  hours  succeeding  labor,  in  patients  suffering  from 
cirrhosis  of  the  liver  far  advanced,  in  cases  complicated  with 
enlarged  and  indurated  prostate  gland,  those  with  urethral 
stricture — in  fact,  I  know  no  reason,  where  it  is  demanded 
for  relief,  why  it  should  not  be  resorted  to.  In  1888  Ver¬ 
neuil  reported  the  results  of  his  application  of  the  treatment 
during  the  fourteen  years  then  just  passed.  He  alleged 
98  per  cent,  of  cures.  He  made  no  distinction  in  the  cases, 


Sept.  13,  1890.] 


MARTINEZ:  COMPOUND  FRACTURE  OF  THE  SKULL. 


293 


“both  external  and  internal,  old  and  recent,  large  and  small, 
those  associated  with  relaxed  sphincters  and  those  with  the 
opposite  condition.”  My  experience  with  the  treatment  has 
been  no  less  satisfactory  than  that  reported  by  Verneuil. 
My  percentage  of  cures  would  be  increased  by  eliminating 
two  cases  of  applicants  for  pensions,  piles  being  the  alleged 
cause  of  disability.  The  applications  were  still  pending 
when  they  reported  slight  if  any  improvement. 

The  dilatation  is  effected  as  follows  :  Hook  the  thumb 
of  your  left  hand  and  the  middle  finger  of  your  right  hand 
so  as  to  include  both  sphincters  on  opposite  sides  of  the 
anus,  and  gradually  but  forcibly  separate  your  hands  until 
all  resistance  ceases,  the  object  being  to  paralyze  the  muscles 
completely.  It  is  commonly  advised  to  oppose  the  thumbs, 
but  in  a  great  many  cases  the  resistance  will  be  found  so 
strong  that  it  will  be  impossible  to  separate  the  thumbs  a 
sufficient  distance.  1  have  in  some  cases  found  the  sphinc¬ 
ters  from  long  contraction  developed  to  such  a  degree  as  to 
give  the  impression  of  pulling  on  an  iron  ring.  I  have  never 
known  any  bad  results  follow  the  procedure.  No  after-treat¬ 
ment  is  necessary,  except  in  cases  where  there  is  complaint 
of  smarting,  which  may  be  relieved  promptly  by  the  appli¬ 
cation  of  a  pledget  of  cotton  saturated  with  a  four-per-cent, 
solution  of  cocaine.  It  is  always  advisable  to  perform  dila¬ 
tation  under  the  influence  of  an  anaesthetic,  the  A.  C.  E. 
mixture  being  the  one  I  always  use. 

Some  halting  wit,  “the  result  of  a  feeble  hour,”  has  stig¬ 
matized  the  advocates  of  dilatation  as  “bung-stretchers”; 
should  we  be  so  characterized,  we  may  console  ourselves 
with  the  knowledge  that  Ephraim  McDowell  was  called  a 
“  belly-ripper.” 


A  CASE  OF 

COMPOUND  FRACTURE  OF  THE  SKULL. 

TREPHINING ;  FORMATION  OF  A  LARGE  CEREBRAL  HERNIA  ; 

ITS  REDUCTION,  AND  COMPLETE  RECOVERY  OF  THE  PATIENT. 

By  JUAN  JOSE  MARTINEZ,  M.  D., 

GRANADA,  NICARAGUA. 

Two  principal  objects  have  prompted  me  to  publish 
this  case  :  (1)  The  nature  of  the  fracture  and  the  treatment 
it  was  subjected  to  previous  to  operation  ;  and  (2)  the  for¬ 
mation  of  an  immense  cerebral  hernia,  with  its  reduction  and 
the  complete  recovery  of  the  patient : 

The  case  has  reference  to  J.  M.  A.,  a  boy  of  seventeen, 
Nicaraguan,  of  a  fairly  healthy  constitution  and  of  good  pre¬ 
vious  history  and  habits.  While  he  was  riding  on  the  platform 
of  a  railway  car  his  hat  flew  off,  and  in  the  attempt  to  catch  it 
he  lost  his  equilibrium  and  fell  off  the  car,  coming  down  on  his 
head.  A  surgeon  was  immediately  summoned,  and  found  the 
boy  in  a  complete  state  of  coma,  with  loud  breathing  and  slow 
pulse. 

On  examination  of  the  head,  he  found  a  lacerated  wound  of 
about  three  inches,  stellate  shaped,  and  about  the  region  of  the 
ascending  frontal  and  of  the  ascending  parietal  convolutions, 
near  the  median  line,  but  to  its  left  side.  He  also  discovered 
the  fractured  bone  pressing  on  the  brain,  but,  either  from  want 
of  knowledge  or  from  indifference  as  to  the  future  of  the  case, 
the  boy  being  poor,  he  sutured  the  ragged  edges,  thus  attempt¬ 
ing  to  hide  his  ignorance  or  his  ill  conscience. 


This  septical  mistake  he  tried  to  render  aseptic  by  ordering 
bichloride-solution  applications.  This  treatment  was  continued 
for  ten  days.  The  boy  began  to  rally  about  three  hours  after 
the  accident,  finding  himself  speechless  and  with  hemiplegia  of 
the  right  side.  I  understand  that  his  pupils  were  equally  con¬ 
tracted,  and  that  the  tongue  was  not  deflected;  had  severe  pain 
in  the  head,  and  about  six  hours  after  the  injury  had  gained  his 
consciousness. 

On  the  tenth  day  I  was  called  to  see  the  case,  and  found  the 
head  a  mass  of  pus  and  hair,  with  an  extremely  offensive  odor; 
the  edges  of  the  wound  were  very  ragged,  and  the  sutures  had  all 
torn  through.  The  patient  was  conscious,  with  complete  aphasia 
and  right  hemiplegia;  defecated  and  urinated  involuntarily. 
Temperature,  105°  F. ;  pulse,  115;  and  respiration,  25.  Had 
daily  chills  and  profuse  perspiration.  In  other  words,  there 
were  symptoms  of  pus  absorption.  On  retracting  the  wound, 
I  found  a  large  piece  of  bone  entirely  fractured  off  from  the 
cranial  vault  and  pressing  greatly  on  the  brain.  Recommended 
immediate  operation. 

On  April  15th,  at  10  a.  m.,  assisted  by  Drs.  R.  and  F.  Cha- 
moiro,  I  proceeded  to  operate. 

Anaesthetized  the  patient  with  the  A.  0.  E.  mixture  and 
used  strict  cleanliness  and  antisepsis.  Extended  the  lower 
angle  of  the  wound  down  to  the  bone,  trephined  in  that 
situation,  removing  the  button  entire,  and,  after  biting  off 
with  the  rongeur  all  the  projecting  spicula  of  bone,  was  able  to 
remove  the  fractured  piece  without  injuring  the  brain  in  the 
least. 

Having  accomplished  this,  I  found  at  the  left  and  superior 
angle  of  the  wound,  and  lying  under  the  skin,  another  piece  of 
bone  fractured  off;  for  its  removal,  extended  that  angle  of  the 
wound  and  was  able  to  extract  it  with  tolerable  ease.  I 
found  the  meninges  torn  and  the  brain  extremely  congested, 
but  no  soft  spots  were  found.  There  remained  in  the  skull  a 
hole  of  about  two  inches  and  a  half  in  diameter. 

Powdered  iodoform  freely  on  the  wound  and  dressed  it 
Operation  lasted  an  hour  and  a  half. 

3  P.  M. — Projectile  vomiting. 

5  P.  M. — Urinated  involuntarily;  has  not  vomited  since; 
no  shock. 

10  P.  M. — Bowels  moved  involuntarily.  R  Pot.  brom., 
gr.  xxx. 

12  P.  M. — Slept  about  an  hour. 

April  16th ,  9  A.  M. — Temperature,  100°  ;  pulse,  120  ;  respi¬ 
ration,  28.  Dressed.  From  this  time  on  the  temperature,  pulse, 
and  respiration  continued  going  down,  and  kept  about  the  nor¬ 
mal. 

April  17th. — Wound  begins  to  attain  a  healthy  condition. 
Brain  protrudes  slightly  through  opening.  A  cerebral  hernia 
that  could  not  be  prevented  was  commencing  to  form,  and  it 
continued  growing  in  size  until  the  tenth  day  after  the  opera¬ 
tion,  when  it  had  attained  the  size  of  a  man’s  fist.  I  consulted 
all  my  works  on  surgery.  Some  advised  me  to  leave  it  alone  to 
degenerate,  others  to  cut  the  protruding  mass.  I  preferred  the 
conservative  plan  and  left  the  tumor  alone,  using  a  fifty-per¬ 
cent.  alcoholic  solution  of  1  to  3,000  bichloride.  This  applica¬ 
tion  was  continued  for  six  weeks,  as  there  was  a  marked  dimi¬ 
nution  of  the  tumor,  preserving  all  the  time  a  hard  and  healthy 
consistency,  and  the  boy  was  gradually  gaining  his  speech  and 
the  use  of  his  limbs. 

Up  to  this  time  the  boy  has  maintained  the  horizontal  posi¬ 
tion. 

June  28th. — Left  his  bed.  The  tumor  has  been  completely 
reduced  and  a  thick  tissue  of  new  formation  covers  the  opening 
in  the  skull.  The  boy  has  gained  flesh  during  his  confinement 
and  is  feeling  very  well. 


29  T 


SULLIVAN:  REPORT  OF  A  CASE  OF  ACUTE  PURULENT  PLEURISY.  [N.  Y.  Mud.  Jour., 


This  result  has  surprised  me,  as  I  did  not  think  the  boy 
would  live  two  days  after  the  operation,  such  was  the  injury 
and  the  condition  of  the  wound. 

As  to  the  reduction  of  the  hernia,  I  do  not  know  how  to 
explain  it.  I  certainly  do  not  think  it  took  place  by  de¬ 
generation,  the  brain  maintaining  such  a  healthy  appearance 
all  the  time  and  the  patient  having  regained  all  his  func¬ 
tions.  Whether  the  alcohol  treatment  had  any  influence  I 
do  not  dare  to  say,  but  should  be  most  happy  to  hear  the 
result  of  another  trial. 


REPORT  OF 

A  CASE  OF  ACUTE  PURULENT  PLEURISY. 

PLEUROTOMY ,  FOLLOWED  BY  RAPID  RECOVERY* 

By  J.  D.  SULLIVAN,  M.D., 

BROOKLYN. 

It  is  only  within  a  comparatively  recent  period  of  time 
that  acute  purulent  pleurisy  has  been  recognized  as  a  pri¬ 
mary  disease.  At  the  time  when  many  of  us  were  receiving 
our  medical  education,  we  were  taught  that  empyema  or  pus 
in  the  pleural  sac  always  resulted  from  a  degeneration  of  a 
serous  or  fibro-serous  fluid,  which  had  been  effused  into 
that  cavity,  and  that  the  change  from  serum  into  pus  was 
due  to  the  admission  of  air  either  through  a  fistula  into  the 
bronchial  tubes  or  through  an  opening  in  the  chest  wall. 
But  parallel  with  the  general  progress  of  medicine  and  sur¬ 
gery  our  views  of  its  pathology  have  materially  changed, 
and  our  knowledge  of  the  subject  largely  increased  and 
better  defined. 

Of  recent  years,  owing  to  aids  given  by  exploratory 
puncture,  and  especially  since  the  invention  and  general  ap¬ 
plication  of  the  aspirator,  purulent  pleurisies  have  been 
thoroughly  investigated.  Although  Dieulafoy  demonstrated 
that  in  all  effused  liquids  in  the  pleural  sac  there  were  pres¬ 
ent  red  globules  and  leucocytes,  and  others  have  established 
the  fact  that  the  apparently  serous  pleural  effusions  gen¬ 
erally  contained  pus  cells,  Wilson  Fox,  in  1877,  showed  that 
there  was  but  little  natural  tendency  in  serous  effusions  to 
undergo  purulent  transformation.  He  expressed  the  opin¬ 
ion  that  the  great  majority  of  suppurative  pleurisies  were 
such  from  the  early  periods  of  the  disease.  From  my  own 
experience  I  am  convinced  that  a  large  proportion,  at  least, 
of  the  cases  termed  empyema  are  primary  purulent  pleuri¬ 
sies.  There  is  undoubtedly  some  peculiarity  in  the  charac¬ 
ter  of  the  inflammation,  or  in  the*  condition  of  the  patient, 
which  causes  the  effusion  to  contain  a  sufficiently  large 
number  of  leucocytes  to  determine  its  purulent  properties. 

The  following  case  is  of  interest  as  proving  the  primary 
character  of  the  disease,  and  illustrating  the  beneficial  effects 
of  early  diagnosis  and  appropriate  treatment: 

Freddie  W.,  aged  seven  years,  of  good  family  history,  was 
taken  sick  while  at  school  on  March  10, 1890,  with  a  very  severe 
pain  in  his  right  side,  followed  by  a  high  fever,  rapid  pulse,  and 
general  distress. 

A  cathartic  was  administered,  and  this  was  followed  by 
quinine  and  Dover’s  powder  in  moderate  doses.  On  the  fol¬ 


*  Read  before  the  Fifth  District  Branch  of  the  New  York  State 
Medical  Association,  at  Kingston,  July  22,  1890. 


lowing  day  his  temperature  was  103°  F.,  pulse  rapid,  and  respi¬ 
ration  considerably  embarrassed  by  the  pain  in  his  right  side. 

Dullness  on  percussion  was  the  only  marked  physical  sign 
elicited  by  examination  of  his  chest.  Medicinal  treatment  had 
but  very  little  effect  in  checking  the  progress  of  the  disease, 
and  he  remained  in  the  same  condition  for  about  a  week,  ex¬ 
cepting  that  the  dullness  on  percussion  on  the  right  side  in¬ 
creased  to  absolute  flatness.  It  was  evident  that  there  was  an 
effusion  taking  place  in  the  right  pleural  cavity,  which  was 
gradually  compressing  the  lung  and  producing  greater  dyspmea. 
The  distress  of  the  little  patient  was  so  great  that  he  was  un¬ 
able  to  get  much  rest  or  take  but  little  food,  and  he  was  ema¬ 
ciating  quite  rapidly.  His  temperature  continued  to  range  from 
102°  to  104°,  and  the  pulse  continued  rapid,  becoming  more 
feeble.  On  the  ninth  day  copious  perspirations  supervened. 
By  the  twelfth  day  the  greater  portion  of  the  right  side  of  his 
chest  was  absolutely  flat  on  percussion,  and  the  lung  was  evi¬ 
dently  compressed  toward  the  apex.  The  copious  perspirations 
aud  rapid  emaciation  led  me  to  suspect  the  existence  of  suppu¬ 
ration  going  on  in  connection  with  the  pleurisy. 

On  March  23d  I  introduced  an  aspirating  needle  into  the 
side,  and  confirmed  my  suspicions  by  drawing  off  a  small  quan¬ 
tity  of  pus.  As  the  needle  became  clogged  by  the  fibrous 
masses  in  the  liquid,  I  was  obliged  to  withdraw  it. 

Deeming  it  prudent  to  make  another  attempt  to  draw  off 
the  fluid  and  wash  out  the  pleural  sac  without  opening  the 
thorax  on  the  next  day,  assisted  by  Dr.  F.  O.  Hickok,  I  intro¬ 
duced  a  medium-sized  trocar  and  cannula  between  the  eighth 
and  ninth  ribs  in  the  median  axillary  line,  and,  having  attached 
the  latter  to  an  aspirator,  succeeded  in  drawing  off  a  few  ounces 
of  pus,  when  the  cannula  became  so  obstructed  by  the  fibrous 
masses  that  I  was  convinced  of  the  impossibility  of  evacuating 
the  pleural  sac  by  that  method. 

With  the  boy  partially  under  the  influence  of  an  anaesthetic, 
I  introduced  a  scalpel  along  the  course  of  the  cannula,  through 
the  thoracic  wall,  and  made  a  free  opening  about  two  inches  in 
length. 

The  pus  was  ejected  with  such  force  that  a  portion  of  it 
was  thrown  a  distance  of  at  least  eight  feet.  The  quantity  of 
pus  and  cheesy  material  evacuated  was  estimated  at  five  pints. 
As  the  fluid  escaped,  severe  coughing  was  induced  and  the  long 
expanded  well.  The  pleural  sac  was  now  washed  out  with  a 
warm  solution  of  chloride  of  sodium,  two  drachms  to  the  pint. 

A  large  pad  of  paper-wool  was  now  placed  over  the  opening 
and  a  bandage  applied.  He  rested  better  the  following  night 
than  he  had  since  his  illness.  The  next  day  his  temperature 
was  nearly  normal,  and  a  cheerful  and  pleasant  countenance  re¬ 
placed  the  picture  of  distress  which  he  presented  during  the  last 
week.  A  rubber  drainage-tube  was  prepared  by  dividing  the 
inner  end  longitudinally  for  half  an  inch  and  deflecting  each  lat¬ 
eral  half  to  a  right  angle  with  the  tube  and  stitching  them  to 
the  side  of  the  tube,  like  the  letter  T,  as  used  by  Professor  T. 
G.  Thomas  for  other  purposes,  and  was  inserted  and  secured 
with  a  large  safety-pin.  The  pleural  sac  was  daily  irrigated 
through  this  tube,  first  with  a  warm  biniodide  solution  (1  to 
12,000),  and  this  was  followed  by  the  solution  of  common  salt 
for  the  purpose  of  removing  the  mercurial.  Within  the  next 
few  days  there  was  a  remarkable  improvement  in  the  little 
patient’s  condition.  The  copious  perspirations  ceased,  his  res¬ 
piration  became  quite  natural,  his  appetite  returned,  he  slept 
well,  and  was  cheerful  and  happy. 

At  the  end  of  four  weeks  the  drainage-tube  was  removed, 
and  five  wreeks  from  the  date  of  the  operation  the  wound  was 
entirely  healed.  On  July  16, 1890,  four  months  after  his  illness, 
I  examined  him  carefully  and  found  but  a  very  slight  retraction 
of  the  right  side  and  a  slight  dullness  on  percussion.  His  res- 


Sept.  13,  1890.]  WEBSTER :  TRAUMATIC  DISLOCATION  OF  THE  CRYSTALLINE  LENS. 


295 


piration  was  quite  normal  and  his  general  health  very  good  in 

every  respect. 

Up  to  within  a  comparatively  recent  period  pleurotomy 
has  been  considered  a  grave  operation,  not  to  be  resorted 
to  until  all  simpler  means  had  failed. 

It  may  be  that  the  tendency  at  the  present  time  is  to¬ 
ward  the  other  extreme,  not  only  to  open  the  chest  but  to 
resect  a  portion  of  a  rib.  .  While  the  latter  procedure  is 
often  justifiable  or  may  be  necessary  in  some  cases,  I  be¬ 
lieve  the  majority  of  patients  with  suppurative  pleurisy  may 
be  cured  by  the  minor  operation,  especially  if  this  be  done 
in  the  early  stage  of  the  disease. 

A  prompt  and  definite  diagnosis  by  means  of  Ihe  aspi¬ 
rating  needle  is  of  the  utmost  importance  in  these  cases,  for 
the  earlier  the  disease  is  recognized  the  more  effectual  will 
be  the  treatment.  In  my  opinion  it  is  perfectly  safe  and 
justifiable  to  introduce  into  the  pleural  sac  an  aseptic  needle, 
properly  guarded,  for  the  purpose  of  diagnosis.  If  simply 
serum  is  found,  its  withdrawal  by  aspiration  will  be  bene¬ 
ficial  to  the  patient.  On  the  other  hand,  if  pus  is  found,  the 
earlier  it  is  evacuated  the  better,  and  pleurotomy  may  be 
done  immediately,  using  the  needle  for  a  guide.  I  have  had 
occasion  to  open  the  pleural  cavity  a  number  of  times,  both 
for  empyema  and  pulmonary  abscess,  but  have  never  yet 
found  it  necessary  to  resect  a  portion  of  a  rib  for  the  pur¬ 
pose  of  drainage.  When  possible,  I  select  the  eighth  inter¬ 
costal  space  in  the  axillary  line  as  the  point  of  puncture. 

The  operation  is  very  simple  and  safe,  and  in  my  experi¬ 
ence  has  always  been  attended  with  good  results. 


TRAUMATIC  DISLOCATION  OF  THE 
CRYSTALLINE  LENS, 

WITH  INCREASED  TENSION  AND  SEVERE  PAIN  ; 

RELIEF  OF  PAIN  AND  RESTORATION  OF  USEFUL  VISION 
FOLLOW  EXTRACTION  OF  THE  LENS. 

By  DAVID  WEBSTER,  M.  D., 

PROFESSOR  OF  OPHTHALMOLOGY  IN  THE  NEW  YORK  POLYCLINIC  AND  IN 
DARTMOUTH  MEDICAL  COLLEGE  ; 

SURGEON  TO  THE  MANHATTAN  EYE  AND  EAR  H08PITAL,  ETC. 

Cornelius  R.,  aged  sixty,  laborer,  native  of  Ireland,  came 
to  the  Manhattan  Eye  and  Ear  Hospital  on  Wednesday  morn¬ 
ing,  April  23,  1890.  He  said  that  he  had  been  pounding  stone, 
and  that  a  piece  of  rock  broken  off  by  his  hammer  had  struck 
his  right  eye.  He  immediately  found  that  he  could  not  see  with 
that  eye,  and  lost  no  time  in  coming  to  the  hospital.  Dr.  W. 
J.  Killen,  the  house  surgeon,  examined  his  eye  and  found  that 
the  anterior  chamber  was  filled  with  blood,  but  that  no  other 
lesion  was  visible.  The  eye  retained  good  perception  of  light. 
The  projection  was  good  except  that  in  the  upper  portion  of 
the  field  it  was  slow.  The  other  eye  had  vision  raised  to 
f$  with  a  +  1  D.  spherical.  The  patient  was  taken  into  the 
hospital,  atropine  dropped  into  the  eye,  and  a  bandage  ap¬ 
plied. 

April  28th.— R.  V.  = L.  V.  =§-£;  no  improvement 
with  glasses.  The  blood  has  been  nearly  all  absorbed  from  the 
anterior  chamber,  and  with  the  ophthalmoscope  the  lens  can  be 
seen  to  be  dislocated  downward,  forward,  and  outward. 

29th. — The  patient  had  much  pain  yesterday  and  last  night. 
The  anterior  chamber  is  very  shallow,  the  iris  being  pressed 
forward  by  the  transparent,  dislocated  lens. 

80th. — The  anterior  chamber  is  almost  nil-;  the  pupil  is 


small ;  the  lens  has  become  slightly  opaque  and  is  pressing  the 
iris  forward.  There  is  severe  pain  and  slight  photophobia. 
Tension  +2.  R.  V.  =  L.  V.  =  f-£. 

Under  these  circumstances  it  was  evident  that  the  dislocated 
lens  must  be  got  rid  of  or  the  eye  would  be  lost.  As  the  eye 
was  very  red  and  inflamed,  aDd  as  ample  clinical  experience  has 
demonstrated  the  fact  that  cocaine  has  very  little  if  any  anaes¬ 
thetic  effect  upon  inflamed  tissues,  the  patient  was  placed  under 
ether.  A  small  upward  section  was  made  with  a  narrow 
Graefe’s  knife  and  enlarged  with  delicate,  blunt-pointed  scissors. 
Pressure  was  made  with  the  spoon  as  in  cataract  extraction, 
but,  in  spite  of  the  best-directed  efforts  of  the  operator,  viti*eous 
escaped  and  the  lens  began  to  glide  slowly  away.  The  opera¬ 
tor,  seeing  that  the  lens  was  about  to  escape  into  the  bottom  of 
the  eye,  quickly  introduced  the  wire  spoon,  and  succeeded,  after 
a  second  attempt,  in  delivering  the  semi-transparent  lens  in  its 
capsule.  Some  vitreous  escaped  with  the  lens  and  the  cornea 
collapsed.  By  delicate  manipulation  the  edges  of  the  wound 
were  coaptated,  a  drop  of  a  solution  of  eserine  (gr.  j  to  §j) 
was  instilled,  and  both  eyes  were  bandaged. 

May  5th. — A  small  mass  of  vitreous,  hanging  from  the  cor¬ 
neal  wound  and  with  every  motion  of  the  upper  eyelid  pro¬ 
ducing  irritation,  was  cautiously  snipped  off  with  scissors.  The 
iris  above  is  folded  backward  upon  the  ciliary  body,  making  it 
look  as  though  there  had  been  an  iridectomy  upward. 

6th. — The  eye  has  been  quiet  since  the  protruding  vitreous 
was  snipped  off.  A  shade  has  been  substituted  for  the  bandage, 
and  the  patient  allowed  to  go  home  and  come  to  the  clinic  as 
an  out-patient. 

8th. — The  eye  is  clearing  up  and  becoming  white  again  very 
rapidly.  Counts  fingers  easily. 

1 

16th. — R.  V.  =  with  +g^.  There  has  been  no  pain 

since  the  extraction  of  the  lens.  Ophthalmoscopic  examina¬ 
tion  shows  floating  bodies  in  the  vitreous. 

June  20th. — V.  =  f-g-  with  +  J. 

There  are  some  points  worth  noticing  in  this  case. 
First,  it  may  be  asked  why  I  did  not  use  the  bident  devised 
by  Dr.  Agnew  and  so  make  sure  of  the  lens.  My  reply  is 
that  my.  experience  with  that  instrument  in  cases  where  the 
lens  is  still  transparent  has  not  been  satisfactory.  In  my 
hands  it  has  interfered  with  getting  the  lens  out  in  its  capsule. 
In  such  cases,  the  capsule  being  opened  and  the  lens  broken, 
a  good  deal  of  soft  lens  matter  is  unavoidably  left  behind. 
In  short,  you  can  not  tell  when  it  is  all  out,  because  it  is 
transparent.  This  transparent  lens  matter  remaining  be¬ 
hind  soon  becomes  opaque,  swells,  and  seriously  interferes 
with  a  smooth  recovery.  Again,  the  rapid  recovery  of  the 
eye  after  so  much  traumatism  was  to  me  something  sur¬ 
prising.  The  patient  had  had  his  lens  dislocated  and  the 
front  of  his  eye  filled  with  haemorrhage,  had  suffered  severe 
inflammatory  reaction  from  the  injury,  and  a  week  later 
had  had  the  additional  traumatism  of  an  operation  with 
loss  of  vitreous  inflicted  upon  the  eye,  and  yet  at  the  end 
of  a  week  from  the  operation  he  was  discharged,  his  eye  as 
well  as  eyes  usually  are  at  the  end  of  two  or  three  weeks 
after  an  ordinary  cataract  extraction,  and  with  vision  that 
would  have  placed  it  among  the  successes  efter  extraction 
of  cataract. 

The  folding  of  the  iris  back  against  the  ciliary  body  is 
an  accident  that  I  have  seen  before  in  cataract  extractions 
where  vitreous  was  lost. 


296 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jock., 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  SEPTEMBER  13,  1890. 

PROTECTIVE  INOCULATION  AGAINST  TUBERCULOSIS. 

Probably  the  most  noteworthy  discovery  reported  at  the 
recent  session  of  the  International  Medical  Congress  was  Pro¬ 
fessor  Koch’s  announcement  of  a  substance  that  has  the  power 
of  preventing  the  growth  of  the  tubercle  bacilli,  not  only  in 
the  test-tube,  but  in  the  animal  organism  as  well.  Guinea-pigs, 
that  are  extraordinarily  susceptible  to  tuberculosis,  inoculated 
with  this  substance  acquire  immunity  to  inoculations  of  the 
tubercle  bacilli;  and  in  animals  affected  with  general  tubercu¬ 
losis,  inoculation  with  the  substance  will  stop  the  morbid  pro¬ 
cess  without  any  injury  to  the  organism.  The  experiments  are 
yet  incomplete,  and  their  author  very  conservatively  refrains 
from  drawing  any  other  conclusion  than  that  of  the  possibility 
of  making  the  body  resistant  to  the  action  of  pathogenic  bac¬ 
teria. 

In  this,  as  in  other  discoveries  that  have  marked  new  eras  in 
the  progress  of  science,  independent  observers  have  touched 
the  threshold  at  the  same  time.  Koch’s  omission  to  state  the 
character  of  his  substance  only  allows  us  to  surmise  that  it  is 
similar  in  character  to  that  discovered  by  two  French  observers, 
who  established  the  date  of  their  discovery  in  somewhat  the 
same  fashion  in  vogue  among  the  philosophers  of  the  sixteenth 
and  seventeenth  centuries.  According  to  Le  Mercredi  medical 
of  August  27th,  Dr.  Grancher  and  Dr.  H.  Martin  deposited  a 
sealed  envelope  with  the  Paris  Academy  of  Medicine  in  Novem¬ 
ber,  1889,  containing  a  description  of  a  method  of  treatment 
by  which  they  had  arrested  for  a  long  time  the  evolution  of 
experimental  tuberculosis  in  rabbits.  The  publicity  that  Pro¬ 
fessor  Koch  gave  to  the  results  he  had  obtained  in  making 
guinea-pigs  refractory  to  tuberculosis,  or  in  curing  incipient  tu¬ 
berculosis,  induced  Grancher  and  Martin  to  publish  their  re¬ 
searches  on  the  same  subject  earlier  than  they  had  intended. 
In  all  their  experiments  they  had  used  the  rabbit,  making  the 
inoculations  by  intravenous  injections,  obtaining  thus  a  tuber¬ 
culosis  that  was  fatal  in  a  short  time,  that  made  local  treatment 
impracticable,  and  that  gave  rise  to  definite  lesions  in  the  liver, 
spleen,  and  lungs.  As  the  tuberculosis  thus  created  was  always 
fatal,  there  was  a  solid  foundation  that  permitted  of  an  exact 
appreciation  of  the  positive  or  negative  results  of  a  method 
that  was  intended  to  confer  a  refractory  condition  or  to  cure 
after  infection. 

Inoculations  were  made,  at  the  same  time,  in  protected  rab¬ 
bits  and  in  test  rabbits  in  a  vein  of  the  ear,  of  the  same  quan¬ 
tity  of  a  virulent  culture  of  the  Bacillus  tuberculosis  diluted 
with  a  small  quantity  of  sterilized  water.  In  a  series  inoculated 
on  December  31,  1889,  the  test  rabbit  died  on  the  twenty -third 
day,  while  the  protected  rabbits  lived  from  a  hundred  and 


twenty-six  to  two  hundred  and  twenty-nine  days  after  the  in¬ 
oculation.  The  necropsies  were  negative;  the  spleen  was  small; 
and  the  liver  was  free  from  bacilli,  though  in  the  circumlobular 
spaces  there  were  some  embryonic  cells,  constituting  a  trace 
of  a  tuberculous  process  on  the  way  to  recovery. 

They  attempted  to  find  a  graduated  virulence  as  well  as  a 
loss  of  that  virulence,  and,  while  not  mathematical,  the  results 
were  sufficiently  constant  to  be  employed  after  the  same  fash¬ 
ion  that  Pasteur  used  desiccated  spinal  cords  for  treating  rabies. 
The  most  virulent  culture  is  designated  as  number  one,  killing 
a  rabbit  in  five  days  or  less ;  the  cultures  numbered  two  and 
three  are  fatal  after  a  variable  time,  according  to  the  resistance 
of  the  animal.  Cultures  four,  five,  and  six  are  less  fatal,  while 
cultures  seven,  eight,  nine,  and  ten  decrease  in  strength  and  do 
not  affect  rabbits. 

A  rabbit  is  inoculated  in  a  vein  of  the  ear  with  half  a  Pra- 
vaz’s  syringeful  of  a  culture  diminished  in  virulence  to  number 
six.  In  a  week  culture  number  three  is  injected,  and  this  is  re¬ 
peated  in  nine  days ;  two  weeks  later  culture  number  two  is 
injected,  then,  nineteen  days  later,  culture  number  one.  After 
inoculation  with  number  one  the  animals  usually  die,  though 
not  so  quickly  nor  with  such  severe  lesions  as  the  test  rabbits 
inoculated  at  the  same  time.  If  the  inoculations  stop  at  num¬ 
ber  two,  the  rabbits  live  for  months  thereafter. 

Very  justly,  these  experimenters  believe  that  they  have  suc¬ 
ceeded  in  giving  to  rabbits  a  prolonged  resistance  against  sure 
and  rapid  experimental  tuberculosis,  and  also  in  conferring  an 
immunity  against  that  disease,  the  duration  of  which  remains 
to  be  determined.  The  probable  benefit  of  these  discoveries  to 
humanity  is  so  patent  that  comment  is  supererogatory. 


THE  REPUTED  CASE  OF  CHOLERA  IN  LONDON. 

Some  alarm  was  felt  throughout  this  country  when,  some 
days  ago,  the  telegraph  announced  that  a  case  of  Asiatic 
cholera  was  reported  from  London.  The  last  English  mail 
brings  the  detailed  history  of  the  case.  According  to  the  Lan¬ 
cet,  the  patient,  a  sailor  of  the  steamship  Duke  of  Argyll,  left 
his  vessel  at  5  p.  m.  on  the- 10th  of  August  in  good  health.  He 
went  to  a  boarding-house  in  Whitechapel  and  continued  well 
until  late  in  the  following  day.  Shortly  before  midnight  he 
was  seized  with  vomiting  and  purging,  but  did  not  seek  medi¬ 
cal  attendance.  On  the  following  morning  he  went  out,  was 
again  attacked  with  the  same  symptoms,  became  very  weak, 
and  was  taken  to  the  Poplar  Hospital,  where,  on  admission, 
he  was  found  to  be  suffering  from  marked  collapse,  cyanosis, 
cramps,  and  violent  vomiting.  Although  the  symptoms  point¬ 
ed  to  Asiatic  cholera,  there  was  nothing  incompatible  with  the 
diagnosis  of  severe  so-called  English  cholera,  or  cholera  nos¬ 
tras;  nevertheless,  every  possible  sanitary  precaution  was  taken. 
No  other  cases  of  a  like  nature  had  occurred  on  the  voyage, 
and  none  have  since  appeared.  The  patient  recovered  under 
appropriate  treatment. 

Another  explanation  might  be  given  of  the  group  of  symp¬ 
toms  observed  in  this  case.  Arsenic  poisoning  presents  a  clin- 


Sept.  13,  1890.] 


MINOR  PARAGRAPHS. 


ical  picture  scarcely  to  be  distinguished  from  that  of  cholera, 
and  on  reading  over  the  report  of  the  house-surgeon  of  the 
Poplar  Hospital  we  were  struck  with  the  resemblance  of  the 
main  features  of  the  case  to  those  of  arsenic  poisoning.  The 
cyanosis,  the  sunken  eye,  the  purging  and  vomiting,  all  are 
present  when  an  overdose  of  arsenic  is  taken,  and  it  is  just 
possible,  when  we  take  into  consideration  how  frequently  such 
accidental  poisonings  occur,  that  the  food  the  sailor  took 
after  landing  may  have  contained  some  such  toxic  agent.  At 
all  events,  it  appears  strange  that,  when  every  sanitary  precau¬ 
tion  was  taken,  no  chemical  analysis  was  made  of  the  food  or 
of  the  excretions.  Possibly  the  next  mail  may  bring  us  the 
particulars  of  such  an  examination. 


MINOR  PARAGRAPHS. 

THE  GUILD  OF  ST.  LUKE. 

The  Lancet  proposes  that  the  medical  profession  shall  have 
an  annual  Sunday  for  the  public  observance  of  religious  duty 
in  relation  with  St.  Luke’s  Day,  October  18th.  The  proposi¬ 
tion  includes  church  attendance  on  the  Sunday  immediately 
preceding  or  following  that  day,  with  some  form  of  discourse 
or  teaching  from  the  gospel  of  “  the  beloved  physician  ”  and  a 
collection  for  some  benevolent  object  especially  binding  upon 
medical  men.  This  ceremonial  should  not  be  limited,  it  sug¬ 
gests,  to  any  one  church,  and  it  is  not  best  perhaps  that  it 
should  be  grouped  together  with  the  Guilds  of  St.  Luke,  since 
the  term  guild  is  to  the  minds  of  some  a  source  of  irritation 
and  antagonism.  The  Lancet  explains  that,  if  a  free  and  wide 
*  organization  could  be  made  in  the  name  of  St.  Luke,  many  phy¬ 
sicians  would  attend  upon  their  own  saint’s  day  who  can  sel¬ 
dom,  in  the  whole  year’s  round,  find  for  themselves  a  day  of 
rest,  and  who  seldom  enter  at  the  church,  or  meeting-house,  or 
chapel  door.  There  are  many  who  stand  ready  to  make  sacri¬ 
fices  in  order  to  gather  with  their  fellow-practitioners  and  who 
would  welcome  this  proposed  Sunday  anniversary.  Another 
advantage  is  hinted  at,  the  fact  of  bringing  about  a  closer  bond 
of  union  between  medical  men  and  clergymen  and  ministers,  so 
that  they  may  know  and  appreciate  one  another  better  and 
work  together  better  at  the  bedside,  as  they  so  often  have  occa¬ 
sion  to  do. 


THE  CENSUS  OF  1890. 

In  addition  to  having  been  made  ridiculous  by  an  abortive 
attempt  to  collect  statistics  that  were  not  wanted  by  means  of 
an  inquisition  that  the  people  would  not  tolerate,  the  census  of 
1890  seems  likely  to  pass  into  history  as  the  first  United  States 
census  that  has  not  been  generally  trusted.  The  Board  of 
Health  of  the  city  of  New  York  has  lately  brought  to  light  pre¬ 
sumptive  evidence  that  the  population  credited  to  the  city  by 
the  Census  Bureau  is  smaller  than  its  actual  population  by  at 
least  a  hundred  thousand,  and  this  is  only  one  of  many  in¬ 
stances  in  which  the  accuracy  of  the  June  enumeration  has  been 
challenged  on  reasonable  grounds.  The  board’s  interest  in  the 
matter  turns  on  the  effect  that  the  census  of  the  city  will  have, 
if  accepted,  on  its  apparent  death-rate,  which  has  for  many 
years  exceeded  its  real  death-rate,  for  reasons  that  we  have 
pointed  out  from  time  to  time.  The  board  expects  to  prove  the 
justice  of  its  contention  by  an  enumeration  undertaken  by  itself 
in  certain  selected  districts,  and  then  demand  a  recount  at  the 
hands  of  the  Government.  What  is  to  be  thought  of  a  census 
bureau  that  seeks  to  obtain  statistics  of  the  morbidity  of  a  par- 


297 

ticular  few  days,  while  at  the  same  time,  by  the  blundering 
shown  in  its  legitimate  work,  it  vitiates  the  vital  statistics  of 
the  greatest  city  of  the  nation  ? 


THE  MEMORIAL  HOSPITAL  AT  JOHNSTOWN. 

The  final  report  of  the  Johnstown  Flood  Relief  Commission 
gives  an  account  of  the  disposition  of  the  $3,740,000  that  was 
poured  through  their  hands.  One  paragraph  of  this  document 
refers  to  the  early,  constant,  and  yet  unended  medical  relief 
that  had  its  origin  in  the  great  calamity.  It  is  not  generally 
known  that  the  sum  of  $40,000  has  been  set  apart  for  the  con¬ 
struction  and  equipment  of  a  memorial  hospital,  and  that  a 
committee  of  the  commission  is  now  engaged  upon  the  work. 
This  hospital,  when  completed,  will  replace  that  which  was  es¬ 
tablished  by  the  Red  Cross  Society  of  Philadelphia  and  con¬ 
tinued  by  its  medical  staff  until  late  in  the  autumn  of  1889, 
when  it  was  transferred  to  the  charge  of  the  local  profession. 
This  has  been  and  continues  to  be  a  most  useful  measure  of  re¬ 
lief.  The  commission  has  been  moved  to  the  construction  of 
the  Memorial  Hospital  by  the  evident  necessity  that  during  the 
present  generation,  at  least,  there  shall  be  medical  aid  to  many 
survivors  of  the  shock  and  exposure  and  injuries  of  the  great 
flood.  The  motive  was  undoubtedly  a  sound  and  wise  one,  but 
the  subsidy  might  have  been  made  larger  without  detriment  to 
its  efficient  operations. 


THE  LATE  DR.  MATTHEWS  DUNCAN. 

A  telegeaphio  dispatch  brings  the  sad  news  of  the  death, 
at  the  age  of  sixty-four,  of  this  very  eminent  obstetrician  and 
gynaecology,  which  took  place  at  Baden  on  the  3d  inst.  Mat¬ 
thews  Duncan  was  born  at  Aberdeen  in  1826,  and  educated  at 
the  grammar  school  of  that  town,  and  at  Marischal  College  and 
University,  completing  his  studies  at  the  University  of  Edin¬ 
burgh  and  afterward  at  Paris.  From  the  outset  of  his  career 
he  took  a  leading  position  in  the  profession.  He  was  associated 
with  the  late  Sir  James  Y.  Simpson  in  the  investigations  lead¬ 
ing  to  the  discovery  of  the  anaesthetic  properties  of  chloroform, 
and  contributed  largely  to  the  diffusion  of  knowledge  concern¬ 
ing  the  drug.  In  1860  he,  with  some  others,  founded  the  Edin¬ 
burgh  Royal  Hospital  for  Sick  Children,  which  is  now  one  of 
the  largest  and  best  institutions  of  the  kind  in  the  world.  In 
1853  Dr.  Duncan  began  his  career  as  a  teacher  of  midwifery  and 
the  diseases  of  women  and  children,  in  connection  with  the 
Surgeons’  Hall  Medical  School,  and  made  for  himself  such  a 
reputation  that  when  Sir  James  Y.  Simpson  died,  in  1870, 
Duncan  was  the  candidate  favored  by  the  profession  for  the 
chair  of  midwifery  in  the  University  of  Edinburgh,  and  his 
claims  were  supported  by  420  former  and  present  pupils.  His 
chief  opponent  was  Dr.  Alexander  Russell  Simpson,  the  nephew 
of  the  late  professor,  who  had  been  a  successful  obstetric  physi¬ 
cian  in  Glasgow,  but  who  had  never  delivered  a  systematic 
course  of  lectures  in  midwifery.  Duncan  was  supported  by  the 
profession,  Simpson  by  the  laity;  and,  as  the  townsmen,  who, 
as  curators  of  the  University,  had  a  large  influence,  voted  to¬ 
gether  for  Simpson,  he  was  successful  in  obtaining  the  nomina¬ 
tion  to  the  chair.  Few  medical  elections  ever  caused  so  much 
feeling.  Indignation  meetings  were  held  in  London  and  largely 
attended  by  the  alumni  of  the  university,  while  the  induction 
of  the  new  professor  was  made  the  scene  of  a  serious  riot  by 
the  indignant  students,  with  whom  Dr.  Matthews  Duncan  was 
very  popular.  In  1877  Dr.  Duncan  accepted  the  chair  of  mid¬ 
wifery  in  the  Medical  School  of  St.  Bartholomew’s  Hospital, 
and  moved  to  London,  where  he  immediately  took  an  enviable 
position  as  a  consultant,  gaining  the  love  and  respect  ot  his  pro- 


298 


MINO R  PA  RA  GRA  PUS.— ITEMS. 


[N.  Y.  Med.  Jour., 


fessional  brethren  as  well  as  that  of  a  large  number  of  patients. 
Besides  numerous  articles  contributed  to  the  journals  of  the 
day,  Matthews  Duncan  was  the  author  of  works  On  Perime¬ 
tritis  and  Parametritis ,  Researches  in  Obstetrics ,  Fecundity , 
Fertility ,  Sterility ,  and  Allied  Topics,  On  the  Mortality  of 
Childbed  and  Maternity  Hospitals ,  and  many  others. 


THE  CATSK1LL  MOUNTAINS. 

Dr.  William  B.  Atkinson,  of  Philadelphia,  has  been  enjoy¬ 
ing  an  outing  in  the  Catskills,  and  writes  to  the  Journal  of  the 
American  Medical  Association  as  follows  :  “  I  dare  to  offer  to 
your  readers  from  the  lofty  Catskills,  and  at  about  the  highest 
point  in  the  range,  some  thoughts  on  mountain  scenery  and 
health  combined  in  place  of  a  didactic  or  clinical  lecture.  The 
rare  atmosphere  united  to  the  grand  scenery  gives  one  a  feeling 
of  exhilaration  which  lifts  him  above  all  thoughts  of  disease  or 
its  concomitant  medication.  Even  hygiene  may  almost  be  ig¬ 
nored,  as  health  here  really  runs  itself.  We  are  so  often  treated 
to  the  phrase  ‘the  Switzerland  of  America’  that  the  term  seems 
to  mean  nothing,  but  for  grandeur  of  mountain  scenery,  by 
which  humanity  lapses  into  nothingness,  this  particular  portion 
of  New  York  surpasses  everything  on  this  continent.  Few  of 
the  hundreds  of  thousands  of  people  living  within  a  radius  of 
two  hundred  and  fifty  or  three  hundred  miles  in  the  teeming 
cities  of  New  York,  Brooklyn,  and  Philadelphia  are  aware  of 
their  proximity  to  such  wonders  of  nature,  and  that  within  half 
a  day’s  journey  they  could  gratify  their  sight  with  a  view 
eclipsing  all  that  we  are  taught  to  regard  as  accessible  only 
after  a  loDg  and  fatiguing  sea  voyage  or  railroad  trip.” 


A  PREMIUM  ON  POPULATION.  # 

At  the  last  session  of  the  Legislature  of  the  Province  of 
Quebec  a  bill  was  passed  authorizing  the  Government  to  offer 
a  reward  of  one  hundred  acres  of  crown  lands  to  the  fathers 
of  all  families  of  twelve  or  more  living  children.  The  prolific 
character  of  the  French  Canadian  habitant  of  the  rural  districts 
is  proverbial,  and  no  sooner  was  the  bill  passed  than  applica¬ 
tions  for  the  one  hundred  acres  came  pouring  in  with  alarming 
rapidity.  Up  to  date  no  fewer  than  1,250  fathers  whose  quivers 
are  full  have  presented  their  claims,  and  the  Premier  has  been 
obliged  to  establish  a  special  office  in  connection  with  the  De¬ 
partment  of  Agriculture  with  a  superintendent  whose  duty  it  is 
to  investigate  the  claims,  which  must  be  supported  by  the  cure , 
the  mayor,  and  the  doctor  of  the  place.  The  cause  of  this  high 
birth-rate  among  the  agricultural  classes  of  Lower  Canada  lies 
in  the  fact  that  early  marriages  are  the  rule ;  added  to  this,  the 
people  lead  a  healthy  life,  morally  and  physically,  and,  though 
ready  money  is  scarce,  wholesome  food  is  plentiful.  This  bill, 
which  has  now  become  law,  will  tend  to  keep  the  members  of 
large  families  at  the  work  of  agriculture,  and  while  it  will  act 
as  an  encouragement  des  autres,  will  powerfully  assist  in  the 
population  of  the  unsettled  districts. 


SO-CALLED  DELTOID  NEURALGIA. 

In  the  Centralblatt  fur  Chirurgie  for  August  9th,  Dr.  D. 
Kulenkampff,  of  Bremen,  remarks  that  the  name  deltoid  neu¬ 
ralgia  is  unhappily  applied  by  Golding-Bird,  in  Guy's  Hospi¬ 
tal  Reports  for  1889,  to  a  rather  commonly  observed  pain  at 
the  point  of  insertion  of  the  deltoid  muscle  when  the  arm  is 
raised,  especially  above  the  horizontal  attitude.  The  pain  is 
sometimes  such  as  to  give  rise  to  a  disability  that  may  be  mis¬ 
taken  for  paresis.  It  almost  always  depends  on  some  injury, 
which  often  is  not  serious,  that  leads  the  patient  to  fix  or  disuse 


the  arm  for  a  few  weeks,  during  which  time  the  neighboring 
muscles  shrink,  while  a  prominence  of  the  deltoid  is  caused  by 
an  accumulation  of  blood  and  lymph  beneath  it,  inducing  irri¬ 
tation  of  the  terminal  twigs  of  the  circumflex  nerve  wTien 
movements  are  attempted.  Sometimes  the  trouble  seems  to  be 
rheumatic.  Golding-Bird  recommends  passive  motion  with  the 
scapula  fixed,  massage,  and  blisters  in  the  treatment.  Kulen¬ 
kampff,  who  considers  blistering  uncalled  for,  has  found  faradi¬ 
zation  a  very  effectual  remedy. 


A  NEW  ANTIDOTE  TO  CHOLERA. 

According  to  the  British  Medical  Journal,  M.  Roux  has 
tried  to  cultivate  the  cholera  microbe  of  Koch  in  an  infusion 
made  from  the  refuse  of  malted  barley  left  after  extraction  in 
the  brewing  of  beer.  It  is  a  liquid  in  which  nearly  all  other 
microbes  grow  well,  except  the  one  above  mentioned.  This  not 
only  will  not  thrive  in  it,  but  when  immersed  in  it  is  quickly- 
killed.  He  has  therefore  suggested  to  the  Societe  des  sciences 
medicates  of  Lyons  that  the  infusion  might  be  of  use  in  the 
treatment  and  prophylaxis  of  cholera. 


THE  STARCH  POULTICE. 

In  La  Medecine  moderne ,  M.  Brocq  remarks  that  the  starch 
poultice  is  almost  always  badly  made.  He  then  gives  the  fol¬ 
lowing  directions  for  making  it:  The  starch  should  be  blended 
thoroughly  with  precisely  the  right  quantity  of  tepid  w-ater  to 
form  a  paste.  Boiling  water  is  poured  on  to  the  paste,  and  the 
mixture  is  left  on  the  fire  for  about  a  minute,  being  stirred 
briskly  so  as  to  make  it  quite  homogeneous.  It  is  then  spread 
on  tarlatane  that  has  previously  had  the  stiffening  soaked  out 
of  it. 


OVERCROWDING  OF  THE  PROFESSION  IN  AUSTRALIA. 

The  Australasian  Medical  Gazette  repeats  its  warning  of 
three  years  ago  to  practitioners  in  older  countries  “  not  to  think 
that  Australia  is  still  the  Eldorado  for  medical  men  it  once 
was.”  On  the  contrary,  it  states,  the  competition  is  perhaps 
even  greater  there  than  in  Europe  and  the  United  States. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  September  9,  1890: 


DISEASES. 

W  eek  ending  Sept.  2. 

Week  ending  Sept.  9. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

42 

11 

30 

10 

Scarlet  fever . 

17 

1 

17 

1 

Cerebro-spinal  meningitis . 

1 

0 

1 

1 

Measles . 

52 

10 

78' 

9 

Diphtheria . 

52 

16 

43 

14 

Varicella . 

9 

0 

0 

0 

The  American  Gynaecological  Society  will  hold  its  fifteenth  annual 
meeting  in  Buffalo,  N.  Y.,  on  Tuesday,  Wednesday,  and  Thursday,  the 
16th,  17th,  and  18th  inst.,  under  the  presidency  of  Dr.  John  P.  Rey¬ 
nolds,  of  Boston.  The  programme  includes  a  discussion  on  The  Diag¬ 
nosis,  Pathology,  and  Treatment  of  Extra-uterine  Pregnancy,  by  Dr.  A. 
W.  Johnstone,  of  Danville,  Ky.,  Dr.  M.  D.  Mann,  of  Buffalo,  Dr.  J.  M. 
Baldy,  of  Philadelphia,  and  others ;  Under  what  Conditions  can  Elec¬ 
tricity  be  of  Positive  Service  to  the  Gynaecologist  ?  by  Dr.  A.  F.  Cur¬ 
rier,  of  New  York;  On  the  Question  of  Amperage  in  the  Treatment  of 
Fibroid  Tumors  by  Electricity,  by  Dr.  W.  C.  Ford,  of  Utica,  N.  Y. ;  In 
Memoriam — Dr.  William  H.  Byford,  by  Dr.  E.  C.  Dudley,  of  Chicago ; 
Vaginal  Fixation  of  the  Stump  in  Abdominal  Hysterectomy,  by  Dr.  II. 


Sept.  13,  1 890.  J 


ITEMS.— PROCEEDINGS  OF  SOCIETIES. 


299 


T.  Byford,  of  Chicago ;  the  president’s  address ;  Injuries  of  the  Uterus 
during  Labor,  by  Dr.  A.  J.  C.  Skene,  of  Brooklyn ;  Is  the  Mortality 
after  Gynaecological  Operations  affected  by  Climatic  Influences  ?  by  Dr. 
II.  C.  Coe,  of  New  York;  Cephalaematoma,  by  Dr.  H.  A.  Kelly,  of  Bal¬ 
timore  ;  Drainage  after  Laparotomy,  by  Dr.  T.  A.  Ashby,  of  Baltimore ; 
The  Relative  Antiseptic  Value  of  the  Biniodide  and  Bichloride  of  Mer¬ 
cury,  by  Dr.  Charles  Jewett,  of  Brooklyn;  A  Modification  of  Tait’s 
Operation  for  Laceration  of  the  Perinaeum  through  the  Sphincter,  by 
Dr.  H.  T.  Hanks,  of  New  York ;  Measurements  of  the  Uterine  Cavity 
in  Childbed,  by  Dr.  W.  L.  Richardson  and  Dr.  A.  D.  Sinclair,  of  Bos¬ 
ton  ;  Cancer  of  the  Uterus  in  the  Negress,  and  Physometra  due  to  Can¬ 
cer  of  the  Uterus  in  the  Negress,  by  Dr.  H.  A.  Kelly,  of  Baltimore ; 
Laparotomy  for  Intrapelvic  Pain  of  Sixteen  Years’  Standing,  by  Dr.  T 
A.  Ashby,  of  Baltimore ;  a  paper  (title  not  announced),  by  Dr.  E.  W. 
Jenks,  of  Detroit;  and  an  exhibition  of  new  gynaecological  instruments, 
by  Dr.  Hanks  and  Dr.  Kelly. 

Society  Meetings  for  the  Coming  Week  : 

Monday,  September  15th :  Hartford,  Conn.,  City  Medical  Association ; 
Chicago  Medical  Society. 

Tuesday,  September  16th:  American  Gynaecological  Society  (Buffalo, 
N.  Y. — first  day) ;  Medical  Society  of  the  County  of  Kings  ;  Ogdens- 
burgh  Medical  Association ;  Medical  Society  of  the  County  of 
W estchester,  N.  Y. ;  Connecticut  River  V alley  Medical  Association 
(Bellows  Falls,  Vt.) ;  Baltimore  Academy  of  Medicine. 

Wednesday,  September  17th:  American  Gynaecological  Society  (second 
day) ;  Medico-legal  Society ;  Northwestern  Medical  and  Surgical 
Society  of  New  York  (private) ;  Harlem  Medical  Association  of  the 
City  of  New  York;  Medical  Society  of  the  County  of  Allegany 
(quarterly),  N.  Y. ;  New  Jersey  Academy  of  Medicine  (Newark). 
Thursday,  September  18th :  American  Gynaecological  Society  (third 
day);  Metropolitan  Medical  Society  (private);  New  Bedford,  Mass., 
Society  for  Medical  Improvement  (private). 

Friday,  September  19th :  Chicago  Gynaecological  Society  ;  Baltimore 
Clinical  Society. 

Saturday,  September  20th :  Clinical  Society  of  the  New  York  Post¬ 
graduate  Medical  School  and  Hospital. 


Jjrjocwbxnp  uf  So  deties. 

NEW  YORK  ACADEMY  OF  MEDICINE. 

Meeting  of  May  15 ,  1890. 

The  President,  Dr.  A.  L.  Loomis,  in  the  Chair. 

The  Auscultatory  Percussor.— Dr.  Louis  L.  Seaman  ex¬ 
hibited  and  explained  a  new  percussor,  designed  and  arranged 
by  him.  Some  phonographic  reproductions  of  notes  previously 
elicited  in  auscultating  a  chest  added  interest  to  the  description 
of  an'  ingenious  instrument. 

Spinal  Surgery ;  a  Report  of  Eight  Cases.— Dr.  Robert 
Abbe  read  a  paper  with  this  title.  He  said  that  his  remarks 
would  not  be  confined  to  giving  a  rose-tinted  picture  of  start¬ 
ling  achievements  of  new  surgery,  but  rather  to  a  serious  re¬ 
view  of  some  of  the  grave  cases  of  spinal  troubles  requiring 
surgical  interference  which  had  of  late  come  under  his  care. 
The  patients  had  all  been  previously  subjected  to  prolonged 
medical  treatment,  and  were,  when  referred  to  the  speaker  by 
the  physicians  or  neurologists,  in  almost  a  hopeless  condition. 
The  popular  idea  among  physicians  had  been  that  the  spinal 
cord  was  more  inaccessible  to  the  surgeon  than  the  brain,  be¬ 
cause  of  its  irregular  bony  coverings  and  the  haemorrhage  from 
the  venus  plexuses  that  enveloped  it,  and  that  injuries  and  dis¬ 
eases  of  it  were  to  be  looked  upon  hopelessly  unless  Nature 
kindly  assumed  to  work  unexpected  recoveries.  It  was  from 


the  doomed  cases  of  paralysis  of  the  lower  half  of  the  body,  and 
some  other  spinal  troubles,  that  an  effort  was  being  made  to 
cull  out  some  cases  which,  heretofore  neglected,  might  yield 
good  results.  The  eight  cases  might  be  divided  into  four 
groups :  (1)  three  of  paraplegia  from  fracture ;  (2)  one  from 
early  curretting  of  a  vertebra  for  Pott’s  disease ;  (3)  two  of 
tumors  of  the  vertebral  canal  with  paraplegia;  and  (4)  two  of 
intradural  section  of  some  of  the  posterior  roots  of  the  brachial 
plexus  for  neuralgia. 

Case  I.  Fracture  of  the  Spine  between  the  Eleventh  and 
Twelfth  Dorsal  Vertebrae ,  with  Complete  Paraplegia ,  Anes¬ 
thesia ,  and  Incontinence. — Operation  was  performed  eleven 
months  after  the  accident.  R.  W.  G.,  aged  twenty-seven,  mer¬ 
chant.  The  patient  had  enjoyed  good  health  until  May  19, 
1888,  when  he  had  fallen  from  a  platform  twenty-one  feet  high, 
while  pushing  off  a  large  beam.  He  fell  with  the  timber  on 
sawdust-covered  ground,  receiving  scalp  wounds,  but  it  was 
impossible  to  say  whether  the  timber  had  struck  him  or  not. 
He  was  unconscious  for  three  hours,  and  was  completely  para¬ 
lyzed  and  insensitive  below  the  waist  when  he  recovered. 
Efforts  were  made,  under  ether,  to  straighten  the  fracture 
deformity  of  the  spine  by  extension  and  manipulation,  but  noth¬ 
ing  was  gained.  A  bedsore  had  formed  at  the  site  of  the  spinal 
deformity,  and  a  water  bed  was  obtained.  At  first  it  was  filled 
with  cold  spring-water.  This  caused  the  patient  so  much  suf¬ 
fering  that,  on  being  placed  upon  it,  he  had  fainted  and  had 
remained  unconscious  for  hours.  Complete  incontinence  of 
urine  had  been  present  from  the  first.  Diarrhoea  was  succeeded 
subsequently  by  complete  inaction  of  the  rectum.  Three 
months  after  the  accident  the  patient  had  resorted  to  a  wheel¬ 
chair  and  attended  to  his  business,  this  being  the  condition 
when  he  was  referred  to  the  speaker.  On  April  12,  1889,  the 
operation  was  performed.  The  method  pursued  being  typical, 
it  was  given  in  detail,  to  prevent  repetition  in  tbe  other  cases. 
The  back  was  shampooed  the  evening  before,  and  a  damp  sub¬ 
limate  dressing  kept  applied  until  the  moment  of  operation. 
The  patient  was  laid  prone,  but  with  one  shoulder  raised  by  a 
sand-pillow,  favoring  easier  respiration  and  inclining  the  back 
toward  the  operator.  A  free  incision  was  now  made  parallel  to 
the  spine  and  half  an  inch  to  one  side,  cutting  the  longissimi  at¬ 
tachments  from  one  side  only,  and  being  carried  clean  down  to  the 
laminae  at  the  second  or  third  pass  of  the  knife.  To  approach  the 
fracture  between  the  eleventh  and  twelfth  vertebrae  the  incision 
was  made  from  the  eighth  dorsal  to  the  first  lumbar  spine.  The 
laminae  were  now  cleared  of  muscles,  which  were  drawn  out¬ 
ward  by  retractors,  and  the  ligaments  divided  above  the  spines 
of  the  eighth  and  below  the  eleventh,  thus  isolating  a  block  of 
four  spines,  whose  bases  were  then  severed  from  their  arches 
by  stout  cutting  pliers.  This  manoeuvre  at  once  allowed  a  re¬ 
traction  of  the  entire  block  of  connected  spines  with  their  mus¬ 
cles  still  attached  on  one  side,  and  the  entire  breadth  of  the 
spinal  arch  was  thus  exposed  without  sacrificing  the  over- 
lyiDg  tissues.  A  pair  of  slightly  curved  rongeurs  was  now  ap¬ 
plied  to  the  lower  edge  of  one  lamina,  and  with  ease  the  entire 
breadth  was  quickly  gnawed  away.  Then  the  arches  of  the 
tenth,  eleventh,  and  twelfth  were  treated  in  the  same  man¬ 
ner,  exposing  the  clean  spinal  cord  to  the  extent  of  two  and  a 
half  inches.  The  twelfth  dorsal  vertebra  was  found  to  have 
been  displaced  backward,  the  fracture  running  through  the 
articular  facets,  the  pedicles,  and  laminm.  The  cord  was  com¬ 
pressed  between  the  arch  of  the  eleventh  above  and  the  upper 
lip  of  the  body  of  the  twelfth  below  ;  the  intervertebral  carti¬ 
lage  had  been  ruptured.  In  half  a  minute  after  the  cord  had 
been  released  from  its  flattened  state,  the  bone-pressure  area 
being  only  half  an  inch  deep,  the  dura  became  quite  as  round 
as  it  was  above  and  below  this  point,  and  presented  a  perfectly 


300 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jocr., 


normal  appearance,  except  that  at  the  upper  portion  it  pulsated. 
The  speaker  emphasized  this  fact  because  in  many  of  the  cases 
reported  the  cord  had  appeared  normal,  and  therefore  the 
dura  had  not  been  opened.  The  wound  was  then  irrigated  and 
dried,  and  the  dura  slit  up  for  two  inches.  Adhesions  of  vari¬ 
ous  density  were  found  within,  attaching  the  meninges  to  the 
dura,  forming  a  complete  circular  dam,  which  shut  off  the  upper 
from  the  lower  part  of  the  canal.  Only  an  ounce  of  clear 
spinal  fluid  escaped,  when  the  head  was  depressed  below  the 
level  of  the  spine.  The  veins  of  the  cord  were  not  distended, 
and  the  adhesions  were  broken  up  with  very  little  force.  The 
cord  was  normal  in  thickness  above  the  involved  part,  then,  by 
a  sloping  rather  than  abrupt  change,  it  merged  into  a  flattened 
band  for  three  quarters  of  an  inch,  retaining  its  breadth,  but 
less  than  half  its  thickness,  the  principal  atrophy  seeming  to 
be  in  the  posterior  columns.  Throughout  this  flattened  portion 
the  white  fasciculi  of  the  cord  could  be  traced  continuously,  so 
that  there  was  no  abrupt  break  in  its  continuity.  Before  the 
operation  it  had  been  proposed  to  the  patient  that  if  the  cord 
was  found  to  be  destroyed  within  narrow  limits,  and  apparent¬ 
ly  sound  above  and  below,  it  might  be  excised  and  the  fresh- 
cut  ends  sutured.  Though  told  that  this  had  never  been  done, 
he  had  accepted  the  experiment.  It  proved  to  be  an  impossi¬ 
ble  operation,  however,  in  this  case ;  the  speaker  had  tried 
to  approximate  the  sound  cord  on  either  side  of  the  damaged 
part  by  traction  made  with  tenacula  imbedded  in  the  meshes 
of  the  membranes  at  such  points  as  would  have  been  available 
for  sutures.  There  was  but  slight  latitude  of  motion  vertically. 
Excision  of  more  than  a  scant  quarter  of  an  inch  would  have 
made  it  impossible  to  approximate  the  ends  by  sutures  that 
would  not  tear  out.  The  damaged  cord  in  this  case  being  of 
three  times  that  length,  and  no  further  repair  being  possible, 
the  dura  was  sutured  by  fine  catgut.  The  displaced  spines 
were  brought  into  line  and  sutured  by  heavy  catgut  to  their 
neighbors  above  and  below.  The  fascia  investing  the  muscles 
then  received  two  or  three  interrupted  catgut  sutures,  with 
gaps  for  drainage,  and  finally  the  skin  was  drawn  partly  to¬ 
gether  by  a  few  catgut  sutures  not  tied  but  left  for  use  at  the 
next  dressing.  No  drainage-tube  was  applied,  but  a  piece  of 
protective,  three  inches  wide,  was  laid  over  the  wound,  the 
skin  edges  being  left  a  quarter  of  an  inch  apart  so  as  to  allow 
of  drainage  from  the  deep  portion.  The  investing  antiseptic 
dressing  was  covered  by  a  plaster  jacket  covering  only  the 
back  like  a  turtle-shell,  and  secured  by  an  enveloping  Canton- 
flannel  binder  pinned  in  front.  In  forty-eight  hours  the  dress¬ 
ing  was  changed.  Drainage  had  been  perfect,  the  wound  had 
healed  except  the  skin,  the  sutures  of  which  were  now  brought 
forward  and  tied  and  a  final  dressing  applied.  From  the  time 
of  the  operation  he  had  had  no  pain  in  the  back  or  extremities. 
The  wound  had  healed  primarily,  leaving  only  a  linear  scar. 
He  had  remained  in  the  hospital  for  three  weeks;  there  had 
been  no  fever  or  other  disturbances ;  his  condition  had  been 
watched  since  the  operation,  and  there  had  been  no  improve¬ 
ment  in  motion  or  sensation.  After  returning  home,  the  pa¬ 
tient  had  written  that  for  six  weeks  there  had  seemed  to  be 
some  improvement,  but  in  a  recent  letter,  quite  a  year  since 
the  operation,  he  admitted  having  gained  nothing.  About  six 
weeks  after  the  operation  he  had  passed  through  a  curious  two 
months’ illness  of  the  nature  of  trance;  he  had  come  out  of 
this  abruptly,  and  was  in  every  way  mentally  himself  again. 
This  condition  was  judged  to  have  been  an  effect  left  by  reac¬ 
tion  after  two  months  of  exalted  excitement  and  harboring  the 
“  exhilarating  sentiment  of  hope,”  followed  by  swift  apprecia¬ 
tion  of  the  unchanged  paralysis,  and  that  it  was  only  one 
of  the  curious  hysterical  manifestations  occasionally  connected 
with  spinal  disturbances. 


Case  II.  Fracture ;  Paraplegia  below  the  Eleventh  Dorsal 
Vertebra ;  Duration ,  Two  Years  and  a  Half . — G.  W.  L.,  aged 
twenty-seven  years.  In  October  of  1886  the  patient  was 
thrown  from  his  horse  and  struck  his  back  across  a  stick  on  the 
ground,  injuring  the  spine  at  the  junction  of  the  dorsal  and  lum¬ 
bar  vertebrae.  Instantaneous  and  complete  paraplegia  resulted 
below  the  waist,  with  paralysis  of  the  bladder  and  rectum.  He 
had  lain  where  he  fell,  exposed  to  sleet  and  snow,  for  a  day 
and  a  half  before  he  was  discovered.  He  was  carried  to  a 
farm-house  and  restoratives  were  administered  ;  bottles  of  hot 
water  were  applied  to  his  feet — so  hot  as  to  cause  blistering, 
which  resulted  in  gangrene.  After  three  weeks  he  was  re¬ 
moved  to  his  home,  when  it  was  found  necessary  to  amputate 
both  legs  below  the  knees.  The  bladder  was  catheterized  for  a 
week  after  the  accident,  but  subsequently  emptied  itself  without 
his  control  or  knowledge.  Rectal  movements  were  also  in¬ 
voluntary.  He  also  suffered  from  severe  sacral  bedsores.  The 
paralyzed  limbs  often  had  a  sense  of  burning  and  pain  ;  bending 
the  knee  forcibly  caused  pain.  At  the  time  the  legs  were  am¬ 
putated  no  anaesthetic  was  used,  but  the  sawing  of  the  bones 
caused  intense  pain.  The  general  health  had  recovered  suffi¬ 
ciently  to  allow  the  patient  to  drive  about  in  his  carriage.  Sev¬ 
eral  months  before  coming  under  the  speaker’s  care,  two  years 
and  a  half  after  the  accident,  the  patient  had  unwisely  remained 
in  his  buggy  about  seven  hours.  His  anaesthesia  had  rendered 
him  unconscious  of  discomfort  from  prolonged  pressure,  and 
there  resulted  an  area  of  pressure  gangrene  under  each  buttock. 
These  sores  had  refused  to  heal.  The  patient  now  being  con¬ 
fined  to  his  back,  and  the  case  so  desperate,  he  was  placed 
under  the  speaker’s  charge  with  the  hope  that  some  method  of 
operation  might  be  devised  for  his  improvement.  Examination 
showed  absolute  paraplegia  and  ansesthesia  below  the  line  cross¬ 
ing  the  sacrum  at  its  upper  border  and  extending  in  front  across 
the  abdomen  two  inches  below  the  navel.  The  bedsores  under 
the  buttocks  were  unhealed,  exposing  the  bone.  There  was  in¬ 
voluntary  muscular  jumping  in  both  legs.  Urine  showed  granu¬ 
lar  casts,  but  no  albumin.  The  patient  had  strong  and  natural 
erections  with  emissions.  It  was  decided  that  the  cord  was  ab¬ 
solutely  severed  at  the  last  dorsal,  but  that  below  the  second 
lumbar  it  must  be  in  a  fairly  healthy  condition.  The  case 
seemed  hopeless  unless  it  were  possible  to  innervate  the  lower 
segment  of  the  cord  by  renewing  its  contact  with  the  upper.  It 
was  suggested,  in  case  the  parts  were  not  too  much  injured, 
“to  cut  off  a  few  of  the  lower  dorsal  roots  long,  and  of  the  lum¬ 
bar  roots  short,  and  suture  them  together,  thus  increasing  the 
chance  of  getting  sensation.”  The  operation  was  performed 
April  18,  1889,  by  the  same  method  as  detailed  in  the  former 
case.  After  exposing  the  spinous  arches  of  the  ninth  dorsal  to 
the  second  lumbar  inclusive,  it  was  found  that  a  massive  and 
dense  eburnated  deposit  of  bone  had  formed  at  the  site  of  the 
eleventh  and  twelfth  dorsal  and  first  lumbar  laminm.  This  was 
with  difficulty  chiseled  and  cut  away  until  the  severed  end  of 
the  spinal  cord  was  exposed,  and  found  to  be  completely  cut 
across  and  the  dura  sealed  up.  Below  this  for  an  inch  and  a 
half  solid  bone  filled  the  vertebral  canal.  The  cord  here  com¬ 
menced  again,  and  its  end  was  found  engaged  in  the  bone  so 
that  spicula  had  grown  into  it.  It  could  not  be  lifted  up  to 
approach  the  upper  end  more  than  half  an  inch,  and  it  was  evi¬ 
dent  that  repair  by  suturing  was  hopeless.  He  had  rallied  well 
from  the  operation. 

Case  III.  Fracture  of  the  Eleventh  Dorsal  Vertebra; 
Paraplegia. — J.  S.,  aged  twenty-one,  coachman.  On  January 
1,  1889,  when  alighting  from  the  rear  platform  of  a  car  which 
was  going  rapidly,  he  was  struck  in  the  small  of  the  back  by 
the  platform,  falling  on  his  hands  and  knees;  pain  was  intense 
in  the  back,  and  paralysis  supervened  at  once.  A  plaster  jacket 


Sept.  13,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


301 


% 


had  been  applied  and  retained  for  a  month.  There  was  incon¬ 
tinence  of  urine  and  fasces.  Some  sensation  in  the  legs  and 
feet.  On  examination,  a  slight  depression  was  seen  between 
the  last  dorsal  and  the  first  lumbar  spines.  A  line  of  anaesthesia 
crossed  tbe  back  at  the  top  of  the  sacrum.  At  the  sides  it  ran 
an  inch  above  the  crest  of  the  ilium  and  crossed  the  abdomen 
two  inches  above  the  pubes.  There  was  atrophy  of  all  the 
muscles  of  the  thighs  and  legs,  complete  paraplegia  and  anaes¬ 
thesia  of  the  skin  of  the  lower  extremities,  showing  persist¬ 
ent  vaso-motor  impressions.  He  was  operated  on  in  February, 
1889,  the  operation  being  essentially  the  same  as  before  re¬ 
corded.  At  a  point  underneath  the  injured  arch  a  circular  dam 
of  lymph  was  found  an  eighth  of  an  inch  wide  between  the 
dura  and  the  cord,  entirely  shutting  off  the  upper  from  the 
lower  part  of  the  canal.  From  above  this  dam  the  arachnoid 
fluid  flowed  freely.  The  cord  at  this  point  showed  evidence  of 
having  been  completely  crushed.  Just  below  the  lymph  dam  a 
mass  of  largely  distended  veins  occupied  the  surface  of  the 
cord,  showing  obstructed  venous  return.  These  entirely  emp¬ 
tied  themselves  upward  when  the  pressure  was  taken  off.  The 
cord  was  entirely  liberated  from  its  adhesions,  the  dura  sutured 
with  fine  catgut,  and  the  wound  closed.  For  two  weeks  follow¬ 
ing  the  operation  there  had  been  hypersesthesia  of  all  the  para¬ 
lyzed  parts,  but  this  had  abated.  The  patient  recovered  rapid¬ 
ly  from  the  operation,  but  with  no  improvement  of  the  para¬ 
plegia.  All  operators  in  cases  of  fracture  paraplegia  of  any 
duration  had  thus  far  arrived  at  about  the  same  conclusion — 
namely,  that  the  pressure  of  bone  was  of  secondary  importance. 
Except  where  the  fracture  involved  only  the  arch,  which  was 
driven  in  by  a  blow — inasmuch  as  the  violence,  usually  a  fall 
and  bending  of  the  back,  which  would  produce  instant  paraly¬ 
sis,  had  done  so  by  a  diastasis  of  the  vertebrae,  the  cartilage  be¬ 
ing  ruptured  and  the  arches  broken,  which  completely  pulpified 
the  spinal  medulla — the  vertebrae  were  very  apt  to  immediate¬ 
ly  resume  their  usual  relations.  If,  however,  the  fracture  took 
place  below  the  last  dorsal,  where  the  medulla  had  disappeared 
and  the  firm  cauda  equina  commenced,  the  crushing  did  not 
usually  destroy  the  nerves,  but  long  bone  pressure  would.  In 
such  cases  an  operation  to  correct  it  was  always  desirable.  It 
still  remained  a  problem,  perhaps  never  to  be  solved,  how  to 
connect  the  lower  segment  of  the  cord  with  the  upper  when 
there  was  a  gap  of  half  an  inch,  and  whether  this  union  would 
restore  functional  connection  with  the  brain,  even  though  its 
reflex  and  independent  activity  might  be  ever  so  good. 

The  next  case  reported  was  given  simply  to  show  the  ease 
with  which  the  vertebral  bodies,  if  carious,  might  be  approached 
from  behind. 

Case  IV.  Pott's  Disease ,  talcen  early  and  treated  as  a  Tuber¬ 
cular  Caries  in  any  Joint  would  be. — E.  K.,  aged  twenty,  glass- 
worker.  Two  years  before  admission  the  man  had  had  a  pleu¬ 
risy  from  which  he  recovered.  Subsequently  he  was  cured  of  a 
fistula  in  ano,  and  when  he  came  into  the  hospital  he  had  slight 
phthisical  changes  in  the  apex  of  the  left  lung  and  a  lumbar 
abscess  prominent  over  the  iliac  crest.  The  latter  was  opened 
in  September,  1889,  and  discharged  profusely  through  three 
sinuses  around  the  crest  of  the  ilium.  In  February  last  the 
speaker  had  found  that  a  long  probe  could  be  passed  upward  to 
the  last  dorsal  vertebra,  and,  as  there  was  no  deformity  and  but 
little  pain,  he  had  considered  the  possibility  of  curetting  the 
carious  bone.  An  incision  was  made  beside  the  twelfth  dorsal, 
guided  by  the  end  of  the  probe.  The  transverse  process  of  the 
twelfth  was  carious  and  was  cleared  away  with  a  bone  curette. 
This  instrument  was  then  worked  into  the  body  of  the  bone 
alongside  the  spinal  dura,  without  injury  to  the  latter,  and  a 
large  excavation  of  softened  bone  removed,  when  on  every  side 
the  curette  encountered  firm  and  apparently  sound  bone.  The 


entire  course  of  the  pus  tract  through  the  soft  parts  was  curetted 
and  douched  with  sublimate  solution,  and  finally  with  a  solution 
of  iodoform  in  ether.  In  six  weeks  the  patient  was  sent  home 
with  only  a  slight  discharge,  and  with  but  one  sinus.  The 
course  of  this  case  showed  that  where  there  were  sinuses  con¬ 
nected  with  a  small  carious  bone  focus,  the  great  proportion  of 
purulent  secretion  was  from  the  sinus  walls,  uniformly  lined 
with  tubercular  granulation.  It  further  illustrated  the  ease 
with  which  the  excavation  and  drainage  could  be  accomplished 
directly  backward  through  the  side  of  the  vertebral  canal,  press¬ 
ing  the  uninjured  dura  one  side. 

Case  V.  Extradural  Tubercular  Tumor  of  the  Spine ,  with 
Complete  Paraplegia ;  Operation;  Recovery.— Patient  present¬ 
ed.  Male,  aged  twenty-two  years,  was  taken  with  a  pain  in  his 
back  in  January,  1888.  The  spine  was  flexible  and  without  de¬ 
formity,  with  the  exception  of  a  slight  fullness  in  the  soft  parts 
to  the  right  of  the  ninth  and  tenth  dorsal  spines.  During  March 
sensation  was  diminished  in  the  legs  and  muscular  power  weak¬ 
ened.  A  line  of  hyperaesthesia  formed  about  his  waist.  Two 
weeks  later  he  could  not  stand  without  support,  and  he  had  un¬ 
controllable  twitchings  of  the  legs,  which  had  become  quite 
anaesthetic.  He  also  had  constant  intercostal  pain,  with  girdle 
pains  about  the  limiting  line  of  disease.  Incontinence  of  urine 
and  faeces  followed.  An  active  hectic  now  set  in,  and  the  pa¬ 
tient  wasted  rapidly.  In  May,  just  two  years  ago,  operation 
was  performed  ;  the  spines  and  arches  of  the  eighth,  ninth,  and 
tenth  dorsal  vertebrae  were  removed.  Outside  the  carious  arches 
of  the  ninth  was  half  an  ounce  of  thick  pus,  but  within  and  filling 
the  vertebral  canal  was  a  small  quantity  of  inspissated  pus  and 
a  large  amount  of  neoplasm,  evidently  tubercular.  It  extended 
upward  and  down  the  canal  for  two  inches  and  a  half,  and  was 
thoroughly  curetted  from  the  cord.  The  usual  dressings  were 
applied.  On  tfie  eighth  day  sensation  began  to  return,  and  then 
he  could  move  his  legs.  From  this  time  on  recovery  was  unin¬ 
terrupted,  with  the  exception  of  a  sinus  which  the  speaker  still 
hoped  to  heal. 

Case  VI.  Pressure  Paraplegia  from  Extradural  Sarcoma. 
— Male,  aged  forty-two  years.  The  patient  had  always  enjoyed 
good  health.  Three  years  ago,  while  placing  a  pedal  under  a 
heavy  piano,  the  instrument  had  been  let  down  and  pressed 
heavily  on  his  back.  After  this  he  had  suffered  pain  for  sev¬ 
eral  days.  Six  months  later,  while  lifting  the  corner  of  a  piano, 
he  was  caught  by  an  excruciating  pain  in  the  back.  No  further 
trouble  ensued  at  this  time.  About  July  1,  1889,  he  had  jarred 
his  spine  severely.  A  week  later  he  had  again  jarred  himself 
by  slipping  on  the  ice  and  plunging  forward  on  his  hands  and 
knees.  In  this  same  month  he  began  to  fail  in  health  and  have 
pain  in  the  back.  His  bowels  became  difficult  to  move,  and  it 
required  great  effort  to  empty  the  bladder.  At  the  end  of  five 
weeks  he  had  found  it  difficult  to  guide  the  limbs.  There  was  no 
high  temperature.  In  the  latter  part  of  August  paraplegia  and 
insensibility  were  found  to  be  complete.  In  October,  1889,  the 
diagnosis  of  pressure  paraplegia  was  made  and  an  early  opera¬ 
tion  advised.  In  January,  1890,  the  patient  had  come  to  New 
York  and  was  advised  a  month  or  six  weeks’  orthopedic  treat¬ 
ment,  hoping  that  the  pressure  might  be  from  Pott’s  disease 
and  that  a  natural  relief  of  intervertebral  pus  might  soon  be 
expected  and  the  paraplegia  cured  without  operation.  The 
looked-for  improvement  did  not  come;  he  grew  rapidly  worse. 
The  following  two  weeks  he  had  suffered  with  an  acute  nephri¬ 
tis  and  a  temperature  of  102  5°  F.  On  March  20th,  the  day  be¬ 
fore  it  had  been  arranged  to  operate  on  him,  he  had  an  unac¬ 
countable  chill,  with  a  temperature  of  104-6°.  This  attack 
lasted  over  two  weeks  before  his  temperature  fell  to  normal. 
During  this  time  the  urine  showed  twenty  per  cent,  of  albumin 
and  various  casts.  There  were  no  pulmonary  complications,  but 


302 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jouk. 


deep  ulceration  of  the  rectal  wall  was  found  which  was  healed 
under  iodoform.  On  April  16th,  the  patient  being  in  fair  condi¬ 
tion,  operation  was  performed.  An  incision  was  made  from  the 
seventh  to  the  eleventh  dorsal  spines.  The  arches  of  the  eighth 
and  ninth,  as  well  as  the  base  of  the  spine  of  the  eighth,  were 
found  somewhat  crumbly  and  eroded  by  a  softish  dark  growth 
which  disintegrated  the  bone  where  it  pressed  outward  from 
the  vertebral  canal.  The  bone  was  unusually  porous  in  the 
neighboring  parts,  not  immediately  involved  in  the  tumor,  and 
bled  freely.  On  removing  the  arches  of  the  eighth,  ninth,  and 
tenth  vertebrae  and  the  pedicle  of  the  eighth,  a  firm  dark  growth 
was  found  to  fill  the  vertebral  canal,  flattening  the  cord  to  half 
its  normal  size.  The  tumor  stopped  abruptly  at  the  ligamentum 
subflava  above  the  eighth  and  extended  downward  an  inch  and 
a  half.  It  was  readily  removed,  leaving  the  dura  with  quite  a 
normal  appearance.  Not  a  trace  of  pus  suggestive  of  tubercu¬ 
lar  caries  was  seen  anywhere.  The  wound  was  dressed  with 
iodoform  gauze,  no  plaster  jacket  being  used.  The  operation 
was  endured  very  well,  but  hiccough  and  vomiting  set  in  and 
could  not  be  relieved,' the  patient  dying  on  the  ninth  day.  A 
careful  examination  of  the  tumor  found  it  to  be  a  round-cell 
sarcoma  without  a  trace  of  leucocytes,  giant  cells,  or  tubercular 
material. 

Case  VII.  Intractable  Brachial  Neuralgia. — The  patient, 
a  man  forty-four  years  of  age  (presented),  had  suffered  for 
two  years  with  intense  neuralgia  of  the  right  brachial  plexus 
appearing  in  the  forearm  and  hand.  It  had  grown  worse, 
until  the  hand  became  disabled  and  the  muscles  atrophied.  As 
the  posterior  interosseous  and  ulnar  nerves  had  been  stretched 
without  abatement  of  pain,  the  arm  was  removed  at  the  deltoid 
insertion  in  the  humerus.  This  did  not  improve  the  condition  ; 
the  patient  felt  as  if  the  hand  and  wrist  were  still  on.  The  possi¬ 
bility  of  the  pain  being  caused  by  a  tumor  or  inflammatory  pro¬ 
cess  near  the  origin  of  the  nerve  roots  led  to  the  following  op¬ 
eration.  The  arches  of  the  fourth,  fifth,  sixth,  and  seventh 
cervical  vertebrae  were  removed,  exposing  more  than  two  inches 
of  the  cord.  No  tumor  or  abnormity  was  felt.  The  speaker 
then  drew  back  the  roots  of  the  sixth  and  seventh  nerves  from 
the  intervertebral  foramina  into  the  vertebral  canal,  and  then 
cut  them  across  just  outside  the  dura,  where  the  sensory  and 
motor  roots  join.  The  wound  was  lightly  packed  with  gauze. 
Recovering  from  the  anassthetic,  he  still  suffered  pain,  seemingly 
in  the  fingers.  This  region  was  supplied  by  the  eighth  cervical 
nerve.  Forty-eight  hours  after  the  operation,  with  the  patient 
prone,  the  dura  was  split  up  for  an  inch  and  a  half,  letting  out 
two  ounces  of  spinal  fluid.  This  was  painless,  the  patient  not 
being  under  an  anaesthetic.  The  speaker  now  picked  up  the 
posterior  roots  of  the  eighth  nerve  within  the  dura,  which  was 
at  the  same  level  as  the  seventh  outside,  and  cut  a  quarter  of  an 
inch  from  it.  Handling  the  nerve  gave  the  patient  the  same 
pain  he  had  complained  of  for  the  past  two  years.  The  dura 
was  sutured  with  catgut ;  union  was  perfect.  The  pain  entirely 
changed  in  character;  it  no  longer  went  down  into  the  fingers, 
but  seemed  to  draw  the  stump.  The  pain  had  continued  to  be 
paroxysmal,  and  was  quite  severe  at  times.  The  skin  was  an¬ 
aesthetic  from  the  acromion  process  downward  on  the  entire 
outer  side  of  the  arm.  There  was  partial  anaesthesia  of  the  an¬ 
terior  and  posterior  aspect  of  the  arm,  and  over  the  shoulder 
from  the  middle  of  the  clavicle  to  the  middle  of  the  scapula, 
while  the  skin  facing  the  axilla  was  rather  hypersesthetic.  This 
condition  had  remained  unchanged  up  to  the  present  time,  a 
year  and  four  months  since  operation,  and  the  patient  thought 
that  he  had  as  much  pain  as  before  the  operation,  and  had  gone 
back  to  taking  a  grain  of  morphine  daily. 

Case  VIII.  Intractable  Neuralgia. — G.  Z.,  aged  forty-five, 
in  1886  had  suffered  with  a  “  drawing  pain”  on  the  ulnar  side 


of  the  hand,  continuing  for  two  months.  It  was  of  such  sever¬ 
ity  that  he  was  obliged  to  give  up  his  business.  The  following 
year  the  nerve  had  been  stretched,  but  the  pain  had  grown  worse, 
extending  over  the  hand  and  forearm.  The  nerve  was  then  ex¬ 
cised,  resulting  in  an  exaggeration  of  the  pain.  The  nerves  of 
the  brachial  plexus  were  now  stretched  in  the  axilla,  but  with¬ 
out  a  relief  from  the  symptoms.  After  the  first  operation  the 
forefinger  became  drawn  backward  and  the  forearm  wasted. 
In  February,  1889,  the  patient  had  come  under  the  speaker’s  care. 
It  was  thought  possible  to  bring  about  sensory  anaesthesia  by 
operation  upon  the  sensory  roots  of  the  brachial  plexus.  Incis¬ 
ion  was  made  to  the  left  of  the  spinous  processes  from  the  third 
cervical  to  the  second  dorsal  vertebrae.  The  laminae  of  the  fifth, 
sixth,  and  seventh  and  first  dorsal  vertebrae  were  cut  away,  ex¬ 
posing  the  dura.  Nothing  abnormal  was  found.  The  dura  was 
slit  up  for  two  inches  and  a  half.  The  cord  was  slightly  con¬ 
gested.  The  posterior  roots  of  the  sixth,  seventh,  eighth,  and 
first  dorsal  nerves  were  lifted  up  and  divided  close  to  the  cord; 
the  free  ends  were  caught  up  and  a  quarter  of  an  inch  exsected. 
The  wound  was  closed  as  usual.  The  patient’s  general  health 
had  improved,  but  there  was  still  pain  in  the  wrist,  though  not 
so  severe  as  before  the  operation.  The  pathologist’s  report  of 
the  exsected  nerve  roots  said  that  inflammatory  exudation  was 
quite  marked  around  the  root  of  the  first  dorsal.  The  basis  for 
this  operation  was  the  fact  that  sensory  conduction  was  isolated 
in  the  posterior  root,  which  was  easily  operated  on  within  the 
dura.  Experiments  showed  that  speedy  and  complete  degener¬ 
ation  backward  into  the  cord  followed  this  section.  It  was  the* 
speaker’s  conviction  that  if  all  five  roots  had  been  cut,  in  his 
cases,  the  chance  of  recurrence  would  have  been  less.  The 
speaker  closed  his  remarks  by  emphasizing  the  advantage  of  the 
method  as  adopted  by  him.  It  was  the  most  speedy  and  the 
least  bloody.  It  preserved  all  the  tissues  in  and  about  the  spines 
which  were  replaced,  and  gave  firmness  to  the  back,  as  well  as 
preventing  a  gap  that  Nature  must  fill.  While  we  were  not  war¬ 
ranted  in  taking  a  sanguinary  view  of  the  results  of  operation, 
yet  surgery,  with  its  possibilities  ever  looming  up,  ought  not  to 
occupy  the  ultra-conservative  ground  of  the  past  in  this  field. 

Dr.  J.  A.  Wyeth  thought  the  region  of  the  eleventh  and 
twelfth  dorsal  vertebrae  evidently  the  site  most  prone  to  injur) 
by  direct  violence.  He  suggested  that  the  cases  calling  for 
surgical  interference  should  be  divided  into  (1)  those  resulting 
from  pressure  upou  the  cord  by  bone,  whether  gradual,  as  in 
Pott’s  disease,  or  from  destruction  by  sudden  violence;  and  (2) 
compression  by  intradural  or  extradural  growth.  The  simplest 
form  was  that  of  the  extradural  growth.  These  tumors  were 
easily  approached  by  removal  of  the  laminae.  Tumors  on 
the  cord  were  more  dangerous  and  recovery  less  sure.  Of 
pressure  by  bone,  that  iu  Pott’s  disease  was  less  severe,  while 
that  from  fracture  was  practically  incurable  so  far  as  complete 
recovery  was  concerned.  He  did  not  think  that  the  operation 
of  resection  of  the  cord  and  the  reunion  of  the  ends  would 
accomplish  much  unless  they  adopted  the  extreme  measure  of 
taking  out  the  body  of  a  vertebra  and  letting  down  of  the  su¬ 
perimposed  structures  wholesale. 

The  speaker  then  narrated  in  brief  the  remarkably  satisfac¬ 
tory  results  in  a  case  of  his  already  recorded,  in  which  complete 
recovery  had  followed  operation  for  compression.  The  patient 
had  been  hopelessly  bedridden  for  two  years.  The  site  of 
the  operation  had  been  from  the  fourth  to  the  sixth  dorsal  ver¬ 
tebrae.  In  the  second  case  there  had  been  fracture  at  the  elev¬ 
enth  dorsal.  The  result  of  operation  had  not  been  very  en¬ 
couraging.  The  speaker  believed  the  field  of  spinal  surgery  to 
be  larger  than  at  present  anticipated. 

Dr.  A.  G.  Gerstek  thought  the  intervening  cicatricial  tissue 
would  prevent  restoration  of  function  in  case  of  division  of  the 


Sept.  13,  1890.] 


BOOK  NOTICES. 


303 


cord.  Operative  interference  seemed  justifiable  because  of  the 
utterly  hopeless  character  of  these  cases  without  it,  and  surgical 
measures  might  be  productive  of  good,  and  certainly  served  the 
purpose  of  investigation.  He  would  not  hesitate  to  resort  to 
the  extreme  measure  suggested  by  Dr.  Wyeth,  provided  it  had 
been  demonstrated  by  experiment  that  reunion  of  the  ends  of  a 
divided  cord  would  result  in  restoration  of  its  physiological  in¬ 
tegrity. 

Dr.  B.  Sachs,  speaking  from  the  standpoint  of  a  neurologist, 
did  not  think  the  recorded  results  in  this  particular  field  of  sur¬ 
gery  had  been  very  encouraging.  He  thought  surgeons  might 
use  more  care  in  the  selection  of  their  cases  for  operation.  Dr. 
Abbe  had  demonstrated  very  decidedly  the  good  results  that 
might  be  obtained  in  tuberculous  cases,  a  type  which  had  been 
considered  as  by  no  means  amenable  to  operation.  He  did  not 
think  so  many  laminae  need  be  removed.  Operations  on  the 
spine  for  neuralgias  he  deprecated. 

Dr.  Abbe  said  that  no  one  would  think  of  operating  on  the 
cord  in  neuralgic  cases  except  as  a  last  resource.  lie  did  not 
advocate  operation  in  cases  of  fracture.  He  thought  any  at¬ 
tempt  to  reunite  the  cord  by  the  removal  of  a  vertebra  would 
destroy  the  patient’s  life. 


oak  itoftces. 


Essentials  of  Gynaecology .  Arranged  in  the  Form  of  Questions 
and  Answers  prepared  especially  for  Students  of  Medicine. 
By  Edwin  B.  Cragin,  M.  D.,  Attending  Gynaecologist  to  the 
Roosevelt  Hospital,  Out-patient  Department,  etc.  With  Fifty- 
eight  Illustrations.  Philadelphia:  W.  B.  Saunders,  1890. 
Pp.  viii-17  to  192.  [Saunders’s  Question  Compends,  No.  10.] 
Books  like  this  one  are  useful  not  only  to  the  student  who 
is  barely  at  the  threshold  of  professional  life,  but  to  the  busy 
practitioner  as  well,  who  can  not  always  afford  the  time  for  the 
prolonged  discussions  of  systematic  treatises.  There  is  many 
a  time  when  one  wants  facts,  pure  and  unadulterated,  and  these 
compends,  multum  in  parvo.  when  w7ell  prepared,  as  this  one 
seems  to  be,  are  often  of  more  service  and  of  wider  scope  than 
their  authors  expect. 

The  Bradshaw  Lecture  on  Colotomy,  Lumbar  and  Iliac,  with 
Special  Reference  to  the  Choice  of  Operation.  Delivered 
before  the  Royal  College  of  Surgeons,  of  England,  December 
5,  1889.  By  Thomas  Bryant,  F.  R.  C.  S.,  M.  Ch.  (Hon.) 
Roy.  Univ.  I.,  etc.  London  :  J.  &  A.  Churchill,  1890.  Pp. 
47. 

Mr.  Bryant  believes  firmly  that  lumbar  should  be  preferred 
to  inguinal  colotomy,  and  he  presents  in  this  lecture  his  answers 
to  those  who  have  objected  to  the  lumbar  operation,  while  he 
emphasizes  the  objections  to  colotomy  and  its  incident  dangers. 
He  presents  his  argument  fairly  and  forcibly,  and  has  made  a 
valuable  addition  to  the  literature  on  this  subject. 


Hand-book  of  Obstetrical  Nursing ,  for  Nurses,  Students,  and 
Mothers.  Comprising  the  Course  of  Instruction  in  Obstet¬ 
rical  Nursing  given  to  the  Pupils  of  the  Training  School 
connected  with  the  Woman’s  Hospital  of  Philadelphia.  By 
Anna  M.  Fullerton,  M.  D.,  etc.  Philadelphia  :  P.  Blakis- 
ton,  Son,  &  Co.,  1890.  Pp.  viii-16  to  214.  [Price,  $1.25.] 

Women  have  a  knack  of  remembering  the  forgotten  things 
and  instituting  small  reforms  that  are  great  reforms.  Dr.  Ful¬ 


lerton’s  hand-book  is  an  illustration  of  this.  Law,  order,  and 
comfort  rob  childbirth  of  half  its  terrors.  What  thoughtful 
woman  has  not  longed  for  the  quiet  cave  of  the  prehistoric  sav¬ 
age  in  place  of  the  trivial  confusion,  lace  and  ribbons,  and  dis¬ 
tracting  petty  cares  that  accompany  the  parturient  state  in  mod¬ 
ern  homes?  If  the  simple  directions  in  this  little  book  could 
always  be  carried  out,  the  lot  of  average  womankind  would  be 
greatly  ameliorated. 


Mother ,  Nurse ,  and  Infant :  a  Manual  especially  designed  for 

the  Guidance  of  Mothers  and  Monthly  Nurses.  By  S.  P. 

Sackett,  M.D.  New  York  :  If.  Campbell  Co.  Pp.  378. 

This  book  is  full  of  negations,  a  series  of  doleful  “  don’ts,” 
instead  of  the  cheerful  affirmation  and  positive  directions  that 
the  subject  requires.  There  are  chapters  devoted  to  remedies 
and  regimen  and  to  a  medical  formulary,  and  a  glossary  that  is 
altogether  unique.  According  to  this  glossary,  the  Falloppian 
tubes  are  two  ducts  or  tubes  floating  in  the  abdomen.  Query  : 
wdiose  abdomen  ?  The  following  remedy  should  never  be  for¬ 
gotten  :  “For  stranguary,  use  bee-tea,  made  by  pouring  a  pint 
of  boiling  water  on  fifteen  or  twenty  honey-bees.”  It  is  quire 
possible  that  Mother ,  Nurse ,  and  Infant  may  meet  with  a  cer¬ 
tain  sale,  for  it  appears  to  dispense  that  dangerous  commodity, 
a  little  learning.  The  mother,  nurse,  or  infant  who  cares  to 
read  of  the  primitive  streak  of  von  Baer,  the  false  amnion  of 
Pander,  the  Ai  or  A4  position,  etc.,  will  find  them  all  referred 
to.  In  fact,  there  are  too  many  things  referred  to  ;  hence  the 
lack  of  value  in  these  three  hundred  and  seventy-eight  pages. 


Experimental  Studies  relating  to  the  Action  of  Eyo seine  Hydro- 
bromate ,  Nitroglycerin ,  Hydrocyanic  Acid,  etc.,  and  certain 
Physiological  Conditions,,  upon  the  Circulation  of  Blood  in 
Man  as  shown  by  the  Sphygmograph.  By  Arthur  C.  Hu- 
gensoiimidt,  of  Paris,  France.  (Presented  on  March  15, 
1887,  before  the  Faculty  of  the  Medical  Department  of  the 
University  of  Pennsylvania  for  the  Degree  of  Doctor  in 
Medicine.) 

This  monograph  is  interesting  so  far  as  it  goes,  and  it  is  to 
be  hoped  that  the  author  will  continue  his  studies  in  more  de¬ 
tail.  The  sphygmographic  tracings  show  much  skill  in  the 
use  of  the  instrument,  which  is  not  one  of  precision,  but  only 
one  of  decision  in  the  hands  of  an  expert.  The  author  calls  at¬ 
tention  to  the  effects  of  deep  respiration  on  the  blood  pressure, 
etc.,  and  gives  some  interesting  tracings  showing  the  effects  of 
food  as  well  as  of  the  drugs  mentioned.  He  makes  no  generali¬ 
zations,  but  presents  certain  facts  clearly  and  concisely,  and  his 
work  is  therefore  of  value. 

Chronic  Bronchitis  and  its  Treatment.  A  Clinical  Study.  By 
M  illiam  Murrell,  M.  D.,  F.  R.  C.  P.,  Lecturer  on  Pharma¬ 
cology  and  Therapeutics  at  the  Westminster  Hospital,  etc. 
Philadelphia:  P.  Blakiston,  Son,  &  Co.,  1890.  Pp.  176. 

This  is  a  practical  book  by  a  practical  man.  It  is  written 
in  a  way  that  shows  a  keen  appreciation  of  the  differences  not 
only  of  cases,  but  of  individual  human  beings.  The  histories 
given  are  told  with  charming  frankness,  and  the  writer’s  com¬ 
ments  on  patients’  statements  are  delicious.  He  addresses  Eng¬ 
lish  physicians  and  speaks  of  English  patients,  but  the  Ameri¬ 
can  physician  may  learn  much  of  practical  value  from  his  work, 
and  must  also  appreciate,  more  than  most  Englishmen,  the 
quaint,  half-humorous  common  sense  of  the  book. 


A  Manual  of  Anatomy  for  Senior  Students.  By  Edmund  Owen, 
M.  B.,  F.  R.  C.  S.,  Surgeon  to  St.  Mary’s  Hospital,  London, 


304 


BOOK  NOTICES.— REPORTS  ON  THE  PROGRESS  OF  MEDICINE.  [N.  Y.  Med.  Jocr., 


etc.  With  Numerous  Illustrations.  London  and  New  York  : 
Longmans,  Green,  &  Co.,  1890.  Pp.  viii-526.  [Price, 
$3.50.] 

This  work  is  more  than  its  name  implies.  A  practitioner 
is  frequently  in  need  of  a  book  which  will  supply  him  with  such 
anatomical  information  as  is  essential  for  his  successful  and  in¬ 
telligent  work,  without  a  wearisome  mass  of  detail.  Mr.  Owen 
has  successfully  attempted  to  supply  this  need  and  has  furnished 
us  with  a  manual  of  practical  anatomy — practical  not  alone  from 
a  surgeon’s  point  of  view,  but  from  a  physician’s  as  well.  It 
Is  written  in  a  pleasant,  readable  style,  and  its  only  fault  is  its 
size — it  might  profitably  be  twice  as  large.  As  it  is,  it  is  a 
multurn  in  parvo  well  worthy  of  a  place  in  every  practitioner’s 
library. 


Lemons  sur  les  maladies  du  larynx.  Faites  a  la  Faculte  de  m6de- 
cine  de  Bordeaux  (cours  libre).  Par  le  Dr.  E.  J.  Motjee, 
Professeur  libre  de  laryngologie,  otologie  et  rhinologie,  etc. 
Becueillies  et  r6dig6es  parleDr.  M.  Natier,  Ancien  chef  de 
clinique  du  Docteur  E.  J.  Moure,  et  revues  par  l’auteur. 
Avec  des  figures  en  noir  dansletexte.  Paris:  Octave  Doin, 
1890.  Pp.  iv-599. 

This  volume  comprises  forty-seven  lectures,  delivered  in  the 
course  on  laryngology  by  the  editor  of  the  Revue  de  laryn¬ 
gologie.  The  lectures  naturally  avoid  the  unnecessary  presenta¬ 
tion  of  conflicting  views,  while  each  subject  receives  thorough 
consideration.  Tuberculous  and  syphilitic  laryngitis  are  espe¬ 
cially  noticeable  for  the  thoroughness  of  their  presentation, 
and  no  text-book  on  this  subject  excels  the  chapters  on  the 
nervous  diseases  of  the  larynx.  The  author  has  taken  advan¬ 
tage  of  his  experience  in  the  recent  epidemic  to  write  a  chapter 
on  the  laryngeal  complications  of  influenza,  comprising  catar¬ 
rhal  laryngitis,  paralysis  and  spasms  of  the  glottis,  and  ulcera¬ 
tions  and  oedema  of  the  larynx. 

As  a  text-book  this  work  has  no  superior,  and  we  hope  to 
see  it  translated  into  English. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

Recherches  cliniques  et  therapeutiaues  sur  l’epilepsie,  l’hysterie  et 
l’idiotie.  Compte  rendu  du  service  des  enfants  idiots,  epileptiques  et 
arrieres  de  Bicetre  pendant  l’annee  1889.  Par  Bourneville,  medecin 
de  Bicetre,  Sollier,  conservateur  du  musee  de  Bicetre,  et  A.  Pilliet,  ancien 
interne  du  service.  Volume  X,  avec  22  figures  dans  le  texte  et  une 
planche  chromo-lithographique.  Paris:  Lecrosnier  et  Babe,  1890. 
Pp.  lvi-188.  [Publications  du  Progres  medical. ] 

The  Physician’s  Companion :  a  Pocket  Reference-Book^  for  Physi¬ 
cians  and  Students.  Bv  Clarence  A.  Bryce,  M.  D.,  Editor  of  the  South¬ 
ern  Clinic ,  etc.  Richmond,  Va.,  1890.  Pp.  160.  [Price,  $1.] 

The  Intestinal  Diseases  of  Infancy  and  Childhood.  Physiology,  Hy¬ 
giene,  Pathology,  and  Therapeutics.  By  A.  Jacobi,  M.  D.,  etc.  Vols. 
I  and  II.  Second  Edition.  Detroit:  George  S.  Davis,  1890.  [The 
Physician’s  Leisure' Library.] 

Transactions  of  the  New  York  State  Medical  Association  for  the 
Year  1889.  Volume  VI.  Edited  for  the  Association  by  Edward  K. 
Dunham,  M.  D.,  of  New  York  County. 

The  Sewerage  of  Columbus,  Ohio.  Address  of  Colonel  George  E. 
Waring,  Jr.,  at  Board  of  Trade  Auditorium,  Columbus,  Ohio,  Monday, 
.June  23,  1890,  and  Discussion  following. 

I.  A  Case  of  Corneal  Transplantation  from  the  Rabbit’s  to  the 
Human  Eye.  II.  A  Singular  Case  of  Injury.  By  William  F.  Smith, 
M.  D.,  Chicago.  [Reprinted  from  the  Archives  of  Ophthalmology.'] 
Anthrax  :  the  Disease  of  the  Egyptian  Plagues.  By  Henry  William 
Blanc,  M.  D.,  New  Orleans.  [Reprinted  from  the  New  Orleans  Medical 
and  Surgical  Journal.] 

Lectures  on  Massage  and  Electricity  in  the  Treatment  of  Disease 
(Masso-electrotherapeutics).  By  Thomas  Stretch  Dowse,  M.  D.,  Fellow 


of  the  College  of  Physicians  of  Edinburgh,  etc.  New  York :  E.  B. 
Treats  Company,  1890.  Pp.  xix-379.  [Price,  $2.75.] 

Beitrage  zur  Augenheilkunde.  Von  Professor  R.  Deutschmann,  in 
Hamburg.  1.  Heft,  mit  10  Abbildungen  in  Text.  Hamburg  und  Leip¬ 
zig  :  Leopold  Voss,  1 890.  Pp.  80. 

The  Use  and  Abuse  of  Pepsin.  By  Gustavus  Eliot,  A.  M.,  M.  D., 
New  Haven,  Conn.  [Reprinted  from  the  Proceedings  of  the  Connecticut 
Medical  Society.  ] 

Drs.  Bourneville  and  Bricon’s  Manual  of  Hypodermic  Medication. 
By  G.  Archie  Stockwell,  M.  D.,  F.  Z.  S.  Detroit:  George  S.  Davis,  1890. 
Pp.  158.  [The  Physician’s  Leisure  Library.] 


Imports  on  %  Jjrogrtss  of  ghbuhtc. 

GENERAL  MEDICINE. 

Of  By  S.  T.  ARMSTRONG,  M.  D. 

Intestinal^  Charbon  in  Man. — Dr.  G.  Bouisson  makes  a  rare  case  of 
intestinal  charbon  in  man  the  subject  of  a  Paris  thesis  this  year.  The 
patient  was  a  tanner,  and  when  brought  to  the  hospital  was  suffering 
from  abdominal  pain,  swelling,  vomiting,  and  algidity,  that  seemed  to 
be  caused  by  intestinal  strangulation.  Death  resulted ;  and  at  the  ne¬ 
cropsy  ecchvmoses  were  noticed  on  the  peritoneal  surface  of  the  intes¬ 
tines  as  far  as  the  termination  of  the  jejunum.  At  this  point  the  in¬ 
testine  was  so  thickened  that  the  lumen  of  the  canal  was  diminished 
one  half ;  this  was  due  to  an  intestinal  thrombus  extending  more  than 
twenty  centimetres,  and  existing  less  extensively  elsewhere.  The 
ecchymoses  were  all  situated  at  the  mesenteric  border  of  the  intestines, 
and  were  limited  to  the  small  intestines,  mesentery,  and  adjacent  lymph 
glands.  They  extended  through  the  wall  to  the  mucous  surface  of  the 
intestine,  attaining  a  thickness  of  about  one  centimetre,  and,  seen  from 
the  surface,  seemed  to  be  a  simple  infiltration  of  blood.  Microscopic¬ 
ally,  sections  of  the  ecchymotic  foci  were  found  to  contain  nunibers  of 
the  charbon  bacilli  that  were  present  only  in  the  most  superficial  por¬ 
tion  of  the  intestine  and  were  not  present  in  the  deeper  portions  of  the 
mucous  or  in  the  muscular  layers.  Cultures  and  inoculations  demon¬ 
strated  that  the  micro-organism  was  the  charbon  bacillus. 

The  '  Contagiousness  of  Tuberculosis. — According  to  Le  Progres 
medical ,  Dr.  Haupt,  of  Soden,  has  endeavored  to  demonstrate  that  the 
contagiousness  of  tuberculosis  is  very  dubious.  The  observations  that 
have  been  made  at  the  baths  of  Soden  are  very  interesting.  Uf  t  tie 
1,500  inhabitants  of  the  place,  101  keep  boarders;  and  usually  these 
women,  with  their  sisters  and  daughters,  nurse  their  phthisical  guests. 
In  some  of  the  houses  the  women  are  assisted  by  nurses  from  some 
neighboring  village.  They  make  the  patients’  beds,  sweep  and  dust  the 
rooms,  remove  the  sputa,  and  generally  work  exposed  to  the  contagion. 
In  winter  the  family  of  the  boarding-house  keeper  occupies  the  same 
rooms  used  by  consumptives  during  the  summer.  From  1855  to  1888, 
48  of  238  boarding-house  keepers  died ;  10  of  the  deaths  were  from 
tuberculosis,  and  in  6  of  these  there  was  a  hereditary  predisposition: 
in  the  other  4  cases  the  disease  was  caused  by  external  causes.  Of 
415  nurses,  17  had  died ;  5  of  the  deaths  were  tuberculous.  In  the 
three  past  years  there  were  76  deaths  in  Soden,  7  of  them  caused  by 
tuberculosis,  2  cases  being  meningeal  and  1  osseous,  each  of  these  in 
infants.  The  4  remaining  deaths  were  not  of  persons  employed  in  the 
houses. 

The  Processes  taking  Place  in  the  Diphtheritic  Membrane. — Dr. 

M.  A.  Ruffer  concludes,  in  a  paper  in  the  British  Medical  Journal  of 
July  26th,  that:  1.  The  bacilli  of  diphtheria  are  present  in  the  most 
superficial  part  of  the  membrane  only  ;  that  is,  in  a  place  where  they  are 
well  within  reach  of  medicinal  agents — an  observation  not  without  in¬ 
terest  from  the  point  of  view  of  treatment. 

2.  In  the  diphtheritic  membrane  there  is  an  active  struggle  taking 
place  between  the  amoeboid  cells  in  the  membrane  and  the  micro-organ¬ 
isms.  In  other  words,  the  diphtheritic  membrane  is  a  battle-fie’d  for 
amoeboid  cells  and  the  pathogenic  microbes  of  diphtheria. 


Sept.  13,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


305 


8.  The  reason  why  the  bacilli  do  not  actually  penetrate  into  the  tis¬ 
sues  is  probably  that  as  soon  as  they  try  to  do  so  they  are  arreted  by 
the  amoeboid  cells  present  in  the  diphtheritic  membrane. 

The  Treatment  of  Scarlatina  by  Acetate  of  Ammonium. — Dr.  Vidal, 
in  a  paper  read  before  the  Paris  Academy  of  Medicine,  concludes,  ac¬ 
cording  to  Le  Mercredi  medical  of  August  6th,  that  there  is  but  little 
doubt  that  acetate  of  ammonium  is  perfectly  tolerated  by  children  in 
doses  of  fifteen  grains  for  each  year  of  their  age,  and  to  adults  as 
high  as  an  ounce  a  day  may  be  administered.  In  these  doses  acetate  of 
ammonium  rapidly  reduces  high  temperature,  thus  making  it  a  desirable 
remedy  in  the  treatment  of  scarlatina,  and  perhaps  also  in  the  other 
eruptive  fevers.  The  action  of  the  medicament  is  most  rapid  if  it  is 
administered  at  the  commencement  of  the  disease. 

The  Treatment  of  Whooping-cough  with  Antipyrine. — Dr.  P.  Ree, 
in  the  Deutsche  med.  Woch.,  No.  19,  1890,  states  that  whooping-cough 
may  be  aborted  by  antipyrine  if  administered  at  the  beginning  of  the 
convulsive  state,  on  the  third  or  fourth  day  following  the  appearance  of 
the  paroxysm  of  pathognomonic  coughing.  The  dose  of  antipyrine 
should  be  one  grain  and  a  half  for  each  year  of  the  child’s  life,  admin¬ 
istering  such  a  dose  three  times  a  day  after  eating ;  the  drug  is  easily 
tolerated  by  the  child,  the  author  never  having  seen  any  intoxication 
following  its  use.  At  a  later  period  in  the  disease  antipyrine  has  no 
action  on  the  process.  It  is  generally  noticed  that  if  the  cough  sud¬ 
denly  ceases,  broncho-pneumonia  supervenes,  the  cough  reappearing 
with  greater  intensity  on  the  cessation  of  the  broncho-pneumonia.  If 
in  the  course  of  whooping-cough  the  paroxysms  of  coughing  suddenly 
cease,  Priessnitz’s  compresses  should  be  applied  to  the  chest,  and  a 
mixture  of  benzoic  acid  and  camphor  (of  each  half  a  grain  three  times 
a  day),  or  tincture  of  ipecac,  should  be  administered  to  avert  the  pneu¬ 
monia. 

Vaccinial  Fever. — Dr.  Peiper,  in  the  proceedings  of  the  Soc.  med.  de 
Qrieswald  for  January  10th,  reports  twenty -three  cases  of  vaccinial  fever 
in  children.  In  six  cases  the  fever  appeared  during  the  third  day,  at¬ 
taining  a  temperature  of  39'6°  C.  Generally  it  developed  between  the 
fourth  and  seventh  day,  attaining  the  highest  temperature  (40°  C.)  on 
the  seventh  or  eighth  day.  It  lasted  from  two  days  and  a  half  to  four 
days  and  a  half,  and  did  not  depend  on.  the  number  of  pustules,  nor 
upon  the  intensity  of  the  local  inflammation.  In  six  cases  of  revacci¬ 
nation  the  author  discovered  but  two  cases  of  fever.  The  fever  is 
rarely  important ;  and  when  it  is  very  high  or  prolonged,  complications 
must  be  feared. 

A  New  Treatment  for  Epilepsy. — According  to  Le  Mercredi  medi¬ 
cal  of  July  30,  1890,  Laufenauer  has  employed  for  all  epileptic  condi¬ 
tions  except  hystero-epilepsy  the  bromide  of  ammonium  and  rubidium. 
He  commences  with  a  dose  of  thirty  grains,  increasing  to  seventy-five 
grains,  though  two  drachms  a  day  usually  suffice.  His  formulary  is : 


B  Bromide  of  ammonium  and  rubidium .  3  jss. ; 

Syrup  of  lemon .  3  v ; 

Water .  ?  x. 


The  Tests  for  Stomach  Acids. — In  his  paper  on  the  pathology  of 
gastric  dyspepsia  in  the  British  Medical  Journal  of  August  9th,  Mr.  D. 
J.  Hamilton  gives  the  various  tests  for  the  acids  contained  in  the  gas¬ 
tric  juice.  In  cases  of  acid  dyspepsia,  an  hour  after  a  meal  starch  will 
not  have  changed  into  maltose  and  dextrin,  and  iodine  will  produce 
the  blue  coloring.  But,  as  maltose  changes  into  grape  sugar  chiefly  in 
the  small  intestine,  it  is  probably  the  transformation  of  cane  sugar  into 
dextrose  and  thence  to  lactic  acid  that  causes  the  large  proportion  of 
the  latter  during  abnormal  digestion. 

After  a  test  meal  the  liquid  is  drawn  off  with  a  stomach  tube  and 
filtered,  and  the  total  acidity  ascertained  by  any  of  the  usual  methods. 
Then  fifty  cubic  centimetres  of  the  filtrate  are  distilled  until  three 
fourths  of  the  quantity  have  passed  over,  when  fifty  additional  centi¬ 
metres  are  added  and  the  distilling  proceeded  with  for  the  same  amount 
as  before.  The  volatile  acids  are  carried  off  and  may  be  quantitatively 
estimated  by  the  titration  methods  ;  the  residue  in  the  retort  is  shaken 
up  with  ether  to  dissolve  out  the  lactic  acid,  the  ethereal  solution  is 
separated  by  a  Geissler’s  funnel,  and  the  liquid  remaining  contains  the 
hydrochloric  acid  and  acid  salts  (phosphates). 

To  estimate  the  quantity  of  lactic  acid,  evaporate  the  ether,  dilute 
the  residue  with  distilled  water  to  fifty  cubic  centimetres,  and  neutralize 


this  with  as  many  cubic  centimetres  of  a  decinormal  solution  of  sodium 
hydrate  (caustic  soda,  0'004  gramme  in  each  cubic  centimetre)  as  neces¬ 
sary,  using  litmus  to  indicate  the  neutralization.  Each  cubic  centime¬ 
tre  of  the  sodium-hydrate  solution  will  neutralize  0'009  gramme  of  lactic 
acid ;  so  multiply  this  decimal  by  the  number  of  cubic  centimetres  of 
the  sodium  solution,  and  the  product  will  be  the  quantity  of  lactic  acid 
in  fifty  cubic  centimetres. 

The  residue  containing  the  hydrochloric  acid  is  neutralized  in  the 
same  way,  one  cubic  centimetre  of  the  test  solution  neutralizing  0'00364 
gramme  of  hydrochloric  acid ;  this  decimal  is  multiplied  by  the  number 
of  cubic  centimetres  of  the  neutralizing  fluid,  and  the  product  is  the 
quantity  of  free  hydrochloric  acid  in  fifty  cubic  centimetres. 

Tropa'olin  in  saturated  watery  or  alcoholic  solutions  changes  from 
a  brown  or  golden-red  color  to  a  ruby-red  color  in  the  presence  of 
minute  quantities  of  free  hydrochloric  or  lactic  acid,  while  the  basic, 
neutral,  and  acid  salts  of  these  or  phosphoric  acids  convert  the  color 
into  a  straw-yellow. 

Hydrochloric  acid  may  be  detected  by  Rheoch’s  test :  a  saturated 
solution  of  a  neutral  acetate  of  iron  is  added  .to  two  cubic  centimetres 
of  a  ten-per-cent,  solution  of  sulphocyanide  of  potassium  until  a  ruby- 
red  color  is  obtained  ;  a  few  drops  of  this  solution  are  placed  in  a  por¬ 
celain  dish,  and  a  hydrochloric-acid  solution  changes  the  color  to  light 
violet,  and  eventually  brown.  Giinzburg’s  test  for  hydrochloric  acid  is 
to  dissolve  two  grammes  of  phloroglucin  and  one  gramme  of  vanillin  in 
one  hundred  cubic  centimetres  of  absolute  alcohol ;  equal  quantities  of 
this  and  the  solution  containing  hydrochloric  acid  are  heated  in  a  white 
porcelain  dish  with  the  formation  of  a  rose-red  color  if  the  acid  is  pres¬ 
ent  ;  neither  organic  acids,  peptone,  nor  albuminous  substances  inter¬ 
fere  with  its  action. 

To  detect  lactic  acid,  add  the  solution  to  fifty  cubic  centimetres  of 
distilled  water  containing  one  drop  of  liquor  ferri  sesquichloridi,  and  a 
yellow  color  results  if  that  acid  is  present.  Uffelman’s  reagent  is  a 
fresh  mixture  of  ten  cubic  centimetres  of  a  four-per-cent,  carbolic-acid 
solution  with  twenty  cubic  centimetres  of  distilled  water  containing  a 
drop  of  liquor  ferri  sesquichloridi ;  the  amethyst-blue  liquid  becomes 
yellow  in  the  presence  of  one  third  its  volume  of  diluted  lactic  acid; 
hydrochloric  acid,  phosphates,  and  albumin  disturb  this  reaction. 

Butyric  acid  may  be  detected  by  its  odor,  and  one  tenth  per  cent, 
gives  with  Uffelman’s  reagent  an  ash-gray  color.  Shaking  the  stomach 
washings  with  ether  will  dissolve  the  fatty  acids,  and  if  the  mixture  is 
thrown  into  water  and  a  little  chloride  of  calcium  added,  oil  globules 
are  set  free. 

In  the  normal  stomach  one  hour  after  a  meal  the  total  acidity  is 
O' 189  per  cent.,  and  there  is  0'044  per  cent,  of  free  hydrochloric  acid. 

Von  Jaksch,  in  the  Zeitschrift  f.  klin.  Med.,  Bd.  xvii,  H.  5,  states  that 
the  absence  of  free  acid,  or  the  existence  of  slight  traces  only,  in  one 
to  three  hours  after  a  test  meal  of  pure  flesh  diet  or  milk,  is  significant 
of  severe  disturbance  of  the  functions  of  the  stomach.  He  made  a 
series  of  experiments  to  determine  the  comparative  sensitiveness  of  the 
different  color  tests,  using  Congo-red  paper,  6  B.  paper,  benzo-purpurin, 
and  Giinzburg’s  and  Boas’s  reagents.  The  Giinzburg  reagent  was  the 
most  reliable,  though  this  would  sometimes  fail  when  even  a  consider¬ 
able  amount  of  free  acid  was  present.  So  a  reliable  color  test  is  yet  to 
be  discovered. 

A  Study  of  the  Chemistry  of  the  Stomach  considered  as  an  Element 
of  Diagnosis. — Dr.  Hayem,  in  a  paper  published  in  Le  Mercredi  medi¬ 
cal  of  July  23d,  states  that  the  methods  used  to  study  the  chemistry  of 
the  stomach,  based  on  the  formation  of  free  hydrochloric  acid  in  the 
gastric  juice,  are  absolutely  insufficient.  The  proportions  of  chlorine 
under  its  diverse  forms,  especially  in  its  combinations  with  albuminoid 
matters,  must  be  estimated  ;  and  a  meal  of  eight  ounces  of  black  tea — 
without  sugar  or  cream — and  two  ounces  of  dry,  white  bread  is  given 
in  the  morning.  An  hour  after  the  repast  was  commenced,  some  of 
the  contents  of  the  stomach  are  obtained  by  a  tube — using  no  water  for 
washing,  but  obtaining  the  sample  by  expression.  If  the  stomach  is 
not  empty  in  the  morning,  lavage  must  first  be  practiced,  and  the  meal 
taken  one  or  two  hours  thereafter.  A  thorough  examination  of  the  ex¬ 
pressed  fluid  is  made. 

As  the  result  of  many  examinations,  the  three  following  categories 
are  established : 


306 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jouh., 


1.  Certain  dyspeptics  have  a  functional  irritation  of  the  stomach 
characterized  at  the  time  by  an  increase  of  the  chlorides,  of  hydro¬ 
chloric  acid,  and  of  the  total  acidity.  There  is  an  excess  of  stomach 
work,  and  the  condition  is  called  hyperpepsia. 

2.  In  others  there  is  a  diminution  that  may  go  as  far  as  annihilation 
of  all  these  constituents ;  this  is  called  hypopepsia,  and  occasionally 
becomes  apepsia. 

3.  Lastly,  in  a  small  number  of  cases,  the  gastric  chemistry  is 
slightly  modified ;  this  is  a  simple  dyspepsia,  probably  caused  by  nerv¬ 
ous  or  mechanical  troubles. 

The  Causes  of  Gastroxia  (Acid  Dyspepsia). — Mr.  D.  J.  Hamilton 

publishes  in  the  British  Medical  Journal  of  August  9th  a  most  excel¬ 
lent  paper  on  the  pathology  of  gastric  dyspepsia.  He  concludes  that 
gastroxia — the  gastroxynsis  of  Rossbach — is  due  to  an  acid,  usually 
lactic,  but  in  rare  cases  hydrochloric ;  though  in  some  cases  the  acidity 
is  due  to  lactic  acid  augmented  by  the  presence  of  various  volatile  or¬ 
ganic  acids.  The  excess  of  lactic  acid  may  be  a  result  of  prolongation 
of  the  natural  lactic-acid  stage  of  digestion,  or  it  may  be  furnished  by 
the  grape  sugar.developed  from  the  sugar  in  the  dietary ;  a  small  part 
of  it  may  be  grape  sugar  resulting  from  the  action  of  salivary  diastase 
on  starch. 

The  cause  of  the  prolongation  of  the  lactic-acid  stage  of  digestion 
is  the  deficiency  in  hydrochloric  acid  that  ought  naturally  to  replace 
the  lactic  acid. 

The  fermentation  of  the  grape  sugar  into  lactic  acid  is  brought 
about  by  living  vegetable  organisms,  always  more  or  less  abundant  in 
the  stomach.  This  fermentation  is  probably  due  in  part  to  deficiency 
in  the  quantity  and  proteolytic  quality  of  the  gastric  juice,  the  carbo¬ 
hydrates  consequently  undergoing  a  faulty  decomposition  while  the 
proteids  remain  undissolved. 

Acidity  caused  by  excess  of  hydrochloric  acid  is  manifested  in  two 
ways :  (a)  Where  the  acid  is  secreted  in  a  gush  immediately  on  the  in¬ 
troduction  of  food,  and  (6)  where  it  accumulates  in  the  stomach  during 
fasting.  In  either  case  the  alkalinity  of  the  saliva  is  neutralized  too 
soon,  and,  the  digestion  of  starchy  food  being  hindered,  it  accumulates 
in  the  stomach. 

Stomach  Washing  in  Children. — In  a  paper  in  the  Bulletin  of  the 
Johns  Hopkins  Hospital  for  July,  1890,  Dr.  W.  D.  Baker  reports  the  re¬ 
sult  of  his  experience  in  two  hundred  cases  of  stomach  washing  for 
gastro-intestinal  disturbance  in  children.  It  quickly  relieved  vomiting 
in  most  cases  after  the  first  washing,  and  in  but  one  case  was  it  neces¬ 
sary  to  stop  milk  food  in  order  to  check  the  vomiting.  In  summer 
diarrhoea,  with  retarded  digestion  and  almost  constant  presence  of  milk 
curds  in  the  stomach,  the  removal  of  the  curds  by  washing  not  only 
gives  the  stomach  rest,  but  prevents  their  passage  into  the  intestine 
with  consequent  irritation  and  fermentation.  It  was  also  used  advan¬ 
tageously  in  constipation  consequent  upon  a  catarrhal  condition  of  the 
gastro-intestinal  canal.  In  one  case  of  carbolic-acid  poisoning  it  was 
used  successfully.  It  should  not  be  used  in  children  having  heart  dis¬ 
ease,  bronchial  or  pulmonary  troubles. 

The  washing  is  done  with  a  soft  Nelaton  catheter,  No.  8,  9,  or  10, 
attached  by  a  short  glass  tube  to  a  piece  of  rubber  tubing,  two  feet 
long,  with  a  two-ounce  funnel  in  the  distal  end.  The  child  is  held,  sit¬ 
ting,  in  the  nurse’s  lap,  with  the  head  slightly  bent  forward ;  a  rubber 
bib  reaches  from  the  nec^  to  a  slop  pail  on  the  floor.  The  tube  is 
moistened  in  warm  water,  passed  into  the  mouth,  and  gradually  forced 
into  the  oesophagus  and  stomach.  Gagging  or  retching  usually  stops 
when  the  tube  enters  the  stomach,  and  any  contents  are  usually  evacu¬ 
ated  through  the  tube  ;  these  should  be  collected  and  examined.  From 
one  to  two  ounces  of  tepid  water  are  then  poured  into  the  funnel,  held 
above  the  level  of  the  child’s  head ;  the  funnel  is  then  lowered  and  the 
stomach  contents  siphoned  out.  This  process  is  repeated  until  the 
washing  from  the  stomach  is  clear. 

Cannabis  Indica  in  Diseases  of  the  Stomach. — Dr.  Germain  See,  in 
Be  Mercredi  medical  of  July  30th,  concludes  that  in  diseases  of  the 
stomach  a  fatty  extract  of  cannabis  indica  in  doses  of  one  grain,  five 
times  a  day  in  a  solution,  is  very  serviceable.  A  greater  dose  is  toxic, 
and  the  alkaloids  do  not  produce  the  same  effect.  The  drug  is  espe¬ 
cially  useful  in  inorganic  diseases  of  the  stomach,  in  which  there  are 
chemical  alterations  of  the  gastric  juice  (hydrochloric  superacidity  is 


most  frequent),  and  in  the  neuroses  that  are  manifested  without  chemi¬ 
cal  modification  of  the  gastric  juice.  In  dyspepsia  manifested  by 
troubles  of  the  appetite,  flatulence,  alterations  in  digestion,  and  reflex 
nervous  troubles  (cardiac  or  cerebral),  cannabis  indica  acts  in  a  constant 
manner  to  quiet  the  painful  sensations  and  re-establish  the  appetite. 
If  these  depend  on  hyperacidity,  the  drug  should  be  associated  with 
large  doses  of  bicarbonate  of  sodium  at  the  end  of  gastric  digestion. 

Cannabis  has  no  action  on  spasms  or  dilatations  of  the  stomach, 
but  it  relieves  spasms  and  vomiting  due  to  disorders  of  the  motor 
nerves.  It  calms  the  painful  sensations  of  pyrosis — due  to  gas  from 
fermentation. 

Gastric  digestion  is  increased  by  cannabis  when  it  is  relaxed  by 
a  paralytic  condition  or  painful  from  superaciditv.  It  does  not  improve 
indigestion  due  to  absence  of  hydrochloric  acid.  The  drug  improves 
reflex  nervous  troubles,  but  it  does  not  change  the  nervous  disposition 
of  hypochondriacs,  hysterical  persons,  or  neurasthenics.  Its  use  de¬ 
mands  the  aid  of  other  curative  methods — alkalies,  purgatives,  and 
diet.  [D extrait  gras  de  haschisch  of  the  French  pharmacopoeia  is  made 
by  the  Arabs  by  boiling  the  flowers  of  the  fresh  plant  with  butter  and 
a  little  water ;  the  latter  is  evaporated,  and  when  the  butter  is  suffi¬ 
ciently  charged  with  the  active  principle  it  is  ready  for  use.  The  prep¬ 
aration  is  unctuous,  tenacious,  of  a  yellow-green  color,  and  nauseous 
odor.] 

Infectious  Icterus,  or  Weil’s  Disease. — Dr.  Ducamp,  in  the  Revue  de 

medecine  for  June,  says  of  this  disease  that  it  seems  to  be  identical  with 
the  essential  icterus  of  Ozanam,  the  pseudo-grave  icterus  of  Greliety 
Bosviel,  the  icteric  fever  of  Lancereaux,  the  hepatic  typhus  of  Lan- 
douzy  and  Mathieu,  the  curable  grave  sporadic  icterus  of  Roudot,  and 
the  infectious  icterus  of  Bernheim.  So,  although  Weil’s  name  has  been 
given  to  the  disease,  it  was  clearly  described  by  Landouzy  three  years 
previous  to  Weil’s  paper. 

Dr.  Ducamp’s  cases  occurred  in  three  of  six  laborers  engaged  in 
cleaning  a  foul  obstructed  sewer  in  Montpellier.  The  slime  was  disin¬ 
fected  by  chloride  of  lime ;  but  all  of  the  workmen  became  ill — three  of 
them  with  infectious  icterus,  two  with  gastro-intestinal  troubles,  and  one 
with  simple  malaise.  There  were  no  other  cases  of  icterus  in  the  street, 
city,  or  hospital,  and  the  men  affected  did  not  live  in  the  same  part  of  the 
city.  The  condition  seemed  grave  and  persistent,  and  was  accompanied 
by  moderate  fever,  pronounced  myalgia,  and  a  marked  icterus  (poly- 
cholic)  that  disappeared  slowly  during  a  long  convalescence.  Infectious 
icterus,  like  all  infectious  diseases,  has  a  period  of  incubation  that 
makes  no  manifestation  in  the  midst  of  perfect  health ;  a  period  of  in¬ 
vasion  when  there  is  no  presage  of  the  disease  that  will  appear;  at 
last  a  period  of  activity,  and  lastly  that  of  decline.  In  these  cases  the 
period  of  incubation  was  five  days.  The  period  of  invasion  was  marked 
by  a  severe  general  condition,  extreme  fatigue,  moderate  fever,  severe 
myalgia  exaggerated  by  pressure  on  the  muscles  of  the  inferior  limbs, 
and  occasionally  vertigo  and  epistaxis.  The  period  of  activity  is  particu¬ 
larly  marked  by  an  intense  polycholic  icterus,  albuminous  urine  in  one 
case,  occasional  nasal  and  cutaneous  haemorrhages,  the  gravity  of  the 
genera]  condition  of  the  case  above  all  attracting  attention.  The  period 
of  decline  is  announced  by  a  diminution  of  icterus  ;  it  is  of  long  dura¬ 
tion,  and  there  may  be  slight  diminution  in  the  volume  of  the  liver. 
The  disease  he  regards  as  of  microbial  origin. 

The  Liver  in  Typhoid  Fever. — Dr.  T.  Legry,  according  to  the  Rev. 
des  sci.  med.  for  July,  finds  that  the  liver  in  typhoid  fever  is  not  in¬ 
creased  in  volume,  except  rarely,  as  it  is  in  alcoholism,  puerperal  fever, 
malarial  poisoning,  and  in  long-continued  diseases.  The  pale  and 
grayish  color  often  erroneously  suggests  a  well-marked  fatty  degenera¬ 
tion.  The  bile  is  generally  pale,  decolorized,  less  abundant,  and  of 
feeble  density.  By  microscopic  examination  a  granulo-fatty  degenera¬ 
tion  is  found  that  is  very  slight  at  the  commencement  of  the  disease, 
and  only  more  extensive  in  cases  of  late  death  or  of  complication;  the 
degeneration  is  always  less  pronounced  than  the  macroscopic  appear¬ 
ance  of  the  liver  indicates.  The  lesion  is  sometimes  circumportal  and 
circumlobular,  more  rarely  perihepatic,  or  altogether  peripheric  and 
central ;  it  is  characterized  by  the  presence  of  fine  granulations,  that 
may  become  confluent,  forming  more  voluminous  droplets,  but  rarely 
attaining  the  size  of  the  fatty  granules  in  tuberculosis.  The  capillaries 
are  dilated  and  full  of  blood  at  the  commencement  of  the  disease,  but 


Sept.  13,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


307 


this  soon  ceases.  The  cells  may  present  a  cloudy  tumefaction,  more 
rarely  a  hyaline  and  transparent  appearance;  they  always  contain  many 
nuclei.  In  the  portal  canals  nodules  made  of  nuclei,  surrounded  with 
protoplasm  arising  from  the  degeneration  of  the  hepatic  cells,  are 
found  ;  these  nodules  are  due  to  microbic  embolism.  The  portal  spaces 
often  present  in  places  a  slight  degree  of  embryonic  infiltration. 

In  eleven  cases  the  presence  of  the  bacillus  of  Eberth  was  demon¬ 
strated  in  sections  of  the  hepatic  parenchyma,  and  positive  cultures  of 
the  bacillus  were  obtained  from  the  liver  tissue.  The  conclusion  is 
that  the  liver  probably  arrests  and  destroys  the  microbes  that  are  in¬ 
troduced  by  the  portal  vein,  that  it  arrests  about  half  of  the  toxic  sub¬ 
stances  contained  in  an  alcoholic  extract  made  with  typhoid  faecal  mat¬ 
ter,  and  that,  lastly,  it  seems  also  to  diminish  the  toxicity  of  the  soluble 
products  secreted  by  the  bacillus  of  Eberth. 

In  ordinary  typhoid  fever  there  are  no  direct  physical  signs  that 
allow  us  to  appreciate  the  anatomical  condition  of  the  liver,  or  the  de¬ 
gree  of  the  performance  of  its  functions.  It  is  by  indirect  symptoms, 
and,  above  all,  by  finding  urobilin  in  the  urine,  that  we  obtain  indications 
of  real  value. 

The  Cause  of  Haematemesis  in  Hepatic  Cirrhosis. — Dr.  Litten,  in 
the  Berl.  klin.  Woch.  of  February  3,  1890,  states  that  in  five  cases  of 
hepatic  cirrhosis  in  which  death  was  caused  by  vomiting  blood  it  was 
ascertained  that  the  source  of  the  haemorrhage  was  the  enormous  varices 
that  ruptured  in  the  inferior  portion  of  the  oesophagus.  Naturally  the 
oesophagus  is  richly  supplied  with  veins  of  which  the  superior  commu¬ 
nicate,  by  means  of  the  thyreoid  vein,  with  the  vena  cava  superior ; 
while  the  inferior  form  about  the  cardiac  extremity  a  large  plexus  that 
communicates  but  moderately  with  the  portal  vein,  and  empties  princi¬ 
pally  into  the  azygos  vein.  Consequently,  as  in  cirrhosis  of  the  liver 
the  portal  vein  becomes  impermeable,  its  blood  passes  in  great  part 
into  the  azygos  vein  that  conducts  it  direct  to  the  vena  cava  superior. 
This  is  particularly  the  case  with  the  blood  of  the  coronary  and  gastro¬ 
duodenal  veins.  As  a  result  of  the  azygos  vein  becoming  distended 
and  incapable  of  receiving  all  the  blood  of  the  oesophageal  plexus, 
there  is  a  formation  of  varices  with  consequent  rupture  simulating  gas- 
trorrhagia. 

The  Varieties  of  Hepatic  Tuberculosis.— Dr.  Hanot  and  Dr.  Gilbert, 
in  the  Archives  gen.  de  med.  for  November,  1890,  make  the  following 
divisions  of  tuberculosis  of  the  liver,  founded  on  the  existing  patho¬ 
logical  conditions :  1.  The  acute  form  is  a  fatty  hypertrophic  tubercu¬ 
losis  of  the  liver  resembling  a  fatty  hypertrophic  cirrhosis.  2.  The 
subacute  forms,  presenting  two  varieties :  a ,  atrophic  fatty  tuberculous 
hepatitis ;  b ,  nodular  parenchymatous  tuberculous  hepatitis.  3.  The 
chronic  forms  of  tuberculous  cirrhosis  and  of  fatty  degeneration. 

Such  distinctions,  of  course,  are  of  chief  value  in  making  necropsy 
reports. 

The  Cause  and  Treatment  of  Diabetic  Coma. — Dr.  Stadelmann,  in 
the  Deutsche  med.  Woch.,  No.  46,  1889,  states  that  he  has  found  cro- 
tonic  acid  in  the  urine  in  certain  cases  of  diabetes.  Minkowski  and 
Kiileg  believe  that  this  acid  results  from  the  decomposition  of  oxybu- 
tyric  acid,  which  should  also  form  acetic  acid.  It  is  on  these  data  that 
the  hypothesis  of  acid  intoxication  in  diabetic  coma  rests,  as  well  as  the 
reason  for  the  intravenous  alkaline  injections.  Of  eleven  cases  treated 
by  this  method  by  various  physicians,  only  one  patient  recovered,  though 
all  the  reporters  agree  on  the  temporary  amelioration  the  injections  pro¬ 
duce.  The  injection  is  made  by  dissolving  186  grammes  of  bicarbonate 
of  sodium  and  286  grammes  of  carbonate  of  sodium  in  four  litres  of 
distilled  water.  A  litre  to  a  litre  and  a  half  may  be  injected  in  the 
case  of  an  adult. 

The  author  prescribes  for  diabetics  large  doses  of  tartrate  of  sodium, 
as  much  as  forty-five  grammes  a  day  having  been  given  without  loss  of 
weight  or  diminution  of  appetite. 

True  diabetic  coma  threatens  those  only  that  have  oxybutyric  acid 
in  the  urine ;  diabetics  that  eliminate  more  than  1-1  gramme  of  am¬ 
monia  daily  run  great  danger,  while  those  eliminating  as  much  as  from 
two  to  six  grammes  are  threatened  by  coma.  When  the  perchloride  of 
.  iron  reaction  occurs  the  presence  of  oxybutyric  acid  is  affirmed,  though 
the  inverse  is  not  always  true.  When  diabetic  coma  is  feared,  a  rigor¬ 
ous  meat  diet  and  large  doses  of  alkalines  should  be  prescribed.  When 
coma  exists,  intravenous  injections  of  bicarbonate  of  sodium  should  be 


given  until  the  urine  becomes  alkaline  ;  the  subcutaneous  injections  of 
soda  should  not  be  practiced,  because  they  are  painful  and  incite  local 
suppuration. 

The  Principles  of  the  Treatment  of  Diabetes  Mellitus. — Dr.  F.  W. 

Pavy  publishes,  in  the  British  Medical  Journal  of  August  16th,  the 
paper  he  read  before  the  Berlin  International  Congress.  He  believes 
that  the  first  consideration  in  the  treatment  of  diabetes  is  to  control  by 
dietetic  measures  the  passage  of  sugar  through  the  system.  The  real 
point,  however,  to  be  aimed  at  is  to  restore  the  assimilative  power  over 
the  carbohydrate  elements  of  food;  and  until  this  has  been  accom¬ 
plished  it  can  not  be  said  that  a  cure  has  been  effected,  the  disease 
only  being  held  in  subjection  and  prevented,  as  long  as  the  condition 
can  be  maintained,  from  progressing  to  an  unfavorable  issue.  The 
maintenance  of  a  normal  state  of  the  system,  by  keeping  it  free  from 
the  passage  of  sugar  through  it,  conduces  most  to  the  restoration  of 
assimilative  power,  and  thus  a  healthy  condition  of  the  body  is  brought 
to  bear  to  help  promote  the  removal  of  the  faulty  state.  He  believes 
opium  and  its  alkaloids,  codeine  and  morphine,  are  the  medicinal 
agents  that  especially  assist  in  the  restoration  of  the  impaired  assimi¬ 
lative  power,  their  influence  being  particularly  noticeable  in  cases  in 
which  the  sugar  has  been  brought  down  to  a  certain  point,  but  not  en¬ 
tirely  removed  by  dieting  ;  these  drugs  will  then  completely  remove  the 
sugar.  The  quantitative  testing  of  sugar  in  the  urine  is  absolutely 
necessary,  not  only  to  regulate  the  treatment  according  to  the  progress 
made,  but  also  to  keep  a  check  upon  the  manner  in  which  the  direc¬ 
tions  given  are  being  carried  out. 

The  Pathogeny  of  Albuminuria  and  Nephritis. — At  a  recent  seance 
of  the  Academy  of  Medicine  of  Paris,  Dr.  Semmola  read  a  paper  in 
which  he  concluded,  according  to  Le  Mercredi  medical  of  July  30th, 
that — 

1.  The  degree  of  albuminuria  is  not  always  in  accord  with  the  in¬ 
tensity  of  the  morbid  renal  processes.  In  toxic  nephritis  produced  by 
agents  that  have  no  alterative  action  on  the  blood,  the  maximum  of 
renal  lesions  and  minimum  of  albuminuria  are  found,  while  in  toxic 
nephritis  of  mineral  origin,  in  general,  a  maximum  of  albuminuria  oc¬ 
curs  that  is  due  both  to  renal  lesions  and  a  dyscrasic  condition. 

2.  In  albuminuria  produced  by  the  injection  of  the  white  of  egg 
only  a  slight  epithelial  alteration  is  necessary.  It  becomes,  therefore, 
a  simple  phenomenon  of  depurative  elimination. 

3.  Such  albuminuria  is  no  less  than  a  functional  effort  to  which  the 
renal  apparatus  does  not  physiologically  tend,  for  in  the  normal  state 
the  albuminoids  received  by  alimentation  are  destined  to  supply  the  in- 
tra-organic  functions  and  not  to  be  eliminated. 

4.  The  eliminative  processes  produce  at  length  secondary  renal  al¬ 
terations  that  should  be  classed  with  toxic  nephritis,  properly  so  called, 
with  the  difference  that  in  the  latter  inflammatory  lesions  predominate, 
while  the  former  are  rather  degenerative. 

5.  The  albuminuria  of  Bright’s  disease  (always  characterized  by 
great  oscillations  in  the  quantity  of  albumin  excreted  at  different  hours 
of  the  day,  because  of  either  the  richness  of  alimentation  in  nitrogenous 
substances,  or  of  causes  that  escape  us)  should  be  classed  among  hamia- 
togenous  albuminurias,  because,  for  anatomical  and  clinical  reasons,  it 
would  be  impossible  to  conceive  of  such  rapid  and  frequent  changes,  in 
a  few  hours  only,  in  the  alteration  of  the  epithelium. 

Arsenite  of  Copper  in  Acute  Affections  of  the  Intestine. — Dr.  H. 
Schulz,  in  the  Deutsche  med.  Woch.,  No.  18,  commends  Aulde’s  treat¬ 
ment  of  acute  intestinal  diseases  by  arsenite  of  copper.  The  best  meth¬ 
od  of  administering  the  drug  is  by  frequently  repeated  fractional  doses, 
for  children  dissolving  one  one-hundredth  of  a  grain  in  four  to  six 
ounces  of  water,  and  giving  a  teaspoonful  of  the  solution  every  ten  to 
thirty  minutes.  It  is  especially  serviceable  in  recent  cases  before  in¬ 
flammation  of  neighboring  organs  commences  ;  and  he  has  employed  it 
in  severe  cases  of  epidemic  cholera,  cholera  morbus,  and  dysentery.  He 
believes  the  favorable  action  of  the  drug  is  due  to  an  energetic  stimu¬ 
lation  of  the  diseased  intestine,  and  a  consequently  conferred  capacity 
to  resist  the  pathogenic  micro-organisms. 

The  Results  of  the  Chronic  Abuse  of  Coffee. — Dr.  F.  Mendel,  in  the 
Berlin  klin.  Wocli.,  No.  40,  1889,  says  that  in  the  industrial  territory 
of  which  Essen  is  the  center  the  working  women  drink  coffee  from 
morning  to  night,  consuming  daily  for  each  individual  a  pound  or  more 


308 


MISCELLANY. 


[N.  Y.  Med.  Jotjr. 


of  Ceylon  coffee  containing  on  an  average  four  grammes  of  caffeine  to 
the  pound.  The  morbid  phenomena  caused  by  the  chronic  abuse  of 
coffee  are  of  three  kinds  : 

1.  Nervous  troubles.  A  feeling  of  general  weakness,  aversion  to 
work,  sadness,  cephalalgia,  and  insomnia.  All  these  symptoms  disap¬ 
pear  more  or  less  when  the  individual  has  taken  a  concentrated  infusion 
of  coffee. 

2.  Muscular  troubles.  A  greater  or  less  decrease  of  vigor  of  mo¬ 
tion  ;  no  more  incapacity  to  accomplish  the  coarser  domestic  labors 
than  to  do  fine  hand-work  ;  trembling  of  the  hands,  even  when  at  rest. 

3.  Circulatory  troubles.  Small,  accelerated,  irregular  pulse;  feeble 
beat  of  the  apex  of  the  heart ;  praecordial  distress  ;  palpitation.  Cold¬ 
ness  of  the  extremities,  appreciable  to  the  patients.  Yellowish-white 
visage,  and  anaemia  of  the  mucous  membranes.  Anorexia  is  frequent, 
and  there  is  nervous  dyspepsia  ;  a  sensation  of  pressure  and  of  fullness 
of  the  stomach,  nausea,  eructations,  cardialgia. 

Isaac  has  called  ( Berlin  klin.  Woch.,  No.  3,  1889)  attention  to  the 
tendency  to  acne  rosacea. 

The  treatment  is  to  stop  the  difficult  work  done  by  the  patient ;  to 
substitute  milk  for  coffee  ;  to  keep  in  the  open  air  ;  to  take  daily  cold 
baths  followed  by  energetic  friction  ;  and  cognac  in  small  doses. 

This  description  will  apply  equally  well  to  those  working  women  in 
America  who  use  tea  in  amounts  proportional  to  the  confinement  and 
physical  strain  incident  to  their  occupation.  The  treatment  would  be 
the  same,  and  can  probably  be  as  easily  adopted  by  working  women  in 
America  as  in  Germany. 


Jftisrdl  attg. 


Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub- 


lished  in  the  Abstract  of  Sanitary  Reports  for  September  5tli : 


CITIES. 

Week  ending — 

Estimated  popu¬ 
lation. 

Total  deaths  from 
all  causes. 

DEATHS 

FROM 

— 

• 

cS 

© 

© 

O 

0> 

> 

.V 

© 

i* 

M 

© 

I 

J1 

T3 

’© 

I 

> 

I 

> 

© 

> 

45 

CO 

3 

■a 

>. 

Eh 

It 

<U 

45 

u 

3 

a 

W 

© 

> 

3 

© 

s- 

8 

XII 

ei 

*E 

£ 

o, 

Q 

to 

© 

1 

© 

s 

bO 

.2  * 
g«  bO 
2  3 
»■©  8 

* 

New  York,  N.  Y.  ... 

Aug.  30. 

1,639,448 

716 

ii 

1 

20 

8 

8 

Chicago,  Ill . 

Aug.  30. 

1,100,000 

369 

IS 

1 

13 

1 

5 

Philadelphia,  Pa . 

Aug.  23. 

L064,277 

11 

3 

8 

9 

Baltimore,  Md . 

Aug.  30. 

500,343 

157 

8 

3 

5 

St.  Louis,  Mo . 

Aug.  30. 

450,000 

161 

4 

A 

Boston,  Mass . 

Aug.  30. 

437^245 

205 

f, 

10 

1 

New  Orleans,  La . 

Aug.  16. 

254^000 

1 

1 

New  Orleans,  La. . . . 

Aug.  23. 

251, C00 

112 

<■> 

1 

i 

Pittsburgh,  Pa . 

Aug.  23. 

240,000 

77 

8 

i 

9 

Detroit,  Mich . 

Aug.  23. 

230,000 

57 

3 

Louisville,  Ky . 

Aug.  23. 

2274100 

68 

5 

2 

Louisville,  Ky . 

Aug.  30. 

227,000 

53 

5 

4 

Milwaukee,  Wis . 

Aug.  29. 

220^000 

83 

*2 

8 

2 

Rochester,  N.  Y . 

Aug.  23. 

135,000 

48 

1 

l 

Rochester,  N.  Y . 

Aug.  30. 

135,000 

4L 

1 

Providence,  R.  1 . 

Aug.  30. 

132,000 

62 

• 

1 

2 

Indianapolis,  Ind.... 

Aug.  29. 

129,346 

28 

2 

o 

2 

Denver,  Col . 

Aug.  29. 

125,000 

50 

12 

2 

1 

Toledo,  Ohio . 

Aug.  29. 

81  i 650 

12 

Nashville,  Tenn . 

Aug.  30. 

75,695 

24 

Fall  River,  Mass . 

Aug.  30. 

74,918 

37 

1 

3 

Portland,  Me . 

Aug.  16. 

42,000 

19 

! 

1 

Portland,  Me . 

Aug.  30. 

42.000 

13 

1 

Galveston,  Texas  .... 

Aug.  8. 

40.000 

14 

1 

Newport,  R.  I . 

Aug.  28. 

20,000 

5 

Rock  Island,  Ill . 

Aug.  25. 

1G,000 

4 

Pensacola,  Fla . 

Aug.  23. 

15,000 

10 

1 

1 

Treatment  of  Typhoid  Fever  by  Cold  Baths. — “  M.  Debove,  in  a 
paper  read  at  the  last  session  of  the  Paris  Societe  Medicale  des  Hopi- 
taux  on  the  treatment  of  typhoid  fever  by  cold  baths,  declared  that  he 
had  not  been  convinced  by  a  recent  paper  of  M.  Merklen  that  this  was 
the  best  treatment.  His  own  mortality  during  the  last  six  years  was  11 
per  cent.,  or  during  the  last  two  years,  9-2  per  cent.  Now  M.  Merklen 
estimates  the  mortality  from  typhoid  in  Paris  hospitals  treated  by  cold 
baths  as  9'92  per  cent.  M.  Debove  does  not  prescribe  active  medica¬ 


tion,  but  believes  in  keeping  up  copious  diuresis.  To  this  end  he  sup¬ 
plies  his  typhoid  patients  with  abundance  of  liquid,  and  if  the  quantity 
of  urine  passed  does  not  appear  to  him  sufficient,  he  ‘  stimulates  the 
zeal  ’  of  the  attendants  to  get  the  patient  to  drink  more ;  the  total 
amount  of  fluid  which  should  be  taken  daily  ought,  he  says,  to  be  not 
less  than  five  or  six  quarts.  M.  Debove,  who  does  not  deny  the  good 
effects  of  baths,  suggests  that  they  are  probably  due  to  the  increased 
quantity  of  urine  secreted,  which,  as  in  the  case  where  diuresis  is  pro¬ 
duced  by  drinking,  carries  off  the  materies  morbi  from  the  system.  Ac¬ 
cording  to  M.  G6rin-Rose,  who  followed  M.  Debove,  still  more  success¬ 
ful  results  may  be  obtained  by  carrying  out  the  following  indications: 
(1)  To  produce  intestinal  antisepsis  by  means  of  naphthol  and  salicylate 
of  bismuth,  (2)  to  lower  the  fever  by  means  of  very  large  doses  of  qui¬ 
nine  and  warm  baths  (at  86°  F.),  and  (3)  to  keep  up  the  patient’s 
strength.  Of  forty-three  patients  treated  during  the  last  eighteen 
months  in  this  way,  only  one  died.” — Lancet. 


ANSWERS  TO  CORRESPONDENTS. 
No.  329. — We  think  you  are  wrong. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purjiose 

favoring  its  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles,  we  ahvays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (Jf  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  pit 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters ,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEYY  YORK  MEDICAL  JOURNAL,  September  20,  1890. 


futures  anb  r  c  s  s  t  s  ♦ 


CLINICAL  LECTURES 

ON  SOME  COMMONLY  OBSERVED  FORMS  OF 

PULMONARY  DISEASE. 

DELIVERED  AT 

THE  NEW  YORK  POST-GRADUATE  MEDICAL  SCHOOL. 

By  JAMES  K.  CROOK,  M.  D., 

INSTRUCTOR  IN  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS,  ETC. 

Lecture  IY. 

Acute  Pleurisy  with  Effusion  ;  Aspiration. — This  patient, 
gentlemen,  is  Mrs.  K.  W.,  aged  twenty-eight.  She  gives  a 
plain  and  suggestive  history,  the  symptoms  beginning  at  a 
very  recent  date.  As  you  see,  she  is  a  very  healthy-looking, 
robust  woman,  and  her  face  gives  no  indication  of  disease. 
She  informs  us  that  she  was  perfectly  well  until  about  four¬ 
teen  days  since,  when  she  was  seized  in  the  evening  with  a 
sharp,  catching  pain  in  the  left  side.  She  remembers  also 
that  she  had  very  cold,  chilly  sensations  for  an  hour  or  two 
before  the  pain  came  on,  but  just  afterward  she  had  high 
fever  and  perspired  freely  during  the  night.  The  pain  was 
much  modified  on  the  morning  following,  but  a  short,  dry 
cough  had  developed  during  the  night.  As  this  cough  con¬ 
tinued  and  the  pain  in  the  side  did  not  disappear  after  sev¬ 
eral  days,  she  deemed  it  advisable  to  see  a  physician,  and 
at  that  time  she  came  under  my  observation.  On  examina¬ 
tion  I  found  a  slight  exaltation  of  temperature — 100°  F. — 
and  a  pulse  of  92.  A  careful  physical  examination  yielded 
negative  results,  save  a  catching  respiration  and  a  limitation 
of  respiratory  movements  on  the  affected  side.  But  when 
the  patient  called  to  see  me  again,  after  a  further  interval  of 
four  days,  I  noticed  that  her  respirations  were  very  panting 
and  hurried,  and  she  informed  me  that  her  breathing  had 
been  getting  shorter  and  shorter  for  several  days  past.  An 
examination  then  disclosed  the  characteristic  physical  signs 
which  we  shall  find  so  well  marked  this  morning.  Her 
temperature  to-day  is  normal,  but  we  find  the  pulse-rate  to 
be  95  to  the  minute.  On  carefully  inspecting  the  chest, 
we  see  that  the  left  side  is  taking  but  little  part  in  the  re¬ 
spiratory  movements.  There  is  also  an  appearance  of  full¬ 
ness  on  that  side.  Palpation  shows  a  complete  absence  of 
vocal  fremitus  almost  from  the  left  clavicle  above  to  the 
bottom  of  the  chest  below.  I  can  feel  the  apex  of  the  heart 
a  little  to  the  right  of  the  sternum,  which  shows  a  displace¬ 
ment  of  at  least  three  inches.  Mensuration  shows  a  pre¬ 
ponderance  of  two  inches  of  the  left  side  over  the  right.  On 
percussion,  I  find  complete  flatness,  both  before  and  behind, 
all  over  the  left  side.  Even  over  the  clavicle  there  is  total 
absence  of  resonance.  When  I  apply  my  ear  to  the  chest 
I  find  a  complete  absence  of  the  respiratory  sounds.  The 
voice  sounds  are  distant  and  muffled.  The  physical  signs 
in  this  case  are  not  to  be  mistaken.  Our  patient  is  suffer¬ 
ing  from  acute  pleurisy,  with  an  enormous  effusion  into  the 
left  pleural  cavity.  If  we  could  have  seen  the  patient  dur¬ 
ing  the  first  twenty-four  hours  of  the  trouble,  we  should 
probably  have  heard  a  grazing  friction  sound  on  the  left 


side.  At  that  time  the  natural  moisture  of  the  inflamed 
portion  of  the  pleura  was  dried  up  and  the  vessels  were  en¬ 
larged  and  swollen.  The  visceral  and  parietal  layers  of  the 
membrane  then  coming  in  contact  and  rubbing  against  each 
other  would  produce  this  grazing  noise,  which  would  indi¬ 
cate  the  first  or  dry  stage  of  the  disease.  This  sound  dis¬ 
appears  as  soon  as  the  exudation  begins  to  form,  so  that  a 
physical  examination  during  the  second  or  third  day,  or 
before  the  fluid  accumulates  in  sufficient  quantity  to  be  rec¬ 
ognized,  is  apt  to  lead  to  rather  negative  results.  The  exu¬ 
dative  products  are  of  two  kinds — a  serous  fluid,  which 
gravitates  to  the  dependent  portions  of  the  cavity,  and  a 
plastic  or  fibrinous  material,  some  of  which  also  sinks  to  the 
bottom  of  the  pleural  cavity,  but  most  of  which  adheres  to 
the  pleura.  The  membrane,  both  above  and  below  the  level 
of  the  fluid,  is  sometimes  enormously  thickened  by  this 
means,  so  that  it  is  often  impossible  to  make  out  the  exact 
surface  line  of  the  effusion.  In  empyema  there  are  abun¬ 
dant  pus  cells  present.  The  fluid  in  this  case  has  continued 
to  increase  until  the  left  side  is  filled  as  high  up  as  the 
clavicle.  The  heart,  as  we  have  seen,  is  pushed  far  out  of 
its  place.  The  left  lung  is  crowded  to  the  upper  and  back 
part  of  the  chest  against  the  vertebral  column,  and  is  re¬ 
ceiving  very  little  if  any  air.  If  a  further  accumulation 
should  take  place,  the  other  lung  will  also  very  soon  become 
embarrassed  in  its  action  and  the  patient’s  condition  will 
become  greatly  aggravated.  If  the  fluid  should  remain  long 
in  the  chest,  the  lung  on  the  affected  side  will  become 
solidified  or  carnified,  as  it  is  termed,  and  will  be  rendered 
permanently  crippled.  The  heart  also  may  be  so  seriously 
interfered  with  as  to  threaten  the  life  of  the  patient.  Now, 
under  these  circumstances,  what  are  the  indications?  If 
the  amount  of  the  effusion  were  slight,  say  extending  up  to 
the  level  of  the  inferior  angle  of  the  scapula,  I  should  rely 
upon  Nature  to  remove  the  fluid  and  aid  it  by  means  of 
hydragogue  cathartics,  diuretics,  and  diaphoretics.  But  in 
cases  like  this,  where  the  effusion  is  considerable  in  amount, 
we  simply  waste  time  by  this  method  of  treatment.  I  have 
spoken  of  this  as  an  acute  case  because  it  is  of  recent  origin, 
but  it  will  inevitably  become  chronic  unless  we  take  active 
means  to  relieve  the  patient. 

In  my  opinion,  aspiration  or  the  operation  of  thora¬ 
centesis  should  be  performed  without  delay  in  all  such 
cases.  By  withdrawing  a  greater  part  of  the  fluid,  Nature 
will  in  many  cases  continue  the  process  and  the  remain¬ 
der  will  be  absorbed.  If  we  allow  it  to  remain,  we  ex¬ 
pose  our  patient  to  all  the  danger  and  distress  of  embar¬ 
rassed  breathing,  an  impeded  heart,  and  a  carnified  lung. 
At  the  same  time,  the  continued  presence  of  the  fluid  fa¬ 
vors  so  heavy  a  plastic  deposit  upon  the  pleural  surface  as 
:o  seriously  modify  or  destroy  its  absorptive  power.  It 
las  been  my  experience  that  aspiration  performed  within 
two  or  three  weeks  after  the  inception  of  the  disease  is  al¬ 
most  invariably  successful  and  requires  no  repetition ; 
whereas,  if  the  fluid  is  allowed  to  remain  longer,  the  opera- 
ion  must  be  repeated  two,  three,  or  perhaps  more  times, 
n  one  neglected  case  which  came  under  my  observation  in 
;be  summer  of  188V,  I  found  it  necessary  to  withdraw  the 


310 


BRIDDON:  LAPARO-COLOTOMY  FOR  STRICTURE  OF  THE  RECTUM.  [N.  Y.  Med.  Jqpb., 


fluid  on  seven  different  occasions.  We  will  now  proceed  to 
operate  in  this  case.  The  instrument  I  employ  is  a  Potain 
Pottle  aspirator.  There  are  as  many  as  twenty-five  or  thirty 
aspirators  in  use  constructed  on  the  same  principle,  but  I 
regard  this  as  one  of  the  best.  Having  bared  the  dorsal 
aspect  of  the  thorax,  I  direct  the  patient  to  sit  with  her  arms 
folded  in  front  of  the  body  in  a  slightly  stooping  position. 
In  cases  of  great  nervousness,  or  fright,  or  weak  heart,  it  is 
not  a  bad  plan  to  perform  the  operation  with  the  patient  in 
the  recumbent  posture  and  administer  an  ounce  or  two  of 
brandy  with  a  little  aromatic  spirit  of  ammonia  before¬ 
hand.  I  now  look  for  an  intercostal  space  below  the  angle 
of  the  scapula  on  the  left  side.  It  is  rather  difficult  to  find 
one  in  this  patient,  as  she  is  rather  stout  and  the  ribs  are  not 
widely  separated.  The  seventh,  being  the  first  and  usually 
the  most  prominent  interspace  below  the  scapula,  is  the  one 
I  usually  select,  and  into  this  I  shall  now  insert  the  needle. 
I  select  one  of  medium  size  for  this  purpose,  having  previ¬ 
ously  treated  it  with  carbolized  oil  and  passed  an  antiseptic 
solution  through  it.  I  now  press  the  forefinger  of  my  left 
hand  into  the  interspace  and  draw  the  skin  slightly  aside. 
This  leaves  the  skin  somewhat  tense,  and  when  the  needle 
is  withdrawn  a  valvular  puncture  will  remain  which  abso¬ 
lutely  excludes  all  air.  I  now  introduce  the  needle,  being 
careful  to  keep  it  in  the  middle  of  the  interspace  and  particu¬ 
larly  avoiding  the  lower  margin  of  the  upper  rib  for  fear  of 
wounding  the  intercostal  artery.  Having  passed  the  needle 
in  to  the  depth  of  an  inch  and  a  half,  I  pump  the  air  from 
the  receiving  bottle  and  turn  the  stopcock.  There  is  an 
immediate  flow  of  fluid  which,  as  you  see,  is  of  an  amber 
or  straw  color  and  not  turbid.  Having  positively  demon¬ 
strated  the  presence  of  an  effusion,  we  are  justified  in  push¬ 
ing  the  needle  to  a  greater  depth  if  required,  as  the  heart 
and  left  lung  are  displaced  far  out  of  harm’s  reach.  This 
fluid  confirms  our  diagnosis  of  simple  fibro-serous  pleurisy. 
If  it  were  purulent  it  would  be  more  viscid  and  cloudy.  I 
allow  it  to  flow  away  until  three  bottlefuls,  almost  three 
quarts,  are  discharged.  As  the  patient  is  now  beginning  to 
feel  a  sensation  of  tightness  or  constriction,  I  desist.  This 
should  invariably  be  done  as  soon  as  such  symptoms  appear. 
Other  warning  events  are  the  occurrence  of  coughing,  cold¬ 
ness  of  the  extremities,  shortness  of  breath,  or  a  weakening 
of  the  pulse.  We  are  advised  by  the  text-books  that  pa¬ 
tients  should  always  lie  in  bed  for  twenty-four  hours  after 
the  operation.  This  can  certainly  do  no  harm,  but  I  do 
not  regard  it  as  necessary  or  even  desirable,  unless  the  pa¬ 
tient  is  in  a  very  weak  and  run-down  condition.  I  have  fre¬ 
quently  aspirated  patients  at  the  clinics  and  in  my  office 
and  allowed  them  to  walk  or  ride  to  their  homes  just  after¬ 
ward  without  the  occurrence  of  any  harmful  manifestations. 
The  dangers  from  aspiration  of  the  thorax  have  been  greatly 
magnified  in  the  past.  No  doubt  more  or  less  harm  has 
been  done  by  means  of  the  old-fashioned  trocar  and  can¬ 
nula,  but  I  consider  the  danger  in  the  use  of  such  an  instru¬ 
ment  as  we  have  here  to  be  almost  infinitesimal.  The  fluid 
is  withdrawn  slowly  enough  to  allow  the  viscera  which 
have  been  displaced  to  approach  their  normal  positions 
gradually  and  without  shock.  A  considerable  time  must 
elapse  after  the  operation  before  there  is  a  complete  reposi¬ 


tion.  This  slow  withdrawal  also  obviates  to  a  great  extent 
the  oedema  of  the  lungs  and  syncope  which  have  been  ob¬ 
served  under  the  use  of  the  trocar  and  cannula.  The  after- 
treatment  in  this  case  will  consist  simply  in  the  observance 
of  careful  dietetic  and  hygienic  rules,  with  the  administra¬ 
tion  of  a  little  digitalis  and  acetate  of  potassium  to  stimulate 
the  heart’s  action  and  promote  free  diuresis.  It  is  entirely 
probable  that  the  small  quantity  of  fluid  remaining  will  be 
absorbed  in  a  week  or  two.  Owing  to  the  plastic  thicken¬ 
ing  of  the  upper  part  of  the  pleura,  considerable  dullness 
still  remains,  but  by  forcible  percussion  I  find  some  reso¬ 
nance,  and  by  auscultation  a  modified  respiratory  murmur  as 
low  down  as  the  sixth  rib  behind.  If  we  find  after  a  week 
or  two  that  the  fluid  is  reaccumulating,  we  will  withdraw  it 

ao-ain.  This  will  not  have  to  be  done  more  than  once  or 
© 

twice  at  the  outside. 

Bibliographical. — In  reviewing  the  subjects  of  the  fore¬ 
going  lectures,  the  author  would  express  his  indebtedness 
to  the  works  of  Biermer,  Burt,  Chew,  Davis,  Donaldson, 
Fagge,  Flint,  Fraentzel,  Gebhart,  Hertz,  Hirt,  Laennec, 
Leyden,  Loomis,  Niemeyer,  Nothnagel,  Pepper,  Salter, 
Traube,  von  Ziemssen,  Waldenburg,  Waters,  Weber,  and 
Zimmermanu. 


(irtghml  Cffmmmrimttons. 


LAPARO-COLOTOMY 
FOR  STRICTURE  OF  THE  RECTUM.* 

By  CHARLES  K.  BRIDDON,  M.  D., 

SURGEON  TO  THE  PRESBYTERIAN  HOSPITAL,  NEW  YORK. 

Opening  the  colon  for  obstruction  occurring  in  the 
lower  bowel,  though  proposed  a  century  and  a  half  ago, 
has  only  been  done  on  a  large  scale  during  the  last  thirty 
or  forty  years,  and  it  is  not  improbable  that  even  now  it 
would  be  resorted  to  much  more  frequently  if  it  were  not 
that  many  surgeons  are  deterred  from  doing  it  on  account 
of  the  great  mortality  as  presented  in  the  comprehensive 
statistics  of  Batt,  Erckelen,  and  others.  Of  course,  it  ought 
to  be  taken  into  account  that  such  records  include  numer¬ 
ous  cases  in  which  the  operation  was  done  before  abdomi¬ 
nal  surgery  had  attained  to  its  present  position,  and  many 
other  cases  too  far  advanced  to  be  aided  by  intervention  of 
any  kind.  I  think  I  am  not  singular  in  the  opinion  that 
no  such  results  follow  operations  done  at  the  present  time. 

I  believe  it  is  recognized  by  all  practical  surgeons  that 
to  derive  the  full  benefit  from  such  interference  the  operation 
must  be  done  early,  not  as  a  last  resort  to  stave  off  a  present 
or  impending  obstruction,  but  as  a  curative  measure ;  it  is 
now  no  longer  a  debatable  question  whether  an  early  coloto- 
my  retards  the  growth  of  cancer  or  the  no  less  clinically 
malignant  cases  of  spreading,  intractable  ulcerations  that 
have  so  long  been  attributed  to  syphilis,  but  which  are  in  no 
wise  influenced  by  treatment  directed  against  that  dyscrasia. 
I  think  it  is  conceded  that  the  operation  does  exercise  such 


*  Read  before  the  New  York  Surgical  Society,  May  14,  1890. 


311 


Sept.  20,  1890.]  BRIDDON:  LAPARO-COLOTOMY  FOR  STRICTURE  OF  THE  RECTUM. 


influence,  that  it  is  of  incalculable  advantage  in  putting  the 
parts  at  rest  and  relieving  the  unceasing  misery  of  tormina 
and  tenesmus  that  nothing  can  assuage;  but  to  obtain  the 
full  measure  of  such  results  it  must  he  done  when  the  first 
symptoms  of  obstruction  manifest  themselves.  I  regard 
the  danger  to  life  when  the  operation  is  done  thus  early  as 
almost  nil,  and  know  of  no  surgical  procedure  that  affords 
such  marked  relief.  Some  have  objected  that  it  is  not  a 
radical  measure ;  that  it  is  only  palliative  and  does  not  cure. 
To  those  I  would  refer  the  cases  that  I  have  reported  where 
patients  were  snatched  from  inevitable  death  by  obstruction 
from  inoperable  cancer,  and  to  one  case  where  the  patient 
survived  an  operation  done  under  such  circumstances  for  a 
period  of  two  years;  to  other  cases  where  patients  worn 
out  by  years  of  suffering  from  ulceration  and  contraction 
were  restored,  and  are  now  living  in  the  enjoyment  of  ap¬ 
parently  perfect  health. 

I  should  not  like  it  to  be  considered  that  I  object  to  the 
extirpation  of  the  disease.  I  believe  that  it  should  always 
be  done,  providing  we  can  get  beyond  the  limits  of  the  dis¬ 
ease,  even  if  it  be  necessary  to  perform  the  operation  of 
Kraske  to  insure  the  removal  of  the  whole ;  but  I  believe 
that  an  artificial  opening  in  the  loin  or  groin  should  be  a 
preliminary  step;  that  colotomy  should  precede  proctectomy. 

In  the  Medical  Record ,  December  28,  1878,  I  published 
a  short  series  of  cases  of  lumbar  colotomy,  and  I  was  so  well 
satisfied  with  the  results  of  those  operations  that  I  continued 
to  practice  it  until  two  or  three  years  ago,  when  I  witnessed 
some  anterior  operations  done  by  my  colleague,  Dr.  Lange, 
and  I  was  so  impressed  with  the  advantages  of  the  method, 
which  I  understood  him  to  say  originated  with  Yerneuil, 
that  I  have  since  restricted  myself  to  that  operation,  and 
the  six  cases  reported  in  this  paper  occurred  in  less  than  a 
year’s  practice  in  the  Presbyterian  Hospital  of  this  city. 

The  objects  and  modifications  in  the  operation  about  to 
be  described  are  to  prevent  the  passage  of  faeces  from  the 
upper  to  the  lower  opening  of  the  gut,  and  troublesome 
prolapse,  both  of  which  annoyances  have  followed  the  or¬ 
dinary  operation.  Madelung’s  operation  was  devised  to 
prevent  the  contents  of  the  alimentary  canal  passing  from 
above  to  the  bowdl  below.  He  cuts  the  bowel  entirely  across, 
stitches  the  upper  end  of  the  divided  intestine  to  the  skin, 
thus  establishing  an  artificial  anus  ;  he  then  invaginates  and 
sutures  the  cut  end  of  the  lower  segment,  dropping  it  into 
the  abdominal  cavity.  The  objection  to  this  is  that  the  gut 
below  frequently  becomes  filled  with  its  own  secretion,  and 
if  the  original  obstruction  is  a  tight  one,  the  patient  will 
suffer  at  times  from  colicky  pains,  which  would  be  mitigated 
if  that  portion  of  the  canal  communicated  with  the  opening 
in  the  abdominal  wall.  Then,  again,  in  the  after-treatment  of 
such  cases  it  may  be,  and  I  think  always  is,  judicious  to  dis¬ 
infect  the  seat  of  disease  from  below  or  above,  and  I  have 
been  well  pleased  with  the  use  of  a  half-  or  one-per-cent, 
solution  of  creolin  for  such  purposes,  continued  daily  for  a 
long  time.  I  am  inclined  to  think  that  in  many  cases  of 
cancer,  irrigation  with  disinfectants  not  only  adds  to  the 
comfort,  but  prolongs  the  life  of  the  patient,  and  I  think 
they  are  equally  beneficial  in  the  badly  ulcerated  syphilitic 
cases. 


With  the  same  object  in  view,  Herbert  Allingham  makes 
an  incision  two  inches  in  length  and  an  inch  inside  the  an¬ 
terior  superior  spine  of  the  ilium,  and  parallel  with  Pou- 
part’s  ligament;  the  divided  peritoneum  is  then  sutured  to 
the  skin.  The  sigmoid  flexure  is  pulled  to  the  surface,  a 
piece  with  a  long  mesentery  is  then  fixed  upon,  and  a 
needle  carrying  carbolized  silk  is  passed  through  the  mes¬ 
entery  close  to  the  intestine  and  secured  to  the  abdominal 
wall  on  both  sides.  The  bowel,  being  slung  over  the  silk 
thread,  is  then  sutured  to  the  opening  in  the  parietal  wall, 
and  it  is  not  opened  until  two  or  three  days  after. 

To  prevent  prolapse  of  the  bowel,  Harrison  Cripps, 
F.  R.  C.  S.,  in  a  very  able  article  on  Inguinal  versus  Lumbar 
Colotomy  ( Brit .  Med.  Jour.,  April  6,  1889),  proposes  to 
select  a  portion  of  the  gut  with  a  meso  only  long  enough 
to  allow  it  to  be  brought  into  easy  contact  with  the  abdomi¬ 
nal  walls.  He  also  makes  his  incision  in  the  linea  semi¬ 
lunaris,  the  advantage  of  which,  I  think,  is  doubtful. 

I  do  not  think  it  a  matter  of  great  importance  whether 
the  incision  in  the  abdominal  wall  is  made  through  the 
muscular  structures  or  through  the  aponeuroses  along  tne 
outer  border  of  the  rectus,  providing  that  it  be  not  made 
too  long.  I  believe  that  large  incisions  are  not  necessary 
for  the  free  exit  of  excreta,  and  that  they  favor  hernial 
protrusions  of  the  small  intestine  into  a  sac  formed  out  of 
the  colon,  and  projecting  it  through  the  opening  in  the 
parietes. 

I  make  my  incision  two  inches  long,  an  inch  above 
and  parallel  with  the  outer  third  of  Poupart’s  ligament, 
through  the  skin  and  muscular  tissues,  and  an  inch  and  a 
quarter  to  an  inch  and  a  half  through  the  serous  membrane. 
Making  the  incision  through  muscle  and  skin  larger  than 
that  through  the  peritonaeum  very  much  facilitates  the 
introduction  of  sutures  in  the  later  steps  of  the  operation. 
A  finger  introduced  into  the  wouud,  directly  down  to  the 
iliac  bone  and  then  directed  inward,  immediately  comes  in 
contact  with  the  large  intestine,  which  is  drawn  into  the 
wound  and  recognized  at  once  by  the  bands  and  glandulae 
epiploicae.  At  this  point  it  will  be  proper  to  select  a 
portion  of  the  gut  that  has  a  -mesentery  that  will  permit 
its  approximation  to  the  abdominal  wall  without  such 
traction  as  would  endanger  the  sutures  in  the  event  of 
meteorism  or  vomiting  occurring  subsequent  to  the  opera¬ 
tion.  This  is  ascertained  by  pulling  on  the  knuckle  that 
presents  and,  if  the  meso  is  too  long,  passing  it  onward, 
between  the  forefingers  and  thumbs  from  above  down¬ 
ward,  drawing  out  the  proximal  and  returning  the  distal 
end,  until  a  portion  is  arrived  at  where  the  mesenteric  at¬ 
tachment  is  judged  to  be  sufficient  to  prevent  prolapse. 

A  noose  of  disinfected  silk  is  now  passed  through  the 
meso  at  its  junction  with  the  gut,  and  sufficient  traction  is 
made  upon  this  to  bring  the  two  columns  of  intestine  form¬ 
ing  the  knuckle  parallel,  and  maintaining  such  relationship 
permanent,  for  the  length  of  an  inch  or  an  inch  and  a 
quarter,  by  the  introduction  of  a  single  or  double  row  of 
Lembert  sutures  on  either  side  of  the  mesentery.  In  the 
application  of  these  sutures  it  is  wise  to  avoid  the  very 
numerous  small  vessels  that  bleed  freely  when  punctured. 

The  next  st6p  is  to  suture  the  parietal  to  the  visceral 


312 


BRIDDON:  LAPARO-COLOTOMY  FOR  STRICTURE  OF  THE  RECTUM.  [N.  Y.  Med.  Jotje., 


peritonaeum,  and  it  is  well  to  use  two  thirds  of  the  opening 
for  the  proximal  and  one  third  for  the  distal  opening  of  the 
gut.  This  line  of  suture  will  be  oblique,  leading  from  the 
point  where  the  mesentery  is  transfixed  by  the  temporary 
ligature  around  the  side  and  crossing  the  gut  about  an  inch 
on  either  side  of  the  point  where  the  contemplated  section 
is  to  be  made.  The  introduction  of  these  sutures  will  be 
facilitated  by  using  small  tenacula  to  lift  the  peritonaeum 
and  hold  it  in  relation  with  the  gut  while  the  sutures  are 
introduced  with  Hagedorn’s  fine  curved  intestine  needle. 

The  gut  must  now  be  divided  transversely;  the  section 
must  involve  the  whole  lumen  of  the  canal,  except  a  very 
narrow  strip  at  the  point  of  attachment  of  the  mesentery. 
When  this  is  done,  the  parts  are  well  irrigated,  the  tem¬ 
porary  ligature  is  removed,  and  the  margins  of  the  incision 
are  united  to  the  skin. 

Even  with  all  these  precautions,  the  two  ends  of  the 
bowel  terminating  on  the  surface  and  attached  to  each 
other  in  parallel  lines  below  the  surface,  it  does  happen,  in 
some  way  inexplicable  to  me,  that  a  portion  of  the  contents 
from  above  will  pass  into  the  gut  below  for  a  few  weeks, 
but  after  that  time  I  think  it  may  be  predicted  that  every¬ 
thing  will  come  through  the  artificial  opening. 

The  operation  described  above  is  only  applicable  to 
cases  where  the  obstruction  is  not  complete.  Its  perform¬ 
ance  requires  the  introduction  of  twenty  or  thirty  Lembert 
end  several  superficial  sutures.  They  are  not  easily  applied, 
and  the  operation  is  a  long  one.  Indeed,  I  have  very  strong 
doubts  whether  it  is  not  best  to  do  the  operation  in  the 
loin  in  those  cases  where  the  obstruction  is  complete  and 
has  lasted  several  days.  In  such  cases  there  is  frequently 
very  great  abdominal  distention,  and,  if  an  anterior  oper¬ 
ation  were  selected,  it  might  be  difficult  to  prevent  infec¬ 
tion  of  the  peritonaeum.  There  is  the  advantage  of  doing 
the  lumbar  operation  when  the  colon  is  distended  that  it 
is  easily  performed,  and  that  the  peritoneal  investment  is 
out  of  the  way. 

In  the  only  two  cases  in  which  I  have  operated  for  com¬ 
plete  obstruction  due  to  stricture  of  the  rectum  the  advan¬ 
tages  of  the  loin  operation  were  manifest.  The  first,  occurring 
in  the  practice  of  Dr.  Hunt,  of  Cornish  Flats,  and  reported 
by  him  in  the  Medical  Record ,  1878,  was  for  obstruction 
lasting  twelve  days,  due  to  inoperable  cancer.  The  lumbar 
operation  was  done,  the  relief  was  prompt,  and  the  patient 
lived  and  was  quite  comfortable  for  two  years  after. 

The  other  case  was  the  last  reported  in  the  present  series, 
also  for  cancer,  out  of  the  reach  of  the  knife  by  any  other 
operation  than  the  one  recommended  by  Kraske.  Com¬ 
plete  obstruction  had  lasted  two  weeks,  the  abdomen  was 
enormously  distended,  and  the  patient’s  condition  was  very 
bad.  The  indications  were  for  a  rapid  operation.  The  anterior 
operation  was  done,  no  attempt  at  the  formation  of  a  spur 
was  made,  the  intestine  was  approximated  to  the  abdominal 
wall  by  a  few  sutures,  and  an  incision  gave  exit  to  a  very 
large  amount  of  fluid  faeces.  The  patien  t  died  in  a  few  hours 
from  shock,  and  the  autopsy  revealed  no  traces  of  peritoneal 
infection. 

Case  I  ( Reported  by  Dr.  David  M.  Marvin).  Carcinoma 
of  the  Rectum  ;  Laparo-colotomy  ;  Recovery. — Thomas  C.,  aged 


forty-nine,  single,  native  of  Ireland,  occupation  laborer,  admit¬ 
ted  to  service  of  Dr.  Briddon,  Presbyterian  Hospital,  October 
10,  1888. 

Family  history  negative;  has  had  rheumatism;  has  been  in¬ 
temperate,  and  uses  alcohol  freely ;  denies  any  syphilitic  taint. 
For  five  months  previous  to  admission,  complained  of  diarrhoea, 
tenesmus,  and  pain  in  the  rectum ;  stools  small,  containing  nui- 
cus  and  blood;  no  abdominal  pain  or  stomach  disturbance; 
has  frequent  micturition,  and  has  lost  flesh  and  strength.  On 
admission,  is  emaciated  and  anjemic ;  skin  dusky,  almost  ic¬ 
teric;  liver  diminished  in  size;  organs  are  otherwise  negative. 
Rectal  examination  reveals  a  tumor  of  the  size  of  a  hen’s  egg  in¬ 
volving  the  anterior  wall  of  the  rectum,  two  inches  above  exter¬ 
nal  sphincter  ;  also  an  annular  growth  at  same  level  extending 
higher  than  the  finger  can  reach  ;  the  new  growth  is  indurated 
and  tender  on  pressure,  and  extends  into  lumen  of  gut,  though 
the  finger  passes  through  it  readily. 

October  21},  1888. — Patient  submitted  to  operation  of  coloto- 
my ;  no  pain  or  elevation  of  temperature  followed.  Bowels 
moved  from  both  the  natural  and  artificial  outlet  on  the  day 
following  the  operation.  Rectum  washed  out  daily  with  one- 
per-cent.  solution  of  creolin  ;  sutures  removed  at  the  end  of  the 
first  week  ;  primary  union. 

During  December  patient  experienced  much  difficulty  in 
urinating;  stream  was  retarded  and  attended  with  pain  and  te¬ 
nesmus  ;  fmcal  matter  passes  through  both  openings. 

In  January  patient  decidedly  improved;  the  trouble  in  urin¬ 
ating  had  ceased,  and  all  the  faeces  passed  through  the  artificial 
opening;  blood  and  mucus  occasionally  discharged  from  the 
anus  ;  odor  controlled  by  the  enemata  of  creolin. 

March  19th. — He  left  the  hospital  very  much  improved  phys¬ 
ically. 

Case  II  ( Reported  by  Dr.  David  M.  Marvin).  Carcinoma 
of  the  Rectum ;  Laparo-colotomy ;  Recovery. — Carl  K.,  aged 
fifty-three  years,  born  in  Germany,  cigar  maker,  married,  en¬ 
tered  Presbyterian  Hospital,  service  of  Dr.  Briddon,  January  8, 
1889. 

Family  history  negative ;  uses  alcohol  moderately  ;  denies 
syphilis;  has  suffered  during  the  past  year  from  what  has  been 
supposed  to  be  piles ;  has  complained  a  good  deal  of  pain  of  a 
very  severe  and  continuous  character ;  stools  mucoid  and  bloody. 
Has  been  steadily  losing  flesh  and  strength  ;  patient  is  anaemic, 
cachectic,  and  much  emaciated.  Rectal  examination  reveals  an 
ulcerated  annular  growth  two  inches  above  the  anus,  indurated, 
and  fixed  immovable  to  adjacent  organs;  it  extends  beyond  the 
reach  of  the  finger. 

January  31,  1889. — Patient  was  submmitted  to  the  opera¬ 
tion  of  colotomy.  Recovery  from  operation  uneventful ;  bowels 
acted  daily,  everything  passing  through  the  artificial  opening; 
he  was  shortly  afterward  removed  from  the  hospital,  and  event¬ 
ually  died  in  his  own  home.  , 

Case  III  ( Reported  by  Dr.  David  M.  Marvin).  Syphilitic 
Stricture  of  the  Rectum  ;  Laparo-colotomy  ;  Recovery. — Mary 
F.,  aged  thirty-one,  native  of  United  States,  married,  house¬ 
wife,  entered  Presbyterian  Hospital,  service  of  Dr.  Briddon, 
January  14,  1889.  Patient  gives  no  alcoholic,  tubercular,  or 
rheumatic  history,  but  a  decided  one  of  syphilis. 

About  nine  years  ago  she  commenced  to  use  purgatives  for 
gradually  increasing  constipation,  and  they  became  less  and  less 
efficient.  Three  years  ago  and  twice  since  was  operated  on  for 
stricture  of  the  rectum,  but  each  time  with  only  temporary  re¬ 
lief.  She  suffers  severely  from  ever-present  pain,  tenesmus, 
and  constipation,  and  has  a  constant  purulent  discharge  from 
the  anus.  The  lower  four  inches  of  the  rectum  is  occupied  by 
a  continuous  ulcerated  surface — irregular,  somewhat  funnel- 
shaped,  and  the  examining  finger  can  not  pass  beyond  it. 


Sept.  20,  1890.]  BRIDDON:  LAPARO-GOLOTOMY  FOR  STRICTURE  OF  THE  RECTUM. 


313 


In  view  of  the  fact  that  long-continued  intelligent  treatment, 
including  incision  of  the  stricture,  and  on  a  subsequent  occa¬ 
sion  proctotomy,  had  done  no  good,  the  patient  was  advised  to 
submit  to  an  operation  for  artificial  anus,  and  that  operation 
was  done  on  January  19,  1889.  The  recovery  after  the  opera¬ 
tion  was  uneventful;  bowels  moved  daily  after  the  third  day; 
temperature  ranged  from  99°  to  100°  F.  till  the  bowels  moved, 
when  it  fell  to  normal  and  remained  there.  The  lower  bowel  was 
washed  out  daily  with  a  one-per-cent,  solution  of  creolin.  On 
February  5th  the  patient  left  the  hospital  in  apparently  perfect 
health,  and  suffering  very  little  if  any  inconvenience  from  the 
artificial  anus. 

Case  IV  ( Reported  by  Dr.  David  M.  Marvin).  Syphilitic 
Stricture  of  the  Rectum  ;  Laparo-colotomy  ;  Recovery. — Mary 
M.,  aged  thirty-three,  married,  born  in  United  States,  housewife, 
was  admitted  to  service  of  Dr.  Briddon,  Presbyterian  Hospital, 
on  March  4,  1889. 

The  patient  gives  no  alcoholic  history.  Six  years  ago  she 
had  an  acute  articular  rheumatism.  At  the  age  of  fifteen  years 
she  contracted  syphilis  from  her  husband.  For  the  past  ten 
years  constipation  has  been  her  chief  trouble,  defecation  being 
attended  with  great  difficulty  and  pain,  added  to  which  she  has 
a  constant  wearing  pain  in  the  left  iliac  fossa.  Latterly  she  has 
ceased  to  have  control  over  her  bowels,  and  has  a  discharge  from 
the  anus  muco-purulent  in  character. 

On  admission,  she  was  found  poorly  nourished  and  anaemic. 
Temperature  100°  F.,  pulse  slightly  accelerated,  urine  negative. 
There  are  some  cutaneous  tabs  around  the  anus.  A  very  tight 
stricture,  which  will  admit  only  the  little  finger  with  difficulty ; 
its  upper  limit  can  not  be  felt.  Per  vaginam  the  greatly  thick¬ 
ened  walls  of  the  rectum  can  he  felt,  l'eaching  up  to  the  limit 
of  the  posterior  fornix.  The  uterus  and,  in  fact,  all  the  pelvic 
organs  are  found  matted  together.  In  the  upper  part  of  the 
posterior  vaginal  wall  is  a  fistula  communicating  with  the  rec¬ 
tum  and  permitting  the  passage  of  faeces. 

On  March  9,  1889,  submitted  to  the  operation  of  colotomy. 
Her  bowels  acted  on  the  fourth  day.  Primary  union  obtained. 
Everything  passed  through  the  artificial  outlet.  The  lower 
bowel  was  irrigated  with  creolin  daily,  her  recto-vaginal  fistula 
ceased  giving  her  any  trouble,  she  gained  remakably  in  health 
and  strength,  and  left  the  hospital  cured  on  March  22d. 

Case  V  ( Reported  by  Dr.  Henry  L.  Shively).  Stricture  of 
the  Rectum  ;  Laparo-colotomy;  Recovery.  Service  of  Dr.  Brid¬ 
don. —  Maggie  L.,  aged  thirty-one,  United  States,  married, 
housewife.  Her  father  died  of  Bright’s  disease ;  otherwise 
there  is  no  morbid  family  history.  She  had  one  child  twelve 
years  ago;  following  her  labor  she  developed  puerperal  fever, 
and  was  confined  to  her  bed  for  a  period  of  three  months.  Seven 
years  ago  she  underwent  an  operation  for  fistula  in  ano,  and, 
three  years  later,  a  second  operation  for  ischio-rectal  abscess. 
The  first  symptoms  of  her  present  trouble  developed  a  few 
weeks  before  the  appearance  of  this  abscess.  She  suffered  from 
obstinate  constipation,  and  there  had  been  a  progressive  loss  of 
flesh  and  strength.  At  times  she  suffers  severely  from  shooting 
pains  in  the  rectum,  and  obscure  abdominal  pain.  Menstruation 
has  always  been  regular. 

On  admission,  the  patient  is  very  poorly  nourished  and  anai- 
mic.  Urine  contains  a  trace  of  albumin,  granular  and  hyaline 
casts.  On  digital  exploration  of  the  rectum,  there  is  detected  a 
firm  annular  stricture,  which,  just  admitting  the  index  finger, 
extends  upward  and  beyond  reach  ;  the  walls  are  very  much  in¬ 
filtrated,  and  the  whole  surface  is  ulcerated.  The  futility  of 
palliative  treatment  having  been  demonstrated  by  the  long-con¬ 
tinued  ineffectual  use  of  bougies,  the  patient  seeks  relief  by 
the  operation  of  colotomy,  which  was  done  on  October  11, 1889. 
The  history  afterward  was  uneventful ;  she  had  no  elevation  of 


temperature,  had  a  few  movements  from  the  natural  outlet, 
and  then  everything  passed  through  the  artificial  opening.  The 
relief  was  marked  and  prompt.  She  at  once  began  to  pick  up 
health  and  strength,  and  was  discharged  cured  on  November 
13th. 

Case  VI  ( Reported  by  Dr.  Franlc  Le  Moyne  Hupp).  Laparo- 
colotomy  for  Complete  Obstruction  of  Fourteen  Days'  Standing , 
due  to  Cancer  of  the  Rectum ;  Death  in  a  Few  Hours  from 
Shock;  History. — Samuel  I.,  aged  fifty-five,  baker,  family  his¬ 
tory  of  no  interest ;  no  rheumatic,  malarial,  nephritic,  or  syphi¬ 
litic  history  ;  there  is  a  mild  alcoholic  habit.  Admitted  to  the 
medical  wards  of  the  Presbyterian  Hospital  on  December  2, 
1889,  giving  the  following  history  :  Two  weeks  previous  to  ad¬ 
mission  he  was  seized  with  general  abdominal  pain ;  its  onset 
was  sudden,  and  its  character  was  sharp  and  shooting.  Except 
one  small  unsatisfactory  motion,  the  bowels  have  been  obsti¬ 
nately  closed  since  the  first  appearance  of  the  pain.  He  has 
also  been  greatly  troubled  with  vomiting. 

On  admission — temperature,  99-5° ;  pulse,  120 ;  patient  is 
fairly  nourished,  but  anaemic ;  face  is  pale,  and  expression  be¬ 
tokens  anxiety.  Tongue  is  coated.  Abdomen  markedly  tense 
and  enlarged,  tender  on  palpation.  In  the  right  inguinal  region 
there  is  more  decided  resistance  to  the  touch  ;  an  elongated 
mass  is  felt,  dull  on  percussion.  In  the  middle  and  upper  part 
of  the  abdomen  a  tympanitic  note  is  obtainable  ;  in  the  left  in¬ 
guinal  region  there  is  dullness,  but  the  bulging  is  less  marked 
than  on  the  right  side.  Says  that  more  than  a  year  ago  he  ex¬ 
perienced  a  similar  but  much  less  severe  attack. 

A  rectal  examination  reveals  an  annular  constriction  about 
a  finger’s  length  above  the  external  sphincter  ;  it  apparently  oc¬ 
cludes  the  lumen  of  the  gut ;  there  are  several  pedunculated 
growths  growing  upon  its  under  surface. 

December  5th. — Patient  is  transferred  to  the  surgical  divis¬ 
ion,  service  of  Dr.  Briddon,  and  immediately  prepared  for  opera¬ 
tion  at  3  p.  m.  Ether  narcosis:  an  incision  was  made  an  inch 
above  and  parallel  with  the  outer  third  of  Pou part’s  ligament, 
two  inches  in  length ;  incision  in  peritonaeum,  an  inch  and  a 
half;  patient’s  condition  was  critical ;  no  attempt  was  made  at 
the  formation  of  a  spur;  the  colon  immediately  came  into  view, 
as  recognized  by  longitudinal  bands  and  appendices  epiploicae. 
It  was  drawn  out,  attached  to  the  opening  in  the  abdominal 
wall  by  a  few  sutures,  and  an  opening  was  at  once  made,  giving 
exit  to  a  large  quantity  of  fluid  faeces  and  a  considerable  quan¬ 
tity  of  gas ;  when  this  ceased,  the  cut  edge  of  the  colon  was 
secured  to  the  skin,  when  a  second  and  more  profuse  discharge 
began,  and  continued  for  some  time.  This  was  followed  by  a 
marked  diminution  in  the  abdominal  distension  ;  but  the  patient 
never  rallied  from  the  shock,  and  died  about  twelve  hours  after 
the  operation. 

In  Case  I  it  will  be  noticed  that  the  contents  of  the  ali¬ 
mentary  canal  continued  to  discharge  through  the  natural 
anus  for  several  weeks ;  this  was  due  to  the  incision  in  the 
intestine  in  that  case  being  made  in  the  longitudinal  in¬ 
stead  of  the  transverse  direction.  It  will  also  be  noted  in 
the  histories  of  the  cancer  cases  that  they  are  reported  as 
having  been  discharged  cured  ;  it  will  be  understood,  of 
course,  that  the  term  applies  only  to  the  conditions  com¬ 
plicating  the  disease,  and  not  to  the  disease  itself. 

In  conclusion,  I  would  beg  to  submit  the  following 
propositions : 

1.  By  abolishing  function  in  that  part  of  the  bowel  be¬ 
low  an  artificial  anus,  and  instituting  another  route  of  in¬ 
gress  for  treatment,  we  retard  those  progressive  destructive 
processes  in  cancer  and  in  the  quasi-syphilitic  ulcerations, 


314 _ MOORE:  THE  RELATIVE  IMMUNITY  FROM  PHTHISIS  IN  COLORADO.  [N.  Y.  Med.  Jour., 


and  eliminate  tlie  principal  causes  of  suffering  associated 
with  those  diseases. 

2.  To  prevent  the  annoyance  caused  by  faeces  passing 
from  the  part  above  to  the  part  below  an  artificial  anus,  we 
must  resort  either  to  the  objectionable  method  of  Made- 
lung,  or  to  some  of  the  various  methods  for  the  formation 
of  an  eperon  or  spur. 

3.  To  prevent  the  annoyance  of  subsequent  prolapse,  we 
must  make  the  section  in  the  abdominal  wall  as  small  as 
consistent  with  the  object  in  view,  preferably  through  mus¬ 
cular  tissue,  following  in  other  respects  the  advice  of 
Cripps,  selecting  a  portion  of  the  colon  that  has  a  meso 
only  long  enough  to  reach  the  surface. 

4.  A  great  deal  can  be  done  in  the  treatment  of  non-can- 
cerous  stricture  by  the  faithful,  gentle,  and  long-continued 
use  of  bougies,  and  other  local  and  constitutional  means; 
but  to  derive  the  full  measure  of  relief  from  iliac  colotomy, 
it  must  be  done  early  and  before  the  occurrence  of  com¬ 
plete  obstruction.  When  that  has  taken  place,  and  we  have 
to  deal  with  a  largely  dilated  abdomen,  I  believe  that  the 
lumbar  operation  is  the  preferable  one. 


REASONS  FOR  THE  RELATIVE  IMMUNITY  FROM 

PULMONARY  PHTHISIS  IN  COLORADO, 

AND  ITS  THERAPEUTIC  IMPORTANCE. 

By  H.  B.  MOORE,  M.  D., 

COLORADO  SPRINGS. 

The  word  relative  might  almost  be  omitted  from  the 
above  wording,  for  the  number  of  cases  of  tuberculosis 
originating  in  Colorado  are  proportionally  so  small  as  com¬ 
pared  with  what  obtains  in  other  parts  of  the  world  that 
immunity  from  tuberculosis  in  Colorado  stands  practically 
as  a  fact.  An  immunity  exists  also  in  some  parts  of  the 
South  American  Andes,  in  certain  restricted  areas  in  the 
Alps,  and  also  in  other  portions  of  the  world,  the  climatol¬ 
ogy  of  which  has  as  yet  been  little  studied.  When  we  ask 
ourselves  for  the  reasons  for  this  immunity  and  look  up 
what  has  been  written  on  the  subject,  we  are  confronted 
with  much  speculation  and  uncertainty.  In  fact,  not  a  small 
portion  of  the  profession  still  holds  to  the  belief  that  if  such 
areas  of  immunity  exist  at  all,  it  is  only  by  virtue  of  an  ab¬ 
sence  of  the  conditions  usually  present  in  thickly  settled 
communities,  or,  in  other  words,  that  it  is  simply  a  nega¬ 
tive,  not  a  positive,  attribute  of  said  areas.  With  a  view 
to  settling  this  point,  the  Swiss  commission  was  appointed  in 
the  year  1865  to  ascertain  and  report  upon  the  sanitary  con¬ 
ditions  and  percentage  of  deaths  from  tuberculosis  at  dif¬ 
ferent  altitudes  in  Switzerland.  The  statistics  accumulated 
by  the  commission  covered  a  period  of  four  years,  and  Mul¬ 
ler  in  his  published  report  states  that,  although  no  areas  of 
absolute  immunity  were  found,  it  was  ascertained  that,  sani¬ 
tary  conditions  remaining  the  same,  a  relative  immunity  ex¬ 
isted  at  various  altitudes,  modified  by  latitude  and  local  con¬ 
ditions.  Independent  observers  in  various  localities  have 
also  given  more  or  less  conclusive  testimony  on  this  point 
— e.ff.,  Kiichenmeister’s  collection  of  statistics  for  Saxony, 
Jacubasch’s  for  the  Hartz  Mountain  region,  and  those  of 


Bremer  for  Gorbersdorf — and  the  fact  is  further  evidenced 
by  the  degree  of  immunity  observed  in  the  highly  situated 
Andean  cities  and  those  of  the  Central  American  and  Mexi¬ 
can  plateaus. 

Prior  to  the  discovery  of  the  tubercle  bacillus  by  Koch 
in  1882,  those  who  sought  to  explain  local  immunity  were 
at  a  disadvantage,  inasmuch  as  the  intimate,  essential  na¬ 
ture  of  the  disease  was  still  unknown.  Since  that  time,  al¬ 
though  bacteriology  is  doubtless  still  in  its  infancy,  much 
has  been  learned  of  the  grosser  laws  governing  bacteria]  life 
and  its  propagation.  We  know,  e.g.,  that  certain  degrees 
of  heat  and  moisture  and  certain  media  present  conditions 
much  more  favorable  than  others  to  these  low  forms  of  life. 
We  also  know  that  these  limits  vary  widely  in  different  bac¬ 
teria.  It  is  from  a  study  of  these  general  laws  and  of  the 
special  facts  relating  to  the  culture  of  the  tubercle  bacillus 
that  we  are  to  draw  data,  whose  comparison  with  the  con¬ 
ditions  found  in  a  given  climatic  zone  will  aid,  at  least  nega¬ 
tively,  in  the  solution  of  the  question.  Without  going  into 
details  exhaustively,  the  main  facts  concerning  the  condi¬ 
tions  essential  to  the  life  and  propagation  of  the  tubercle 
bacillus,  as  determined  by  experiments  in  artificial  media, 
are  briefly  as  follows  :  The  bacillus  itself  is  extremely  fas¬ 
tidious  as  to  its  culture  medium  and  extraordinarily  sensi¬ 
tive  to  changes  of  environment.  In  ordinary  culture  me¬ 
dia — gelatin,  agar-agar,  and  bouillon — it  grows  either  not  at 
all  or  very  incompletely,  and  it  is  only  in  blood  serum  that 
it  thrives.  This  sensitiveness  is  further  exhibited  to  a 
marked  extent  against  changes  of  temperature  and  dryness. 
Above  108°  and  below  86°  F.  development  ceases  entirely 
and  is  only  complete  at  the  temperature  of  the  body. 

This  fact  is  so  rigid  that  in  its  cultivation  an  oven  kept 
at  a  uniform  temperature  is  a  necessity,  and  added  to  this 
is  the  third  fact,  that,  owing  to  its  very  slow  growth,  there 
must  be  an  undisturbed  continuance  of  these  conditions  for 
a  relatively  long  period.  In  the  face  of  this,  it  might  be  a 
matter  for  wonder  that  the  tubercle  bacillus  existed  at  all 
were  it  not  that  its  spores  are  as  exceptionally  resistent  and 
unyielding  to  adverse  influences  as  the  bacillus  itself  is  the 
reverse.  This  spore  formation  goes  on  both  in  the  body 
and  outside  in  the  sputum,  and  the  resulting  spores  are 
among  the  most  resistent  known.  They  will  stand  dryness 
for  months,  temperatures  of  boiling  point  for  hours,  and 
long  exposure  to  low  temperatures  as  well.  From  a  consid¬ 
eration  of  the  foregoing,  we  can  readily  see  that  if  bacilli 
were  all  we  had  to  contend  with,  many  climates  could  offer 
strong  anti-tubercular  properties.  The  disease  might  even 
soon  cease  to  exist ;  but,  unfortunately,  tubercular  spores 
have  such  powers  of  resistance  that  probably  no  habitable 
climate  could  enjoy  immunity  by  virtue  of  any  specific  anti¬ 
septic  properties  possessed  by  it.  It  is,  however,  doubtless 
true  that  spore  formation  and  the  consequent  multiplication 
of  bacilli  are  much  inhibited  by  the  conditions  peculiar  to 
mountain  regions.  Miquel  ascertained  that  in  a  given  quan¬ 
tity  of  air  taken  as  a  standard  for  comparison  there  were 
absolutely  no  bacteria  over  the  Mer  de  Glace  at  Chamounix, 
Switzerland  ;  that  in  the  same  bulk  of  air  in  a  hotel  corri¬ 
dor  at  Lucerne  were  twenty-five  and  in  Paris  seven  thou¬ 
sand.  Of  course  the  overwhelming  majority  of  these  or- 


Sept.  20,  1890.]  MOORE:  THE  RELATIVE  IMMUNITY  FROM  PHTHISIS  IN  COLORADO 


315 


ganisms  were  non-pathogenic,  and  these  facts  admit  of  but 
limited  application  to  the  subject  under  consideration.  The 
presence,  then,  of  any  specific  germicidal  effects  in  high  alti¬ 
tudes  not  being  admitted,  we  must  look  for  the  reasons  for 
immunity  in  some  change  in  the  individual  whereby  he  loses 
his  susceptibility,  or,  in  other  words,  no  longer  presents  a 
ground  adapted  to  the  reception  or  growth  of  tubercular 
seed,  or,  as  the  bacteriologist  would  put  it,  he  ceases  to  be 
a  suituable  culture  medium.  These  changes  in  individuals 
living  in  the  immune  areas  of  Colorado  are  due  to  the  fol¬ 
lowing  essential  climatic  peculiarities,  whose  effects  and 
therapeutic  significance  will  be  briefly  considered  in  the 
order  named  :  Atmospheric  attenuation,  dryness,  purity,  in¬ 
creased  opportunity  for  out-of-door  life,  and  sandy,  porous 
soil. 

Among  the  most  conspicuous  effects  of  high  altitudes  is 
the  increased  expansive  power  of  the  lungs.  This  fact  is  so 
generally  known  and  recognized  that  it  needs  no  comment. 
It  signifies,  of  course,  that,  owing  to  the  atmospheric  attenu¬ 
ation,  to  fully  meet  the  needs  of  the  system  greater  respira¬ 
tory  activity  is  necessary,  and  that  portions  of  the  lungs 
but  little  used  at  sea-level  are  brought  into  requisition,  and 
the  whole  organ  takes  on  increased  functional  activity  with 
all  the  incidental  nutritive  advantages,  according  to  the 
known  law  that  tubercle  has  a  special  affinity  for  organs 
that  functionate  incompletely,  and  its  converse,  that  their 
.power  of  resistance  and  vitality  exhibit  a  direct  ratio  to 
their  functional  activity. 

The  effects  upon  the  heart  and  its  nutrition  are  also  con¬ 
spicuous.  At  first  the  pulsations  are  considerably  increased 
n  frequency,  but  this  disappears  after  a  time,  as  the  heart 
jecomes  gradually  larger  and  the  performance  of  its  work 
nore  vigorous.  In  this  connection  the  observations  of 
Rokitansky  are  of  much  interest.  He  declared  that  the 
ieart  and  vessels  were  always  relatively  small  in  chronic 
ffithisis.  I  have  often  heard  Formad,  coroner’s  physician  in 
Philadelphia,  say  that  he  had  observed  the  same  thing  in 
arge  numbers  of  autopsies,  and  Bremer,  of  the  Gorbersdorf 
leilanstalt,  said  that  it  held  true  of  the  14,000  cases  treated 
it  his  institution  during  its  history.  Bremer  was  a  pro- 
lounced  believer  in  the  theory  that  this  relative  smallness 
fas  a  prominent  setiological  factor  in  the  production  of 
ihthisis,  and  that  the  benefit  of  the  high-altitude  treatment 
fas  to  no  inconsiderable  extent  due  to  the  effect  upon  the 
ieart  and  closely  related  pulmonary  nutrition.  Although  this 
aay  seem  rather  hypothetical  from  our  present  standpoint 
nd  mode  of  thought,  yet  it  is  better  not  to  blind  ourselves 
o  its  possible  overtowering  importance  in  predisposition, 
specially  when  we  reflect  upon  how  slight  is  our  knowl- 
dge  as  to  the  essential  nature  of  predisposition.  It  is  at 
ny  rate  obvious  that  any  change  of  environment  having 
)r  ^ts  consequences  such  marked  effect  upon  respiration 
nd  circulation  must  be  powerful  for  good  or  evil. 

As  a  further  effect  of  high  altitudes  is  to  be  mentioned 
iie  marked  improvement  in  appetite  and  assimilation.  This 
3ems  to  occur  independently  of  any  qualities  in  mountain 
nmates  other  than  atmospheric  attenuation  and  the  cold, 
lacing  air,  and  probably  by  the  power  these  qualities  pos- 
ss  of  imparting  to  all  of  the  organs  a  more  perfect  func¬ 


tional  life,  combined  with  a  tonic  effect  upon  the  nervous 
system,  thus  overcoming  “  vulnerability  ”  of  tissue.  The 
r61e  played  by  extreme  dryness  can,  it  seems,  hardly  be  ex¬ 
aggerated,  and  in  its  direct  effect  upon  the  local  process  is 
probably  nearly  equal  in  importance  to  elevation.  Dr.  Deni¬ 
son,  of  Denver,  who  has  given  this  subject  special  study,  has 
made  some  interesting  observations  on  the  increased  osmosis 
of  watery  vapors  at  points  on  the  eastern  slope  of  the  Rocky 
Mountains  taken  as  a  type  of  dry  climates  and  places  upon 
the  Atlantic  seaboard.  He  also  says  that  “  if  we  knew  to¬ 
day  the  absolute  humidity  of,  or  the  average  amount  of 
vapor  in,  a  cubic  foot  of  air  in  all  parts  of  the  country,  we 
should  have  one  of  the  most  valuable  indications  possible  of 
the  best  localities  for  phthisical  patients.  With  some  reser¬ 
vation  as  to  temperature,  the  smallest  ratios'  wo.uld  indicate 
where  consumption  seldom  originates.”  The  infrequency 
of  phthisis  in  the  dry  parts  of  Egypt,  Australia,  Arizona, 
and  other  places  furnishes  good  evidence  of  the  correctness 
of  this  view,  at  least  as  an  adjunct  to  altitude;  and  in  cases 
in  which,  for  any  reason,  high  altitude  is  contra-indicated, 
and  the  patient  can  not  be  allowed  to  enjoy  a  combination 
of  the  two,  a  low  altitude  with  dryness  should  be  chosen. 

An  absolutely  dry  air,  possessing,  as  it  does,  great  ab¬ 
sorbent  power,  is  actively  opposedto  suppuration,  being,  as 
it  were,  a  constantly  applied  aseptic  blotting-pad  to  suppu- 
lating  surfaces,  and  quickly  drying  up  those  patches  of 
broncho-pulmonary  catarrh  so  frequently  the  nidi  for  tuber¬ 
cular  infection.  The  drying,  shriveling  process  which  beef 
or  carcasses  exposed  to  the  air  in  exceedingly  dry  countries 
undergoes  will  be  a  familiar  and  remembered  example  bv 
those  who  have  observed  it.  Apropos  to  this  subject,  I 
wish  to  make  a  few  remarks  on  equability  of  temperature 
and  wind. 

Exceedingly  dry  countries,  like  Colorado,  show  an  en¬ 
tile  absence  of  that  equability  which  is  the  concomitant 
of  and  can  only  be  secured  by  the  latent  equalizing  influ¬ 
ence  of  large  surrounding  bodies  of  water  and  moist  atmos¬ 
pheres,  of  which  Florida  is  an  example  ;  hence  those  writers 
who  speak  of  “  dry  equable  climates  ”  affirm  what  is  para¬ 
doxical  and,  from  the  teachings  of  physical  science,  impossi¬ 
ble.  As  for  wind,  a  study  of  the  mechanism  of  its  production 
will  show  that  it  also  is  a  necessary  feature  of  dry  climates, 
and  if  it  is  not  found  in  a  special  area,  it  can  only  be  a  local 
accident— the  result  of  a  sheltering  range  of  hills  or  spur  of 
mountains.  Dryness  has  the  further  advantage  of  robbing 
oscillations  of  temperature  of  the  danger  and  discomfort 
otherwise  attending  them.  The  special  purity  of  mountain 
air  is  well  shown  by  the  results  of  Miquel’s  observations  above 
alluded  to,  which  have  obtained  such  wide-spread  currency, 
and,  excepting  warmth,  purity  is  the  most  classic  desidera¬ 
tum  in  the  selection  of  climate  for  phthisis.  Dr.  Anderson, 
of  Colorado  Springs,  believes  that  the  beneficial  effect  of  the 
Colorado  climate  is  due  almost  entirely  to  the  purity  of  the 
aii  and  its  aseptic  condition.  This  is  also  the  view  of  many 
of  the  most  eminent  clinicians  of  Europe  and  this  country, 
and  its  importance  is  emphasized  by  the  preponderating  in¬ 
fluence  in  the  production  of  phthisis  of  crowding  and  poor 
ventilation.  Now,  while  I  have  no  intention  of  being  hereti¬ 
cal  upon  such  an  essentially  orthodox  point  as  the  necessity 


SWAIN:  ADENOID  TISSUE  IN  THE  NASO-PHARYNX  AND  PHARYNX.  [N.  Y.  Med.  Joub., 


316 

for  pure  air  in  general,  yet  I  think  its  importance  has  occupied 
the  professional  mind  for  a  long  time  to  the  exclusion  of 
what  are  in  this  connection  more  unique  climatic  attributes. 
Otherwise  how  can  we  account  for  the  degree  of  immunity 
which  still  exists  in  many  large,  growing  cities  at  high  alti¬ 
tude,  of  which  Denver  may  be  regarded  as  an  example.  The 
sanitary  conditions  in  these  cities  are  certainly  not  above  the 
average  for  cities  of  their  size  ;  in  many  cases  conspicuous¬ 
ly  worse,  as  evidenced  by  the  prevalence  of  typhoid  fever 
and  other  diseases  associated  with  such  conditions.  In 
view  of  this  high  appreciation  for  pure  air,  it  is  curious  to 
note  the  proposal  in  Germany  not  long  ago  to  treat  pul¬ 
monary  tuberculosis  by  spray  inhalations  of  highly  foetid, 
stagnant  water,  containing  the  Bacterium  termo  in  large 
quantities — the  theory  being  that  these  bacteria  would  an¬ 
tagonize  and  eventually  destroy  the  bacilli  of  tuberculosis 
in  the  lungs  in  a  manner  similar  to  what  occurs  in  impure 
artificial  culture  media.  Many  who  gave  this  seemingly 
unpromising  method  a  trial  professed  benefit,  but  most  met 
with  negative  results. 

Our  next  point,  the  largely  increased  opportunity  for 
out-of-door  life  furnished  by  the  climate  of  Colorado,  be¬ 
comes  obvious  when  one  learns  of  the  unprecedentedly 
large  number  of  sunshiny  days  during  the  year  and  the 
average  monthly  temperature  throughout  the  same,  ren¬ 
dering  out-of-door  life  not  only  possible,  but  a  pleasure 
during  every  month.  In  this  respect  the  advantage  of 
Colorado  over  the  Engadine  and  similar  high-altitude  re¬ 
sorts  abroad  is  most  conspicuous.  Of  the  happy  influence 
exerted  by  out-of-door  life,  particularly  in  early  cases,  no 
one  has  a  doubt.  It  has  been  the  universal  experience 
everywhere  in  localities  of  no  special  promise.  The  last 
point  to  be  mentioned  is  the  character  of  the  soil,  which, 
along  the  eastern  slope  of  the  mountains  in  Colorado,  is 
sandy  and  porous.  Dr.  Solly  states  that  in  the  neighbor¬ 
hood  of  Colorado  Springs  this  sandy,  porous  soil  obtains  to 
the  depth  of  sixty  feet.  Dr.  Bowditch,  of  Boston,  and 
others  since  have  accumulated  a  mass  of  evidence  to  show 
that  phthisis  is  much  more  frequent  in  localities  having  a 
heavy,  moist,  or  clayey  soil,  and,  although  some  have  at¬ 
tempted  to  show  that  the  opposite  character  of  soil  has 
some  special  positive  virtue,  it  seems  more  rational  to  at¬ 
tribute  the  salutary  influence  of  sandy,  porous  soils  to  their 
influence  on  dryness  of  air  and  drainage.  We  owe  the  im¬ 
munity  in  Colorado,  then,  chiefly  to  the  physiological  effects 
of  high  altitude.  This  is  powerfully  supplemented  by  ex¬ 
treme  dr v ness,  while  the  almost  unbroken  sunshine  and 
favorable  temperatures  lead  to  a  maximum  amount  of  out- 
of-door  life,  rendering  the  specific  action  of  altitude  thor¬ 
oughly  available.  Probably  no  one  of  these  climatic  attri¬ 
butes  would  be  sufficient  in  itself,  but  the  sum  of  these  con¬ 
ditions  effect  such  a  change  in  the  human  economy,  viewed 
in  the  light  of  a  medium  for  tubercular  cultivation,  that  it 
becomes  unfitted  to  the  end  ;  and  in  cases  of  the  disease 
not  too  far  advanced,  this  influence  antagonistic  to  the  tu¬ 
bercular  process  is  so  strong  that  it  becomes  antidotal  and 
a  most  valuable  therapeutic  agent. 

To  fully  appreciate  the  fairness  of  this  conclusion,  a  cor¬ 
rect  conception  of  the  natural  history  of  phthisis  is  most 


essential.  It  has  been  variously  estimated  by  different  ob¬ 
servers  that  the  lesions  denoting  a  pre-existing  phthisis 
are  found  in  from  thirty  to  sixty  per  cent,  of  all  autopsies. 
Very  many  of  these  people  have  had  phthisis  and  recovered 
without  knowing  it.  Flint  has  shown  that  in  a  large  num¬ 
ber  of  cases  of  phthisis  there  is  an  intrinsic  tendency  to  re¬ 
covery  irrespective  of  any  special  treatment  or  management. 
In  these  cases  the  system  exhibits  a  marked  tolerance  for 
the  disease,  and  it  occasions  but  little  disturbance. 

In  all  ordinary  cases  of  phthisis  pursuing  a  chronic 
course,  Nature  makes  strong  and  repeated  efforts  at  self-cure, 
the  tubercular  mass  frequently  becoming  encysted  and 
shrinking  into  a  hard,  atrophied,  innocuous  mass.  When 
these  efforts  are  not  successful,  the  repeated  attempts  at 
fencing  in  and  curing  are  not  less  evident,  both  clinically 
and  post  mortem.  Thus  we  see  that  phthisis  is  not  a  dis¬ 
ease  that  is  necessarily  fatal,  and  it  appears  that  these  cli¬ 
matic  influences  which  we  are  considering  are  just  sufficient 
to  turn  the  balance  in  assisting  Nature  on  the  local  process, 
and  to  put  the  stamp  of  success  on  what  she  herself  so  ear¬ 
nestly  attempts.  I  know  of  no  words  that  better  express 
what  may  be  expected  in  properly  selected  cases  coming  to; 
Colorado  than  these  by  Dr.  Knight,  of  Boston :  “  It  is 
perhaps  not  too  much  to  say  that  the  prognosis  in  this  class 
of  cases  (early  apex  disease)  has  been  changed  from  very 
bad  to  very  good.”  _ 

ADENOID  TISSUE 

IN  THE  NASO-PHAEYNX  AND  PHARYNX. 

PRELIMINARY  REPORT* 

By  H.  L.  SWAIN,  M.  D., 

NEW  HAVEN,  CONN. 

Several  years  ago,  while  studying  the  development  and 
history  of  the  lingual  tonsil,  many  observations  were  made 
upon  this  variety  of  tissue  as  it  presents  itself  in  other  por¬ 
tions  of  the  pharynx,  and  it  was  the  writer’s  purpose,  at 
some  future  date,  to  continue  the  study  of  these  latter  por¬ 
tions  of  adenoid  tissue,  tracing  the  life  history  of  the  whole 
mass.  To  a  few  observations  thus  made  in  obedience  to  the 
above  purpose  the  writer  would  ask  your  lenient  attention, 
hoping  more  to  elicit  thereby  a  discussion  that  shall  prove 
profitable,  rather  than  with  any  idea  of  adding  anything  of 
value  to  the  knowledge  already  at  hand  in  extant  litera¬ 
ture. 

Since  beginning  the  work  in  this  direction  much  has 
been  written  on  this  tissue,  and  a  great  many  points  which 
interested  the  writer  at  the  start  have  been  definitely  set¬ 
tled,  but  at  the  same  time  the  field  has  broadened,  and  so,- 
instead  of  busying  ourselves  with  minute  details,  let  us  con¬ 
sider  as  a  whole  this  ring  of  tissue  which  we  are  pleased 
to  call  adenoid,  situated,  at  the  junction  of  the  oesophagus 
at  its  dilated  upper  extremity  and  the  mucous  membrane  ot 
the  mouth  and  nose.  In  so  doing,  however,  we  may  not 
slight  its  principal  component  parts,  but  must  consider  them 
in  their  relations  to  each  other  and  to  the  whole,  and  then 
joint  or  comparative  life  history. 

*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


Sept.  20,  I89DQ  aWAIN :  ADENOW  TWM  IN  THE~  NASOPHARYNX  AND  PHJ * ysx 


Situated  as  is  this  ring  of  tissue,  acting  as  a  sort  of 
bridge  or  other  bond  of  connection  between  structures 
which  are,  on  the  one  hand,  originally  developed  from  the 
entoderm  of  the  embryo,  and,  on  the  other,  with  parts 
largely  affected  by  ectodermoidal  influences,  it  differs  from 
the  tissue  in  its  immediate  neighborhood  quite  considera¬ 
bly.  It  also  has  slight  variations  in  the  structure  of  its  dif¬ 
ferent  parts— a  difference  in  their  life  history— for  some  parts 
atrophy  early,  while  others  seem  as  active  as  ever  even  up 
to  the  middfe  of  life,  and  yet  all  these  differences  are  to  be 
more  than  outnumbered  by  the  variety  of  opinions  as  to 

the  purpose  of  the  adenoid  tissue  and  its  function  in  our 
economy. 

To  state  in  general  what  we  know  of  the  life  history  of 
these  interesting  parts,  we  might  put  it  as  follows  :  That  way 
back,  early  in  the  uterine  existence  of  man,  the  deposit  of 
small  cells  underneath  what  then  is  the  epithelium  of  the 
naso-pharynx  and  pharynx  begins,  accompanied  or  at  times 
preceded  by  a  slight  furrowing  of  the  membrane;  very 
soon  after  this  beginning  comes  the  outwandering  of  the 
same  cells  through  the  epithelium.  At  some  time  later, 
the  date  varying  in  different  portions  as  does  that  of  the 
beginning,  thickening  takes  place,  and  soon  development  of 
follicles.  After  a  time,  when  extra  uterine  life  has  begun, 
all  parts  grow  on  apparently  alike  until  puberty,  or  toward 
adult  life.  Then  activity  seems  to  subside  and  a  gradual 
retraction  takes  place.  In  general,  we  find  already  in  late 
youth  a  beginning  of  atrophy  in  the  pharynx  tonsil,  later 
on  the  faucial  tonsil  begins  its  retrogression,  while  way  into 
adult  life  we  find  the  lingual  tonsil  still  unatrophied.  * 

The  apparent  corollary  of  the  foregoing  is  borne  out  in 
clinical  experience,  for  we  have  in  young  children  the  adenoid 
tissue  in  the  naso-pharynx  and  faucial  region  more  often  af¬ 
fected  by  disease.  In  youth  and  early  adult  life  the  faucial 
tissue  attracts  our  attention,  while  in  a  large  majority  of 
the  cases  which  demand  treatment  the  lingual  tonsil  seldom 
appears  to  be  affected  before  the  twenty-fifth  year.  Of 
course  we  have  many  exceptions,  as  acute  affections  of  the 
pharynx  tonsil  in  the  adult,  or  enlargements  of  the  lingual 
onsil  in  the  child.  There  is  also,  in  general,  the  same 
>rder  of  development— that  is,  the  pharynx  tonsil  begins 
•ertamly  as  early  or  earlier  than  the  faucial,  while  both 
•recede  the  full  development  of  the  lingual  tonsil  by  quite 
1  on£  Penod-  In  all,  the  formation  of  follicles  follows  at 
•ome  considerable  time  interval  after  the  deposit  of  small 
ells  takes  place,  and  in  the  case  of  the  lingual  tonsil  it 
eems  quite  certain  that  pathological  conditions  favor  the 
arher  development  of  the  follicles,  and  that  the  more  hy- 
•ertrophied  a  portion  becomes,  the  more  follicles  it  con- 
ams.  It  proves  to  be  also  true  that  in  the  atrophy  of  the 
mgual  tonsil  the  follicles  first  break  down  and  disappear, 
nd  then  a  general  diminution  in  the  number  of  cells  in  the 
titrating  mass  under  epithelium.  This  would  seem  to  be 
180  J.rue  of  the  other  portions  of  this  tissue  in  the  pharynx, 

«t,  from  individual  investigation,  the  writer  can  not  say,’ 

>rt  is  is  one  of  the  points  aimed  at  in  investigating  this 
abject,  and  it  is  proposed  to  examine  all  portions  of  this 
ssue  at  the  different  periods  in  life,  making  comparative 
bservations  on  the  condition  of  the  different  parts. 


317 


In  studying  the  development  of  the  pharynx  tonsil  we 
have  a  great  authority  in  Killian  (5),*  and  the  observations 
made  by  the  writer  entirely  coincide  with  his,  so  I  shall 
venture  to  quote  him  quite  at  length.  He  examined  in  all 
some  sixty-five  human  embryos,  and  found  that,  while  the 
real  bursa  pharyngea,  according  to  Froriep,  came  as  early 
as  about  the  eleventh  week,  the  first  folds  in  the  mucous 
membrane  at  the  vault  of  the  pharynx  appeared  at  the  be¬ 
ginning  of  the  sixth  month.  These  folds  preceded  any  ap¬ 
pearance  of  small  cells,  which  begins  usually  toward  the  last 
of  the  sixth  month.  During  the  seventh  and  eighth  months 
the  folds  assume  a  size  sufficient  to  be  discovered  bv  the 
naked  eye.  Soon  they  assume  the  irregular  details  familiar 
from  observation  in  the  adult,  the  folds  being  often  upright 
with  occasional  transverse.  There  is  every  variety  of  form 
and  extent  m  the  case  of  these  changes,  and  the  time  of 
t  eir  appearance  is  far  from  regular,  or  the  tonsil  may  be 
wanting  entirely  at  birth.  The  real  adenoid  tissue  is 
formed  by  the  mucous  membrane  taking  up  numerous 
round  cells,  until  it  becomes  quite  full  and,  by  a  rapid  pro¬ 
liferation  of  these  cells,  grows  considerably  thicker.  In  the 
beginning  the  whole  process  confines  itself  to  the  posterior 
three  quarters  of  the  roof  of  the  pharynx  ;  later  it  spreads 
down  on  to  the  posterior  wall  of  the  pharynx.  It  is  always 
thickest  in  the  front  region  of  the  bursa-*'.  just  in  frc/nt 

of  the  angle  or  curve  formed  by  the  roof  with  the  posterior 
wall  of  the  pharynx.  Toward  the  end  of  the  embryonal  life 
these  folds  become  thick  protuberances  and  form  deep  fur¬ 
rows  of  which  the  middle  one  appears  to  be  the  greater 
At  about  this  same  time  the  follicles  (Schmidt)  (10)  appear 
although  m  certain  cases  they  may  not  be  found  for  some 
time  after  birth.  These  glands  have  no  hollow  spot,  as  in 
the  case  of  the  other  collections  of  conglobate  glands.'  Mu¬ 
cous  glands  are  more  abundant  in  the  superior-lateral 
regions  of  the  naso-pharynx. 

After  birth  there  is  an  apparent  change  of  position  of 
die  pharynx  tonsil  which  he  states  as  follows :  “  The  pharynx 
;onsil  of  man  moves,  between  the  sixth  month  of  embryonic 
life  and  end  of  the  second  decennium,  from  the  baso- 
sphenoidal  to  the  baso-occipital  region.” 

From  his  studies  in  comparative  anatomy  he  concludes 
that  in  mammals  the  pharynx  tonsil  is  not  so  constant  as 
the  faucial  tonsil  in  its  occurrence,  but  at  least  is  as  fre¬ 
quent  as  the  lingual.  In  the  lower  forms  of  life,  as  in  birds 
and  reptiles,  it  is  present  in  a  well-developed  form,  and 
therefore,  of  all  these  collections  of  lymphatic  tissue  in  the 
throat,  is  the  oldest.  Perhaps  right  here  is  a  favorable  op. 
portu nity  of  stating  some  observations  by  Beard  (1),  reported 
in  an  article  entitled  The  Old  Mouth  and  the  New.  In 
this  he  seems  to  present  logical  reasons  for  supposing  that 
the  old  mouth— viz.,  the  mouth  which  the  lowest  grades  of 
animals,  as  the  worm,  possess,  a  direct  continuation  of  the 
oesophagus  to  the  surface— was  by  means  of  the  hypophy 
sis  cerebri  through  the  present  infundibulum  to  the  upper 
and  back  part  of  the  head.  Such  having  been  the  case,  we 
have  abundant  reason  for  the  fact  of  the  frequent  occur¬ 
rence  of  the  pharynx  tonsil  in  the  lower  grades  of  animals, 


*  Numbers  refer  to  literature. 


318 


SWAIN:  ADENOID  TISSUE  IN  TEE  NAS O-PEAR YNX  AND  PEAR7NX.  [N.  Y.  Med,  Jour. 


and  in  this  latter  the  reason  for  the  earlier  development 


and  activity  of  these  tissues  in  man. 

One  other  point  of  importance  and  I  am  done  with  the 
embryology  of  this  part:  “We  must  conclude  that  all 
three  tonsils  and  the  whole  adenoid  tissue  at  the  beginning 
of  the  embryonic  intestine  are  formed  by  the  participation 
of  the  entoderm  as  motive  principle,  and  the  mesoderm  as 
the  source  of  the  adenoid  infiltration.  These  paits  must  be 
looked  upon  as  morphologically  similar  to  the  lymphatic 
organs  of  the  whole  intestinal  canal.” 

°We  find  in  these  statements  of  Killian  much  which  is 
not  in  strict  accordance  with  the  hitherto  accepted  views, 
but  I  can  heartily  agree  with  him  when  he  states  that  the 
real  bursa  pharyngea,  pure  and  simple,  as  described  by 
Tornwaldt  and  Luschka,  has  only  a  somewhat  inconstant 
embryonal  existence,  and  does  not  persist  as  such  in  the 
adult,  or  even  long  into  childhood.  It  is  not  the  dilated 
end  of  the  hypophysis  cerebri,  or  rather  the  canal  from  it 
to  the  pharynx.  The  true  bursa  exists  before  the  tonsil 
proper  begins,  and  is  not  to  be  confounded  with  the  recessus 
pharyngeus  medius  of  the  adult,  differing  thus  entirely 
from  Schwabach  (12)  and  Ganghofner  (4).  Poelchen  (8)  is 
perhaps  the  latest  writer  on  this  subject.  He  avoids  all 
questions  as  to  the  bursa  or  recessus,  but  insists  that  the 
median  groove  exists  all  through  life,  and  must  necessarily 
do  so,  because  this  portion  is  attached  so  firmly  to  the  base 
of  the  skull,  between  the  insertions  of  the  longus  capitis 
muscles.  In  a  patient  where  the  side  of  the  face  had  for 
suro-ical  reasons  been  almost  entirely  removed,  thus  giving 
a  clear  view  directly  into  the  naso-pharynx,  it  was  the  only 
portion  of  the  pharynx  which  did  not  participate  in  the 
motions  of  the  act  of  swallowiug,  the  pharynx  walls  always 
coming  together  from  side  to  side. 

Having  thus  considered  the  upper  portion  of  the  ring 
of  adenoid  tissue,  as  we  come  down  on  either  side  we  have 
the  lesser  accumulations,  such  as  the  tube  tonsils,  the  lateral 
column  of  the  pharynx,  and  then  we  come  to  the  faucial 
tonsils.  Concerning  the  first  two  I  have  little  to  say,  but 
a  point  that  I  have  not  yet  sufficiently  proved  seems,  how¬ 
ever,  to  be  probable  from  abundant  clinical  observation — 
viz.,  that,  while  the  lateral  columns  may  not  possess  any 
actual  conglobate  glands  in  any  number,  still,  in  common 
with  the  lingual  tonsil,  they  preserve  a  later  activity  than 
the  other  parts,  for  we  frequently  find  them  hypertrophied 
together  in  late  adult  life. 

Of  faucial  tonsils  we  know  definitely  that  the  beginning 
is  as  a  fine  groove,  around  which  the  infiltration  accumu¬ 
lates,  which  goes  on  to  the  formation  of  deep  sulci  and  the 
development  of  the  organ  so  familiar  to  us  all.  In  point 
of  time  the  faucial  tonsil  seems  to  begin  about  the  same 
time  or  perhaps  a  little  later  than  the  bursa  pharyngea  of 
Killian.  According  to  Kolliker,  the  follicles  of  the  con¬ 
globate  gland  are  always  nicely  developed  at  birth,  and  he 
mentions  the  same  as  a  fact  in  connection  with  the  lingual 
tonsil.  As  regards  the  latter,  such  is,  from  my  own  obser¬ 
vations,  not  at  all  constantly  the  case,  for,  as  stated  in  an¬ 
other  place,  many  cases  of  young  children  were  examined 
where  not  a  follicle  was  to  be  found.  The  time  seems  to 
be  quite  uncertain,  and  as  regards  the  first  appearance  of 


the  infiltration,  I  have  not  had  a  chance  to  examine  very 
young  embryos.  Suffice  it  to  say  that  this  same  infiltration 
antedates  the  appearance  of  actual  follicles  by  a  considera¬ 
ble  interval,  and  at  some  future  time  I  hope,  from  human 
embryos  now  in  my  possession,  to  be  able  to  speak  more 
definitely.  In  animals  the  lingual  tonsils  begin  at  a  de¬ 
cidedly  later  interval  than  the  others  in  almost  every  in¬ 
stance. 

Having  observed  these  differences  in  the  time  and  kind 
of  formation  in  the  various  parts  of  the  throat,  we  find  a 
very  beautiful  connection  with  the  observed  facts  in  clinical 
history.  The  pharynx  tonsil,  the  older  organ  in  the  history 
of  animal  life,  is  first  affected  in  childhood  by  whatever  of 
pathological  changes  take  place  in  this  tissue,  and  having 
fulfilled,  as  it  were,  its  mission,  even  when  not  affected 
pathologically,  it  later  atrophies,  and  this  work  is  assumed 
by  other  parts.  What  is  true  of  this  portion  seems  later 
true  of  the  faucial  tonsil,  while,  to  finish  up  with  the  work, 
we  have,  as  the  more  persistent  member  of  the  group,  the 
lingual  tonsil,  and  perhaps  the  lateral  pharyngeal  columns. 
A  later  report  will  deal  with  this  retrograde  metamorphosis. 

Evidently  this  tissue  is  not  present  in  our  bodies  in  the 
position  which  it  occupies  without  fulfilling  some  definite 
purpose,  and  is  it  not  possible  to  make  some  inference  from 
this  peculiar  history  of  development  and  atrophy? 

Killian  states  that  the  only  function  which  these  con¬ 
siderable  surfaces,  through  which  multitudes  of  leucocytes 
are  constantly  emigrating,  seem  to  possess,  is  evident  in 
the  power  which  these  cells  have  to  destroy  micro-organ¬ 
isms.  Hence  he  would  argue  that  the  pharynx  tonsil,  being 
the  first  met  by  the  incoming  air,  would  play  the  greater 
part  in  ridding  the  system  of  th'ese  dangerous  elements  al¬ 
ways  present  in  the  air  about  us.  More  of  these  little  creat¬ 
ures  are  to  be  supposed  to  be  present  in  the  impure  air  that 
occurs  in  close  rooms,  and  consequently  there  would  be  a 
greater  demand  put  upon  this  organ  in  the  animals  subject 
to  these  conditions — i.  e.,  man  and  the  house  or  domestic 
animals.  This  increase  in  demand  for  leucocytes  would 
lead  in  the  course  of  generations  to  a  greater  development 
of  these  tissues,  and  man  and  the  animals  referred  to  would 
come  to  possess  larger  adenoid  collections,  a  fact  borne  out 
by  his  observations  in  comparative  anatomy,  excepting,  per¬ 
haps,  that  rodents,  save  the  rabbit,  do  not  appear  to  be 
blessed  with  much  of  any  adenoid  tissue. 

The  converse  was  equally  well  borne  out  by  his  observa¬ 
tions,  for  in  those  animals  where  the  nose  is  long  and  very 
complicated,  and  the  air  does  not  come  directly  in  contact 
with  the  pharynx  tonsil,  as  in  man,  no  such  eminent  demand 
would  be  made  on  this  tonsil,  and  so  in  succeeding  genera¬ 
tions  we  would  see  it  disappear  as  is  the  case  with  many 
mammals.  His  opinion  is  somewhat  influenced,  if  we  may 
be  allowed  the  inference,  by  the  interesting  account  which 
Metschnikoff  (6,  7)  gives  of  the  warfare  waged  by  the  leu¬ 
cocytes  or  their  analogue  in  the  Sprosspilzenkrankheit  of 
the  Daphnidce,  and  against  the  erysipelas  micrococci.  He 
observed  unquestionable  examples  of  the  antagonism  exist¬ 
ing  in  these  cases,  and  so  the  inference  was  fair  that  a  like 
animosity  exists  against  other  micro-organisms. 

Spicer  (13)  believes,  in  common  with  H.  Fox,  that  the 


Sept.  20,  1890.]  SWAIN:  ADENOID  TISSUE  IN  THE  NASO-PEARYNX  AND  PHARYNX. 


319 


pharynx  tonsil,  as  also  the  other  adenoid  tissue,  acts  as  a 
preventive  against  too  great  a  use  of  fluid,  in  that,  in  the 
pause  between  each  two  acts  of  swallowing,  they  absorb 
the  fluid  of  mucous  membrane  of  the  mouth,  as  also  certain 
parts  of  the  food  while  they  are  passing  by  ;  and  finally,  as 
a  place  of  nourishment  for  the  leucocytes,  they  take  part  in 
production  of  blood. 

In  common  with  Schmidt  and  Stohr  (14),  they  all  agree 
that  the  collection  of  the  leucocytes  here  must  have  some 
significance  in  regard  to  the  blood  ;  in  short,  adenoid  tissue 
is  a  sort  of  blood-producing  organ ;  but  Killian  rather 
puts  this  feature  in  the  background  and  thinks  the  func¬ 
tion  is  more  in  the  way  of  protection  against  deleterious 
matter. 

Davidoff  (3),  in  speaking  of  the  leucocytes  in  the  intes¬ 
tinal  epithelium,  puts  another  interpretation  upon  their 
presence  in  this  situation,  and,  far  from  supposing  them  to 
be  fighting  micro-organisms,  he  conceives  that  they  are  the 
carriers  of  some  of  the  digested  food  through  the  epithelium 
into  the  intestine.  Thus  he  believes  in  direct  opposition  to 
Stohr,  who  first  drew  attention  to  the  immense  immigration 
into  the  throat.  Stohr,  while  he  says  but  little  about  the 
fate  of  the  leucocytes  after  they  leave  the  epithelium,  dis¬ 
tinctly  believes  in  there  being  some  relationship  existing 
between  the  demand  of  the  rest  of  the  body  for  leucocytes 
and  the  number  present  in  adenoid  tissue,  for  he  mentions 
an  almost  complete  lack  of  cell  immigration  in  several  cases 
of  persistent  formation  of  pus,  pyo-pneumothorax,  and  a 
considerable  lessening  of  the  normal  number  in  a  case  of 
leucaemia. 

Whichever  of  these  theories  we  adopt,  we  can  not  escape 
from  certain  difficulties  in  trying  to  explain  certain  observed 
phenomena.  For  example,  if  the  so]e  purpose  of  the  ade¬ 
noid  tissue  of  the  throat  is  to  furnish  leucocytes,  which 
shall  protect  us  from  the  invading  host  of  rapacious  micro¬ 
organisms,  then  we  may  safely  conclude  that  for  those  who 
breathe  through  the  nose  the  pharynx  tonsil  is  really  the 
most  valuable  in  this  particular.  Is  it  not  strange,  then, 
that  this  should  be  the  first  to  atrophy,  when  it  is  the  one 
most  needed?  To  be  sure  there  are  the  other  parts  still 
left,  but  they  can  not  get  at  the  inspired  air.  Or  must  we 
suppose  that  the  pharynx  tonsil  takes  care  of  the  air,  while 
the  faucial  and  lingual  do  duty  in  fighting  the  organisms 
present  in  the  secretions  of  the  mouth  and  pharynx?  This 
takes  place  in  the  youth  of  the  individual,  and  later  in  the 
adult  there  is  not  such  an  urgent  necessity  for  such  protec¬ 
tion  in  that  other  organs  may  do  the  work,  or  the  system 
be  more  capable  of  resisting.  Certainly  if  the  above  be  the 
case,  we  must  not  be  hasty  in  removing  enlargements  of 
these  organs  unless  we  find  them  to  be  producing  disease 
of  other  parts,  for  one  can  not  have  too  many  leucocytes  at 
his  command.  And  yet  while  we  find  these  little  incon¬ 
sistencies,  surely  we  must  almost  a  'priori  conclude  that  the 
leucocytes  must  exercise  some  protective  influence,  and  that 
an  active  one,  for  how  could  we  otherwise  so  often  escape 
infection  ?  Surely  nothing  would  seem  more  favorable  to 
the  ingress  of  organisms  in  the  system  than  the  tonsils, 
which  present  in  the  lacunae  the  most  convenient  of  resting 
places  for  microbes,  and  then  in  the  openings  which  un¬ 


questionably  exist  in  the  epithelium  we  have  an  almost 
open  door  for  the  entrance  of  the  little  micrococcus.  Granted 
that  the  majority  of  the  organisms  referred  to  are  entirely 
innocuous,  still  some  are  not,  and  were  it  not  for  some  act¬ 
ive  interference,  we  must  often  become  infected  under  the 
conditions  just  quoted. 

The  question  of  retrograde  metamorphoses  or  patho¬ 
logical  changes  we  must  leave  for  the  report  of  future  ob¬ 
servation,  which  I  hope  to  make.  Meanwhile  let  me  simply 
mention  again  the  observation  of  Poelchen,  which  he  cites 
to  explain  the  very  frequent  appearance  of  and  persistence 
of  diseased  conditions  of  the  secretion  high  up  in  the  naso¬ 
pharynx.  The  close  union  of  the  apex  of  the  recessus  me- 
dius  by  fibro-cartilaginous  bands  to  the  base  of  skull  be¬ 
tween  the  muscles  rectus  capitis  gives  an  immobility  to  the 
parts  that  tends  to  the  retention  of  secretions,  and  that  the 
more  as  by  the  movement  of  the  side  walls  toward  each 
other  it  is  into  this  recessus  that  the  secretions  are  poured 
as  into  a  conduit.  The  deduction  is  to  supply  what  nature 
does  not  afford,  and  especially  to  be  observant  of  adhesions 
or  thickenings,  which  may  hinder  the  easy  downward  flow 
from  the  recessus. 

Literature. 

1.  Beard,  J.  The  Old  Mouth  and  the  New.  Anatomischer 
Anzeiger,  1888,  p.  15. 

2.  Bloch,  E.  Ueber  die  Bursa  pharyngea.  Berlin.  Jdin. 
Wochensclir .,  Nr.  14,  S.  269-273. 

3.  V.  Davidoff,  M.  Untersuch.  liber  d.  Bezieb ungen  d. 
Darmepitbels  zura  lymphoid.  Gewebe.  Arch.  f.  mikro.  Anat ., 
Bd.  29,  S.  495. 

4.  Ganghofner,  F.  Ueber  die  Tonsillaund  Bursa  pharyngea. 
Sitzungsberichte  d.  Jcais.  AJcadem.  d.  Wissensch..  Jahrgang  1878, 
Bd.  lxxviii,  Abtheil.  iii,  S.  178. 

5.  Killian,  G.  Ueber  die  Bursa  und  Tonsilla  pharyngea. 
Morphol.  Jahrb.,  Bd.  xiv,  S.  618-711. 

6.  Metschnikoff,  Elias.  Ueber  eine  Sprosspilzkrankheit  der 
Daphnien.  Virchow’s  Archiv,  Bd.  xevi,  177. 

7.  Metschnikoff.  Ueber  den  Kampf  der  Zellen  gegen  Ery- 
sipelkokken.  Virchow’s  Archiv ,  Bd.  evii,  S.  209. 

8.  Poelchen,  R.  •  Zur  Anatomie  der  Nasenrachenraumes. 
Virchow’s  Archiv ,  Bd.  cxix,  S.  118. 

9.  Schaeffer.  Bursa  pharyngea  und  Tonsilla  pharyngea. 
Monatsschrift  f.  Ohrenheilhunde,  Nr.  8,  S.  207.  As  quoted  in 
Hermann  u.  Schwalbe’s  Jahresbericht ,  Bd.  xvii,  319. 

10.  Schmidt,  F.  Th.  Das  folliculare  Driisengewebe  d. 
Schleimhaut  d.  Mundbohle  und  des  Schlundes,  etc.  Zeitsch.  f. 
wissensch.  Zoologie ,  Bd.  xiii,  S.  221. 

11.  Schwabacb,  D.  Ueber  die  Bursa  pharyngea.  Archiv 
f.  milcrosc.  Anatomie ,  Bd.  xxix,  S.  61. 

12.  Schwabach.  Zur  Entwickelung  der  Rachentonsille.  Ar¬ 
chiv  f.  milcrosc.  Anatomie ,  Bd.  xxxii,  S.  187. 

13.  Spicer,  Scaner.  The  Tonsils  (Faucial,  Lingual,  Pharyn¬ 
geal,  and  Discrete):  Their  Functions  and  Relation  to  Affections 
of  Throat  and  Nose.  Lancet ,  1888,  ii,  No.  17,  805. 

14.  Stohr,  Philipp.  Ueber  Mandeln  und  Balgdriisen.  Vir¬ 
chow’s  Archiv,  Bd.  xcvii,  S.  211. 

15.  Swain,  H.  L.  Die  Balgdriisen  am  Zungengrunde  und 
deren  Hypertrophie.  Deutsch.  Archiv  f.  Min.  Med.,  Bd.  xxxix, 
S.  504. 

16.  Suchannek.  Beitrag  zur  normal,  u.  patbolog.  Anat.  des 
Rachengewolbes.  Ziegler  and  Nauw’erk,  review  in  Hermann 
u.  Schwalbe’s  Jahresber.,  Bd.  xvii,  S.  320. 


320 


TYNER:  PRELIMINARY  CAPSULOTOMY 

PRELIMINARY  CAPSULOTOMY 
IN  THE  EXTRACTION  OF  CATARACT. 

By  T.  J.  TYNER,  M.  D., 

AUSTIN,  TEXAS. 

Owing  to  the  great  amount  of  literature  recently  de¬ 
voted  to  the  subject  of  cataract  extraction,  I  owe  it  to  you 
as  a  matter  of  courtesy,  as  well  as  in  justice  to  myself,  to 
say  I  would  not  presume  to  bring  it  forward  now  had  I 
not  failed  after  diligent  search  to  find  a  precedent  for  the 
operation  which  I  shall  hereafter  describe,  and  which  I  be¬ 
lieve  possesses  some  merit.  The  nearest  approach  to  it  is 
in  opening  the  capsule  with  the  point  of  the  knife  as  it  en¬ 
ters  the  anterior  chamber  while  the  section  is  being  made 
and  with  which  you  are  all  familiar. 

The  leading  point  in  the  operation  is  in  making  the 
capsulotomy  the  primary  step,  thereby  enabling  the  operator 
to  deliver  the  lens  at  the  very  moment  the  corneal  section 
is  completed.  I  will  not  encroach  upon  your  time  with  the 
progressive  history  of  the  many  methods  devised  by  differ¬ 
ent  operators,  nor  with  the  details  of  this  operation  as  to 
instruments,  antiseptics,  after-treatment,  etc.,  as  they  differ 
in  no  essential  particular  from  the  generally  accepted  meas¬ 
ures  in  other  methods. 

Supposing  the  eye  to  be  now  ready.  A  Bowman  stop- 
needle  is  thrust  into  the  anterior  chamber — the  pupil  hav¬ 
ing  been  previously  dilated— the  point  of  which,  and  also 
the  entire  field  of  the  incision,  are  in  full  view. 

The  capsule  is  now  lacerated  in  its  upper  quadrant,  the 
line  of  incision  corresponding  to  the  upper  pupillary  curve 
of  the  iris.  In  this  manipulation  and  in  withdrawing  the 
needle,  the  greatest  care  should  be  observed  that  no  aque¬ 
ous  is  lost.  The  eye  is  now  practically  undisturbed  and  as 
favorable  for  the  corneal  section  as  before,  which  is  to  be 
done  quickly,  using  a  Graefe  knife,  preferably  rather  broad. 
When  the  section  is  finished,  pressure  with  the  flat  of  the 
blade  causes  the  corneal  opening  to  gape,  when  at  the  same 
moment  counter-pressure  with  the  fixing  forceps  below  aids 
the  expulsion  and  the  lens  glides  out  through  the  still  open 
pupil  with  surprising  ease. 

I  will  mention  here  that  the  lens,  having  no  choice,  or 
rather  no  other  avenue  of  escape,  almost  always  indicates  a 
tendency  to  tollow  the  knife  as  the  corneal  incision  is  pro¬ 
gressing,  and  when  it  is  finished  the  lens  is  partly  in  the  an¬ 
terior  chamber.  I  state  this  to  demonstrate  why  it  is  so 
promptly  delivered  and  that  the  foregoing  expression  is  not 
extravagant. 

The  operation  is  simple  throughout  and  easily  done, 
and  is  accomplished  when  the  most  difficult  part  in  other 
methods  begins.  An  additional  point  of  interest  is:  If  the 
lens  is  susceptible  of  being  dislocated— and  this  is  made 
manifest  so  soon  as  the  needle  touches  the  capsule — there 
is,  in  my  experience,  no  way  to  accomplish  it  so  perfectly 
and  harmlessly  as  with  the  needle  at  this  stage  of  the  op¬ 
eration.  This  is  somewhat  similar  to  Delgardo’s  method, 
and,  strange  to  say,  was  the  result  in  my  first  case,  which 
occurred  last  October.  Since  then  I  have  performed  the 
operation  twelve  times  with  a  good  result  in  each  one,  or,  to 
be  more  definite,  with  the  exception  of  two  cases,  the  result 


IN  EXTRACTION  OF  CATARACT.  [N,  Y.  Med.  Joob., 

was  far  better  than  that  formerly  achieved.  In  the  two 
cases  referred  to  there  was  severe  iritis  with  posterior  syn¬ 
echia,  and  in  four  others  it  was  manifest,  but  only  in  a  very 
mild  form.  In  the  remaining  six  cases  there  was  absolutely 
no  reaction.  I  am  inclined  to  think  the  iritis  was  in  part 
due  to  the  excessive  strength  of  the  atropine  used  in  dilat¬ 
ing  the  pupil,  which,  a  few  hours  after  the  operation,  reas¬ 
serts  itself,  hence  crowding  the  iris  nearer  the  corneal 
wound.  I  now  use  the  weakest  solution  of  atropine  that 
will  serve  the  purpose.  Eserine  might  be  useful  in  some 
cases,  though  as  yet  I  have  not  felt  the  necessity  of  resort¬ 
ing  to  it. 

I  neglected  to  mention  in  the  foregoing  statement  that 
in  three  of  the  cases  the  lenses  were  extracted  in  their  cap¬ 
sules. 

If  you  will  now  bear  with  me  a  few  moments  longer, 
and  I  trust  not  without  interest,  I  will  relate  the  circum¬ 
stances,  which  by  the  way  were  partly  accidental,  that  led 
up  to  the  development  of  the  operative  procedure  above 
described.  In  July,  1885,  I  operated  on  a  Mexican,  and 
while  I  was  opening  the  capsule,  having  done  an  iridectomy, 
fluid  vitreous  escaped  so  rapidly  that  the  globe  was  so  col¬ 
lapsed  that  the  lens  could  only  be  delivered  by  the  aid  of 
the  iris  forceps,  having  fallen  into  the  posterior  chamber. 
Singular  to  say,  there  was  a  good  recovery  with  useful 
vision,  which  result  encouraged  me  a  few  weeks  later  to 
attempt  the  extraction  in  the  other  eve.  Anticipating  the 
same  condition  of  vitreous,  the  thought  suggested  itself  to 
open  the  capsule  with  a  needle  previous  to  making  the  cor¬ 
neal  section.  This  was  successfully  performed,  and,  while 
there  was  loss  of  vitreous  (fluid),  it  was  slight  compared  to 
the  first.  This  case  is  recorded  in  the  published  statistics  of 
Texas  surgery  in  1886.  This  little  procedure  passed  out  of 
my  mind  until  the  discussion  became  so  general  in  regard  to 
a  return  to  the  simple  extraction,  which  later  on  was  adopted 
by  most  operators.  It  was  not  my  wish  to  give  up  the  iridec- 
tomy,  but  in  the  mean  time,  however,  I  had  several  cases  in 
which  the  lens  popped  out  through  the  pupil  just  as  the 
section  was  completed — one  in  which  I  had  opened  the 
capsule  with  the  point  of  the  knife  as  it  entered  the  anterior 
chamber,  the  patient  at  the  moment  the  section  was  fin¬ 
ished  squeezing  the  eye.  Another  case  was  traumatic,  in 
which  the  particle  of  steel  could  be  distinctly  seen  in  the 
lens,  which  had  thoroughly  lacerated  the  capsule.  This  was 
a  fac-simile  of  the  preceding  case,  the  fragment  of  steel 
coming  with  the  lens.  This  case,  together  with  others,  im¬ 
pressed  upon  my  mind  that  the  lens  indicated  a  tendency 
to  escape,  and,  as  a  natural  consequence,  sought  the  course 
of  least  resistance.  LTpon  this  hypothesis  I  endeavored  to 
make  the  simple  extraction  in  this  way — i.  e.,  by  opening 
the  capsule  with  the  point  of  the  knife  ;  but  it  was  attended 
by  so  many  failures  to  make  the  rapid  extraction  without 
injury  to  the  iris  that  I  abandoned  it.  About  this  time  I 
recalled  to  mind  the  preliminary  capsulotomy  done  with  the 
needle  in  1885,  which  a  few  months  later  (after  returning 
from  my  summer  vacation)  I  put  into  practice  with  the 
results  as  above  given. 


Sept.  20,  1890.] 


LEADING  ARTICLES. 


321 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  SEPTEMBER  20,  1890. 


THE  ACTION  OF  MICROBIAL  PRODUCTS  ON  MICROBES  AND 
ON  THE  ORGANISM. 

“  Microbes  are  always  the  indispensable  cause  of  virulence; 
they  are  always  the  cause  of  immunity,  I  dare  not  say  the  in¬ 
dispensable  cause,  but  they  only  produce  their  effects  by  means 
of  the  chemical  matters  that  they  secrete.”  With  these  words 
Professor  Bouchard  premises,  in  the  Revue  de  medecine  for 
July,  one  of  the  most  comprehensive  studies  of  the  action  of 
the  products  secreted  by  pathogenic  micro-organisms  that  have 
appeared.  The  subject  has  been  studied  experimentally  by  the 
action  of  bacterial  products  on  microbes;  by  the  action,  both 
harmful  and  useful,  of  these  products  on  the  animal  organism ; 
by  the  action  that  the  products  of  a  microbe  exercise  on  the 
infection  produced  not  only  by  that  but  also  by  another  mi¬ 
crobe;  and  by  an  examination  of  the  measures  by  which  these 
products  influence  infection,  by  their  action  both  on  the  mi¬ 
crobe-destroying  state  of  the  humors  and  on  phagocytosis. 

The  products  of  the  vitality  of  a  microbe,  as  of  all  living 
cells,  are  multiple.  Many  of  these  substances  are  not  toxic, 
but  the  toxic  matters  of  a  single  kind  of  microbe  are  numerous; 
they  are  diastases,  alkaloids,  volatile  acids,  etc.  And  the  author 
believes  that  the  inoculable  are  distinct  from  the  toxic  matters. 
Among  the  local  lesions  of  infection,  the  chemical  alterations 
of  tissue  depend  on  diastase,  but  it  is  extremely  probable  that 
the  paralysis  of  the  leucocytes,  the  obstacle  to  phagocytosis,  is 
due  to  some  other  toxic  substances,  called  toxines.  Infectious 
fever  seems  to  be  due  to  diastatic  substances,  and  perhaps  to 
certain  cellular  alterations  that  occur  in  the  liver,  kidneys,  and 
muscles,  while  any  nervous  phenomena  depend  on  the  toxines. 
Whatever  the  substance  that  produces  immunity,  it  is  not  be¬ 
lieved  that  it  is  a  diastase. 

The  conclusions  deduced  from  the  experiments  seem  to 
prove  that  among  the  substances  secreted  by  microbes  is  a  sub¬ 
stance  capable  of  injuring  directly  the  development,  multiplica¬ 
tion,  and  secretion  of  the  micro-organism,  although  this  is  indi¬ 
rectly  favorable  to  the  microbe  by  chemically  modifying  the 
environment.  There  are  substances  secreted  by  a  microbe  that 
are  either  inhibitory  or  favorable  for  microbes  of  other  species. 
There  are  microbes  that  secrete  substances  poisonous  to  ani¬ 
mals,  and  it  is  this  toxicity  that  constitutes  the  virulence  of  a 
microbe. 

While  there  are  pathogenic  microbes  that  secrete  inoculable 
matter,  it  is  not  by  its  presence  alone  that  this  matter  pro¬ 
duces  immunity,  for  in  some  way  the  inoculable  matters  so 
impress  the  animal  organism  that  even  when  they  are  elimi¬ 
nated  the  humors  permanently  remain  less  propitious  to  the 
vitality  of  the  same  microbe.  The  inoculable  substances 


change  the  activity  of  the  cells  in  some  fashion,  so  that  even 
when  eliminated  the  leucocytes,  though  confronted  by  the 
same  microbe,  more  abundantly  effect  diapedesis  and  more  en¬ 
ergetically  accomplish  their  phagocytic  function. 

Though  the  soluble  matters  of  a  microbe  when  injected  at 
the  same  time  with  an  inoculation  of  the  same  microbe  render 
the  infection  more  intense,  yet  the  same  matters  injected  some 
days  before  inoculation,  far  from  aggravating  the  infection,  in¬ 
hibit  or  attenuate  it.  With  antagonistic  microbes — that  is  to 
say,  those  in  which  a  simultaneous  inoculation  generally  devel¬ 
ops  one  only — it  is  noticed  that  the  soluble  matters  of  the 
stronger  inhibit  the  weaker,  though  if  injected  at  the  same  time 
with  an  inoculation  of  the  weaker  they  produce  a  moderation 
and  attenuation  of  the  infection  most  pronounced  if  given  in 
the  same  locality.  Auxiliary  microbes  may,  by  the  inoculation 
of  one  or  the  injection  of  its  soluble  products,  allow  the  other 
to  develop  in  an  animal  that  is  naturally  refractory,  though,  in 
case  the  virulence  of  the  microbe  should  be  slowly  attenuated, 
it  would  only  develop  in  an  unrefractory  animal. 

The  bacteria-destroying  condition  of  the  animal  organism 
produced  by  the  injection  of  bacterial  matters  should  appear  at 
the  end  of  the  first  twenty-four  hours ;  and  it  is  neither  sup¬ 
pressed  nor  suspended  by  a  new  injection  of  such  substances 
as  have  conferred  the  immunity.  In  animals  that  have  a  natu¬ 
ral  or  acquired  immunity,  and  that  are  capable  of  resisting  a 
pathogenic  microbe  by  phagocytosis,  the  soluble  products  of 
that  microbe  would  inhibit  phagocytosis,  while  in  animals 
having  no  immunity,  natural  or  acquired,  but  capable  of  resist¬ 
ing  non-pathogenic  or  attenuated  pathogenic  microbes  by 
phagocytosis,  the  products  of  a  virulent  microbe  will  inhibit  the 
phagocytosis.  These  results  prompt  the  question  of  what 
other  substances,  microbial  or  not,  can  produce  the  same  effect 
on  phagocytosis,  or  is  the  latter  the  mechanism  by  which  they 
act? 


(ESOPHAGEAL  VARIX  A  CAUSE  OF  HA3MATEMESIS. 

Sudden  death  by  hsematemesis  is  a  not  uncommon  event  in 
cirrhosis  of  the  liver,  and  cases  where,  without  any  warning, 
a  person  habitually  intemperate  vomits  blood  occur  with  suffi¬ 
cient  frequency  to  render  the  study  of  the  exact  mechanism  of 
the  haemorrhage  a  matter  of  some  importance.  Latterly  the 
whole  question  of  portal  obstruction  and  its  effects  has  been 
receiving  a  good  deal  of  attention.  Litten  ( Berliner  klinische 
Wochenschrift)  has  been  experimenting  upon  the  circulation  in 
the  liver  of  dogs  and  studying  the  clinical  phenomena  in  portal 
obstruction.  In  five  cases  of  hepatic  cirrhosis  where  death  was 
caused  by  vomiting  of  blood  he  has  found  that  the  fatal  out¬ 
flow  came  from  the  rupture  of  enormous  varicosities  situated 
at  the  lower  end  of  the  oesophagus.  For  the  whole  extent  of 
its  course  the  gullet  is  richly  supplied  with  veins,  and  of  these 
the  upper  ones,  by  means  of  the  inferior  thyreoid  veins,  empty 
into  the  superior  vena  cava,  while  the  veins  supplying  the  lower 
part  of  the  tube  form  above  the  cardia  a  large  plexus  communi¬ 
cating  but  in  a  very  slight  degree  with  the  portal  vein,  and 
emptying  mainly  into  the  vena  azygos.  When,  as  occurs  in 


322 


MINOR  PARAGRAPHS. 


[H.  Y.  Med.  Jotjk. 


cirrhosis  of  the  liver,  the  flow  of  blood  in  the  portal  vein  be¬ 
comes  obstructed,  its  blood  passes  for  the  most  part  into  the 
vena  azygos,  which  conducts  it  directly  to  the  superior  vena 
cava.  The  blood  of  the  gastric  coronary  veins  and  that  of  the 
gastro-duodenal  veins  especially  passes  in  this  direction.  As  a 
result,  the  vena  azygos,  already  overloaded,  can  not  receive  all 
the  blood  of  the  oesophageal  plexus,  hence  the  formation  of 
varices  the  rupture  of  which  gives  rise  to  a  hasmatemesis  and 
leads  to  the  supposition  that  the  vessels  in  the  stomach  have 
given  way. 

The  same  subject  occupied  the  attention  of  the  Section  in 
Medicine  at  the  recent  meeting  of  the  British  Medical  Associa¬ 
tion  at  Birmingham.  The  liability  to  sudden  death  from  hm- 
matemesis  in  cases  where  there  was  no  ascites,  or  in  fact  any 
symptoms,  was  emphasized  in  Dr.  Saundby’s  paper  on  the  Va¬ 
rieties  of  Hepatic  Cirrhosis.  Dr.  Stacy  Wilson’s  paper  dealt 
especially  with  varices  as  a  cause  of  hasmatemesis  in  cirrhosis 
of  the  liver.  He  drew  attention  to  the  dilatation  which  took 
place  in  the  veins  in  the  lower  part  of  the  oesophagus,  which  in 
some  cases  prevented  ascites,  and  pointed  out  the  effect  of  the 
sphincter  of  the  cardiac  end  of  the  stomach  in  preventing  the 
blood  of  the  coronary  vessels  from  getting  into  the  oesophageal 
branches  in  normal  conditions,  but  said  that,  when  portal  ob¬ 
struction  occurred,  the  tension  in  the  coronary  vessels  over¬ 
came  the  action  of  the  sphincter,  and  the  oesophageal  veins  be¬ 
came  varicose  and  might  rupture.  He  thought  this  was  a  com¬ 
mon  cause  of  hmmatemesis.  He  had  found  oesophageal  varices 
in  five  cases  of  hepatic  cirrhosis,  and  in  most  of  these  there  was 
rupture.  Dr.  Ratcliffe  exhibited  specimens  of  varicose  ulcers 
in  the  oesophagus  and  one  in  which  there  was  thrombosis  of 
one  of  the  oesophageal  veins,  from  cases  of  hepatic  cirrhosis  in 
which  hasmatemesis  had  occurred. 


MINOR  PARAGRAPHS. 

FATAL  POISONING  BY  MUSSELS. 

Sir  Charles  Cameron,  M.  D.,  of  Dublin,  contributes  to  the 
British  Medical  Journal  a  preliminary  note  regarding  the  Sea- 
point  tragedy  from  mussel  poisoning,  whereby  five  persons  lost 
their  lives.  At  Seapoint,  near  Dublin,  a  family  of  seven,  con¬ 
sisting  of  the  mother,  her  five  children,  and  a  maid-servant,  par¬ 
took  of  a  meal  of  stewed  mussels.  They  were  all  made  sick 
within  twenty  minutes  after  the  ingestion  of  the  meal,  and  in 
an  hour  one  of  the  children  was  dead.  The  mother  and  three 
other  children  succumbed  before  the  second  hour  had  elapsed. 
The  symptoms  began  with  the  pain  of  pins  and  needles  in  the 
hands.  Graver  symptoms  followed  rapidly,  such  as  vomiting, 
dyspnoea,  swelling  of  the  face,  loss  of  co-ordination  in  move¬ 
ment,  convulsions,  and  spasmodic  movements  of  the  arms. 
Death  appeared  to  take  place  by  asphyxia,  the  faces  being  in¬ 
tensely  livid.  One  child  and  the  servant,  who  probably  ate 
only  a  few  of  the  mussels,  recovered.  The  pond  whence  the 
shell-fish  were  obtained  is  a  small  body  of  water  to  which  the 
sea  has  access  at  high  tide;  it  also  receives  fresh  water  and 
some  sewage.  The  water  at  high  tide  shows  twice  as  much 
saltness  as  when  the  tide  is  out.  The  drainage  from  the  land  is 
necessarily,  from  certain  local  conditions,  impure.  The  un¬ 
cooked  mussels  that  remained  at  the  place  of  poisoning  differed 


from  other  mussels  obtained  from  the  open  sea  in  having  much 
larger  livers,  and  their  shells  were  very  brittle.  The  generic 
tests  applied,  in  order  to  discover  if  an  alkaloid  was  present 
clearly  proved  that  a  leucomaine  existed,  which,  indeed,  was 
obtained  in  crystals,  visible  under  the  microscope,  and  corre¬ 
sponding  to  the  substance  that  Brieger  has  described  as  occur¬ 
ring  in  the  poisonous  mussels  examined  by  him.  The  quantity 
of  the  leucomaine  thus  separated  by  Dr.  Cameron  was  insuffi¬ 
cient  for  a  thorough  examination,  and  it  became  necessary  for 
him  to  procure  a  further  supply  of  the  shell-fish  from  the  pond 
above  mentioned.  He  expects  to  extract  therefrom  a  substan¬ 
tial  quantity  of  the  leucomaine,  for  the  purpose  of  a  complete 
identification  of  it  with  the  mytilotoxine,  C8H6H02,  of  Brieger. 
The  Seapoint  calamity  is  another  instance  of  poisonous  shell¬ 
fish  being  the  product  of  a  foul  or  stagnant  water.  The  liver 
of  the  poisonous  fish  becomes  the  seat  of  disease  and  generates 
the  leucomaine,  the  disease  in  question  probably  being  the  re¬ 
sult  of  the  injurious  action  of  its  food  supplied  from  a  contami¬ 
nated  pond-water.  Dr.  Cameron  states  that  he  has  examined 
the  literature  bearing  upon  mussel  poisoning,  and  has  found 
that  many  of  the  waters  whence  the  mussels  have  been  ob¬ 
tained  were  stagnant  or  impregnated  with  sewage. 


THE  AMERICAN  DERMATOLOGICAL  ASSOCIATION. 

The  Richfield  meeting  of  the  association  was  a  most  success¬ 
ful  one.  To  this  two  factors  contributed  :  First,  the  character 
of  the  scientific  work;  secondly,  the  liberal  hospitality  of  Mr. 
Proctor,  the  owner  of  the  new  bathing  establishment,  and  the 
courtesy  of  Dr.  C.  C.  Ransom,  the  medical  superintendent. 
Elsewhere  we  give  an  abstract  of  the  scientific  proceedings;  it 
is  our  purpose  now  to  note  the  social  side  of  the  meeting  alone. 
The  association  assembled  on  a  Tuesday  morning  in  the  sola¬ 
rium  of  the  new  bathing  establishment.  After  dinner  the  mem¬ 
bers  were  driven  around  Lake  Canadarago.  In  the  evening  the 
grounds  of  the  Spring  House  were  illuminated  with  Chinese 
lanterns  and  the  members  were  conducted  through  all  parts  of 
the  well-equipped  bath-house.  After  the  evening  meeting  a 
supper  was  given  in  Dr.  Ransom’s  offices.  On  Wednesday 
afternoon,  by  Mr.  Proctor’s  invitation,  the  members  went  to 
Lake  Otsego,  some  twelve  miles  off,  and  partook  of  a  fish  and 
game  dinner.  The  entire  service  of  the  baths  was  placed  at 
their  disposal  for  the  time  being.  The  baths  themselves  are 
deserving  of  special  mention.  For  size,  arrangement,  and  com¬ 
pleteness  they  are  unsurpassed.  They  are  arranged  in  two 
corresponding  halves  for  the  two  sexes,  each  half  containing 
some  thirty-eight  separate  baths  with  a  large  resting  room,  and 
a  complete  Turkish  bath.  Besides  these  there  are  a  swimming 
bath,  inhalation  and  pulverization  rooms,  gymnasia,  a  solarium, 
doctor’s  offices,  a  drinking  fountain,  a  bazaar,  a  barber’s  shop, 
and  a  chiropodist’s  room.  The  whole  establishment  is  watched 
over,  as  well  as  the  persons  who  use  it,  by  the  very  competent 
medical  superintendent.  The  association  elected  officers  for  the 
ensuing  year  as  follows:  Dr.  F.  B.  Greenough,  of  Boston,  presi¬ 
dent;  Dr.  L.  H.  Denslow,  of  St.  Paul,  vice-president;  and  Dr. 
G.  T.  Jackson,  of  Hew  York,  secretary  and  treasurer.  Four 
new  members  were  elected,  namely,  Dr.  J.  A.  Fordyce  and  Dr. 
C.  W.  Cutler,  of  Hew  York;  Dr.  M.  B.  Hartzell,  of  Philadel¬ 
phia  ;  and  Dr.  J.  Grindon,  of  St.  Louis. 


A  NEW  CULTURE  FLUID. 

Dr.  G.  M.  Sternberg  gives  the  Medical  News  a  short  note, 
interesting  to  laboratory-workers  and  others,  on  the  use  of  the 
j  fluid  contained  in  unripe  cocoanuts  as  a  culture  medium.  This 


Sept.  20,  1890.] 


MINOR  PA  RA  GRAPHS.— ITEMS. 


323 


fluid,  unlike  that  of  the  ripe  nut,  is  devoid  of  all  milky  appear¬ 
ance  and  is  perfectly  transparent.  By  the  people  of  the  West 
Indies  it  is  known  as  agua  coco,  or  cocoanut  water,  and  is  very 
popular  as  a  refreshing  drink;  at  the  railway  stations  and  res¬ 
taurants  may  be  seen  piles  of  the  unripe  nuts,  which  at  a  mo¬ 
ment’s  notice  can  be  broken  open  and  made  to  yield  a  tumbler¬ 
ful  of  the  fluid  at  a  trifling  cost.  The  cocoanut  is  a  germ-proof 
receptacle,  and,  if  care  is  taken  in  the  removal  of  its  fluid,  the 
latter  requires  no  sterilization  at  the  time  of  its  reception  into 
the  bacteriologist’s  tubes  or  flasks.  Dr.  Sternberg  has  been 
able  to  store  it  away  almost  indefinitely  for  future  use,  the  fluid 
remaining  perfectly  transparent  and  ready  for  immediate  use. 
Heating  the  fluid  will  cause  in  it  a  slight  precipitate.  He  has 
employed  this  medium  quite  extensively  during  the  past  two 
years,  although  he  has  been  cognizant  of  some  of  its  properties 
since  1879,  and  has  found  it  of  great  convenience.  Certain 
micro-organisms  multiply  in  it  more  rapidly  than  others  in  con¬ 
sequence  of  its  slightly  acid  reaction  when  first  obtained  from 
the  nut.  This  reaction  makes  it  unsuitable  for  cultures  of  cer¬ 
tain  of  the  pathogenic  bacteria,  but,  when  desired,  it  is  a  sim¬ 
ple  matter  to  neutralize  it.  A  detailed  chemical  analysis  of  the 
fluid  is  given  in  the  paper. 


THE  FAITH  CURE  AND  MANSLAUGHTER. 

A  very  sad  occurrence  in  connection  with  the  faith  cure  is 
reported  from  Toronto.  Mr.  John  Kent,  a  well-known  citizen, 
had  been  the  subject  of  diabetes  for  several  years,  but  had  been 
in  a  state  of  fair  general  health  and  in  a  condition  to  attend  to 
his  business.  On  the  advice  of  his  physician  be  had  adopted  a 
form  of  diet  under  the  use  of  which  the  sugar  in  the  urine  was 
said  to  he  diminishing  in  quantity  and  the  patient  to  be  gaining 
in  health  and  strength.  Not  satisfied  with  the  progress  he  was 
making,  he  put  himself  in  the  hands  of  the  Christian  scientists, 
jvho  were  both  numerous  and  popular  in  Toronto.  The  usual 
process  of  faith  cure  was  gone  through  with.  He  was  told  to 
eat  what  he  pleased,  did  so,  and  died  of  diabetic  coma.  A  coro¬ 
ner’s  inquest  was  held,  which  ended  in  a  verdict  of  manslaughter 
against  Mrs.  Stewart,  the  so-called  scientist,  “in  that  he  (Kent) 
came  to  his  death  through  the  gross  ignorance  of  Mrs.  Stewart, 
who  undertook  to  cure  him  of  his  disease,  in  not  advising  him 
to  continue  the  restricted  diet  prescribed  by  his  former  physi¬ 
cian.”  The  coroner,  after  summing  up  the  evidence,  charged 
directly  against  the  accused.  When  cross-examined,  Mrs.  Stew¬ 
art  admitted  that  she  knew  very  little  of  medical  science.  She 
was  arrested  and  held  in  bail  to  stand  her  trial  for  manslaughter 
at  the  next  session  of  the  Court  of  Queen’s  Bench. 


KEFIR. 

Professor  Uffelmann,  of  Vienna,  has  made  an  examination 
of  that  preparation  of  milk  called  kefir,  which  has  recently 
been  lauded  by  physicians  of  Berlin  and  Paris  as  well  as  Vi¬ 
enna  for  its  power  of  assisting  stomach  digestion,  strengthening 
the  nervous  system,  and  increasing  the  weight  of  the  body. 
According  to  the  Medical  Press  and  Circular ,  he  finds  that  the 
kefir  ferment  converts  the  milk  into  alcohol,  carbonic  acid, 
hemi-albumose,  and  peptone  compounds.  The  casein  is  broken 
up  into  small  particles  in  combination  with  the  fat,  forming  a 
kind  of  emulsion.  Uffelmann  holds  that  the  lactic  acid  converts 
the  casein  into  very  fine  coagula,  and  relieves  the  gastric  acid  of 
a  great  part  of  its  work.  The  carbonic  acid  increases  peristalsis 
and  the  flow  of  the  gastric  juice.  The  peptones  and  alcohol  make 
the  combination  better  borne  and  cause  it  to  contribute  to  nu¬ 
tritive  accumulation  and  assimilation.  These  are  the  reasons, 


he  thinks,  for  the  growing  repute  of  kefir  as  a  means  to  the 
rapid  increase  of  the  weight  of  the  body. 


SPERMINE. 

According  to  Le  Mercredi  medical ,  Dr.  Pohl,  of  St.  Peters¬ 
burg,  believes  that  certain  crystals  found  in  semen  are,  as  stated 
by  Schreider,  the  phosphate  of  an  organic  base,  spermine,  that 
is  identical,  according  to  Laderberg  and  Obel,  with  ethyleni- 
mine.  Dr.  Pohl  has  extracted  spermine  from  the  testicles  of 
young  rabbits,  and  finds  experimentally  that  it  decreases  the 
action  of  the  heart  while  it  increases  general  energy  and  stimu¬ 
lates  the  nervous  and  genital  systems.  He  believes  that  the 
action  of  castoreum  and  musk  is  due  to  the  presence  of  sper¬ 
mine. 


THE  URINE  OF  OPIUM  HABITUES. 

Dr.  J.  B.  Mattison,  of  the  Brooklyn  Home  for  Habitues, 
writes  to  us  concerning  a  statement  that  he  has  met  with  in 
contemporary  periodical  medical  literature,  to  the  effect  that 
the  addition  of  tincture  of  chloride  of  iron  to  the  urine  of  a 
subject  of  the  opium  habit  will  produce  a  blue  tint  showing  the 
presence  of  morphine.  Dr.  Mattison  declares  that  the  state¬ 
ment  is  not  true. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  September  16,  1890  : 


DISEASES. 

Week  ending  Sept.  9. 

W  eek  ending  Sept.  16. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

30 

10 

67 

13 

Scarlet  fever . 

17 

1 

39 

1 

Cerebro-spinal  meningitis . 

1 

1 

1 

1 

Measles . 

78 

9 

32 

3 

Diphtheria . 

43 

14 

47 

19 

The  American  Gynaecological  Society. — The  members  in  attendance 
at  the  Buffalo  meeting  were  entertained  on  Thursday  by  the  Buffalo 
Medical  Club  with  an  excursion  to  Niagara  and  a  dinner  on  the  return 
to  Buffalo. 

The  Randall’s  Island  Hospital. — Dr.  James  R.  Goffe  has  been  ap¬ 
pointed  visiting  gynaecologist  to  the  hospital. 

The  Jenkins  Medical  Association,  of  Yonkers,  will  hold  its  regular 
meeting  at  the  house  of  Dr.  N.  A.  Warren,  on  Thursday  evening,  the 
26th  inst.  Dr.  C.  W.  Packard,  of  New  York,  will  read  a  paper  on  Sur¬ 
gical  Insomnia. 

The  late  Dr.  Silas  H.  Douglas. — At  a  meeting  of  the  Department 
of  Medicine  and  Surgery  of  the  University  of  Michigan,  held  on  the 
4th  of  September,  1890,  the  following  minute  was  adopted,  with  direc¬ 
tion  that  it  be  entered  in  the  records  of  the  faculty : 

“  Silas  Hamilton  Douglas,  one  of  the  founders  of  this  department 
of  the  university  and  for  twenty-eight  years  a  member  of  this  faculty, 
died  in  Ann  Arbor,  August  26,  1890,  at  the  age  of  seventy-four  years. 
He  was  one  of  a  very  few  strong  men  of  steady  purpose,  who  opened  a 
way  for  medical  education  in  this  State,  and  from  the  first  determined 
that  broader  foundations  should  be  laid  for  the  support  of  medical 
learning.  Elected  as  professor  of  chemistry  in  this  university  on  Au¬ 
gust  6,  1846,  he  was  soon  active  in  those  movements  which  obtained 
the  adoption  by  the  Board  of  Regents  of  a  plan  for  the  organization 
of  a  department  of  medicine,  presented  by  Dr.  Zina  Pitcher  and  others, 
January  17,  1848.  His  interest  in  medicine  was  direct  and  personal; 
he  had  entered  upon  practice  as  a  physician  before  he  became  a  college 
teacher,  and  in  the  beginning  of  the  medical  school  he  held  for  a  time 


324 


ITEMS. 


[N.  Y.  Mkd.  Jour., 


the  chair  of  materia  medica  in  addition  to  that  of  chemistry.  Dr. 
Douglas  was  one  of  the  original  members  of  this  body  who  have 
served,  each  in  turn  for  a  considerable  period,  as  the  dean  of  the  fac¬ 
ulty.  Of  these  but  one  remains  with  us,  now  our  honored  presiding 
officer,  a  witness  of  the  growth  of  medical  education,  rising  evenly  and 
surely  upon  the  foundations  laid  by  these  fathers.  Early  in  the  build¬ 
ing  of  the  foundations  Professor  Douglas  set  out  to  provide  for  the 
laboratory  method  of  study,  then  nearly  unknown  in  medical  schools, 
yet  a  method  which  lias  become  characteristic  of  the  finest  training  of 
the  time.  When  Dr.  Douglas  had  labored  in  the  university  for  ten 
years,  on  May  8,  1856,  the  Board  of  Regents  made  provision  for  the 
erection  of  a  building  under  his  charge  to  serve  as  a  chemical  labora¬ 
tory.  Of  this  it  is  stated  in  President  Tappan’s  annual  report  of  the 
following  year  that  it  was  ‘  one  of  the  most  complete  and  efficient  in 
our  country.’  To  this  and  its  development  Professor  Douglas  gave  the 
best  years  of  his  life.  It  was  due  to  the  indomitable  courage  and  un¬ 
yielding  perseverance  strongly  knit  in  his  sturdy  nature  that  laborato¬ 
ries  of  science  gained  an  early  and  vigorous  growth  in  this  institution. 
And  it  was  through  his  interest  in  medical  education  that  medical  stu¬ 
dents  received  the  best  of  laboratory  opportunities.  A  stanch  defender 
of  the  interests  of  tbe  Department  of  Medicine  and  Surgery,  he  was 
confident  of  its  future  strength  and  service.  To  him  and  his  early 
associates  in  medical  education  a  great  debt  of  gratitude  is  due.  We 
remember  his  services  with  thanksgiving  and  write  his  name  with 
honor. 

“  To  his  family  and  his  relatives  we  desire  to  extend  our  sympa¬ 
thies,  and  we  invoke  for  them  the  consolations  of  the  religious  faith 
which  he  sustained.” 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army ,  from  August  31  to  September  13,  1890  : 

De  Witt,  Theodore  P.,  First  Lieutenant  and  Assistant  Surgeon,  is 
granted  leave  of  absence  for  one  month,  to  take  effect  September 
15,  1890.  S.  0.  *76,  Headquarters  Department  of  Texas,  San  An¬ 
tonio,  Texas,  September  1,  1890. 

Appointment. 

Baxter,  Jedediah  H.,  Colonel  and  Chief  Medical  Purveyor.  To  be 
Surgeon-General,  with  the  rank  of  brigadier-general,  August  16, 
1890,  vice  Moore,  retired  from  active  service.  Headquarters  of  the 
Army,  A.  G.  0.,  Washington,  September  1,  1890. 

By  direction  of  the  Acting  Secretary  of  War,  a  board  of  medical  offi¬ 
cers,  to  consist  of  Vollum,  Edward  P.,  Colonel  and  Surgeon;  Stern¬ 
berg,  George  M.,  Major  and  Surgeon ;  Hartsuff,  Albert,  Major 
and  Surgeon;  Hopkins,  William  E.,  Captain  and  Assistant  Sur¬ 
geon,  is  constituted  to  meet  in  New  York  city  on  October  15,  1890, 
or  as  soon  thereafter  as  practicable,  for  the  examination  of  candi¬ 
dates  for  admission  into  the  medical  corps  of  the  army.  Par.  8, 
S.  0.  213,  A.  G.  0.,  Washington,  D.  C.,  September  11,  1890. 
Corson,  Joseph  K.,  Major  and  Surgeon,  is  relieved  from  duty  at  Fort 
Sherman,  Idaho,  by  direction  of  the  Acting  Secretary  of  War,  and 
will  report  in  person  to  the  commanding  officer,  W ashington  Bar¬ 
racks,  District  of  Columbia,  for  duty  at  that  station.  Par.  4,  S.  0. 
212,  A.  G.  0.,  September  10,  1890. 

By  direction  of  the  Acting  Secretary  of  War,  the  following  changes  in 
the  stations  and  duties  of  officers  of  the  medical  department  are 
ordered:  Hf.izmann,  Charles  L.,  Major  and  Surgeon,  is  relieved 
from  duty  at  San  Antonio,  Texas,  and  will  report  in  person  to  the 
commanding  officer  at  Fort  Clark,  Texas,  for  duty  at  that  station, 
to  relieve  Moseley,  Edward  B.,  Captain  and  Assistant  Surgeon,  who, 
upon  being  relieved  by  Major  Heizmann,  will  report  in  person  to 
the  commanding  officer  at  San  Antonio,  Texas,  for  duty  at  that 
station.  Par.  23,  S.  0.  211,  A.  G.  0.,  Washington,  D.  C.,  September 
9,  1890. 

Carter,  Edward  C.,  Captain  and  Assistant  Surgeon,  is  granted  leave 
of  absence  for  one  month.  Par.  2,  S.  0.  108,  Headquarters  De¬ 
partment  of  the  Columbia,  September  6,  1890. 

Jarvis,  Nathan  S.,  First  Lieutenant  and  Assistant  Surgeon,  is  relieved 
from  duty  at  Fort  Verde,  Arizona  Territory,  by  direction  of  the  Act¬ 


ing  Secretary  of  War,  and  will  report  in  person  to  the  commanding 
officer,  San  Carlos,  Arizona  Territory,  for  duty  at  that  station.  Par. 
2,  S.  0.  208,  A.  G.  0.,  Washington,  D.  C.,  September  5,  1890. 

Woodhull,  A.  A.,  Major  and  Surgeon,  is  granted  leave  of  absence  for 
one  month,  on  surgeon’s  certificate  of  disability,  with  permission  to 
go  beyond  the  limits  of  the  department.  Par.  1,  S.  0.  122,  Depart' 
ment  of  the  Missouri,  September  5,  1890. 

Wood,  Leonard,  First  Lieutenant  and  Assistant  Surgeon.  Leave  of 
absence  for  one  month,  to  take  effect  on  or  about  October  20,  1890, 
is  hereby  granted,  with  permission  to  apply  for  an  extension  of  one 
month.  Par.  1,  S.  0.  74,  Department  of  California,  San  Francisco, 
Cal.,  August  30,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 

of  the  United  States  Navy  for  the  two  weeks  ending  September  13,  1890 : 

Wise,  J.  C.,  Surgeon.  Detached  from  Torpedo  Station  and  ordered  to 
the  U.  S.  Steamer  Alliance. 

Fitzsimons,  Paul,  Surgeon.  Ordered  to  the  Torpedo  Station,  Newport, 
R.  I. 

Bright,  George  A.,  Surgeon.  Detached  from  the  U.  S.  Steamer  Con¬ 
stellation  and  ordered  to  Naval  Academy. 

Olcott,  F.  W.,  Assistant  Surgeon.  Promoted  to  be  Passed  Assistant 
Surgeon. 

Wentworth,  A.  R.,  Passed  Assistant  Surgeon,  requests  to  withdraw 
resignation.  Granted. 

Crawford,  M.  H.,  Passed  Assistant  Surgeon.  Detached  from  the  U.  S 
Steamer  Monongahela  and  granted  two  months  leave  of  absence. 

Keeney,  James  F.,  Assistant  Surgeon.  Detached  from  the  U.  S. 
Steamer  Richmond  and  granted  two  months  leave  of  absence. 

Lowndes,  Charles  H.  T.,  Assistant  Surgeon.  Detached  from  Naval 
Academy  and  ordered  to  the  U.  S.  Steamer  Richmond. 

Woolverton,  Theoison,  Medical  Director.  Ordered  to  the  U.  S.  Steamer 
Philadelphia.  September  15,  1890. 

Penrose,  Thomas  N.,  Medical  Inspector.  Detached  from  the  U.  S. 
Steamer  Richmond. 

Gardner,  J.  E.,  Passed  Assistant  Surgeon.  Detached  from  the  U.  S. 
Fish-Commission  Steamer  Albatross. 

Drake,  N.  H.,  Passed  Assistant  Surgeon.  Detached  from  the  U.  S. 
Coast-Survey  Steamer  McArthur,  and  ordered  to  the  U.  S.  Fish. 
Commission  Steamer  Albatross. 

Berryhill,  T.  A.,  Passed  Assistant  Surgeon.  Detached  from  the  Hos¬ 
pital,  Mare  Island,  California,  and  ordered  to  the  U.  S.  Coast-Survey 
Steamer  McArthur. 

Heffinger,  A.  C.,  Passed  Assistant  Surgeon.  Ordered  before  Retiring 
Board,  October  1,  1890. 

Marine-Hospital  Service. —  Official  List  of  Changes  of  Stations  and 

Duties  of  Medical  Officers  of  the  United  States  Marine- Hospital  Service 

from  August  12  to  September  6,  1890 : 

Vansant,  John,  Surgeon.  Granted  leave  of  absence  for  thirty  days,  to 
take  effect  upon  return  of  Assistant  Surgeon  J.  C.  Perry  to  duty. 
September  5,  1890. 

Wyman,  Walter,  Surgeon.  To  proceed  to  Cape  Charles  Quarantine 
Station,  on  special  duty.  August  25,  1890. 

Stoner,  George  W.,  Surgeon.  Granted  leave  of  absence  for  four  days. 
August  19,  1890. 

Carmichael,  D.  A.,  Passed  Assistant  Surgeon.  Leave  of  absence  ex¬ 
tended  fifteen  days.  August  26,  1890. 

Ames,  R.  P.  M.,  Passed  Assistant  Surgeon.  To  proceed  to  Memphis, 
Tenn.,  on  temporary  duty. 

Devan,  S.  C.,  Passed  Assistant  Surgeon.  Leave  extended  five  days  on 
account  of  sickness.  August  12,  1890. 

Williams,  L.  L.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  thirty  days.  September  5,  1890. 

Goodwin,  H.  F.,  Assistant  Surgeon.  Granted  leave  of  absence  for  thirty 
days.  August  21,  1890. 

Cobb,  J.  0.,  Assistant  Surgeon.  To  proceed  to  Marine  Hospital,  De¬ 
troit,  Mich.,  for  duty.  August  16,  1890. 

Hussey,  S.  H.,  Assistant  Surgeon.  Granted  leave  of  absence  for  thirty 
days.  August  19,  1890. 


Sept.  20,  1890.] 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES. 


325 


Perry,  J.  C.,  Assistant  Surgeon.  Granted  leave  of  absence  for  twenty 
days,  to  take  effect  when  relieved.  September  3,  1890. 

Young,  G.  B.,  Assistant  Surgeon.  To  rejoin  his  station  at  St.  Louis, 
Mo.,  when  relieved.  September  3,  1890. 

Appointment. 

Rosenau,  Milton  J.,  Assistant  Surgeon.  Commissioned  as  an  Assistant 
Surgeon  by  the  President,  August  25,  1890.  Ordered  to  Chicago, 
Ill.,  for  temporary  duty.  August  27,  1890. 

Society  Meetings  for  the  Coming  Week  : 

Monday,  September  22d :  Medical  Society  of  the  County  of  New  York  ; 
Boston  Society  for  Medical  Improvement ;  Lawrence,  Mass.,  Medical 
Club  (private) ;  Cambridge,  Mass.,  Society  for  Medical  Improve¬ 
ment  ;  Baltimore  Medical  Association. 

Tuesday,  September  23d :  New  York  Dermatological  Society  (private) ; 
Buffalo  Obstetrical  Society  (private) ;  Medical  Society  of  the  County 
of  Lewis  (quarterly),  N.  Y. 

Wednesday,  September  2 Ifh :  New  York  Pathological  Society;  Ameri¬ 
can  Microscopical  Society  of  the  City  of  New  York  ;  Medical  So¬ 
ciety  of  the  County  of  Albany,  N.  Y. ;  Auburn  City,  N.  Y.,  Medical 
Association ;  Berkshire,  Mass.,  District  Medical  Society  (Pittsfield). 

Thursday,  September  25th  :  New  York  Orthopaedic  Society  ;  Brooklyn 
Pathological  Society ;  Roxbury,  Mass.,  Society  for  Medical  Improve¬ 
ment  (private) ;  New  London,  Conn.,  County  Medical  Society  (Extra 
— New  London) ;  Pathological  Society  of  Philadelphia. 

Friday,  September  26th  :  Yorkville  Medical  Association  (private) ;  New 
York  Society  of  German  Physicians  ;  New  York  Clinical  Society 
(private)  ;  Philadelphia  Clinical  Society ;  Philadelphia  Laryngological 
Society. 


letters  to  %  (Stoitor, 


HAEMORRHAGE  AFTER  AMYGDALOTOMY. 

Saratoga  Springs,  N.  Y.,  September  8,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  I  have  read  with  much  interest  Dr.  Jonathan  Wright’s 
article  on  Haemorrhage  after  Amygdalotomy,  in  the  Journal  for 
August  30th,  and  would  report  two  cases  that  have  occurred  in 
my  practice.  The  first  was  in  a  boy,  eleven  years  old.  The 
hypertrophied  right  tonsil  was  removed  with  Mathieu’s  amyg- 
dalotome  in  March,  1882.  The  haemorrhage  was  quite  pro¬ 
fuse,  but  was  controlled  with  styptic  applications  and  pressure 
on  the  cut  surface,  with  ice  externally  and  counter-pressure. 
The  other  case  was  that  of  a  young  lady,  eighteen  years  old, 
weighing  nearly  two  hundred  pounds,  and  extremely  nervous. 
I  had  attended  her  about  ten  years  before  in  a  fairly  seri¬ 
ous  attack  of  scarlet  fever,  and  at  that  time  both  tonsils 
were  somewhat  hypertrophied.  I  advised  their  removal  as 
aoon  as  she  was  well  from  the  fever,  but  nothing  was 
done  till  the  winter  of  1889,  when  I  used  Donaldson’s  treat¬ 
ment  (by  small  incisions  and  the  insertion  of  a  crystal  of 
chromic  acid  into  each  cut),  but  with  little  or  no  effect.  The 
removal  of  the  tonsils  was  declined  at  that  time.  Both  tonsils 
were  now  very  large,  the  left  one  pushing  the  uvula  to  one  side. 
On  June  29,  1889,  I  amputated  the  right  tonsil,  having  injected 
a  teu-per-cent.  solution  of  cocaine  into  it.  Rest  and  a  tanno- 
gallic-acid  gargle  were  used  after  the  operation;  the  bleeding 
was  very  slight,  and  there  was  little  or  no  pain.  On  July  14th 
I  removed  the  left  tonsil  in  the  same  manner.  It  was  hard  and 
leathery.  There  was  no  pain  in  its  removal,  but  there  was  a 
little  more  bleeding  than  at  the  other  operation.  I  left  the  pa¬ 
tient  comfortable  an  hour  later,  but  within  another  hour  I  was 
called,  and  found  that  she  had  had  profuse  haemorrhage ;  she 
was  pale,  had  no  pulse  at  the  wrist,  and  had  fainted  two  or 


three  times.  The  bleeding  was  controlled  by  applying  sponges 
saturated  with  solution  of  persulphate  of  iron  to  the  wound  and 
ice  externally,  firm  pressure  being  made  and  kept  up  for  an 
hour,  and  stimulants,  ergot,  gallic  acid,  and  opium  given  in¬ 
ternally.  She  made  a  good  recovery,  being  of  course  under 
treatment  for  some  time  for  the  resulting  anaemia.  The  instru¬ 
ment  used  was  the  same  as  the  one  employed  on  the  boy. 

W.  H.  Hall,  M.  D. 


Jjrocet&inp  oi  Soricths. 

NEW  YORK  SURGICAL  SOCIETY. 

Meeting  of  May  Ilf ,  1890. 

The  President,  Dr.  C.  K.  Briddon,  in  the  Chair. 

Laparo-colotomy  for  Stricture  of  the  Rectum. — The 

President  read  a  paper  with  this  title.  (See  page  310.) 

Calculus  of  the  Kidney ;  Removal  of  the  Organ. — Dr.  A. 

G.  Gerster  presented  a  woman,  aged  fifty-six,  who,  six  years 
before,  had  experienced  some  marked  pain  in  the  hypogastric 
region,  pain  on  micturition,  and  rigors.  The  urine  was  turbid. 
Alternating  with  periods  of  abeyance,  this  condition  had  con¬ 
tinued  four  years.  Two  years  ago  intense  pain  had  initiated 
the  appearance  of  a  tumor  in  the  left  loin.  Fourteen  months 
ago  abscess  was  diagnosticated,  and,  on  incision,  a  quantity  of 
pus  was  evacuated.  After  this  the  general  condition  had  some¬ 
what  improved.  On  her  admission  into  Mount  Sinai  Hospital 
a  discharging  sinus  was  found  in  the  left  lumbar  region,  leading 
down  to  a  slightly  movable  tumor,  readily  made  out  on  bimanual 
palpation.  The  tortuosity  of  the  sinus  had  prevented  the  probe 
entering  more  than  two  inches.  At  this  time  the  urine  was 
about  normal  as  to  quantity,  but  contained  much  pus,  albumin, 
and  blood,  but  no  casts.  There  seemed  no  reasonable  doubt 
that  a  diseased  kidney  would  be  found  at  the  bottom  of  the 
sinus,  and  operative  interference  was  arranged  for.  The  right 
kidney  being  first  made  out  by  palpation,  the  left  was  then  ex¬ 
posed  by  a  slightly  oblique,  nearly  transverse  incision,  four 
inches  in  length,  carried  through  the  loin.  The  sinus  was  seen 
leading  into  the  pelvis  of  the  organ,  which  was  much  shrunken 
and  peculiarly  lobulated.  After  it  was  peeled  out  of  its  fibrous 
capsule,  an  elastic  ligature  was  thrown  around  the  vessels  and 
ureter,  just  in  front  of  the  hilum.  When  the  kidney  was  cut  away, 
a  small  stone  was  found  to  have  been  caught  in  the  ligature, 
but  this  came  away  on  gentle  traction.  The  pelvis  of  the  kid¬ 
ney  contained  a  number  of  uric-acid  stones  and  about  two 
ounces  of  thick  pus.  The  secreting  tissue  of  the  organ  was 
found  replaced  by  cicatricial  masses.  During  the  attempt  at 
liberating  the  kidney  a  rent  was  accidentally  made  in  a  pro¬ 
truding  fold  of  the  peritomeum.  This  was  closed  by  a  few  cat¬ 
gut  sutures.  The  wound  was  then  packed  with  iodoform  gauze 
and  the  patient  put  to  bed  in  a  slightly  collapsed  condition. 
On  the  day  following,  the  temperature  was  99°  F.,  the  urine 
scanty,  but  the  general  condition  good.  The  next  day  twenty- 
four  ounces  and  a  half  of  urine  were  passed  in  the  twenty-four 
hours.  The  urine  at  first  contained  considerable  pus,  casts,  and 
renal  epithelium,  but  these  gradually  disappeared.  The  liga¬ 
ture  came  away  in  about  three  weeks,  and  the  wound  was  then 
closed  by  secondary  suture.  In  three  weeks  more  the  patient 
was  discharged  cured,  with  a  slight  trace  of  pus  in  the  urine. 
The  muscles  had  reunited  without  any  difficulty,  and  the  patient 
made  no  complaint  of  any  disability  in  moving  her  trunk.  Her 
general  condition  had  very  much  improved  since  the  operation, 


326 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jocr., 


though  the  speaker  did  not  believe  the  other  kidney  was  actu¬ 
ally  sound.  The  specimen  he  presented  showed  how  shrunken 
the  organ  was. 

Dr.  L.  A.  Stimson  asked  if  tlie  descending  colon  had  been 
recognized. 

Dr.  Gerster  said  it  bad  not  come  into  view.  The  intestine 
which  had  protruded  was  small  intestine.  He  must  have  come 
into  very  close  proximity  to  the  colon,  but  after  the  accident 
he  had  not  continued  to  work  in  the  fat  surrounding  the  cica¬ 
tricial  masses. 

The  President  asked  whether  the  incision  would  be  applica¬ 
ble  to  a  large  kidney. 

Dr.  Gerster  believed  that  it  gave  more  space  than  any  sin¬ 
gle  incision  he  had  ever  tried.  The  secondary  suture  had  been  a 
very  simple  affair,  and  had  aided  the  closure  of  the  very  large 
wound  through  the  muscle. 

Dr.  Stimson  thought  it  showed  the  advantage  of  doing  the 
operation  at  separate  sittings. 

The  President  asked  if  it  did  not  render  the  secondary 
operation  difficult  from  t  he  fact  of  the  cicatricial  tissue  clinging 
to  the  wound. 

Dr.  Gerster  replied  that  the  easiest  operations  he  had  done 
had  been  secondary,  and  the  most  difficult  had  been  the  primary 
operations. 

The  President  said  his  experience  had  been  just  the  re¬ 
verse. 

Dr.  Gerster  said  that,  in  attempting  to  follow  the  line  of 
the  sinus,  it  was  difficult,  but  if  the  incision  was  made  in  any 
cicatricial  tissue,  it  could  be  carried  through  perfectly  normal 
tissue,  and  the  kidney  recognized  as  easily  as  in  the  primary 
operation.  lie  believed,  however,  that  it  would  not  do  to  pass 
a  hasty  judgment  on  the  respective  merits  of  these  two  meth¬ 
ods.  The  primary  operation  had  the  great  advantage  that 
after  splitting  the  fatty  capsule  and  enucleating  the  kidney  with 
its  own  primary  capsule,  the  treatment  of  the  pedicle  became 
much  more  easy.  It  did  not  leave  behind  a  mass  of  pedicle 
which  compelled  the  adoption  of  open  treatment.  The  wound 
might  be  closed,  and  only  a  drainage-tube  left  in. 

Abscess  of  the  Liver. — Dr.  J.  A.  Wyeth  presented  a  pa¬ 
tient  who  had  come  to  him  some  four  months  before  after  hav¬ 
ing  been  in  one  of  the  city  hospitals  for  a  considerable  time  for 
a  tumor  in  the  region  of  the  liver.  Examination  by  the  speaker 
resulted  in  a  diagnosis  of  abscess  of  the  liver.  Incision  over  the 
most  prominent  part  of  the  tumor  resulted  in  the  evacuation  of 
a  large  quantity  of  pus,  with  liver  tissue.  The  cavity  was  then 
scraped  out.  The  man  recovered  rapidly  and  was  now  entirely 
well.  A  small  tube  was  still  in  the  wound,  through  which  there 
escaped  about  ten  minims  of  a  sero-purulent  fluid  daily.  There 
was  no  history  which  had  pointed  to  the  causation  in  this  case. 
The  man  had  always  lived  in  this  climate. 

The  President  said  that  these  cases  were  unusual  in  this 
climate.  He  had  operated  in  quite  a  number,  and  during  one 
term  of  service  he  had  had  three  cases  of  liver  abscess  in  the 
wards  of  the  Presbj'terian  Hospital  at  one  time,  and  two  of 
these  were  of  unusual  interest.  One  patient  was  brought  into 
the  hospital  suffering  from  suppurative  peritonitis  due  to  rup¬ 
ture  of  an  abscess  into  the  abdominal  cavity ;  a  physical  exami¬ 
nation  revealed  hepatic  dullness  high  up,  and  an  incision  be¬ 
tween  two  ribs  permitted  the  finger  to  pass  through  the  adher¬ 
ent  pleura  and  into  the  substance  of  the  liver  itself.  Guided  by 
the  finger,  a  very  large  curved  trocar  was  passed  into  the  cav¬ 
ity  of  an  abscess  that  communicated  with  the  peritonaeum.  The 
speaker  then  opened  the  peritonaeum  in  both  inguinal  regions, 
passed  a  drainage-tube  through  from  one  to  the  other,  and  irri¬ 
gated  the  cavity  of  the  peritonaeum  through  a  tube  introduced 
into  the  opening  made  in  the  abscess  and  intercostal  space. 


One  of  the  other  cases  was  still  more  remarkable.  An  old 
woman  was  in  the  medical  wards  of  the  hospital,  and  a  very 
thorough  examination  and  extended  observation  had  warranted 
the  physician  in  charge  in  expressing  the  opinion  that  she  was 
the  subject  of  liver  abscess.  She  was  jaundiced,  her  liver  pro¬ 
jected  several  inches  below  the  free  border  of  the  ribs,  and  she 
had  very  severe  and  irregular  rigors.  The  speaker  made  on  in¬ 
cision  about  two  inches  long,  and  parallel  with  the  border  of 
the  ribs,  on  the  right  side.  When  the  peritonaeum  was  cleanly 
exposed  it  was  evident  that  there  were  no  adhesions  between 
tbe  convex  surface  of  the  liver  and  the  abdominal  wall,  and  the 
organ  could  be  seen  moving  up  and  down,  as  influenced  by  res¬ 
piration.  The  wound  was  packed  with  gauze,  and,  five  days 
after,  the  liver  was  needled  in  various  directions  through  the 
bottom  of  the  wound  without  detecting  pus.  After  scraping 
the  surface  of  the  wound  and  making  it  aseptic,  he  opened  the 
abdominal  cavity,  extending  the  incision  across  the  median  line 
a  distance  of  five  or  six  inches.  He  then  satisfactorily  demon¬ 
strated  to  the  gentlemen  present  that  there  was  no  abscess. 
Nearly  the  whole  of  the  free  convex  surface  of  the  liver  was 
critically  examined,  and  then  the  organ  was  rotated  on  its  trans¬ 
verse  axis,  so  as  to  expose  a  large  portion  of  its  lower  surface; 
it  looked  like  a  liver  in  the  early  stage  of  cirrhosis;  its  surface 
was  finely  tuberculated  and  rosy  red  in  color;  the  ligamentum 
suspensorium  hepatis  was  very  much  enlarged  and  oedematous 
— so  much  so  that  at  first  it  was  supposed  to  be  a  knuckle  of  in¬ 
testine.  The  whole  operation  was  done  under  the  strictest  an¬ 
tiseptic  precautions,  and  the  abdominal  wound  was  carefully 
closed.  He  was  very  much  surprised  at  the  very  remarkable  re¬ 
sult  that  followed  this  apparently  harsh  procedure.  The  patient 
had  no  more  chills,  recovered  from  the  effects  of  the  operation 
without  accident,  and  left  the  hospital  in  a  few  weeks. 

Referring  to  the  presence  of  the  drainage-tube  in  Dr.  Wyeth’s 
patient,  the  president  would  warn  against  the  possible  danger 
of  the  tube’s  being  drawn  into  the  sinus  or  cavity  by  inspira¬ 
tion.  He  had  recorded  one  case  in  which  he  had  operated  for 
the  evacuation  of  a  large  quantity  of  bile,  due  to  extensive  rupt¬ 
ure  of  the  liver,  and  so  encapsulated  that  the  peritonaeum  was 
not  invaded.  Three  days  before  operating  he  had  removed  be¬ 
tween  sixty  and  seventy  ounces  of  apparently  pure  bile  by  tbe 
needle,  and  had  given  prompt  relief,  but  it  was  only  of  short 
duration,  and  a  free  incision  had  given  exit  to  as  much  more. 
A  large  drain,  eight  or  nine  inches  long,  was  introduced,  and 
bile  had  continued  to  flow  through  it  for  several  months.  One 
afternoon  he  was  informed  that  the  tube  was  missing,  and  he 
made  an  ineffectual  attempt  to  find  it.  He  then  suspected  that 
the  patient  had  taken  it  out  and  made  away  with  it,  but  this 
was  stoutly  denied.  When  informed  that  it  would  be  necessary 
to  perform  a  possible  serious  operation  to  find  it,  the  patient 
still  denied  that  he  had  interfered  with  it.  He  was  etherized, 
and  a  long  and  tedious  effort  was  made  with  lith otrites  and 
variously  shaped  snares.  The  sinus  was  a  tortuous  one,  and  ap¬ 
peared  to  lead  into  a  cavity  situated  behind  the  middle  of  the 
sternum.  On  subsequent  occasions  attempts  were  made,  but 
the  tube  was  never  found.  The  discharge  gradually  diminished, 
but  never  entirely  ceased.  The  patient  gained  in  health  and 
strength  sufficiently  to  resume  his  occupation — that  of  a  brick- 
maker. 

Dr.  Gerster  thought  that  in  the  case  in  which  so  much 
manipulation  of  the  liver  had  been  done  the  result  might 
have  been  the  dislodgment  of  some  obstruction  in  the  gall¬ 
bladder. 

Operative  Procedures  in  the  Bone  Diseases  of  Childhood 

was  the  title  of  a  paper  read  by  Dr.  V.  P.  Gibney.  (See  page 

181.) 

Dr.  Stimson  said  the  statements  as  to  the  superiority  of  ar- 


Sept.  20,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


327 


threctomy  in  the  treatment  of  diseases  of  the  knee,  if  by  that 
was  meant  extirpation  of  the  capsule  alone,  were  not  borne 
out  by  his  experience.  Extirpation  of  the  capsule  alone,  in  his 
experience,  had  been  followed  by  return  of  the  disease  and  re¬ 
course  to  excision  in  every  case.  He  was  surprised  to  hear 
that,  excision  of  the  knee  joint  had  not  given  Dr.  Gibney  good 
results.  The  speaker  was  under  the  impression  that  it  was  the 
general  experience  that  this  operation  did  not  contain  many 
elements  of  danger  to  the  patient’s  life,  and  that  it  was  gen¬ 
erally  followed  by  permanent,  satisfactory,  and  complete  re¬ 
covery.  Of  course,  he  did  not  mean  recovery  in  every  case, 
but  as  an  operation  for  tubercular  disease  it  was  the  one  which, 
in  his  experience,  had  given  the  best  results. 

Dr.  Gerstek  thought  that  all  cases  could  not  be  judged  by 
one  standard.  A  distinction  must  be  made  between  tubercu¬ 
lous  joints  in  children  and  those  in  adults,  and  different  prin¬ 
ciples  must  obtain  in  practice.  When  it  was  remembered  that 
a  very  large  number  of  the  tuberculous  knee  joints  occurred 
among  the  poorer  classes,  with  whom  prolonged  treatment  was 
impossible,  there  was  no  alternative  but  to  amputate  the  limb 
or  excise  the  joint.  Undoubtedly  in  children  the  removal  of 
the  capsular  ligament  and  semilunar  cartilages  yielded  excellent 
results  at  certain  hands.  He  had  read  many  reports  to  this 
effect  by  authors  of  note,  and  believed  that  for  children  the 
method  certainly  deserved  trial  before  excision. 

Dr.  Wyeth  said  that  his  ideas  on  this  subject  led  him  rather 
decidedly  into  the  operative  field  for  the  treatment  of  knee- 
joint  troubles,  regardless  of  the  age  of  the  child.  In  the  five 
or  six  cases  operated  on  by  him  this  winter  the  patients  had  all 
been  from  twelve  to  fifteen  years  of  age.  He  thought  it  rare 
to  meet  with  a  child  under  five  years  with  a  tuberculous  osteo¬ 
arthritis  at  the  knee.  lie  had  never  given  much  consideration 
to  the  question  of  lack  of  development  in  the  bones,  because 
he  believed  that  persistent  meddling  with  the  joint  for  from 
one  to  five  years,  which  might  anyway  end  in  ankylosis  or 
something  more  serious,  was  fraught  with  such  danger  that  he 
was  inclined  to  discourage  delay  and  deal  promptly  with  these 
joints  by  excision.  He  could  not  recall  a  single  instance  in  his 
experience  of  death  resulting  from  excision  of  the  knee  joint, 
except,  of  course,  in  some  traumatic  cases.  He  thought  the 
operation  was  an  exceedingly  safe  one.  He  thought  it  impera¬ 
tive  that  permanent  drainage  should  be  established.  This  was 
especially  important  in  hip-joint  disease  where  a  clean  arthrec- 
tomy,  with  excision,  was  not  made. 

Dr.  F.  Kammerer  thought  the  question  of  the  merits  of  ar- 
threctomy  or  excision  was  still  sub  judice.  He  had  resected  a 
great  many  times,  and  had  generally  found  the  focus  of  the 
trouble  in  the  bone  itself.  He  considered  the  conservative 
treatment  suggested  by  Dr.  Gibney  as  perfectly  in  place.  He 
had  on  the  Continent  witnessed  many  resections  which  ought 
never  to  have  been  done.  The  moment  crepitus  was  felt  it  was 
the  signal  for  resection,  decapitation,  or  subtrochanteric  resec¬ 
tion  when  conservative  measures  would  undoubtedly  have  given 
much  better  results. 

Dr.  Gibney  said  that  he  felt  with  Dr.  Stimson  that  excision 
of  the  knee  for  adults  was  the  thing  to  do,  but  the  line  had  to 
be  drawn  between  children  and  older  children  and  adults.  By 
arthrectomy  he  meant  complete  eradication  of  the  capsule  with 
the  cartilage  and  entire  removal  of  any  diseased  foci.  He  be¬ 
lieved  that  it  was  the  custom  to  wait  too  long  in  the  case  of 
adults.  They  were  told  to  put  the  joints  at  rest.  The  joints 
gradually  got  unstable,  abscess  appeared,  and  the  patient  was 
then  allowed  to  go  around  waiting  for  the  abscess  to  mature- 
These  cases  were  much  better  taken  hold  of  early,  the  disease 
excised,  and  the  patients  thus  insured  good  sound  limbs  upon 
which  they  could  earn  a  living. 


Perforating  Wound  of  the  Heart ;  Survival  for  Eighteen 

Hours. — Dr.  Stimson  showed  a  heart  which  had  been  taken 
from  an  Italian,  thirty-two  years  of  age,  who  had  been  stabbed 
in  seven  places  in  the  chest,  abdomen,  and  arms,  ne  had  been 
brought  to  the  Chambers  Street  Hospital  in  a  state  of  profound 
shock,  his  condition  being  such  that  no  surgical  interference 
was  deemed  justifiable,  and  he  died  eighteen  hours  later.  The 
knife  had  penetrated  the  wall  of  the  chest  an  inch  to  the  right 
of  the  left  nipple,  and  perforated  the  right  ventricle,  making  a 
wound  one  quarter  of  an  inch  long  on  its  anterior  surface,  one 
third  of  an  inch  below  the  anterior  cusp  of  the  semilunar  valve 
of  the  pulmonary  artery,  and  just  puncturing  the  opposite  wall 
an  inch  and  a  half  from  the  posterior  interventricular  septum. 
The  valves  and  the  chord  aa  tendineaa  were  uninjured.  He  had  also 
a  wound  three  quarters  of  an  inch  long  situated  two  inches  and 
a  half  below  and  two  inches  to  the  left  of  the  umbilicus,  which 
penetrated  the  abdominal  cavity,  but  had  not  wounded  any  of 
the  viscera. 

Meeting  of  May  28,  1890. 

The  President,  Dr.  C.'K,  Briddon,  in  the  Chair. 

Injury  from  the  Use  of  Esmarch’s  Bandage.— Dr.  L.  A. 

Stimson  presented  a  young  man  who  had  come  under  treatment 
last  March  for  a  non-suppurative  tubercular  affection  of  the 
right  wrist,  for  which  excision  of  the  wrist  was  resorted  to. 
The  Esmarch  bandage  was  applied  in  the  usual  manner,  with 
the  rubber  tourniquet  about  the  middle  of  the  arm.  The  wound 
had  healed  without  incident,  hut  the  patient  was  now,  two 
months  since  the  operation,  unable  to  move  any  of  the  muscles 
of  the  forearm  or  hand.  The  galvanic  current  showed  some  re¬ 
action,  and  the  speaker  thought  he  was  able  to  provoke  con¬ 
traction  of  some  of  the  muscles  by  application  of  the  current  to 
the  brachial  plexus.  The  evidence  was,  however,  not  very  posi¬ 
tive.  The  patient  had  been  examined  by  Dr.  Starr,  who  thought 
the  paralysis  was  due  either  to  contusion  of  the  nerves  of  the 
arm  by  the  cord  applied  during  the  operation,  or  else  to  the 
temporary  ischaemia  of  the  muscles  produced  at  the  same 
time.  Innervation  through  the  three  main  trunks  was  com¬ 
pletely  lost,  the  reaction  of  degeneration  was  very  marked,  and 
the  change  seemed  to  be  especially  marked  in  the  interossei 
muscles.  According  to  Dr.  Starr,  the  prognosis  was  good. 
The  case  seemed  of  interest  because  of  the  very  general  use 
of  the  means  which  appeared  in  this  instance  responsible  for 
the  trouble. 

Dr.  0.  MoBurney  asked  what  form  of  constricting  band  had 
been  used. 

Dr.  Stimson  replied  that  he  thought  it  was  a  large  rubber 
tube. 

Dr.  McBurney  did  not  think  this  so  good  as  the  broad  band, 
because  of  its  enormously  increased  contusing  force.  He  had 
frequently  seen  the  skin  rise  between  the  turns  of  rubber  band. 
He  thought  this  form  of  baud  far  more  likely  to  cause  mischief 
both  to  the  skin  and  to  the  parts  beneath.  He  would  suggest 
that  possibly  this  might  have  acted  as  a  cause  of  the  trouble  in 
this  case.  The  difficulty  might  be  avoided  by  using  a  very  broad 
band.  A  three-inch  band  wound  a  good  many  times  about  the 
arm  would  give  very  little  evidence  upon  the  skin  of  its  applica¬ 
tion. 

The  President  said  he  had  seen  two  cases  in  which  trouble 
had  arisen  from  this  bandaging,  and  it  had  followed  the  use  of 
the  narrow  band,  either  as  a  tube  or  in  the  solid  form. 

Dr.  Stimson  said  that  this  was  not  a  cord,  but  a  hollow  tube 
which  flattened  out  during  its  application.  He  doubted  if  the 
breadth  of  the  band  was  an  important  feature,  and  thought  the 
danger  lay  rather  in  unduly  multiplying  the  number  of  super¬ 
imposed  turns  of  the  bandage  about  the  limbs. 


328 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mkd.  Joor., 


Dr.  Gerster  reported  four  cases  in  which  trouble  had  fol¬ 
lowed  the  use  of  the  broad  band.  He  did  not  wish  to  say  that 
the  narrow  band  was  harmless.  The  difficulty  did  not  depend 
upon  the  band,  but  upon  the  traction  exercised  and  the  amount 
of  soft  tissue  involved.  It  was  a  general  failing  to  use  more 
force  and  compression  than  was  necessary.  It  was  his  custom, 
when  dealing  with  the  upper  extremities,  to  have  an  assistant 
hold  the  radial  pulse  and  to  allow  one  more  turn  of  the  bandage 
after  the  pulse  was  reported  gone. 

Irreducible  Intracoracoid  Luxation  of  the  Head  of  the 
Humerus;  Operation.— Dr.  Stimson  presented  a  man,  fifty- 
three  years  of  age,  who  last  April  had  fallen  into  the  water  from 
a  row-boat  in  which  he  was  standing.  He  had  swum  a  few  feet 
to  a  neighboring  tog,  into  which  he  was  lifted  by  his  extended 
arms.  He  immediately  felt  severe  pain  in  the  shoulders  and 
arms,  and  was  brought  to  the  Chambers  Street  Hospital.  It 
was  there  found  that  he  had  a  dislocation  of  each  shoulder.  On 
the  right  side  it  was  well  marked,  the  head  of  the  humerus  lying 
below  and  a  little  to  the  inner  side  of  the  coracoid  process.  On 
the  left  side  the  head  of  the  humerus  lay  farther  inward,  the 
case  being  one  of  well-marked  intracoracoid  dislocation.  The 
dislocation  on  the  right  side  was  reduced  without  much  diffi¬ 
culty  under  ether.  All  efforts  to  reduce  the  one  on  the  left  side 
failed.  The  condition  of  things  was  explained  to  the  patient, 
and  an  operation  was  performed  on  the  following  day.  On  ex¬ 
posing  the  joint  cavity  by  an  anterior  incision,  the  condition  of 
things  at  once  became  clear.  The  head  of  the  humerus  lay  well 
to  the  inner  side,  and  its  neck  was  crossed  on  its  outer  side  and 
above  by  the  untorn  tendon  of  the  subscapularis  muscle.  After 
division  of  this  tendon  the  head  of  the  bone  was  easily  returned 
to  its  place.  The  patient  had  made  an  uneventful  recovery  so 
far  as  the  wound  was  concerned.  There  was  now  a  decided 
droop  of  the  head  of  the  right  humerus,  with  paralysis  of 
the  deltoid.  On  the  left  side  the  arm  was  quite  powerless, 
and  considerably  swollen.  The  speaker  did  not  think  that 
this  swelling  had  arisen  from  any  interference  with  the  vein, 
but  thought  that  it  was  probably  due  to  interference  with  the 
lymphatic  return  or  to  some  damage  of  the  nerve  supply  of  the 
limb. 

Fracture  of  the  Patella ;  Treatment  by  Arthrotomy  and 

the  Use  of  Silk  Suture.  — The  third  case  presented  by  Dr. 
Stimson  was  one  of  fracture  of  the  patella.  The  speaker  had 
expressed  his  opinion  that  the  open  operation,  with  suture  of 
the  fragments,  was  only  to  be  done  in  exceptional  cases,  and 
this  was  a  case  of  that  type.  He  presented  the  case  to  call  at¬ 
tention  to  certain  modifications  in  the  method.  The  patient,  a 
man,  forty-six  years  of  age,  had  fallen  from  a  considerable 
height  and  had  fractured  his  right  patella  and  also  both  bones 
of  his  leg,  and  had  sustained  other  injuries.  The  fracture  of 
the  patella  was  slightly  comminuted.  There  was  a  large  and 
deep  bruise  of  the  soft  parts  of  the  front  of  the  knee,  which 
made  it  probable  that  sloughing  would  ensue,  and  this,  in  the 
speaker’s  opinion,  contra-indicated  the  employment  of  his  usual 
method.  He  had  therefore  done  the  open  operation  uuder  co¬ 
caine.  He  had  made  a  vertical  incision  over  the  patella,  ex¬ 
posing  the  seat  of  the  fracture.  It  was  of  a  variety  which  he 
had  never  before  encountered.  It  was  oblique  from  below  up¬ 
ward  and  backward,  and  the  lower  fragment  was  chipped  at  its 
edge.  Along  the  line  of  fracture  two  pieces  were  loose  and 
were  removed.  Instead  of  suturing  the  bone,  he  had  applied 
a  mediate  suture  of  it  through  the  tendon  of  the  quadriceps 
and  the  ligamentum  patellae,  as  in  the  subcutaneous  method. 
The  external  wound  was  then  closed,  and  the  patient  put  to  bed 
with  the  limb  in  plaster  of  Paris.  This  dressing  was  left  on 
seven  days.  After  the  second  dressing  the  splints  were  kept 
on  four  weeks.  The  patient  now  had  forty-five  degrees  of  flex¬ 


ion.  This  modification  of  mediate  suture  of  silk,  passed  through 
the  tendon  of  the  quadriceps  and  the  ligamentum  patelhe,  re¬ 
moved  some  of  the  objections  to  the  metallic  suture.  It  was 
easy  of  application,  and,  so  far  as  could  be  judged  by  a  single 
application,  would  yield  an  equally  good  result. 

Dr.  McBcjrney  thought  the  operation  was  a  very  admirable 
application  of  a  very  good  principle.  Many  of  his  hearers  could 
recall  cases  of  very  acute  suppuration  following  the  introduc¬ 
tion  of  a  single  wire. 

Two  Cases  of  Extirpation  of  the  Penis  for  Cancer.— 

Dr.  F.  Ivammerer  presented  two  patients  upon  whom  he  had 
performed  extirpation  of  the  penis.  The  organ  had  seemed  so 
far  involved  that  amputation  was  not  deemed  advisable.  This 
method,  though  practiced  for  the  first  time  more  than  fifty 
years  ago,  was  not  of  frequent  application.  The  author  thought, 
however,  that  it  gave  the  best  guarantee  of  radical  removal  of 
all  diseased  parts,  and  had  the  advantage  of  removing  the  ex¬ 
ternal  orifice  of  the  urethra  into  the  perinseum.  Both  cases 
were  of  far-advanced  infiltration  of  the  corpora  cavernosa,  with 
secondary  infiltration  of  the  inguinal  glands.  The  operation 
was  begun  by  an  elliptical  incision  at  the  root  of  the  penis; 
from  its  lower  point  the  incision  was  continued  through  the 
scrotum  and  carried  down  to  the  corpus  spongiosum  of  the  ure¬ 
thra.  The  testicles  were  held  backward  and  the  ischial  and 
pubic  veins  of  the  corpora  cavernosa  were  exposed  by  dissec¬ 
tion.  This  was  continued  over  the  upper  surface  of  the  penis 
toward  the  ramus  of  the  pubes,  separating  the  suspensory  liga¬ 
ment  and  bringing  the  dorsal  veins  into  view.  When  the  penis 
was  drawn  down  and  away  from  the  arcus  pubis  the  vessels 
were  so  much  on  the  stretch  that  it  proved  difficult  to  free 
them  from  the  tissue  in  which  they  were  imbedded  to  a  suffi¬ 
cient  extent  to  allow  of  the  passage  of  a  ligature.  The  opera¬ 
tor  had,  therefore,  resorted  in  both  cases  to  the  expedient  of 
cutting  through  the  spongy  portion  of  the  urethra  immediately 
before  the  bulbous  and  separating  it  from  the  corpora  caver¬ 
nosa.  The  index  finger  of  the  left  hand  was  then  passed  from 
below  into  the  angle  formed  by  the  corpora  cavernosa,  when 
no  difficulty  was  found  in  ligating  the  vessels.  He  now  cut 
away  the  corpora  from  the  ischial  veins,  which  practically 
ended  the  operation.  The  urethra  was  fastened  in  the  peri¬ 
neum,  the  scrotum  united  by  sutures.  The  glands  were  re¬ 
moved  about  ten  days  later,  which  seemed  to  the  operator  a 
better  plan  than  that  of  removing  them  at  the  time  of  the  first 
operation,  thus  avoiding  infection  of  the  inguinal  wound  from 
an  ulcerating  cancer  and  allowing  the  glandular  infiltration  in 
the  groin  time  to  subside  if  any  of  it  was  due  to  absorption 
from  the  ulcerated  surface  of  the  cancer. 

Pancreatic  Cyst. — Dr.  Ivammerer  presented  a  patient  upon 
whom  he  had  operated  for  pancreatic  cyst.  Last  January  the 
patient,  while  pulling  a  truck,  experienced  sudden  pain  in  the 
region  of  the  stomach  and  grew  faint.  He  vomited  soon  after. 
During  the  following  days  pain  and  vomiting  continued.  From 
that  time  the  patient  had  been  the  subject  of  paroxysms  of 
pain,  chiefly  during  and  after  meals,  but  also  at  other  intervals, 
in  the  epigastric  region.  He  first  noticed  a  swelling  about  three 
weeks  after  the  accident.  The  paroxysms  had  become  much 
less  intense  until  about  six  weeks  ago,  when  the  tumor  began 
to  increase  in  size  rapidly.  About  four  weeks  ago  a  round 
point,  afterward  becoming  of  about  the  size  of  a  man’s  head, 
appeared,  occupying  the  epigastric  and  left  hypochondriac  re¬ 
gion;  distinct  fluctuation  could  be  elicited,  and  puncture  drew 
out  a  yellowish  fluid,  alkaline  in  reaction,  containing  considera¬ 
ble  albumin,  but  no  ferments,  uric  acid,  or  booklets.  The  stom¬ 
ach  was  found  on  the  upper  and  the  colon  on  the  lower  border 
of  this  tumor,  which  was  now  movable  and  showed  marked 
transmitted  pulsation.  At  the  operation  the  peritoneal  cavity 


Sept.  20,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


329 


was  opened  over  the  most  prominent  part  of  the  tumor.  It  was 
found  that  the  cyst  had,  as  had  been  diagnosticated,  developed 
in  the  bursa  omentalis,  having  on  its  anterior  surface  the  gas- 
tro-colic  ligament  firmly  adherent  to  the  cyst  wall.  The  trans¬ 
verse  colon  crossed  the  abdominal  incision  (from  the  ensiform 
cartilage  to  the  umbilicus)  a  little  below  its  middle,  leaving  a 
space  of  only  about  two  inches  between  the  stomach  and  colon 
for  an  incision  of  the  cyst.  The  lower  part  of  the  abdominal 
incision  was  closed  far  enough  to  cover  the  colon.  The  adher¬ 
ent  gastro-colic  ligament  was  sewed  to  the  parietal  peritonaeum 
at  the  abdominal  incision.  Ten  days  afterward  the  cyst  was  in¬ 
cised  with  the  galvano-cautery.  There  was  considerable  haem¬ 
orrhage  from  the  vessels  in  the  gastro-colic  ligament.  About 
two  quarts  and  a  half  of  the  before-mentioned  fluid  were  evacu 
ated.  The  smallness  of  the  incision  did  not  admit  of  an  ocular 
inspection  of  the  cavity.  A  good-sized  drainage-tube  was  in¬ 
troduced.  The  walls  of  the  cyst  continued  to  secrete  copiously 
during  the  first  week,  but  during  the  second  week  the  cavity 
shrank  rapidly,  and  now  only  a  small  sinus  led  into  the  ab¬ 
domen  for  about  two  or  three  inches.  The  location  of  the 
tumor,  its  topographical  relation  to  the  stomach  and  colon,  the 
history  of  traumatism,  the  rapid  growth,  and  the  colicky  pains 
left  one  in  doubt  as  to  the  nature  of  the  cyst  and  as  to  whether 
the  absence  of  some  or  all  of  the  components  of  pancreatic  fluid 
in  the  contents  of  the  tumor  proved  anything  in  favor  of  or 
against  the  diagnosis  of  cyst  of  the  pancreas. 

Cancer  of  the  Rectum ;  Operation ;  no  Recurrence  after 
Five  Years. — Dr.  Gerster  showed  a  patient  upon  whom  he 
had  operated  in  November,  1884,  for  cancer  of  the  rectum.  At 
this  time  about  five  inches  and  a  half  of  the  rectum  were  re¬ 
moved.  A  secondary  operation  was  performed  for  the  purpose 
of  insuring  a  practicable  sphincter.  There  had  been  no  recur¬ 
rence  of  the  disease  for  five  years.  The  patient  had  married 
and  both  his  children  were  born  with  marked  anal  stenosis. 

Dr.  Kammerer  said  it  had  been  his  experience  that  cancers 
of  the  rectum  gave  a  better  prognosis  than  cancers  elsewhere. 

An  Essay  upon  the  Classification  of  the  various  Forms 
of  Appendicitis  and  Perityphlitic  Abscess,  with  Practical 
Conclusions. — This  was  the  title  of  a  paper  by  Dr.  A.  G.  Gers- 
ter.  (See  page  6.) 

The  discussion  of  this  paper  was  postponed  until  next  Oc¬ 
tober. 

Recurrent  Appendicitis.— Dr.  McBurney  narrated  the 
following  history:  J.  K.  0.,  aged  thirty-nine  years.  Family 
history  entirely  negative.  The  patient,  with  the  exception  of 
being  subject  to  dyspepsia  and  having  had  occasional  attacks  of 
colic  when  a  small  boy,  had  always  enjoyed  good  health  pre¬ 
vious  to  his  first  attack.  He  had  had  six  attacks  in  all,  occur¬ 
ring  as  follows  :  March  2, 1889,  April  13,  June  15,  September  13, 
November  2,  and  March  26, 1890.  In  each  of  these  attacks,  with 
the  exception  of  the  second,  in  which  the  pain  was  located  in 
the  left  iliac  fo9sa,  the  pain  began  along  a  line  a  little  above  the 
umbilicus  and  settled  more  or  less  quickly  in  the  right  iliac  re¬ 
gion.  The  point  of  most  acute  pain  had  been  in  each  case,  with 
the  exception  mentioned,  two  inches  from  the  right  anterior 
superior  spine  toward  the  umbilicus.  All  the  attacks  had  been 
considered  intestinal  obstruction,  and  all  had  been  treated  with 
morphine  and  enemata.  After  the  last  attack  some  soreness 
had  remained  in  the  right  iliac  region  for  a  long  time.  The 
bowels  were  kept  regular  with  a  laxative  mixture.  On  his  ad¬ 
mission  to  the  hospital,  May  17,  1890,  the  patient  seemed  to  be 
fairly  nourished.  There  was  no  prostration.  Pressure  at  the 
point  named  caused  pain.  Pressure  elsewhere  on  the  abdomen 
caused  some  discomfort,  but  there  was  nothing  definite  except 
at  that  particular  point.  On  deep  pressure  the  appendix  could 
be  readily  felt.  It  was  somewhat  thickened  and  movable  and 


extended  from  the  point  named  downward  and  inward  along 
the  internal  border  of  the  rectus.  An  operation  was  performed 
on  May  20th.  The  usual  incisions  were  made.  The  appendix 
was  found  to  be  an  inch  and  a  half  long,  lying  posteriorly 
and  pointing  down  and  to  the  right.  There  were  no  adhesions 
among  the  intestines.  The  appendix  itself  had  a  mesentery  and 
was  bound  firmly  to  the  gut  by  adhesions.  It  was  hard  and 
thickened  by  chronic  inflammation.  Heavy  catgut  suture  was 
applied  to  the  base  of  the  appendix,  which  was  then  cut  through 
and  carefully  separated  from  the  mesentery  and  adhesions  and 
removed.  On  account  of  a  few  drops  of  yellowish  fluid  which 
escaped  at  the  base  of  the  appendix,  this  part  of  the  wound  was 
packed  with  iodoform  gauze.  A  drainage-tube  was  also  inserted 
at  this  point.  There  was  no  irrigating  of  the  abdominal  cavity. 
The  upper  part  of  the  wound  was  then  sutured  with  heavy  silk 
passed  through  peritonaeum,  muscle,  and  skin,  superficial  skin 
sutures  and  finally  an  iodoform  dressing  being  used.  The  dress¬ 
ing  was  removed  for  the  first  time  on  May  25th,  five  days  after 
the  operation.  The  wound  was  clean,  there  was  no  pus,  and 
the  packing  was  removed.  From  this  time  on  the  patient  had 
made  an  uninterrupted  recovery. 

Acute  Appendicitis— Dr.  MoBurney  also  related  the  fol¬ 
lowing:  T.  H.,  aged  twenty-three  years.  Family  and  personal 
history  negative.  The  patient  had  never  bad  a  previous  attack. 
On  March  25th,  about  8  p.  m.,  he  first  felt  a  pain  in  his  right 
inguinal  region,  like  a  stitch  in  his  side,  as  he  expressed  it. 
By  the  end  of  twenty  minutes  the  pain  had  become  so  intense 
that  he  nearly  fainted.  This  pain  kept  up  all  night  without 
intermission,  except  that,  about  2  a.  m.,  he  experienced  some 
slight  relief  for  a  short  time,  but  did  not  sleep.  A  physician 
had  been  called  in  within  half  an  hour  after  the  attack  began, 
and  nine  hypodermics  were  given  during  the  night — about  a 
grain  and  a  half  of  morphine  in  all.  No  great  relief  was  afford¬ 
ed  ;  the  pain  was  so  severe  that  the  patient  was  said  to  have 
been  semi-delirious  in  consequence.  The  bowels  were  consti¬ 
pated  during  the  attack.  The  patient  was  admitted  to  the  hos¬ 
pital  on  March  26th,  at  10  p.  m.  At  that  time  there  was  severe 
pain  in  the  right  iDguinal  region.  There  was  a  point  of  tender¬ 
ness  two  inches  to  the  inner  side  of  the  anterior  superior  spine 
of  the  ilium  on  the  right  side.  This  point  was  quite  circum¬ 
scribed,  and  a  slight  tumefaction  was  felt  on  deep  pressure. 
There  was  some  tympanites.  An  operation  was  performed  at 
11  p.  m.  The  intestines  were  not  adherent;  the  appendix 
pointed  upward,  slightly  backward,  and  to  the  right.  It  was 
stiff,  but  was  not  perforated.  There  were  a  few  old  adhesions 
about  it.  The  adhesions  and  the  mesentery  of  the  appendix 
were  ligated  with  catgut  and  divided.  A  few  oozing  points 
were  touched  with  the  Paquelin  cautery,  and  the  appendix  was 
ligated  at  its  base,  cut  off,  and  removed.  It  was  found  to  be 
filled  with  a  mass  of  fecal  concretions,  and  there  was  a  slight 
catarrhal  condition  of  its  mucous  membrane.  There  was  no 
irrigation  of  the  abdominal  cavity  and  no  drainage,  but  the 
wound  was  completely  closed.  The  dressings  were  of  iodoform 
and  bichloride  of  mercury.  The  patient  had  made  a  progressive 
recovery  and  was  discharged,  April  22d,  cured. 

Cystoscopy. — Dr.  Willy  Meyer  showed  a  specimen  of  a 
tumor  of  the  bladder  which  had  been  diagnosticated  by  means 
of  the  cystoscope.  The  patient  was  a  man,  forty-four  years  of 
age,  who  had  presented  the  ordinary  characteristic  symptoms. 
The  growth  was  removed  by  suprapubic  cystotomy. 

Cancer  of  the  Pharynx  and  (Esophagus. — Dr.  Kammerer 
exhibited  a  specimen  of  cancer  of  the  pharynx  and  oesophagus 
which  was  of  interest  from  a  diagnostic  point  of  view.  The 
disease  was  of  nine  months’  standing.  Four  months  before, 
the  diagnosis  of  cancer  of  the  posterior  wall  of  the  larynx  had 
been  made  by  a  competent  laryngologist.  Of  late  the  patient 


330 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


had  been  able  to  swallow  liquids  only.  There  were  never  any 
symptoms  of  dyspnoea.  Externally  a  distinct  thickening,  cor¬ 
responding  to  the  upper  part  of  the  oesophagus,  could  be  plainly 
felt  behind  the  larynx,  but  it  was  deemed  probable  that  the 
oesophagus  might  be  reached  below  the  tumor  from  the  neck  by 
oesophagotomy.  This  attempt  failed,  and  gastrotomy  was  per¬ 
formed  as  a  last  resort.  The  patient  died  from  exhaustion  two 
days  later.  The  post-mortem  showed  that  the  tumor  occupied 
about  six  inches  of  the  pharynx  and  oesophagus,  although  so 
great  an  extent  of  the  tumor  could  hardly  have  been  assumed. 
The  larynx  was  intact. 

Portable  Suture  Reels. — The  President  showed  a  glass 
apparatus  constructed  with  a  view  to  the  convenient  and  safe 
carrying  of  sterilized  sutures  of  gut  or  silk.  He  thought  the 
arrangement  the  best  he  had  seen,  and  had  demonstrated  that 
it  would  stand  rough  handling  without  injury  to  itself  or  its 
contents. 

Impervious  Penile  Urethra  complicated  with  Impacted 
Calculi  in  the  Membranous  Urethra  and  in  the  Bladder— 

The  President  reported  the  following  case:  D.  McC.,  aged 
forty-nine,  entered  the  Presbyterian  Hospital  on  January  14, 
1890,  with  the  following  history  :  For  four  years  he  had  not 
been  able  to  pass  any  urine  through  the  urethra.  It  had  all 
come  through  several  sinuses  in  the  right  side  of  the  scrotum. 
There  was  a  history  of  gonorrhoea  in  early  life.  Examination 
of  the  urethra  revealed  the  presence  of  several  strictures,  vary¬ 
ing  in  size  from  that  of  a  No.  2  to  that  of  a  filiform  bougie. 
The  urethra  became  impervious  at  five  inches  from  the  meatus. 
In  the  right  side  of  the  scrotum  there  were  found  several 
sinuses,  close  together,  from  which  urine  constantly  dribbled. 
There  was  considerable  excoriation  in  this  region,  with  marked 
induration  of  the  tissues  of  the  right  side  of  the  scrotum.  The 
urine  was  alkaline  and  contained  five  per  cent,  of  albumin,  with 
pus  and  phosphates.  The  general  nutrition  of  the  patient  was 
so  impaired  that  he  was  put  on  tonic  treatment  previous  to  an 
operation.  On  February  17th  ether  was  administered.  A 
probe  was  passed  into  the  opening  in  the  side  of  the  scrotum 
with  the  hope  that  the  urethra  might  be  entered,  but  the  course 
was  so  serpentine  that  the  canal  was  not  found.  This  tortuous 
scrotal  sinus  was  divided,  and  the  incision  was  then  continued 
into  the  median  line  posteriorly  and  carefully  deepened,  for 
there  was  no  guide.  At  this  stage  in  the  operation  the  granu¬ 
lation  tissue  was  thoroughly  scraped  away.  This  revealed  an 
opening  in  the  apex  of  the  wound  leading  toward  the  penile 
urethra.  It  admitted  only  a  filiform  bougie,  and  for  only  an 
inch.  Further  section  in  the  median  line  cut  through  the  cica¬ 
tricial  tissue,  and  after  more  diligent  search  the  opening  into 
the  urethra  was  found,  not  in  the  median  line,  but  well  over  to 
the  ramus  of  the  ischium  on  the  right  side.  A  filiform  bougie 
was  then  passed  through  the  penile  urethra  and  was  then  armed 
with  a  fine  silk  thread  to  which  was  attached  a  lozenge-shaped 
blade  with  blunt  corners  at  the  obtuse  angles.  This  was  drawn 
through,  dividing  the  structures  so  that  a  No.  30  sound  could 
be  passed  easily.  On  exploration,  the  proximal  end  of  the 
urethra  was  found  dilated  into  a  cavity  containing  a  number  of 
soft  calculi  and  a  considerable  quantity  of  sabulous  matter. 
This  cavity  was  distinct  from  the  prostatic  portion  of  the 
urethra  and  bladder.  In  the  bladder  there  were  found  three 
calculi,  varying  in  size  from  that  of  a  split  pea  to  an  inch  in 
length  by  half  an  inch  in  diameter;  these  were  removed  by 
dilating  the  prostatic  portion  of  the  urethra.  The  subsequent 
treatment  of  the  case  consisted  of  frequent  irrigation  of  the 
bladder  and  the  passage  of  a  sound  every  four  days.  The  re¬ 
covery  was  uneventful.  The  urine  became  normal,  the  patient 
gained  rapidly  in  flesh  and  strength,  the  wound  healed  kindly, 
and  he  left  the  hospital,  cured,  on  April  16th. 


AMERICAN  DERMATOLOGICAL  ASSOCIATION. 

Fourteenth  Annual  Meeting ,  held  at  Richfield  Springs ,  Septem¬ 
ber  2,  <§,  and  4,  1890. 

The  President,  Dr.  Prince  A.  Morrow,  of  New  York,  in  the 

Chair. 

The  President’s  Address.— The  address  dealt  first  with  the 
present  position  of  dermatology.  Those  engaged  in  this  spe¬ 
cialty  had  abundant  cause  for  congratulation.  Only  a  few  years 
ago  dermatology  had  little  standing  in  this  country.  Previous 
to  1876  only  twelve  schools  gave  special  instruction  in  this  de¬ 
partment.  To-day  dermatology  was  recognized  in  the  teaching 
faculty  in  eighty-six  schools,  and  perhaps  more.  He  asked, 
however,  whether  this  showed  a  healthy  growth  or  merely  a 
mushroom  growth.  There  was  reason  to  believe  that  there 
were  many  and  grave  defects  in  the  existing  system  of  instruc¬ 
tion.  It  was  not  the  amount  but  the  quality  and  efficiency  of 
the  instruction  that  constituted  the  criterion  of  its  value.  For 
the  successful  teaching  of  dermatology  two  conditions  were 
essential,  namely,  capacity  in  the  instructor  and  abundance  and 
variety  of  clinical  material.  It  must  be  admitted  that  the  ca¬ 
pacity  of  some  of  the  teachers  in  our  medical  schools  was 
doubtful,  while  the  clinical  material  in  the  majority  of  cases 
was  inadequate.  Even  in  large  cities  the  clinical  material  was 
too  much  dispersed— in  New  York,  for  instance.  For  a  thor¬ 
ough  study  of  cases  and  of  the  results  of  treatment  a  hospi¬ 
tal  was  necessary.  In  medical  schools  cases  of  skin  disease 
should  be  presented  only  to  advanced  students,  not  to  those 
taking  the  first  or  second  year’s  course.  The  study  of  these 
diseases  should  be  obligatory,  which  it  was  not  now  in  any 
school  in  the  country,  so  far  as  he  knew.  If  clinical  material 
was  not  abundant,  and  the  study  of  dermatology  was  made  obli¬ 
gatory,  he  thought  it  a  question  whether  it  would  not  be  better 
to  leave  instruction  in  this  department  to  post-graduate  schools. 
It  was  a  question  also  whether  this  post-graduate  instruction 
could  not  be  better  provided  for  in  organized  institutions  than 
in  independent  organizations. 

In  the  matter  of  nomenclature,  new  names  were  being  intro¬ 
duced  into  dermatology  which  were  not  destined  to  retain  a 
permanent  position,  and,  while  an  essentially  new  disease  re¬ 
quired  a  new  name,  he  would  protest  against  the  present  neo- 
logical  craze.  He  suggested  the  propriety  of  introducing  some 
subject  for  special  discussion  at  the  annual  meetings. 

Observations  on  Prurigo,  Clinical  and  Pathological— Dr. 
R.  W.  Taylor,  of  New  York,  read  the  paper.  At  the  first  meet¬ 
ing  of  the  society  Dr.  Campbell  had  read  a  paper  on  prurigo, 
and  it  appeared  that  only  six  cases  had  then  occurred  in  the  ex¬ 
perience  of  those  present.  New  interest  had  been  excited  since 
the  reading  of  a  paper  on  this  subject  last  year,  in  which  the  au¬ 
thor  gave  accounts  cf  twelve  cases  seen  by  him  in  Chicago. 
The  combined  experience  of  all  present  at  that  discussion  had 
included  only  eighteen  cases.  Dr.  Taylor  thought  the  disease 
more  common  in  America  than  these  statements  would  lead  one 
to  suppose.  It  was  probable  many  cases  escaped  recognition 
and  were  classed  as  eczema,  scabies,  phtheiriasis,  ecthyma,  im¬ 
petigo,  and  even  ichthyosis.  This  was  due  in  part  to  the  fact 
that  there  were  no  good  plates  representing  the  clinical  aspects 
of  the  disease  accessible  to  the  general  profession.  He  under¬ 
took  to  remedy  this  deficiency  to  some  extent  by  giving  photo¬ 
graphs  and  a  full  description  of  a  recent  typical  case,  and  also 
alluded  to  the  casual  concomitants  and  modifying  conditions 
during  the  course  of  the  disease.  The  patient  was  a  healthy 
girl,  aged  nine,  of  healthy  American  parents,  in  good  circum¬ 
stances,  and  with  healthful  surroundings.  When  four  years  old 
she  began  to  scratch,  and  little  red  pimples,  which  appeared  on 


Sept.  20,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


331 


the  face,  forearms,  and  legs,  were  attributed  by  the  parents  to 
mosquito  bites.  The  disease  had  recurred  every  year  up  to  the 
child’s  visit  to  the  hospital,  in  January  of  this  year.  The  ex¬ 
pression  of  the  face  was  then  rather  dull,  the  color  being  the 
typical  white,  somewhat  ashy  hue,  of  prurigo.  Over  the  fore¬ 
head,  the  temporal  region,  and  the  cheek  there  was  a  copious 
eruption  of  small  conical  papules,  some  whiter  than  the  skin, 
others  of  rather  a  yellowish  hue,  and  others  capped  with  a 
blood  crust,  the  result  of  scratching.  They  were  not  developed 
on  the  site  of  sebaceous  glands.  There  was  no  marked  dryness 
or  want  of  vitality  in  the  hair,  as  he  had  seen  in  severe  cases; 
there  was  slight  mealy  desquamation  in  the  scalp.  As  pointed 
out  by  Ilebra,  the  eruption  did  not  appear  on  the  neck  and 
nucha,  but  began  to  develop  where  the  shoulder  merged  into 
the  neck.  The  principal  eruption  was  on  the  back  of  the  band 
and  forearm  and  on  the  outer  and  anterior  surface  of  the  legs, 
where  the  papules  were  as  large  as  a  split  pea.  There  were 
some  on  the  arms,  the  buttocks,  and  the  thighs.  They  were 
scattered  without  semblance  of  grouping,  conical  in  shape,  and 
firm;  some  of  the  color  of  the  skin,  others  of  a  reddish  hue, 
others  capped  with  a  blood  crust.  Variations  in  the  appearance 
of  the  disease  were  observed  under  certain  complications,  and 
shown  in  photographs.  Dr.  Taylor  read  the  report  of  Dr.  Ira 
Van  Giesen,  who  had  studied  sections  under  the  microscope. 

A  Clinical  Study  of  Pruritus  Hiemalis— Dr.  W.  T.  Cor- 
lett,  of  Cleveland,  read  the  paper.  The  affection  had  first  been 
pointed  out  as  a  disease  sui  generis  by  Dr.  Du  bring,  and  at 
about  the  same  time  by  Jonathan  Hutchinson,  since  when  it  had 
been  little  written  about.  It  was  seldom  seen  save  in  certain 
localities— in  the  Southern  States  only  during  cold  waves.  On 
the  southern  border  of  Lake  Erie  it  was  well  defined  and  not 
uncommon.  He  related  three  cases  illustrating  different  points 
of  interest  connected  with  the  disease.  In  one  it  had  recurred 
during  the  cold  season  for  over  twenty- two  years;  in  another 
the  eruption  had  the  appearance  at  times  of  urticarious  patches, 
two  or  three  inches  in  diameter,  confined  to  the  extremities, 
subsiding  in  about  ten  minutes,  leaving  for  a  while  a  dark-yel¬ 
lowish  spot.  The  third  case  was  in  a  negro,  showing  that  that 
race  was  not  exempt.  The  writer’s  experience  went  to  show 
that  the  state  of  the  general  health  had  no  appreciable  effect  on 
the  pruritus;  that  the  local  irritation  of  the  clothing,  although 
capable  of  aggravating  the  malady,  was  not  of  itself  able  to  pro¬ 
duce  it ;  meteorological  conditions  appeared  to  be  the  main 
aetiological  factor.  These  were  most  potent  with  a  low  tem¬ 
perature,  low  humidity,  and  a  wind  blowing  from  the  north¬ 
west.  These  influences  were  favorable  to  evaporation,  and  the 
low  temperature  reduced  the  glandular  activity  of  the  skin  to 
the  minimum.  As  a  consequence,  the  skin  became  harsh,  the 
peripheral  nerves  were  irritated,  and  the  disease  was  induced. 
He  did  not  think  the  primary  irritation  could  be  central,  else  in 
time  it  would  give  rise  to  a  less  fleeting  disease.  It  was  not  in¬ 
frequently  associated  with  other  neuroses  of  the  skin,  these 
neuroses,  however,  only  showing  the  peculiar  susceptibility  of 
the  nervous  system.  The  treatment  was  largely  palliative.  In¬ 
ternal  medication  seemed  to  have  little  effect.  Locally  he  had 
used  ichthyol  and  resorcin  with  advantage.  A  warm  and  moist 
climate  seemed  to  have  the  best  effect. 

Pruritus. — Dr.  E.  B.  Bronson,  of  New  York,  in  an  argu¬ 
mentative  paper  on  this  subject,  gave  the  following  conclusions: 

1.  That  there  was  a  sense  of  contact  independent  of  the  sense 
of  pselaphesis.  2.  That  this  sense  of  contact  was  the  sense  dis¬ 
turbed  in  pruritus.  3.  That  it  concerned  primarily  simple  cu¬ 
taneous  nerves  or  nerve-endings  situated  superficially  and  prob¬ 
ably  in  the  epidermis.  4.  That  the  disturbance  in  pruritus  was 
of  the  nature  of  a  dyseesthesia  due  to  accumulated  or  obstructed 
nerve  excitation  with  imperfect  conduction  of  the  generated 


force  into  correlated  forms  of  nerve  energy.  5.  That  scratch¬ 
ing  relieved  itching  by  directing  the  excitation  into  freer  chan¬ 
nels  of  sensation,  sometimes,  especially  when  severe,  substitut¬ 
ing  either  painful  or  voluptuous  sensations  for  the  pruritus.  6. 
That  the  voluptuous  sensations  which  might  attend  pruritus 
were  a  manifestation  of  a  generalized  aphrodisiac  sense,  repre¬ 
senting  a  phase  of  common  sensation  that  had  its  source  in  the 
sense  of  contact. 

Cutaneous  Tuberculosis.— Dr.  J.  T.  Bowen,  of  Boston,  read 
a  paper  containing  the  histories  of  a  number  of  cases  of  cutane¬ 
ous  tuberculosis,  together  with  histological  studies,  and  ex¬ 
pressed  the  view,  also  entertained  by  Dr.  White,  through  whose 
courtesy  some  of  the  cases  had  been  seen,  that  several  affections 
of  the  skin  not  yet  recognized  as  inoculable  would  be  proved  to 
be  so,  and  their  relation  to  tuberculosis  be  demonstrated. 

The  Treatment  of  Dermatitis  Herpetiformis.— Dr.  L.  A. 
Duhring,  of  Philadelphia,  said  that  the  several  papers  published 
by  him  on  dermatitis  herpetiformis  during  the  past  five  years  had 
contained  no  reference  to  treatment.  Having  now  reported  ten 
or  twelve  cases,  it  seemed  appropriate  to  speak  of  the  treatment 
of  this  exceedingly  rebellious  disease.  Each  group  of  cases  based 
on  the  setiological  factors  at  work  required  special  handling. 
A  speedy  cure  was  not  to  be  looked  for.  It  must  be  remem¬ 
bered  that  the  disease,  as  a  rule,  was  multiform  in  character, 
and  the  several  varieties  naturally  called  for  different  formulae, 
especially  as  to  the  strength  of  the  remedy.  His  experience 
had  been  that  milder  remedies  were  called  for  in  the  erythema¬ 
tous  than  in  the  vesicular  and  bullous  forms.  A  difficulty  to 
contend  with  was  the  tendency  of  the  disease  to  repeat  itself, 
a  new  crop  coming  out  before  the  older  ones  had  disappeared. 
Almost  all  his  cases  had  been  chronic  and  had  previously  un¬ 
dergone  all  manner  of  treatment.  He  had  long  since  arrived 
at  the  conclusion  that  most  benefit  was  to  be  derived  from 
stimulating  applications,  especially  those  which  acted  as  revul¬ 
sives — tar,  carbolic  acid,  sulphur,  thymol,  ichthyol,  resorcin, 
etc.  That  which  had  proved  of  greatest  value  in  his  hands  had 
been  sulphur  ointment,  two  drachms  to  the  ounce,  applied  by 
thorougli  and  long  rubbing  so  as  to  make  a  positive  impression 
upon  the  skin,  causing,  as  it  were,  local  shock.  Special  em¬ 
phasis  was  placed  upon  the  manner  of  making  the  application. 
Internal  remedies  had  proved  of  little  avail  in  most  cases. 

Atrophia  Maculosa  et  Striata  following  Typhoid  Fever. 
— Dr.  F.  J.  Shepherd,  of  Montreal,  presented  the  history  of  a 
case,  illustrated  by  photographs.  It  had  occurred  in  a  boy  of 
fifteen  years,  brought  to  the  hospital  with  typhoid  fever.  Dur¬ 
ing  the  course  of  the  disease  he  was  delirious  and  had  epileptic 
attacks.  Macular  lines  formed,  extending  across  the  patellae 
and  around  the  anterior  aspect  of  the  thigh  to  near  the  middle, 
some  being  several  inches  long.  They  were  of  a  reddish  color 
and  afterward  became  paler;  they  were  not  distinctly  shiny 
and  were  grooved.  The  interesting  point  in  the  case  was  the 
occurrence  of  the  atrophic  lines  in  a  boy  during  acute  fever. 
He  did  not  think  their  presence  could  be  accounted  for,  as  they 
were  in  oedematous  subjects,  by  stretching.  There  seemed  to 
be  a  nerve  element  in  the  causation. 

Immigrant  Dermatoses. — Dr.  J.  C.  White,  of  Boston,  read 
a  paper  with  this  title.  It  included  an  account  of  the  affections 
of  the  skin  induced  by  life  on  shipboard,  those  induced  after 
arrival  by  conditions  not  existing  previously,  and  those  seen  in 
other  countries,  but  not  in  native  Americans.  Conditions  on 
shipboard  tending  to  induce  skin  affections  were  mental  depres¬ 
sion  on  leaving  home,  seasickness,  filth  and  foul  air,  constipa¬ 
tion,  inability  to  take  exercise,  and  contact  with  others  having 
contagious  disease.  It  was  not  uncommon  for  young  persons 
;o  come  a  week  or  ten  days  after  landing  with  an  urticarial, 
bullous,  or  eczematous  eruption.  Vaccination  on  shipboard 


332 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


not  infrequently  left  a  local  sore  of  wider  area  than  usual,  due 
perhaps  to  a  depressed  state  of  health  and  the  fact  that  the  pa¬ 
tient  had  not  been  revaccinated  since  childhood.  Under  the 
second  head  the  causes  were  new  agencies  not  existing  at  home> 
among  them  being,  perhaps,  mosquitoes.  Under  the  third  head, 
imported  affections,  the  most  common  was  scabies;  among  oth¬ 
ers  was  that  rare  affection,  melanosis  lenticularis  progressiva, 
none  of  the  cases  here,  as  far  as  he  knew,  being  in  native 
American  stock.  Prurigo  also  might  be  regarded  as  an  im¬ 
ported  disease,  and  was  seen  scarcely  elsewhere  than  in  cities 
with  a  large  foreign  population,  like  New  York  and  Chicago. 
The  relative  prevalence  of  vegetable  parasitic  affections  among 
us  was  likely  to  be  largely  influenced  by  immigration.  Tinea 
favosa,  tinea  trichophytina,  and  tinea  versicolor  were  commoner 
in  countries  whence  we  received  many  immigrants  than  they 
were  here.  The  satne  was  true  of  tubercular  affections  of  the 
skin,  and  he  was  disposed  to  regard  lupus,  scrofulodermia, 
scrofulous  gummata,  tuberculosis  verrucosa,  etc.,  as  closely  al¬ 
lied  affections.  Leprosy  was  another  imported  disease,  coming 
from  many  sources.  In  conclusion,  the  author  suggested  the 
propriety  of  memorializing  the  National  Government  with  re¬ 
gard  to  carrying  out  the  following  measures:  1.  To  cleanse  all 
immigrants  of  animal  parasites  on  their  landing  by  treatment 
of  the  person  and  clothing.  2.  To  retain  in  quarantine  all  im¬ 
migrants  with  other  contagious  diseases,  including  venereal 
affections,  a  sufficient  time  for  treatment.  3.  To  return  to 
their  homes  all  persons  affected  with  such  contagious  diseases 
as  it  was  impracticable  to  treat  in  such  manner,  such  as  leprosy, 
tuberculosis,  and  advanced  syphilis.  4.  To  provide  for  efficient 
medical  inspection  at  foreign  ports  of  emigration,  with  the  power 
of  arresting  the  transfer  of  dangerous  diseases  to  this  country. 

A  Case  of  Second  Infection  with  Syphilis  and  a  Case  of 
Syphilitic  Infection  in  a  Person  Hereditarily  Syphilitic. — 
Dr.  Taylor  gave  detailed  histories  of  the  two  cases  which  had 
come  under  his  observation  within  a  year.  The  first  was  in  a 
sickly-looking  woman,  aged  thirty-eight,  who  entered  Charity 
Hospital  in  January  last.  Eleven  years  ago  she  had  syphilis, 
having  had  hard  swelling  of  the  external  genitals,  enlargement 
of  the  glands,  an  eruption  shortly  afterward  all  over  the  body, 
and  headache  at  night.  In  the  second  year  she  had  rheumatoid 
pains  and  mucous  patches,  and  in  the  third  year  serpiginous 
syphilides,  etc.  She  married  and  gave  birth  to  two  weakly 
children,  which  soon  died.  Her  husband  having  died,  she  again 
lapsed  in  virtue,  and  came  to  Charity  Hosptal  in  January  last, 
broken  down  in  health.  There  were  typical  miliary  syphilides 
scattered  over  nearly  the  entire  surface.  All  the  ganglia  were 
decidedly  enlarged.  There  were  mucous  patches  of  the  tongue 
and  mouth  and  evidences  of  alopecia.  She  suffered  with  pain 
in  the  joints,  worse  at  night.  The  second  attack  was  much 
more  severe  than  the  first.  She  was  now  improving  under 
mercurial  treatment. 

The  second  case  was  one  of  acquired  syphilis  in  a  person 
hereditarily  syphilitic.  The  woman  came  to  him  first  in  1879, 
aged  nineteen,  when  he  treated  her  for  a  destructive  syphilitic 
sore  on  the  face,  arising  from  hereditary  syphilis,  a  clear  his¬ 
tory  of  which  was  afterward  given  him  by  her  mother,  who  had 
acquired  syphilis  three  months  before  the  child’s  birth.  The 
child  had  a  rash,  condylomata,  and  snuffles,  and  was  weakly. 
Five  years  after  his  patient’s  first  visit,  in  1885,  she  returned, 
and  had  then  macular  roseola  and  scaling  syphilides  all  over  the 
body,  condylomata  of  the  genitals,  mucous  patches  of  the  phar¬ 
ynx,  etc.  The  infection  began  in  the  right  labium,  and  was 
contracted  from  the  husband.  The  glands  were  all  enlarged, 
and  there  was  alopecia.  She  had  since  been  cured. 

Electrolysis  in  the  Treatment  of  Lupus  Vulgaris.— Dr. 
G.  T.  Jackson,  of  New  York,  in  a  paper  on  this  subject,  said 


the  advantages  that  electrolysis  offered  in  the  treatment  0f  lupus 
vulgaris,  compared  with  other  and  older  measures,  were  as  fol¬ 
lows:  1.  It  was  comparatively  painless,  and  there  was  no  need 
of  an  anaesthetic.  2.  There  was  not  the  slightest  loss  of  blood 
and  thus  there  was  no  dread  of  a  surgical  operation.  3.  The 
patient  was  not  kept  a  moment  from  his  regular  business  there 
was  no  deformity  caused  by  the  treatment,  and  there  was  no 
after-treatment  or  application  to  mar  the  appearance.  He  was 
also  spared  the  discomfort  of  a  swollen  face  and  eyes,  the  ordi¬ 
nary  attendant  on  the  arsenical  or  pyrogallic-acid  treatment.  4. 
The  treatment  went  to  the  root  of  the  disease,  with  far  more 
exactness  and  less  damage  to  the  surrounding  skin  than  any 
other  caustic  or  surgical  method.  5.  The  scar  left  was  smooth 
and  not  unsightly.  6.  The  result  obtained  was  as  good  as  by 
any  previous  method,  if  not  better. 

Plica,  —  Dr.  H.  W.  Stelwagon,  of  Philadelphia,  showed 
photographs  from  a  case  that  he  had  seen  a  few  months  before. 
He  was  not  sure  that  plica  was  the  right  name  for  it.  An  Irish¬ 
woman  who  had  come  to  be  treated  for  acne  called  his  atten¬ 
tion  to  a  lock  of  hair,  as  thick  as  one’s  thumb,  springing 
from  the  middle  of  the  occipital  region,  closely  matted  to¬ 
gether,  and  falling  as  low  as  the  ankles,  terminating  in  a 
brush-like  end.  It  was  not  sticky  and  had  begun  to  grow  four 
years  before,  without  apparent  cause.  The  rest  of  the  hair 
fell  over  the  shoulders  and  was  not  matted.  There  was  no  un¬ 
cleanliness. 

The  Treatment  of  Erysipelas.— Dr.  0.  W.  Allen,  of  New 
York,  based  a  paper  on  the  results  of  treatment  during  the  past 
two  years  of  419  cases  in  the  hospitals  on  Blackwell’s  Island, 
not  under  his  care,  and  47  cases  in  his  own  practice  during  the 
same  time.  The  author  thought  that,  although  tending  to  pur¬ 
sue  a  definite  and  usually  favorable  course,  the  disease  could  be 
checked  in  its  progress  by  treatment.  Among  the  applications 
that  had  been  used  were  boric  acid,  iodine,  resorcin,  bicarbonate 
of  sodium,  ichthyol,  collodion,  and  aristol,  and  scarification  with 
the  knife  and  the  application  of  plaster  strips  had  been  used. 
He  was  disposed  to  think  favorably  of  scarification  and  adhesive 
plaster,  separately  or  together  in  the  same  case,  but  had  tried 
them  in  only  about  two  cases. 

Notes  on  Pilocarpine  in  Dermatology.— Dr.  H.  G.  Klotz, 
of  New  \ork,  gave  a  review  of  the  history  of  pilocarpine  in 
dermatology,  and  said  it  had  not  met  with  the  acceptance  that 
might  have  been  expected  if  its  other  therapeutic  virtues  had 
been  at  all  proportionate  to  its  diaphoretic  qualities.  He  had 
employed  it  in  a  few  cases,  including  eczema,  pruritus  of  the 
anus,  and  affections  with  dryness  and  irritation.  The  result  had 
been  such  as  to  encourage  him  to  give  it  a  further  trial.  It 
might  be  given  internally  or  by  hypodermic  injection,  in  small 
doses,  long  continued.  A  tenth  of  a  grain  was  likely  to  prove 
sufficient  to  keep  the  skin  moist. 

Aristol. — Dr.  Allen  read  a  paper  giving  the  results  of  his 
experience  with  this  new  remedy,  and  summed  up  with  the 
statement  that  it  seemed  to  possess  valuable  cicatrizing,  granu¬ 
lating,  and  stimulating  qualities,  was  void  of  the  objectionable 
odor  of  iodoform,  and  seemed  valuable  in  certain  dermatological 
cases. 

Results  of  the  Treatment  of  Dermatological  Cases  with 
sulphur  W ater  at  Richfield  Springs. — Dr.  0.  0.  Ransom,  the 
jhysician  in  charge  of  the  new  bathing  establishment,  by  invita¬ 
tion,  gave  the  results  of  treatment  of  dermatological  cases  there. 
Since  the  new  bath  had  been  completed,  during  the  summer, 
twenty-two  cases  had  been  treated,  including  nine  of  eczema, 
one  of  psoriasis,  four  of  seborrhoea,  one  of  pruritus,  and  two  of 
urticaria.  There  had  been  marked  improvement  in  nearly  all 
these  cases,  and  in  some  a  cure.  The  baths  were  of  a  tempera¬ 
ture  usually  of  from  95°  to  106°  F.,  lasting  from  seven  to  fif- 


Sept.  20,  1890.] 


SPECIAL  ARTICLES. 


teen  minutes.  A  longer  stay  in  the  sulphur  bath  had  a  depress¬ 
ing  effect,  lasting  some  hours. 

The  meeting  adopted  resolutions  expressing  appreciation  of 
the  very  extensive  and  complete  equipment  for  water  treat¬ 
ment  established  by  Mr.  Proctor  at  the  Springs. 


j§pmal  Articles. 

LETTERS  TO  MY  HOUSE  PHYSICIANS. 

By  WILLIAM  OSLER,  M.  D., 

BALTIMORE. 

Letter  Y. 

Heidelberg  and  Strassbttrg. 

Dear  H. :  We  stayed  a  day  at  Frankfort,  as  I  was  anxious  to  visit 
Weigert,  and  my  colleague  wished  to  see  Edinger  about  methods  of 
brain  preparation.  After  Cohnlieim’s  death,  in  1884,  Weigert  left 
Leipsic  and  accepted  the  charge  of  the  Laboratory  of  the  Senckenberg- 
ischen  Stifts  (a  hospital  founded  in  1763  by  Dr.  Senckenberg),  a  posi¬ 
tion  which  has  been  occupied  by  several  most  distinguished  German 
professors,  notably  Soemmerring,  the  anatomist.  It  would  be  difficult 
to  mention  a  histologist  to  whom  the  profession  is  more  indebted  than 
to  Professor  Weigert,  as  by  the  introduction  of  the  aniline  stains  he 
has  revolutionized  the  study  of  bacteriology,  while  his  special  methods 
have  been  of  incalculable  service  in  normal  and  pathological  histology. 
We  found  him  busy  at  a  new  stain  for  neuroglia,  which  will  show  the 
connective-tissue  framework  as  plainly  as  his  well-known  method  does 
the  medullated  nerve  fibers.  It  is  not  yet  perfected,  but  he  demon¬ 
strated  specimens  of  extraordinary  beauty,  showing  the  rich  plexus  of 
fibers  in  the  gray  matter  of  the  cord.  The  stain  will  be  most  useful  in 
determining  slight  grades  of  sclerosis,  as  it  picks  out  unerringly  every 
neuroglia  element.  The  method  is  not  sufficiently  matured  to  warrant 
publication,  and  in  this  respect  Weigert  exercises  a  most  commendable 
caution.  He  will  work  month  after  month,  early  and  late,  until  every 
possible  modification  has  been  tried  and  every  contingency  met  before 
the  plan  is  finally  approved  and  announced.  I  was  in  the  laboratory  at 
Leipsic  when  he  was  working  at  his  celebrated  nerve  stain,  and  the 
patient  thoroughness  with  which  day  by  day  the  method  was  tested, 
then  improved,  and  at  last  completed,  was  a  valuable  lesson,  and  showed 
a  spirit  which  all  of  us  might  emulate.  Another  important  stain  for 
elastic  fibers  will  also  be  ready  soon,  which  brings  out  the  most  delicate 
fibrils  with  the  greatest  distinctness,  such,  for  example,  as  a  set  of  longi¬ 
tudinally  arranged  filaments  just  beneath  the  endothelial  lining  of  the 
arteries.  There  are  places  in  the  laboratory  for  six  or  eight  special 
students,  and,  with  so  genial  a  teacher  and  so  thorough  a  master  of  his¬ 
tological  methods,  it  is  not  surprising  to  hear  that  the  applicants  are 
numerous. 

Edinger  was  extremely  kind  in  showing  us  his  collection  of  brain 
sections,  which  is  particularly  rich  in  those  of  the  frog  and  turtle ;  but 
he  is  also,  as  you  know  from  his  excellent  little  work,  a  diligent  student 
of  human  cerebral  anatomy.  It  is  remarkable  that  a  man  engaged  in 
active  practice  can  spare  time  for  these  studies,  but  I  suppose  he  has 
learned  the  secret  of  the  value  of  odd  minutes  and  spare  hours.  He 
had  recently  received  from  Dr.  Ramon  y  Cajal,  the  Spanish  histologist, 
a  specimen  illustrating  his  remarkable  discovery  of  the  branching  of 
the  nerve  fibers  in  the  spinal  cord.  The  sections  prepared  by  Golgi’s 
well-known  method  showed  collateral  branches  from  the  axis-cylinder 
process,  some  of  which  form  a  dense  plexus  about  the  ganglion  cell. 

At  Heidelberg  we  found  the  outside  attractions  of  this  ideal  univer¬ 
sity  town  too  strong  for  much  medical  visiting.  Of  course  we  saw  Pro¬ 
fessor  Erb,  whose  extensive  writings  on  the  nervous  system  are  as 
highly  appreciated  in  America  as  in  Europe,  and  in  his  morning  rounds 
we  found  a  rich  material  in  well-arranged  wards.  For  many  years  the 
clinic  here  has  been  particularly  strong  in  the  department  of  neurology, 
the  result  no  doubt  of  the  impetus  given  by  the  master  mind  of  Fried- 


333 

reich  ;  and  Erb  and  Franz  Schultze,  now  professor  at  Bonn,  have  worthi¬ 
ly  maintained  its  reputation.  Naturally  there  were  cases  of  Friedreich’s 
ataxia  and  of  Erb’s  dystrophia  muscularis  progressiva  on  exhibition.  A 
short  time  before  our  visit,  Horsley  had  come  over  from  London  to  op¬ 
erate  on  a  son  of  the  late  Professor  Chelius,  who  had  paraplegia,  the 
result  of  an  injury  in  the  hunting  field.  Erb  stated  that  it  was  too 
soon  to  say  how  far  the  operation  had  been  successful.  One  gets  the 
impression  that  everything  works  smoothly  at  the  medical  clinic,  and  I 
can  well  understand  how  it  is  that  the  young  men  who  have  been  here 
speak  very  warmly  of  it  as  a  most  agreeable  place  for  post-graduate 
study. 

The  pathological  laboratory  has  long  been  a  favorite  resort  for 
American  students,  and  we  are  indebted  to  Professor  Arnold  for  a  very 
pleasant  hour  in  its  various  departments.  He  is  one  of  the  most  expert 
histologists  in  Europe,  and^having  been  for  years  familiar  with  his  nu¬ 
merous  and  elaborate  contributions  in  Virchow’s  Archiv ,  I  was  par¬ 
ticularly  glad  to  have  an  opportunity  of  meeting  him. 

At  the  biological  laboratory  we  saw  Professor  Butschli,  perhaps 
the  greatest  living  authority  on  the  protozoa.  He  talked  most  interest¬ 
ingly  about  the  pathogenic  sporozoa  and  the  haematozoa  of  birds  and 
fishes.  He  had  lately  seen  in  Italy  the  malarial  organisms,  and  it  was 
gratifying  to  hear  that,  although  he  had  had  grave  doubts  at  first,  he 
had  been  convinced  of  their  parasitic  nature.  The  problem  of  the  life 
history  of  these  parasites  outside  the  body  could  be  best  attacked  in  a 
biological  laboratory,  under  the  direction  of  a  man  thoroughly  ac¬ 
quainted  with  the  conditions  of  growth  of  the  protozoa.  By  the  way,  a 
knowledge  of  these  organisms  is  gradually  reaching  this  country.  Pro¬ 
fessor  Rosenbach,  of  Breslau,  was  with  us  at  the  hospital  last  autumn 
for  a  day  or  two,  and  we  showed  him  the  various  forms,  but  he  did  not 
seem  at  all  convinced.  He  has  recently,  however,  had  opportunities  of 
studying  cases,  and  has  published  a  paper  expressing  his  concurrence 
with  Laveran’s  views.  Quincke,  too,  of  Kiel,  one  of  the  highest  au¬ 
thorities  on  the  blood,  has  within  the  past  few  weeks  described  the 
parasites  in  several  cases.  As  we  strolled  along  the  Castle  Road  we 
inquired  the  nature  of  the  large  building  close  to  the  hotel,  and  were 
told  that  it  was  Professor  Schweninger’s  “  Kur-Anstalt.”  You  know,  I 
dare  say,  the  story  of  the  Munich  Docent  who  became  Bismarck’s  phy¬ 
sician,  and  was  foisted  into  the  Berlin  faculty  as  professor  of  derma¬ 
tology.  Certainly  he  has  shown  great  wisdom  in  the  choice  of  a  locality 
in  which  to  make  the  fat  lean  and  the  lean  fat.  We  were  shown 
through  the  place  by  the  resident  physician,  and,  so  far  as  we  could 
gather,  the  remedial  agents  employed  were  the  old-time  favorites  of 
Asclepiades — regimen,  exercise,  baths,  and  friction.  The  professor 
appears  once  a  week  and  directs  the  treatment. 

With  only  three  or  four  days  to  spend  at  Heidelberg,  we  escaped 
quickly  from  hospitals  and  laboratories,  and  in  delightful  mountain 
walks,  at  the  castle,  and,  must  it  be  said,  at  “Zum  Perkeo,”  we  tried 
to  recognize,  if  not  to  feel,  the  romance  which  fills  every  nook  and 
corner  of  this  place.  A  month’s  sojourn  in  this  earthly  paradise  would 
be  the  thing  for  the  tired,  patient-worn  doctor  who  goes  to  Europe  for 
rest.  Resisting  the  devil,  which  drives  so  many  of  us  from  Dan  to 
Beersheba,  racketing  about  in  a  restless  holiday,  let  him  unpack  his 
trunk  at  the  Castle  Hotel  and  spend  his  days  on  the  mountains,  and  he 
will  find  peace  of  mind  and  rest  of  body. 

With  the  exception,  perhaps,  of  certain  of  the  new  laboratories  at 
Berlin,  the  university  buildings  at  Strassburg  are  the  finest  in  Ger¬ 
many,  having  been  paid  for  by  the  Imperial  Government,  which  still 
furnishes  the  means  of  support.  They  are  on  a  most  magnificent  scale, 
and  comprise  on  the  east  side  of  the  town  the  central  university  build¬ 
ing  and  the  chemical,  physical,  geological,  and  botanical  laboratories, 
while  on  the  south  side  near  the  old  City  Hospital  are  the  various  insti¬ 
tutes  devoted  to  physiology,,  physiological  chemistry,  pathology,  anato¬ 
my,  and  pharmacology,  and  the  clinic  for  nervous  and  mental  diseases. 
Together  the  latter  form  a  most  imposing  group,  just  within  the  forti¬ 
fication  wall,  with  the  buildings  not  too  close  to  spoil  the  architectural 
effects  and  each  within  easy  access  of  the  other,  so  that  no  time  is  lost 
by  the  student. 

The  medical  clinic  is  still  in  the  City  Hospital,  but  new  accommo¬ 
dations  have  been  promised  and  are  much  needed,  as  the  old  building 
looks  like  a  survival  from  the  tenth  century.  Professor  Naunyn,  who 


BOOK  NOTICES. 


[N.  Y.  Med.  Jotra., 


334 

succeeded  Kussmaul  about  eighteen  months  ago,  is  a  representative 


German  clinician,  thoroughly  scientific,  thoroughly  practical,  an  ardent 
worker,  an  admirable  teacher,  and  a  most  genial  colleague.  Like  his 
teacher,  Frerichs,  he  is  an  able  chemist  and  a  good  experimenter.  He 
has  had  a  varied  professorial  career,  having  occupied  in  succession  the 
chair  of  medicine  at  Dorpat,  Bern,  and  Konigsberg.  The  method  of 
teaching  is  practically  the  same  as  at  other  German  schools,  but  on 
two  mornings  of  the  week  the  class  is  taken  into  the  wards  and  the 
students  are  drilled  at  the  bedside.  We  were  present  at  one  of  these 
demonstrations,  which  was  perfect  of  its  kind,  but,  as  is  so  often  the 
case,  there  were  too  many  men  clustering  about  the  patient.  Professor 
Naunyn  then  took  us  through  all  the  wards  and  pointed  out  several 
cases  of  special  interest,  among  them  one  of  Virchow’s  hyperplasia  of 
the  circulatory  system  in  a  young  girl,  and  another  of  hepatic  intermit¬ 
tent  fever.  In  the  chemical  laboratory  we  found  in  progress  experiments 
on  the  brains  of  birds,  conducted  by  one  of  the  assistants,  and  researches 
on  the  chemistry  of  gall-stones  and  the  pathology  of  diabetes.  The  col¬ 
lection  of  gall-stones  was  very  fine,  and  the  professor  has  recently  dem¬ 
onstrated  certain  canaliculi  through  which  the  cholesterin  reaches  the 
central  parts. 

At  the  pathological  laboratory  Professor  von  Recklinghausen  was 
just  about  to  lecture,  and  we  heard  a  very  concise  yet  clear  explanation 
of  the  pathology  of  emphysema  and  bronchiectasis.  I  am  sure  many 
teachers  would  have  spent  three  lectures  in  covering  the  same  ground; 
only  a  few  typical,  perfectly  illustrative  specimens  were  shown.  The 
demonstration  courses,  the  daily  sections,  the  classes  in  pathological 
histology,  and  the  private  work  are  personally  conducted  by  the  di¬ 
rector,  who  seems  to  leave  very  little  to  the  assistants.  This  is  one 
reason,  perhaps,  of  the  popularity  of  this  laboratory  with  foreigners. 
It  was  rather  surprising  to  see  the  students  cutting  sections  in  the  old 
free-hand  method  with  the  razor,  but  the  professor  insists  that  often  a 
better  idea  of  the  changes  in  a  tissue  can  be  had  from  a  moderately 
thick  than  from  an  extremely  thin  section.  A  point  of  much  greater 
value  was  the  care  with  which  fresh  specimens  were  examined  either  by 
section  or  by  teasing.  The  uniform  kindness  and  the  untiring  patience 
with  which  Professor  von  Recklinghausen  treats  the  young  men  who 
work  under  him  finds  its  proper  reward  in  the  affection  with  which  he 
is  regarded  by  them. 

An  illustration  of  the  catholic  character  of  the  mind  of  the  great 
master,  Virchow,  is  afforded  by  the  fact  that  four  of  the  greatest 
physiological  chemists  of  Germany  grew  up  under  his  inspiration — 
Hoppe-Seyler,  Kiihne,  Liebreich,  and  Salkowski.  The  Physiological 
Chemistry  Institute,  presided  over  by  the  first  mentioned  of  these  men, 
is  by  far  the  most  complete  in  the  world,  and  has  been  planned  and 
equipped  regardless  of  expense.  There  were  few  men  I  was  more  cu¬ 
rious  to  see  than  Hoppe-Seyler.  In  the  first  place,  as  our  respect  for 
a  subject  is  oftentimes  in  direct  proportion  to  our  ignorance,  I  had 
never,  in  spite  of  a  period  of  study  with  Salkowski,  outgrown  a  sense 
of  the  deepest  reverence  for  physiological  chemistry — a  reverence  which 
was  increased,  if  possible,  by  an  acquaintance  with  the  works  of  the 
Strassburg  professor  ;  and  then  my  assistant  and  successor  at  McGill, 
Dr.  Wesley  Mills,  during  a  prolonged  stay  “  learned  his  great  language, 
caught  his  clear  accents,”  and  made  me  feel  that  as  a  man  and  as  a 
worker  Hoppe-Seyler  was  in  some  ways  exceptional.  We  found  a  class 
of  about  thirty  students  listening  to  a  lecture  on  gastric  digestion,  the 
steps  of  which  were  very  skillfully  shown.  The  greater  part  of  the 
time  was  occupied  with  a  discussion  of  the  nature  and  varieties  of 
peptone.  It  was  gratifying  to  hear  the  name  of  Dr.  Chittenden,  of 
Y  ale,  so  frequently  mentioned,  on  whose  work  the  professor  seemed  to 
place  a  very  high  estimate.  Hoppe-Seyler  is  an  older  man  than  I  ex¬ 
pected  to  find,  but  he  is  vigorous  and  active  and  has  a  very  friendly 
and  attractive  manner.  I  knew  that  the  institute  was  a  large  one,  but 
the  great  extent  and  the  completeness  in  every  detail  were  a  revelation. 
The  advantages  for  research  work  are  so  favorable  that  the  special 
laboratory  is  always  full  of  men  from  all  parts  of  the  world.  The  stu¬ 
dents  can  follow  practically  in  the  general  laboratory  the  subject  upon 
which  the  professor  is  lecturing,  but  it  is  to  be  seen  at  a  glance  that 
the  prime  object  of  the  institution  is  investigation. 

Professor  Schmiedeberg  very  kindly  showed  us  his  Pharmacological 
Institute,  which  is  also,  I  believe,  without  parallel  among  similar  institu¬ 


tions.  As  you  will  find  an  admirable  description  by  Dr.  Sibley,  with  il¬ 
lustrations,  of  the  chief  Strassburg  laboratories  in  the  early  numbers  of 
the  British  Medical  Journal  of  this  year,  I  will  spare  you  the  account  of 
physiological  and  anatomical  institutes.  In  the  former,  besides  Pro¬ 
fessor  Goltz’s  dogs  in  a  more  or  less  brainless  condition,  the  work  of 
Professor  Ewald  interested  us  intensely  as  an  illustration  of  micro-chi- 
rurgy.  In  operating  on  the  semicircular  canals  of  pigeons,  in  order 
to  obviate  all  unnecessary  laceration  and  bleeding,  the  dissection,  with 
the  strictest  antiseptic  precautions,  was  made  under  a  specially  devised 
low-power  microscope,  and  the  vein,  not  so  big  as  the  finest  thread, 
which  runs  over  the  canal,  was  included  between  two  ligatures  and  cut. 
He  had  the  tiniest  little  instruments,  and  every  detail  was  carried  out 
in  miniature.  I  must  mention  the  extreme  kindness  of  Professor 
Schwalbe,  with  whom  we  spent  the  last,  as  in  many  ways  it  was  our 
best,  day  in  Germany. 

Now,  as  you  are  in  part  a  Teuton,  it  may  interest  you  to  know  the 
general  impression  one  gets  of  the  professional  work  over  here.  I 
should  say  that  the  characteristic  which  stands  out  in  bold  relief  in  Ger¬ 
man  scientific  life  is  the  paramount  importance  of  knowledge  for  its 
own  sake.  To  know  certain  things  thoroughly  and  to  contribute  to  an 
increase  in  our  knowledge  of  them  seems  to  satisfy  the  ambition  of 
many  of  the  best  minds.  The  presence  in  every  medical  center  of  a 
class  of  men  devoted  to  scientific  work  gives  a  totally  different  aspect 
to  professional  aspirations.  While  with  us — and  in  England — the  young 
man  may  start  with  an  ardent  desire  to  devote  his  life  to  science,  he  is 
soon  dragged  into  the  mill  of  practice,  and  at  forty  years  of  age  the 
“guinea  stamp  ”  is  on  all  his  work.  His  aspirations  and  his  early  years 
of  sacrifice  have  done  him  good,  but  we  are  the  losers  and  we  miss 
sadly  the  leaven  which  such  a  class  would  bring  into  our  professional 
life.  We  need  men  like  Joseph  Leidy  and  the  late  John  C.  Dalton,  who, 
with  us  yet  not  of  us,  can  look  at  problems  apart  from  practice  and 
pecuniary  considerations.  * 

I  have  said  much  in  my  letters  of  splendid  laboratories  and  costly 
institutes,  but  to  stand  agape  before  the  magnificent  structures  which 
adorn  so  many  university  towns  of  Germany  and  to  wonder  how  many 
millions  of  marks  they  cost  and  how  they  ever  could  be  paid  for,  is  the 
sort  of  admiration  which  Caliban  yielded  to  Prospero.  Men  will  pay 
dear  for  what  they  prize  dearly,  and  the  true  homage  must  be  given  to 
the  spirit  which  makes  this  vast  expenditure  a  necessity.  To  that  Geist 
the  entire  world  to-day  stands  debtor,  as  over  every  department  of  prac¬ 
tical  knowledge  has  it  silently  brooded,  often  unrecognized,  sometimes 
when  recognized  not  thanked. 

The  universities  of  Germany  are  her  chief  glory,  and  the  greatest 
boon  she  can  give  to  us  in  the  New  World  is  to  return  our  young  men 
infected  with  the  spirit  of  earnestness  and  with  the  love  of  thorough¬ 
ness  which  characterize  the  work  done  in  them. 


oak  gUittfs. 


L' intoxication  chronique  par  la  morphine  et  ses  diverses  formes. 
Par  le  Dr.  L.  R.  Regnier,  ancien  interne  en  m6decine  des 
hopitaux  de  Paris.  Paris:  E.  Lecrosnier  et  Bab6, 1890.  Pp. 
5  to  171.  [Publications  du  Progres  medical .] 

In  this  interesting  monograph  the  author  concludes  that  the 
prolonged  use  of  opium  or  its  alkaloids  produces  a  chronic  in¬ 
toxication,  morphinism.  The  intoxication  may  be  due  to  in¬ 
evitable  therapeutic  necessity  or  to  a  pathological  desire  origi¬ 
nating  from  the  temperament  of  the  individual.  The  mor- 
phinise  is  distinguished  by  the  absence  of  psycho-sensorial 
phenomena,  and  by  the  absence  of  grave  symptoms  when  the 
drug  is  stopped.  The  morphinomaniac  is  distinguished  by  the 
almost  constant  presence  of  a  nervous  state,  hereditary  or  ac¬ 
quired  by  disease;  or  by  physical  or  psychical  symptoms  of  de¬ 
generation,  indicated  by  a  mixture  of  psycho-sensorial  phenom¬ 
ena  with  manifestations  usual  in  ordinary  morphine  intoxica- 


Sept.  20,  1890.] 


BOOK  NOTICES.— NE W  INVENTIONS. 


335 


tion.  Morphine  intoxication  rarely  produces  complete  loss  of 
responsibility,  and  it  does  not  cause  irresistible  impulses;  the 
latter,  however,  are  present  in  a  morphinomauiac,  especially 
when  deprived  of  the  drug. 

Morphinomaniacs  should  be  confined  in  asylums  until  they 
are  cured,  if  such  a  result  is  possible. 

The  author  has  collected  a  large  number  of  illustrative 
cases,  and  completes  his  work  with  a  copious  bibliography. 


Die  Untersuchung  der  hinteren  Larynxwand.  Yon  Dr.  Gustav 
Killian,  Privatdocent  fur  Laryngologie  und  Rhinologie  in 
Freiburg  i.  Breisgau.  Mit40  Abbildungen  in  Texte.  Jena: 
Gustav  Fischer,  1890.  Pp.  77. 

The  author  enters  into  an  interesting  theoretical  considera¬ 
tion  of  the  methods  of  inspecting  the  posterior  wall  of  the 
larynx,  proving  by  trigonometrical  calculations  the  proper 
angle  for  the  mirror  and  attitude  of  the  head  in  order  to  admit 
of  an  inspection  of  that  region.  The  desired  end  can  be  ob¬ 
tained  by  two  methods:  one  with  the  head  thrown  backward 
and  a  mirror  (holding  the  epiglottis  out  of  the  way)  reflecting 
the  posterior  surface  of  the  larynx  on  a  second  mirror  held 
against  the  velum  palati;  the  second,  with  the  patient  standing 
and  holding  the  head  forward  with  the  face  downward,  and 
the  physician  kneeling  to  obtain  the  reflection  of  the  posterior 
wall  in  a  mirror  held  against  the  velum.  A  number  of  cases 
are  cited  in  evidence  of  the  necessity  of  inspecting  the  posterior 
a3  well  as  the  anterior  laryngeal  surface ;  and  they  demonstrate 
the  practical  applicability  of  the  methods  described. 


Rheumatism  and  Gout.  By  F.  Leroy  Satterlee,  M.  D  ,  Ph.  D., 
Professor  of  Chemistry,  Materia  Medica,  and  Therapeutics 
in  the  New  York  College  of  Dentistry,  etc.  Detroit:  George 
S.  Davis,  1890.  Pp.  83.  [The  Physician’s  Leisure  Library.] 
This  excellent  monograph,  while  containing  little  that  is 
new,  is  eminently  practical  and  presents  the  subject  in  a  con¬ 
cise  and  interesting  manner.  It  deals  chiefly  with  treatment. 
The  author,  holding  firmly  the  uric-acid  theory  of  causation, 
relies  almost  exclusively  upon  diet,  cholagogues,  and  alkalies. 
His  sweeping  condemnation  of  the  salicylates  in  rheumatism 
and  of  colchicum  in  gout  is  to  be  regretted. 

A  particular  merit  of  the  book  is  its  literary  style. 


years  at  his  disposal,  Dr.  Iveyes  should  be  able  to  speak  au¬ 
thoritatively  of  that  subject. 


Practical  Electricity  in  Medicine  and  Surgery.  By  G.  A. 
Liebig,  Jr.,  Ph.  D.,  Assistant  in  Electricity,  Johns  Hopkins 
University,  etc.,  and  George  H.  Rohe,  M.  D.,  Professor  of 
Obstetrics  and  Hygiene,  College  of  Physicians  and  Surgeons, 
Baltimore,  etc.  Profusely  illustrated.  Philadelphia  and 
London:  F.  A.  Davis,  1890.  Pp.  viii-3  to  383.  [Price, 
$2.] 

Tnis  is  a  thoroughly  useful  book,  with  the  exception,  per¬ 
haps,  of  its  superabundance  of  formulae,  which  make  the  first 
part  a  trifle  too  technical  for  the  average  practitioner.  The 
science  of  electrical  forces,  the  various  forms  of  electrical  and 
magnetic  apparatus  available  for  medical  and  surgical  work,  the 
best  methods  of  caring  for  batteries,  the  effects  of  electric  cur¬ 
rents  upon  tissues  and  organs  of  the  body  in  health  and  disease, 
the  general  therapeutic  effects  of  electricity,  modes  of  applica¬ 
tion — especially  in  gynaecology,  diseases  of  the  skin,  and  dis¬ 
eases  of  the  male  genito-urinary  organs— are  carefully  consid¬ 
ered  and  practical  suggestions  are  formulated.  Whatever  brings 
into  greater  knowledge  electricity  as  a  remedial  agent  must  be 
received  with  gratitude.  The  work  under  consideration  aids  in 
the  accomplishment  of  this  purpose. 


Transactions  of  the  American  Orthopaedic  Association.  Third 
Session,  held  at  Boston,  Mass.,  September  IT,  18,  and  19, 
1889.  Volume  II. 

In  this  volume  the  principal  subjects  in  orthopaedic  surgery 
are  dealt  with  by  the  leading  men  of  the  country.  Hip  disease 
is  given  special  consideration,  both  in  original  articles  and  in 
the  discussions. 

The  volume  will  be  a  valuable  addition  to  a  surgical  library. 


fteto  Jnbcntions,  etc. 


Diabetes  Mellitus  and  Insipidus.  By  Andrew  H.  Smith,  M.  D., 
Professor  of  Clinical  Medicine  and  Therapeutics  at  the  New 
York  Post-graduate  Medical  School  and  Hospital,  etc.  De¬ 
troit  :  George  S.  Davis,  1890.  Pp.  74. 

The  author  states  that  the  object  of  this  little  work  is  not 
to  compress  into  the  fewest  possible  words  all  that  is  known  or 
surmised  in  regard  to  diabetes,  but  to  give  the 
points  that  will  most  interest  those  who  have  to 
manage  cases  of  this  disease.  Undetermined  ques¬ 
tions  are  not  discussed.  Prevention,  dietetic  treat¬ 
ment,  the  use  of  drugs,  and  hygienic  measures 
are  carefully  considered,  and  the  best  methods  in¬ 
dicated.  As  the  outcome  of  experience  and  skill, 
the  brochure  recommends  itself  alike  to  the  general 
and  to  the  special  practitioner. 


A  FEW  NEW  CUTTING  INSTRUMENTS  FOR  NASAL  WORK. 
By  A.  T.  Veeder,  M.  D., 

SCHENECTADY,  N.  Y. 

Having  recently  had  made  by  Snowden,  of  Philadelphia,  and  remod¬ 
eled  by  Messrs.  Tiemann  &  Co.,  of  New  Tork,  several  nasal  cutting  in¬ 
struments  or  forceps,  I  give  below  illustrations  of  the  same. 


Some  Fallacies  concerning  Syphilis.  By  E.  L.  Keyes,  M  .D., 
etc.  Detroit:  George  S.  Davis,  1890.  Pp.  vi-71.  [The 
Physician’s  Leisure  Library.] 

This  monograph  is  so  clearly  written  that  one  is  in  no  sense 
left  in  doubt  as  to  the  writer’s  opinions.  The  mercurial  treat¬ 
ment  is  well  supported,  and,  with  records  of  more  than  forty 


The  first — somewhat  of  the  order  of  a  septal  punch — I  have  used 
with  great  comfort,  quickly  making  a  passage  through  the  nose  where 
there  was  partial  opening  or  complete  occlusion  of  the  nares  by  reason 
of  bridges  of  bone  or  bone  and  cartilage  extending  all  the  way  across, 
producing  either  permanent  pressure  against  or  indentation  of  the  tur¬ 
binated  bodies. 

This  cutting  punch  or  forceps,  the  edge  of  the  cutting  part  of  w'hic 


336 


MISCELLANY. 


[N.  Y.  Mkd.  Jons. 


is  of  well-tempered  steel,  in  operating  is  pressed  on  the  reverse  blade  of 
the  instrument,  which  is  flat  and  faced  with  a  thin  plate  of  German  sil¬ 
ver  so  that  the  edge  may  not  be  quickly  dulled,  and  yet  not  so  quickly 
indented  as  the  softer  metal  copper  might  be.  It  cuts  through  bone 
easily  in  a  very  few  seconds,  and  does  away,  in  my  hands,  with  a  good 
deal  of  protracted  and  troublesome  sawing,  leaving  separated  surfaces 
which  heal  quickly  and  smoothly.  Several  widths  and  sizes  are  needed, 
inasmuch  as  all  noses  are  not  of  the  same  proportion. 

The  ends  which  enter  the  nose  should  be  two  inches  and  a  half  in 
length  from  the  point  where  the  two  blades  are  connected.  Also  the 
instruments,  as  will  be  observed  in  the  cuts,  have  a  curved  and  angular 
form,  which  allows  the  eye  to  see  straight  into  the  nose  while  they  are 
introduced,  and  the  reopening  spring  gives  convenient  and  quick  move¬ 
ment. 

The  other  two  are  simply  right  and  left  cutting  forceps,  having  one 
cutting  edge  or  blade  to  press  flat  against  the  septum,  bringing  it  down 
on  the  smooth  face  of  the  opposite  blade,  which  has  also  a  thin  plate  of 
German  silver  to  receive  the  pressure  of  the  cutting  edge. 

These  two  instruments  are  designed  for  the  quick  removal  of  small 
ecchondroses  or  exostoses  which  present  the  shelf-like  form. 

September  9,  1890. 


Hlxsr*Il  ang. 


Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon -General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  September  12th: 


DEATHS  FROM— 


CITIES. 

S 

•3 

a 

is 

Estimated  po] 
lation. 

Total  deaths  \ 
all  causes 

Cholera.  | 

Yellow  fever. 

H 

a 

'2 

a 

Varioloid. 

Varicella. 

Typhus  fever. 

Enteric  fever. 

Scarlet  fever. 

Diphtheria. 

Measles. 

Whoopiug- 
cough . 

Philadelphia,  Pa . 

Aug.  30. 

1,064,277 

390 

11 

9 

1 1 

Brooklyn,  N.  Y . 

Aug.  30. 

871,852 

397 

4 

9 

7 

Brooklyn,  N.  Y . 

Sept.  6. 

871,852 

378 

0 

o 

l 

Baltimore,  Md . 

Sept.  6. 

500,343 

158 

f, 

,1 

A 

Bostojj,  Mass . 

Sept.  6. 

446,507 

191 

7 

1 

Cincinnati,  Ohio . 

Sept.  5. 

325,000 

94 

3 

.... 

New  Orleans,  La . 

Aug.  30. 

254,000 

106 

*  * 

1 

*  * 

Washington,  D.  C  .. . 

Aug.  30. 

250,000 

125 

7 

9 

0 

1 

Washington,  D.  C  ... 

Sept.  6. 

250,000 

100 

8 

i 

1 

.... 

Pittsburgh,  Pa . 

Aug.  30. 

24(1,000 

81 

Detroit,  Mich . 

Aug.  30. 

230,000 

76 

o 

10 

1 

Milwaukee,  Wis . 

Sept.  6. 

220,000 

86 

i 

9 

Minneapolis,  Minn... 

Aug.  30. 

200,000 

45 

3 

*  * 

3 

1 

.... 

Minneapolis,  Minn. . . 

Sept.  6. 

200,000 

47 

1 

1 

.... 

Kansas  City,  Mo . 

Aug.  30. 

135,000 

33 

1 

.... 

Kansas  City,  Mo . 

Sept.  6. 

135,000 

20 

3 

Rochester,  N.  Y . 

Sept.  5. 

1*5,000 

49 

1 

1 

Providence,  R.  I . 

Sept.  6. 

130,000 

50 

1 

9 

1 

Indianapolis,  Ind.... 

Sept.  5. 

129,346 

27 

1 

l 

Richmond,  Va . 

Aug.  30. 

100,000 

46 

i 

1 

Richmond,  Ya . 

Sept.  6. 

100,000 

33 

9 

•  • 

3 

*  * 

Toledo,  Ohio . 

Sept.  5. 

81,650 

35 

i 

3 

.... 

Nashville,  Tenn . 

Sept.  6. 

75,695 

30 

1 

Fall  River,  Mass . 

Sept.  6. 

75,000 

24 

1 

Charleston,  S.  C . 

Aug.  30. 

60,145 

58 

3 

Charleston,  S.  C . 

Sept.  6. 

60,145 

32 

Portland,  Me . 

Sept.  6. 

42.000 

11 

Galveston,  Texas  .... 

Aug.  15. 

40.000 

14 

Galveston,  Texas. . . . 

Aug.  22. 

40,000 

7 

i 

Galveston,  Texas.... 

Aug.  29. 

40,000 

20 

1 

i 

Binghamton,  N.  Y. . . 

Sept.  6. 

85,000 

7 

*  .  . 

Altoona,  Pa . 

Aug.  2. 

34,397 

13 

Altoona,  Pa . 

Aug.  9. 

34,397 

14 

Altoona,  Pa . 

Aug.  16. 

34,397 

11 

Yonkers,  N.  Y . 

Aug.  30. 

32,000 

10 

Yonkers,  N.  Y . 

Sept.  6. 

32,000 

10 

Auburn,  N.  Y . 

Aug.  30. 

26.000 

12 

i 

Auburn,  N.  Y . 

Sept.  6. 

26,000 

7 

Newton,  Mass . 

Aug.  30. 

22,011 

11 

l 

Rock  Island,  Ill . 

Aug.  30. 

16,000 

3 

Pensacola,  Fla . 

Aug.  30. 

15,000 

5 

2 

Spirometry. — “  M.  Joal,  of  Mont  Dore,  has  made  a  number  of  ob¬ 
servations  in  spirometry  that  lead  him  to  the  conclusion  that  many 
nasal  and  pharyngeal  affections  produce  a  distinct  diminution  in  the 
capacity  of  the  lungs.  Thus  in  cases  where  hypertrophic  rhinitis,  ade¬ 


noid  tumors  of  the  naso-pharynx,  chronic  coryza,  etc.,  have  been  cured 
the  capacity  of  the  lungs,  as  measured  by  the  spirometer,  is  frequently 
increased  by  a  quarter,  and  occasionally  even  doubled.  M.  Joal  has 
frequently  found  that  public  singers,  when  they  complain  of  fatigue  of 
the  voice  or  of  diminution  in  its  power  or  range,  are  suffering  from 
some,  perhaps  quite  unsuspected,  trouble  in  the  nose  or  pharynx,  and 
that  if  this  is  cured  the  voice  recovers  itself  completelv.  He  suggests 
that  professional  singers  should  know  their  own  respiratory  capacity, 
and  that  this  should  be  occasionally  tested,  so  that  any  diminution  may 
serve  to  give  a  warning  of  possible  mischief  in  the  nose  or  pharynx, 
which,  if  attended  to  in  time,  may  be  met  by  appropriate  treatment." 
— Lancet. 


ANSWERS  TO  CORRESPONDENTS. 

No.  330. — There  is  no  advantage  in  stitching  the  wall  of  the  blad¬ 
der  to  the  skin. 

No.  331. — The  excess  of  acid  in  the  tincture  of  iron  is  neutralized 
by  the  sodium  tartrate  contained  in  the  preparation,  and  the  resulting 
mixture  is  said  to  be  tasteless  and  the  systemic  action  of  the  iron  to  be 
facilitated  rather  than  impaired. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow - 
ing: 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles,  we  aheays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed :  ( 1 )  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (3)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of— we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  anj 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  gut 
into  the  typesetters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases ,  or  deal  with  subjects  of  little  interest  to  the  medical  projession 
at  large.  We  can  not  enter  irdo  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number ,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  arunver  to  his  note 
is  to  be  looked  for .  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  September  27,  1890. 


(Drtgtnal  Communications. 

A  CASE  OF  BRAIN  SURGERY 

and  its  relations  to  cerebral  localization. 

By  WILLIAM  A.  HAMMOND,  M.  D., 

WASHINGTON,  D.  C. 

Miss  G.  entered  my  Sanitarium  July  20, 1890,  suffering  from 
an  old  left  hemiplegia,  epileptic  convulsions,  mental  deteriora¬ 
tion,  and  occasional  paroxysms  of  maniacal  excitement.  The 
clinical  history  taken  by  Dr.  E.  L.  Tompkins,  the  resident  phy¬ 
sician,  soon  after  her  admission,  is  as  follows: 

Nineteen  years  of  age.  Father,  Italian  ;  mother,  American. 
Residence,  Marshall,  Texas.  Family  history  good,  Father  and 
mother  healthy.  No  history  of  syphilis.  The  patient  was  born 
healthy  and.  normal.  Rather  difficult  labor,  but  no  forceps  was 
used.  First  sickness  occurred  when  the  infant  was  five  weeks 
old  and  consisted  of  cholera  infantum.  During  this  attack  she 
became  rigid,  arms  and  legs  contracted  and  flexed,  more  pro¬ 
nounced  on  the  left  side  than  on  the  right.  Right  side  recov¬ 
ered,  but  the  left  side  remained  more  or  less  contracted.  Short¬ 
ly  after  this  she  had  aural  catarrh  on  the  left  side  and  a  very 
offensive  discharge.  From  this  she  apparently  entirely  recov¬ 
ered  without  impairment  of  hearing.  During  the  period  of 
teething  she  had  “spasms”  accompanied  with  frothing  at  the 
mouth.  She  had  no  more  of  these  attacks  until  she  was  about 
five  years  old,  when,  upon  one  occasion  while  sitting  quietly  in 
a  chair,  she  was  seized  with  a  convulsion  attended  with  uncon¬ 
sciousness,  frothing  at  the  mouth,  and  a  deviation  of  the  eyes 
toward  the  left  side.  She  had  no  other  seizures  after  that  for 
a  year,  when  another  ensued  similar  to  the  last.  After  that  the 
convulsions  became  more  frequent,  occurring  at  intervals  of 
from  one  to  six  months.  They  generally  began  with  a  rigor 
down  the  back,  cold  hands  and  feet,  and  trembling  of  the  left 
side.  It  was  impossible  to  get  her  warm  until  after  the  attack. 
During  this  period  she  was  under  no  special  treatment  except 
during  a  seizure,  when  a  physician  would  be  called  in.  Meas¬ 
ures,  however,  were  adopted  for  rectifying  the  contractures. 
These  consisted  of  electricity  (faradism),  massage,  and  tenoto¬ 
mies,  which  did  not  improve  matters.  When  she  was  about 
ten  years  of  age  the  seizures  assumed  a  different  form ;  there 
were  nausea  and  vomiting,  and  again  they  were  ushered  in  with 
a  period  of  great  excitement,  during  which  she  would  sing  and 
shout  loudly.  As  she  was  very  pious,  everything  of  a  religious 
nature  would  cause  great  mental  disturbance.  For  the  last 
four  years  she  has  been  aware,  for  sometimes  as  long  as  twelve 
hours,  that  an  attack  was  about  to  occur,  as  she  would  be  pale, 
especially  around  the  eyes,  “bumps”  would  make  their  appear¬ 
ance  on  the  face,  and  there  was  more  or  less  vertigo  with  mental 
confusion.  After  the  occurrence  of  a  paroxysm  her  mind 
would  clear  up  and  she  would  feel  much  better.  Sometimes 
there  was  loss  of  consciousness  and  again  not,  but  she  was 
always  greatly  frightened  before  and  for  some  time  after  the 
seizure.  Began  menstruating  at  twelve  years  of  age,  each  pe¬ 
riod  lasting  four  or  five  days;  was  regular  for  about  a  year  and 
then  ceased  menstruating  for  two  years;  since  then  has  been 
irregular.  Epileptic  convulsions  much  more  severe  at  the  time 
menstruation  ought  to  have  appeared.  Left  hand  apparently 
stopped  growing  some  six  years  ago,  as  also  did  the  left  foot. 
For  the  last  five  years  she  has  exhibited  marked  symptoms  of 
mental  derangement,  committing  many  singular  actions  and 
being  very  silly  and  weak-minded.  Has  been  to  school  for  a 
short  time,  but  would  have  headache  and  fits  when  studying 
for  any  considerable  period.  At  times  could  read  very  well,  at 


other  times  would  seem  unable  to  read.  Her  memory  has  been 
apparently  good,  especially  in  regard  to  matters  concerning 
herself.  Has  had  none  of  the  ordinary  children’s  diseases  ex¬ 
cept  measles.  For  the  last  six  months  her  mental  symptoms 
have  been  much  more  intense,  singing  loudly  on  improper  occa¬ 
sions,  and  making  a  great  deal  of  noise,  also  using  very  bad 
language;  religion  and  money  being  subjects  that  would  espe¬ 
cially  disturb  her. 

Examining  her  on  her  admission  to  the  Sanitarium,  I  found 
that  both  mind  and  body  were  undeveloped.  Her  expression 
indicated  a  state  of  decided  imbecility,  though  at  times  in  the 
course  of  my  conversation  with  her  she  exhibited  considerable 
sharpness.  The  left  hand  was  in  a  state  of  extreme  flexure  and 
was  permanently  contracted,  although  several  of  the  flexor  mus¬ 
cles  had  been  divided  by  a  surgical  operation.  The  elbow  also 
was  in  a  state  of  flexion,  though  not  fixedly  contracted,  there 
being  some  slight  degree  of  action.  The  muscles  about  the 
shoulder  joint,  especially  the  deltoid,  were  paralyzed  and  atro¬ 
phied.  The  whole  extremity  was  in  a  state  of  atrophy,  and 
there  was  not  a  muscle  that  was  not  more  or  less  paralyzed. 

The  left  lower  extremity  was  in  a  similar  state,  though  not 
anything  like  to  the  same  extent.  The  muscles  of  the  hip  and 
thigh  were  in  tolerably  good  condition.  The  extensors  of  the 
foot,  especially  the  tibialis  anticus  and  peroneal  muscles,  were 
possessed  of  very  slight  contractile  power.  The  gastrocnemius 
and  solans  muscles  were  in  a  state  of  contraction,  although  the 
tendo  Achillis  had  been  divided  several  times.  All  of  the  para¬ 
lyzed  muscles  of  both  the  upper  and  lower  extremity  exhibited 
diminished  electric  excitability. 

The  left  side  of  the  face  was  much  less  mobile  than  the  right. 
There  was  no  permanent  strabismus,  but  occasionally  there  had 
been  double  vision  ;  the  pupils  were  equal  and  reacted  well  to 
light  and  to  near  and  far  vision.  The  tongue  was  apparently 
mobile,  but  when  protruded  deviated  strongly  to  the  left,  the 
paralyzed  side.  The  speech  was  somewhat  indistinct,  the  lingual 
sounds  were  imperfectly  formed,  and  there  appeared  to  be  a 
deficient  adeptness  in  using  the  tongue  for  purposes  of  articula¬ 
tion.  Occasionally  there  had  been  difficulty  in  swallowing. 
The  eyesight  was  not  materially  affected,  but  upon  ophthalmo¬ 
scopic  examination  I  found  a  venous  congestion  of  both  retinas 
and  chorioids  with  somewhat  whitened  discs.  The  hearing  was 
not  impaired,  though,  as  stated  in  the  clinical  history,  there  had 
been  in  early  life  profuse  otorrbeea.  The  patient,  although  nine¬ 
teen  years  of  age,  was  physically  undeveloped  ;  the  skull  was 
unsymmetrical,  the  right  side  being  distinctly  smaller  than  the 
left.  Latterly  the  epileptic  convulsions  had  become  more  fre¬ 
quent.  Sometimes  the  muscular  spasms  were  confined  to  the 
left  side  of  the  face,  left  arm  and  leg,  hut  again,  though  origi¬ 
nating  in  these  parts,  they  became  general.  There  was  always 
loss  of  consciousness. 

Within  the  last  four  or  five  months  the  convulsive  seizures 
had  not  only  been  more  frequent,  but  she  had  become  subject 
to  paroxysms  of  intense  excitement,  during  which  she  raved 
incoherently  and  was  very  abusive  to  those  about  her,  using 
profane  and  filthy  language.  On  any  attempt  being  made  to  re¬ 
strain  her  she  fought  with  her  arms,  legs,  and  teeth  in  a  manner 
which  can  only  be  described  as  ferocious.  Even  a  few  words 
of  reproof  were  sufficient  at  times  to  bring  on  these  attacks, 
which  in  all  essential  respects  were  not  different  from  those  of 
acute  mania. 

I  gave  it  as  my  opinion  that  she  was  suffering  from  a  mor¬ 
bid  growth  of  some  kind,  involving  the  left  parietal  lobe  and 
part  of  the  frontal  lobe,  especially  the  ascending  parietal  convo¬ 
lution  and  the  ascending  frontal  convolution.  1  expressed  my 
willingness  to  undertake  an  operation  for  the  patient’s  relief.  I 


338 


HAMMOND:  A  CASE  OF  BRAIN  SURGERY. 


[N.  Y.  Med.  Jouh., 


explained  to  the  parents  that  the  prospect  of  cure  was  very  re¬ 
mote,  but  that  I  thought  there  was  nothing  else  that  offered  the 
slightest  hope  of  alleviation;  that  without  such  operation  the 
child  would  become  permanently  insane,  and  would  probably 
•die  in  a  few  months ;  and  that  it  was  quite  probable  that  during 
one  of  the  paroxysms  of  maniacal  excitement  to  which  she  was 
subject  she  might  commit  some  act  of  extreme  violence,  even 
to  the  extent  of  homicide,  and  that  there  was  some  hope  that 
an  operation,  if  based  upon  a  correct  diagnosis,  would  result  in 
the  cure  of  the  epilepsy  and  of  the  paroxysms  of  insanity.  The 
paralysis  I  regarded  as  absolutely  irremediable.  They  expressed 
their  desire  that  the  operation  should  be  performed,  and  the 
patient  herself,  to  whom  the  matter  was  as  fully  explained  as 
was  possible,  was  equally  anxious  to  have  anything  done  that 
afforded  her  even  the  slightest  prospect  of  relief. 

Accordingly,  on  the  morning  of  July  23d,  at  eleven  o’clock, 
assisted  by  Dr.  Tompkins,  the  resident  physician  of  the  Sani¬ 
tarium,  and  Dr.  Pedigo,  of  Roanoke,  Ya.,  I  began  the  opera¬ 
tion.  The  patient  was  first  completely  anaesthetized  and  the 
scalp  covering  the  parietal  and  lateral  frontal  portions  of  the 
skull  shaved.  The  first  point  was  to  determine  by  measure¬ 
ments  the  exact  situation  of  the  fissure  of  Rolando.  There  are 
many  methods  of  doing  this,  some  of  them  exceedingly  trouble¬ 
some  and  complex,  without  thereby  being  of  any  greater  prac¬ 
tical  adaptability.  The  fissure  of  Rolando  is  very  rarely  in  ex¬ 
actly  the  same  relative  position  in  any  two  brains,  and  those 
processes  for  determining  its  location  and  direction  by  external 
indications,  involving  the  measurement  of  angles  to  a  fraction 
of  a  degree  and  lines  to  the  fraction  of  a  millimetre,  are  pedan¬ 
tic  and  useless.  It  has  always  appeared  to  me,  and  I  have  veri¬ 
fied  it  by  many  observations,  that  the  method  of  Reid*  is  suffi¬ 
ciently  exact  for  all  practical  purposes,  and  that  the  fissure  of 


Rolando  does  not,  in  one  case  out  of  a  hundred,  lie  as  much  as 
the  eighth  of  an  inch  anteriorly  or  posteriorly  of  the  line  drawn 
according  to  his  method.  A  surgeon,  therefore,  has  simply  to 
proceed,  guided  by  the  directions  he  has  given,  and,  placing  the 
center-pin  of  the  trephine  on  the  line  obtained,  he  will  reach 

*  The  Principal  Fissures  and  Convolutions  of  the  Cerebrum.  Lan¬ 
cet ,  1884. 


the  fissure  of  Rolando  as  often  as  he  may  make  the  attempt.  In 
the  accompanying  figure,  taken  from  Reid’s  paper,  his  process  is 
clearly  shown.  It  is  described  as  follows  :  A  base  line  is  drawn 
from  the  inferior  margin  of  the  orbit  through  the  external  audi¬ 
tory  meatus.  Two  perpendiculars,  F  and  D,  are  then  drawn; 
the  one,  D,  is  raised  from  the  depression  in  front  of  the  external 
auditory  meatus,  the  other,  F,  from  the  posterior  border  of  the 
mastoid  process.  A  line  drawn  from  a  point  an  inch  and  a 
quarter  behind  the  external  angular  process  of  the  frontal  bone 
to  another  three  quarters  of  an  inch  below  the  most  prominent 
part  of  the  parietal  eminence  will  indicate  the  position  of  the 
fissure  of  Sylvius.  Now  let  a  line  be  drawn  from  the  upper  ex¬ 
tremity  of  the  perpendicular  F  to  tbe  point  on  D  where  it  is 
intersected  by  the  line  indicating  the  fissure  of  Sylvius,  and  we 
have  the  position  of  the  fissure  of  Rolando. 


I  have  ascertained  from  repeated  measurements  that  this 
process  can  be  greatly  simplified  as  shown  in  Fig.  2.  The  base 
line  and  the  two  perpendiculars  are  the  same  as  in  Reid’s  figure, 
but  a  line,  A,  B,  is  drawn  parallel  to  the  base  line  from  a  point 
on  the  forehead  an  inch  above  the  supra-orbital  foramen  to  the 
perpendicular,  D.  Now  a  diagonal  drawn  from  the  superior 
extremity  of  the  perpendicular,  F,  to  the  point  of  intersection 
of  the  line,  A,  B,  with  the  perpendicular,  D,  will  indicate  the 
course  of  the  fissure  of  Rolando. 

The  scalp  having  been  marked  according  to  this  method,  a 
horseshoe  incision  with  the  convexity  pointing  posteriorly  was 
made;  the  flaps  of  integument  and  pericranium  were  raised  and  an 
inch  trephine  applied  so  that  the  center-pin  was  fixed  on  the  line 
of  what  I  had  determined  to  be  the  course  of  the  fissure  of  Rolan¬ 
do,  and  about  half  an  inch  interiorly  to  the  sagittal  suture.  The 
crown  of  the  instrument  was  intended  to  embrace  within  its 
limits  that  portion  of  the  skull  immediately  over  the  superior 
parts  of  the  ascending  frontal  and  ascending  parietal  convolu¬ 
tions.  The  button  of  bone  was  removed  and  the  dura  mater, 
arachnoid,  and  pia  mater  were  found  to  be  adherent  to  each 
other.  While  dissecting  them  apart  a  profuse  hemorrhage 
started  from  the  anterior  border  of  the  wound  which  could  Dot 
be  arrested  until  half  an  inch  more  of  the  skull  was  removed 
with  the  rongeur.  An  artery  was  then  tied  and  the  hemorrhage 


HAMMOND:  A  CASE  OF  BRAIN  SURGERY. 


Sept.  27,  1890.] 

immediately  stopped.  The  surface  of  the  brain  was  then 
cleansed  of  blood  and  the  debris  of  bone,  when  it  was  found  that 
a  bluish  membrane  protruded,  very  much  resembling  in  appear¬ 
ance  the  longitudinal  sinus.  Renewed  examination  showed  that 
it  could  not  be  this  vessel,  and  it  was  at  once  punctured  with  a 
sharp-pointed  bistoury.  Immediately  a  stream  of  serous  fluid 
free  from  odor  spurted  out  as  if  from  a  syringe  to  a  distance  of 
two  or  three  feet,  and  continued  to  flow  for  about  ten  minutes 
with  diminished  force.  The  wound  in  the  membranes  was  en¬ 
larged  to  the  extent  of  half  an  inch  and  a  probe  was  introduced  ; 
it  could  be  passed  downward  and  forward  for  about  two  inches 
without  meeting  with  an  obstruction.  At  this  time  the  patient 
was  in  a  state  approaching  collapse,  and  whisky  was  adminis¬ 
tered  hypodermically.  In  a  minute  or  so  the  pulse  became 
better. 

As  the  fluid  still  continued  to  flow  from  the  opening  in  the 
skull  and  brain,  I  determined  to  introduce  a  drainage-tube.  At 
once  the  fluid  began  to  flow  more  freely.  The  tube  was  intro¬ 
duced  along  the  line  of  the  fissure  of  Rolando  and  passed  in  for 
three  inches  without  meeting  with  obstruction.  The  button  of 
bone  was  not  replaced,  but  the  wound  was  closed  around  the 
drainage-lube,  which  was  left  in  place  and  through  which  fluid 
still  continued  to  flow.  Antiseptic  dressings  were  applied  and 
the  patient  put  to  bed.  I  may  state  that  antiseptic  measures 
were  adopted  throughout  the  whole  course  of  the  operation. 

Soon  after  being  put  to  bed  the  patient  had  a  severe  chill, 
which  was  stopped  by  putting  bags  of  hot  water  to  the  body. 

On  emerging  from  the  state  of  anaesthesia  the  patient  was 
noisy  and  excited  and  complained  of  some  pain  in  the  head.  A 
quarter  of  a  grain  of  morphine  was  given  hypodermically,  and 
sleep  ensued  almost  immediately  ;  9  p.  m.,  patient  still  asleep, 
temperature  98,4°,  pulse  120;  profuse  watery  discharge  from 
the  drainage-tube,  dressings  being  completely  saturated ;  12 
p.  m.,  patient  still  asleep  ;  urine  drawn  off  by  catheter. 

July  21Jh,  6  a.  m. — Temperature  99-4°,  pulse  164;  milk  and 
whisky  administered ;  passed  urine  voluntarily;  was  quiet,  talked 
rationally,  although  occasionally  she  made  slight  attempts  to  re¬ 
move  the  dressings  from  her  head  ;  8.45  a.  m.,  temperature  99-8°, 
pulse  118.  The  dressings,  being  saturated  with  a  watery  discharge 
which  still  continued  to  flow,  were  removed  and  the  brain  cav¬ 
ity  irrigated  through  the  drainage-tube  with  a  solution  of  cor¬ 
rosive  sublimate  (1  to  4,000).  New  dressings  somewhat  lighter 
in  character  were  applied  ;  one  sixth  of  a  grain  of  morphine  ad¬ 
ministered  hypodermically  ;  12  m.,  dressings  changed,  still  satu¬ 
rated  with  the  exudation  from  the  drainage-tube;  temperature 
99°  ;  6  p.  m.,  four  grains  of  acetanilide  to  be  repeated  every  four 
hours  ;  9.30  p.  m.,  temperature  101°,  pulse  132. 

July  25th,  1.20  a.  m. — Temperature  99-4°,  pulse  120;  4.20 
a.m.,  temperature  100-6°,  pulse  130,  vomited;  6.45  a.  m.,  tem¬ 
perature  101-2°,  pulse  142  ;  digitalis  normal  liquor  two  minims, 
two  ounces  of  whisky  every  two  hours;  9  a.m.,  temperature 
104°,  pulse  150,  body  sponged  with  cold  water,  temperature 
falling  almost  immediately  to  103°;  1.15  p.  m.,  temperature 
102-6°,  pulse  144 ;  the  drainage-tube  becoming  closed,  it  was 
removed  and  a  new  one  put  in  ;  one  fourth  of  a  grain  of  mor¬ 
phine  administered  hypodermically  ;  4  p.  m.,  temperature  104°, 
pulse  156;  patient  quiet  but  easily  aroused  into  activity,  giving 
rational  answers  when  spoken  to ;  5.45  p.  m.,  temperature  102*8°, 
pulse  154;  one  eighth  of  a  grain  of  morphine  at  5  p.m.;  ace¬ 
tanilide  four  grains,  has  been  continued  every  four  lioux-s ;  8 
p.  m.,  temperature  104-6°,  pulse  160;  10  p.  m.,  temperature 
104-2°,  pulse  150;  12  m.,  temperature  103°,  pulse  140;  one 
one-hundredth  of  a  grain  of  digitaline  hypodermically,  to  be  re¬ 
peated  every  two  hours. 

July  26th,  2  a.  m. — Temperature  102"8°,  pulse  156  ;  4  a.  m., 
temperature  103°,  pulse  156  ;  one  fourth  of  a  gx-ain  of  sulphate 


339 

of  morphine  hypodermically;  has  been  very  restless  all  night; 
answers  x-ationally  when  spoken  to ;  asked  to  see  her  father  and 
mother;  7.15  a.m.,  temperature  103-2°,  pulse  156;  11  a.m., 
temperature  103-4°,  pulse  156;  one  ounce  of  magnesia  sulph. ; 
bowels  moved  at  11  a.m.  At  12  m.,  febricide  pill  given;  1 
p.  m.,  tenxpei-ature  103-2°,  pulse  156  ;  3  p.  m.,  texnperature  105-2°, 
pulse  156;  ice  kept  to  head  ;  Dover’s  powder,  six  grains;  4.15 
p.  m.,  tempei-ature  103-6°,  pulse  168;  7  p.  m.,  temperature 
103-4°,  pulse  154.  Another  febricide  pill  was  given,  and  the 
body  sponged  with  cold  water;  8.15  p.  m.,  temperatui-e  101-4°, 
pulse  154;  11  p.  m.,  temperature  102-8°,  pulse  150;  one  sixth 
of  a  grain  of  sulphate  of  morphine  at  12  p.  m.,  hypodermically. 

July  27th ,  1  a.m. — Temperature  102°,  pulse  138;  3  a.m., 
temperature  102-4°,  pulse  150;  7  a.  m.,  temperature  103°,  pulse 
156;  i-ested  very  well  during  the  night;  9  a.  m.,  temperature 
102-8°,  pulse  154;  11  a.m.,  sponged  with  ice-water,  the  tem¬ 
perature  falling  almost  immediately  to  100-8°,  but  rising  at 
12.45  p.  m.  to  102-4*,  pulse  154;  1  p.  m.,  temperature  103°,  pulse 
158;  3  p.  m.,  temperature  102-4°,  pulse  148;  has  been  in  light 
stupor  for  the  last  twelve  houi-s,  from  which  she  can  be  roused 
without  much  difficulty  and  answers  rationally  ;  5  p.  m.,  tem¬ 
perature  102-2°,  pulse  144;  9.25  p.m.,  temperature  103°,  pulse 
146  ;  very  little  discharge  from  the  drainage-tube;  probe  passed 
entirely  through  it  in  order  to  ascertain  whether  it  was  open 
or  not. 

July  28th,  1.45  a.m. — Temperature  103*8°,  pulse  156;  2.45 
a.  m.,  temperature  103-2°,  pulse  154;  9  a.m.,  has  been  quiet  all 
night,  breathing  regularly  with  but  little  acceleration;  tem¬ 
perature  103-4°,  pulse  160;  11.30  a.  m.,  temperature  103-6°, 
pulse  168.  From  this  time  on  the  respirations  became  slower 
and  irregular;  the  temperature  remained  at  104°,  the  pulse  not 
falling  below  160.  Stimulants,  which  had  been  systematically 
administered,  together  with  antifebrile  remedies,  such  as  ace¬ 
tanilide  and  febricide,  no  longer  produced  the  slightest  effect. 
It  was  evident  she  was  sinking,  and  at  times  there  was  the 
Cbeyne-Stokes  respiration.  Further  medication  was  discon¬ 
tinued,  as  she  was  unable  to  swallow  and  was  in  a  state  of 
stupor.  She  remained  in  this  condition  through  the  afternoon  of 
the  28th,  and  at  7  p.  m.  died,  the  sixth  day  after  the  operation. 

The  post-mortem  examination  was  made  on  the  following 
morning,  the  29th,  at  11  o’clock.  The  wound  in  the  scalp  had 
united  by  first  intention,  except  at  the  point  where  the  drain¬ 
age-tube  had  been  inserted.  On  removing  the  calvaria,  ad¬ 
hesions  were  found  to  exist  between  the  right  frontal  lobe  and 
frontal  bone,  also  thickening  of  the  dura  mater  throughout  the 
course  of  the  longitudinal  sinus  extending  for  about  an  inch  on 
each  side.  Nearly  the  whole  of  the  right  parietal  lobe  and  upper 
and  postei-ior  part  of  the  frontal  lobe  seemed  to  have  disappeai-ed, 
for  the  membranes  were  greatly  collapsed.  The  operation  ap¬ 
peared  to  have  touched  the  superior  apex  of  the  depressed  por¬ 
tion.  There  was  slight  congestion  of  the  membranes  of  the  left 
side,  especially  those  covering  the  frontal  lobe.  The  brain  was 
removed  and  the  membranes  were  opened;  these  were  found 
thickened  throughout  their  wdiole  extent  and  were  strongly  ad¬ 
herent  to  the  base  of  the  skull  and  to  each  other,  it  being  im¬ 
possible  to  separate  the  dura  mater  from  the  membranes  be¬ 
neath.  All  these  adhesions  were  evidently  old.  An  incision 
was  now  made  through  the  vertical  axis  of  the  membranes  and 
a  cyst  was  found  coexistent  with  nearly  the  whole  right  parie¬ 
tal  lobe,  the  convolutions  of  which  portion  had  entirely  disap¬ 
peared.  The  ascending  frontal  convolution,  except  its  interior 
and  horizontal  portion,  was  also  absent;  otherwise  the  frontal 
lobe  was  in  good  condition.  The  anterior  portion  of  the  oc¬ 
cipital  lobe  was  also  implicated,  so  that  a  portion  of  the  middle 
and  inferior  convolutions  had  disappeai-ed. 

Interiorly  it  was  ascertained  that  the  cyst  involved  likew-ise 


340 


SOLIS- COHEN:  LOOK  BEYOND  THE  NOSE. 


[N.  Y.  Med.  Joub., 


the  temporal  lobe,  and  that  the  superior  temporal  convolution 
and  about  one  half  of  the  middle  temporal  convolution  were 
absent. 

Further  examination  showed  that  not  a  vestige  of  the  island 
of  Reil  remained,  that  the  anterior  and  external  third  of  the 
caudate  nucleus  and  a  like  portion  of  the  lenticular  nucleus  of 
the  corpus  striatum  were  absent,  and  that  the  internal  capsule 
was  greatly  atrophied.  Continuing  the  dissection,  it  was  dis¬ 
covered  that  the  cyst  was  separated  from  the  lateral  ventricle 
anteriorly  by  a  very  thin  lamina  of  cerebral  tissue. 

A  second  cyst  of  about  the  size  of  a  large  almond  and  in¬ 
volving  the  inferior  temporal  convolution  was  also  found  to 
exist.  There  were  no  cerebritis,  no  recent  meningitis,  and  no 


haemorrhage.  The  extent  of  the  lesion  is  seen  in  the  woodcut 
(Fig.  B),  where  it  is  indicated  by  the  dotted  line  a.  The  tem¬ 
poral  cyst  is  shown  in  profile  at  i. 

It  is  thus  seen  that  the  diagnosis  was  substantially  cor¬ 
rect,  though  the  lesion  was  much  more  extensive  than  there 
was  any  reason  to  suspect.  Probably  the  original  disease 
was  an  extensive  meningitis,  the  arachnoid  being  especially 
implicated  in  the  regions  where  the  cysts  were  discovered. 
It  is  certainly  remarkable  that  life  should  persist  for  nearly 
nineteen  years  under  such  a  condition  of  brain  disease. 
The  fact  of  the  destruction  of  the  island  of  Reil  is  interest¬ 
ing  in  connection  with  the  circumstances  that  it  was  on  the 
right  side  and  that  there  had  been  little  speech  disturbance. 
In  other  respects  it  is  seen  that  the  case  is  strikingly  cor¬ 
roborative  of  the  doctrine  of  cerebral  localization  as  laid 
down  by  Nothn-agel,  Ferrier,  Exner,  and  others. 

I  should  have  mentioned  that  the  contour  of  the  rrnht 

© 

hemisphere  indicated  this  half  of  the  brain  to  be  decidedly 
smaller  than  the  corresponding  left  half. 

In  undertaking  this  operation  1  had  no  idea  of  limiting 
its  extent  by  any  other  consideration  than  that  of  the  re¬ 
quirements  of  the  occasion.  I  was  very  confident  that  the 
morbid  growth  was  not  limited  to  the  superior  parts  of  the 
ascending  frontal  and  ascending  parietal  convolutions,  and 
I  intended  to  remove,  either  by  further  trephining  or  by 
the  rongeur,  as  much  of  the  skull  as  might  be  requisite. 
The  facts,  however,  that  the  growth  was  cystic  and  that  the 
fluid  was  readily  evacuated  obviated  the  necessity  of  more 
extensive  operative  procedure. 

In  regard  to  the  cause  of  death  I  have  no  very  satisfac¬ 
tory  explanation  to  offer.  The  patient  bad  fully  recovered 
from  the  shock  of  the  operation,  there  was  no  recent  inflam¬ 


matory  action  anywhere  in  the  brain  or  its  membranes,  and 
the  wound  was  in  a  perfectly  healthy  condition,  the  scalp 
having  united,  as  I  have  said,  throughout  nearly  its  whole 
extent.  An  examination  of  the  lungs  and  kidneys  was  not 
permitted,  but  there  is  no  reason  for  thinking  that  these 
organs  were  in  a  state  of  disease. 


LOOK  BEYOND  THE  NOSE.* 

By  SOLOMON  SOLIS-COHEN,  M.  D., 

PHILADELPHIA. 

The  benefits  of  an  enlightened  and  liberal  specialism 
are  so  generally  admitted  that  it  is  unnecessary  to  recount 
them.  But  while  liberal  and  enlightened  specialism  has 
contributed  and  will  continue  to  contribute  in  largest  meas- 
ure  to  the  progress  of  medicine,  there  is  a  danger,  a  press¬ 
ing  and  increasing  danger,  that  narrow  and  unenlightened 
specialism  will  offer  hindrance  equally  great. 

There  is  a  tendency,  more  especially  upon  the  part  of 
those  who  have  had  insufficient  experience  in  general  medi¬ 
cine — or  perhaps  not  any — before  undertaking  exclusive 
practice,  to  magnify  the  importance  of  local  lesions  coinci¬ 
dent  with  certain  general  disorders  of  the  system,  or  with 
local  disease  in  some  other  region.  While  this  tendency 
is  perhaps  most  strikingly  manifested  by  some  others,  yet 
nowhere  is  it  more  pernicious  than  in  the  domain  of  rhi- 
nology.  To  discuss  particulars  rather  than  generalities, 
and  selecting  a  single  particular  as  type  in  order  to  save  time 
— especially  have  malformations  and  enlargements  of  nasal 
tissues  been  advanced  as  the  sole  and  efficient  cause  of  per¬ 
sistent  and  distressing  headaches. 

That  in  some  cases  this  is  true  the  experience  of  com¬ 
petent  observers  places  beyond  question,  but  that  it  is  true 
to  anything  like  the  extent  one  would  infer  from  many 
contributions  to  the  literature  of  the  subject,  my  own  expe- 
rience  at  least  leads  me  to  doubt.*j  |In  illustration  of  this 
fact  I  desire  to  report  three  cases,  typical  of  many  :)>. 

Case  I. — Mrs.  R.,  thirty-two  years  of  age,  consulted  me  in 
the  hope  of  obtaining  relief  from  a  headache,  which  she  said 
was  dependent  upon  nasal  trouble,  and  from  which  she  had 
suffered  more  or  less  since  she  was  twelve  years  of  age,  but 
more  particularly  during  the  last  decade.  She  had  been  for 
something  like  two  years — though  latterly  quite  irregular  in 
her  visits — under  the  care  of  a  specialist  of  ability,  who  had 
told  her  that  her  headache  was  due  to  trouble  in  the  nasal 
cavities,  although  of  what  exact  nature  she  had  not  been  in¬ 
formed  ;  and  she  had  undergone  several  operations,  two  of 
them  under  ether.  She  did  not  know  what  had  been  done. 
During  treatment  antipyrine  had  been  prescribed  for  temporary 
relief  of  paroxysms  of  headache. 

Examination  of  the  nose  showed  a  badly  deviated  septum 
in  contact  with  the  middle  turbinated  body  on  the  left  side,  a 
polyp  attached  to  the  middle  turbinated  body  on  the  right  side, 
with  a  general  condition  of  chronic  inflammation  and  thicken¬ 
ing  of  the  mucous  membrane.  The  pharyngeal  tissues  were 
also  thickened  and  inflamed.  As  a  matter  of  course,  the  polyp 
was  removed  from  the  right  nasal  passage  and  the  point  of  i:n- 


*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


Sept.  27,  1890.] 


MacCOY:  MYXOMA  OF  THE  NASO-PnARYNX. 


plantation  cauterized.  This,  however,  while  it  relieved  some 
distress  in  breathing,  had  no  effect  on  the  headache,  which  was 
as  persistent  and  as  painful  as  ever.  The  nose  was  kept  clean 
bv  an  alkaline  detergent  wash,  and  as,  notwithstanding  the  de¬ 
viation  of  the  septum,  sufficient  air  was  obtained  for  purposes 
of  respiration,  no  further  operative  interference  was  under¬ 
taken,  while  the  attempt  was  made  to  determine  the  course  and 
cause  of  the  headache  independently  of  the  nasal  conditions. 
It  was  ascertained  that  there  would  be  two  or  three  days  com¬ 
paratively  free  from  headache,  and  then  for  two  or  three  days 
more  a  succession  of  paroxysms. 

Studying  these  paroxysms,  the  fact  was  developed  that  they 
occurred  principally  in  the  afternoon — that  is  to  say,  while  be¬ 
ginning  in  the  morning,  severity  was  not  marked  until  about 
twelve  o’clock,  and  the  maximum  of  pain  was  reached  at  six 
o’clock  in  the  evening,  after  which  the  pain  gradually  faded 
away.  This  suggested  a  possible  malarial  origin,  and  a  history 
of  attacks  of  intermittent  fever,  once  previous  to  the  first  ap¬ 
pearance  of  the  headache  and  twice  subsequently,  was  elicited. 
No  enlargement  of  the  spleen  or  liver  was  detected  ;  heart  and 
hmgs  were  normal;  nothing  of  pathological  import  was  found 
iD  the  urine.  Unfortunately,  the  blood  was  not  examined  for 
plasmodia.  The  patient  said  she  could  not  take  quinine  on  ac¬ 
count  of  the  ringing  in  the  ears  soon  produced ;  nevertheless, 
quinine  hydrobromide  was  administered  in  doses  of  fifteen 
grains  daily,  divided  into  three  portions,  of  which  the  first  was 
taken  upon  getting  up  in  the  morning,  about  seven  o’clock,  the 
next  at  ten,  and  the  next  at  twelve.  In  addition,  five  grains  of 
salicin  with  two  of  ergotin  were  taken  at  6  p.  m.  and  again  at 
bedtime.  The  first  day  there  was  a  slight  headache  about  four 
o’clock  in  the  afternoon  which  lasted  but  a  short  time.  The 
same  thing  occurred  the  following  day,  and  the  daily  dose  of  the 
quinine  salt  was  increased  to  twenty  grains.  Since  that  there 
has  been  increasing  freedom  and  finally  no  return  of  headache 
for  a  period  of  more  than  a  month.  Medication  has  been  modi¬ 
fied  accordingly.  The  patient  states  that  in  twenty  years  she 
had  not  previously  been  free  from  headache  for  a  week.  This 
is  an  exaggeration  I  believe,  but  it  may  be  accepted  as  a  fact 
that,  at  least,  she  is  very  much  better  now  than  at  any  time 
during  that  period,  and  that  the  improvement  is  due  to  consti¬ 
tutional  and  not  to  local  treatment. 

The  nasal  septum  remains  deviated  and  in  contact  with  the 
middle  turbinated  body. 

Case  II. — Mr.  Y.,  aged  twenty-one,  has  a  deviated  and 
thickened  septum  in  contact  with  the  middle  turbinated  bodies 
on  both  sides,  a  posterior  enlargement  of  the  lower  turbinated 
body  of  the  right  side,  and  also  engorgement  of  the  erectile  tis¬ 
sue  upon  each  side  of  the  bony  septum  posteriorly.  He  has  no 
reflex  troubles  of  any  kind,  and  says  he  does  not  know  what 
headache  means. 

Case  III. — Miss  X.,  aged  twenty-seven,  has  had  excruciat¬ 
ing  headaches  and  occasional  periods  of  insomnia  for  years,  and 
has  been  under  the  treatment  of  a  number  of  practitioners 
specialists  in  various  lines. 

The  first  physician  whom  she  consulted — a  woman — attrib¬ 
uted  her  troubles  to  the  uterus,  and  she  was  for  three  months 
an  inmate  of  a  sanitarium,  undergoing  special  treatment.  Her 
next  adviser  scouted  the  uterine  theory  and  found  a  sufficient 
cause  for  her  distress  in  refractive  errors  of  the  eyes,  which  he 
corrected.  The  third  believed  it  to  be  entirely  nervous,  curable 
by  electricity,  which  he  applies  indeed  to  the  treatment  of  all 
diseases,  and  she  says  that  he  benefited  her  more  than  either  of 
the  others.  The  fourth,  fifth,  and  sixth  were  homoeopathists, 
the  seventh  a  gynaecologist,  and  I  had  the  honor  of  being  the 
eighth.  At  this  time  the  patient  was  under  the  idea  that  the 
nose  was  the  fons  et  origo  mall. 


341 

I  found  deviation  of  the  septum,  thickening  of  the  nasal 
mucous  membrane,  and  engorgement  of  the  glandular  tissues  of 
the  vault  of  the  pharynx.  In  order  to  determine  whether  the 
nose  was  really  the  source  of  this  patient’s  long-continued  dis¬ 
tress,  I  treated  it,  and  succeeded  in  relieving  what  slight  nasal 
symptoms  existed  and  in  so  far  rectifying  the  deviation  of  the 
septum  as  to  obviate  any  contact  of  tissues;  but  neither  the 
headache  nor  the  insomnia  was  benefited  in  the  slightest  de¬ 
gree.  The  patient  was  hysterical,  there  could  be  no  question 
of  that;  but  careful  inquiry  into  her  general  health  showed  a 
condition  of  feeble  digestion  and  atony  of  the  intestine  asso¬ 
ciated  with  gastro-intestinal  catarrh  and  a  consequent  litbsemia. 
Treatment  was  directed  to  this  condition,  with  improvement, 
hut  not  absolute  cure.  Becoming  dissatisfied  with  her  slow 
progress,  the  patient  consulted  a  ninth  adviser— a  second  ocu¬ 
list,  who,  I  know,  had  never  practiced  medicine.  He  found  that 
the  previous  correction  had  been  all  wrong,  and  consequently 
had  aggravated  instead  of  relieving  her  headaches  and  general 
nervous  mal-condition,  while  his  correction  was  bound  at  once 
to  restore  her  to  robust  health  and  freedom  from  pain.  That  it 
did  not  do  so  is  evidenced  by  her  return  to  me  some  two 
months  later,  when  the  constitutional  treatment  was  resumed. 
The  patient  was  not  well,  but  very  much  improved  when  I  last 
saw  her,  and  I  have  no  doubt  that  proper  regulation  of  diet 
and  of  daily  life  carried  out  faithfully  would  eventually  relieve 
whatever  actual  physical  pain  is  present. 

These  cases  are  cited  simply  as  instances  of  what  must 
be  common  in  the  practice  of  every  physician  who  is  com¬ 
petent  to  examine  the  nose,  but  also  mindful  of  the  facts 
not  only  that  there  are  other  organs  in  the  human  body, 
but  that  there  is,  too,  such  an  entity  as  a  whole  organism, 
not  to  be  looked  upon  merely  as  a  thing  of  shreds  and 
patches. 

There  are  conditions  of  headache  and  other  nervous  dis¬ 
turbances,  including  asthma,  dependent  doubtless  upon  nasal 
lesions  ;  but  men,  at  least  those  who,  like  myself,  are  in  act¬ 
ive  general  practice,  meet  with  a  far  greater  number  of  cases 
of  these  conditions  in  which  there  is  no  nasal  abnormity, 
or  in  which  nasal  abnormities  are  not  causative  but  merely 
coincident.  Furthermore,  every  fellow  of  this  association 
must  have  seen  quite  a  large  number  of  cases  a  laige 
majority  indeed — of  nasal  lesions  in  which  none  of  these 
nervous  phenomena  were  manifested,  as  well  as  many  cases 
in  which  nasal  symptoms  themselves  were  dependent  upon 
systemic  causes.  The  conclusion  draws  itself;  there  is  no 
need  for  elaboration.  It  is  simply  this :  Let  us  examine 
the  nose  as  well  as  the  other  organs  of  our  patients,  either 
as  a  matter  of  routine  or  when  special  indications  present; 
let  us  treat  secundum  artem  whatever  nasal  condition  de¬ 
mands  treatment ;  but  let  us  not  forget  also  to  look  beyond 
the  nose. 


A  CASE  OF  MYXOMA  OF  TIIE  NASO-PIIARYNX 

IN  A  CHILD  SIX  YEARS  OLD.* 

By  ALEXANDER  W.  MaoCOY,  M.  D., 

PHILADELPHIA. 

The  recital  of  the  history  of  the  following  case  of 
myxomatous  tumor  of  the  naso-pharynx  is  given  because  of 

*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


342 


KNIGHT:  FIBROSARCOMA  OF  THE  RIGHT  NASAL  FOSSA.  [N.  Y.  Med.  Jour., 


the  rarity  of  such  growths  in  this  region,  and  also  because 
the  extreme  youth  of  the  subject  adds  even  more  to  the 
rarity.  My  fellow-members  have  probably  had  similar  cases 
in  their  experience,  but  I  am  not  aware  that  many  such 
pathological  conditions  have  been  put  on  record  by  them. 

In  a  rather  extended  experience  in  private  and  hospital 
piactice,  this  is  the  first  case  of  the  kind  which  I  have  seen 
in  so  young  a  child.  The  occurrence  of  myxomatous  tu¬ 
mors  in  the  nasal  passages  of  children  is  rare,  even  making 
due  allowance  not  only  for  the  cases  already  reported,  but 
also  for  those  not  in  print,  of  which  we  have  verbal  knowl¬ 
edge.  In  my  own  experience  I  can  recall  but  one  case  of 
nasal  polypus  in  a  child,  and  this  occurred  in  an  infant 
under  one  year  of  age. 

It  was  seen  in  the  right  nostril  upon  anterior  in 
spection,  blocking  the  respiratory  tract,  and  was  removed 
by  the  Jarvis  snare.  This  case  came  under  observation 
$  during  the  seven  years  which  have  elapsed 
since  I  have  not  seen  a  similar  case.  While  we  seldom  see 
myxomatous  development  in  the  nasal  chambers  of  chil- 
dien,  the  dictum  enunciated  by  Lennox  Browne  that 
“  P°lypi  may  occur  at  any  age  ”  is  undoubtedly  true.  This 
statement  of  Browne’s  should,  however,  be  qualified  by  ac¬ 
ceptance  of  the  doctrine  that  all  myxomatous  degeneration 
or  development  is  dependent  upon  a  prior  inflammation  in 
the  regions  where  it  occurs;  and  that  the  inflammation 
must  have  been  of  some  duration.  The  rarity  of  these 
myxomatous  developments  in  childhood  can  be  explained 
by  the  fact  that  there  are  few  children  who  have  had 
chronic  colds  of  sufficient  duration  to  develop  the  patho¬ 
logical  changes  necessary  for  the  growth  of  polypi.  This 
is  not  only  dependent  upon  the  fewness  of  years,  but  also 
upon  the  ability  of  youth  to  resist  true  hypertrophic 
changes.  What  has  been  said  in  explanation  of  the  rarity 
of  myxomatous  changes  in  childhood  in  the  nasal  chambers 
applies  with  even  more  force  to  similar  changes  in  the  naso - 
■pharyngeal  region.  Myxomatous  development  in  the  naso¬ 
pharynx  is  still  more  rarely  noticed  in  children — if  we  ac¬ 
cept  the  consensus  of  opinion  as  expressed  in  literature. 

The  following  case  came  under  my  notice  in  February, 
1890.  The  subject  of  this  history  was  a  patient  of  Dr.  Ken- 
nedy,  of  Clifton  Heights,  who  kindly  asked  me  to  examine 
the  case  with  him. 

Dr.  Kennedy  had  already  clearly  made  out  the  tumor, 
and  came  for  an  opinion  as  to  its  nature,  and  also  as  to 
measures  for  its  removal.  The  notes  of  this  case  up  to  the 
date  of  removal  have  been  kindly  furnished  to  me  by  Dr. 
Kennedy,  and  are  as  follows: 


lent  discharge  which  filled  the  nasal  chambers.  Mouth-breath¬ 
ing  was  absolutely  necessary  for  respiration.  The  voice  was  flat 
and  thick.  The  expression  of  the  face  was  quite  similar  to  that 
seen  in  cases  of  hypertrophy  of  the  pharyngeal  tonsil. 

Examination  by  the  rhinoscopic  mirror  revealed  a  large,  pale- 
pinkish  mass  completely  filling  up  the  naso-pharyngeal  region. 
The  growth  did  not  show  below  the  soft  palate,  but  could  readi¬ 
ly  be  seen  upon  elevating  the  palate.  There  was  considerable 
discharge  from  the  naso-pharyngeal  space;  not  much  redness  of 
the  fauces,  and  only  a  moderate  bulging  of  the  soft  palate.  Ex¬ 
amination  with  the  finger  showed  a  large,  elastic  tumor;  the 
finger  could,  with  some  difficulty,  he  made  to  pass  around  the 
growth.  It  was  only  slightly  movable  and  appeared  to  be 
firmer  than  a  myxomatous  tumor,  but  not  so  dense  as  a  fibroid. 
An  attachment  (of  about  half  an  inch  in  diameter)  was  clearly 
made  out,  springing  from  the  free  surface  of  the  vomer  and  con¬ 
fined  to  the  lower  part  of  it. 

On  February  28,  1890,  the  tumor  was  quickly  and  success¬ 
fully  removed  (after  the  application  of  cocaine  and  etherization) 
by  the  galvano-cautery  snare.  The  long  loop  of  wire  was  passed 
through  the  nostril  and  gradually  insinuated  along  the  upper 
surface  of  the  soft  palate  until  it  could  be  felt  by  the  finger  in 
the  naso-pbarynx,  when  it  was  widened  and  carried  back  to  the 
posterior  wall  of  the  pharynx  and  pushed  up  by  tbe  finger  until 
it  could  go  no  farther;  the  loop  was  then  reeled  in,  the  finger 
acting  as  a  guide  to  the  base  of  the  growth.  After  the  wire  had 
been  firmly  tightened,  the  current  was  turned  on  and  the  pedicle 
cut  through.  The  tumor  failed  to  “  materialize  ”  in  the  fauces, 
and  the  finger  had  to  be  inserted  into  the  naso-pharyngeal  space 
and  hooked  around  it,  when  the  tumor  fell  out  of  the  open 
mouth  upon  the  floor.  There  was  but  a  trifling  haemorrhage. 
Afterward  the  child  had  no  reac¬ 
tion,  and  at  once  the  functions 
of  the  Dasal  chambers  were  com¬ 
pletely  restored.  Since  the  date 
of  removal  the  child  has  enjoyed 
perfect  health.  There  has  been 
no  recurrence. 

The  tumor  (which  I  offer 
for  your  inspection)  weighed  six 
drachms  aud  was  pyriform  in  shape, 
scopic  examination  is  as  follows: 

Dear  Dr.  MaoCoy:  Dr.  Packard  has  made  sections  of  the 
tumor  which  you  removed  from  the  posteiuor  nares  of  a  child. 
Its  pedicle  is  composed  of  loose-meshed  fibrous  tissue,  while  the 
body  of  the  growth  from  without  inward  is  made  up  of  an  en¬ 
velope  of  epithelium,  a  layer  of  soft  fibrous  tissue  interspersed 
with  elastic  tissue,  and  a  center  composed  of  myxomatous  tissue 
through  which  are  scattered  numerous  round  lymphoid  cells. 
The  tumor  bears  the  general  characteristics  of  a  submucous 
myxoma.  Yours  truly,  G.  W.  Sohweinitz.” 

I  have  also  had  prepared  a  micro-photograph  of  the 
sections. 


The  report  of  the  micro- 


Annie  I.,  aged  six  years,  had  always  enjoyed  good  health 
until  September,  1888,  at  which  time  she  contracted  a  heavy 
cold  by  the  practice  of  wetting  her  hair.  This  acute  coryza  de¬ 
veloped  into  a  chronic  rhinitis.  Complete  occlusion  of  the  nos¬ 
trils  did  not  take  place  until  March,  1889,  from  which  time  she 
has  not  been  able  to  breathe  through  the  nostrils.  Through 
June  and  July,  1889,  she  became  greatly  emaciated  ;  her  mouth 
was  kept  wide  open.  There  was  rapid  respiration  and  loss  of 
appetite.  The  physician  and  family  were  fearful  that  she  would 
die.  She  quickly  responded  to  proper  remedies  and  regained 
her  general  health.  An  examination  revealed  complete  occlu¬ 
sion  of  both  nostrils.  From  the  nostrils  poured  a  muco-puru- 


A  CASE  OF 

FIBROSARCOMA  OF  THE  RIGHT  NASAL  FOSSA, 
WITH  UNUSUAL  CLINICAL  HISTORY* 

By  CHARLES  H.  KNIGHT,  M.  D. 

The  following  report  is  robbed  of  much  of  its  value  by 
the  absence  of  post-mortem  observations,  yet  the  occurrence 
of  several  remarkable  phenomena  as  the  case  progressed 

*  Read  before  the  American  Larvngologieal  Association  at  its 
twelfth  annual  congress. 


Sept.  27,  1890.] 


KNIGHT:  FIBROSARCOMA  OF  THE  RIGHT  NASAL  FOSSA. 


343 


— 


seem  to  make  it  worthy  of  more  complete  record.  The 
specimen  herewith  exhibited  occupied  the  naso-pharynx, 
but  is  no  doubt  a  portion  only  of  a  neoplasm  which  had  its 
origin  within  the  nasal  cavity.  The  patient  came  to  the 
Tbroat  Department  of  the  Manhattan  Eye  and  Ear  Hospital 
in  September,  1 886,  giving  the  following  history  : 

P.  D.,  aged  forty-two,  baker,  married.  Family  history  good. 
Patient  has  had  no  illness  since  childhood.  About  twelve  years 
ago  he  received  a  violent  blow  on  the  bridge  of  the  nose.  The 
precise  extent  of  the  injury  sustained  is  not  known.  For  the 
last  two  years  he  has  had  more  or  less  nasal  obstruction  and  ca¬ 
tarrhal  discharge.  The  sense  of  smell  has  become  impaired,  and 
he  has  been  annoyed  by  frequent  sneezing  and  pretty  constant 
frontal  headache.  His  friends  have  noticed  a  marked  change 
in  his  disposition.  He  has  become  irritable,  surly,  indisposed 
to  work,  and,  contrary  to  his  previous  habit,  has  often  taken 
liquor  to  excess.  He  has  had  no  haemorrhages  until  two  months 
ago,  when  he  expelled  from  the  right  anterior  naris  masses  of 
bloody  tissue,  and  at  about  the  same  time  hawked  out  from  the 
posterior  nares  a  fleshy  mass  as  large  as  a  robin’s  egg.  Two 
weeks  ago  the  right  eye  became  almost  closed  from  an  oedema- 
tous  swelling  of  the  lids,  and  there  was  considerable  swelling 
and  sensitiveness  in  the  right  infra-orbital  region. 

On  examination,  the  right  naris  was  found  completely  oc¬ 
cluded  by  a  soft,  vascular,  and  very  sensitive  mass,  somewhat 
resembling  an  old  myxoma.  It  extended  quite  to  the  margin 
of  the  nostril,  and  with  a  rhinoscopic  mirror  a  growth  as  large 
as  a  hickory-nut  could  be  seen  projecting  into  the  naso-pharynx. 
No  glandular  enlargements  could  be  discovered  and  there  was 
no  cachexia.  An  attempt  to  surround  the  growth  with  a  loop 
of  wire  caused  profuse  haemorrhage  and  extreme  pain,  upon 
which  cocaine  had  no  effect.  A  large  piece  was  finally  removed 
from  the  anterior  portion  of  the  tumor  by  means  of  a  cold 
wire  snare.  The  growth  reproduced  itself  with  astonishing 
rapidity,  and  when  examined  three  days  later  it  had  almost  re¬ 
gained  its  original  dimensions.  Under  the  microscope  the  ap¬ 
pearances  characteristic  of  fibrosarcoma  were  seen. 

The  patient  then  went  to  the  New  York  Hospital,  where 
Dr.  Weir  performed  Chassaignac’s  operation  (November  15th). 
An  incision  was  made  across  the  nose  at  the  level  of  the  eyes 
downward  and  along  the  right  labio-nasal  junction  to  the  left 
ala.  The  nasal  bones  were  sawed  through  and  the  nose  tilted 
to  the  left  so  as  to  expose  the  tumor.  A  quantity  of  soft  growth 
was  removed  by  means  of  the  curette  and  the  wire  loop,  wheu 
it  was  found  that  the  neoplasm  invaded  the  ethmoidal  and 
sphenoidal  cells,  and  that  it  could  not  safely  be  further  fol¬ 
lowed.  The  cavity  was  packed  with  iodoform  gauze  after  clos¬ 
ing  the  external  wound  with  sutures.  The  patient  made  a  good 
recovery  from  the  operation.* 

Six  weeks  afterward  (December  27th)  he  reappeared  at  the 
Manhattan  Eye  and  Ear  Hospital  with  his  nostril  blocked  by  a 
recurrence  of  the  neoplasm,  and  complaining  of  amblyopia  and 
impaired  vision  in  his  right  eye.  There  was  marked  divergent 
strabismus.  In  the  course  of  a  week  (January  11th)  the  sight 
in  that  eye  was  completely  lost.  He  could  not  distinguish  light 
from  darkness.  At  this  time  an  ophthalmoscopic  examination 
by  Dr.  Roosa,  Dr.  Emerson,  aud  others  showed  no  change  in 
the  fundus.  A  week  later  (January  18th)  the  left  eye  began  to 
lose  its  power.  Still  the  ophthalmoscope  discovered  nothing 
abnormal.  The  process  went  on  until  in  two  weeks  (February 
1st)  he  became  totally  blind.  There  was  no  impairment  of 
hearing  and  no  muscular  paralysis.  The  tumor  then  projected 

*  N.  Y.  Med.  Jour.,  March  12,  1889  ;  also  Case  XXXV  iu  Bosworth 
on  Diseases  of  the  Nose  and  Throat ,  p.  444. 


from  the  anterior  naris,  and  the  line  of  Weir’s  incision  was 
breaking  down.  It  filled  the  naso-pharynx  to  such  an  extent 
as  to  interfere  seriously  with  speech  and  deglutition.  Several 
attacks  of  wild  delirium  had  occurred  in  which  the  patient  had 
attempted  to  jump  from  the  window.  No  rise  of  temperature 
was  noted.  Two  weeks  later  (February  14th)  the  right  eye  and 
side  of  the  face  had  disappeared  beneath  a  fungoid  mass  of 
friable,  vascular  tissue,  from  which  there  was  constant  oozing 
of  bloody  serum.  The  fcetor  was  almost  intolerable.  The  tumor 
had  extended  backward,  so  that  speech  was  unintelligible  and 
dysphagia  was  extreme.  But  little  nourishment  could  be  taken, 
and  the  patient  had  become  much  emaciated.  He  had  various 
mental  hallucinations  and  was  at  times  violent.  Most  of  the 
time  he  was  in  a  condition  of  stupor. 

Just  a  week  from  the  time  of  the  last  visit  (February  21st), 
about  three  months  from  the  date  of  the  operation  and  less 
than  five  months  after  he  first  came  under  observation,  I  re¬ 
ceived  an  urgent  summons,  as  the  patient  was  said  to  be  bleed¬ 
ing  to  death.  On  reaching  him,  I  found  a  most  gh,astly  spectacle. 
It  seems  that  during  an  attack  of  delirium  a  short  time  before 
he  had  torn  off  a  portion  of  the  tumor  from  his  face,  and  had 
also  passed  his  fingers  into  his  mouth  and  dragged  out  an  irregu¬ 
lar  mass,  which  was  probably  that  part  of  the  tumor  filling  the 
naso-pharynx.  The  rush  of  blood  was  so  profuse  as  almost  to 
suffocate  him,  and  in  a  few  moments  he  was  thought  to  be 
dead.  On  my  arrival,  the  bleeding  had  ceased,  but  the  patient 
and  the  bed  on  which  he  lay  were  covered  with  blood.  His 
breathing  was  rapid  and  shallow,  his  pulse  was  hardly  percep¬ 
tible,  and  he  was  in  a  comatose  condition,  from  wbmh  he  could 
Dot  be  roused.  Death  occurred  in  about  five  ho>’  An  autopsy 
was  not  permitted. 

It  would  have  been  interesting  to  determine,  if  possible, 
the  origin  and  distribution  of  this  neoplasm.  The  early 
period  at  which  indications  of  invasion  of  the  cranial  cavity 
appeared  would  suggest  that  the  growth  probably  began  in 
the  sphenoidal  or  ethmoidal  cells,  thence  extending  both 
upward  and  downward.  Such  being  the  case,  no  operative 
interference  could  have  been  very  promising,  yet  resection 
of  the  jaw  would  have  given  better  access  to  the  region 
affected,  and  might  have  permitted  a  more  radical  removal 
of  the  growth.  On  this  point  Weir  thus  expresses  him¬ 
self  :  “  Irrespective  of  the  cerebi’al  extension,  it  would  have 
been  better  in  this  case  to  do  the  usual  partial  resection  of 
the  jaw,  according  to  Maisonneuve’s  suggestion,  as  this 
would  not  only  have  allowed  a  more  thorough  extirpation 
of  the  growth,  but  would  have  enabled  one  to  detect  and 
to  treat  early  any  recurrence.” 

In  the  words  of  Butlin,  as  found  in  his  work  on  The 
Operative  Surgery  of  Malignant  Disease ,  “it  is  almost 
always  necessary  to  remove  at  the  same  time  some  of  the 
surrounding  tissues — in  some  instances  a  very  wide  area — 
in  order  to  prevent  a  local  recurrence  of  the  disease.”  In 
cases  of  this  class  it  is  often  difficult  to  determine  beforehand 
the  exact  origin  and  situation  of  the  neoplasm.  Hence 
it  is  doubly  important,  if  any  operation  be  undertaken, 
to  select  one  which  will  give  us  the  most  ample  opportunity 
for  thorough  inspection  of  the  region.  Partial  and  pallia¬ 
tive  operations  should  be  discouraged,  except  in  so  far  as 
they  may  be  demanded  for  the  removal  of  obstruction  to 
swallowing  or  breathing,  or  for  the  arrest  of  haemorrhage. 

It  is  doubtless  true  that  malignant  tumors  of  the  naso¬ 
pharynx  and  those  of  the  nasal  fossae  do  not  belong  in  pre 


344 


JARVIS:  RABIES  FROM  THE  BITE  OF  A  SKUNK. 


[N.  Y.  Med.  Jour., 


cisely  the  same  category ;  the  former,  being  more  accessi¬ 
ble,  may  therefore  be  more  completely  engaged  in  the  loop 
of  an  ecraseur,  or  may  come  within  the  scope  of  less  for¬ 
midable  procedures,  such  as  electrolysis.  But  a  large  pro¬ 
portion  of  these  cases  come  to  us  when  the  limitations  of 
the  neoplasm  can  no  longer  be  clearly  defined.  We  can 
not  with  certainty  determine  its  attachments.  The  prin¬ 
ciple  suggested  by  Butlin  seems  to  apply  as  strongly  to 
malignant  disease  here  as  elsewhere.  If  extirpation  be 
attempted,  we  must  be  sure  that  more  than  the  diseased 
tissue  is  included,  in  order  to  insure  a  successful  result. 
We  hear  of  many  instances  in  which  an  operation  was  be¬ 
gun  and  soon  abandoned  because  the  growth  was  found  to 
have  passed  the  line  of  safety.  Recent  literature  gives  us 
contradictory  opinions  as  to  the  best  method  of  attacking 
cases  of  this  kind.  At  the  close  of  the  report  of  a  case  of 
naso-pharyngeal  carcinoma  in  the  New  York  Medical  Jour¬ 
nal  for  March  8,  1890,  Dr.  Sidney  Allan  Fox  recommends 
“  thorough  removal,  from  time  to  time,  of  the  growth  with 
the  post-nasal  cutting  forceps  and  wire  snare.”  He  main¬ 
tains  that  in  this  way  the  removal  may  be  radical  (?),  and, 
under  cocaine,  almost  devoid  of  pain.  He  objects  to  the 
various  capital  operations,  on  the  ground'that  they  are  dan¬ 
gerous  and  cause  more  or  less  mutilation. 

On  the  other  hand,  in  a  memoir  on  The  Diagnosis  and 
Treatment  of  Malignant  Tumors  of  the  Nasal  Fossae,  in  the 
Annales  des  mal.  du  larynx,  etc.,  March,  1890,  and  trans¬ 
lated  in  the  May  number  of  the  Journal  of  Laryngology  and 
Rhinology ,  Dr.  A.  F.  Plicque  takes  a  very  decided  stand  as 
to  the  use  of  forceps  for  ablation  and  the  wire  snare.  In 
speaking  of  pedunculated  malignant  tumors,  he  says  that 
they  should  never  be  removed  in  this  manner,  but  always 
by  an  external  incision.  The  latter  opinion  would  seem  to 
commend  itself  to  our  judgment.  Many  cases  are  on  rec¬ 
ord  in  which  the  surgeon  has  endeavored  to  satisfy  him¬ 
self  with  milder  measures  and  has  finally  been  compelled 
to  resort  to  the  more  radical  method.  Meanwhile  valuable 
time  has  been  lost,  and  the  patient  may  be  in  poor  condi¬ 
tion  to  withstand  the  shock  of  the  major  operation.  More¬ 
over,  the  growth  has  been  extending,  thus  diminishing  the 
probability  of  thorough  extirpation,  and  increasing  that  of 
local  recurrence  and  generalization. 

The  conclusion  seems,  therefore,  to  be  forced  upon  us 
that  when  we  have  determined  to  attempt  the  removal  of  a 
malignant  tumor  of  the  nose  or  naso-pharynx,  the  extent  or 
implantation  of  which  is  in  doubt ,  we  should  approach  it  by 
an  external  incision,  removing  enough  of  the  bony  struct¬ 
ures  to  permit  us  to  trace  the  neoplasm  to  its  origin. 

In  connection  with  the  case  which  has  been  reported, 
another  question  of  interest  presents  itself.  Did  the  trau¬ 
matism  received  ten  years  before  the  beginning  of  symp¬ 
toms  bear  a  causative  relation  to  subsequent  developments? 
We  are  familiar  with  the  influence  of  prolonged  irritation 
in  the  aetiology  of  certain  forms  of  malignant  disease,  as 
epithelioma  of  the  lip  and  chimney-sweep’s  cancer,  and  it  is 
the  general  custom  to  search  for  a  history  of  injury  in  cases 
of  carcinoma.  Watson,  in  his  work  on  Diseases  of  the  Nose , 
page  282,  says  that  recurring  nasal  fibromata  show  a  tend¬ 
ency  to  assume  a  sarcomatous  type,  and  Bosworth  ( Dis¬ 


eases  of  the  Nose  and  Throat ,  page  445)  reports  a  case  in 
which  sarcoma  developed  after  “  polypi  had  been  operated 
on  rather  harshly  by  means  of  forceps.” 

A  similar  case  has  been  reported  by  Heymann.*  A  pa¬ 
tient  who  had  several  times  been  operated  on  for  nasal 
polyp  finally  appeared  with  a  large  intranasal  tumor,  which, 
on  extirpation,  proved  to  be  a  melanotic  sarcoma,  at  many 
points  undergoing  carcinomatous  degeneration.  Cases  of 
spontaneous  transformation  are  rare.  The  observations  of 
Michel,  Hopman,  and  Schaeffer  lack  certain  essentials.  The 
only  authentic  case  on  record  seems  to  be  one  reported  by 
Bayer,f  which  was  verified  by  microscopical  examination 
and  proved  to  be  a  villiform  carcinoma  implanted  .upon  a 
simple  mucous  polyp.  In  looking  over  the  forty-one  cases 
collected  by  Bosworth,  we  find  no  light  thrown  upon  this 
question.  Yet  it  is  one  which  from  a  medico-legal  stand¬ 
point  might  be  of  some  importance.  For  example,  in  my 
own  case  the  patient  himself  and  his  friends  were  convinced 
that  his  nasal  trouble  was  the  direct  consequence  of  a  blow, 
and  it  was  seriously  proposed  to  have  his  assailant  arrested. 
There  is,  however,  a  marked  disproportion  between  the 
number  of  cases  of  malignant  disease  of  the  nasal  fossa} 
and  of  injury  to  the  nose.  Hundreds  of  cases  of  nasal  myx¬ 
omata,  requiring  many  operations  and  involving  no  small 
degree  of  traumatism,  come  yearly  to  our  clinics,  yet  not 
more  than  a  dozen  cases  can  be  found  in  which  malignant  * 
degeneration  of  a  benign  growth  can  be  suspected.  It  would 
seem,  therefore,  that  we  can  not  justly  attribute  to  trauma¬ 
tism  a  causative  agency;  to  repeat  an  opinion  elsewhere  ex¬ 
pressed — it  alone  is  not  capable  of  creating  malignancy. 


A  CASE  OF 

KABIES  FROM  THE  BITE  OF  A  SKUNK. 

By  N.  S.  JARVIS,  M.  D., 

FIRST  LIEUTENANT  AND  ASSISTANT  SURGEON,  U.  8.  ARMY, 

FORT  VERDE,  ARIZONA. 

(. Published  by  authority  of  the  Surgeon- General.) 

The  following  case  will  go  further  to  encourage  the  tra¬ 
dition  that  the  bite  of  the  skunk  is  productive  of  rabies. 
Whether  the  term  “rabies  mephitica,”  applied  by  Jane  way 
[Med.  Record ,  March,  1875),  is  scientifically  correct  or  not 
I  can  not  say,  but  I  am  compelled  to  admit,  from  my  obser. 
vation  of  this  case,  that  one  would  naturally  adopt  the  term 
“rabies”  were  he  familiar  with  the  clinical  phenomena  of 
that  terrible  malady. 

On  the  10th  of  May,  1890,  Dr.  William  Stephenson,  at  that 
time  post  surgeon  at  Fort  Verde,  was  called  upon  to  attend 
Charles  Morris,  a  settler  living  in  the  vicinity  of  the  post,  who 
stated  that  the  night  previous  he  had  been  bitten  on  the  nose 
by  a  skunk  while  asleep  on  the  ground  some  miles  down  the 
valley.  The  wound  was  located  at  the  junction  of  the  osseous 
and  cartilaginous  portions  of  the  nose,  and  the  impressions  of 
the  animal’s  sharp  teeth  were  distinct. 

Dr.  Stephenson,  I  am  told,  carefully  washed  the  wound  and 
injected  into  the  tissues  a  saturated  solution  of  potassium  per¬ 
manganate.  On  the  morning  of  June  16th  I  was  asked  to  visit 

*  Rev.  mem.  de  taryngotogie ,  etc.,  No.  1,  1888,  p.  24. 

j-  Rev.  mem.  de  laryngologie,  etc.,  January,  1887,  p.  17. 


Sept.  27,  1890.] 


INGALS:  CARTILAGINOUS  TUMORS  OF  THE  LARYNX. 


Mr.  Morris,  who  had  come  from  his  ranch  to  the  post  trader’s 
store  and  awaited  my  arrival  there.  I  called  at  9  a.  m.  and 
found  the  patient  impatiently  walking  the  floor  and  apparently 
in  great  alarm  ;  he  had  been  seized  with  peculiar  tingling  pains 
originating  from  the  wound  the  day  before,  and  had  slept  none 
during  the  entire  night.  The  wound  had  healed  entirely  some 
time  since,  leaving  a  bluish-colored  cicatrix.  The  peculiar  sen¬ 
sations  complained  of  starting  from  this  scar  he  described  as 
shooting  over  the  entire  scalp.  He  also  stated  that  he  could 
barely  “catch  his  breath,”  and  experienced  a  sense  of  weight 
in  the  epigastric  region,  with  difficulty  of  swallowing. 

Morris  was  a  robust  man,  forty-nine  years  of  age,  had  al¬ 
ways  been  healthy,  hut  had,  I  understand,  been  considerable 
of  a  drinker  for  some  years.  Nearly  every  family  in  these 
frontier  settlements  is  supplied  with  what  they  term  a  “doctor 
book,”  such  as  Gunn’s  Family  Medicine ,  Foote’s  Household 
Medicine ,  etc.  Thinking  that  Morris  had  been  reading  about 
the  symptoms  of  hydrophobia  and  was  suffering  from  the  effects 
of  his  imagination,  I  tried  to  divert  his  mind  by  assuring  him 
of  the  absurdity  of  the  idea,  and,  to  further  quiet  him,  adminis¬ 
tered  potassium  bromide  every  hour. 

At  1.30  p.  m.  I  called,  and  the  patient  stated  that  the  ting¬ 
ling  sensations  were  not  so  frequent,  but  the  abdominal  pain 
and  gasping  were  still  prominent.  He  was  unable  to  swallow 
water  except  in  very  small  quantities.  His  pulse  was  slow  and 
full,  the  skin  clammy  and  covered  with  perspiration.  Irritation 
of  the  wound  on  the  nose  immediately  produced  irregular  con¬ 
vulsive  movements  of  the  whole  frame.  The  abdominal  pain 
seemed  to  be  produced  by  spasmodic  contractions  of  the  dia¬ 
phragm  ;  the  breathing  was  short  and  jerky. 

At  this  time  I  administered  a  hypodermic  injection  of  eight 
minims  of  Magendie’s  solution,  and  was  surprised  to  see  the 
entire  absence  of  its  usual  soothing  effect.  I  directed  that  the 
patient  be  kept  in  a  darkened  room  and  as  quiet  as  possible. 
At  8.30  p.  m.  I  found  no  abatement  in  the  symptoms ;  the  appar¬ 
ent  attempts  to  vomit  some  irritating  substance  were  frequent 
and  weakening.  He  was  utterly  unable  to  swallow  liquid  or 
solid  food,  yet  complained  of  extreme  thirst  and  hunger.  I 
then  administered  half  a  grain  of  sulphate  of  morphine  and  one 
sixtieth  of  a  grain  of  sulphate  of  atropine  by  hypodermic  injec¬ 
tion.  The  patient  rested  quietly  for  about  two  hours,  but  on 
awakening  at  the  expiration  of  that  time  the  symptoms  re¬ 
turned  in  all  their  intensity.  He  would  frequently  jump  sud¬ 
denly  from  ,tbe  bed  and  rush  toward  the  door  as  if  to  inhale 
fresh  air.  The  occurrence  of  the  shooting  pain  would  elicit  a 
shudder  from  his  entire  frame  as  if  he  were  suddenly  subjected 
to  a  chill.  I  again  administered  an  injection  of  morphine  and 
atropine,  and,  leaving  some  to  be  given  during  the  night  should 
his  paroxysms  continue,  left  the  patient  at  10.30  p.  m.,  return¬ 
ing  early  the  next  morning  (June  17th).  I  now  became  thor¬ 
oughly  alarmed  at  the  man’s  condition.  Attempts  to  swallow 
were  futile;  the  liquid,  regurgitating  into  the  nostrils  and  en¬ 
tering  the  larynx,  aggravated  the  attacks  of  dyspnoea.  Saliva 
flowed  from  the  mouth  and  gathered  in  foamy  masses  on  the 
mustache  and  on  the  cheeks.  The  pulse  was  still  slow,  but  was 
not  so  full  and  strong  as  on  the  previous  day.  The  spasmodic 
contractions  of  the  diaphragm  were  frequent  and  painful  and 
the  patient  was  uncontrollable  in  bis  restlessness. 

I  then  attempted  to  relieve  the  symptoms  by  inhalations  of 
amyl  nitrite,  twenty-five  minims  being  placed  on  a  soft  rag  and 
applied  to  the  nostrils.  Although  sufficient  was  used  to  affect 
all  in  the  vicinity  of  the  patient,  the  effect  upon  him  was  prac¬ 
tically  nil.  Chloroform  was  administered  with  no  effect  ex¬ 
cept  to  alarmingly  weaken  him.  Beef  extract  and  brandy  were 
administered  by  rectal  injection  and  were  well  retained.  The 
patient  passed  his  urine  several  times  during  the  previous  day 


345 

and  on  this  morning,  but  had  no  evacuation  from  the  bowels. 
Morphine  sulphate  and  atropine  were  then  administered  in 
quantities  sufficient  to  narcotize  a  healthy  man,  but  with  little 
or  no  result.  The  patient’s  struggles  for  breath  and  attempts 
to  vomit  were  extremely  pitiful;  he  assumed  every  position,  at 
times  walking  on  all  fours,  groveling  on  the  floor  and  rushing 
from  one  part  of  the  building  to  another.  At  the  same  time 
the  abdominal  contractions  and  gasping  attempts  to  fill  his  lungs 
produced  a  sound  similar  to  the  croupy  cry  of  a  child.  It  oc¬ 
curred  to  me  that  this  was  the  so-called  “  bark  ”  of  a  hydro- 
phobic  victim,  which  the  newpaper  descriptions  usually  con¬ 
tain.  In  order  to  restrain  the  patient,  I  was  compelled  to  hand¬ 
cuff  him  and  tie  his  shoulders  and  feet  by  stout  rope  to  the  cot 
on  which  he  was  lying.  In  fact,  he  requested  it  himself,  pos¬ 
sibly  fearing  lest  he  should  do  some  injury  to  those  around 
him.  At  about  1  p.  m.  he  expelled  a  large  quantity  of  blood 
from  his  throat,  some  of  which  entered  his  trachea  and  pro¬ 
duced  the  most  painful  struggles.  The  slightest  touch  or  mo¬ 
tion  would  give  rise  to  the  peculiar  shuddering  movements  of 
the  body.  From  this  time  on  the  pulse  began  to  fail,  and  the 
poor  wretch  expired  suddenly  at  5.30  p.  m.,  evidently  by  sudden 
paralysis  of  the  muscles  of  respiration.  An  autopsy  was  not 
obtainable.  Except  toward  the  last  two  hours,  his  intellect  was 
clear. 

I  leave  it  to  those  who  have  witnessed  cases  of  hydro¬ 
phobia  to  say  whether  one  would  be  justified  in  applying 
that  term  in  this  instance;  I  had  never  observed  a  case 
before,  and  my  knowledge  of  the  agonizing  malady  is  based 
upon  a  perusal  of  the  literature  of  the  subject.  The  fact 
that  two  men  in  this  vicinity  have  died  with  similar  symp¬ 
toms  after  the  bite  of  a  skunk  within  the  last  ten  years 
would  certainly  justify  me  in  believing  that  the  bite  of  this 
animal  is  at  times  poisonous,  if  not  productive  of  rabies. 
The  skunk  escaped  after  inflicting  the  wound  in  this  case. 

I  notice  that  Dr.  Sears,  at  the  recent  convention  of  the 
American  Medical  Association,  stated  that  the  bite  of  the 
polecat  frequently  produced  rabies  {Med.  Record ,  June  7, 
1890,  p.  664).  See  also  article  by  Acting  Assistant  Sur¬ 
geon  J.  A.  Wol i,  American  Journal  of  the  Medical  Sciences , 
October,  1875. 


SUPPLEMENTAL  REPORT  ON 
CARTILAGINOUS  TUMORS  OF  THE  LARYNX 
AND  WARTY  GROWTHS  IN  THE  NOSE.* 

By  E.  FLETCHER  INGALS,  A.  M.,  M.  D., 

CHICAGO. 

At  the  meeting  of  the  American  Laryngological  Asso¬ 
ciation,  held  in  Washington,  September,  1888,  I  reported 
the  case  of  a  young  man  suffering  from  a  cartilaginous  tu¬ 
mor,  just  beneath  the  vocal  cords,  which  grew  from  the 
lower  portion  of  the  thyreoid  cartilage.  This  growth  I  had 
been  treating  by  the  local  application  of  chromic  acid  in 
full  strength. 

At  the  time  the  growth  seemed  to  have  been  practically 
cured,  but  the  following  month  the  patient  again  consulted 
me,  when  I  found  a  slight  thickening  of  the  right  half  of 
the  base  of  the  tumor.  I  again  cauterized  the  growth  with 
chromic  acid,  and  subsequently,  on  one  or  two  occasions, 

*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


346 


IN  GALS:  UNILATERAL  PARALYSIS  OF  G RICO- A  R  Y  TEEN  01  D  MUSCLE .  [N.  Y.  Med.  Jour., 


similar  applications  were  made,  with  the  effect  of  com¬ 
pletely  destroying  it.  During  the  past  year  there  has  been 
no  recurrence,  and  now  the  patient  may  fairly  be  pro¬ 
nounced  cured.  In  this  case  the  growth  measured  origi¬ 
nally  one  centimetre  in  diameter  by  seven  centimetres  in 
thickness.  Internal  remedies  and  local  applications  of  vari¬ 
ous  kinds  had  done  no  good,  and  finally  there  seemed  no 
way  of  removing  it,  excepting  by  laryngotomy,  until  I  tried 
the  plan  of  gradual  destruction  by  chromic  acid.  Altogether 
twelve  or  thirteen  applications  of  the  acid  were  made,  a 
mass  of  the  fused  acid  about  as  large  as  a  millet  seed  be¬ 
ing  used  each  time.  Owing  to  the  patient’s  business,  in¬ 
tervals  of  from  three  weeks  to  several  months  intervened 
between  the  various  cauterizations.  At  present  the  parts 
appear  normal ;  even  the  mucous  membrane  shows  no  cica¬ 
trix,  and  the  thickening  has  entirely  disappeared.  The 
acid  seems  to  have  caused  absorption  rather  than  destruc¬ 
tion.  Intense  congestion  followed  each  cauterization,  but 
I  never  observed  ulceration  of  the  parts  after  the  applica¬ 
tions.  However,  I  seldom  saw  the  patient  for  several  weeks 
after  cauterization.  From  the  final  result  in  this  case  I  can 
strongly  urge  a  faithful  and  long-continued  trial  of  this 
method  of  treatment  in  laryngeal  growths  which  can  not 
be  thoroughly  eradicated  by  forceps. 

At  the  last  meeting  of  this  association  I  reported  a  case 
of  warty  growths  in  the  nose  which  I  had  cauterized  from 
time  to  time  with  chromic  acid,  nitric  acid,  nitrate  of  sil¬ 
ver,  or  the  galvano-cautery.  I  had  hopes  of  curing  the  case 
by  these  agents,  but  the  warts  continued  to  return.  For 
about  two  months  after  my  report  was  written  I  either  ap¬ 
plied  chromic  acid  or  used  the  galvano-cautery  about  once 
a  week,  for  the  destruction  of  all  warty  growths  that  ap¬ 
peared.  On  the  7  th  of  August,  1889,  I  applied  to  the 
growth  the  tincture  of  thuja  occidentalis  and  gave  to  the 
patient  the  same  preparation,  which  he  was  directed  to  ap¬ 
ply  twice  daily  with  a  pledget  of  cotton,  which  was  to  re¬ 
main  for  twenty  minutes.  At  the  same  time  he  was  told 
to  take  internally  teaspoonful  doses  of  the  remedy  three 
times  each  day.  He  made  the  local  applications  faithfully 
and  for  a  few  days  took  the  medicine  internally  with  con¬ 
siderable  regularity,  but  afterward  he  limited  the  treatment 
to  local  applications.  During  the  next  ten  weeks  I  saw  the 
patient  eight  or  ten  times  and  made  six  or  eight  applica¬ 
tions  of  chromic  acid  to  small  warts  as  they  appeared.  At 
the  end  of  this  time  I  find  it  noted  in  the  record  that  there 
was  no  appearance  of  warty  growths.  The  patient  still  used 
the  thuja  occidentalis  locally,  though  not  with  great  regu¬ 
larity.  Subsequently  the  mucous  membrane  of  that  side 
had  a  tendency  to  become  dry,  for  which  it  was  treated 
from  time  to  time  with  various  remedies.  About  a  month 
after  the  final  disappearance  of  the  warts  the  patient  was 
given  a  spray  of  two  grains  of  carbolic  acid  and  two  grains 
of  camphor  to  the  ounce  of  liquid  albolene,  which  he  used 
for  a  short  time.  It  is  now  seven  months  since  the  last  of 
the  warty  growths  were  destroyed  and  none  have  returned. 
What  the  influence  of  the  thuja  occidentalis  has  been  upon 
this  case  it  is  impossible  to  say;  but, from  its  time-honored 
reputation  for  curing  warty  growths  and  from  the  fact  that 
previous  remedies  had  failed,  I  think  it  fair  to  give  it  a  por¬ 


tion  of  the  credit,  though  doubtless  the  occasional  use  of 
chromicacid  had  something  to  do  with  the  result;  however, 
during  the  treatment  it  was  very  apparent  that  the  growths 
did  not  reappear  as  quickly,  and  that  they  enlarged  much 
more  slowly  after  the  thuja  occidentalis  had  been  in  use  a 
short  time. 

70  State  Street. 


UNILATERAL  PARALYSIS  OF 
THE  LATERAL  CRICO-ARYTJENOID  MUSCLE. 

(LATERAL  ADDUCTOR  OF  THE  YOCAL  CORD.) 

PECULIAR  CASES* 

By  E.  FLETCHER  INGALS,  A.  M.,  M.  D., 

CHICAGO. 

Although  bilateral  paralysis  of  the  adductors  of  the 
vocal  cords  is  a  common  affection,  unilateral  paralysis  is 
not  often  met  with  excepting  as  the  result  of  compression 
or  injury  of  the  recurrent  nerve,  as,  for  example,  in  aneu¬ 
rysms  of  the  aorta  or  malignant  disease  of  the  oesophagus. 
The  affection  is,  however,  met  with  in  rare  instances  of 
lead  and  arsenical  poisoning,  and  it  is  sometimes  observed 
as  the  result  of  exposure  to  cold.  It  is  sometimes  attrib¬ 
uted  to  rheumatism  or  phthisis,  and  is  occasionally  seen  as 
the  result  of  accident  or  surgical  wounds.  When  accom¬ 
panied  by  paralysis  of  the  same  side  of  the  tongue  or  palate 
it  is  of  centric  origin.  Two  cases  which  I  wish  to  report, 
although  following  shortly  after  surgical  operations  in  the 
mouth  and  naso-pharynx,  appear  to  be  of  hysterical  char¬ 
acter,  though  one  would  seem  to  prove  that  an  injury  to 
the  terminal  extremities  of  one  branch  of  the  eighth  pair 
may,  through  reflex  influences,  produce  paralysis  of  distant 
muscles  supplied  by  an  entirely  different  branch  of  the 
same  nerve,  and  the  other  would  appear  to  indicate  that,  in 
the  same  way,  paralysis  may  be  produced  in  one  of  the 
distant  muscles  supplied  by  the  pneumogastric  branch  of 
the  eighth  pair,  while  the  injury  causing  it  occurred  to  the 
terminal  loops  of  one  of  the  branches  of  the  fifth  pair. 

In  these  cases  the  usual  dysphonia  was  present  and  the 
sounds  produced  by  coughing  or  sneezing  were  more  or 
less  altered.  In  neither  were  there  evidences  of  hysteria 
or  symptoms  indicating  constitutional  disease.  There  was 
neither  swelling  nor  congestion  of  the  larynx  in  either  case, 
and  in  neither  was  there  any  evidence  of  injury  to  the  re¬ 
current  nerve.  The  first  patient  recovered  after  a  few  weeks 
of,  mainly,  constitutional  treatment;  the  second  had  been 
treated  by  another  physician  for  over  two  months  before 
coming  to  me,  and  has  now  been  under  my  care  for  about 
four  weeks  without  perceptible  improvement. 

Case  I. — Miss  M.  P.,  aged  twenty-two,  school-teacher. 
This  patient  told  me  that  two  weeks  previously  she  had  some 
teeth  extracted,  which  caused  her  to  faint,  and  that  twenty- four 
hours  later  the  voice  was  suddenly  lost  so  that  she  could  only 
speak  in  a  whisper,  but  her  voice  had  considerably  improved. 
When  she  consulted  me  she  spoke  in  a  coarse  whisper  and  com¬ 
plained  of  slight  pain  at  times  in  the  left  shoulder  and  back 
and  of  some  difficulty  in  swallowing,  which  had  been  present 
since  the  voice  was  first  lost.  Otherwise  she  was  in  perfect 

*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


Sept.  27,  1890.] 


AULDE:  THE  PHARMACOLOGY  OF  ERGOT. 


347 


health;  the  appetite  was  good  and  digestion  normal.  I  found 
the  voice  of  about  one  half  its  normal  intensity.  There  was 
no  difficulty  in  respiration  and  no  cough  except  when  attempt¬ 
ing  to  swallow  fluids.  She  was  despondent  for  fear  of  being 
unable  to  return  to  her  work/ but  there  were  no  evidences  of 
hysteria.  There  was  evident  paresis  of  the  depressors  of  the 
epiglottis,  as  indicated  by  her  difficulty  in  swallowing,  though 
the  condition  was  not  discernible  upon  laryngoscopic  examina¬ 
tion. 

Examination  of  the  vocal  cords  showed  absence  of  either 
congestion  or  swelling.  On  phonation,  the  left  cord  passed 
about  three  millimetres  beyond  the  median  line,  but  the  right 
one  remained  motionless  at  the  side  of  the  larynx.  At  her  first 
visit  I  applied  a  simple  stimulating  spray  to  the  larynx  and 
ordered  pills  containing  iron  and  quinine  with  one  twentieth  of 
a  grain  of  strychnine  in  each.  At  her  second  visit  the  same 
local  application  was  made  and  the  strychnine  continued,  though 
the  other  remedies  were  changed.  A  week  later  there  had 
been  no  material  improvement.  The  faradaic  current  was  then 
applied  to  the  cord  itself  by  means  of  a  double  electrode.  The 
internal  remedies  were  continued.  A  few  days  later  the  fara¬ 
daic  current  was  again  employed  and  the  dose  of  strychnine 
was  increased  to  one  sixteenth  of  a  grain.  Four  days  later  the 
same  treatment  was  repeated.  At  her  next  visit  (twenty  days 
after  she  had  first  consulted  me)  .it  was  noted  that,  although 
the  right  cord  itself  was  motionless,  the  tissues  covering  the 
right  arytsenoid  cartilage  moved  considerably  on  phonation. 
Three  days  later  there  had  been  slight,  if  any,  improvement. 
The  faradaic  current  was  then  discontinued,  but  the  strychnine 
was  increased  to  one  twelfth  of  a  grain  three  times  daily.  From 
this  time  on  I  made  no  local  applications.  About  a  week  later, 
as  the  patient  wished  to  return  to  her  home  in  the  country,  I 
increased  the  dose  of  strychnine  to  one  tenth  of  a  grain  and 
gave  her  in  addition  a  grain  and  a  half  of  quinine,  a  grain  of  the 
valerianate  of  zinc,  and  one  fortieth  of  a  grain  of  nitrate  of 
sanguinarine  three  times  a  day.  She  was  allowed  also  to  apply 
the  faradaic  current  over  the  larynx  as  suited  her  inclination. 
I  heard  nothing  more  from  the  patient  for  five  weeks.  During 
that  time  she  had  continued  the  treatment,  and  she  then  re¬ 
ported  herself  completely  cured.  There  was  no  subsequent 
return  of  the  dysphonia.  Some  months  later  I  saw  the  patient 
and  found  that  the  paralysis  had  entirely  disappeared. 

Case  II.— Miss  L.  B.,  aged  nineteen.  This  patient  came  to 
me  in  the  latter  part  of  March  on  account  of  difficulty  in  speak¬ 
ing,  which  not  only  interfered  with  her  ordinary  voice  but  pre¬ 
vented  singing.  She  stated  that  for  a  year  and  a  half  she  had 
been  troubled  with  catarrh,  and  that  recently  she  had  been 
under  the  treatment  of  another  physician  for  this  affection.  He 
had  found  enlargement  of  Luschka’s  tonsil,  which  he  had  re¬ 
moved  at  two  different  operations.  The  first  operation  gave 
her  much  pain,  but  at  the  second  operation  cocaine  was  used 
more  freely  and  there  had  been  little  or  no  suffering.  Upon  the 
day  following  the  second  operation  she  had  been  comfortable 
and  had  used  her  voice  more  than  usual,  but  on  arising  the  next 
morning — that  is,  two  days  after  the  operation — she  found  her¬ 
self  unable  to  speak  louder  than  a  whisper.  This  occurred 
eight  weeks  before  the  time  she  first  consulted  me.  In  the 
mean  time  her  voice  had  gradually  improved  until  at  the  time  I 
saw  her  she  could  speak  aloud  in  a  husky  tone,  but  she  was 
unable  to  sing.  During  these  two  months  she  had  been  under 
the  treatment  of  her  physician,  and  had  received  several  appli¬ 
cations  of  the  faradaic  current.  Her  general  health  was  excellent 
and  she  had  no  cough  or  dyspnoea. 

I  found  the  nares  and  naso-pharynx  essentially  normal,  but 
there  was  some  inflammation  of  the  Eustachian  tubes.  Upon 
examination  of  the  larynx,  I  found  the  right  vocal  cord  com¬ 


pletely  abducted  and  immovable  upon  attempted  phonation. 
There  was  no  congestion  or  swelling  of  the  parts.  I  applied 
the  static  current  and  recommended  the  internal  use  of  strych¬ 
nine,  but  she  did  not  place  herself  under  my  care  until  nearly 
two  weeks  later.  Upon  her  return,  I  applied  to  the  Eustachian 
tubes  and  middle  ear  an  oily  solution  of  carbolic  acid,  gr.  ij, 
and  menthol,  gr.  v,  in  liquid  alboline,  §  j.  This  was  introduced 
through  the  naso-pharynx  by  means  of  my  ordinary  atomizer, 
with  a  long  bent  tip,  the  nostril  being  held  while  the  spray  was 
being  thrown  in.  I  applied  to  the  larynx  a  slightly  stimulating 
spray,  mainly  for  its  psychical  effects,  and  used  the  static  cur¬ 
rent  externally  over  the  larynx.  Thereafter  she  took  sulphate 
of  strychnine  in  gradually  increasing  doses  until  she  experienced 
a  peculiar  nervousness  about  twenty  minutes  after  taking  the 
medicine.  This  did  not  occur  until  the  dose  had  reached  one 
tenth  of  a  grain  three  times  daily.  It  was  found  that  half  this 
dose  could  be  taken  six  times  daily  without  inconvenience, 
therefore  this  method  was  adopted.  The  case  is  still  under 
treatment.  On  phonation,  the  supra-arytsenoid  cartilages  of  the 
right  side  move  a  little,  but  the  vocal  cord  remains  motionless 
and  the  left  cord  nearly  meets  its  fellow  far  to  the  right  of  the 
median  line.  The  question  has  arisen  in  my  mind  whether  this 
paralysis  could  have  preceded  her  attack  of  aphonia,  but  every¬ 
thing  in  the  history  of  the  case  seems  to  prove  that  it  did  not, 
and  the  most  critical  examination  fails  to  detect  any  other  than 
a  hysterical  origin,  either  centric  or  along  the  course  of  the 
pneumogastric  or  recurrent  laryngeal  nerve. 

This  patient  was  completely  cured  in  four  weeks  after 
the  foregoing  was  written,  and  there  has  been  no  recurrence. 

70  State  Street. 


STUDIES  IN  THERAPEUTICS. 

THE  PHARMACOLOGY  OF  ERGOT. 

By  JOHN  AULDE,  M.  D., 

PHILADELPHIA. 

The  dangers  from  the  use  of  ergot  are  not  so  great  as 
one  would  suppose  from  a  study  of  the  effects  upon  the 
system.  Large  doses,  short  of  poisoning,  if  continued  for 
a  sufficient  time,  will  cause  paralysis,  and  anaesthesia  with 
coldness  of  the  surface,  these  phenomena  being  due  to  a 
lack  of  blood-supply  to  the  affected  tissues,  as  will  appear 
further  on  in  this  discussion.  When  given  in  sufficient 
quantity,  ergot  produces  all  the  symptoms  of  an  irritant 
poison,  such  as  nausea,  colic,  giddiness,  dilatation  of  the 
pupil,  with  dimness  of  vision  and  stupor,  often  accompanied 
by  diarrhoea ‘and  vomiting.  Poisoning  is  referred  to  as 
ergotism,  and  epidemics  have  occurred  at  different  times  in 
countries  where  rye-bread  forms  a  food-staple,  but  the  sys¬ 
tem  appears  to  be  very  tolerant  of  large  doses  given  for 
medicinal  purposes.  Ergotism  presents  two  varieties  of 
symptoms  ;  they  may  be  simply  gangrenous  or  in  the  nature 
of  nervous  manifestations — such  as  formication,  paralysis  of 
sensation  in  the  extremities,  sclerosis  of  the  postero-lateral 
columns,  and  possibly  epileptiform  seizures.  These  symp¬ 
toms  may  appear  either  in  the  acute  or  chi'onic  form,  al¬ 
though  they  are  not  separated  by  well-marked  pathological 
differences,  and  the  only  guide  is  that  the  latter  more  gen¬ 
erally  are  to  be  seen  as  the  effect  of  living  for  a  time  upon 
bread  made  from  diseased  grain,  and  is  more  likely  to  affect 
a  number  of  persons  than  a  single  individual. 


348 


AULDE:  TEE  PHARMACOLOGY  OF  ERGOT. 


[N.  Y.  Mkd.  Jour., 


The  action  of  ergot  is  antagonized  by  the  exhibition  of 
nitrite  of  amyl,  which  possesses  the  property  of  dilating 
the  arterial  capillaries,  and  possibly  also  by  glonoin  and  by 
all  those  remedies  which  cause  depression  as  a  secondary 
effect — such  as  aconite,  veratrum  viride,  tobacco,  and  lobelia- 
After  the  immediate  difficulty  has  been  met  and  overcome, 
potassium  iodide,  corrosive  sublimate,  and  the  diffusible 
stimulants — like  carbonate  and  iodide  of  ammonium — should 
be  administered,  while  the  persistent  use  of  oxygen  gas  is 
to  be  commended.  Cerebral  symptoms  may  be  avoided, 
for  a  time  at  least,  by  compelling  the  patient  to  retain  the 
recumbent  position.  The  remedies  which  can  be  relied 
upon  as  synergists  are  cold,  digitalis,  and  electricity,  when 
administered  in  such  a  manner  that  the  primary  action 
favors  the  contraction  of  the  minute  blood-vessels;  bella¬ 
donna,  too,  when  taken  in  such  quantity  as  to  produce  a 
degree  of  narcotism,  will  be  found  to  favor  the  action  of 
ergot. 

The  antidotes  are  tannin  and  stimulants,  besides  the  in¬ 
halation  of  oxygen  to  prevent  paralysis  of  respiration,  which 
is  the  mode  of  death  from  ergotism. 

Absorption  from  the  stomach,  or  its  use  hypodermati- 
cally,  will  produce  the  full  physiological  effects  of  the 
drug,  although  the  history  of  the  epidemics  which  have 
occurred  would  lead  us  to  suspect  that  want  of  proper  food 
may  have  something  to  do  with  their  development,  as  ordi¬ 
narily  no  bad  results  attend  the  exhibition  of  medicinal 
doses. 

Of  the  active  principles,  sphacelinic  acid  appears  to  be 
the  most  characteristic  of  ergot  in  its  effects  upon  the  uter¬ 
us,  as  well  as  upon  the  arterioles,  but  the  active  principle, 
cornutine,  is  entitled  to  a  share  of  credit,  as  its  action  upon 
the  blood-vessels  is  very  decided.  Ergotinic  acid,  when 
given  alone,  reduces  the  blood-pressure,  showing  that  in  its 
crude  form  ergot  is  a  complex  product.  Ergotin,  or  Bon- 
jean’s  ergotine,  is  a  product  now  on  the  market,  and  that 
is  the  preparation  generally  referred  to,  although  it  is  liable 
to  be  inert  from  faulty  methods  of  preparation,  and  as  these 
are  defects  which  are  at  all  times  unavoidable,  due  allow¬ 
ance  must  be  made  in  the  case  of  adverse  reports  upon  any 
preparation.  The  perfection  of  the  product  is  always  to  be 
considered,  but  this  is  especially  demanded  when  the  hypo¬ 
dermatic  method  is  to  be  adopted. 

Neither  ergotinic  acid  nor  ergotinine  appear  to  possess 
the  property  of  influencing  or  inducing  uterine  contrac¬ 
tions.  The  former  causes  very  decided  nervous  symptoms, 
while  the  latter  can  be  removed  from  ergot  without  appar¬ 
ently  affecting  its  properties.  The  action  of  ergot  prepa¬ 
rations  will  therefore  depend  upon  the  amount  of  sphace¬ 
linic  acid  and  cornutine  they  contain,  which  leads  to 
the  observation  that  physicians  will  do  well  to  confine 
themselves  to  assayed  preparations  until  the  different  act¬ 
ive  principles  have  been  fully  studied  and  placed  on  the 
market. 

Ergot  has  been  variously  classed  as  a  stimulant  and 
oxytocic,  and  its  general  action  has  long  been  regarded  as 
an  emmenagogue  and  ecbolic,  but  later  knowledge  of  dis¬ 
eased  conditions  has  greatly  widened  the  field  of  its  useful¬ 
ness,  and  there  are  other  indications  for  this  drug  than  to 


cause  contraction  of  the  uterus  and  check  haimorrhages. 
It  causes  dilatation  of  the  pupil ;  acting  upon  the  blood¬ 
vessels  as  a  styptic,  it  is  closely  connected  with  astringents, 
which  nearly  all  coagulate  albuminous  substances. 

The  nervous  system  is  distinctly  affected  by  prepara¬ 
tions  of  ergot,  although  Ringer  asserts  that  its  action  upon 
the  heart  is  not  due  to  the  effect  upon  the  vagus  (inhibi¬ 
tion),  but  to  its  direct  action  upon  the  cardiac  muscle.  Brun- 
ton  has  observed  that  the  circulation  in  the  frog’s  heart 
is  not  always  attended  with  the  same  symptoms,  although 
he  believes  that  slowing  and  diastolic  arrest  are  due  to  the 
action  of  ergot  on  the  inhibitory  apparatus.  This  slowing 
of  the  heart,  with  less  powerful  contractions,  and  final  ar¬ 
rest  in  diastole,  he  thinks,  is  due  to  the  depressing  action  of 
the  drug  on  the  motor  ganglia  of  the  heart.  He  suggests 
also  the  probability  that  ergot  affects  the  heart  muscle  as 
it  does  the  arterioles,  and  that,  in  addition  thereto,  inhibi¬ 
tion  is  effected  through  the  vagus  acting  upon  the  cardiac 
ganglia.  The  investigations  of  this  industrious  author  have 
been  very  carefully  conducted,  and  will  be  of  immense 
value  to  those  who  may  wish  to  undertake  experimental  re¬ 
searches  on  their  own  account.  For  convenience  the  fol¬ 
lowing  observations  are  selected:  Cornutine,  he  says,  is  the 
principle  which  is  concerned  in  the  stimulation  of  the  vaso¬ 
motor  center,  causing  a  rise  in  blood-pressure,  but,  with  due 
respect,  it  is  suggested  that  the  word  irritant  would  better 
express  the  action  which  this  drug  is  supposed  to  have  upon 
the  vaso-motor  center,  and  the  context  is  a  sufficient  in¬ 
dorsement  of  the  exception  made,  as  he  goes  on  to  say  that 
it  is  very  doubtful  whether  these  nerves  are  stimulated  by 
drugs,  as  he  has  not  been  able  to  demonstrate  whether  the 
action  is  upon  the  terminal  filaments  or  in  the  muscular 
walls.  On  the  whole,  it  is  accepted  that  the  function  of  the 
motor  nerves  is  somewhat  heightened,  while  the  sensory 
nerves  as  well  as  the  spinal  cord  are  paralyzed. 

Much  controversy  has  arisen  regarding  the  action  of 
ergot  upon  the  circulation,  and  it  has  been  proved  experi¬ 
mentally  that  ergot  causes  contraction  of  the  smaller  ar¬ 
teries  by  acting  on  their  muscular  walls,  thus  increasing 
the  systemic  blood-pressure.  The  facts  can  not  longer  be 
denied  that  ergot  affects  more  especially  tissues  that  present 
excessive  vascularity — as  in  the  gravid  uterus,  thyreoid  en¬ 
largement,  and  hypertrophy  of  the  spleen  and  of  the  prostate. 
Not  only  is  there  cerebral  and  spinal  anaemia,  with  blanched 
appearance  of  the  face  and  coldness  of  the  skin,  but  there 
are  other  evidences  of  arterial  anaemia  and  consequent  ve¬ 
nous  dilatation,  with  distention  of  the  abdominal  vessels — 
a  condition  which  interferes  with  the  regular  distribution 
of  the  drug  throughout  the  system,  and  which  should  be 
avoided  when  the  administration  is  to  be  long  continued. 
It  is  readily  admitted  that  ergot  causes  gangrene  by  dimin¬ 
ishing  the  caliber  of  the  vessels  and  obstructing  the  circu- 
lation,  but  the  method  by  which  this  object  is  secured  has 
long  been  a  bone  of  contention.  It  will  therefore  not  be 
considered  out  of  place  should  the  matter  be  referred  to  here 
as  viewed  from  the  clinical  standpoint. 

Bartholow  says  the  notion  that  ergot  causes  contraction 
of  the  arteries  by  stimulating  the  vaso-motor  system  and 
its  muscular  apparatus  has  long  been  entertained,  and  he  is 


AULDE:  THE  PH  A  RMA  COLO  GY  OF  ERGO  T. 


349 


Sept.  27,  1890.] 
disposed  to  adopt  Wernich’ 

that  the  arteries  become  smaller  by  passive  collapse,  by 
reason  of  a  deficient  supply  of  arterial  blood,  lie  reasons 
that,  as  active  movements  of  the  muscular  fibers  of  the  in¬ 
testines  and  uterus  may  be  induced  by  arterial  anaemia, 
these  increased  peristalses  and  uterine  contractions  must  be 
due  to  “diminished  cardiac  energy,  dilatation  of  the  veins, 
and  arterial  anaemia,”  thus  eliminating  the  influence  which 
has  heretofore  been  supposed  to  rest  with  the  sympathetic 
system.  The  explanation  is  complicated  and  difficult  to 
comprehend,  and,  besides,  it  starts  the  student  on  a  line  of 
investigation  with  a  view  to  determine  the  cause  of  this 
sudden  change  of  base.  Would  it  not  be  well  in  this  case 
to  assume  that  the  nearest  approach  to  the  facts  lies  in 
assuming  that  ergot  so  affects  the  sympathetic  nervous  sys¬ 
tem  that  control  over  the  muscular  fibers  of  both  intestinal 
canal  and  uterus  is  suspended,  and  that,  possessing  inherent 
contractile  properties,  these  muscular  fibers  contract,  the 
result  being  arterial  anaemia?  If  this  theory  is  adopted,  it 
follows  that  all  unstriped  muscular  fiber  wherever  found  in 
the  human  body  is  similarly  affected;  and  the  proposition 
is  substantially  true. 

This  explanation  apparently  is  confirmed  by  the  use  of 
the  drug,  and  is  sufficient  to  account  for  the  contradictory 
statements  which  have  been  made  regarding  certain  prepa¬ 
rations,  as  well  as  the  varied  effects  which  have  been  noted 
by  different  observers.  Thus  in  the  case  of  pulmonary 
haemorrhage,  or  post-partum  haemorrhage,  the  administra¬ 
tion  of  a  drachm  or  more  is  generally  followed  in  due  time 
by  a  subsidence  of  all  the  dangerous  symptoms,  and  the 
preparation  is  pronounced  good;  but,  should  the  emergency 
again  occur  in  the  course  of  a  few  hours,  a  repetition  of  the 
dose  is  apparently  useless,  and  the  drug  is  condemned. 
The  difficulty  here  lies  not  so  much  in  the  preparation  as 
in  the  method  of  administration.  The  initial  dose  produces 
arterial  anaemia  at  the  same  time  that  it  causes  a  cessation 
of  the  haemorrhage,  but  arterial  anaemia,  with  its  attendant 
constriction  of  the  arterioles,  prevents  the  drug  from  reach¬ 
ing  the  affected  tissues  in  sufficient  quantity  to  produce  an 
effect  commensurate  with  the  amount  taken  the  second 
time.  The  first  dose  practically  destroys  itself  by  causing 
arterial  anaemia  with  dilatation  of  the  abdominal  veins,  and 
the  second  dose  soon  reaches  the  same  pocket.  Should  the 
patient  insist  upon  maintaining  the  upright  position,  cere¬ 
bral  symptoms  will  not  long  be  delayed,  and  if  continued 
for  a  length  of  time,  distinct  physiological  indications  of 
ergotism  will  be  manifested. 

These  symptoms  resemble  in  some  respects  the  condi¬ 
tions  which  attend  upon  somatic  death  before  cellular  death 
has  taken  place.  An  illustration  is  found  in  the  emptied 
cardiac  cavities,  the  contracted  and  bloodless  arteries,  auc. 
in  the  involuntary  contractions  which  occur  in  the  parturi¬ 
ent  womb,  which  has  been  known  to  expel  the  child  in  utero 
after  the  death  of  the  mother  ;’  and  yet  no  one  has  thus  far 
interpreted  the  phenomena  above  described  as  being  due 
to  stimulation  of  the  sympathetic  system,  nor  has  it  been 
pointed  out  as  an  illustration  of  passive  collapse  of  the  ar¬ 
teries.  The  absurdity  of  these  propositions  furnishes  no 
inducement  for  argument,  and  for  the  same  reason  the 


“  temporary  hypothesis  ”  regarding  inhibition,  so  far  as  it 
relates  to  ergot,  should  be  discarded. 

The  benefits  to  be  derived  from  the  appropriate  exhibi¬ 
tion  of  small  doses  of  this  drug,  in  view  of  the  foregoing 
propositions,  are  now  readily  understood;  the  explanation 
is  simple,  and  apparently  the  demonstration  is  complete. 
When  a  comparatively  small  quantity  is  introduced  into 
the  system,  and  the  dose  frequently  repeated,  the  nerves 
controlling  the  caliber  of  the  blood-vessels  are  constantly 
under  its  influence  ;  their  power  over  the  muscular  fibers 
is  suspended  or  held  in  abeyance,  and  not  until  considera¬ 
ble  time  has  elapsed  will  pronounced  general  arterial  anae¬ 
mia  take  place  ;  the  operation  of  the  drug  is  constant,  the 
effect  more  permanent,  and  likewise  more  certain,  when 
small  doses  are  administered.  The  deduction  is  not  war¬ 
ranted,  however,  that  large  doses  are  always  contra-indi¬ 
cated  ;  on  the  contrary,  there  are  times  when  it  is  desired 
to  get  the  immediate  effects  of  the  drug,  and  in  such  emer¬ 
gencies  a  drachm  or  more  may  be  given  with  the  expecta¬ 
tion  that  good  results  will  attend  its  use,  providing  the 
stomach  does  not  rebel. 

The  true  position  of  ergot  in  its  entirety,  with  refer¬ 
ence  to  its  paralyzing  action  upon  respiration,  in  the  light 
of  this  explanation  can  not  fail  to  be  appreciated.  Embar¬ 
rassment  of  respiration  naturally  attends  upon  diminished 
blood-supply,  a  condition  which  involves  the  systemic  to  an 
equal  extent  with  the  pulmonary  circulation.  Defective  in¬ 
ternal  respiration  becomes  a  factor  of  paramount  impor¬ 
tance,  and  the  attending  phenomena  are  thus  rendered  ex¬ 
plicable,  and  to  a  certain  extent  conclusive,  regarding  the 
position  assumed.  It  will  be  noticed  that  I  have  not  in 
this  discussion  taken  into  consideration  the  special  action 
of  the  respective  substances  which  have  been  isolated  and 
are  now  recognized  as  active  principles,  and  in  explanation 
it  should  be  added  that  for  the  most  part  they  may  be 
looked  upon  more  as  laboratory  curiosities  than  astherapeu- 
tic  agents,  because  at  present  they  are  not  produced  in  suffi¬ 
cient  quantity  to  enable  the  physician  to  supply  his  pa¬ 
tients  with  them.  Doubtless  the  time  will  come  when  their 
specific  uses  will  be  of  great  benefit  to  the  medical  profes¬ 
sion,  but  until  material  advances  have  been  made  in  our 
methods  of  pharmacy  we  must  be  satisfied  to  continue  the 
use  of  the  crude  drug. 

A  study  of  the  effects  of  large  doses,  medicinal  doses, 
and  small  doses  would  be  an  interesting  subject,  but  so  much 
has  already  been  said  that  it  is  believed  this  matter  may 
with  propriety  be  omitted.  Whoever  will  consider  candid¬ 
ly  what  has  already  been  said  needs  no  caution  as  to  the 
proper  methods  for  using  this  remedy  so  far  as  it  affects 
the  circulation.  However,  a  few  words  may  be  added  .  that 
it  contracts  the  arterioles  like  digitalis  ;  that,  like  digitalis, 
it  is  a  vascular  sedative,  and  lessens  the  flow  of  blood 
through  the  vessels  (arterioles),  and  for  this  reason  it  has 
been  successfully  used  in  controlling  local  inflammatory  ac¬ 
tion.  Acting  thus  upon  the  blood-vessels,  ergot  may  be 
employed  as  a  styptic,  and  is  therefore  closely  allied  to  as¬ 
tringents.  The  slowing  of  the  heart  follows  upon  the  in¬ 
creased  amount  of  work  the  organ  is  called  upon  to  perform 
in  forcing  the  blood  through  the  contracted  blood-vessels 


theory,  announced  in  1870, 


and  for  the  same  reason  the  rate  of  the  pulse  is  lowered, 
while  the  arterial  tension  is  considerably  raised.  The  effect 
thus  produced  upon  the  brain  may  develop  syncope,  or  the 
presence  of  the  drug  in  the  tissues  may  be  sufficient  to  cause 
symptoms  of  narcotism. 

Respiration  is  slowed,  and,  as  has  already  been  stated, 
death  takes  place  from  paralysis  of  this  function.  Ergot  in 
decided  doses  lowers  the  temperature,  and,  when  long  con 
tinued,  the  general  action  simulates  in  some  respects  certain 
forms  of  disease. 

As  mentioned  above,  the  action  of  ergot  is  manifested 
upon  the  involuntary  muscular  fibers  throughout  the  body, 
and  is  not,  as  was  long  supposed,  confined  to  the  muscular 
fibers  of  the  uterus  ;  other  organs — as  the  heart,  the  kid¬ 
neys,  the  liver,  and  the  muscular  walls  of  the  intestine _ are 

also  affected,  and,  when  given  hypodermatically,  may  cause 
inco-ordination,  anaesthesia,  and  paralysis. 

A  noticeable  feature  in  connection  with  the  develop 
ment  of  ergotism  is  the  fact  that  functional  activity  of  the 
digestive  system  is  greatly  increased,  and  the  appetite  be¬ 
comes  ravenous  ;  this  condition  may  be  accounted  for,  in 
part  at  least,  by  the  determination  of  blood  to  the  abdom¬ 
inal  veins,  showing  that  it  is  the  physical  rather  than  the 
nervous  system  which  is  affected.  Peristalsis  is  increased, 
and  there  is  an  increased  secretion  from  mucous  surfaces, 
but  small  doses,  even  when  long  continued,  present  no 
physiological  derangements  except  as  regards  the  face. 
Large  doses  set  up  gastro-intestinal  irritation.  So  far,  no 
investigations  have  been  made  to  determine  its  effect  upon 
the  composition  of  the  blood. 

In  addition  to  what  has  been  said,  the  action  of  ergot 
upon  the  genito-urinary  system  may  be  summed  up  in  a  few 
words.  By  its  exhibition,  contractions  of  the  muscular  fibers 
of  the  uterus  are  set  up  different  from  those  which  occur 
normally  by  reason  of  their  tonicity,  and  to  express  this 
peculiarity  the  word  tetanic  has  been  adopted.  Brunton 
suggests  that  this  action  may  be  partly  due  to  the  influence 
of  the  drug  upon  the  uterine  center  in  the  spinal  cord.  By 
reason  of  the  property  just  mentioned,  ergot  has  been  classed 
as  a  direct  emmenagogue.  The  mode  of  action  of  ecbolics 
is  still  undecided,  although  there  is  no  question  but  that 
ergot  is  one  of  the  first.  The  urine  is  increased  in  amount, 
but  this  can  not  be  accepted  as  an  indication  for  its  use  in 
the  treatment  of  diabetes  insipidus,  a  condition  which  prob¬ 
ably  depends  upon  a  relaxed  state  of  the  renal  tissues,  which 
ergot  promptly  overcomes.  There  is  reason  to  believe  also 
that  the  muscular  fibers  of  the  bladder  respond  to  the  influ¬ 
ence  of  this  drug. 

1910  Arch  Street. 

J^EW  TESTS  FOR  BINOCULAR  VISION  * 

By  J.  A.  LIPPINCOTT,  M.  D., 

PITTSBURGH,  PA. 

Tests  for  binocular  vision  are  of  two  classes — 1,  those 
for  determining  the  presence  or  absence  of  uniocular  blind¬ 
ness  ;  and  2,  those  for  establishing  the  existence  or  non- 

*  Read  before  the  American  Ophthalmological  Society  at  its  twenty- 
sixth  annual  meeting. 


existence  of  binocular  single  or  stereoscopic  vision.  The 
former  class  includes  all  the  methods  of  preventing  the 
sound  eye  from  seeing— e.  g.,  placing  a  strong  convex  glass 
in  front  of  it,  as  suggested  by  Harlan,*  or  a  strong  concave 
glass,  as  mentioned  by  Juler,f  or  rendering  certain  letters 
of  a  word  invisible,  as  in  Snellen’s  \  test,  etc.  This  class 
also  includes  the  examination  of  the  pupil  reflexes  direct 
and  indirect.  The  second  class  includes  Hering’s  test  and 
the  temporary  strabismus  test  with  a  prism,  as  well  as  the 
various  tests  with  the  stereoscope,  etc. 

The  tests  which  I  venture  to  present  for  your  consid¬ 
eration  to-day  belong  to  the  second  class.  Like  other  tests 
of  this  class,  they  may,  of  course,  when  they  elicit  positive 
results,  take  the  place  of  tests  of  the  first  class,  and  so  may 
be  of  use  in  the  detection  of  malingering.  If,  on  the  other 
hand,  the  results  are  negative,  they  demonstrate  only  the  ab¬ 
sence  of  binocular  single  vision,  and  not  the  presence  of 
monocular  blindness. 

In  1875  Dr.  Wadsworth#  reported  a  case  in  which  a 
~  cyl.,  ax^s  vert.,  before  the  left  eye,  and  -f-  -£-$  cyl., 
axis  45°,  before  the  right,  produced  an  apparent  conver¬ 
gence  of  parallel  lines  toward  the  left  side.  On  November 
3,  1888,  the  Journal  of  the  American  Medical  Association 
contained  an  article  by  Dr.  H.  Culbertson  in  which  he  re¬ 
ferred  to  phenomena  similar  to  that  observed  by  Dr.  Wads¬ 
worth.  In  March,  1889,  I  published  in  the  Archives  of 
Ophthalmology  an  article  on  The  Binocular  Metamorphop- 
sia  produced  by  Correcting  Glasses,  in  which  I  gave  the 
results  of  a  large  number  of  observations  and  experiments. 
These  results,  or  rather  those  of  them  that  have  a  bearing 
on  the  purpose  of  the  present  paper,  may  be  briefly  restated 
as  follows : 

1.  A  -f-  spherical  placed  before  one  eye  makes  the  cor¬ 
responding  side  of  a  rectangle  appear  higher  than  the  other 
side. 

2.  A  spherical  makes  the  corresponding  side  appear 
lower. 

3.  A  +  cyl.,  vertical,  increases ,  whereas  a  -j-  cyl.,  hori¬ 
zontal,  lessens  the  apparent  height  of  the  corresponding  side. 

4-  A  —  cyl.,  vertical,  lessens,  whereas  a  —  cyl.,  hori¬ 
zontal,  increases  the  apparent  height  of  the  corresponding 
side. 


*  Trans,  of  the  Amer.  Ophthal.  Soc.  for  1882,  p.  400. 
f  Ophthalmic  Science  and  Practice,  Philadelphia,  p.  227. 

X  Snellen’s  test  is  to  be  considered  as  a  test  rather  for  the  absence 

of  monocular  blindness  than  for  the  presence  of  binocular  single  vis¬ 
ion,  because,  as  ordinarily  applied — viz.,  with  one  eye  covered  with  a 
colored  glass  if  all  the  letters  are  visible,  we  know  that  both  eyes 
see,  but  we  do  not  know  that  they  see  in  unison,  since  the  covered  eve 
may  no  longer  fix.  If,  on  the  contrary,  we  cover  one  eye  with  a  glass 
of  one  and  the  other  eye  with  a  glass  of  the  other  complementary  color, 
and  if  the  word  still  remains  visible,  we  demonstrate  the  presence  not 
only  of  binocular ,  but  of  binocular  single  vision. 

The  test  just  alluded  to,  and  the  various  prismatic  tests,  with  the 
exception  of  the  one  to  be  mentioned  in  a  subsequent  foot-note,  are, 
strictly  speaking,  tests  for  binocular  single,  but  not  for  stereoscopic 
vision,  the  latter  involving  the  element  of  depth  or  estimation  of  dis¬ 
tance,  in  which  the  varying  degree  of  convergence  of  the  optic  axes 
plays  the  leading  role.  The  distinction  may,  however,  be  regarded  as 
theoretical  rather  than  practical. 

#  Trans,  of  the  Amer.  Oph.  Soc.  for  1875,  p.  342. 


Sept.  27,  18900 _ LIPPINCOTT:  NEW  TESTS 

5.  A  -(-  cyl.,  axis  pointing  upward  and  outward,  before 
either  (and  still  more  decidedly  before  each)  eye  makes 
the  top  of  a  rectangle  appear  narrower  than  the  bottom, 
while  if  the  axis  point  upward  and  inward  the  top  appears 

wider. 

6.  —  Cylinders,  axes  upward  and  outward,  increase, 
whereas  those  with  axis  pointing  upward  and  inward  lessen 
the  apparent  relative  width  of  the  top. 

7.  Binocular  vision  is  necessary  for  the  production  of 
optical  metamorphopsia.  Hence  the  lens  must  not  be  so 
strong  as  to  make  the  image  sufficiently  blurred  to  be  in¬ 
capable  of  fusion  with  that  formed  by  the  other  eye,  for  in 
that  case  the  blurred  image  is  suppressed  mentally  and 
monocular  vision  thus  practically  established. 

At  the  last  meeting  of  this  society,  Dr.  Green  *  sug¬ 
gested  the  most  plausible  explanation  yet  given  of  the  ap¬ 
pearances  above  described,  although  this  explanation  seems 
unsatisfactory  in  some  respects. 

The  appearances  can  be  elicited  in  the  case  of  all  per¬ 
sons — emmetropes,  ametropes,  or  anisometropes.  The  only 
sine  qua  non  is  the  possession  of  binocular  single  or  stereo¬ 
scopic  vision.  Such  being  the  case,  it  has  occurred  to  me 
to  employ  the  phenomena  of  optical  metamorphopsy  as 
stereoscopic  tests. j 

In  applying  these  tests,  I  usually  hold  a  +  2  cylinder, 
vertical,  before  one  eye  with  one  hand,  while  with  the 
other  I  hold  up  a  twelve-inch-square  card  at  the  ordinary 
reading  distance,  and  then  ask  which  of  the  two  sides  is  the 
higher.  The  answer  is  generally  pretty  prompt  and  decided. 
I  then  quickly  put  the  card  to  one  side,  turn  the  axis  of  the 
cylinder  to  the  horizontal,  and  again  hold  up  the  card. 
The  side,  which  in  the  first  instance  appeared  higher,  now 
appears  lower  than  the  other.  If  I  wish  to  confirm  the  re¬ 
sults  obtained  with  the  -j-  cylinder,  I  employ  a  —  2  cylin¬ 
der,  first  with  the  axis  vertical,  making  the  corresponding 
side  appear  lower,  and  then  with  the  axis  horizontal,  pro¬ 
ducing  the  contrary  effect.  If  I  wish  to  make  assurance 
doubly  sure,  I  make  the  top  of  the  card  appear  wider  or 
narrower  than  the  bottom  by  holding  either  one  or  two 
cylinders  with  axis  oblique  before  the  eyes,  etc. 

The  advantages  which  may  be  claimed  for  these  tests 
are  their  variety  and  their  simplicity.  They  are  stereo¬ 
scopic  tests  with  the  stereoscope  left  out.  The  unsuspect¬ 
ing  patient  may  in  the  space  of  a  few  minutes  be  examined 
and  cross-examined  again  and  again  with  no  more  extensive 
apparatus  than  a  rectangular  card  or  book  and  two  or  three 
lenses  from  an  ordinary  trial  case. 

Besides  enabling  the  examiner  to  dispense  with  the 
stereoscope  and  its  attendant  paraphernalia,  a  signal  advan¬ 
tage  is  that  we  have  the  patient  more  completely  under  con¬ 
trol.  We  can  better  observe  him  than  if  his  eyes  are  hid¬ 
den  behind  the  eye-pieces  of  the  stereoscope,  and  can  thus 
effectually  guard  against  any  experiments  which  he  may,  it 
of  an  investigating  turn  of  mind,  desire  to  try  as  to  the  ef- 

*  Tram,  of  the  Amer.  Ophth.  Soc.  for  1 889. 

f  The  apparent  concavity  ( Kriimmung )  and  convexity  ( W dibung) 
produced  in  a  plane  surface  by  prisms,  bases  out  or  in,  explained  by 
Nagel  in  Graefe  u.  Saemisch’s  Handbuch ,  Bd.  vi,  S.  366,  answer  the 

same  purpose. 


FOR  BINOCULAR  VISION. _ 351 

feet  of  closing  one  eye.  Besides,  the  changes  can  be  rung 
with  such  rapidity  as  to  confuse  the  most  accomplished 
malingerer  if  he  actually  possesses  binocular  single  vision. 

I  think  it  important  on  practical  as  well  as  on  theoreti¬ 
cal  grounds  to  have  a  test  for  stereoscopic  vision  which 
can  be  quickly  and  easily  applied.  In  refraction  work,  for 
example,  we  are  sometimes  in  doubt  as  to  the  propriety  or 
necessity  of  correcting  both  eyes,  owing  to  the  patient’s  in¬ 
ability  to  decide  whether  or  not  he  sees  better  with  both 
eyes  than  with  one.  In  such  cases  we  may  be  aided  by  know¬ 
ing  whether  the  stereoscopic  faculty  is  present.  To  illus¬ 
trate  : 

Case  I. — E.  P.  A.  has  S.  R.  E.  =  8/CO. ;  L.  E.,  do.  R.  E.  — 
13-4  o.,  20°,  S.  =  20/Lx;  L.  E.  -  12  -  4  c.,  165°,  S.  = 
20  /  Lx.  Reads  best  with  R.  E.  —  7  —  3*5  c.,  20°  ;  L.  E.  —  7  — 
3-5  c.,  165° ;  P.  D.  .62  mm.  With  these  glasses  a  vertical  prism 
develops  at  twenty  feet  distance  esophoria  =  prism  5,  and  at 
reading  distance  exophoria  =  prism  6.  In  near  fixation  each 
eye,  on  being  covered,  swings  out  about  two  mm.  With  both 
eyes  corrected  for  reading,  patient  can  not  positively  state 
whether  or  not  the  two  eyes  are  better  than  one.  Sometimes 
they  seem  better  and  sometimes  not.  The  metamorph optic  test 
shows  that  stereoscopic  vision  is  possible,  though  not  constant. 
Hence  I  corrected  both  eyes  in  the  expectation  that  the  binocu¬ 
lar  impulse,  although  now  feeble,  may  in  time  be  developed  and 
strengthened. 

Case  II. — Dr.  A.  M.  N.,  aged  fifty-eight :  S.  R.  E.  =  20  /  C  +  • 
With  +1-25  +  1  c.,  110°,  S.  =  20/ xx  — ;  L.  E.  emm.  S.  = 
20  /xx.  Reads  best  R.  E.  +  4.  +  1  c.,  110°  ;  L.  E.  +  3.  Thus 
fitted,  patient  could  not  say  whether  or  not  the  right  eye  helped 
vision.  But  metamorphopsia  was  present,  and  therefore  I  cor¬ 
rected  both  eyes. 

Of  course  I  do  not  mean  to  say  that  the  possession  of 
stereoscopic  vision  always  makes  it  desirable  to  correct 
both  eyes,  because  every  one  knows  that  there  are  cases  of 
anisometropia  which,  although  showing  undoubted  stereo¬ 
scopic  vision  (and  indeed  because  of  it),  will  tolerate  the 
correction  of  only  one  eye.  On  the  other  hand,  the  absence 
of  stereoscopic  vision  is  not  an  infallible  indication  for  cor¬ 
recting  only  one  eye,  because  we,  in  rare  instances,  find 
persons  who  use  one  eye  for  remote  and  the  other  for  near 
vision. 

On  one  occasion  the  stereoscopic  test  led  me  to  discover 
a  condition  which  I  had  previously  overlooked. 

Case  III.— Miss  O.  L.  F.,  aged  fifty-five :  R.  E.  (operated 
upon  for  cataract,  October,  1887)  +  11  +  2  c.,  hor.,  S.  = 
20  /  xx  —  ;  L.  E.  (operated  upon  October,  1888)  +  12,  S.  = 
20  /  xxx.  At  the  time  I  was  making  some  experiments  with  re¬ 
gard  to  metamorphopsia  in  aphakial  eyes,  and  I  found  that  in 
this  case  metamorphoptic  phenomena  could  not  be  elicited.  On 
seeking  the  cause,  there  was  discovered  a  slight  deviation  up¬ 
ward  of  left  eye  =  prism  4.  On  adding  to  her  reading  glat-ses 
the  appropriate  vertical  prism,  stereoscopic  vision  was  promptly 
established,  and  reading  was  now  better  accomplished  with  both 
eyes  than  with  one. 

Not  long  ago  I  was  asked  by  a  man  who  had  been  oper¬ 
ated  upon  for  cataract,  whether  he  could  go  back  to  his 
trade  of  bottle-maker.  His  vision  is  unusually  good.  R.  E. 
+  6-5  +  -75  c.,  62°,  S.  =  20/  xx  +  ;  L.  E.  +  6-5  +  1’5  c., 
172°,  S.  =  20  /  xii.  Before  answering  his  question,  know¬ 
ing  how  important  it  would  be  for  him  to  estimate  distance 


352 


CHAPIN :  UTERUS  BILOCULARIS  UNICOLLIS. 


[N.  Y.  Med.  Joub., 


correctly,  his  stereoscopic  vision  was  tested  and  found  per¬ 
fect.  I  unhesitatingly  assured  him  that  he  would  have  no 
difficulty.  He  has  since  told  me  that  he  can  now  work 
better  than  ever.  This  is  doubtless  owin<r  to  the  fact  that, 
before  the  cataracts  developed,  he  must  have  been  myopic, 
as  may  be  inferred  from  the  comparatively  weak  glass  now 
required  to  overcome  his  aphakia. 

In  conclusion,  it  may  be  said  that  the  tests  here  sug¬ 
gested  furnish  a  convenient  means  of  investigating  certain 
theoretical  questions,  such  as  the  comparative  frequency  of 
stereoscopic  vision  in  general,  and  especially  in  anisome¬ 
tropia,  in  monocular  amblyopia,*  after  the  correction  of 
strabismus,  etc.  But  a  discussion  of  these  points  is  beyond 
the  purpose  of  the  present  paper. 


A  CASE  OF 

UTERUS  BILOCULARIS  UNICOLLIS. 

By  WARREN  B.  CHAPIN,  A.  M.,  M.  D. 

So  many  cases  of  uterine  anomalies  are  now  on  record 
that  we  are  enabled  to  classify  the  different  forms  of  mal¬ 
formation,  and  have  ceased  to  regard  them  as  anything  out 
of  the  common.  The  diagnosis  of  the  existence  of  such 
malformations  and  their  exact  form  is  difficult,  owing  to  the 
concealed  location  of  the  organ  and  the  relative  absence  of 
distinguishing  symptoms,  and  the  occurrence  of  these  mal¬ 
formations  would  seem  of  much  greater  frequency  than  the 
recorded  cases  show.  I  am  induced  to  report  the  following 
case,  evidently  that  of  uterus  bilocularis,  chiefly  on  account 
of  the  peculiarity  of  .the  dividing  septum,  which  differs  in 
form  from  that  usually  found  in  the  bilocular  uterus. 


On  July  14th  Mrs.  S.,  aged  twenty-four  years,  primipara, 
four  months  pregnant,  was  seized  with  labor  pains.  On  exam¬ 
ination,  the  os  was  found  slightly  dilated,  and  nothing  abnormal 

in  appearance  of  the 
cervix  for  that  period 
of  pregnancy.  Em¬ 
ployed  the  usual  treat¬ 
ment  for  abortion, 
and  several  days  la¬ 
ter,  the  secundines 
not  having  been  ex¬ 
pelled,  proceeded  to 
empty  the  uterus.  On 
vaginal  examination, 
found  the  os  well  di¬ 
lated,  but  the  uterus 
was  apparently  emp¬ 
ty.  On  again  intro¬ 
ducing  my  finger  into 
the  uterus,  found  a 
second  cavity  which 
contained  the  pla¬ 
centa,  and  which  was 
separated  by  a  wedge- 
shaped  septum  from  the  cavity  into  which  my  finger  had  first 
been  introduced.  The  course  of  the  abortion  presented  no  un¬ 
usual  features,  excepting  that  scarcely  any  blood  was  lost.  The 


*  Better  expressed  by  “  anisopia,”  suggested  by  Dr.  Ryder  to  im¬ 
ply  inequality  of  visual  acuity  in  the  two  eyes. 


fact  that  the  examining  finger  was  first  introduced  into  the 
empty  cavity  shows  how  easily  a  mistake  in  diagnosis  could 
have  been  made,  and,  owing  to  the  retained  secundines,  septic 
symptoms  set  up.  As  may  be  seen  in  Fig.  1,  the  dividing  sep¬ 
tum  is  wedge-shaped,  having  its  base  at  the  fundus  uteri  and  its 
apex  ending  crescentically  at  the  internal  os,  instead  of  being 
about  the  same  gen¬ 
eral  thickness  from 
fundus  to  termina¬ 
tion,  as  is  usual  iu 
the  uterus  bilocularis. 

The  gravid  cavity  was 
of  about  double  the 
size  of  the  other,  with 
thinner  uterine  walls, 
and  it  had  evidently 
pushed  the  septum 
over  against  the  un¬ 
impregnated  cavity  as 
it  increased  in  size. 

The  cervical  canal  is 
common  to  both  cavi¬ 
ties.  Fig.  2  shows 
the  probable  position 
of  the  septum  be¬ 
fore  conception  took  Fig.  2. 

place,  it  having  as¬ 
sumed  nearly  that  position  since  the  uterus  was  emptied.  The 
dotted  lines  in  Fig.  2  show  the  shape  of  the  septum  as  usually 
found  in  the  bilocular  uterus. 

In  consequence  of  the  wedge-shaped  septum,  the  wide-spread 
separation  of  the  cavities  and  their  lateral  direction  would  lead 
to  the  diagnosis  of  uterus  bicornis;  but,  on  bimanual  examina¬ 
tion,  the  uterus  was  found  to  consist  of  a  single  body,  which 
was  somewhat  larger  than  is  usual  at  the  fourth  month  of  preg¬ 
nancy.  There  was  no  separation  at  the  fundus,  and  the  con¬ 
vexity  of  the  uterus  was  normal  in  shape,  with  the  exception  of 
an  enlargement  on  one  side,  due  to  its  gravid  state. 

Since  writing  the  foregoing,  I  have  delivered  the  patient  of 
a  six  months’  foetus,  which  occupied  the  cavity  I  had  supposed 
to  be  unimpregnated. 

On  August  12th,  twenty-nine  days  after  delivery  of  the  first 
foetus,  the  patient  complained  of  severe  pains  in  the  abdomen 
and  back.  Her  abdomen,  which  was  nearly  flat  when  I  last  saw 
her  two  weeks  before,  now  had  the  appearance  of  the  sixth  or 
seventh  month  of  pregnancy.  She  said  it  had  suddenly  grown 
large  about  a  week  after  I  last  saw  her. 

I  found  the  os  well  dilated,  and  a  foetal  head  presenting  from 
the  right  cavity,  the  one  I  had  supposed  to  be  unimpregnated. 
The  left  cavity  was  dilated  sufficient  to  admit  my  two  fingers. 
A  few  hours  later  she  gave  birth  to  a  small  six  months’  foetus, 
which  was  still  contained  within  the  unruptured  amniotic  sac, 
and  surrounded  by  the  placenta. 

Subsequent  examination  of  the  uterus  confirmed  my  diagno¬ 
sis  of  a  bilocular  uterus  with  a  wedge-shaped  septum.  At  the 
first  examination  I  was  led  to  believe  that  the  right  cavity  was 
unimpregnated,  from  the  fact  that  my  finger  entered  it  for  at 
least  two  inches  without  encountering  a  foreign  body. 

114  West  One  Hundred  and  Fourth  Street. 


Rush  Medical  College. — The  chair  of  medical  practice  in  the  Rush 
Medical  College,  Chicago,  made  vacant  by  the  death  of  Professor  J. 
Adams  Allen,  is  said  to  have  been  offered  to  Dr.  Henry  M.  Lyman, 
formerly  professor  of  chemistry  and  of  diseases  of  the  nervous  system 
id  the  same  institution.  Dr.  Harold  N.  Moyer  has  been  elected  to  the 
professorship  of  physiology. 


LEADING  ARTICLES. 


353 


Sept.  27,  1890.] 


THE 


NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 


Published  by 
D.  Appleton  &  Co. 


Edited  by 
Frank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  SEPTEMBER  27,  1890. 


ERRORS  IN  THE  DIAGNOSIS  OF  INFECTIOUS  DISEASES. 

In  many  cities  there  exists  to  a  greater  or  less  extent  a  feel¬ 
ing  of  jealousy  between  the  medical  officers  of  hospitals  and  those 
whose  practice  lies  among  the  class  of  people  who  frequent  such 
institutions.  A  great  deal  of  this  feeling  arises  out  of  differ¬ 
ences  of  opinion  as  to  the  diagnosis  of  infectious  disease.  For 
instance,  a  child  has  a  sore  throat,  the  physician  called  in  has 
to  make  a  rapid  diagnosis  on  very  doubtful  symptoms,  for  he 
must  protect  the  other  children,  and  to  wait  until  he  is  quite 
sure  about  the  throat  means  that  he  is  to  wait  until  diphtheria 
has  time  to  fasten  itself  upon  the  others.  With  much  difficulty 
he  persuades  the  mother  to  take  the  child  to  the  hospital, 
where  a  few  hours  later  she  is  told  that  the  child  has  not  diph¬ 
theria  at  all,  or  that  it  has  scarlet  fever,  the  rash  having  become 
developed  in  the  mean  time.  Possibly  the  hospital  doctor  may 
have  more  experience,  but  as  a  matter  of  fact  he  is  generally 
young,  while  the  outside  man  is  commonly  his  senior,  and  the 
bitterness  of  the  difference  of  opinion  is  intensified.  We  do 
not  mean  to  say  that  in  all  instances  the  hospital  physician  is 
right,  but  it  is  plain  that  he  acts  at  a  great  advantage.  The 
case  is  more  advanced  when  it  reaches  him  and  he  is  not  obliged 
to  act  upon  the  very  spur  of  the  moment.  The  patient  can  be 
put  into  a  general  ward  for  observation  for  a  few  hours  and 
additional  advice  can  be  obtained. 

In  the  Glasgow  Medical  Journal  Dr.  Russell,  the  well-known 
health  officer  of  that  city,  deals  with  the  subject  of  errors  iu 
the  diagnosis  of  the  infectious  diseases.  To  begin  with,  typhus 
and  typhoid  fevers  very  commonly  are  mistaken  the  one  tor  the 
other,  and  both  for  other  diseases.  In  a  localized  outbreak  of 
typhus  cases  of  this  disease  were  found  by  the  health  officers 
to  have  been  diagnosticated,  the  majority  as  “enteric,”  and  the 
initial  case  had  been  treated  as  inflammation  of  the  lungs.  Of 
1,499  consecutive  patients  sent  into  the  Belvidere  Hospital  as 
suffering  from  infectious  disease,  114,  or  7'6  per  cent.,  did  not 
suffer  from  the  particular  affection  for  which  they  had  been 
sent  in,  and  of  those  114,  no  fewer  than  85,  or  5-7  per  cent,  of 
the  whole  number,  had  no  infectious  disease  at  all.  Mistakes 
in  scarlet  fever,  measles,  and  whooping-cough  are  few.  In  only 
three  per  cent,  of  the  scarlet-fever  cases  was  the  diagnosis 
wrong,  and  one  per  cent,  only  of  the  patients  had  no  infectious 
disease.  Errors  were  excessive  in  enteric  and  typhus  fever, 
and  also  iu  diphtheria.  Seventeen  per  cent,  of  the  persons 
sent  in  with  a  diagnosis  of  enteric  fever  had  not  that  disorder, 
and  most  of  them  had  no  infectious  disease  at  all.  Of  the  cer¬ 
tificates  of  diphtheria,  twenty-four  per  cent,  were  wrong  anc 
about  twelve  per  cent,  of  the  patients  had  no  infectious  com¬ 
plaint.  Forty-four,  per  cent,  of  those  said  to  have  typhus  were 


free  from  that  fever,  and  half  of  that  proportion  did  not  re¬ 
quire  hospital  treatment.  Of  the  forty-two  cases  erroneously 
designated  enteric  fever,  fourteen  were  inflammation  of  the 
lungs,  five  simple  diarrhoea,  four  disease  of  the  brain,  five  va¬ 
rious  chronic  affections,  and  four  typhus;  the  remaining  ten 
oatients  were  absolutely  non-febrile.  Of  the  sixteen  oases 
wrongly  certified  as  typhus,  three  were  pneumonia,  one  was 
purpura,  and  one  alcoholism.  Three  patients  had  no  obvious 
disease,  and  eight  suffered  from  typhoid  fever.  When  the  diag¬ 
nosis  of  diphtheria  was  erroneous  half  the  patients  had  scarlet 
fever  and  the  other  half  simple  inflammation  of  the  throat.  In 
fifty-eight  cases  the  cautious  diagnosis  of  “  fever  ”  was  given; 
twenty-four  of  these  turned  out  to  be  typhoid,  nine  typhus,  six 
scarlet  fever,  three  measles,  and  one  whooping-cough.  Of  the 
remaining  fifteen,  lung  inflammations  accounted  for  nine  and 
three  were  non-febrile. 

These  figures  afford  food  for  very  serious  reflection.  The 
protection  of  the  community  from  disease  depends  upon  its 
prompt  recognition,  and  that  can  not  be  effected  unless  those 
intrusted  with  this  public  duty  are  specially  trained  for  the 
purpose.  Dr.  Russell’s  report  has  been  followed  in  Great  Brit¬ 
ain  by  a  cry  for  the  better  instruction  of  students  in  the  diag¬ 
nosis  of  infectious  disease,  and  it  would  be  well  if  in  this 
country  we  turned  our  attention  in  the  same  direction.  It  is 
not  an  exaggeration  to  say  that  ninety-nine  per  cent,  of  those 
who  are  graduated  in  our  colleges  are  devoid  of  any  practical 
knowledge  relating  to  the  recognition  of  infectious  diseases  in 
their  early  stages,  and  it  is  quite  possible  that  a  young  graduate 
might  in  his  first  year’s  work  stumble  upon  an  initial  case  of 
diphtheria,  typhoid  fever,  or  scarlatina,  the  prompt  handling 
of  which  might  save  the  community  all  the  miseries  incident 
on  sickness  and  death  from  that  disease. 


A  SURGEON’S  SERMON  ON  HOSPITALS. 

It  is  not  often  that  we  are  called  upon  to  record  the  fact 
that  one  of  our  profession  has  been  addressing  the  public  di¬ 
rectly.  Appeals  for  aid  toward  our  great  charities  are  gener¬ 
ally  left  for  the  lay  workers  connected  with  such  institutions. 
Hospital  Sunday  services  were  held  in  London  on  the  15th  of 
June,  and  a  large  amount  of  money  was  collected.  No  doubt 
many  eloquent  sermons  were  preached  at  the  hundred  or  more 
churches  at  which  this  special  collection  was  made,  but  we 
venture  to  say  that  the  best  sermon  preached  for  the  hospitals 
came,  not  from  the  pulpit,  but  from  the  platform  at  the  public 
meeting  summoned  by  the  Lord  Mayor  for  the  purpose  of  pio- 
moting  the  welfare  of  the  hospitals  of  London  by  means  of  the 
Metropolitan  Hospital  Sunday  Fund,  and  the  preacher  of  that 
sermon  was  Mr.  Jonathan  Hutchinson,  a  man  who  has  honestly 
earned  the  love  and  respect  of  all  members  of  our  profession. 
In  the  selection  of  Mr.  Hutchinson  the  hospitals  gained  the 
services  of  an  eloquent  and  earnest  pleader,  and  any  one  who 
loves  his  fellow-man  must  be  the  better  for  reading  his  address. 
Mr.  Hutchinson  spoke  of  himself  as  one  who  had  been  a  long 
time  behind  the  scenes,  and  who  knew  much  of  the  workings 


354 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Jour., 


of  not  a  few  hospitals,  and  he  solemnly  declared  his  belief  that 
no  institutions  in  the  world  were  on  the  whole  better  managec 
than  the  hospitals  of  the  British  metropolis.  He  then  dealt 
with  the  various  charges  brought  against  modern  hospitals, 
some  of  which  he  believed  were  to  a  certain  extent  true,  but 
to  an  insignificantly  small  extent,  and  he  showed  how  some 
of  the  charges  neutralized  others.  Thus,  it  was  said  that  out¬ 
patients  were  hurriedly  examined  and  seen  by  deputy,  while 
others  declared  that  the  attractions  of  the  out-patient  depart¬ 
ment  were  so  great  that  people  comparatively  well  to  do  de- 
sei  ted  their  family  advisers,  and  thus  the  medical  profession 
was  defrauded.  But  abuses  such  as  the  last  named  affectec 
chiefly  the  special  hospitals,  and  therefore  the  consultant  suf¬ 
fered  and  not  the  general  practitioner. 

The  definition  of  a  modern  hospital  which  best  pleases  Mr. 
Hutchinson,  and  which  he  likes  to  keep  constantly  in  mind,  is 
that  it  is  an  institution  for  the  prevention  of  orphanage.  Not 
that  all  or  nearly  all  the  maladies  treated  entail  danger  to  life, 
nor  that  all  the  patients  are  parents,  but  a  large  proportion  of 
hospital  practice  does  concern  those  who  have  others  depend¬ 
ent  upon  them,  and  we  may  suitably  recognize  degrees  of  in¬ 
capacity  short  of  actual  death,  for  the  loss  of  a  limb  or  an  eye 
or  a  permanent  impairment  in  health  may  easily  entail  on  a 
man’s  family  calamities  little  short  of  what  would  have  fol¬ 
lowed  his  death.  Such  a  definition  helps  us  to  some  adequate 
conception  of  the  real  value  of  such  institutions  and  places 
medical  charity  in  the  position  which  it  really  ought  to  occupy 
—that  of  the  foremost  of  all  forms  of  beneficence.  Hospitals 
are  the  schools  in  which  medical  science  is  cultivated  and  from 
which  those  go  forth  who  spread  its  benefits  all  over  the  world. 
Within  1  ecent  years  some  diseases  have  been  nearly  extermi¬ 
nated,  the  ratio  of  mortality  from  nearly  all  has  been  greatly 
diminished,  and  the  average  duration  of  human  life  has  been 
definitely  increased.  We  are  at  war  with  death,  not  the  divine 
ordinance  of  death,  which  we  accept  thankfully  as  one  which 
favors  the  progress  of  our  race,  but  with  death  in  its  premature 
and  irregular  forms.  We  wish  to  prevent  and  remedy  the  dis¬ 
abilities  of  life,  the  disqualifications  for  usefulness  in  its  duties 
and  enjoyment  of  its  happiness.  We  wish  to  prevent  orphan¬ 
hood  in  all  forms  and  degrees. 

Some  persons  think  that  it  would  be  better  if  hospitals  were 
supported  by  the  state,  but  with  them  the  speaker  did  not 
agree.  Free  giving  was  an  education  involving  self-educa¬ 
tion.  The  act  of  giving  might  become  by  custom  the  source  of 
one  of  the  highest  forms  of  pleasure  of  which  our  natures  were 
capable ;  and  no  such  gratification  attended  the  payment  of  a 
tax  or  rate.  If,  however,  we  rejected  a  state-imposed  tax,  Mr 
Hutchinson  proposed  a  self-imposed  tax  on  health  in  its  place! 
Those  who  had  to  bear  the  sufferings  of  illness  should  not  be 
made  to  pay  for  it.  As  we  valued  the  possession  of  sound 
lungs,  of  strong  limbs,  of  unimpaired  eyesight,  of  a  face  and 
figure  which,  free  from  deformity  and  defect,  permitted  of  our 
mixing  with  our  fellows  with  mutual  pleasure,  so  let  us  meas¬ 
ure  the  contributions  which  we  made  for  the  help  of  those  to 
whom  one  or  other  of  these  blessings  was  denied.  The  heart’s 


sympathies  depended  almost  wholly  upon  our  power  of  realiz¬ 
ing  what  suffering  really  was.  An  unimaginative  person  could 
not,  for  example,  realize  what  it  was  to  be  blind.  He  could 
walk  and  run,  and  he  never  troubled  himself  to  imagine  what 
it  was  to  be  lame.  The  imaginative  faculty  was,  then,  the 
highest  of  all  human  endowments,  since  it  was  at  the  bottom  of 
all  generous  emotions.  Let  any  one  who  was  conscious  of  lack 
of  sympathy  with  the  afflicted  go  for  a  week  to  his  usual  city 
vocations  with  a  black  patch  covering  one  eye;  let  him  wear 
for  one  day  a  wooden  leg,  a  truss,  or  a  spinal  apparatus,  and 
he  would  find  his  fellow  feelings  for  those  in  need  of  such  ap¬ 
pliances  vastly  increased.  Let  him  choose  some  leisure  day  in 
the  country  in  bright  spring  and  resolutely  for  twenty-four 
hours  keep  a  bandage  placed  over  both  eyes.  His  would  be  a 
hopeless  case  if  the  next  morning  he  did  not  send  a  contribu¬ 
tion  to  the  hospital.  The  speaker  concluded  his  address  with 
an  earnest  appeal  to  the  young  men  and  maidens  who,  in  pos¬ 
session  of  vigor  and  beauty,  regarded  the  future  of  life  with 
unclouded  hope,  to  those  in  middle  age  who  were  enabled  to 
rejoice  in  their  own  or  their  children’s  health,  and  to  those 
who,  although  now  old,  could  look  back  with  thankfulness  on 
the  events  of  life. 


MINOR  PARAGRAPHS. 

THE  PROFESSIONAL  MARK  OF  BAKERS. 

Dr.  G.  Ranzier,  in  a  paper  in  the  Gazette  hebdomudaire  des 
sciences  medicates  de  Montpellier ,  describes  a  professional  mark 
that  is  nearly  always  present  in  Montpellier  bakers,  and  that 
possesses  a  medico-legal  interest.  His  attention  was  first  called 
to  it  by  a  typhoid-fever  patient,  a  baker,  who  had  on  the  dorsal 
surface  of  the  articulation  of  the  first  and  second  phalanges  of 
each  finger  a  large,  round  callosity  covering  the  width  of  the 
finger.  It  was  a  hardening  of  the  epidermis  without  participa¬ 
tion  of  the  deeper  structures,  and  almost  disappeared  during 
the  two  months’  treatment  of  the  case.  When  questioned  re¬ 
garding  the  callosities,  colloquially  known  as  bastets  or  coussi- 
nets,  the  boy  stated  that  bakers  always  had  them.  This  state¬ 
ment  was  subsequently  verified.  The  repeated  shock  of  the 
flexed  fingers  against  the  dough  in  kneading  produces  the  cal¬ 
losities.  Where  the  kneading  is  done  mechanically,  of  course, 
such  stigmata  will  not  be  found.  The  author  states  that  neither 
Tardieu,  Max,  nor  Vernois,  in  their  publications  on  the  profes¬ 
sional  stigmata,  refers  to  this  mark  of  the  baker  that  may  be 
of  medico-legal  value. 


MR.  HUTCHINSON’S  TREATMENT  OF  RINGWORM. 

Mr.  Jonathan  Hutchinson  gives,  in  his  Archives  of  Surgery, 
the  prescription  upon  which  he  has  “settled  down  in  tolerable 
content”  for  the  treatment  of  ringworm,  after  having  tried  a 
great  variety  of  remedies  without  equal  satisfaction.  He  relies 
chiefly  on  chrysophanic  acid.  He  orders  as  a  wash  for  the 
scalp  one  drachm  of  Wright’s  liquor  carbonis  detergens  to  the 
lint  of  hot  water.  Twice  a  week  the  scalp  should  be  well 
washed  with  this,  and  all  scales  and  crusts  should  be  removed. 
The  hair  is  cut  close  or  shaved.  The  chrysophanic-acid  oint¬ 
ment  contains  a  drachm  of  chrysophanic  acid,  twenty  grains  of 
ammoniated  mercury,  a  drachm  of  lanoline,  six  drachms  of 
jenzoated  lard,  and  ten  minims  of  liquor  carbonis  detergens. 
This  ointment  is  to  be  rubbed  in  more  or  less  freely,  according 
;o  its  effects,  night  and  morning,  or  latterly  every  night  only* 


MINOR  PA  RAO  RAPHS.— ITEMS. 


355 


Sept.  27,  1890.] 

The  care  will  be  slow  probably,  aiul  the  secret  of  success  con¬ 
sists  in  the  patient  continuance  of  the  same  remedy.  To  those 
who  persevere  he  promises  recovery;  it  is  Only  the  impatient 
who  are  disappointed.  lie  has  no  faith  in  the  rapid  cure  of 

ringworm. 

THE  STATE  MEDICAL  SOCIETY  OF  ARKANSAS. 

Acting  in  accordance  with  the  advice  given  by  a  recent 
president,  Dr.  Orto,  the  society  has  established  a  monthly  jour¬ 
nal.  The  first  number  is  dated  July,  1890,  and  contains,  among 
other  matter,  Dr.  Orto’s  presidential  address,  a  number  of 
papers  read  at  the  fifteenth  annual  meeting,  and  the  minutes  of 
the  meeting.  The  journal  is  edited  by  Dr.  Lorenzo  P.  Gibson, 
of  Little  Rock,  under  the  supervision  of  a  board  of  trustees  con¬ 
sisting  of  Dr.  P.  O.  Hooper,  Dr.  J.  H.  Southall,  Dr.  J.  A.  Dib- 
rell,  Dr.  Zaphney  Orto,  and  Dr.  W.  B.  Lawrence.  It  presents 
a  creditable  appearance,  and  will  doubtless  aid  materially  in 
furthering  the  society’s  work. 


THE  FRENCH  LAW  REGARDING  TWINS. 

According  to  the  Medical  Press  and  Circular ,  a  law  passed 
years  ago  in  France  regards  the  last-born  as  the  eldest  in  the 
case  of  twins.  Consequently,  when  both  of  them  survive  and 
both  are  boys,  on  reaching  manhood  the  second-born  is  required 
to  serve  in  the  army,  for  he  has  been  legally  adjudged  to  be  the 
eldest.  The  reason  for  this  is  said  to  be  that  by  some  extraor¬ 
dinary  calculation  the  medical  men  who  were  consulted  at  the 
time  the  law  was  framed  came  to  the  conclusion  that  the  last- 
horn  of  twins  was  always  the  first  conceived. 


THE  MIDWIFERY  DISPENSARY. 

We  have  already  spoken  in  commendation  of  this  institu¬ 
tion,  and  we  are  glad  to  learn  from  its  published  statement, 
dated  July  18th,  that  it  has  afforded  medical  aid  to  a  large  num¬ 
ber  of  applicants,  and  given  instruction  to  thirty-one  students, 
although  it  has  been  in  operation  considerably  less  than  a  year. 
The  dispensary  is  exceedingly  well  managed,  and  we  doubt  not 
that  it  will  continue  to  grow  in  professional  and  public  esteem. 


THE  PARIS  POLICLINIQUE. 

An  institution  entitled  the  Policlinique  de  Paris  has  been 
opened  at  No.  28,  rue  Mazarine,  for  the  purposes  of  furnishing 
medical  aid  to  the  poor  and  of  giving  practical  instruction  to 
medical  students.  From  the  information  given  in  its  journal, 
the  Annales  de  la  Policlinique  de  Paris ,  we  judge  that  it  closely 
resembles  the  post-graduate  teaching  institutions  of  America. 


THE  ASHEVILLE  MEDICAL  REVIEW. 

This  is  the  title  of  a  new  monthly  journal  which  gives  as  its 
reasons  for  existence  the  purpose  of  keeping  the  profession  in¬ 
formed  as  to  the  advantages  of  Asheville  as  a  resort  for  invalids 
and  that  of  supplying  the  requirements  of  western  North  Caro¬ 
lina  and  eastern  Tennessee  for  a  local  medical  journal.  It  con¬ 
tains  the  official  reports  of  the  proceedings  of  the  Buncombe 
County  Medical  Society.  It  is  edited  by  Dr.  Frank  T.  Meri¬ 
wether  and  Dr.  II.  Longstreet  Taylor. 


ITEMS,  ETC. 

The  New  York  State  Preliminary  Examinations. — The  examiners 
delegated  by  the  Board  of  Regents  of  the  University  of  the  State  of 
New  York  to  examine  persons  entering  upon  the  study  of  medicine, 


under  the  new  law,  began  their  work  on  Tuesday  in  New  York,  Brook¬ 
lyn,  Buffalo,  Albany,  and  Syracuse.  The  candidates  were  examined  in 
arithmetic,  geography,  grammar,  English  composition,  United  States 
history,  physics,  and  physiology.  The  following  was  the  examination 
in  geography : 

1.  Define  latitude  and  longitude  and  tell  how  each  is  reckoned.  2. 
Mention  the  grand  divisions  of  the  globe  in  the  order  of  their  impor¬ 
tance,  and  give  a  reason  for  your  answer.  3.  What  is  a  sea,  a  strait,  a 
watershed?  4.  Describe  the  two  principal  forms  of  government.  5. 
Draw  an  outline  map  of  the  United  States  and  locate  upon  it  two  prin¬ 
cipal  mountain  chains  and  the  Mississippi  River  and  three  of  its  princi¬ 
pal  tributaries.  6.  Mention  in  order  the  States  in  which  you  would 
travel,  by  direct  route,  from  Chicago  to  Washington.  7.  Mention  in 
the  order  of  their  size  the  largest  three  cities  of  the  United  States,  as 
determined  by  the  census  of  1890.  8.  Mention  three  cities  in  the  State 
of  New  York  where  law  or  medical  schools  are  located.  9.  Which  of 
the  New  England  States,  if  any,  does  not  engage  largely  in  manufact¬ 
ures?  What  is  its  principal  industry  ?  10.  Mention  in  order  the  cities 
on  the  New  York  Central  Railroad  between  Buffalo  and  Albany.  11. 
What  States  of  Central  America  have  recently  been  at  war?  12.  De¬ 
scribe  the  vegetable  and  mineral  products  of  South  America.  13.  What 
country  of  South  America  recently  changed  its  form  of  government, 
and  what  was  the  change?  14.  Write  the  names  of  the  following 
countries,  and  after  each  give  its  form  of  government  and  capital :  Eng¬ 
land,  Italy,  France,  Germany.  15.  In  what  countries  would  you  travel 
in  going  by  the  shortest  route  from  Madrid  to  St.  Petersburg?  16. 
What  countries  border  on  France?  17.  Give  the  names  of  the  largest 
four  rivers  of  France  and  tell  into  what  each  empties.  18.  Mention 
two  exports  of  the  empire  of  Japan.  19.  Describe  the  Congo  River, 
telling  where  it  rises,  in  what  direction  it  flows,  and  into  what  it  emp¬ 
ties,  and  give  the  name  of  the  explorer  who  first  traced  it  from  its 
source  to  its  mouth. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  September  23,  1890: 


DISEASES. 

Week  ending  Sept.  16. 

Week  ending  Sept.  23. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

57 

13 

39 

13 

Scarlet  fever . 

39 

1 

17 

7 

Cerebro-spinal  meningitis . 

1 

1 

1 

0 

Measles . 

32 

3 

45 

6 

Diphtheria . 

47 

19 

42  . 

17 

The  New  York  Polyclinic. — It  is  announced  that  this  institution 
will  exclude  from  its  matriculates  in  future  all  persons  who  are  not 
graduates  of  regular  medical  colleges  or,  having  attended  one  or  more 
courses  of  lectures  at  such  a  college,  have  a  legal  permit  to  practice. 

The  Chicago  College  of  Physicians  and  Surgeons. — Dr.  James  A. 
Lydston,  late  chief  of  the  eye  and  ear  department  of  the  Pension  Bureau 
at  Washington,  has  been  elected  professor  of  chemistry  in  the  college. 

Changes  of  Address. — Dr.  J.  Conger  Bryan,  to  No.  357  West  Fif¬ 
tieth  Street ;  Dr.  Egbert  H.  Grandin,  to  No.  36  East  Fifty-eighth 
Street. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  September  20,  1890 : 
Olcott,  F.  W.,  Passed  Assistant  Surgeon,  ordered  to  the  U.  S.  Steamer 
Alert. 

Society  Meetings  for  the  Coming  Week  : 

Tuesday,  September  30th :  Boston  Society  of  Medical  Sciences. 
Wednesday,  October  1st:  Society  of  the  Alumni  of  Bellevue  Hospital; 
Harlem  Medical  Association  of  the  City  of  New  York;  Medical  Mi¬ 
croscopical  Society  of  Brooklyn ;  Medical  Society  of  the  County  of 
Richmond  (Stapleton),  N.  Y. ;  Penobscot,  Me.,  County  Medical  So¬ 
ciety  (Bangor) ;  Bridgeport,  Conn.,  Medical  Association ;  Philadel¬ 
phia  County  Medical  Society. 

Thursday,  October  2d:  New  York  Academy  of  Medicine;  Metropolitan 
Medical  Society  (private) ;  Society  of  Physicians  of  the  Village  of 


356 


LETTERS  TO  TEE  EDITOR. 


[N.  Y.  Med.  Jour., 


Canandaigua ;  Boston  Medico-psychological  Association  ;  Obstetrical 
Society  of  Philadelphia ;  United  States  Naval  Medical  Society 
(Washington);  Washington,  Vt.,  County  Medical  Society. 

Friday,  October  3d:  Practitioners’  Society  of  New  York  (private) ; 
Baltimore  Clinical  Society. 

Saturday,  October  ftli:  Clinical  Society  of  the  New  York  Post-gradu¬ 
ate  Medical  School  and  Hospital;  Manhattan  Medical  and  Surgical 
Society  (private);  Miller’s  River,  Mass.,  Medical  Society. 


fellers  to  llje  (Sftttor. 


“  PINK-EYE.” 

New  York,  September  15,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal  : 

Sir:  In  your  issue  of  September  6,  1890,  is  a  letter  relative 
to  pink-eye  over  the  signature  of  John  E.  Weeks,  M.  D. 

Your  correspondent  wishes  to  notice  my  article  which  ap¬ 
peared  in  your  issue  of  June  28,  1890,  in  order  to  correct  what 
he  is  pleased  to  denominate  “some  errors.” 

The  paper  published  in  your  Journal  was  read  before  the 
New  York  County  Medical  Association.  The  aggrieved  gentle¬ 
man  was  present  and  full  opportunity  was  given  him  to  reply 
to  my  criticism  on  his  work.  Before  writing  my  paper,  being 
desirous  of  doing  full  justice,  I  wrote  asking  your  correspond¬ 
ent  for  his  latest  reprint  on  the  subject  of  pink-eye,  and  for 
the  list  of  all  those  observers  who  had  noticed  his  experiments 
in  print. 

I  mad  -this  statement  in  my  paper:  “No  one  has,  as  far  as 
I  am  aware,  repeated  his  (your  correspondent’s)  experiments, 
nor  has  any  one  essayed  to  make  an  analysis  of  the  evidence  he 
has  furnished.” 

In  reply  to  this  your  correspondent  refers  me  to  an  article 
by  Kartulis  in  the  Gtrbl.f.  Bad.  u.  ParasitenJc.,  p.  289,  1887, 
in  which  he  says  I  will  find  a  full  confirmation  of  the  results 
previously  arrived  at  by  him.  I  have  not  by  me  the  letter  in 
which  your  correspondent  kindly  sent  me  the  bibliography  of 
pink-eye,  but  I  am  sure  this  citation  was  not  among  the  others. 
In  the  publication  above  referred  to  I  find  an  article  by  Kartu¬ 
lis,  of  Alexandria,  on  the  ^Etiology  of  Egyptian  Catarrhal  Con¬ 
junctivitis.  Kartulis,  without  giving  in  detail  his  methods, 
simply  states  that  he  found  a  bacillus  in  this  disease,  and  sim¬ 
ply  gives  some  slight  description  of  it.  In  so  far  as  it  is  a  bacil¬ 
lus  and  is  found  in  the  eye  of  catarrhal  conjunctivis,  I  am  will¬ 
ing  to  admit  that  it  bears  some  likeness  to  the  so-called  “bacil¬ 
lus  Weeksii.”  The  other  marks  which  it  possesses  do  not,  in 
my  opinion,  strengthen  the  claims  of  your  correspondent. 
Kartulis  observes :  “It  is  an  important  question  whether  our 
(G-er.,  unsere ,  meaning  his  own)  bacilli  are  identical  with  those 
found  by  Leber,  Kuschbert,  and  Neisser  in  xerosis  of  the  con¬ 
junctiva.” 

He  further  remarks  that  these  observers  discovered  in  this 
affection  micro-organisms  similar  to  those  of  mouse  septicfemia. 

Your  correspondent,  in  his  reprint  from  the  Med.  Record  of 
May  21,  1887,  refers  to  a  bacillus  observed  by  Koch  in  Egypt 
in  cases  of  catarrhal  conjunctivitis,  and  opines  that  it  is  proba¬ 
bly  the  same  that  he  himself  has  described.  Kartulis  refers  to 
this  discovery  of  Koch,  and  says  that  the  bacillus  of  Koch  re¬ 
sembles  that  of  mouse  septicaemia  in  size,  form,  and  situation. 

Your  correspondent  states  that  Dr.  Knapp  showed  him  some 
specimens  of  microbes  obtained  from  the  deposits  about  the 
teeth  in  one  case  and  from  a  corneal  ulcer  in  another  that  in 
form  resembled  the  small  bacillus  which  he  claims  is  the  patho¬ 


genic  microbe  of  pink-eye.  Now,  Kartulis  thinks  it  a  weighty 
question  whether  or  not  the  bacillus  he  describes  is  identical 
with  that  of  xerosis  conjunctivas,  and  he  finds  a  distinct  likeness 
between  Koch’s  conjunctivitis  bacillus  and  that  of  mouse  septi¬ 
caemia.  Your  correspondent  considers  Koch  to  have  described 
the  same  bacillus  that  he  has  seen,  and  likewise  considers  Kar¬ 
tulis  to  have  made  a  “full  confirmation  ”  of  his  (your  corre¬ 
spondent’s)  results.  Absolute  identity  is  a  very  difficult  matter 
to  prove.  I  venture  the  moderate  opinion  that  absolute  iden¬ 
tity  is  not  proved  in  this  case.  One  must  be  forgiven  for  being 
hypercritical  in  matters  of  science. 

Kartulis,  whose  work  was  published  in  February,  1887,  does 
not  refer  to  the  results  of  your  correspondent,  although  his  first 
communication  on  this  subject  was  made  in  the  Archives  of 
Ophthalmology  in  1886.  Foreign  writers  are  great  sticklers  in 
the  matter  of  bibliography,  and  it  is  at  least  surprising  that  so 
important  a  claim  as  your  correspondent  makes  has  been  over¬ 
looked  by  Kartulis.  If  any  one  else  has  made  a  “full  confir¬ 
mation  ”  of  the  claims  of  your  correspondent  I  am  unaware 
of  it. 

Quoting  in  substance  from  the  work  of  your  correspondent, 
I  stated  he  was  unable  to  make  a  pure  culture  of  his  bacillus. 
Referring  to  this  statement  of  mine,  he  says  in  his  letter  to  you : 
“Since  writing  the  articles  referred  to  above  I  have  produced  a 
pure  cultivation  of  the  bacillus,  photographs  of  which  have  been 
made.”  At  the  time  of  reading  my  article  I  was  unaware  of 
the  existence  of  his  pure  culture.  He  might  easily  have  stated 
this  to  me  in  his  letter,  but  he  preferred  to  keep  it  silent  and 
produce  with  a  flourish  in  his  reply  before  the  society  photo¬ 
graphs  which  he  said  showed  pure  cultures  of  his  bacillus. 

I  am  quite  sure  he  had  never  up  to  that  time  stated  publicly 
his  success  in  obtaining  a  pure  culture.  But  these  things  had 
no  bearing  whatsoever  on  the  statements  of  my  paper,  since 
that  was  written  before  he  had  divulged  his  secret  to  the  world. 

That  these  photographs  were  shown  at  the  Tenth  Interna¬ 
tional  Medical  Congress  in  Berlin,  a  thing  to  which  your  corre¬ 
spondent  feelingly  alludes,  I  take  it,  proves  nothing  more  than 
many  other  demonstrations  in  medical  matters  that  have  been 
more  conclusive  to  the  authors  or  demonstrators  than  to  others. 
Your  correspondent  goes  on  to  say  that  the  existence  of  these 
purecultures  was  known  to  me  before  my  article  was  published. 
Now  to  one  who  runs  and  reads  this  statement  might  easily  be 
deceptive.  As  before  stated,  the  first  intimation  I  had  of  bis 
purecultures  was  that  which  I  obtained  when  in  his  reply  to 
my  criticism  he  produced  his  photographs  before  the  society. 
My  paper  was  handed  in  to  your  Journal  as  it  was  read  before 
the  society,  and  I  take  it,  it  neither  behooved  me  nor  was  it 
necessary  for  me  to  make  any  corrections  or  after-statements. 
His  reply  to  me  was  given  full  justice  in  the  report  of  the  pro¬ 
ceedings  by  the  Medical  Record ,  and  it  is  my  particular  desire 
to  call  the  attention  of  your  readers  to  a  clear  statement  of  this 
point.  It  seems  to  me  it  became  your  correspondent  to  make 
this  plain  beyond  peradventure. 

\  our  correspondent  quotes  the  following  from  my  article: 
“The  small  bacillus  (together  with  the  clubbed  bacillus)  was 
found  in  the  secretion  in  every  case.” 

He  writes  in  reply  :  “  There  is  no  authority  whatever  in  my 
article  for  the  clause  included  in  parenthesis  in  this  quotation.” 

On  page  13  of  this  reprint  from  the  Medical  Record ,  May  21, 
1887,  he  writes:  “Having  found  a  medium  on  which  the  bacil¬ 
lus  would  develop,  although  feebly,  my  next  endeavor  was  to 
make  a  pure  culture."  (Italics  your  correspondent’s.)  “The 
bacillus  in  the  tubes  was  contaminated  with  a  club-shaped  [ba¬ 
cillus?]  (or  one  that  soon  became  clubbed)  which  developed 
about  as  rapidly  as  the  small  bacillus,  and  repeated  endeavors 
to  separate  the  two  proved  fruitless.'1'1  (Italics  my  own.)  Fur- 


Sept.  27,  1890.] 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES.  357 


ther  on  he  states  that  he  was  unable  to  separate  the  two,  even 
though  they  were  carried  to  the  sixteenth  generation. 

Your  correspondent  refers  to  his  test  tubes,  but,  as  these 
were  inoculated  originally  from  cases,  the  statement  by  infer¬ 
ence  holds  equally  good  for  them. 

I  admit  freely  that  the  “clause  included  in  parenthesis” 
does  not  occur  in  his  original,  but  its  equivalent  does,  and  that 
man  must  be  narrow,  hypercritical,  and  unreasonable  who  de¬ 
mands  that  a  thing  should  always  be  said  in  the  same  language. 

It  is  clear  to  my  mind  that  there  is  authority  for  the  “  clause 
included  in  parenthesis,”  the  statement  of  your  correspondent 

to  the  contrary  notwithstanding. 

John  Herbert  Claiborne,  M.  D. 


PRELIMINARY  CAPSULOTOMY  IN  THE  EXTRACTION  OF 

CATARACT. 

Syracuse,  N.  Y. 

To  the  Editor  of  the  New  YorTc  Medical  Journal : 

Sir:  In  your  issue  of  September  20th  Dr.  T.  J.  Tyner’s  in¬ 
teresting  communication  upon  the  subject  of  Preliminary  Cap- 
sulotomy  in  the  Extraction  of  Cataract  contains  the  statement 
that  he  has  been  unable  to  find  a  precedent  for  the  operation 
described.  The  same  procedure,  however,  was  described  by 
Drake-Brockman  in  1884  and  possibly  earlier ;  and  by  Hiemel, 
of  Leipsic,  in  1888.  Drake-Brockman  gives  a  complete  statis¬ 
tical  report  of  his  cataract  cases  in  the  Ophthalmic  Review 
(August,  1884,  and  November,  1888).  He  had,  up  to  the  date 
of  his  last  communication,  operated  by  this  method  two  thou¬ 
sand  one  hundred  and  seven  times. 

The  method  is  described  under  the  name  of  “  primary  cap¬ 
sule  rupture,”  a  term  which  seems  preferable  to  that  of  “  pre¬ 
liminary  capsulotomy,”  as  the  latter  suggests  an  interval  of  time 
between  capsulotomy  and  the  extraction  of  the  lens  (as  in  pre¬ 
liminary  iridectomy). 

Hiemel’s  paper  was  read  before  the  International  Congress 
of  Ophthalmology  held  at  Heidelberg  in  1888,  and  reference  to 
it  will  be  found  in  the  American  Journal  of  Ophthalmology  for 

that  year. 

I  was  more  particularly  interested  in  Dr.  Tyner  s  communi¬ 
cation  because  three  years  or  so  ago  the  same  idea  occurred  to 
myself,  and  I  thought  it  original  until  shortly  afterward  I  read 
the  record  of  Drake-Brockman’s  immense  experience  in  cataract 
operations.  If  one  may  judge  from  the  brief  notice  of  Iliemel  s 
paper,  it  seems  possible  that  he  also  was  under  the  impression 
that  his  procedure  was  a  new  one.  Of  the  value  ot  the  proced¬ 
ure  Drake-Brockman’s  experience  seems  to  leave  no  doubt. 

F.  W.  Marlow,  M.  D. 


IJrotettrxntgs  oi  Societies. 


CANADIAN  MEDICAL  ASSOCIATION. 

Twenty-third  Annual  Meeting ,  held  at  Toronto ,  September  9, 

10,  and  11,  1890. 

The  President’s  Address. — Dr.  I.  Ross,  the  retiring  presi¬ 
dent,  in  his  opening  address,  gave  a  resume  of  the  year’s  prog¬ 
ress  in  medicine.  He  spoke  of  the  success  of  the  meeting  of 
last  year,  which  was  held  at  Banff  Springs,  in  the  Rocky  Mount¬ 
ains.  The  desirability  of  the  establishment  of  a  system  of  regis¬ 
tration  of  medical  degrees,  uniform  for  the  whole  Dominion, 
was  pointed  out.  At  present,  as  the  law  now  stood,  a  practi¬ 
tioner  must  take  out  a  license  to  practice  for  each  province. 


The  system  of  contract  work  and  supplying  medical  attendance 
to  benefit  societies  at  low  rates  of  remuneration  was  con¬ 
demned. 

The  Address  in  Medicine  was  given  by  Dr.  Prevost,  of 
Ottawa,  who  chose  as  his  text  the  advances  made  in  medicine 
recently  by  the  aid  of  bacteriological  research,  alluding  to  the 
work  of  Pasteur  and  Koch.  But  first  he  dealt  with  the  recent 
increase  of  our  knowledge  of  nervous  diseases  and  the  improve¬ 
ments  evident  in  the  treatment  of  such  diseases  as  hysteria  and 
insanity.  This  paper  was  received  with  great  interest,  not  only 
from  its  excellent  character,  but  from  the  fact  that  the  speaker, 
a  Frenchman  by  birth  and  education,  chose  to  use  English  in 
his  address  out  of  compliment  to  the  nationality  of  the  large 
majority  of  his  hearers. 

The  Address  in  Surgery  was  intrusted  to  Dr.  Chown,  of 
Winnipeg,  who,  after  some  general  remarks  on  the  progress  of 
surgery,  approached  the  special  subject  he  had  .chosen,  the 
pathology  and  treatment  of  hydatid  disease.  In  the  Province 
of  Manitoba  there  were  very  many  Icelandic  immigrants,  among 
whom  hydatid  disease  was  very  common.  The  speaker  then 
narrated  the  history  of  a  case  of  hydatids  affecting  the  abdomi¬ 
nal  cavity  and  several  of  the  organs.  The  abdomen  was  opened 
and  the  cyst  removed.  The  address  was  illustrated  with  the 
exhibition  of  numerous  preparations  of  cystic  parasites. 

The  Address  in  Obstetrics  was  given  by  Dr.  J.  Chalmers 
Camefon,  of  Montreal,  who  selected  the  subject  ot  Temperature 
in  the  Puerperal  Period.  It  was  necessary,  he  said,  to  have 
clear  ideas  respecting  the  normal  and  physiological  before  we 
could  understand  the  abnormal  and  pathological.  After  de¬ 
scribing  fully  the  course  of  the  temperature  and  pulse  during 
the  latter  months  of  gestation,  labor,  and  the  puerperium,  he 
drew  the  following  conclusions:  1.  The  temperature  of  a  healthy 
pregnant  woman  during  the  last  four  months  is  the  same  as  in 
the  healthy  non-pregnant  state.  2.  Labor  raises  the  tempera¬ 
ture.  The  amount  of  rise  depends  upon  the  length  and  severity 
of  labor,  particularly  of  the  second  stage.  It  is  higher  in  primi- 
parae  than  in  multiparse,  higher  after  irregular  than  after  regu¬ 
lar  labors.  8.  In  the  first  twenty-four  hours  after  labor  the 
temperature  rises  and  then  falls,  the  height  it  attains  depending 
chiefly  upon  the  time  of  day  when  labor  terminates.  The  rise 
is  greatest  in  labors  terminating  during  the  day,  least  in  labors 
terminating  during  the  night.  4.  From  the  second  to  the  eighth 
day  the  average  daily  temperature  varies  less  than  half  a  de¬ 
gree  from  day  to  day  ;  but  there  is  a  diurnal  variation  of  one 
degree  to  one  degree  and  a  half  between  the  maximum  and 
minimum  of  each  day.  The  maximum  daily  temperature  is  usu¬ 
ally  at  10  a.m.;  the  minimum  at  midnight;  the  average  at 
6  a.  m.  and  8  p.  m.  The  daily  observations  should  be  made  at 
these  latter  hours.  5.  The  pulse  falls  steadily  from  the  conclu¬ 
sion  of  labor  to  the  end  of  the  first  week  from  61  to  50.  The 
fall  is  equally  marked  in  primiparae  and  in  multiparse.  There 
is  a  difference  of  17  between  the  maximum  and  minimum  of 
each  day.  It  is  slowest  at  midnight,  quickest  at  8  a.  m.  6.  In 
hospital  practice  the  best  results  show  a  normal  temperature 
curve  in  about  seventy  per  cent,  of  the  cases.  In  private  prac¬ 
tice  the  ratio  should  be  at  least  eighty  per  cent. 

After  showing  the  fallacy  of  popular  notions  respecting  so- 
called  milk-fever  and  ephemeral  fever,  it  was  contended  that  a 
rational  treatment  could  only  be  attained  when  the  profession 
grasped  the  fundamental  fact  that  the  normal  temperature  curve 
during  the  puerperium  differed  little  from  that  of  health,  that 
lactation  was  a  physiological  process,  unattended  with  fever, 
and  that  when  febrile  symptoms  did  occur,  their  explanation 
must  be  sought  in  some  pathological  condition,  not  in  the  estab¬ 
lishment  of  a  physiological  function. 

In  describing  the  aetiology  of  fever  during  the  puerperium 


358 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Joob., 


the  cases  were  divided  into  infections  and  non-infectious.  It 
was  argued  that  septic  conditions  were  far  more  common  than 
was  usually  supposed,  for  septic  wound  infection  might  vary  in 
the  severity  of  its  course  and  symptoms,  like  scarlatina,  small¬ 
pox,  or  diphtheria.  The  modus  operandi  of  septic  wound  in¬ 
fection  was  minutely  described,  and  a  short  description  given 
of  the  origin,  symptoms,  and  course  of  vulvar,  vaginal,  and 
uterine  inflammation,  cellulitis,  lymphangeitis,  peritonitis,  and 
acute  septicaemia,  illustrated  by  charts.  The  course  of  lung 
troubles,  the  exanthemata,  erysipelas,  diphtheria,  etc.,  in  the 
puerperal  period  was  described  and  some  differences  of  opinion 
were  explained  and  reconciled. 

Among  the  non-infectious  febrile  conditions,  emotional  fever, 
exposure  to  cold,  and  reflex  irritation,  such  as  from  digestive 
disturbances,  were  fully  considered  and  illustrated  by  charts 
and  cases. 

Since  a  high  temperature  during  the  puerperal  period  might 
mean  a  great  deal  or  nothing,  the  necessity  of  a  careful  diagno¬ 
sis  was  insisted  upon  before  severe  intra-uterine  medication  was 
adopted.  Without  diagnosis  treatment  was  apt  to  be  one  of 
passive  expectancy  or  else  fussy  meddlesomeness.  In  conclu¬ 
sion,  a  strong  appeal  was  made  for  rigid  antisepsis  during  the 
progress  of  labor,  the  accoucheur  taking  as  much  precaution 
with  himself,  his  instruments,  and  the  genital  tract  as  if  about 
to  undertake  a  surgical  operation.  The  use  of  lubricants,  fre¬ 
quent  or  prolonged  vaginal  examination,  and  routine  douching 
during  the  puerperium  were  deprecated.  The  use  of  corrosive 
sublimate  (1  to  1,000)  for  the  hands  and  external  washings,  1 
to  2,000  for  vaginal  douche  after  labor,  the  careful  inspection 
of  the  vulvar  and  lower  fourth  of  the  vagina  after  labor,  and 
the  closing  of  tears  and  fissures,  were  strongly  recommended. 
The  routine  use  of  the  thermometer  often  gave  the  first  warn¬ 
ing  of  inflammatory  mischief  and  enabled  precautionary  meas¬ 
ures  to  be  taken.  Gynaecologists  told  a  sad  tale  of  the  miseries 
and  sufferings  of  women  from  neglected  inflammatory  troubles 
traceable  to  confinement,  which  could  readily  have  been  pre 
vented.  Such  a  record  was  not  creditable.  We  should  not 
merely  he  content  that  our  patients  recovered  ;  we  should  be 
concerned  as  to  how  they  recovered,  and  timely  care  and  atten¬ 
tion  would  insure  comparative  immunity  from  a  host  of  dis¬ 
tressing  ailments  which  rendered  the  lives  of  women  a  burden  ; 
so  it  was  our  bounden  duty  as  humane  men  and  intelligent  phy¬ 
sicians  to  realize  our  responsibilities  and  adopt  all  reasonable 
precautions. 

The  Medical  Section. — After  the  reading  of  the  surgical 
address  the  sectional  work  began.  The  chair  was  taken  by  Dr. 
MoPhedran,  of  Toronto,  Dr.  F.  G.  Fini.ey  having  been  ap¬ 
pointed  secretary. 

Cardiac  Complications  of  Gonorrhoeal  Rheumatism.— 

Dr.  E.  L.  MaoDonnell,  of  Montreal,  read  a  paper  in  which  he 
reviewed  the  literature  of  the  subject  and  analyzed  the  histories 
of  twenty-seven  cases  of  gonorrhoeal  rheumatism  treated  in  the 
wards  of  the  Montreal  General  Hospital.  Of  these,  there  were 
six  in  which  the  physical  signs  of  cardiac  disease  were  found, 
hut  in  three  it  was  possible  that  an  endocarditis  from  acute 
rheumatism  or  from  scarlet  fever  might  have  been  present.  In 
the  remaining  three  cases  no  other  cause  but  gonorrhoeal  rheu¬ 
matism  was  present.  In  the  last  case  recorded  the  patient, 
aged  twenty-two,  while  suffering  from  a  urethral  discharge, 
was  exposed  to  cold,  and  had  rigors  and  slight  pains  in  the 
joints,  principally  in  the  knees.  These  symptoms  were  fol¬ 
lowed  by  prsecordial  pain  and  urgent  dyspnoea.  Physical  signs 
of  pericarditis  were  almost  immediately  discovered.  Subse¬ 
quently  pleurisy  developed  and  a  murmur  supposed  to  be  of 
endocardial  origin  remained.  The  reader  of  the  paper  con¬ 
cluded  from  these  observations  that  gonorrhoeal  rheumatism 


was  sometimes,  though  very  rarely,  associated  with  affections 
of  the  endo-pericardium  and  tbe  pleura. 

Dr.  J.  E.  Graham,  of  Toronto,  was  not  prepared  to  agree 
with  the  reader  of  the  paper  as  to  the  exact  diagnosis  of  tbe 
last  case  cited.  He  thought  it  not  improbable  that  the  cardiac 
and  pleural  attacks  were  due  to  ordinary  acute  rheumatism,  and 
that  the  pressure  of  the  urethral  discharge  had  no  bearing  upon 
the  case.  In  support  of  this  view  he  brought  forward  the  fact 
that  the  joint  pains  were  of  a  very  trivial  character  and  that  it 
was  not  uncommon  in  cases  of  ordinary  acute  rheumatism  to 
meet  with  severe  cardiac  symptoms  where  articular  manifesta¬ 
tions  were  almost  altogether  in  abeyance.  Another  explanation 
of  the  occurrence  of  cardiac  valvular  affections  with  gonorrhoea 
might  be  found  in  the  possibility  that  a  recent  gonorrhoea  might 
light  up  an  old  endocarditis,  just  as  in  malignant  endocarditis 
the  seat  of  old  standing  disease  on  the  valves  was  found  to  he 
the  special  point  of  attack. 

Dr.  MaoDonnell  said  in  reply  that  in  some  of  the  cases  of 
supposed  gonorrhoeal  endo-pericarditis  the  joint  pain  was  en¬ 
tirely  absent,  and  that,  in  the  opinion  of  some  of  the  writers  he 
had  quoted,  notably  Marty,  joint  affection  was  not  considered 
a  necessary  middle  term  between  the  urethral  discharge  and 
the  heart  affection. 

(To  be  concluded.) 


AMERICAN  LARYNGOLOGICAL  ASSOCIATION. 

Twelfth  Annual  Congress,  held  at  Baltimore ,  on  Thursday , 

-  Friday ,  and  Saturday ,  May  29,  30,  and  31,  1890. 

The  President,  Dr.  John  N.  Mackenzie,  of  Baltimore, 
in  the  Chair. 

(Continued  from  page  27 J.) 

Look  beyond  the  Nose. — Dr.  S.  Solis-Cohen  read  a  paper 
with  this  title.  (See  page  340.) 

Dr.  Roe:  The  communication  which  has  just  been  read 
touches  a  subject  upon  which  I  have  myself  written  a  paper; 
and  I  have  but  little  more  to  say  on  the  topic  discussed.  One 
point,  however,  I  may  refer  to:  It  is  the  nervous  symptoms  of 
nasal  obstruction.  Headache,  of  course,  always  indicates  some¬ 
thing  wrong,  some  abnormal  condition  ;  but  any  man  who  at¬ 
tempts  to  ascribe  a  headache  in  every  instance  to  a  single  spe¬ 
cific  cause  should  be  regarded  as  scarcely  less  abnormal  than 
the  headache  itself.  There  are  unquestionably  a  great  many 
headaches  produced  by  diseases  of  the  nose,  but  this  is  very  far 
from  saying  that  all  headaches  are  thus  caused.  We  see  two 
cases  of  headache  attended  by  precisely  the  same  condition  in 
the  nose — for  example,  pressure  of  a  turbinated  body  upon  the 
septum.  In  one  case  the  removal  of  the  obstruction  will  re¬ 
lieve  the  headache  at  once,  in  the  other  the  same  treatment 
will  have  no  effect  upon  the  headache.  Tbe  explanation  of  this 
is  that  in  the  latter  case  the  headache  is  due  to  some  other 
cause.  Where  the  headache  is  relieved  by  an  operation  it  is 
probably  because  there  was  some  pressure  upon  nerve-filaments, 
tbe  irritation  being  transmitted  to  the  brain  by  nerve  connec¬ 
tion;  the  operation  cures  by  removing  tbe  source  of  irritation. 
The  result,  however,  can  not  always  be  predicted.  We  can  not 
always  promise  that  the  headache  will  at  once  disappear,  but 
the  operation  is  .proper  under  the  circumstances.  I  have  seen 
many  cases  in  which  complete  relief  from  a  persistent  headache 
followed  the  removal  of  a  nasal  obstruction.  About  two  weeks 
ago  a  man  with  nasal  difficulty  came  to  me  for  treatment.  He 
said  nothing  about  headache,  and  I  did  not  ask  him  regarding 
such  a  symptom. 

Having  been  relieved  of  the  abnormal  condition  in  the  nose 
— there  was  marked  pressure  between  the  middle  turbinated 


Sept.  27,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


body  and  the  septum — he  returned  to  me  very  grateful  and 
said  that  I  had  oured  his  headache  also.  It  seemed  that  for 
three  or  four  years  he  had  suffered  from  headache,  and  be  had 
been  told  by  a  physician,  who  had  unsuccessfully  treated  him 
for  it,  that  it  was  constitutional,  and  he  had  made  up  his  mind 
to  bear  it  for  the  rest  of  his  life.  Thinking  it  incurable,  he  said 
nothing  to  me  about  it,  and  was  much  surprised  to  find  after 
the  operation  that  it  had  disappeared.  Of  course,  the  facts  in 
Dr.  Cohen’s  paper  go  without  saying.  It  is  well  known  that 
we  may  have  a  variety  of  symptoms  from  the  same  cause,  and 
a  local  condition  does  not  always  give  rise  to  the  same  nervous 
disturbance.  The  nasal  obstruction  may  be  the  primary  cause 
of  a  headache,  or  it  may  be  only  an  incidental  concomitant. 

Dr.  Jarvis:  The  last  speaker  has  recalled  to  my  mind  a 
thought  which  may  throw  some  light  upon  the  fact  that  nerv¬ 
ous  symptoms  appear  in  one  person  and  not  in  another.  I  have 
seen  a  large  number  of  such  cases  in  dispensary  and  private 
practice  and  have  often  noticed  this  phenomenon.  Among  the 
poorer  classes  we  find  marked  distortion  of  the  nasal  septum, 
and  nasal  obstruction  is  very  common,  but  it  is  apparently  not 
attended  by  much  discomfort,  since  the  nervous  symptoms 
which  are  usual  among  the  wealthy  class  are  entirely  wanting. 
In  reading  Stanley’s  account  of  his  African  expedition,  I  was 
much  interested  in  his  statement  that  the  native  Africans  paid 
but  little  attention  to  their  wounds;  and  even  when  severely 
lacerated  and  torn,  they  acted  as  if  they  were  mere  scratches; 
the  wounds,  furthermore,  healed  quickly,  in  marked  contrast 
to  those  of  the  whites  of  the  party,  who  suffered  seriously  from 
the  slightest  injuries.  The  blacks  for  generations  had  been 
used  to  exposure  of  their  bodies,  and  in  consequence  their 
nervous  system  had  become  accustomed  to  injuries  of  this  kind 
— in  other  words,  they  had  become  less  sensitive  to  external 
irritation.  There  is  just  this  difference  between  the  educated 
or  wealthy  and  the  laboring  classes:  the  latter  are  far  less  sus¬ 
ceptible  to  external  irritations  than  the  former,  on  account  of 
the  inertia  of  their  nervous  system.  I  have  found  a  slight 
amount  of  nasal  obstruction  in  a  brain-worker  producing  a 
great  deal  of  distress,  headache,  etc.,  while  a  much  greater 
amount  in  a  laboring  man  may  give  rise  to  no  discomfort  at  all. 
The  nerve  symptoms  are  due  to  the  increased  susceptibility  of 
the  central  nervous  system  to  peripheral  impressions. 

A  Case  of  Myxoma  of  the  Naso-pharynx  in  a  Child  Six 
Years  Old.  — Dr.  Alexander  W.  MaoCot  read  a  paper  on  this 
subject.  (See  page  841.) 

The  President  said  that  he  had  reported  two  cases  of 
myxoma  and  had  referred  to  them  in  Dr.  Keating’s  Cyclopedia 
of  Diseases  of  Children.  “  They  occurred  in  the  same  family,  in 
brother  and  sister;  one  was  four  years  of  age  and  the  other  six. 
In  the  one,  the  mother  had  noticed  something  protruding  from 
the  nose  at  one  year  of  age,  in  the  other  the  growth  was  prob¬ 
ably  congenital  in  origin.  I  removed  both  with  the  cold  wire 
snare.  These  growths  in  children  are  not  common.  Morell 
Mackenzie  in  all  his  large  practice  never  saw  one  under  the  age 
of  sixteen  years.  Bartholini  and  other  older  writers  reported 
cases  of  polypus  in  children,  but  in  those  days  the  diagnosis  was 
not  made  as  carefully  as  at  present,  and  the  distinction  was  not 
clearly  drawn  between  these  cases  and  simple  hypertrophy.” 

Dr.  Swain:  This  tumor  has  the  appearance  of  a  fibro-myx- 
oma.  I  have  seen  such  a  case  in  a  child  eight  years  of  age .  I 
do  not  know  the  outcome  of  it,  but  think  it  may  be  of  interest 
to  mention  it  in  this  connection. 

A  Case  of  Fibro-sarcoma  of  the  Right  Nasal  Fossa  with 
Unusual  Clinical  History. — Dr.  C.  H.  Knight  read  a  paper 
with  this  title.  (See  page  342.) 

Dr.  Bosworth  :  The  author  takes  the  ground  in  this  pa¬ 
per  that  the  more  radical  operation  is  indicated  in  sarcoma  of  ' 


359 

the  naso-pharynx.  In  this  I  take  issue  with  him,  and  regard 
the  question  as  far  from  being  settled.  The  only  case  of  sar¬ 
coma  of  the  naso-pharynx  followed  by  recovery  that  I  know  of 
was  one  in  which  a  severe  operation  could  not  be  borne  and  the 
patient  was  treated  with  the  mildest  measures  only.  I  reported 
this  case  to  the  American  Medical  Association  several  years  ago. 
Butlin,  in  his  monograph,  says  that  sarcoma  at  first  is  a  purely 
local  disease.  I  hold  that  if  we  treat  it  as  a  local  disease. we 
are  on  safe  ground.  At  the  present  time  we  can  get  at  all  parts 
of  the  nose  without  resorting  to  the  operations  mentioned  ;  the 
old  operations  are  no  longer  necessary.  The  best  results  have 
followed  the  plan  of  attacking  the  growth  through  the  nose  and, 
by  careful  manipulation,  taking  it  away  piecemeal.  In  my  own 
experience,  sarcoma  is  best  treated  in  this  way,  using  the  cold 
wire  snare.  In  carcinoma  it  does  not  matter  what  is  done;  my 
experience  is  that  no  form  of  treatment  is  of  service. 

Dr.  Mulhall  :  I  wish  to  place  upon  record  a  case  bearing 
some  resemblance  to  the  one  which  Dr.  Knight  has  just  report¬ 
ed.  It  was  one  of  small-celled  sarcoma  invading  both  nostrils. 
The  case  also  has  some  bearing  upon  the  question  of  the  trau¬ 
matic  origin  of  these  growths.  The  patient,  a  man  about  fifty 
years  of  age,  had  been  injured  by  a  fall  upon  the  railroad,  strik¬ 
ing  his  nose  upon  a  tie,  about  a  year  before  the  disease  appeared, 
and  he  attributed  the  disease  to  the  fall.  He  came  to  me  with 
a  mass  of  bleeding,  fungous  material  projecting  from  both  nos¬ 
trils.  Upon  touching  it,  haemorrhage  was  caused.  I  questioned 
if  any  operation  would  be  of  service,  but  I  advised  the  removal 
piecemeal  with  the  galvano-cautery  and  discountenanced  any 
radical  operation.  After  I  succeeded  in  clearing  one  nostril, 
he  gave  up  coming  to  me,  and  resorted  to  the  use  of  morphine. 
He  died  in  about  four  months  with  repeated  haemorrhages  and 
inanition ;  the  disease  lasted  about  a  year  altogether. 

Dr.  Bosworth  :  The  case  is  reported  as  one  of  fibro-sar¬ 
coma.  Was  there  any  change  in  the  character  of  the  tumor  or 
its  appearance  corresponding  with  the  occurrence  of  malig¬ 
nancy  ? 

Dr.  Knight  :  While  under  my  observation  the  neoplasm 
was  fibro-sarcomatous.  In  speaking  of  the  “  radical  operation,” 
I  refer  not  to  Ohassaignac’s  or  Ollier’s,  but  rather  to  one  like 
Maisonneuve’s,  which  exposes  the  region  to  its  utmost  limit.  It 
may  be  true  that  carcinoma  is  better  let  alone.  Is  it  not  equally 
true  in  sarcoma  that  a  policy  of  non-interference  is  more  judi¬ 
cious  than  a  prolonged  series  of  nibblings  at  the  surface  of  a 
growth  which  is  steadily  progressing  beyond  our  reach  ? 

Adenoid  Tissue  in  the  Naso-pharynx  and  Pharynx ; 
Preliminary  Report. — Dr.  H.  L.  Swain,  of  New  Haven,  read 
a  paper  on  this  subject.  (See  page  316.) 

Dr.  Bosworth:  Dr.  Swain’s  paper  is  very  interesting  and 
timely.  Just  now  considerable  attention  is  directed  to  the  lym¬ 
phatic  tissue  in  the  vault  of  the  pharynx,  the  base  of  the  tongue, 
and  in  the  fauces.  What  are  its  functions?  what  its  patho¬ 
logical  relations?  but,  prominently,  what  constitutes  a  patho¬ 
logical  condition  of  this  structure?  I  confess  that  I  do  not  look 
with  much  favor  upon  the  speculations  which  have  been  ad¬ 
vanced  as  to  the  function  of  this  tissue.  For  instance,  when 
Scanes  Spicer  says  that  it  is  placed  there  to  drink  up  superflu¬ 
ous  fluid,  it  does  not,  in  my  opinion,  rise  to  the  dignity  of  a 
physiological  theory  ;  nor,  when  Killian  says  it  is  there  in  order 
to  destroy  micro-organisms,  do  I  regard  it  as  much  more 
rational.  It  is  very  evident  that  it  can  act  upon  only  a  very 
small  part  of  the  inspired  air,  and  can  exercise  only  a  very  slight 
effect  in  this  way.  In  diseased  conditions  it  might,  on  the 
contrary,  act  as  traps  for  pathogenic  micro-organisms,  and  af¬ 
ford  a  suitable  culture  ground,  as  in  diphtheria.  As  a  matter 
of  fact,  many  of  the  diseases  of  young  children  are  contracted 
in  this  way,  such  as  scarlet  fever,  measles,  diphtheria,  follicular 


360 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


amygdalitis,  etc.  All  of  these  are  evidently  due  in  many  cases  to 
the  fact  that  these  disease  germs  are  introduced  and  developed 
there.  Again,  in  confirmation  of  Killian’s  theory,  may  it  not 
be  that  this  function  of  destroying  organisms  is  itself  destroyed 
by  the  diseased  condition  of  the  glands  which  arrests  their 
function?  Another  important  question  to  be  solved  is,  What 
constitutes  a  diseased  condition  of  the  adenoid  tissue  in  the 
vault  of  the  pharynx ?  Are  adenoid  growths  abnormal?  Are 
the  small  pearly  bodies  so  often  seen  there  evidence  of  disease? 
Again,  the  manifestations  of  a  catarrhal  process  in  this  region 
are  different  at  different  ages  ;  up  to  fifteen  or  twenty  years  of 
age  this  region  is  the  most  frequent  source  of  a  catarrhal  dis¬ 
charge;  from  twenty  to  forty,  intranasal  disease  is  the  rule; 
while  from  forty  to  sixty  it  is  back  again  in  the  naso-pharynx. 
In  children  the  disorder  is  due  to  hypertrophy  of  the  lymphatic 
structures  in  the  vault  of  the  pharynx  ;  in  adult  life  the  adenoid 
tissue  is  shrunken  up,  and  atrophic  changes  occur.  Another 
problem  is.  Where  does  all  the  mucous  secretion  come  from  in 
cases  of  naso-pharyngeal  catarrh  ?  Adenoid  tissue  does  not 
secrete  mucus.  What  is  the  possible  source  of  the  discharge? 
It  is  possible  that  the  pain  may  be  due  to  the  shrinkage  of  the 
adenoid  tissue  which  imprisons  the  terminal  fibers  of  nerves; 
but  where  does  all  the  secretion  come  from?  I  do  not  believe 
Schwalbach’s  theory;  it  is  not  reasonable,  aud  I  can  not  accept 
it.  At  the  opening  of  a  recent  meeting  of  the  British  Laryn- 
gological  Association,  Mackenzie  Kennedy  said  that  if  any  one 
could  tell  us  how  to  cure  naso-pharyngeal  catarrh  he  would  con¬ 
fer  the  greatest  benefit  upon  laryngology.  We  treat  it,  it  is  true, 
after  a  fashion,  but,  after  all,  do  we  know  anything  about  it? 

Dr.  Langmaid  :  I  would  ask  Dr.  Swain  to  illustrate  his  re¬ 
marks  upon  the  blackboard.  What  is  meant  by  the  statement 
that  when  there  is  a  demand  by  the  blood  for  more  leucocytes 
there  is  a  diminution  of  adenoid  tissue? 

Dr.  Bosworth  :  I  should  like  to  ask,  also,  if  the  author 
based  the  remark  that  adenoid-tissue  function  was  to  make 
blood  upon  any  personal  observation  or  experiment? 

Dr.  Swain:  In  answer  to  Dr.  Langmaid,  the  only  observa¬ 
tions  I  know  , of  are  those  made  by  Stohr  and  two  made  by  my¬ 
self.  Stohr  found  that  in  a  case  of  pyo-pneumothorax,  upon 
examination  of  the  throat,  there  were  hardly  any  follicles  in  the 
adenoid  tissue;  and,  secondly,  that  the  number  of  leucocytes 
lying  in  the  epithelium  was  very  much  less.  In  a  case  of  leu- 
cocythsemia  he  made  similar  observations,  although  the  appear¬ 
ances  were  not  so  well  marked.  My  own  observations  were  in 
a  case  of  bone  tuberculosis,  and  in  one  of  pure  pulmonary  tuber¬ 
culosis.  I  found  in  the  lingual  tonsil  there  was  great  diminu¬ 
tion  and  atrophy  of  gland  tissue  at  the  base  of  the  tongue.  The 
conglobate  glands  were  very  much  atrophied. 

With  regard  to  the  point  raised  by  Dr.  Bosworth  concern¬ 
ing  the  source  of  the  great  quantity  of  secretion,  in  the  obser¬ 
vations  made  by  Killian  and  in  my  own  there  was  no  connec¬ 
tion  found  between  the  amount  of  increase  in  the  adenoid  tissue 
and  that  in  the  racemose  glands,  increase  in  the  latter  not  al¬ 
ways  following  the  same  in  the  former.  As  to  the  explanation 
referred  to  by  Dr.  Bosworth,  why  it  was  necessary  for  the  lym¬ 
phoid  tissue  to  go  through  this  process  of  diminution  and 
atrophy,  I  can  not  say  anything,  except  that  it  is  necessary. 
We  see  it  so  much  in  our  cases  that  we  must  believe  it  to  be  the 
inevitable  course  of  adenoid  tissue  in  this  situation  to  undergo 
this  degeneration  and  atrophy.  I  may  not  have  made  it  very 
clear  in  my  paper,  but  I  think  the  point  made  by  Killian  a  very 
important  one. 

Supplemental  Report  on  Cartilaginous  Tumors  of  the 
Larynx  and  Warty  Growths  in  the  Nose.— Dr.  E.  Fletcher 
Ingals,  of  Chicago,  read  a  paper  on  this  subject.  (See  page 
345.) 


Dr.  Bosworth  :  In  connection  with  this  subject  I  will  refer 
casually  to  a  case  I  saw  four  months  ago.  It  was  a  broad  papil¬ 
loma  upon  the  tongue  and  palatal  arches  in  a  child  three  months 
of  age.  I  applied  thuja  occidentalis,  but  without  any  efiect 
whatever.  The  growth  subsequently  disappeared  under  the  use 
of  glacial  acetic  acid.  I  thought  this  case  might  be  interesting 
as  showing  the  failure  of  thuja.  These  growths  in  the  nose  are 
quite  frequent.  I  have  seen  half  a  dozen  cases  within  the  last 
year  ;  they  are  probably  usually  mistaken  for  small  polypi.  In 
ray  cases  I  snared  them  off  and  cauterized  the  base  with  chromic 
acid.  My  own  experience  has  failed  to  show  me  where  the 
reputation  of  thuja  has  been  maintained. 

Dr.  Jarvis  :  I  have  had  some  experience  in  connection  with 
these  growths,  especially  in  their  treatment  with  chromic  acid, 
when  occurring  in  the  larynx.  I  was  perhaps  the  first  to  point 
out  the  fact  that  this  agent  would  completely  remove  the  growth 
as  well  as  prevent  its  recurrence.  Hering  afterward  came  out 
in  its  favor.  There  is  one  point  about  it  that  should  be  men¬ 
tioned — namely,  the  advantage  that  it  does  not  reach  beyond 
the  papillomatous  tissue  in  its  effects ;  it  furthermore  does  no 
harm  to  the  healthy  mucous  membrane  in  the  immediate  vicin¬ 
ity  of  the  growth.  This  is  due  to  the  diversity  of  the  tissue. 
Cartilage  is  not  affected  by  small  applications  of  the  acid.  It 
acts  by  progressive  superficial  sphacelation.  The  effect  is  regu¬ 
lated  by  the  quantity  used;  if  small,  no  danger  can  follow.  I 
have  seen  only  two  cases  of  nasal  papilloma.  One  I  should  not 
call  a  case  of  true  papilloma.  It  was  in  a  boy  about  sixteen  and 
was  a  modified  polypus — a  polypoid  growth,  in  fact.  It  had  not 
the  raspberry-like,  irregular  surface,  but  it  had  been  altered  by 
previous  applications.  I  called  it  a  teleangeiectatic  polypus.  It 
bled  easily.  The  other  case  I  at  first  considered  one  of  true 
papilloma,  but  afterward  came  to  the  conclusion  that  it  was  a 
case  of  epithelioma,  as  I  think  many  of  them  are.  It  was  not 
changed  by  long  treatment,  and  extreme  radical  measures  had 
no  permanent  effect  upon  it. 

Dr.  Mhlhall:  There  seems  to  be  some  confusion  in  this  dis¬ 
cussion  between  warty  growths  and  papillomata.  I  recall  a  pa¬ 
per  by  Hopmann,  who  professed  to  have  seen  a  hundred  and 
twenty  cases  of  warty  growths  in  the  nose.  I  wondered  why 
I  had  never  seen  a  case.  A  patient  applied  to  me  a  short  time 
ago  for  treatment  for  “  warts  ”  in  his  nose,  which  I  found  to  be 
papilloma,  such  as  we  find  in  the  larynx.  It  grew  from  the  an¬ 
terior  portion  of  the  middle  turbinated  bone,  and  looked  exactly 
like  a  small  bunch  of  grapes.  I  saw  the  case  just  before  I  left, 
and  operated  upon  it.  It  was  readily  removed,  and  the  opera¬ 
tion  afforded  much  relief  to  the  breathing.  I  desire  to  place 
this  on  record  as  the  first  case  I  have  seen  of  papilloma  of  the 
nose.  (The  speaker  presented  a  specimen  of  nasal  papilloma.) 

The  President  inquired  of  Dr.  Mulhall  if  the  growth  in  his 
case  was  large  and  if  it  might  not  have  been  a  portion  of  the 
erectile  body. 

Dr.  Mulhall  :  The  growth  was  large  aud  could  be  with¬ 
drawn  from  the  nose  partially,  but  again  retracted ;  it  was  some¬ 
what  elastic.  The  middle  and  upper  turbinated  bodies  were 
free. 

The  President  :  I  have  seen  prolapse  of  the  mucous  mem¬ 
brane  from  the  anterior  portion  of  the  turbinated  body  which 
could  be  withdrawn  from  the  nose  in  the  manner  just  men¬ 
tioned,  and  which  had  been  mistaken  for  polypus. 

Dr.  MaoCoy  :  I  can  recall  three  cases  of  warty  growths,  all 
growing  in  the  vestibule,  having  the  appearance  already  de¬ 
scribed.  I  removed  them  with  the  galvano-cautery.  There 
was  some  tendency  to  return,  but  they  were  all  ultimately 
cured. 

Dr.  Delavan  :  One  of  the  interesting  features  of  this  dis¬ 
cussion  is  the  general  consensus  of  opinion  as  to  the  rarity  of 


PROCEEDINGS  OF  SOCIETIES. 


361 


Sept.  27,  1890.] 

the  case.  I  was  much  surprised  at  the  statements  of  Hopmann, 
and  think  that  there  must  be  something  peculiar  in  the  cases 
coming  to  him,  as  in  my  experience  papilloma  in  this  situation 
is  a  rare  disease. 

The  President,:  I  fully  agree  with  Dr.  Bosworth  that  these 
papillomatous  tumors  are  likely  to  grow  just  within  the  vesti¬ 
bule,  and  are  more  common  than  is  generally  supposed ;  but 
growing  further  within  the  nose  they  are  rare.  I  can  recall 
only  two  cases  of  this  kind  in  my  experience.  I  think  the  re¬ 
mark  of  Dr.  Jarvis  very  well  founded  and  appropriate.  Where 
we  find  a  papillary  growth  with  a  broad  base  and  a  tendency  to 
bleed  we  should  be  on  the  lookout  for  carcinoma.  I  think 
that  Hopmann  mistook  for  papilloma  the  changes  that  occur  in 
the  ordinary  transition  from  the  secondary  to  the  tertiary  form 
of  chronic  rhinitis.  Cross-sections  of  these  bodies  under  the 
microscope  resemble  papillomatous  tissue,  whereas  they  actu¬ 
ally  consist  of  turbinated  erectile  tissue.  I  think  that  Hop¬ 
mann,  in  some  cases  at  least,  mistook  these  outgrowths  for 
papillomata.  I  desire  to  call  attention  to  an  important  clini¬ 
cal  point :  Sometimes  patients  complain  for  a  long  time  of  a 
sense  of  fullness  of  the  nostril  and  other  symptoms  of  hyper¬ 
trophic  catarrh,  and  after  a  while  expel  little  pieces  of  fleshy 
as  they  term  them,  from  the  nose.  Afterward  they  find  that 
they  can  breathe  better,  and  that  the  obstruction  in  the  nose 
has  disappeared.  The  reason  is,  that  under  the  influence  of  the 
atrophic  process  these  little  bodies  are  separated  and  slough  off. 
It  does  not  mean  that  the  patient  has  gotten  well,  but  simply 
that  the  hypertrophic  process  has  gone  on  to  atrophy.  Under 
the  microscope,  sections  of  these  bodies  resemble  papillomatous 
growths  in  structure,  and  may  be  mistaken  for  them,  while  they 
are  really  the  results  of  hypertrophic  degeneration. 

Dr.  Ingals:  I  think  that  this  mulberry-like  appearance  of 
the  turbinated  body  is  probably  the  reason  that  Hopmann,  and 
probably  some  others,  have  found  so  many  so-called  cases  of 
papilloma  of  the  nose,  as  a  mistake  might  easily  be  made.  I 
have  often  seen  this  condition,  which  is  not  that  of  a  true  papil¬ 
loma,  but  I  have  never  seen  but  the  one  reported  in  which  the 
growths  had  the  appearance  of  warts.  In  this  particular  case 
the  growths,  which  recurred  many  times,  did  not  resemble 
papillomatous  tumors  in  the  larynx  in  any  way.  They  grew  first 
from  the  septum,  and  afterward  from  the  turbinated  body,  and 
had  all  the  appearance  of  warty  growths  as  we  commonly  see 
them  upon  the  hands. 

As  to  the  thuja  occidentalis  :  I  did  not  wish  to  try  to  prove 
that  it  had  any  special  value,  though  this  has  been  alleged  for 
it;  but  I  must  say  that  the  patient  did  much  better  after  using 
it  than  he  had  been  doing  before.  It  is  possible  that  it  may 
make  some  difference  whether  a  fresh  tincture  is  used  or  not. 
The  preparation  I  employed  was  prepared  at  the  time  from  the 
fresh  leaves  of  the  arbor  vitae. 

Hoarseness  and  Loss  of  Voice  caused  by  Wrong  Vocal 

Methods. — Ur.  S.  W.  Langmaid,  of  Boston,  read  a  paper  on 
this  subject.  (To  be  published.) 

Dr.  Delavan:  It  will  be  generally  conceded  that  no  higher 
authority  than  Dr.  Langmaid  could  discuss  the  questions  pre¬ 
sented  in  this  paper.  To  it  we  can  only  add  the  testimony  of 
our  own  experience.  From  the  statements  of  noted  singers 
who  have  been  trained  under  the  system  which  the  reader  of  the 
paper  describes,  as  well  as  from  my  own  personal  experience  in 
practical  vocalization,  I  am  able  to  confirm  the  views  which  he 
has  expressed.  Not  infrequently  cases  have  come  to  me  com¬ 
plaining  of  some  laryngeal  difficulty  in  which  a  diagnosis  from 
simple  inspection  of  the  larynx  was  impossible,  and  a  correct 
solution  of  the  matter  only  arrived  at  by  a  careful  study  of  the 
vocal  methods  of  the  patient  and  the  discovery  of  its  defects. 
In  many  instances  faulty  voice-production  will  be  found  to  be 


the  true  explanation  of  an  otherwise  inexplicable  difficulty.  Of 
course  it  is  of  great  importance  for  us  to  understand  our  cases 
in  order  that  we  may  properly  treat  them,  and,  understanding 
them,  to  see  that  the  treatment  employed  be  not  confined  to 
local  applications,  but  that  the  faulty  methods  of  vocalization 
be  corrected  under  the  training  of  a  competent  teacher.  Again, 
the  services  of  the  vocal  instructor  are  of  great  value  in  the 
treatment  of  certain  chronic  conditions  of  laryngeal  disease. 
I  am  in  the  habit  of  referring  patients  to  a  skillful  teacher  for 
the  purpose  of  obtaining  systematic  exercise  of  the  laryngeal 
muscles,  just  as  in  appropriate  cases  the  surgeon  resorts  to  pas¬ 
sive  motion.  It  is  to  be  hoped  that  Dr.  Langmaid  will  continue 
to  offer  us  such  studies  as  this  through  his  work.  Aided  by 
that  of  Dr.  French,  we  should  be  in  a  position  to  recognize  and 
successfully  treat  many  cases  which  now  are  wholly  misunder¬ 
stood. 

Dr.  Henkel  :  I  am  reminded  by  the  paper  of  a  class  of  cases 
in  which  I  have  taken  much  interest — cases  in  which  there  is 
vocal  disability  due  to  some  structural  defect  in  the  nasal  pas¬ 
sages  or  naso-pharynx.  Such  patients  suffer  injury  to  the  throat 
and  voice  from  the  demands  made  upon  the  vocal  organ  beyond 
what  is  customary  in  speech,  even  though  there  be  nothing 
faulty  in  the  vocal  method.  It  is  of  importance  to  recognize 
this  defective  condition,  for  many  teachers  and  pupils  are  puz¬ 
zled  to  account  for  the  failure  of  promising  voices  in  which  the 
defect  is  due  to  a  lack  of  co-ordination,  as  it  were,  between  the 
primary  tone-organ  and  the  resonating  apparatus.  The  re¬ 
moval  of  a  septal  ridge  or  of  adenoids  uot  infrequently  restores 
the  power  and  quality  to  the  voice.  I  recall  a  tenor  who 
gained  a  minor  third  in  his  compass  after  the  removal  of  a  sep¬ 
tal  ridge  from  which  he  had  suffered  no  inflammation  or  ob¬ 
struction  of  which  he  was  aware. 

Dr.  Mulhall:  The  matter  which  the  last  speaker  refers  to 
is  hardly  germain  to  the  subject  of  the  paper.  If  we  were  to 
go  into  the  discussion  of  the  effects  of  abnormities  of  the  air- 
passages  upon  the  formation  of  tone  we  should  hardly  get 
through  with  it  before  our  final  adjournment.  There  is  one 
point,  however,  that  I  would  like  to  have  discussed.  It  is  the 
so-called  “abdominal”  method  of  singing  or  managing  the 
voice.  I  wish  that  every  singing-master  could  have  this  paper 
of  Dr.  Langmaid’s  put  into  his  hand.  I  agree  with  the  essay¬ 
ist  that  any  singer  who  is  conscious  of  effort  above  the  clavicle 
while  singing  is  using  a  wrong  method.  I  wish  to  speak  of 
the  abdominal  method.  We  notice  with  what  ease  the  tenor 
of  the  Italian  opera  produces  the  high  notes  without  even 
flushing  his  face,  and  he  can  sing  the  whole  evening  without 
apparent  fatigue,  because  he  has  had  the  benefit  of  proper 
training  in  the  formation  of  tones  and  uses  his  abdominal  mus¬ 
cles  in  singing.  I  recall  the  case  of  a  theological  student  who 
found  in  preaching  that  he  got  tired  in  half  an  hour  and  lost 
his  voice.  I  found  that  he  was  using  his  sterno-cleido  mastoid 
and  other  neck  muscles  in  producing  his  pathetic  effects.  I  in¬ 
structed  him  to  concentrate  his  mind  upon  the  action  of  his 
abdominal  muscles  in  public  speaking  and  to  forget  his  throat. 
He  practiced  this  and  taught  himself  this  method  that  I  have 
described,  and  found  that  he  could  preach  for  two  hours  at  a 
time  without  any  hoarseness  whatever.  The  method  of  using 
the  voice  by  which  the  very  walls  of  the  theatre  are  made  to 
vibrate  with  the  volume  of  sound  is  familiar  to  those  who 
attend  Italian  opera;  the  effects  are  produced  by  the  action  of 
the  abdominal  muscles  and  the  diaphragm.  Many  singing- 
teachers  in  this  country  apparently  do  not  know  this.  The 
teachers  in  the  theological  seminaries  do  not  know  how  to  in¬ 
struct  students  in  the  proper  use  of  these  muscles.  1  might  men¬ 
tion  a  case  which  may  not  be  exactly  germain  to  the  subject. 
A  prominent  teacher  in  St.  Louis  sent  one  of  her  pupils  to  me 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mien.  Joor., 


362 


because  she  could  not  get  beyond  a  certain  note  in  the  scale. 
Upon  examination,  I  found  a  very  peculiar  condition.  As  the 
voice  rises  in  the  scale  the  epiglottis  usually  becomes  more  and 
more  erect,  becoming  vertical  with  the  high  notes.  This  young 
lady  had  enlarged  papillse  at  the  base  of  the  tongue,  which 
were  so  large  as  to  interfere  with  the  epiglottis  and  prevent  it 
from  erecting  itself  to  form  the  notes.  I  removed  these  growths 
with  a  wire  snare,  and  it  added  two  notes  to  her  upper  register 
and  gave  a  really  brilliant  result. 

Dr.  Mackenzie:  Faulty  training  must  be  recognized  as  a 
cause  of  vocal  defects,  and  in  overcoming  them  much  time  and 
patience  are  needed.  I  agree  with  Dr.  Mulhall  in  regard  to 
bridling  the  tongue.  The  isolation  of  the  naso  pharynx  is  due 
to  the  rising  of  the  dorsum  of  the  tongue  to  meet  the  descend¬ 
ing  walls  of  the  pharynx  and  uvula.  The  motions  of  the  tongue 
have  a  great  deal  to  do  with  the  formation  of  tones,  and  any¬ 
thing  encroaching  upon  the  naso-pharynx  or  the  tongue  is  an 
important  factor  in  the  destruction  of  the  mechanism  of  voice. 
The  instruction  given  by  singing-teachers  to  keep  the  tongue 
upon  the  floor  of  the  mouth  is  not  physiological.  It  checks  and 
cripples  the  movements  of  the  throat  muscles,  the  tensor  palati, 
and  the  middle  constrictor  of  the  pharynx;  even  the  buccina¬ 
tors  are  under  restraint.  It  is  the  opinion  of  Meyer,  of  Zurich, 
that  the  middle  constrictor  of  the  pharynx  is  not  concerned  in 
swallowing,  but  is  concerned  in  speech  and  in  singing,  there¬ 
fore  a  very  important  agent  in  vocalization.  In  the  production 
of  certain  notes  there  is  a  pushing  forward  of  the  middle  fibers 
of  this  muscle  toward  the  palate.  It  has  been  shown  conclu¬ 
sively  that  this  bulging  of  the  middle  constrictor  muscle,  upon 
which  the  soft  palate  rests,  is  of  special  use,  as  together  they 
produce  a  complete  isolation  of  the  mouth  and  nose  in  the  pro¬ 
duction  of  certain  notes.  With  regard  to  Dr.  Hinkel’s  observa¬ 
tion,  the  fact  is  already  well  known.  With  regard  to  Dr.  Mul- 
hall’s  remarks,  it  was  Mandl  who  pointed  out  in  his  writings 
with  more  clearness  than  the  others  the  importance  of  the  ab¬ 
dominal  method.  In  the  Italian  school  great  attention  is  paid 
to  this  method  of  developing  the  abdominal  muscles.  The  sug¬ 
gestion  of  Dr.  Mulhall  is  a  very^proper  one,  and  should  he  put 
in  operation  in  our  daily  work  ;  by  it  we  may  succeed  in  cur¬ 
ing  cases  that  otherwise  we  could  not  benefit. 

Dr.  Langmaid:  I  feel  gratified  by  the  discussion  which  has 
been  given  to  the  subject,  which  I  have  had  under  considera¬ 
tion  for  a  long  time.  I  have  said  in  my  paper  that  there  are 
wrong  vocal  methods,  and  I  have  been  asked  to  formulate  the 
right  vocal  method.  I  know  many  wrong  ones  from  the  effects 
that  are  produced  by  them  ;  what  is  the  right  one  I  hope  to  be 
able  to  state  at  some  future  time.  With  regard  to  the  class  of 
singers  referred  to,  who  are  conscious  of  effort  and  difficulty  in 
the  use  of  their  voice,  we  must  be  careful  in  our  advice  and 
prognosis.  I  have  been  impressed  for  years  that  the  method  of 
holding  the  tongue  down  in  the  production  of  vocal  sounds  is  a 
wrong  one.  I  made  many  observations  during  several  years, 
and  became  finally  convinced  that  this  was  the  source  of  all  the 
difficulty  in  certain  cases.  I  found  patients  relieved  by  correct¬ 
ing  this  method,  so  that  I  am  satisfied  that  this  was  a  correct 
view.  Dr.  Hinkel  referred  to  the  fact  that  nasal  stenosis  pro¬ 
duces  changes  in  the  voice,  and  Dr.  Mackenzie  seems  to  agree 
with  him  that  such  disorders  are  frequent  causes  of  voice  diffi¬ 
culties.  I  am  satisfied  that  Dr.  Hinkel  is  correct  in  his  observa¬ 
tion  upon  his  case,  but  I  am  not  satisfied  that  it  is  by  any  means 
a  great  cause  of  voice  defects.  A  partial  filling  up  of  the  naso¬ 
pharynx  is  not  constant  in  its  effects  upon  the  voice;  it  may  or 
may  not  impair  it.  Of  course,  if  the  pharynx  were  completely 
filled  it  would  affect  the  voice,  hut  there  is  no  evidence  that  a 
partial  filling  up  would  have  any  such  consequences.  I  entirely 
indorse  the  remarks  by  Dr.  Mulhall  with  regard  to  the  taking 


of  the  attention  away  from  the  throat;  it  is  very  important  to  a 
correct  vocal  method.  I  also  approve  his  remarks  upon  the  ab¬ 
dominal  method.  This  is  very  interesting,  and  I  intend  to  make 
some  observations  upon  breathing  if  I  live  long  enough.  There 
is  much  to  be  learned  with  regard  to  correct  methods  of  breath¬ 
ing.  With  reference  to  the  case  of  the  clergyman,  the  observa¬ 
tion  was  a  just  one.  I  have  elsewhere  said  that  the  laryngeal 
muscles  were  in  position  to  place  the  vocal  organs  in  proper 
place  to  form  a  given  tone  without  the  wind-blast.  The  wind- 
blast  does  not  produce  the  pitch;  the  larynx  is  properly  ad¬ 
justed  for  the  tone  before  the  wind-blast  reaches  it.  If  we  had 
to  depend  upon  the  delicate  adjustment  of  the  wind-blast,  bow 
many  would  be  able  to  sing  in  tune  ?  The  muscles  instinctively 
put  the  cords  in  position  to  produce  the  note,  which  is  virtually 
produced  before  the  wind- blast  comes,  which  puts  them  in  vi¬ 
bration  and  gives  out  the  tone.  When  the  wind-blast  is  strong 
it  seems  as  if  the  cords  would  not  be  able  to  resist  it,  and  yet 
they  do  not  yield.  The  station,  as  I  call  it,  is  immovable  when 
the  wind-blast  comes ;  the  muscle  does  not  give  at  all ;  if  it  did, 
the  tone  would  change  and  be  either  sharp  or  fiat.  Therefore 
the  distinction  is  that  the  note  is  not  made  by  the  wind-blast, 
but  it  is  carried  on  by  the  wind-blast,  and  intensified  by  increase 
of  the  wind-blast.  Now  the  question  comes  up,  “  What  portion 
of  the  abdominal  muscles  should  be  brought  into  play  to  pro¬ 
duce  the  result  most  effectively  ?  ”  This  I  will  reserve  for 
future  consideration.  With  regard  to  the  case  of  Dr.  Mulhall, 
I  described  one  exactly  similar  to  his.  I  made  one  attempt  to 
remove  the  growth  and  told  the  patient  to  come  back,  but  he 
never  did.  The  growth  in  this  case  had  already  decidedly  im¬ 
paired  the  mobility  of  the  epiglottis.  In  reply  to  Dr.  Mulhall, 
I  might  state  that  in  a  paper  by  Morell  Mackenzie  upon  the 
voice  he  says  that  some  singers  protrude  the  abdomen  and 
some  retract  it.  With  regard  to  the  tongue,  we  must  remem¬ 
ber  that  tongues  are  of  different  shapes  naturally  ;  some  are  flat 
and  broad,  others  narrow  or  wedge-like.  Because  some  singers 
sing  with  a  flat  tongue,  it  does  not  follow  that  others  must  do 
it.  I  am  satisfied  that  the  position  and  shape  of  the  tongue  de¬ 
pend  upon  the  motions  of  the  muscles  of  the  larynx.  The  fact 
is  that  some  singers  sing  with  the  back  of  the  tongue  raised, 
and  it  is  also  a  fact  that  others,  equally  good,  sing  with  the 
tongue  flat. 

The  President:  What  do  you  think  of  the  method  in  which 
the  tone  is  thrown  to  the  bridge  of  the  nose? 

Dr.  Langmaid  :  This  question  might  be  construed  the  wrong 
way.  That  the  resonance  is  universal  and  involves  the  hard 
parts  and  also  the  soft  parts  is  true;  that  the  voice  which  is 
not  reflected  is  a  dull  voice,  as  the  singer  says,  is  true;  but  that 
these  are  the  only  parts  which  reflect  the  voice  is  certainly  not 
true;  ill  results  to  the  laryngeal  muscles  and  the  voice  will 
come  from  an  attempt  to  follow  this  method.  I  have  endeav¬ 
ored  to  confine  my  paper  to  one  form  of  wrong  method  of  voice 
training,  so  that  I  could  not  be  contradicted  without  having  an 
answer  prepared.  By  keeping  on  one  subject  I  hoped  to  avoid 
vagueness  in  the  discussion  which  would  follow. 

The  President  :  Do  you  not  think  that  the  nasal  and  acces¬ 
sory  chambers  are  too  much  neglected  in  the  usual  teaching  of 
singing  ? 

Dr.  Langmaid:  Not  by  the  best  teachers.  The  methods 
pursued  are  those  intended  to  develop  the  best  acoustic  quali¬ 
ties.  For  the  same  reason  the  Italians  have  always  made  use 
of  the  resonance  of  the  head.  If  you  choose  to  call  it  nasal 
resonance  you  may  do  so. 

Unilateral  Paralysis  of  the  Lateral  Crico-arytaenoid 
Muscle. — Dr.  Ingals  read  a  paper  with  this  title.  (See  page 
346.) 

Dr.  Bosworth  :  There  is  one  interesting  point  which  occurs 


BOOK  NOTICKS. 


Sept.  27,  1890.] 

to  me.  In  several  cases  of  paralysis  of  one  side  of  the  larynx, 
with  complete  loss  of  voice,  and  in  two  instances  of  falsetto 
voice,  the  voice  afterward  became  almost  absolutely  normal; 
the  voice  returned,  although  the  paralysis  persisted.  This  was 
accomplished  by  the  healthy  cord  swinging  over  to  the  para¬ 
lyzed  side  so  as  to  make  up  for  the  loss  of  power  on  that  side. 

A  Case  of  Unilateral  Paralysis  of  the  Abductors  of  the 
Larynx,  the  Result  of  an  Attack  of  Bulbar  Disease  with 
Unusual  Symptoms. — Dr.  F.  H.  Boswoktii,  of  New  York, 
read  a  paper  with  this  title.  (To  be  published.) 

Dr.  Westbrook:  I  should  like  to  ask  the  author  of  the 
paper  if  he  would  not  consider  it  possible  that  the  short  du¬ 
ration  of  the  motor  paralysis,  the  suddenness  of  onset,  and 
subsequent  histoi’v  of  the  case,  might  rather  tend  to  exclude 
the  idea  of  lesion  of  the  medulla.  A  lesion  of  the  medulla 
sufficient  to  cause  so  extensive  a  paralysis,  to  give  complete 
hemiplegia,  I  should  not  think  could  be  recovered  from  so 
readily.  I  should  think  that  a  case  like  this  might  be  accounted 
for  on  the  supposition  of  an  embolus  passing  into  the  middle 
cerebral  artery,  or  a  thrombus  in  the  sinus  or  in  one  of  the  other 
vessels  at  the  base.  An  embolus  or  thrombus  affecting  the 
internal  capsule  might  account  for  the  paralysis.  But  the  whole 
thing  might  be  due  to  a  tumor  or  clot  in  one  of  the  venous 
sinuses  at  the  base  of  the  brain.  It  seems  more  probable  that 
it  was  of  this  character  than  that  it  was  a  lesion  of  the  medulla 
itself;  a  lesion  of  such  extensive  nature  as  this  must  have  been, 
occurring  near  the  medullary  center  for  respiration  and  the 
vaso-motor  center,  would  have  been  likely  to  be  quickly  fatal. 
At  all  events,  the  patient  would  not  be  likely  to  recover  so  com¬ 
pletely  or  quickly. 

Dr.  Bosworth:  In  reply  to  the  question,  I  would  say  that 
there  is  no  doubt  about  the  bulbar  nature  of  the  lesion  in  view 
of  the  extent  of  the  paralysis.  There  was  loss  of  deglutition 
and  of  power  in  other  muscles  supplied  by  the  eighth  pair  of 
nerves;  the  laryngeal  paralysis  with  hemiplegia  all  point  to  the 
bulb  or  the  origin  of  the  eighth  pair  of  nerves  in  the  floor  of 
the  ventricle.  The  extent  of  the  case,  the  history  of  a  chronic 
suppurative  process  in  a  closed  cavity,  suggest  thrombosis  of 
one  of  the  small  arteries,  from  the  basilar  supplying  the  me¬ 
dulla.  The  absorption  of  the  embolus  would  account  for  the 
rapid  recovery,  for  the  occurrence  of  softening  would  naturally 
take  some  time.  An  interesting  point  is  the  occurrence  of 
hemiplegia.  I  recall  no  case  on  record  in  which  thrombosis  in 
the  medulla  caused  hemiplegia,  which  makes  this  case  espe¬ 
cially  interesting.  There  was  also  some  cervical  adenitis,  which 
still  further  supported  the  view  of  lesion  at  the  base  and  in  the 
cerebellum. 


§ook  Jtcixas. 


International  Atlas  of  Bare  Shin  Diseases.  Editors  :  Malcolm 
Morris,  London;  P.  G.  Unna,  Hamburg;  L.  A.  Dtjhring, 
Philadelphia;  H.  Leloir,  Lille.  I  and  II.  Philadelphia: 
J.  B.  Lippincott  Company,  1889. 

The  issue  of  this  work,  to  which  we  have  before  alluded,  in¬ 
dicates  the  cosmopolitan  tendency  of  medical  literature.  The 
description  which  accompanies  each  of  the  plates  is  given  in 
English,  French,  and  German,  first  in  the  language  of  the  au¬ 
thor,  which  is  then  translated,  so  that  a  knowledge  of  the  Eu¬ 
ropean  languages  is  not  necessary  for  the  complete  enjoyment 
of  the  work.  Parts  I  and  II  contain  excellent  presentations 
and  descriptions  of  lymphangeioma  circumscriptum,  ulerythema 
acneiforme,  lupus  semisclerosus  linguae,  sarcoma  pigmentosum 


363 

diffusum  multiplex,  keratodermia  symmetrica  erythematosa, 
angeiokeratoma,  and  ulcus  molle  mammae.  It  would  be  diffi¬ 
cult  to  find  better  and  more  life  like  presentations  of  these  dis¬ 
eases,  and  the  work  should  certainly  be  in  the  possession  of 
every  dermatologist. 

Diseases  of  the  Bectum  and  Anus,  their  Pathology,  Diagnosis, 
and  Treatment.  By  Charles  B.  Kelsey,  A.  B.,  M.  D.,  Pro¬ 
fessor  of  Diseases  of  the  Rectum  at  the  New  York  Post¬ 
graduate  Medical  School  and  Hospital,  etc.  Third  Edition, 
rewritten  and  enlarged.  With  Two  Chromo-lithographs 
and  One  Hundred  and  Sixty-eight  Illustrations.  New  York  : 
William  Wood  &  Co.,  1890.  Pp.  x-483. 

The  third  edition  of  this  well-known  work  comes  to  us  re¬ 
vised  and  considerably  augmented.  We  note  in  the  chapter  on 
haemorrhoids  that  the  author  still  views  Whitehead’s  operation 
with  a  disfavor  that  is  not  entertained  by  many  excellent  sur¬ 
geons.  The  chapters  on  the  treatment  of  benign  and  malignant 
strictures  of  the  rectum,  and  on  the  formation  and  closure  of 
artificial  anus,  have  been  completely  rewritten.  While  the  au¬ 
thor  believes  that  in  certain  cases  lumbar  colotomy  is  particu¬ 
larly  applicable,  yet  his  preference  is  for  inguinal  colotomy  ; 
and  he  wisely  urges  that  this  operation  should  not  be  a  dernier 
ressort ,  but  a  measure  that  should  be  used  early  to  delay  the 
course  of  malignant  disease  and  often  to  cure  non-malignant 
troubles.  The  sections  on  enterorrhaphy  and  the  closure  of 
artificial  anus  explain  the  latest  operations  for  these  conditions. 

The  volume  is  excellently  illustrated,  and  is  virtually  a  new- 
work. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

A  Text-book  of  Practical  Therapeutics,  with  Especial  Reference  to 
the  Application  of  Remedial  Measures  to  Disease  and  their  Employ¬ 
ment  upon  a  Rational  Basis.  By  Hobart  Amory  Hare,  M.  D.  (Univ. 
of  Pa.),  B.  Sc.,  Clinical  Professor  of  the  Diseases  of  Children  and 
Demonstrator  of  Therapeutics  in  the  University  of  Pennsylvania,  etc. 
Philadelphia:  Lea  Brothers  &  Co.,  1890.  Pp.  vi-17  to  632.  [Price, 
$3.76.] 

Salol  in  Acute  Tonsillitis  and  Pharyngitis.  By  Jonathan  Wright, 
M.  D.,  of  Brooklyn,  N.  Y.  [Reprinted  from  the  American  Journal  of 
the  Medical  Sciences.] 

A  Classification  of  Intra-nasal  and  Naso-pharyngeal  Diseases.  By 
Lennox  Browne,  F.  R.  C.  S.  Ed.,  etc.  [Reprinted  from  the  Journal  of 
Laryngology  and  Rhinology.\ 

An  Analysis  of  Some  of  the  Ocular  Symptoms  observed  in  So-called 
General  Paresis.  By  Charles  A.  Oliver,  M.  D.,  Philadelphia.  [Re¬ 
printed  from  the  Transactions  of  the  American  Ophthalmological  So¬ 
ciety.] 

An  Explanation  of  the  Phenomena  of  Immunity  and  Contagion, 
based  upon  the  Action  of  Physical  and  Biological  Laws.  By  J.  W. 
McLaughlin,  M.  D.,  Austin,  Texas.  [Reprinted  from  the  Transac¬ 
tions  of  the  Texas  State  Medical  Association.] 

Spinal  Surgery.  A  Report  of  Eight  Cases.  By  Robert  Abbe,  M.  D. 
[Reprinted  from  the  Medical  Record.] 

Address  in  Hygiene.  By  Thomas  J.  Mays,  M.  D.,  of  Philadelphia. 
[Reprinted  from  the  Transactions  of  the  Medical  Society  of  the  State  of 
Pennsylvania.] 

The  Relation  of  Eye-Strain  to  General  Medicine.  By  George  M. 
Gould,  M.  D.,  Philadelphia.  [Reprinted  from  the  Medical  Wem] 

Transactions  of  the  Association  of  American  Physicians,  Fifth  Ses¬ 
sion,  held  at  Washington,  D.  C.,  May  13,  14,  and  16,  1890.  Volume  V. 

Nouvelle  iconographie  de  le  Salpetriere,  clinique  des  maladies  du 
systbme  nerveux.  Publiee  sous  la  direction  du  Professeur  Charcot 
(de  PInstitut),  par  Paul  Richer,  Gilles  de  la  Tourette,  Albert  Londe  et 
Georges  Guinon.  Troisibme  annee.  Juillet  et  aout,  No.  4.  Paris : 
Lecrosnier  et  Bab6,  1890. 

Medical  Diagnosis,  with  Special  Reference  to  Practical  Medicine. 
A  Guide  to  the  Knowledge  and  Discrimination  of  Diseases.  By  J.  M. 
Da  Costa,  M.  D.,  LL.  D.,  Professor  of  Practice  of  Medicine  and  of  Clin- 


364 


MISCELLANY. 


ical  Medicine  at  the  Jefferson  Medical  College,  Philadelphia.  Illus¬ 
trated  with  Engravings  on  Wood.  Seventh  Edition,  revised,  Phila¬ 
delphia :  J.  B.  Lippincott  Company,  1890.  Pp.  16-17  to  995.  Price, 
$6.] 

Dust  and  its  Dangers.  By  T.  Mitchell  Prudden,  M.  D.,  etc.  New 
York:  G.  P.  Putnam’s  Sons,  1890.  Pp.  111. 

A  System  of  Oral  Surgery;  being  a  Treatise  on  the  Diseases -and 
Surgery  of  the  Mouth,  Jaws,  Face,  Teeth,  and  Associate  Parts.  By 
James  E.  Garretson,  A.  M.,  M.  D.,  D.  D.  S.,  President  of  the  Medico- 
chirurgical  Hospital  and  Emeritus  Professor  of  Oral  and  General  Clin¬ 
ical  Surgery  in  the  Medico-chirurgical  College,  Philadelphia,  etc.  Illus¬ 
trated  with  Numerous  Wood-cuts  and  Steel  Plates.  Fifth  Edition,  thor¬ 
oughly  revised,  with  Additions.  Philadelphia :  J.  B.  Lippincott  Com¬ 
pany,  1890.  Pp.  xliv-25  to  1364.  [Price,  $9.] 

Massage.  A  Primer  for  Nurses.  By  Sarah  E.  Post,  M.  D.  Lect¬ 
ures  before  the  Training  Schools  for  Nurses  connected  with  Bellevue, 
Mt.  Sinai,  and  St.  Luke’s  Hospitals,  New  York;  also  with  the  Memo¬ 
rial  Hospital,  Orange,  N.  J.  New  York  :  The  Nightingale  Publishing 
Co.,  1890.  Pp.  9  to  47. 

Brain  Surgery,  with  Report  of  Eleven  Cases.  By  H.  0.  Walker, 
M.  D.,  Detroit,  Mich.  [Reprinted  from  the  Medical  and  Surgical  Re¬ 
porter .] 

A  Few  Words  on  Vaccination.  By  Major  Greenwood,  M.  R.  C.  S., 
L.  R.  C.  P.  Lond.  Second  Edition.  London  :  Douglas  &  Co.  [Price,  6c?.] 

Description  of  a  Series  of  Tests  for  the  Detection  and  Determina¬ 
tion  of  Subnormal  Color-Perception  (Color-Blindness),  designed  for  Use 
in  Railway  Service.  By  Charles  A.  Oliver,  M.  D.,  of  Philadelphia. 
[Reprinted  from  the  Transactions  of  the  American  Ophthalmological 
Society.  ] 

Some  Points  in  the  Treatment  of  Gonorrhoea.  By  Gardner  W. 
Allen,  M.  D.  [Reprinted  from  the  Boston  Medical  and  Surgical  Jour¬ 
nal '.J 

A  Preliminary  Study  of  the  Ptomaines  from  the  Culture-Liquids  of 
the  Hog-Cholera  Germ.  By  E.  A.  v.  Schweinitz,  Ph.  D.  [Reprinted 
from  the  Medical  Weirs.] 

Report  of  the  First  Annual  Commencement  of  the  Training  School 
for  Nurses  of  Wilkesbarre  City  Hospital,  June  18,  1890. 

Zur  operativen  Entfernung  eingeklemmter  Gelenkmiiuse  des  Knie- 
gelenkes.  Von  Prof.  Dr.  Max  Schuller  in  Berlin.  [Sonderabdruck  aus 
der  Deutschen  medicinischen  Wochenschrift.] 

Neue  Beitrage  zur  Kenntniss  der  syphilitischen  Gelenkentziind- 
ungen.  Von  Dr.  Friedr.  Rubinstein  (Berlin).  [Separat-Abdruck  aus 
No.  16  des  Aerztl.  Praktikers .] 

Zur  Behandlung  der  gonorrhoischen  Gelenk-  und  Schleimbeutel- 
entziindungen.  Von  Dr.  Fr.  Rubinstein  in  Berlin.  [Sonderabdruck 
aus  Therapeutische  Monatshefte .] 


Utisr^llang. 


The  American  Orthopaedic  Association.— At  the  recent  meeting,  the 
president,  Dr.  De  Forest  Willard,  of  Philadelphia,  after  welcoming  the 
members,  narrated  his  experiences  in  the  observation  of  orthopedics  in 
Europe  during  the  past  summer.  He  congratulated  American  ortho¬ 
pedic  surgeons  upon  their  decided  superiority  as  regarded  the  applica¬ 
tion  of  general  and  surgical  knowledge  and  the  benefit  to  be  derived 
from  operative  measures  in  the  correction  and  relief  of  deformities. 
The  safety,  rapidity,  and  ease  with  which  many  bodily  defects  could  be 
rectified  by  the  knife  and  chisel,  and  the  great  advances  made  in  the 
practice  of  antiseptic  surgery,  were,  as  a  means  of  relief,  more  fully 
appreciated  by  Americans  than  by  others.  He  would,  however,  give 
all  credit  to  Maceweu  for  his  advocacy  of  osteotomy,  while  to  Lister 
belonged  the  honor  of  securing  that  advance  in  surgery  which  in  its 
varying  applications  had  revolutionized  surgical  practice.  In  regard  to 
mechanical  advances,  the  invention  and  application  of  mechanical  meas¬ 
ures  for  the  correction  of  deformities,  for  securing  rest,  for  traction, 
for  immobilization,  and  for  the  proper  treatment  of  joint  diseases, 


[N.  Y.  Mkd.  Jour. 

Americans  could  justly  maintain  that  they  were  in  the  first  rank.  He 
then  alluded  to  the  orthopaedic  section  of  the  International  Medical  Con¬ 
gress,  which  had  been  established  through  American  efforts.  The  most 
novel  idea  associated  with  this  particular  branch  of  the  work  shown  at 
the  exhibition  of  Berlin  was  the  ivory  joints  of  Gluck  by  which  he  pro¬ 
posed  to  replace  the  excised  portions  of  bone.  These  joints  were  in¬ 
tended  to  remain  permanently  in  position,  and  to  maintain  the  proper 
functions  of  the  limb.  While  the  subject  was  only  yet  in  its  experi¬ 
mental  stage,  in  both  theory  and  practice,  yet  he  deemed  it  worthy  of 
consideration.  Dr.  Bely’s  apparatus  for  the  correction  of  deformities 
of  the  chest  arising  from  lateral  curvature  of  the  spine  by  weight 
pressure  exercised  upon  the  individual  in  a  stooping  posture  was  highly 
commended.  The  president  closed  his  remarks  by  referring  regretfully 
to  the  death  of  two  of  the  members,  Dr.  Lewis  Hall  Sayre,  of  New 
York,  and  Dr.  David  Prince,  of  Illinois. 


ANSWERS  TO  CORRESPONDENTS. 

No.  332. — We  think  not. 

No.  333. — The  name  is  French,  not  German. 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti¬ 
cles,  we  alivays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (i)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  typesetters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  cither  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters ,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  ami  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him. 
in  care  of  the  piddishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  MW  YORK  MEDICAL  JOURNAL,  October  4,  1890. 


Ccrtures  anti  gUb  r  c  ss  cs  . 


THE  DOCTORATE  ADDRESS 

DELIVERED  BEFORE  THE 

GRADUATING  CLASS  OF  THE  KENTUCKY  SCHOOL  OF  MEDICINE, 

June  19,  1890. 

By  THE  HON.  J.  PROOTOR  KNOTT, 

GOVERNOR  OF  KENTUCKY. 

[After  a  humorous  exordium  which  at  once  put  him 
completely  en  rapport  with  his  audience,  Governor  Knott 
said  :] 

Pardon  me,  however,  if  I  call  your  attention  at  the  very 
threshold  to  the  duties  and  responsibilities  of  the  profes¬ 
sion  to  which  you  have  consecrated  your  talents,  your  en¬ 
ergies,  and  your  lives.  No  other  calling  known  among 
men  demands  a  more  absolute  self-abnegation  than  the  one 
you  have  chosen.  No  other  vocation — not  even  the  sacred 
ministration  of  religion  itself — requires  a  more  constant 
exercise  of  the  higher  faculties  of  the  human  mind  or  a 
more  earnest  devotion  of  the  purer  and  nobler  attributes 
ef  the  human  soul. 

The  physician  who  is  thoroughly  imbued  with  the  true 
spirit  of  the  Hippocratic  oath  not  only  dedicates  his  life 
o  the  service  of  his  fellow-man,  but  abjures  everything  that 
:an  impair  his  usefulness,  degrade  his  profession,  or  debase 
he  dignity  of  his  manhood.  Wherever  the  plaintive  voice 
>f  human  suffering  calls — whether  from  the  palace  or  the 
lovel,  the  sumptuous  abode  of  luxurious  ease  or  the  infec- 
ious  wards  of  the  loathsome  lazar-house — regardless  of 
:verv  consideration  of  his  own  security  or  comfort,  un- 
nindful  of  the  tempest  that  may  rage  around  him  or  of 
he  insidious  virus  of  contagion  that  may  steal  into  the 
:itadel  of  his  life  with  the  very  air  he  breathes,  he  must 
£0.  While  the  life  or  death  of  his  stricken  patient  may 
mng  upon  his  tenderness  and  skill  he  is  the  anxious  suf- 
erer’s  loadstar  of  hope,  the  repository  of  his  confidence, 
he  custodian  of  his  honor,  his  friend  and  adviser  in 
ns  last  dark  hour,  and  the  comforter  of  the  loved  ones 
vho  may  gather  in  impotent  anguish  about  his  dying 
much. 

If  there  is  one  of  your  number  who  has  failed  to  realize 
n  all  their  awful  solemnity  the  tremendous  obligations  in- 
eparable  from  such  duties  and  responsibilities,  or  who  has 
lot  resolved  that,  so  far  as  God  hath  given  him  the  capacity, 
ie  will  emulate  the  virtues  and  rival  the  skill  of  the  most 
accomplished  of  his  compeers  or  the  proudest  of  his  pre- 
leccssors,  I  would  tell  him  now,  in  all  sincerity  and  candor, 
hat  he  has  made  a  grave  mistake  in  his  calling — the  noble 
irofession  of  medicine  is  not  for  him. 

I  congratulate  myself  in  the  belief,  however,  that  none 
>f  you  are  so  ignoble  in  your  aspirations  as  to  be  content 
vith  the  mean  promise  of  the  old  Spanish  proverb  “that  in 
village  where  every  one  else  is  blind  the  one-eyed  man  is 
ing.”  On  the  contrary,  I  feel  confident  that  I  voice  the 
manimous  sentiment  of  your  class  when  I  say  that  one  who 
ould  be  degraded  enough  to  take  advantage  of  the  unsus- 
'ecting  credulity  of  his  fellow-man  and  ignorantly  tamper 


with  his  life  or  his  health,  with  no  higher  motive  than  the 
gratification  of  a  sordid,  unholy  lust  for  gain,  trusting  to 
the  kind  offices  of  the  undertaker  to  hide  the  evidences  of 
his  murderous  charlatanry  out  of  sight,  it  would  be  the 
basest  flattery  to  call  a  scoundrel.  I  am  satisfied  that  there 
is  not  one  of  you  who  is  not  inspired  by  the  noble  ambi¬ 
tion  to  become,  not  only  the  peer  of  the  proudest  of  your 
chosen  profession,  but  princeps  inter  pares. 

You  should  remember,  however,  that  such  a  position 
among  the  truly  great  does  not  “come  by  nature,”  as  hon¬ 
est  Dogberry  supposed  to  be  the  case  with  reading  and 
writing.  If  you  would  occupy  it,  you  must  win  it  for 
yourselves.  If  you  would  wear  the  laurel,  you  must  bear 
the  heat  and  dust  of  the  arena.  You  can  never  scale  the 
perilous  pinnacle  of  professional  distinction  by  standing 
idly  at  its  base  and  gazing  listlessly  at  the  coveted  diadem 
that  glitters  upon  its  summit.  You  must  climb  the  dizzy 
height  with  slow  and  painful  toil,  and  you  had  better  real¬ 
ize  that  fact  at  once. 

Let  me  conjure  you,  therefore,  to  set  about  it  now. 
Eschew,  this  hour  and  for  life,  whatever  may  tend  to  impair 
your  faculties  or  impede  your  progress.  Concentrate  all 
the  energies  of  your  nature  upon  the  achievement  of  that 
one  grand  object  and  enter  upon  it  with  an  invincible  con¬ 
fidence  in  yourselves.  Do  not  mistake  me,  I  pray  you.  I 
do  not  mean  the  ridiculous  self-conceit  of  the  contemptible 
coxcomb  of  the  profession,  who  imagines,  because  he  has 
his  diploma,  that  his  number  six  hat  covers  all  the  medical 
science  that  has  been  developed  since  the  birth  of  Chiron 
the  Centaur.  When  I  counsel  confidence  in  yourselves,  I 
mean  courage — a  brave,  manly,  unconquerable  reliance  upon 
your  own  exertions;  an  abiding  consciousness  that  what¬ 
ever  man  has  done  man  may  do  again ;  the  cheerful  con¬ 
viction  that  Hercules  helps  those  who  help  themselves. 
You  may  do  this  and  still  incur  no  risk  of  being  dazzled 
by  your  admiration  of  your  own  intellectual  endowments. 
Extraordinary  as  the  natural  abilities  of  some  of  the  more 
brilliant  of  your  profession  may  appear  to  you,  the  mental 
disparity  between  them  and  yourselves  is  by  no  means  so 
great  as  you  may  possibly  suppose.  Axtell  or  Sunol  may 
be  able  to  go  a  mile  or  ten  miles,  perhaps,  much  quicker 
than  a  common  plug,  but  the  plug  will  make  it  in  his  own 
time  if  he  keeps  on  plugging. 

Remember  that  he  who  is  capable  of  thoroughly  mas¬ 
tering  the  five  fundamental  rules  of  arithmetic  may  in  time,, 
by  patient  and  persistent  effort,  solve  with  facility  and 
pleasure  the  most  abstruse  proposition  in  the  highest  range 
of  mathematics  and  make  himself  as  familiar  with  the  sub¬ 
lime  machinery  of  the  sidereal  universe  as  with  the  sim¬ 
plest  piece  of  mechanism  fabricated  by  human  hands. 
What  he  may  lack  in  natural  aptitude  he  may  supply  by 
well-directed  energy  and  patient  perseverance.  Fix  your 
eye  steadily  upon  the  bright  goal  of  your  ambition  and  con¬ 
stantly  press  toward  it 

“Like  the  Pontic  Sea, 

Whose  icy  current  and  compulsive  course 
Ne’er  feels  retiring  ebb,  but  keeps  due  on 
To  the  Propontic  and  the  Hellespont.” 


KNOTT:  DOCTORATE  ADDRESS. 


[N.  Y.  Med.  Jotjk., 


I  am  aware  that  when  you  look  over  the  long  catalogue 
of  illustrious  names  that  adorn  the  annals  of  your  profes¬ 
sion  and  consider  the  wonderful  contributions  they  have 
made  to  the  sciences  of  medicine  and  surgery,  you  are  apt 
to  think  that  your  predecessors  have  left  you  nothing  to 
do  but  to  practice  what  they  have  taught,  or,  at  best,  to 
glean  a  well-reaped  field  where  there  is  no  glory  to  be  won 
and  no  garlands  to  be  woven.  Yet  there  was  never  a  graver 
mistake.  Your  profession,  with  all  its  marvelous  develop¬ 
ment  in  learning  and  all  its  astonishing  exhibitions  of  skill, 
has  but  barely  approached  the  domain  of  scientific  truth 
and  anchored  in  some  of  its  smaller  inlets.  The  occasional 
adventurer  who  has  gone  ashore  has  only  picked  up  a  few 
trifling  pebbles  that  lay  scattered  along  the  beach.  The 
territory  remaining  to  be  explored  is  as  illimitable  as  the 
universe  itself. 

The  saying  is  trite  indeed  that,  of  all  the  great  de¬ 
partments  of  human  knowledge,  medicine  is  that  in  which 
the  accomplished  results  are  most  obviously  tentative  and 
imperfect — the  one  in  which  the  range  of  unrealized  pos¬ 
sibilities  is  most  varied  and  extensive,  and  the  one  from 
which  the  most  astonishing  and  beneficent  returns  might 
be  expected  if  the  same  patient  and  intelligent  investigation 
were  directed  to  it  that  has  been  employed  during  the  cur¬ 
rent  century  in  mechanical  invention  and  material  develop¬ 
ment.  Let  me  exhort  you,  then,  to  learn,  above  all  things, 
“  to  labor  and  to  wait.”  The  world  was  not  finished  in  a 
day  ;  the  mountain-range,  whose  snow-clad  summit  is  kissed 
by  the  earliest  gleam  of  the  morning  sun,  was  not  the 
growth  of  an  hour,  but  the  slow  product  of  myriads.of  ages. 
The  history  of  human  progress  is  crowded  with  illustrations 
of  the  fact  that  we  are  constantly  in  contact  with  principles 
and  conditions  which  have  remained  unobserved  since  crea¬ 
tion’s  dawn,  waiting  for  some  patient,  inquisitive  thinker 
to  recognize  and  develop  them — great  germinal  truths  which 
mav  become  the  prolific  sources  of  incalculable  benefits  to 
our  race ;  and,  for  aught  we  know,  the  one  who  will  be 
crowned  by  the  common  acclaim  of  coming  ages  as  the 
greatest  of  all  the  discoverers  in  medical  science  the  world 
has  ever  known,  from  the  age  of  the  Asclepiadae  to  the 
present  hour,  may  be  sitting  at  this  moment  in  your  midst. 

Have  you  ever  traced  the  tremendous  consequences 
which  have  frequently  resulted  from  an  accidental  thought 
or  the  most  trivial  and  aimless  experiment?  Over  twenty- 
five  hundred  years  ago  Thales,  of  Miletus,  observed  that  by 
rubbing  a  bit  of  amber  it  was  made  to  attract  light  objects 
with  which  it  was  brought  in  contact.  Thousands  gazed  in 
stupid  wonder  upon  the  mysterious  phenomenon.  It  was 
noticed  three  hundred  years  afterward  by  Theophrastus, 
and  four  hundred  years  later  by  Pliny  ;  yet  none  of  them 
ever  dreamed  that,  in  the  subtle  agency  which  they  supposed 
barely  capable  of  lifting  a  feather,  there  lurked  the  strength 
of  a  sleeping  giant,  more  marvelous  in  the  magnitude  and 
versatility  of  its  powers  than  all  the  fabled  genii  of  the 
East.  But  a  little  less  than  a  century  ago,  by  the  most 
trifling  of  all  possible  accidents,  the  attention  of  one  of 
your  own  profession  was  directed  to  the  same  occult  force 
under  different  and  totally  unsuspected  conditions.  His 
observations  upon  the  accidental  discovery  he  had  made 


inaugurated  a  series  of  intelligent  experiments,  and  to-day 
electricity  is  the  ready  servant  of  man  in  all  his  manifold 
necessities.  Tractable  as  the  homing  dove,  it  carries  his 
messages  around  the  world  with  the  speed  of  thought.  It 
is  the  unerring  instrument  of  the  enlightened  scientist  in 
his  most  subtle  investigations,  the  indispensable  implement 
of  the  ingenious  artisan  in  his  most  delicate  handicraft,  and 
one  of  the  most  effective  agencies  of  the  skillful  physician 
in  relieving  the  sufferings  of  his  fellow-beings.  It  propels 
our  machinery  with  the  power  of  a  thousand  horses,  and 
mocks  the  effulgence  of  the  noonday  sun  with  the  dazzling 
splendor  of  its  light.  And  yet  how  little  we  know  of  the 
real  nature  or  the  ultimate  possibilities  of  that  wonderful 
agency  which  would,  perhaps,  have  remained  dormant  for 
ages  yet  to  come  but  for  the  initial  observations  of  Gal- 
vani ! 

If  I  have  dwelt  at  undue  length  upon  this  familiar  illus¬ 
tration,  selected  at  random  from  a  multitude  that  might  be 
adduced,  I  have  done  so  to  impress  upon  your  minds,  not 
only  the  pregnant  truth  that  the  wide  field  of  useful  labor 
you  have  selected  teems  with  rich  rewards  for  your  intelli¬ 
gent  toil,  but  the  paramount  importance  of  constantly  culti¬ 
vating  correct  habits  of  observation  and  thought.  Aristotle 
was  right  when  he  said  that  “  incredulity  is  the  source  of 
all  wisdom.”  You  should  think  for  yourselves — closely, 
carefully,  patiently,  and  independently  upon  everything  that 
mav  come  under  your  notice,  that  may  be  at  all  cognate  to 
your  profession,  and  never  be  satisfied  that  you  know 
enough  about  anything  as  long  as  anything  about  it  re¬ 
mains  unknown.  Take  nothing  for  granted  that  may  seem 
inconsistent  with  correct  reason  or  established  facts,  simply 
because  some  one  of  acknowledged  authority  may  have 
said  it;  and  reject  nothing  as  unworthy  of  your  investiga¬ 
tion  on  account  of  its  apparent  insignificance,  or  because  it 
does  not  seem  to  square  precisely  with  the  preconceived 
theories  of  the  faculty. 

Had  Jenner  been  less  observant,  or  less  inquisitive,  or 
too  bigoted,  or  too  indolent  for  investigation,  he  would 
probably  have  been  content  to  prescribe  some  simple  salve 
for  the  pustule  on  the  milkmaid’s  hand,  and  thousands 
would  be  dying  to-day  of  small-pox  who  enjoy  an  absolute 
immunity  from  that  dangerous  and  disgusting  disease. 
Whether  the  old  Jesuit  fathers  taught  the  doctrine  that 
“the  proof  of  the  pudding  is  in  chewing  the  bag”  I  do  not 
know ;  but  if  the  doctor  who  accompanied  one  of  their  early 
missions  to  Peru  had  not  adopted  the  custom  prevalent 
among  the  aborigines  of  chewing  the  bark  in  order  to  as¬ 
certain  the  nature  of  the  tree,  it  is  probable  that  quinine, 
the  sine  qua  non  of  his  more  modern  professional  brethren, 
would  have  been  postponed  for  centuries. 

In  the  first  year  of  the  present  century  Sir  Humphry 
Davy  suggested  the  employment  of  nitrous  oxide  as  an 
anaesthetic  in  surgery;  but,  as  the  suggestion  came  from  a 
layman,  it  was  passed  unheeded,  if  not  with  silent  disdain, 
by  the  great  lights  of  your  profession.  Eighteen  years  later 
Michael  Faraday  called  attention  to  the  anaesthetic  effects 
of  sulphuric  ether,  but  it  was  regarded  merely  as  a  matter 
for  curious  experiment  in  the  lecture-room,  but  of  no  prac¬ 
tical  consequence.  Nearly  forty  years  ago  an  obscure  but 


Oct.  4,  1890.] 


KNOTT:  DOCTORATE  ADDRESS. 


367 


inquisitive  countryman  happened  to  be  present  when  one  of 
his  neighbors  was  bitten  by  a  rattlesnake.  He  not  only  ob¬ 
served  the  almost  instantaneous  effect  of  the  poison,  but  ex¬ 
amined  the  fang,  and  finding  it  to  be  a  finely-pointed  tube 
through  which  the  virus  had  been  injected  into  the  circula¬ 
tion  of  the  victim,  it  occurred  to  him  at  once  that  the  effects 
of  an  anodyne  administered  in  a  similar  manner  would  be 
equally  prompt.  He  carried  the  murderous  tooth  to  an  in¬ 
telligent  physician,  explained  its  operation,  and  begged  him 
to  have  an  instrument  made  by  which  morphine  and  other 
medicines  might  be  similarly  applied  for  the  relief  of  human 
suffering.  The  doctor  smiled  at  his  rustic  simplicity,  but 
now  he  would  consider  himself  everlastingly  disgraced  if  he 
should  be  caught  without  a  hypodermic  syringe  and  a  little 
phial  of  morphine  and  atropine  in  his  vest  pocket. 

I  mention  these  facts  not  only  to  illustrate  the  impor¬ 
tance  of  your  paying  attention  to  little  things,  but  to  warn 
you  not  to  reject  an  apparently  reasonable  suggestion  with¬ 
out  proper  investigation,  no  matter  from  what  source  it  may 
come.  The  leading  principles  taught  by  “the  great  father 
of  medicine”  himself  were  those  of  rational  empiricism. 
He  neither  attempted  nor  pretended  to  form  his  theories 
from  a  priori  reasoning,  but  made  a  careful  study  of  the 
phenomena  of  nature,  and  from  them  deduced  such  conclu¬ 
sions  as  those  phenomena  seemed  to  justify. 

The  celebrated  Cornelius  Celsus,  the  contemporary,  if 
not  an  associate,  of  Horace  and  Ovid,  although  a  follower 
of  Hippocrates  and  Asclepiades,  was  not  a  blind  adherent 
of  any  sect.  He  did  not  hesitate  to  dissent  from  the  views 
of  his  illustrious  prototypes  where  he  thought  they  were  in 
error,  and  accepted  with  equal  impartiality  whatever  he 
found  to  commend,  whether  in  the  teachings  of  the  Em¬ 
pirics,  the  Dogmatics,  the  Methodics,  or  the  Eclectics;  and 
the  immortal  Claudius  Galenus  himself,  the  most  distin¬ 
guished  and  the  most  esteemed  of  all  the  ancient  apostles 
of  medical  science,  while  strenuously  maintaining  the  supe¬ 
riority  of  theory  over  mere  empiricism,  blended  in  his  own 
school  the  empirical  knowledge  he  had  derived  from  the 
teachings  of  Satyrus,  Stratonicus,  and  Escbrion.  In  short, 
the  man  who  makes  himself  truly  great  in  any  calling  is  the 
one  who  has  sense  enough  to  know  a  good  thing  when  he 
sees  it,  and  decision  of  character  enough  to  make  it  useful 
whenever  he  may  find  it. 

Whatever  you  may  accomplish,  however,  in  your  pro¬ 
fessional  career,  you  should  make  up  your  minds  not  to  be 
surprised  to  find  yourselves  deprived  of  much  of  the  credit 
that  may  be  justly  due  you.  In  your  profession,  as  in  all 

others — 

“  Full  many  a  flower  is  born  to  blush  unseen, 

And  waste  its  sweetness  on  the  desert  air,” 

while,  on  the  other  hand,  full  many  a  name  shines  upon  the 
envied  page  of  history  with  a  borrowed  light  to  which  it  is 
not  entitled,  and  which  its  owner  himself  would  not  pretend 

to  claim. 

Both  of  these  ideas  are  illustrated,  to  some  extent,  in 
the  present  fame  of  the  celebrated  William  Harvey.  If 
that  illustrious  man  could  return  to  the  earth  to-night  he 
would  probably  be  astounded  to  find  himself  regarded  by 
millions  of  people,  including  a  large  majority  of  even  the 


more  intelligent  classes,  as  the  first  discoverer  of  the  mere 
movement  of  the  blood  in  the  human  body,  a  fact  familiar 
to  thousands  from  the  earliest  antiquity.  He  was  not  even 
the  first  to  suggest  the  idea  of  its  circulation,  which,  it  is- 
said,  was,  at  least  remotely,  conjectured  by  the  immortal 
Stagirite  himself,  and  still  more  distinctly  by  Mondinor 
Berenger,  and  others  of  more  modern  times.  Whether  it 
was  observed  by  the  great  Yesalius  or  not,  we  have  no 
means  of  knowing,  but  it  is  certain  that  the  leading  out¬ 
lines,  not  only  of  the  pulmonary  but  the  larger  circulation, 
were  taught  by  his  friend  and  successor,  the  ill-fated  Mi¬ 
chael  Servetus,  more  than  fifty  years  before  Harvey  was  born  ; 
and  still  more  clearly  by  others,  especially  by  Harvey’s  pre¬ 
ceptor  in  anatomy — Fabricius — who  pointed  out  to  his 
pupil  the  valves  in  the  veins  of  the  extremities,  and  set  his 
inquisitive  mind  to  investigating  their  office.  If  he  could 
stand  where  I  stand  and  speak  to  you  as  I  do  to-night,  he 
would  tell  you  that  he  only  did  what  some  of  you  may  yet 
do  with  respect  to  some  other  important  but  unsettled  ques¬ 
tion  in  your  profession — that  he  was  not  willing  to  sit 
down,  content  with  what  others  had  ascertained,  but  that 
he  gathered  up  all  the  facts  already  known,  improved  upon 
the  knowledge  of  his  predecessors,  and,  by  a  series  of  pa¬ 
tient,  intelligent,  and  carefully-conducted  experiments,  elab¬ 
orated  an  already  existing  theory,  and  demonstrated  its 
truth  to  the  exclusion  of  a  doubt. 

I  have  alluded  to  the  example  of  this  famous  physician, 
however,  more  especially  to  emphasize  the  important  truth 
that,  without  a  certain  degree  of  dissatisfaction  with  the 
existing  condition  of  professional  learning,  coupled  with  a 
passionate  disposition  for  honest,  earnest,  independent,  and 
intelligent  inquiry,  anything  like  progress  in  medical  sci¬ 
ence  is  an  impossibility.  It  is  universally  admitted  that 
among  all  the  brilliant  names  that  illustrate  the  earlier  an¬ 
nals,  if  not  the  entire  history  of  your  profession,  that  of 
Galen  stands  pre-eminent.  Yet  it  would  have  been  far 
better  for  the  human  family,  perhaps,  if  Galen  had  never 
been  born. 

The  blind,  abject,  almost  idolatrous  deference  of  his  suc¬ 
cessors  to  his  teachings,  with  all  their  crudities  and  absurdi¬ 
ties,  postponed  everything  like  genuine  progress  in  scien¬ 
tific  medicine  for  centuries.  They  regarded  his  writings  as 
the  ultimate  authority  from  which  there  could  be  no  appeal, 
and  rejected  with  disdainful  scorn  whatever  appeared  to  be 
inconsistent  with  his  dicta.  In  their  vain  attempts  to  rec¬ 
oncile  the  theories  of  their  master  with  the  phenomena  of 
Nature,  they  had  but  little  time  to  interrogate  Nature  her¬ 
self,  and  still  less  inclination  to  pursue  the  study  of  medical 
science  in  those  fields  in  which  it  can  be  followed  with  any 
assurance  of  success.  Eschewing  everything  like  originality 
of  thought  or  independence  of  inquiry,  they  went  on  for 
more  than  five  hundred  years,  stifling  intelligent  investiga¬ 
tion  and  killing  their  patients  according  to  the  most  ap¬ 
proved  methods  of  Galenian  science. 

I  would  warn  you,  however,  that  if  it  should  be  your 
fortunate  lot  to  make  any  great  discovery  or  improvement 
in  the  practice  of  your  chosen  art,  or  any  very  remarkable 
contribution  to  medical  science,  you  should  be  prepared  for 
a  general  howl  of  dissent  from  the  less  profound  and  more 


368 


KNOTT:  DOCTORATE  ADDRESS. 


[N.  Y.  Med.  Joub., 


pretentious  of  your  professional  brethren  until  it  shall  have 
received  the  approbation  of  their  acknowledged  leaders.  I 
atn  not  fully  prepared  to  believe  that  the  man  who  first 
suggested  the  practicability  of  carrying  corn  in  both  ends 
of  the  bag  when  going  to  the  mill,  instead  of  the  old  prac¬ 
tice  of  putting  a  rock  in  one  end  to  balance  the  corn  in  the 
other,  was  actually  mobbed  by  his  indignant  neighbors  as  a 
dangerous  revolutionist ;  but  I  suppose  it  is  really  true  that 
Galileo  barely  escaped  a  sound  roasting  for  expressing  the 
opinion  that  the  earth  moved  around  the  sun,  and  not  the 
sun  around  the  earth.  It  is  a  fact,  at  any  rate,  that  the 
disturber  of  ancient  prejudices  or  long-accepted  opinions 
generally  raises  a  storm  about  his  head,  and  nowhere  has 
that  truth  been  more  frequently  or  more  strikingly  illustrated 
than  in  the  history  of  the  medical  profession. 

When  Galen,  at  the  solicitation  of  many  of  the  most 
distinguished  philosophers  and  men  of  rank,  commenced  a 
course  of  lectures  in  the  Imperial  City  upon  the  anatomy 
of  the  human  system,  the  novelty  of  his  teachings  and  the 
bold  contempt  with  which  he  assailed  the  long-accepted 
fallacies  of  his  predecessors  raised  such  a  tempest  of  indig¬ 
nant  criticism  among  his  professional  rivals  that  he  was  not 
•only  compelled  to  abandon  the  rostrum,  but  to  get  out  of 
Home.  And  when  Vesalius,  in  the  sixteenth  century,  de¬ 
fied  the  authority  of  Galen,  which  was  still  considered  su¬ 
preme,  and  destroyed  by  actual  demonstration  the  credit  of 
nearly  all  the  learning  to  which  the  earlier  masters  had 
pretended  ;  when  he  swept  away  the  long-venerated  rubbish 
of  ancient  error  and  laid  the  immutable  foundation  upon 
which  the  splendid  fabric  of  modern  medical  science  has 
been  reared,  he  brought  upon  himself  a  perfect  deluge  of 
virulent  reproach  from  even  the  most  distinguished  of  his 
professional  contemporaries.  And  you  will  perhaps  be  sur¬ 
prised  to  learn  that  among  the  foremost  of  his  detractors 
was  the  celebrated  Falloppius,  concerning  whom,  I  have  no 
doubt,  you  have  heard  a  good  deal  from  your  diffident 
but  distinguished  dean,  unless  his  lectures  have  been  too 
much  abridged  by  his  characteristic  taciturnity. 

When  Harvey  first  published  to  the  world  his  beautiful 
demonstration  of  the  true  theory  of  the  circulation  of  the 
blood,  it  is  said  that  there  was  not  a  single  physician  over 
forty  years  of  age,  either  in  Great  Britain  or  on  the  Con¬ 
tinent,  who  coincided  with  his  views.  On  the  contrary, 
his  practice  fell  away  from  him,  and  he  was  for  years  the 
object  of  the  extremest  obloquy  and  abuse.  Nor  was  it  until 
after  his  experiments  had  been  repeated,  and  his  observa¬ 
tions  indorsed  by  many  of  the  most  eminent  anatomists 
and  physiologists  of  the  period,  that  his  theory  was  accept¬ 
ed  by  the  far  more  numerous  class  of  his  brethren  who 
were  profound  in  nothing  but  their  ignorance  of  scientific 
truth,  and  their  conceit  of  their  own  professional  culture 
and  ability. 

J 

And  so  when  Dr.  Ephraim  McDowell  published  his 
modest  account  of  his  first  ovariotomy,  some  eight  years 
after  it  was  performed,  it  was  denounced  as  a  falsehood, 
and  its  author  held  up  by  the  leading  medical  and  surgical 
writers  of  the  day  as  a  liar  and  an  impostor  ;  and  it  was  not 
until  ten  years  after  that  the  learned  editor  of  the  London 
Medico-chirurgical  Review ,  who  had  been  one  of  his  most 


malignant  satirists,  had  the  grace  to  thank  God  that  he  had 
lived  to  ask  pardon  of  the  great  pioneer  surgeon  of  Ken¬ 
tucky  for  the  injustice  he  had  done  him. 

It  is  an  ill  wind,  however,  that  blows  nobody  any  good; 
and  it  is  probable  that  the  world  is  indebted  to  the  intoler¬ 
ance  of  the  medical  profession  during  the  fifteenth  and  six¬ 
teenth  centuries  toward  any  improvement  or  innovation  in 
their  own  peculiar  department  of  learning  for  the  initial 
step  in  the  wonderful  development  of  astronomical  science 
which  has  taken  place  since  that  period.  About  the  year 
1500  a  German  physician,  becoming  disgusted  with  the 
bigoted  deference  to  the  doctrines  of  the  earlier  masters, 
which  seemed  to  render  any  advancement  in  the  philosophy 
or  practice  of  his  profession  an  impossibility,  abandoned 
it  and  devoted  himself  to  the  study  of  mathematics.  He 
soon  detected  the  absurdities  of  the  Ptolemaic  hypothesis 
concerning  our  system  of  planets,  and  revived  the  theory 
of  Pythagoras  that  the  sun  was  the  center  of  a  series  of 
spheres,  including  our  earth,  which  revolved  around  it, 
and  also  upon  their  respective  axes.  For  thirty  years  he 
labored  on  the  demonstration  of  that  sublime  truth,  and 
to-night  the  name  of  Nicholas  Copernicus,  the  great  proto¬ 
type  of  Kepler,  Galileo,  Newton,  Herschel,  and  Leverrier, 
remains  written  upon  the  star-decked  vault  of  heaven  in 
characters  of  ineffable  glory,  to  be  hyrnned  by  the  spheres 
as  long  as  they  shall  continue  in  their  wondrous  pathway 
through  the  skies. 

I  hope  I  have  made  myself  clearly  understood  in  urging 
upon  you  the  importance  of  thinking  and  investigating  for 
yourselves.  Mark  me :  I  would  by  no  means  advise  you 
to  tamper  with  the  health  or  trifle  with  the  lives  of  your 
patients  by  reckless  or  questionable  experiments;  far  from 
it,  indeed.  You  had  infinitely  better  confine  yourselves  to 
catnip,  comfrey,  and  elecampane  for  the  sake  of  your  own 
consciences  as  well  as  for  their  safety.  I  simply  mean  that, 
while  you  should  act  prudently,  you  should  act  independ¬ 
ently  ;  that  you  should  not  regard  everything  you  see  in 
the  text-books  as  absolutely  infallible,  nor  reject  anything 
because  it  may  not  be  backed  by  the  ipse  dixit  of  some  rec¬ 
ognized  authority  in  the  profession. 

John  of  Salisbury,  one  of  the  most  celebrated  scholars 
and  among  the  wittiest  writers  of  the  twelfth  century,  has 
left  us  a  sketch,  in  his  Polgcraticon,  of  the  average  medical 
graduate  of  his  period,  which  I  beg  leave  to  read  to  you,  in 
order  that  you  may  see  the  immense  difference  between 
them  and  some  of  the  newly-fledged  physicians  of  the  pres¬ 
ent  enlightened  day.  He  says: 

“They  return  from  college  full  of  flimsy  theories  to 
practice  what  they  have  learned.  Galen  and  Hippocrates 
are  continually  in  their  mouths.  They  speak  aphorisms 
on  every  subject,  and  make  their  hearers  stare  at  their 
long,  unknown,  and  high-sounding  words.  The  good  peo¬ 
ple  believe  that  they  can  do  anything  because  they  pretend 
to  all  things.  They  have  but  two  maxims  which  they 
never  violate — never  mind  the  poor;  never  refuse  money 
from  the  rich.” 

We  find  an  occasional  survivor  of  this  species  even  in 
our  own  age,  and  if  there  is  one  of  vou  who  has  made  up 
his  mind  to  prostitute  his  sublime  profession  solely  to  the 


Oct.  4,  1890.] 


RIDLON:  SIXTY-TWO  CASES  OF  HIP  DISEASE. 


869 


sordid  purpose  of  accumulating  lucre  he  will  be  certain  to 
take  his  place  among  them,  and  you  will  soon  find  him  re¬ 
sorting  to  all  the  artifices  of  the  knavish  quack  in  order  to 
magnify  his  own  importance  and  to  multiply  his  chances 
for  “  gathering  gainful  pillage.” 

On  a  county  court  day,  when  the  streets  are  full  of  coun¬ 
try  folk,  he  will  rush  out  of  his  office,  fling  his  pill-bags 
across  his  saddle,  mount  his  horse,  and  gallop  off  on  a  sup¬ 
posititious  call,  as  though  life  or  death  depended  on  his 
speed;  and,  after  an  hour  or  two,  he  will  come  galloping 
back  again,  run  into  his  office,  rush  out  again  and  scurry 
away  in  the  opposite  direction.  He  will  be  a  prompt  at¬ 
tendant  of  the  most  popular  church  in  town,  where  he  will 
sit  “  as  demure  as  a  harlot  at  a  christening  ”  until  some  im¬ 
pecunious  emissary,  whom  he  has  hired  for  a  trifling  con¬ 
sideration  to  do  so,  hurries  in  with  a  most  anxious  expres¬ 
sion  on  his  countenance  and  calls  him  out  just  as  the  service 
has  reached  its  most  solemn  point. 

If  he  should  happen  to  perform  some  trifling  operation 
in  minor  surgery,  he  will  have  it  paraded  in  the  local  news¬ 
paper  as  one  of  the  most  astonishing  feats  of  the  scalpel 
since  the  days  of  Antyllus  or  Heliodorus  ;  but  if  he  should 
venture  beyond  his  depth,  and  cut  off  the  wrong  leg,  or 
have  his  victim  die  under  the  knife,  he  will  contrive  to  have 
as  little  said  about  it  as  possible,  and  satisfy  the  community 

that  the  patient’s  death  was  only  a  question  of  time  any- 

-  • 

way. 

While  constantly  parading  exaggerated  accounts  of  his 
own  superior  learning  and  skill,  he  will  lose  no  opportunity 
to  injure  his  absent  rival  by  insidiously  depreciating  his 
merits  or  openly  misrepresenting  him  behind  his  back.  If 
he  should  be  called  to  a  patient  in  the  absence  of  the  family 
physician,  he  will  not  fail  to  pronounce  the  medicine  which 
the  doctor  has  left  a  deadly  poison,  and  then  prescribe  the 
same  thing  under  another  name.  If  a  consulting  physi¬ 
cian  should  say,  in  the  presence  of  the  patient,  that  he 
might  safely  rely  upon  the  uvis  medicatrix  naturce ,”  he  will 
whisper  to  some  officious  friend  of  the  sick  person  standing 
by:  “That  will  kill  him  quicker  than  strychnine.”  In 
speaking  with  one  of  the  unlettered  multitude  about  his 
practice,  he  will  never  use  a  term  his  hearer  will  be  likely 
to  understand,  if  he  can  think  of  a  technical  synonym  of 
“  learned  length  and  thundering  sound.”  He  will  never 
prescribe  such  a  thing  as  a  common  poultice,  but  will  rec¬ 
ommend  a  cataplasm  of  certain  ingredients.  He  will  not 
even  suggest  a  wash  of  ordinary  salt  and  water  ;  it  must  be 
a  saturated  solution  of  sodium  chloride.  As  I  have  already 
said,  however,  I  am  happy  in  the  conviction  that  none  of 
the  gifted  and  aspiring  young  men  whom  I  have  the  honor 
to  address  to-night  will  ever  condescend  to  the  low  artifices 
or  be  content  with  the  degraded  level  of  the  vulgar  sham, 
the  mere  knavish  pretender. 

Mr.  Sergeant  Balentyne,  the  celebrated  English  barris¬ 
ter,  on  being  asked  what  was  the  highest  qualification  for  a 
Lord  Chief-Justice,  replied  that  “a  Lord  Chief-Justice 
should,  in  the  first  place,  be  a  gentleman,  and  then,  if  he 
should  know  a  little  law,  it  would  be  so  much  the  better.” 
And  so  I  would  say,  while  it  may  be  necessary  in  the  prac¬ 
tice  of  your  profession  that  you  should  know  something 


about  medical  science,  it  is  absolutely  indispensable  that 
you  should  be  gentlemen  !  By  this  I  do  not  mean  that  you 
should  simply  cultivate  the  graces  and  practice  the  ordinary 
amenities  of  courteous  intercourse  common  to  polite  society, 
but  that  you  should  at  all  times,  and  under  all  circumstances, 
illustrate  the  heaven-inspired  virtues  of  honest,  earnest,  no¬ 
ble  Christian  men.  That  you  should  spurn  with  indignant 
scorn  the  low,  mean  vices  of  envy,  malice,  and  evil  speak¬ 
ing,  and  never  suffer  yourselves  to  be  betrayed  into  any¬ 
thing  that  can  degrade  your  manhood  or  cast  the  slightest 
stain  upon  the  bright  escutcheon  of  your  honorable  profes¬ 
sion.  Above  all  things,  let  your  demeanor  toward  your  pro¬ 
fessional  brethren  be  candid,  manly,  and  just,  and  your  de¬ 
portment  to  your  patients  kind,  considerate,  and  conscien¬ 
tious. 

I  feel  that  I  owe  you  an  apology  for  having  detained 
you  so  long,  but  while  I  bid  you  the  heartiest  Godspeed  in 
your  chosen  career,  I  trust  you  will  permit  me  to  hope  that 
if  you  shall  at  some  time  in  the  great  unexplored  future  that 
lies  before  you  recall  a  single  word  I  have  spoken,  by  which 
you  have  been  comforted  or  encouraged  in  the  attainment 
of  the  success  to  which  you  aspire,  you  will  not  regret  the 
courteous  attention  you  have  given  me,  and  for  which  I 
tender  you  my  profoundest  thanks. 


(frighted  Comnumkaftons. 


A  REPORT  OF 

SIXTY-TWO  CASES  OF  HIP  DISEASE 

Observed  in  the  Practice  of  Hugh  Owen  Thomas ,  of  Liverpool* 

By  JOHN  RIDLON,  M.  D., 

ASSISTANT  SURGEON  AT  THE  VANDERBILT  CLINIC,  NEW  YORK. 

With  a  desire  to  present  for  your  consideration  further 
facts  regarding  the  use  of  the  Thomas  hip  splint,  I  spent 
twelve  days  during  the  month  of  June  of  this  year  in  Liver¬ 
pool,  and  examined  all  the  cases  of  hip  disease  coming 
under  the  observation  of  Mr.  Thomas  during  that  time. 

It  had  been  my  desire  to  make  a  report  upon  cured 
cases,  but  I  found  that  no  records  of  cases  had  been  kept, 
and  that  even  the  names  and  addresses  of  patients  were 
wanting.  I  therefore  contented  myself  with  taking  all  cases 
as  they  came,  not  with  the  idea  of  showing  ultimate  results, 
but  rather  the  presenting  of  a  picture  of  Mr.  Thomas’s  daily 
work.  New  cases  will  be  presented  ;  cases  where  the  treat¬ 
ment  has  just  been  commenced  ;  cases  that  have  been  under 
treatment  one  and  two  years  ;  cases  that  have  been  under 
treatment  five  and  six  years;  cured  cases;  cases  among  the 
poor  and  among  the  well-to-do;  and  cases  that  have  done 
badly  and  cases  that  have  done  well.  I  realize,  as  must 
every  one  else,  that  a  much  more  brilliant  showing  would 
have  been  made  had  only  cured  cases  been  considered ;  but 
it  is  not  to  make  a  brilliant  showing  that  I  present  this  re- 


*  Read  before  the  American  Orthopiedic  Association,  September  18, 
1890. 


370 


RID  LON:  SIXTY- TWO  CASES  OF  HIP  DISEASE. 


[N.  Y.  Med.  Jotr., 


port ;  my  only  desire  is  to  present  to  you  the  facts  as  I 
found  them. 

Every  opportunity  was  given  me  by  Mr.  Thomas  to 
question  and  examine  the  patients ;  and  the  facts  which  I 
shall  present  to  you  were  obtained  from  the  patients  them¬ 
selves,  or  their  parents,  and  the  measurements  were  all 
made  by  me. 

Statements  as  to  the  degree  of  deformity  present  when 
treatment  was  commenced,  and  as  to  the  length  of  time 
spent  in  bed,  I  found  to  be  so  uncertain  that  they  have 
been  omitted;  and  I  have  contented  myself  with  recording 
only  the  time  from  the  beginning  of  the  limp  or  pain,  or 
both,  to  the  commencement  of  treatment;  the  time  which 
the  long  splint  was  worn;  the  time  which  the  short  splint 
was  worn  ;  the  time  since  treatment  was  discontinued,  in 
cured  cases ;  the  presence  or  absence  of  abscesses,  and,  if 
present,  when  they  appeared  and  how  many,  and  the  sinuses 
remaining;  and  the  presence  or  absence  of  pain.  The  ex¬ 
amination  consisted  of  inspecting  the  patient  as  to  his  gen¬ 
eral  condition  ;  noting  the  presence  of  abscesses,  sinuses, 
and  cicatrices  of  sinuses ;  flexing  the  sound  leg  on  the  chest 
while  the  affected  leg  was  held  in  full  extension;  measur¬ 
ing  the  length  of  the  legs  and  the  degree  of  flexion  and  of 
abduction  or  adduction ;  and  testing  the  motion  in  those 
cases  where  the  splint  was  for  any  cause  removed.  The 
standard  position  taken  for  measuring  flexion  was  that 
which  is  known  as  “Thomas’s  flexion-test  position” — that 
is  to  say,  the  sound  leg  is  flexed  on  the  chest  to  such  a  de¬ 
gree  that  the  elbow  can  be  hooked  through  the  flexure  of 
the  knee,  the  anterior  surface  of  the  elbow  being  in  contact 
with  the  popliteal  space,  and  the  forearm  at  right  angles 
across  the  body.  This  position  effectually  overcomes  all 
lordosis,  and  in  some  cases  gives  a  lumbar  kyphosis,  so  that 
if  the  affected  leg  can  be  carried  down  to  the  table,  the  pa¬ 
tient,  of  course,  being  supine,  it  shows  that  the  joint  is  free 
from  all  flexion,  and  that  extension  to  a  certain  degree  is 
possible.  With  the  patient  then  in  the  flexion-test  position, 
the  angle  of  flexion  was  measured  after  the  plan  of  Dr. 
Kingsley,  of  Boston.*  In  those  cases  where  motion  was 
not  tested,  because  the  patient  was  not  removed  from  the 
splint,  if  the  sound  leg  could  be  flexed  on  the  chest  to  the 
flexion-test  position  while  the  affected  leg  was  confined  in 
the  splint,  the  popliteal  space  resting  on  the  table,  it  was 
considered  as  being  free  from  flexion,  and  so  noted.  It  will 
be  found  that  in  all  cases  where  flexion  is  present,  or  where 
any  special  joint  tenderness  remains,  it  will  either  be  impos¬ 
sible  to  flex  the  sound  leg  to  the  flexion-test  position,  or 
very  painful;  and  that  involuntary  muscular  spasm  can  be 
as  readily  detected  as  on  manipulating  the  affected  leg.  I 
have  on  that  account  noted  whether  there  was  present  or 
absent  tenderness  on  flexing  tbe  sound  leg  into  the  flexion- 
test  position.  The  terms  “  real  ”  and  “  apparent  ”  shorten¬ 
ing  or  lengthening  are  used  in  the  same  sense  as  suggested 
by  Dr.  Lovett, f  of  Boston,  and  the  abduction  or  adduction 
is  calculated  by  Dr.  Lovett’s  table. 

Sixty-two  cases  of  unilateral  hip  disease  were  seen  and 


*  G.  L.  Kingsley,  Boston  Med.  and  Surg.  Jour.,  July  5,  1888. 
t  R-  W.  Lovett,  Boston  Med.  and  Surg.  Jour.,  March  8,  1888. 


examined.  Four  of  them  (I,  II,  III,  IV)  were  new  cases  and 
are  recorded  simply  to  show  the  condition  of  cases  when 
they  present  for  treatment.  They  are  omitted  from  all  the 
calculations  excepting  that  of  the  average  duration  of  the 
limp  before  commencement  of  treatment. 

The  three  cases,  to  wit,  XXXIIT,  LX,  LXI,  were  in  chil¬ 
dren  in  well-to-do  families,  and  had  received  the  care  that 
we  are  accustomed  to  expect  in  private  cases.  It  is  not 
surprising,  then,  to  find  that  in  these  cases  the  results  are 
better  than  the  average  in  the  other  cases.  All  the  remain¬ 
ing  cases  were  from  among  the  poorer  classes,  who,  from 
ignorance  and  poverty,  had  received  no  better  care  than 
the  dispensary  class  receive  with  us.  Indeed,  many  of  them 
were  charity  cases,  and  the  sum  total  which  these  patients 
pay  to  Mr.  Tbomas  for  splint  and  treatment  is,  I  have  no 
doubt,  no  greater  than  dispensary  patients  with  us  are  ac¬ 
customed  to  pay  for  the  traction  hip-splint,  and  in  many  cases 
not  as  much.  It  should,  therefore,  be  evident  that  any  as¬ 
sumption  that  Mr.  Thomas  ought  to  get  better  results  than 
have  elsewhere  been  reported,  because  his  patients  are  pri¬ 
vate  patients,  is  unfair. 

The  average  duration  of  limp  before  treatment  was  com¬ 
menced  in  these  sixty-two  cases  was  a  little  over  ten  months. 

The  average  duration  of  treatment  was  not  computed,  as 
only  a  few  were  cured  cases,  and  as  many  had  been  under 
treatment  but  a  short  time. 

The  “  long  splint  ”  referred  to  is  that  which  is  ordinarily 
known  as  the  Thomas  splint,  and  extends  from  the  lower 
angle  of  the  scapula  to  the  lower  third  of  the  leg.  The 
“short  splint”  is  the  long  splint  cut  off,  and  not  extending 
below  the  knee.  Contrary  to  what  we  have  been  taught,  it 
was  found  that  the  long  splint  had  not  always  been  put  on 
at  the  beginning  of  treatment,  but  that  the  short  splint, 
which  “does  not  lock  the  knee,”  had  been  put  on  instead. 
In  some  cases  the  short  splint  had  been  replaced  later  by 
the  long  splint,  but  in  other  cases  its  use  had  been  continued 
throughout  the  entire  course  of  treatment.  Contrary,  also, 
to  what  we  have  been  taught,  nearly  all  of  these  children 
were  found  walking  around  without  high  patten  and 
crutches.  In  the  same  way  patients  were  allowed  to  walk 
before  the  deformity  had  been  overcome,  and  while  muscu¬ 
lar  spasm  and  deformity,  and  sometimes  pain,  still  persisted. 

Of  the  58  patients  that  had  been  under  treatment  for  a 
longer  or  shorter  time,  24  had  shortening,  24  had  adduc¬ 
tion,  5  had  abduction,  3  had  inward  rotation,  and  2  had 
outward  rotation.  In  the  cases  where  abduction  coexisted 
with  shortening  the  abduction  was  an  advantage,  as  it  com¬ 
pensated  in  a  measure  for  the  shortening. 

Of  the  24  patients  who  had  real  shortening,  2  had  \ 
inch,  9  had  ^  inch,  4  had  f  inch,  3  had  1  inch,  4  had 
inch,  1  had  2  inches,  and  1  had  2£  inches.  In  2  cases 
the  affected  leg  was  actually  longer  than  the  other  leg. 

One  patient  had  in-knee,  apparently  resulting  from  the 
action  of  the  adductor  muscles  of  the  thigh,  while  the  ankle 
was  held  by  the  splint  aDd  the  knee  was  not.  It  should  be 
noted  that  this  patient  was  walking  around  without  patten 
and  crutches,  while  there  still  remained  a  very  tense  invol¬ 
untary  spasm  of  the  adductor  muscles. 

Of  the  58  cases,  23  had,  at  some  time  during  their 


Oct.  4,  1890.] 


RID  LON:  SIXTY- TWO  GASES  OF  HIP  DISEASE. 


371 


course,  some  before,  but  many  after  treatment  had  been 
commenced,  presented  one  or  more  abscesses.  Of  these, 
one  had  disappeared  without  opening  and  another  was  fast 

disappearing. 

In  31  cases  the  motion  was  not  tested,  for  the  reasons 
above  stated.  In  27  it  was  tested;  12  patients  had  no  mo¬ 
tion,  10  had  some  motion,  2  had  motion  to  ninety  degrees, 
and  3  had  normal  motion.  It  should  be  borne  in  mind  that 
these  27  cases  in  which  motion  was  tested  were  either  cured 
cases,  or  so  well  advanced  in  convalescence  that  it  was  not 
thought  in  any  way  a  risk  to  test  the  motion  very  thor¬ 
oughly  ;  while  of  those  not  tested  it  would  seem  probable 
that  very  many  would  have  shown  considerable  motion,  in¬ 
asmuch  as  they  showed  free  flexion  of  the  well  leg  to  the 
tlexion-test  position  ;  or,  in  other  words,  they  showed  nor¬ 
mal  extension  of  the  affected  limb. 

All  these  patients,  unless  otherwise  so  stated,  were  in 
good  general  health. 

The  record  of  the  cases  is  as  follows : 

Case  I. — Female,  fifteen  years  old  ;  has  limped  at  times  and 
complained  of  some  pain  for  three  years.  There  is  involuntary 
muscular  spasm  and  flinching  on  manipulating  the  leg,  but  there 
is  no  deformity,  and  the  patient  can  be  put  in  the  “Thomas 
flexion-test  position  ”  without  pain  or  any  special  effort.  Mr. 
Thomas  refused  to  commence  treatment  without  further  ob¬ 
serving  the  case. 

Case  II.— Female,  twelve  years  old;  limped  for  six  months  ; 
no  complaint  of  pain ;  no  night  cries;  no  abscess;  general  con¬ 
dition  fairly  good  ;  one  inch  real,  but  only  a  quarter  of  an  inch 
apparent  shortening;  abduction,  six  degrees;  flexion,  twenty 
degrees ;  some  motion  in  flexion  ;  well-marked  involuntary  mus¬ 
cular  spasm.  Hip  splint  now  applied. 

Case  III.— Female,  eight  years  old  ;  limped  for  three  months 
before  treatment  was  commenced ;  long  splint  applied  at  the 
Liverpool  Infirmary  two  months  ago;  now  seen  by  Mr.  Thomas 
for  the  first  time;  an  abscess  has  been  noticed  for  the  past 
week;  no  pain;  no  tenderness  on  flexing  the  sound  leg  to  the 
flexion-test  position ;  no  abduction ;  no  adduction ;  some  mo¬ 
tion  in  all  directions,  limited  by  muscular  spasm. 

Case  IV.— Female,  eleven  years  old;  began  to  limp  nine 
months  ago ;  a  splint  was  put  on  six  months  ago  by  a  Manches¬ 
ter  surgeon,  but  it  is  too  flexible  to  be  of  any  use;  patient  now 
seen  by  Mr.  Thomas  for  the  first  time;  abscess  noticed  two 
weeks  ago ;  has  some  screaming  in  sleep,  but  no  pain  other¬ 
wise;  some  tenderness  on  palpation  and  manipulation;  muscu¬ 
lar  spasm  well  marked;  no  real  shortening;  half  an  inch  ap¬ 
parent  shortening ;  adduction,  four  degrees ;  flexion,  thirty-nine 
degrees;  very  little  motion  in  any  direction.  A  new  splint  was 
applied. 

Case  V. — Female,  nine  years  old  ;  has  limped  at  times  for 
four  years;  has  not  complained  of  pain;  no  abscess;  muscular 
spasm  well  marked ;  very  little  tenderness  on  gentle  manipula¬ 
tion  ;  leg  one  quarter  of  an  inch  longer  than  the  leg  of  the  op¬ 
posite  side;  flexion,  thirty  degrees;  no  abduction;  no  adduc¬ 
tion;  very  little  motion  in  any  direction;  splint  now  applied 
for  the  first  time.  I  saw  the  patient  again  at  the  end  of  a  week. 
The  flexion  had  been  completely  reduced  and  there  had  been 
no  pain. 

Case  \  I. — Male,  nine  years  old ;  limp  and  some  pain  for 
four  months  before  treatment  was  commenced  ;  has  worn  long 
splint  one  week ;  has  swelling  in  the  groin,  but  fluctuation  is 
doubtful;  has  night  cries;  tenderness  on  flexing  the  sound  leg 
to  the  flexion-test  position ;  marked  muscular  spasm ;  has  not 


yet  been  allowed  to  walk;  no  shortening;  no  flexion;  no  ab- 
Auction  ;  no  adduction  ;  motion  not  tested. 

Case  VII.  Male,  six  years  old  ;  limp  and  pain  for  six  months 
before  treatment  was  commenced;  has  worn  long  splint  for 
ten  weeks;  still  has  some  njght  pain,  but  is  allowed  to  walk 
without  crutches;  no  abscess;  some  tenderness  on  flexing  the 
sound  leg  to  flexion-test  position  ;  no  real,  but  half  an  inch  ap¬ 
parent  shortening;  adduction,  four  degrees;  no  flexion;  motion 
not  tested. 

Case  VIII.— Male,  three  years  and  a  quarter  old  ;  has  never 
walked;  when  three  months  old  had  a  fall,  and  splint  was  put 
on  at  once  at  the  Liverpool  Infirmary  and  was  worn  for  a  year ; 
then  came  under  care  of  Mr.  Thomas,  and  has  continued  to 
wear  the  splint  for  two  years  more  ;  no  abscess  ;  no  pain  for  a 
long  time  past;  no  tenderness  on  flexing  the  sound  leg  to  the 
flexion-test  position  ;  no  real  shortening  ;  two  inches  apparent 
shortening;  adduction,  twenty-one  degrees ;  no  flexion  ;  motion 
not  tested. 

Case  IX.— Female,  twelve  years  old  ;  limped  for  six  months 
before  treatment  was  commenced ;  has  worn  long  splint  for  nine 
months;  no  abscess;  no  tenderness  on  flexing  the  sound  leg  to 
flexion-test  position;  no  real  shortening;  an  inch  and  three 
quarters  apparent  shortening  ;  adduction,  fourteen  degrees  ;  no 
flexion  ;  considerable  inward  rotation  ;  motion  not  tested. 

Case  X. — Male,  four  years  old  ;  limp  and  pain  for  nine 
months  before  treatment  was  commenced  ;  has  worn  long  splint 
twelvemonths;  an  abscess  appeared  soon  after  splint  was  ap¬ 
plied,  and  is  now  near  breaking;  no  pain  now;  no  tenderness 
on  flexing  the  sound  leg  to  flexion-test  position;  no  real  short¬ 
ening;  an  inch  apparent  shortening;  adduction,  nine  degrees; 
no  flexion  ;  motion  not  tested. 

Case  XI. — Male,  four  years  old;  limped  for  three  weeks  be¬ 
fore  treatment  was  commenced  ;  has  worn  the  long  splint  for  six¬ 
teen  months;  some  thickening  in  the  groin,  but  no  fluctuation 
can  be  made  out;  no  pain  ;  no  tenderness  on  flexing  the  sound 
leg  to  flexion-test  position;  a  quarter  of  an  inch  real  and  an 
inch  and  a  quarter  apparent  shortening  ;  adduction,  nine  de¬ 
grees;  no  flexion;  motion  not  tested. 

Case  XII. — Female,  fourteen  years  old ;  limped  for  nine 
months  before  treatment  was  commenced;  wore  splint  for  six 
months  before  coming  to  Mr.  Thomas,  and  has  continued  to 
wear  the  long  splint  for  eight  months  since;  abscess  was  pres¬ 
ent  when  she  first  came  under  the  care  of  Mr.  Thomas;  it  has 
never  opened,  and  has  now  for  some  time  been  growing  smaller ; 
suffered  great  pain  and  could  not  walk  for  a  long  time  ;  no  pain 
now  ;  no  tenderness  on  flexing  the  sound  leg  to  flexion-test 
position ;  half  an  inch  real  and  an  inch  and  a  half  apparent 
shortening;  adduction,  seven  degrees;  no  flexion;  motion  not 
tested. 

Case  XIII. — Male,  six  years  old ;  limped  for  two  weeks  be¬ 
fore  treatment  was  commenced ;  has  worn  long  splint  eight 
months;  no  abscess;  no  pain;  no  tenderness  on  flexing  the 
sound  leg  to  flexion-test  position;  no  real  shortening;  three 
quarters  of  an  inch  apparent  shortening;  adduction,  seven  de¬ 
grees;  no  flexion  ;  motion  not  tested. 

Case  XIV. — Female,  six  years  old  ;  limp  and  pain  for  six 
months  before  treatment  was  commenced  ;  has  worn  long  splint 
two  weeks;  was  unable  to  walk  for  the  last  week  before  the 
splint  was  applied;  no  abscess;  no  pain  now  ;  some  tenderness 
on  flexing  the  sound  leg  to  flexion-test  position;  half  an  inch 
real  and  an  inch  apparent  shortening;  adduction,  four  degrees ; 
no  flexion  ;  motion  not  tested. 

Case  XV. — Male,  thirty  years  old  ;  limped  for  five  years  be¬ 
fore  treatment  was  commenced  ;  has  worn  short  splint  three 
years;  has  had  eight  abscesses;  one  sinus  remains;  no  pain 
now ;  no  tenderness  on  flexing  the  sound  leg  to  flexion-test  po- 


372 


RIDLON:  S1XT7-TW0  CASES  OF  EIP  DISEASE. 


[N.  Y.  Med.  Jour., 


sition;  two  inches  real  but  only  an  inch  apparent  shortening; 
abduction,  six  degrees;  no  flexion;  no  motion. 

Case  XVI. — Female,  four  years  old  ;  limped  for  three 
months  before  treatment  was  commenced  ;  has  worn  long  splint 
for  six  months;  abscess,  noticed  four  months  ago,  broke  two 
days  ago  ;  has  no  pain  ;  no  tenderness  on  flexing  the  sound  leg 
to  flexion-test  position;  no  real  shortening;  half  an  inch  ap¬ 
parent  shortening ;  adduction,  four  degrees;  no  flexion;  some 
motion. 

Case  XVII. — Male,  eleven  years  old  ;  limp  and  pain  for  six 
months  before  treatment  was  commenced ;  wore  short  splint 
for  two  months;  since  then  has  worn  long  splint  for  twenty 
months;  abscess  appeared  four  months  after  treatment  was 
commenced,  but  disappeared  without  aspiration  or  opening; 
no  pain  ;  no  tenderness  on  flexing  the  sound  leg  to  flexion-test 
position ;  an  inch  and  a  half  real  shortening,  but  only  three 
quarters  of  an  inch  apparent  shortening;  abduction,  five  de¬ 
grees;  no  flexion;  motion  not  tested. 

Case  XVIII. — Female,  fifteen  years  old  ;  limped  for  five 
months  before  treatment  was  commenced ;  has  worn  the  long 
splint  fifteen  months;  no  abscess;  no  pain  on  flexing  the  sound 
leg  to  flexion-test  position;  half  an  inch  real  shortening;  half 
an  inch  apparent  lengthening;  abduction,  seven  degrees;  no 
flexion  ;  motion  not  tested. 

Case  XIX. — Male,  twenty-one  years  old ;  limped  for  two 
years  before  treatment  was  commenced  ;  wore  long  splint  three 
years  ;  after  going  without  splint  for  twelve  months  an  abscess 
formed,  opened  spontaneously,  and  discharged  for  six  months; 
during  this  time  a  short  splint  was  applied,  and  has  now  been 
worn  eighteen  months;  no  pain;  no  tenderness  on  flexing  the 
sound  leg  to  flexion-test  position  ;  an  inch  and  a  half  real,  but 
only  half  an  inch  apparent  shortening;  abduction,  six  degrees; 
no  flexion  ;  some  motion. 

Case  XX. — Male,  four  years  and  a  half  old  ;  is  a  remarkably 
large  child  for  his  age ;  limped  for  twelve  hours  before  treat¬ 
ment  was  commenced  ;  has  worn  long  splint  for  two  months; 
no  abscess ;  no  pain  ;  no  tenderness  on  flexing  the  sound  leg  to 
flexion-test  position;  no  real  shortening  or  lengthening;  half 
an  inch  apparent  lengthening;  abduction,  four  degrees;  no 
flexion;  motion  not  tested. 

Case  XXL — Male,  seven  years  old  ;  was  hurt  by  a  cricket- 
ball  five  weeks  before  treatment  was  commenced  ;  has  worn 
long  splint  fourteen  months;  no  abscess;  no  pain;  no  tender¬ 
ness  on  flexing  the  sound  leg  to  flexion-test  position  ;  no  real 
shortening  or  lengthening  ;  half  an  inch  apparent  lengthening ; 
abduction  four  degrees;  no  flexion  ;  motion  not  tested. 

Case  XXII. — Male,  five  years  old;  limp  and  pain  at  times 
for  two  months  and  a  half  before  treatment  was  commenced; 
has  worn  long  splint  for  two  months;  no  abscess;  no  pain; 
slight  tenderness  on  flexing  the  sound  leg  to  flexion-test  posi¬ 
tion ;  no  real  shortening;  half  an  inch  apparent  shortening; 
adduction,  four  degrees ;  no  flexion ;  some  inward  rotation ; 
motion  not  tested. 

Case  XXIII. — Female,  four  years  old;  having  been  cured 
without  deformity  or  stiffness,  relapsed  two  years  after  treat¬ 
ment  had  been  discontinued,  and  has  now  been  wearing  short 
splint  two  months;  one  cicatrix;  no  pain;  no  tenderness  on 
flexing  the  sound  leg  to  flexion-test  position;  no  shortening; 
adduction,  four  degrees;  no  flexion  ;  no  rotation;  slight  motion. 

Case  XXIV. — Male,  ten  years  old  ;  limp  and  pain  for  six 
weeks  before  treatment  was  commenced  ;  has  worn  long  splint 
for  six  years;  has  had  three  abscesses,  from  which  two  sinuses 
remain,  and  another  abscess  broke  into  the  intestine;  had  albu¬ 
minuria  for  many  months,  and  was  in  a  very  precarious  condi¬ 
tion;  no  albuminuria  now;  is  fat  and  in  good  color  ;  no  pain 
for  a  very  long  time  ;  half  an  inch  real  and  two  inches  appar¬ 


ent  shortening;  adduction,  sixteen  degrees;  no  flexion  ;  no  mo¬ 
tion.  Has  walked  about  for  a  long  time  without  patten  and 
crutches. 

Case  XXV. — Male,  six  years  old  ;  limped  for  three  months 
before  treatment  was  commenced;  has  worn  long  splint  eight¬ 
een  months;  no  abscess;  no  pain  ;  no  tenderness  on  flexing 
the  sound  leg  to  flexion-test  position  ;  no  shortening;  no  abduc¬ 
tion  ;  no  adduction  ;  no  flexion;  slight  motion  in  all  directions. 

Case  XXVI. — Female,  eleven  years  old;  limp  and  pain  for 
two  years  before  treatment  was  commenced ;  wore  long  splint 
for  two  years;  has  worn  short  splint  for  one  year;  no  abscess; 
no  pain  for  a  long  time;  no  real  shortening;  one  inch  apparent 
shortening;  adduction,  eight  degrees;  flexion,  twenty-five  de¬ 
grees;  no  motion. 

Case  XXVII. — Male,  two  years  old  ;  has  had  trouble  since 
birth;  long  splint  was  put  on  when  four  months  old ;  it  has 
been  very  difficult  to  keep  patient  properly  in  the  splint,  and 
he  runs  about  constantly  ;  no  abscess  ;  no  pain  ;  no  tenderness 
on  flexing  the  sound  leg  to  flexion-test  position  ;  half  an  inch 
shortening;  no  abduction;  no  adduction;  no  flexion;  some 
motion  in  all  directions. 

Case  XXVIII. — Male,  nine  years  old;  limp  and  pain  for 
seven  months  before  treatment  was  commenced;  wore  long 
splint  for  three  years;  has  worn  short  splint  two  years;  ab¬ 
scess  four  years  ago,  and  another  three  years  ago;  no  sinuses; 
no  pain;  no  tenderness  on  flexing  the  sound  leg  to  flexion-test 
position ;  three  quarters  of  an  inch  real  and  two  inches  apparent, 
shortening;  adduction,  ten  degrees;  flexion,  twenty-two  de¬ 
grees;  no  motion.  Lives  far  away  and  has  been  seen  but  once 
in  three  months.  He  has  walked  about  without  patten  and 
crutches. 

Case  XXIX. — Male,  fifteen  years  old  ;  limp  and  pain  for 
seven  years  before  treatment  was  commenced ;  father  is  con¬ 
sumptive;  wore  long  splint  two  years;  has  worn  short  splint 
one  year;  had  one  abscess  before  treatment  was  commenced ; 
no  pain;  no  tenderness  on  flexing  the  sound  leg  to  flexion-test 
position ;  patient  has  grown  very  rapidly  and  is  a  very  tall  boy 
for  his  age;  an  inch  and  a  half  real  shortening,  two  inches  ap¬ 
parent  shortening;  adduction,  four  degrees ;  no  flexion;  some 
motion  in  all  directions. 

Case  XXX. — Male,  seven  years  old  ;  limped  for  four  months 
before  treatment  was  commenced :  wore  long  splint  fifteen 
months;  has  worn  short  splint  twelve  months;  no  abscess;  no 
pain ;  no  tenderness  on  flexing  the  sound  leg  to  flexion-test 
position ;  half  an  inch  real  and  an  inch  and  a  half  apparent 
shortening;  adduction,  four  degrees;  flexion,  twenty  degrees ; 
no  motion. 

Case  XXXI. — Female,  nine  years  old  ;  strained  joint  skip¬ 
ping  rope;  limped  and  had  pain  at  times  for  three  years  and  a 
quarter  before  treatment  was  commenced ;  was  kept  in  bed  one 
month  before  the  splint  was  applied  ;  wore  long  splint  eighteen 
months;  has  worn  short  splint  for  eighteen  months;  no  ab¬ 
scess;  no  pain  for  a  long  time;  no  tenderness  on  flexing  the 
sound  leg  to  flexion-test  position;  quarter  of  an  inch  real  and 
three  quarters  of  an  inch  apparent  shortening;  adduction,  four 
degrees;  no  flexion  ;  some  motion. 

Case  XXXII. — Female,  ten  years  old;  limped  for  four 
months  before  treatment  was  commenced  ;  has  worn  long  splint 
for  ten  months  ;  has  in-knee  of  eight  weeks’  duration,  resulting 
from  the  use  of  the  splint;  no  abscess  ;  no  pain;  no  tenderness 
on  flexing  the  sound  leg  to  flexion-test  position  ;  shortening  and 
the  consequent  adduction  not  measured  because  of  the  in-knee; 
no  flexion  ;  motion  not  tested. 

Case  XXXIII. — Female,  eight  years  old;  limp  and  some 
pain  for  three  weeks  before  treatment  was  commenced;  has 
worn  short  splint  for  three  months ;  never  has  worn  long  splint, 


Oct.  4,  1890.] 


RIDLON:  SIXTY-TWO  CASES  OF  HIP  DISEASE. 


but  has  not  been  allowed  to  walk;  no  abscess;  no  pain  since 
treatment  was  commenced ;  no  shortening;  no  flexion;  no  ad¬ 
duction;  no  abduction;  normal  motion  in  all  directions;  now 
to  be  allowed  to  walk  with  crutches. 

Case  XXXIV. — Male,  forty-two  years  old;  limp  and  pain 
for  twelve  months  before  treatment  was  commenced  ;  no  trau¬ 
matic  cause;  has  never  worn  the  long  splint;  has  worn  short 
splint  for  three  months;  no  abscess;  no  tenderness  on  flexing 
the  sound  leg  to  flexion-test  position;  no  pain  ;  no  shortening; 
no  flexion ;  no  adduction;  no  abduction  ;  no  rotation;  motion 
not  tested. 

Case  XXXV. — Male,  sixteen  years  old;  limped  for  five 
weeks  before  treatment  was  commenced  ;  has  worn  long  splint 
for  nine  months;  deep  fluctuation  in  groin;  still  has  some 
pain;  some  tenderness  on  flexing  the  sound  leg  to  flexion-test 
position;  three  quarters  of  an  inch  real  shortening;  no  abduc¬ 
tion  ;  no  adduction;  no  flexion;  motion  not  tested. 

Case  XXXVI. — Female,  nine  years  old  ;  limped  for  twelve 
months  before  treatment  was  commenced  ;  has  worn  long  splint 
twelvemonths;  small  area  of  deep  fluctuation  in  front  of  the 
joint;  no  pain  ;  no  tenderness  on  flexing  the  sound  leg  to  flexion- 
test  position;  no  real  shortening;  half  an  inch  apparent  short¬ 
ening;  adduction,  four  degrees;  no  flexion ;  motion  not  tested. 

Case  XXXVII. — Male,  fourteen  years  old;  limp  and  pain 
for  three  months  before  treatment  was  commenced  ;  has  worn 
xong  splint  for  two  years;  two  sinuses  in  the  groin  for  the  past 
eighteen  months;  no  pain  now;  no  tenderness  on  flexing. the 
sound  leg  to  flexion-test  position  ;  no  shortening;  no  abduction  ; 
no  adduction;  no  flexion;  no  motion. 

Case  XXXVIII. — Male,  eight  years  old  ;  limped  for  fourteen 
months  before  treatment  was  commenced  ;  has  worn  long  splint 
for  ten  months;  no  abscess;  no  pain  ;  no  tenderness  on  flexing 
the  sound  leg  to  flexion-test  position;  no  shortening;  no  ab¬ 
duction  ;  no  adduction  ;  no  flexion  ;  some  motion. 

Case  XXXIX. — Female,  eight  years  old;  limp  and  pain  for 
twelve  months  before  treatment  was  commenced;  has  worn 
long  splint  three  years ;  first  abscess  ten  months  after  treatment 
was  commenced,  and  second  soon  after  first;  two  sinuses  re¬ 
main  ;  no  pain ;  no  tenderness  on  flexing  the  sound  leg  to  flexion- 
test  position ;  no  shortening ;  no  abduction;  no  adduction;  no 
flexion  ;  motion  not  tested. 

Case  XL. — Male,  twenty  months  old ;  pain  and  stiffness  for 
six  weeks  before  treatment  was  commenced  ;  has  worn  long 
splint  ten  months;  one  abscess  opened  spontaneously  three 
months  ago;  sinus  remains;  another  abscess  now  present  point¬ 
ing  in  two  places;  no  pain;  no  tenderness  on  flexing  the  sound 
leg  to  flexion-test  position;  no  shortening;  no  abduction;  no 
adduction;  no  flexion  ;  motion  not  tested. 

Case  XLI. — Male,  thirteen  years  old;  limp  and  pain  for  one 
year  before  treatment  was  commenced  ;  has  worn  long  splint 
a  year  and  a  half;  first  abscess  opened  twenty  months  ago, 
and  a  second  three  months  ago;  one  sinus  remains;  no  pain 
now;  no  tenderness  on  flexing  the  sound  leg  to  flexion-test 
position;  no  shortening;  no  abduction;  no  adduction;  no 
flexion  ;  motion  not  tested. 

Case  XLII. — Female,  fourteen  years  old  ;  limped  for  three 
months  before  treatment  was  commenced  ;  never  wore  long 
splint;  has  worn  short  splint  four  months;  had  one  abscess; 
no  sinus ;  has  had  disease,  with  abscess  at  right  elbow,  for  eight 
months;  no  pain  now  ;  some  tenderness  on  flexiDg  the  sound 
mg  to  flexion-test  position  ;  general  condition  fairly  good  ;  no 
real  shortening;  three  quarters  of  an  inch  apparent  shortening; 
adduction,  three  degrees  ;  no  flexion  ;  motion  not  tested. 

Case  XLIII. — Male,  thirteen  years  old ;  limped  for  three 
weeks  before  treatment  was  commenced  ;  wore  long  splint  for 
six  years  ;  has  worn  short  splint  for  two  years  and  a  half ;  was 


373 

in  Liverpool  Infirmary  nine  months  at  commencement  of  treat¬ 
ment,  not  under  Mr.  Thomas  ;  has  had  three  abscesses ;  the  last 
closed  three  years  ago;  all  appeared  while  under  the  care  of 
Mr.  Ihomas;  an  inch  and  a  half  real  shortening;  no  abduc¬ 
tion  ;  no  adduction  ;  no  flexion  ;  some  outward  rotation  ;  mo¬ 
tion  not  tested. 

Case  XLIV.— Female,  eleven  years  old  ;  limp  and  pain  for 
two  years  before  treatment  was  commenced  ;  wore  long  splint 
for  two  years;  has  worn  short  splint  for  one  year;  an  abscess 
opened  spontaneously  at  about  the  time  treatment  was  com¬ 
menced;  it  closed  after  discharging  for  about  a  year  ;  no  pain 
since  that  time  ;  no  tenderness  on  manipulation  ;  one  inch  real 
shoi tening ,  no  abduction;  no  adduction  ;  no  flexion  ;  no  mo¬ 
tion. 

Case  XLV.—  Female,  nine  yearsold;  limped  for fourmonths 
before  treatment  was  commenced ;  wore  long  splint  for  ten 
months;  has  worn  short  splint  two  months;  when  three  years 
old  wore  a  Thomas  splint,  but  not  under  Thomas’s  care,  for  ten 
months ;  no  abscess ;  no  pain ;  no  tenderness  on  flexing  the 
sound  leg  to  flexion-test  position;  no  shortening;  no  abduc¬ 
tion  ;  no  adduction  ;  no  flexion  ;  some  motion  in  all  directions. 

t  °ABE  XLVL— Male,  twenty  years  old  ;  suddenly  attacked 
with  pain  and  limping  one  month  before  treatment  was  com¬ 
menced  ;  no  traumatism  ;  has  worn  long  splint  ten  months;  no 
abscess ;  no  pain  now  ;  no  tenderness  on  flexing  the  sound  leg 
to  flexion-test  position ;  one  inch  shortening;  no  abduction ;  no 
adduction;  no  flexion  ;  no  motion. 

Case  XLVII. — Male,  twenty-one  years  old;  limped  for 
twelve  months  before  treatment  was  commenced  ;  wore  long 
splint  for  eighteen  months;  has  worn  short  splint  for  four 
years;  abscess  opened  spontaneously  before  treatment  was  com¬ 
menced  and  still  discharges ;  no  pain  ;  no  tenderness  on  flexing 
the  sound  leg  to  flexion-test  position  ;  one  inch  shortening;  no 
abduction  ;  no  adduction  ;  no  flexion  ;  motion  not  tested. 

Case  XLVIIL— Male,  six  years  old  ;  limped  for  two  days 
before  treatment  was  commenced ;  wore  long  splint  for  two 
years;  has  worn  short  splint  three  months;  no  abscess;  no 
pain;  no  tenderness  on  flexing  the  sound  leg  to  flexion-test 
position  ;  three  quarters  of  an  inch  real  and  one  inch  and  three 
quarters  apparent  shortening;  adduction,  nine  degrees;  no 
flexion  ;  motion  not  tested. 

Case  XLIX.— Male,  six  years  old  ;  limped  for  three  months 
before  treatment  was  commenced  ;  has  worn  long  splint  for 
two  years;  no  abscess;  no  pain;  no  tenderness  on  flexing  the 
sound  leg  to  flexion-test  position  ;  leg  one  quarter  of  an  inch 
longer  than  well  leg;  no  abduction  ;  no  adduction  ;  no  flexion  ; 
motion  not  tested. 

Case  L.— Female,  eight  years  old  ;  limped  for  four  months 
before  treatment  was  commenced ;  has  worn  long  splint  twelve 
months;  no  abscess;  no  pain;  no  tenderness  on  flexing  the 
sound  leg  to  flexion-test  position;  no  shortening;  no  abduc¬ 
tion  ;  no  adduction  ;  no  flexion  ;  no  motion. 

Case  LI.— Male,  three  years  old  ;  limped  for  five  weeks  be¬ 
fore  treatment  was  commenced;  has  worn  long  splint  fourteen 
months;  no  abscess;  no  pain;  no  tenderness  on  flexing  the 
sound  leg  to  flexion-test  position;  no  shortening;  no  abduc¬ 
tion  ;  no  adduction  ;  no  flexion  ;  motion  not  tested. 

Case  LIL— Female,  five  years  old  ;  limp  and  crying  in  sleep 
for  two  weeks  before  treatment  was  commenced  ;  has  worn  long 
splint  two  months;  no  abscess ;  still  has  crying  in  sleep,  but 
does  not  complain  of  other  pain  ;  some  tenderness  on  flexing 
the  sound  leg  to  flexion-test  position  ;  no  shortening ;  no  ab¬ 
duction ;  no  adduction  ;  no  flexion  ;  motion  not  tested. 

Case  LIII. — Male,  six  years  old;  limped  for  six  weeks  be¬ 
fore  treatment  was  commenced ;  has  worn  long  splint  for  one 
week ;  no  abscess ;  no  pain  ;  no  tenderness  on  flexing  the  sound 


374 


PURDY:  TEE  INFLUENCES  OF  CLIMATE  OVER  B RIGHTS  DISEASE.  [N.  Y.  Med.  Jocb., 


leg  to  flexion-test  position;  no  shortening;  no  abduction;  no 
adduction;  no  flexion  ;  motion  not  tested. 

Case  LIY. — Male,  four  years  old  ;  limp  and  some  pain  for 
three  years  before  treatment  was  commenced;  has  worn  long 
splint  for  three  months  ;  no  abscess ;  no  pain  of  late  ;  no  tender¬ 
ness  on  flexing  the  sound  leg  to  flexion-test  position;  no  short¬ 
ening  ;  no  abduction ;  no  adduction  ;  no  flexion  ;  motion  not 
tested. 

Case  LV. — Female,  eleven  years  old ;  limp  and  pain  for  six 
months  before  treatment  was  commenced;  wore  long  splint 
four  years;  has  now  been  without  treatment  for  two  weeks; 
no  abscess ;  no  pain ;  no  tenderness  on  manipulating  leg ;  no 
shortening;  adduction,  two  degrees;  no  flexion;  slight  inward 
rotation ;  no  motion. 

Case  LYI.  — Male,  seventeen  years  old  ;  twisted  hip  in  kick¬ 
ing  a  foot-ball,  and  was  seen  next  day ;  was  kept  in  bed  three 
months  without  any  mechanical  treatment;  then  had  the  long 
splint  for  one  year,  and  the  short  splint  for  two  years ;  has  had 
no  treatment  for  the  past  six  months  ;  no  abscess;  no  pain  for 
a  long  time ;  pain  was  very  great  for  a  long  time  at  the  com¬ 
mencement  of  the  trouble ;  no  tenderness  on  manipulating  the 
leg;  no  shortening ;  no  abduction;  no  adduction;  no  flexion; 
normal  motion  in  all  directions. 

Case  LVII.— Male,  twenty-two  years  old  ;  limp  and  pain  for 
six  months  before  treatment  was  commenced;  wore  long  splint 
for  three  years  and  a  half;  no  pain  for  a  long  time;  cicatrices 
of  six  sinuses  present ;  has  been  without  treatment  for  four 
months;  no  tenderness  on  manipulating  leg ;  three  fourths  of 
an  inch  real  shortening  ;  one  inch  and  a  quarter  apparent  short¬ 
ening  ;  adduction,  eight  degrees  ;  flexion,  thirty-one  degrees;  no 
motion. 

Case  LVIII. — Male,  three  years  old;  limped  for  two  weeks 
before  treatment  was  commenced;  wore  long  splint  thirteen 
months;  no  treatment  for  past  three  months;  no  abscess;  no 
pain;  no  tenderness  on  manipulation;  no  shortening;  no  ab¬ 
duction ;  no  adduction;  no  flexion;  considerable  outward  rota¬ 
tion;  all  motions,  except  inward  rotation,  smooth  and  free  to 
ninety  degrees. 

Case  LIX. — Male,  twenty-two  years  old ;  limped  for  five 
years  before  treatment  was  commenced;  wore  long  splint  two 
weeks;  wore  short  splint  four  years  and  four  months;  no  treat¬ 
ment  for  past  four  months;  no  abscess;  no  pain  now;  no  ten¬ 
derness  on  flexing  the  sound  leg  to  flexion-test  position ;  two 
inches  and  a  half  shortening  ;  great  trochanter  two  inches  and 
a  half  above  N61aton’s  line;  no  abduction;  no  adduction;  no 
flexion ;  no  motion. 

Case  LX. — Female,  twelve  years  old ;  limped  for  three 
months  before  treatment  was  commenced;  woi-e  long  splint 
two  years;  had  five  abscesses;  no  treatment  for  past  three 
years;  half  an  inch  shortening;  no  abduction;  no  adduc¬ 
tion;  no  flexion;  some  motion  in  all  directions;  walks  with 
scarcely  any  limp,  and  can  go  up  and  down  stairs  without 
difficulty. 

Case  LXI.— Male,  eight  years  old;  limped  for  four  months 
before  treatment  was  commenced;  wore  long  splint  two  years 
and  a  half;  has  had  no  treatment  for  past  year;  no  abscess;  no 
muscular  spasm ;  no  shortening;  no  abduction;  no  adduction; 
no  flexion;  free  motion  in  all  directions  to  ninety  degrees;  runs 
and  walks  without  limp  or  inconvenience. 

Case  LXII.— Female,  twenty  years  old;  limp  commenced 
one  year  before  treatment ;  became  unable  to  walk  and  suffered 
great  pain ;  had  haemorrhages  from  the  lungs ;  wore  long  splint 
three  years;  no  treatment  for  past  twelve  months;  general 
condition  excellent;  no  pain  now;  no  tenderness  on  manipula¬ 
tion  ;  half  an  inch  shortening;  no  abduction;  no  adduction; 
no  flexion  ;  normal  motion  in  all  directions. 


From  a  study  of  these  cases  conclusions  can  not  prop¬ 
erly  be  drawn  ;  but,  as  I  have  probably  given  them  a  more 
careful  consideration  than  any  one  else  ever  will,  I  will  ven¬ 
ture  the  following  suggestions  : 

Very  many  of  these  patients  that  have  had  the  short 
splint  applied  before  muscular  spasm  and  pain  had  subsided 
and  before  deformity  had  been  reduced,  that  have  been  al¬ 
lowed  to  walk  around  without  high  patten  and  crutches — 
that  is  to  say,  those  whose  joints  have  only  been  partially 
immobilized,  without  being  protected  from  the  pressure  of 
superincumbent  weight  and  the  concussion  of  walking — 
present  a  moderate  degree  of  adduction,  absence  of  motion, 
and,  in  a  few  cases,  slight  flexion,  and  in  one  instance  in¬ 
knee. 

On  the  other  hand,  those  patients  that  have  worn  the 
long  splint  until  cured,  that  have  remained  in  the  horizontal 
position  until  all  pain  and  muscular  spasm  had  subsided, 
and  had  then  used  the  high  patten  and  crutches  and  had 
had  the  benefit  of  intelligent  care  and  nursing,  have  been 
cured  without  flexion  or  other  deformity  than  the  shorten¬ 
ing  due  to  actual  bone  erosion  and  arrested  growth,  and 
they  have  shown  motion  in  a  very  large  proportion  of  cases 
and  in  not  a  few  has  there  been  normal  motion. 

The  absence  of  any  traction  force,  either  in  the  line  of 
the  shaft  or  of  the  neck  of  the  femur,  does  not  seem  to 
have  increased  the  number  of  patients  having  abscesses  or 
the  number  of  abscesses  in  each  case,  nor  to  have  increased 
the  frequency  of  shortening  or  the  amount  of  shortening 
in  each  case.  No  case  has  given  any  signs  of  perforation 
of  the  acetabulum  by  the  head  of  the  femur,  and  in  only  one 
has  there  been  any  indication  of  perforation  by  suppuration. 
And  involuntary  muscular  spasm  and  pain  arising  therefrom 
are  noticeable  for  their  absence.  In  a  word,  those  patients 
who  have  had  no  traction  are  found  to  be  remarkably 
free  from  all  those  conditions  which  we  have  been  taught 
can  only  be  relieved  by  persistent  and  long-continued 
traction. 

In  conclusion,  nothing  appears  to  indicate  that  the  prin¬ 
ciples  upon  which  Mr.  Thomas  has  based  his  teaching  are 
in  any  way  at  fault,  though  in  practice  there  is  still  some¬ 
what  to  be  desired. 

337  West  Fifty-seventh  Street. 


THE  INFLUENCES  OF 

CLIMATE  IN  THE  UNITED  STATES  OYER 
BRIGHT’S  DISEASE. 

By  CHARLES  W.  PURDY,  M.  D., 

CHICAGO. 

In  attempting  a  systematic  study  of  the  influences  ex¬ 
erted  by  climate  over  special  forms  of  disease,  the  value  of 
the  results  obtained  will  depend  largely  upon  the  geo¬ 
graphical  extent  and  variation  of  the  territory  considered. 
It  is,  furthermore,  important  that  the  lives  and  habits  of 
the  people  comprising  the  whole  area  considered  should  be 
as  nearly  similar  as  possible,  not  only  socially  and  domes¬ 
tically,  but  also  as  regards  their  surroundings  and  influences 
politically. 


Oct.  4,  1890.]  PURDY:  TEE  INFLUENCES  OF  CLIMATE  OVER  BRIO  EPS  DISEASE. 


375 


In  all  these  respects  the  United  States  of  America 
possesses  the  most  eminent  advantages.  It  comprises  a 
territory  three  thousand  miles  in  length  by  two  thousand 
miles  in  width.  Its  area  is  over  three  millions  and  a  half 
of  square  miles,  which  is  twenty-nine  times  larger  than 
Great  Britain  and  Ireland,  or  nearly  equal  in  extent  to  the 
whole  continent  of  Europe.  It  possesses  all  ranges  of 
mean  temperature  for  the  year,  from  35°  F.  to  75°  F. ;  all 
altitudes,  from  the  sea-level  to  fifteen  thousand  feet ;  all 
ranges  of  rainfall,  from  ten  to  sixty  inches.  The  conditions 
of  its  atmosphere  embrace  the  features  of  extreme  dryness 
characteristic  of  far  inland  plains,  of  cool  moisture  from 
great  inland  lakes,  and  the  influences  of  the  sea  varied  by 
two  oceans  and  numerous  ocean  currents.  Its  northeastern 
border  is  covered  with  snow  nearly  half  of  the  year,  and 
during  the  same  time  its  southern  coast  is  covered  with 
vegetation  of  almost  tropical  luxuriance.  It  will  therefore 
be  seen  that  such  a  wide  range  of  geographical  and  climatic 
features  enables  us  to  readily  determine  many  questions  re¬ 
lating  to  the  influence  of  climate  over  disease  which  are 
difficult  and  even  impossible  to  solve  in  those  countries 
possessing  a  more  limited  area  and  climatic  range. 

In  addition  to  this,  the  unrivaled  facilities  of  intercom¬ 
munication  possessed  by  the  United  States,  including  the 
railway,  press,  post,  and  telegraph,  bring  the  population 
nearer  together  and  make  the  people  more  nearly  a  unit  in 
habits  and  life  than  has  hitherto  been  attained  in  any  age 
or  country  of  equal  extent. 

Unfortunately,  however,  with  all  these  unsurpassed  natu¬ 
ral  advantages  for  scientific  investigation,  the  United  States 
at  present  is  placed  at  great  disadvantage  as  compared  with 
the  older,  and  in  fact  with  all  other  civilized  nations,  in  the 
fact  that,  unlike  them,  it  has  no  uniform  system  of  regis¬ 
tration  of  vital  statistics.  Indeed,  were  it  not  for  the  data 
afforded  by  the  census,  it  would  be  impossible  to  arrive  at 
any  conclusions  in  the  field  under  consideration  which  could 
be  looked  upon  as  even  approximately  correct.  Fortunately, 
in  the  last  census — that  of  1880 — special  efforts  were  put 
forth  to  obtain  more  complete  and  accurate  returns  of 
deaths  than  had  before  been  furnished,  and  likewise  to 
make  the  returns  more  accurate  as  regards  the  causes  of 
death. 

In  availing  myself  of  the  data  afforded  by  the  Tenth 
Census  the  same  course  has  been  followed,  with  the  view 
of  eliminating  errors,  which  I  adopted  in  the  study  of  cli¬ 
matic  influences  over  other  diseases.*  Thus  all  States  and 
Territories  furnishing  a  total  mortality  of  less  than  five 
thousand  have  been  excluded  from  the  estimates  as  too 
small  to  give  trustworthy  data. 

The  total  number  of  deaths  in  the  United  States  for 
the  year  1880,  as  recorded  by  the  census  returns,  was 
756,893,  and  of  these  5,386  were  returned  under  the  head 
of  Bright’s  disease.  These  returns  give  us  an  average  ratio 
of  7T1  deaths  from  Bright’s  disease  in  each  1,000  deaths 
for  the  whole  country.  In  order  to  bring  out  in  strong 
contrast  the  relative  ratios  of  mortality  from  Bright’s  dis. 
ease  in  the  different  States  and  Territories,  I  have  constructed 


Table  I,  which  gives  the  total  mortality,  the  mortality  from 
Bright’s  disease,  and  the  ratio  of  the  latter  to  each  1,000 
deaths  in  each  State. 

Table  I. 


Deaths  from  Bright's  Disease  to  eaeh  1,000  Deaths ,  by  States ,  in  the 
United  States  for  1880. 


STATES. 

Total  deaths. 

Deaths  from 
Bright’s  disease 

Ratio 
to  1,000. 

Alabama . 

17,929 

86 

4-79 

Arkansas  . 

14,812 

29 

1-95 

California . 

11,530 

81 

7-02 

Connecticut . 

9,179 

132 

14-48 

Georgia . 

21,549 

36 

1-67 

Illinois  ...  . 

45,017 

213 

4-73 

Indiana . 

31,213 

108 

3-46 

Iowa . 

19,377 

67 

3-45 

Kansas . 

15,160 

38 

2-50 

Kentucky . 

23,718 

78 

3-28 

Louisiana . 

14,514 

105 

7-23 

Maine . 

9,523 

89 

9-34 

Maryland . 

16,919 

195 

11-52 

Massachusetts . 

33,149 

431 

13-00 

Michigan . 

19,743 

100 

5-06 

Minnesota  . 

9,037 

35 

3-86 

Mississippi . 

14,583 

38 

2-60 

Missouri . 

36,615 

106 

2-89 

Nebraska . 

5,930 

10 

1-68 

New  Hampshire . 

5,584 

71 

12-70 

New  Jersey . 

8,474 

242 

28-55 

New  York . 

88,332 

1,779 

20-13 

North  Carolina . 

21,547 

40 

1-85 

Ohio ....  . 

42,610 

256 

6-00 

Pennsylvania . 

63,881 

491 

7-68 

South  Carolina . 

15,728 

39 

2-47 

Tennessee  . 

25,919 

39 

1-11 

Texas  . 

24,735 

53 

2-14 

Vermont . 

5,024 

52 

10-33 

Virginia . 

24,681 

73 

2-95 

West  Virginia . 

7,418 

33 

4-46 

Wisconsin . 

16,011 

80 

4-99 

A  glance  at  Table  I  discloses  the  fact  that  the  mortality 
from  Bright’s  disease  in  the  State  of  New  Jersey  exceeds 
the  average  for  the  whole  country  by  a  little  over  four 
times.  New  York  State  comes  next  in  order,  exceeding  the 
average  nearly  three  times.  Connecticut  follows,  with  a 
ratio  of  over  double  the  average,  while  Massachusetts  and 
New  Hampshire  follow,  almost  doubling  the  average  for 
the  country.  Whatever  be  the  causative  influences,  these 
five  adjoining  States  form  a  strip  of  territory,  reaching 
from  the  39th  to  the  45th  parallel,  which  is  especially  pro¬ 
lific  of  Bright’s  disease. 

Before  it  will  be  possible  to  assume  with  reason  that  the 
increased  fatality  from  Bright’s  disease  in  this  region  is  due 
to  special  features  of  the  climate,  it  must  first  be  ascertained 
if  the  States  furnishing  lower  death-rates  from  the  disease 
than  the  average  differ  essentially  in  their  climatic  features 
from  those  just  named.  By  again  referring  to  Table  I  it  will 
be  seen  that  the  State  of  Tennessee  furnishes  a  death-rate 
from  Bright’s  disease  which  is  less  by  six  times  than  the. 
average  for  the  whole  country — viz.,  I’ll.  Georgia  follows 
in  order  with  a  ratio  of  1’67 — about  four  times  less  than 
the  average.  Nebraska  follows  with  about  the  same  ratio. 
North  Carolina  and  Arkansas  are  next  in  order,  their  ratios 
of  mortality  from  the  disease  being  less  than  the  average  by 
about  three  times  and  a  half.  The  States  of  Tennessee, 
Georgia,  North  Carolina,  and  Arkansas  form  an  adjoining 
tract  of  territory,  extending  from  the  31st  to  the  37th 


*  Treatise  on  Diabetes. 


376 _ PURDY:  THE  INFLUENCES  OF  CLIMATE  OVER  BRIGHTS  DISEASE.  [N.  Y.  Med.  Joub. 


parallel,  which  lies  at  directly  the  opposite  point  of  the 
compass  from  the  States  which  furnish  the  highest  death- 
rate  from  Bright’s  disease  in  the  country.  Now,  in  every 
instance  the  five  States  furnishing  the  lowest  ratios  of  mor¬ 
tality  from  Bright’s  disease  possess  distinct  and  similar 
characteristics  of  climate,  the  chief  features  of  which  are 
dryness ,  equability,  and  warmth.  On  the  other  hand,  in 
every  instance  the  five  States  furnishing  the  highest  death- 
rate  from  Bright’s  disease  possess  distinct  and  similar  char¬ 
acteristics  of  climate,  the  chief  features  of  which  are  di¬ 
rectly  the  opposite  of  those  of  the  States  furnishing  the 
lowest  death-rates  from  the  disease — viz.,  moisture ,  coolness, 
and  changeability . 

The  variation  of  the  death-rate  from  Bright’s  disease 
in  each  individual  State  named  is  so  decided  a  departure 
from  the  average  for  the  whole  country — 200  to  600  per 
cent. — that  ample  room  is  left  for  errors  through  other  and 
minor  causes,  whose  influence  is  not  ignored  and  will  be 
considered  later. 

It  is  well  known  to  climatologists,  however,  that  more 
accurate  and  trustworthy  results  are  to  be  reached  in  esti¬ 
mating  the  influences  of  climate  over  disease  by  grouping 
together  large  areas  of  territory,  including  several  States,  in 
part  or  whole,  whose  chief  climatic  features  are  as  near 
similar  as  possible.  By  taking  each  of  these  grand  groups 
as  the  unit  of  calculations,  many  errors  are  eliminated  from 
the  estimates  that  must  necessarily  creep  into  the  calcula¬ 
tions  when  the  State  is  taken  as  the  unit ;  and,  moreover* 
by  so  doing,  a  more  limited  and  purely  political  division 
of  territory  is  substituted  by  a  larger  and  purely  climatic 
division. 

In  order  to  further  facilitate  the  study  of  the  climatic 
features  of  Bright’s  disease  in  the  United  States  by  grand 
groups,*  I  have  constructed  Table  II,  which  gives  the  ratio 
of  deaths  from  Bright’s  disease,  the  mean  annual  tempera¬ 
ture,  the  annual  rainfall,  the  elevation,  and  the  population 
of  each  grand  group. 

Table  II. 


Deaths  from  Bright's  Disease  in  each  1,000  Deaths  in  the  United  States 
for  1880,  in  Grand  Groups,  showing  Climatic  Features  and  Popu¬ 
lation  of  each  Group. 


REGION. 

Ratio  to 
1,000. 

Mean  tem¬ 
perature  F. 

Mean  rain¬ 
fall  in 
inches. 

Elevation, 
in  feet. 

Population. 

1.  North  Atlantic  coast  region . 

2.  Middle  Atlantic  coast  region . 

3.  South  Atlantic  coast  region . 

4.  Gulf  coast  region . 

5.  Northeastern  hills  and  plateaus  .. 

6.  Central  Appalachian  region . 

7.  Northern  lake  region . 

8.  The  interior  plateau  region . 

9.  The  Ohio  River  belt . 

10.  Southern  Central  Appalachian  re¬ 
gion  . 

17-38 

19-73 

2-59 

941 

11-20 

8-23 

7- 17 

8- 32 

5  83 

2- 63 
299 
314 

3- 73 

1  97 
3-70 
3-59 
2-80 
5-21 
8-72 
3-92 
304 

40-50° 

45-60 

60-65 

70-75 

35-45 

40-45 

45-50 

45-50 

45-55 

45-55 

65-70 

60-65 

40-50 

60-70 

50-60 

50-55 

40-55 

40-50 

45-65 

45-65 

50-60 

40-50 

45-55 

50-60 

55 

35-45 

35-40 

30-40 

40-45 

45-50 

45-50 

50-60 

50-55 

30-50 

85-50 

40-45 

25-40 

20^0 

30-40 

20-60 

10-20 

10-20 

100-  500 

Below  100 
“  100 
“  100 
500-  2,500 
Above  500 
200-  300 

100-  200 
300-  1,000 

1,000-  2,000 
B’lowl,000 
100-  300 

Above  500 
100-  500 

500-  1,500 
Ab’veljOOO 
500-  1,000 
Ab’vel,000 
100-  2,000 
1,500-  5,000 
4,000-10,000 

2,616,870 

4,376,135 

875,086 

1,056,034 

1,669,229 

2,344,089 

3,049,402 

5,714,683 

2,440,339 

2,697,958 

3,625,545 

710,250 

1,990,917 

2,932,676 

4,403,662 

5,721,836 

835,694 

1,123,419 

715,781 

324,268 

931,910 

11.  Southern  interior  plateau  .. . 

12.  South  Mississippi  river  belt . 

13.  North  Mississippi  river  belt . 

14.  Southwest  central  region . 

15.  Central  region  (plains,  etc.) . 

16.  Prairie  region . 

17.  The  Missouri  river  belt . 

18.  The  Northwestern  region . 

19.  Pacific  coast  region . 

20.  Region  of  Western  Plains . 

21.  The  Cordilleran  region . 

*  The  grouping  herewith  adopted  is  that  proposed  by  Mr.  Gannett, 
the  geographer  of  the  Census. 


Upon  examination  of  Table  II,  it  will  be  seen  that 
Bright’s  disease  attains  its  highest  mortality  in  the  Middle 
Atlantic  coast  region  — 19-73  in  1,000 — or  considerably 
over  two  and  a  half  times  more  than  the  average  for  the 
whole  country.  The  North  Atlantic  coast  region  comes 
next  in  order,  the  ratio  being  17*38  in  1,000.  The  north¬ 
eastern  hills  and  plateaus  furnish  the  next  highest  ratio 
— 11*20  in  1,000  deaths.  The  average  for  the  three  re¬ 
gions  just  named  is  16-15  in  1,000 — or  nearly  two  and  a 
half  times  higher  than  the  average  for  the  whole  country. 
If  we  examine  the  climatic  features  of  this  tract  as  a  whole, 
it  must  be  conceded  to  be  the  coldest,  the  most  exposed,  the 
most  changeable,  as  well  as  among  the  most  humid  in  the 
United  States.  The  Middle  Atlantic  coast  region,  which 
furnishes  the  highest  ratio  of  mortality  from  Bright’s  dis¬ 
ease  (19-73)  of  the  grand  groups,  is  by  no  means  the  cold¬ 
est  region  in  the  country,  although  the  northern  half  thereof 
is  very  cold,  the  mean  temperature  range  for  the  year  be¬ 
ing  only  45°  to  50°  F.  The  climate  is  eminently  a  moist 
one,  for,  in  addition  to  the  direct  influence  of  the  sea,  the 
surface  of  the  country  is  low  and  sandy,  and  along  parts  of 
the  coast — notably  that  of  New  Jersey — there  are  sandy 
reefs,  shoreward  from  which  are  lagoons  succeeded  by  ex¬ 
tensive  areas  of  swamp.  Further  inland  the  country  is  low, 
nowhere  rising  to  exceed  one  hundred  feet  above  the  sea. 
In  addition  to  this,  the  mean  annual  rainfall  is  high — forty- 
five  to  sixty  inches.  The  changes  of  temperature  are  fre¬ 
quent,  often  sudden,  and  sometimes  extreme.  On  the 
whole,  however,  so  far  as  the  temperature  is  concerned,  the 
mean  range  is  from  10°  to  15°  F.  higher  than  in  the  regions 
of  the  North  Atlantic  coast  and  the  northeastern  hills  and 
plateaus,  where  the  death-rate  from  the  disease  is  somewhat 
lower.  It  may  therefore  be  properly  asked,  What  deter¬ 
mines  the  greater  mortality  from  Bright’s  disease  in  the 
Middle  Atlantic  coast  region  over  that  in  the  North  Atlantic 
coast  and  northeastern  hills  and  plateaus,  since  the  climate 
in  the  two  latter  regions  possesses  the  chief  features  which 
we  have  thus  far  found  prolific  of  the  disease,  to  a  degree  at 
least  as  marked  as  in  the  Middle  Atlantic  coast  region  ? 

In  attempting  a  solution  of  this  question  it  should  first 
be  remembered  that  the  Middle  Atlantic  coast  region  con¬ 
tains  most  of  the  larger  and  older  cities  of  the  country,  and 
consequently  much  of  the  national  wealth.  Now,  it  is  well 
known  that  wealth  encourages  a  course  of  living  that  espe- 
cially  predisposes  to  Bright’s  disease.  Indeed,  no  fact  has 
become  more  widely  recognized  than  that  chronic  Bright’s 
disease  (interstitial  nephritis)  is  largely  the  outgrowth  of 
luxurious  living — the  over-taxation  of  the  kidneys  in  elimi¬ 
nating  the  waste  products  of  highly  nitrogenous  foods. 
Moreover,  this  form  of  Bright’s  disease  is  uncommon  before 
the  age  of  forty  years;  indeed,  it  is  most  frequent  after  fifty. 
The  Middle  Atlantic  coast  region,  containing  so  large  a  pro¬ 
portion  of  the  older  and  wealthier  population  of  the  coun¬ 
try,  must  therefore  necessarily  have  a  higher  ratio  of  mor¬ 
tality  from  the  interstitial  form  of  Bright’s  disease.  Be¬ 
sides  this,  nearly  one  half  of  the  population  of  the  Middle 
Atlantic  coast  region  is  urban,  and  that  form  of  renal  dis¬ 
ease  known  as  amyloid  degeneration  of  the  kidney  (com¬ 
monly  returned  under  the  head  of  Bright’s  disease  on  ac- 


Oct.  4,  1890.]  PURDY:  TEE  INFLUENCES  OF  CLIMATE  OVER  B RIGHT'S  DISEASE. 


377 


count  of  its  accompanying  dropsy  and  highly  albuminous 
urine)  must  be  more  frequent  there  since  it  is  so  largely  the 
outgrowth  of  syphilis,  a  disease  always  more  frequent  in 
large  cities.  Lastly,  old  age,  scarlatina,  and  pneumonia  are 
factors  which  stand  in  close  causative  relationship  to  Bright’s 
disease  as  a  whole,  and  these  factors  are  possessed  by  the 
region  in  question  to  a  degree  perhaps  exceeding  any  region 
in  the  United  States.  If,  therefore,  we  consider  the  aetiol¬ 
ogy  of  Bright’s  disease  apart  from  climatic  influences,  we 
find  that  the  Middle  Atlantic  coast  region  possesses  the  gen¬ 
eral  elements  of  cause  of  the  disease  to  a  degree  exceeding 
any  other  region  of  the  country.  Add  to  this  the  influences 
of  climate  whose  leading  features  tend  strongly  toward  high 
mortality  from  the  disease,  and  the  solution  of  the  question 
no  longer  seems  a  difficult  problem. 

If  now  we  direct  attention  to  the  North  Atlantic  coast 
region  we  find  that  the  death-rate  from  Bright’s  disease  is 
very  high — 17*38  in  1,000.  The  climate  of  this  region  is 
the  most  trying  in  many  respects  of  the  whole  country. 
The  mean  temperature  is  45°  F.,  and  the  mean  rainfall 
is  about  forty-five  inches.  This  region  is  exposed  to  the 
damp  chilling  winds  from  the  North  Atlantic  Ocean.  In 
short,  the  climate  is  eminently  a  cold,  moist,  and  change¬ 
able  one.  The  general  causes  of  Bright’s  disease,  apart 
from  climatic  influences,  are  not  so  marked  as  in  the  Mid¬ 
dle  Atlantic  coast  region,  and  therefore  the  high  mortality 
of  the  disease  in  this  region  is  probably  more  purely  due  to 
the  special  features  of  climate  named. 

The  next  highest  death-rate  from  Bright’s  disease  is 
reached  in  the  Northeastern  hills  and  plateaus — viz.,  11*20 
in  1,000.  Although  possessing  the  third  highest  ratio  of 
mortality5' from  the  disease  of  the  grand  groups,  the  ratio 
is  considerably  lower  than  in  either  of  the  two  last  grand 
groups  considered.  The  climate  of  the  Northeastern  hills 
and  plateaus  is  exceedingly  cold,  the  mean  range  of  tem¬ 
perature  being  but  40°  F.  This  region  is  also  an  exposed 
one  owing  to  its  high  altitude.  It  lacks,  however,  the  char¬ 
acter  of  humidity  to  the  degree  possessed  by  the  two  regions 
just  considered.  It  is  removed  from  the  direct  influence  of 
the  sea  and  has  a  mean  rainfall  of  only  about  forty  inches. 
There  can  be  little  doubt  that  the  lessened  mortality  in  this 
region  from  Bright’s  disease  as  compared  with  the  two 
regions  last  considered  is  largely  due  to  the  comparative 
dryness  of  the  atmosphere,  while  a  high  mortality,  as  com¬ 
pared  with  the  whole  country,  is  still  maintained  by  the 
cold  and  exposed  position  of  this  region. 

If  now  we  turn  to  the  Southwest  central  region,  we  find 
the  rate  of  death  from  Bright’s  disease  to  be  the  lowest  of 
all  the  grand  groups  in  the  country — viz.,  1*97  in  1,000. 
The  climate  in  this  region  is  eminently  a  dry,  warm ,  and 
equable  one.  With  a  mean  annual  temperature  of  from 
60°  to  70°  F.,  and  a  mean  rainfall  of  thirty-five  to  forty 
inches,  its  chief  climatic  features  are  directly  opposite  to 
those  of  the  grand  groups  which  furnish  the  highest  death- 
rates  from  Bright’s  disease  in  the  country. 

The  South  Atlantic  coast  region  furnishes  the  next 
lowest  ratio  of  mortality  from  Bright’s  disease  of  the 
grand  groups — viz.,  2*59  in  1,000.  The  mean  tempera¬ 
ture  of  this  region  is  60°  to  G5°  F.,  and  the  mean  rain¬ 


fall  is  fifty-five  inches.  The  climate  of  this  region  is  a 
warm  though  rather  moist  one.  It  will  be  remembered 
that  the  South  Atlantic  coast  is  washed  by  the  Gulf  Stream 
before  the  latter  has  had  time  to  mingle  to  any  extent  with 
the  cool  waters  of  the  Atlantic  Ocean,  and  therefore  the 
east  winds  are  warm  and  balmy.  In  addition,  this  region 
is  sheltered  from  the  north  and  west  winds  by  the  Ap¬ 
palachian  range  of  mountains,  and  therefore  the  equability 
of  its  temperature  is  most  marked.  We  learn  from  these 
facts  that  equable  warmth  tends  to  induce  a  low  death-rate 
from  Bright’s  disease,  even  though  the  climate  is  a  moist 
one,  and  this  statement  is  confirmed  by  the  fact  that  the 
Bahama  Islands,  which  are  otf  the  South  Atlantic  coast 
region,  possess  a  climate  that  is  esteemed  for  its  favorable 
influence  over  Bright’s  disease  the  world  over. 

The  Southern  Central  Appalachian  region  furnishes  the 
next  lowest  death-rate  from  Bright’s  disease  of  the  grand 
groups — viz.,  2*63  per  1,000.  This  region  may  be  prac¬ 
tically  considered  a  continuation  of  the  South  Atlantic 
coast  region  to  the  westward.  It  differs  from  the  latter 
chiefly  in  possessing  a  drier  atmosphere  at  the  expense  of 
one  slightly  cooler,  depending  upon  its  higher  altitude  and 
greater  distance  from  the  sea. 

The  three  grand  groups  just  described,  if  considered  as 
a  whole,  form  a  large  tract  of  practically  inland  territory  of 
crescent  shape,  the  curve  of  which  corresponds  with  that  of 
the  north  line  of  the  Gulf  coast.  It  is  removed  from  the 
latter  sufficiently  far  to  escape  the  moisture  of  the  sea,  and 
yet  it  is  situated  sufficiently  near  to  receive  the  tempering 
influences  of  its  warmth  and  equability.  On  the  north  and 
east  it  is  protected  by  the  base  of  the  great  Appalachian 
range  of  mountains.  The  conditions  are  therefore  such, 
on  the  whole,  as  to  produce  warmth,  equability,  and  dry¬ 
ness  of  climate  to  a  degree  nowhere  else  attained  in  any 
tract  of  equal  extent  in  the  United  States.  We  must  there¬ 
fore  conclude  that — whether  we  take  the  State,  the  grand 
group,  or  a  group  of  grand  groups,  as  the  unit  of  calcula¬ 
tions — that  which  combines  the  highest  range  of  temperature 
with  the  greatest  equability  and  dryness  of  the  atmosphere 
furnishes  the  lowest  death-rate  from  Bright’s  disease,  and, 
vice  versa,  that  which  combines  the  lowest  temperature 
range  with  the  greatest  degree  of  atmospheric  moisture  and 
changeability  furnishes  the  highest  death-rate  from  the  dis¬ 
ease.  It  is  true  that  a  few  apparent  contradictions  to  these 
rules  may  be  found,  but,  upon  careful  consideration,  most 
if  not  all  of  these  are  readily  harmonized.  Thus  it  will  be 
observed  by  glancing  at  Table  II  that  the  Gulf  and  Pacific 
coast  regions  furnish  death-rates  from'Bright’s  disease  con. 
siderably  above  the  average  for  the  whole  country.  At 
first  thought  this  might  perhaps  seem  surprising,  consider¬ 
ing  the  climatic  features  of  these  regions  and  the  further 
fact  that  it  has  become  the  fashion  in  the  United  States  to 
send  those  afflicted  with  Bright’s  disease  to  one  or  the 
other  of  these  localities  for  curative  purposes.  Upon  re¬ 
flection,  however,  the  fact  explains  itself,  for  many  of  those 
in  practice  can  attest  that  numbers  of  their  patients  do  not 
return,  or,  if  they  do,  they  leave  the  records  of  their  deaths 
to  swell  the  death-rates  of  the  disease  in  the  places  under 
consideration. 


3"8 _ GILLIAM:  TOTAL  VAGINAL  EXTIRPATION  OF  THE  UTERUS.  [N.  Y.  Med.  Jode, 

With  regard  to  altitude,  it  may  be  stated  that  statistics 


do  not  indicate  that  it  very  materially  influences  the  death- 
rate  from  Bright’s  disease  further  than  its  influence  over 
temperature  is  concerned.  In  the  northeastern  hills  and 
plateaus,  where  the  elevation  above  the  sea  averages  per¬ 
haps  2,000  feet,  the  mortality  from  Bright’s  disease  reaches 
the  third  highest  ratio  of  the  grand  groups  of  the  country. 
On  the  other  hand,  in  the  Southern  Central  Appalachian 
region,  where  the  altitude  is  even  higher,  the  mortality  from 
the  disease  sinks  to  the  third  lowest  of  the  grand  groups  of 
the  country. 

Again,  the  Middle  Atlantic  coast  region  .furnishes  the 
highest  ratio  of  mortality  from  the  disease  of  all  the  grand 
groups  in  the  country,  and  this  region  possesses  a  mean  alti¬ 
tude  of  less  than  100  feet  above  the  sea;  while,  on  the 
other  hand,  in  the  Cordilleran  region  the  altitude  altogether 
exceeds  that  of  any  other  grand  group  in  the  country,  yet 
we  find  the  death-rate  from  Bright’s  disease  in  this  region 
to  be  only  3’04  in  1,000 — considerably  less  than  half  the 
average  for  the  whole  country. 

In  view  of  these  observations,  it  must  be  concluded  that 
the  influence  of  altitude  over  Bright’s  disease  in  general  is 
very  slight  as  compared  with  those  features  of  climate  al¬ 
ready  considered.  In  this  connection  the  fact  should  not 
be  overlooked  that  in  those  forms  of  Bright’s  disease  which 
are  complicated  by  advanced  cardiac  disease,  notably  the 
late  stages  of  interstitial  nephritis^  high  altitudes  are  dis¬ 
tinctly  dangerous.  In  such  cases  the  heart  failure  is  has¬ 
tened  by  the  high  altitude,  which  in  turn  is  very  prone  to 
bring  on  fatal  uraimia. 

A  review  of  these  investigations  substantiates  the  fol¬ 
lowing  conclusions : 

1.  That  the  chief  features  of  climate  in  the  United 
States  which  most  strongly  tend  to  increase  the  death-rate 
from  Bright’s  disease  are  cold,  moisture,  and  changeability 
of  temperature. 

2.  That  the  elements  of  climate  which  tend  in  the 
greatest  degree  to  decrease  the  death-rate  from  Bright’s 
disease  are  warmth,  dryness,  and  equability. 

3.  That  cold  most  markedly  increases  the  mortality 
from  Bright’s  disease  when  associated  with  moisture,  a 
comparatively  low  temperature  being  well  borne  if  the  at¬ 
mosphere  is  a  dry  one. 

4.  That  a  comparatively  high  degree  of  humidity  of 
the  atmosphere  does  not  markedly  increase  the  mortality 
from  Bright’s  disease  if  accompanied  by  warmth  and  equa¬ 
bility. 

5.  That  the  most  unfavorable  residence  localities  for 
patients  afflicted  with  Bright’s  disease  in  the  United  States 
are  comprised  within  the  Atlantic  coast  region  and  North¬ 
eastern  hills,  which  include  the  States  of  New  Jersey,  New 
T  ork,  Connecticut,  Massachusetts,  New  Hampshire,  and 
Vermont. 

6.  I  hat  the  most  favorable  residence  localities  are 
chiefly  comprised  within  the  Southern  interior,  and  espe¬ 
cially  include  the  States  of  Tennessee,  Georgia,  North  Caro¬ 
lina,  Arkansas,  and  Texas. 

7.  Finally,  a  practical  lesson  may  be  learned  from  these 
investigations  as  follows :  That,  since  climate  so  decidedly 


influences  the  mortality  from  Bright’s  disease,  those  who 
are  afflicted  with  the  disease  or  possess  strong  hereditary 
or  other  tendencies  thereto  should  wear  such  garments  as 
most  directly  tend  to  neutralize  the  evil  influences  of  cli¬ 
mate  over  the  disease — viz.,  those  combining  the  minimum 
power  of  radiation  of  body  heat  with  the  highest  hygroscopic 
properties  ;  and  since  wool  possesses  these  qualities  to  a  degree 
unapproached  by  any  other  textile ,  all-wool  garments  should 
be  worn  next  the  skin  throughout  the  year. 

163  State  Street. 


TOTAL  VAGINAL  EXTIRPATION  OF  THE  UTERUS 

RANDOM  NOTES. 

By  D.  TOD  GILLIAM,  M.  D., 

PROFESSOR  OF  OBSTETRICS  AND  GYNAECOLOGY,  STARLING  MEDICAL  COLLEGE, 

COLUMBUS,  OHIO. 

As  between  supravaginal  amputation  and  total  extirpa¬ 
tion  of  the  cancerous  uterus,  about  which  so  much  is  being 
said  and  written  nowadays,  I  shall  draw  no  invidious  line. 
Doubtless  each  has  its  sphere  of  utility,  and  the  time  will 
come  when  the  indications  for  one  or  the  other  will  be  more 
clearly  defined.  The  relative  mortality  of  the  two  opera¬ 
tions  is  about  two  to  one  in  favor  of  the  less  radical  opera¬ 
tion.  While  under  expert  hands  the  death-rate  of  vaginal 
hysterectomy  has  been  reduced  to  five  per  cent.,  yet  in  the 
aggregate  of  all  operations  it  is  probably  not  less  than  fif¬ 
teen  to  twenty  per  cent.  Supravaginal  amputation  in  like 
manner  gives  a  death-rate  of  about  seven  per  cent.,  whereas 
in  the  hands  of  a  favored  few  it  does  not  exceed  over  two 
to  three  per  cent.  Recurrences  are  a  little  less  frequent  and 
are  longer  delayed  in  vaginal  hysterectomy,  giving  an  aver¬ 
age  exemption  of  about  thirty -three  percent,  after  two  years 
to  some  German  operators.  As  to  the  indications  for  one 
or  the  other,  the  high  amputation  has  a  much  broader  range 
than  total  extirpation.  The  latter  is  not  to  be  thought  of 
in  cases  where  the  mobility  of  the  uterus  is  much  restricted. 
It  is  a  good  rule,  and  one  generally  observed,  not  to  attempt 
total  extirpation  in  any  case  w'here  the  cervix  can  not  be 
drawn  down  to  the  vulva  ;  also  in  very  large  uteri,  or  where 
there  is  a  complication  with  fibroid  or  other  massive  growth, 
or  where  there  are  strong  adhesions,  or  the  vaginal  canal  is 
unusually  narrow  and  deep,  or  when,  as  occasionally  hap¬ 
pens,  the  intestines  are  adherent  to  the  uterus,  or  when 
the  broad  ligaments  are  obviously  involved  in  the  disease 
as  manifested  by  thickening,  induration,  and  absence  of  elas¬ 
ticity.  It  is  safer  in  every  case  before  operating  to  not 
only  sound  the  uterus  and  test  its  mobility,  but  also  to  anaes¬ 
thetize  the  patient,  and,  drawing  the  uterus  down,  make  a 
thorough  rectal  exploration.  In  case  of  intestinal  adhesions, 
if  they  should  prove  very  firm,  the  operation  should  be 
abandoned,  otherwise  they  may  be  better  dealt  with  after 
one  ol  the  ligaments  is  severed  and  the  uterus  brought  to 
light,  provided  always  the  adhesions  are  confined  to  the 
uterus  proper. 

In  case  the  cervix  is  gone  and  the  cavity  of  the  uterus 
so  diseased  as  to  be  very  friable,  traction  can  be  made  by  a 
diverging  double  tenaculum  forceps  introduced  into  the 
cavity  and  expanded,  using  very  moderate  force  until  the 


Oct.  4,  1890.] 


GILLIAM:  TOTAL  VAGINAL  EXTIRPATION  OF  THE  UTERUS. 


379 


outer  surface  of  the  uterus  has  been  cleared  sufficiently  to 
admit  of  a  good  hold  by  the  volsella. 

In  a  recent  case  the  high  operation  had  been  previously 
performed  and  a  dense,  cicatricial  tissue  formed  between 
the  bladder  and  the  uterus;  the  cavity  was  cancerous  to  the 
fundus.  Even  the  tenaculum  forceps  plowed  through  it 
when  much  traction  was  used.  I  was  exceedingly  uneasy 
about  this  case,  fearing  that  the  scar  tissue  would  divert  me 
from  my  course  into  the  bladder  or  uterus,  but  by  graduat¬ 
ing  the  traction  just  so  as  to  steady  the  uterus,  I  carefully 
worked  my  way  for  a  short  distance  through  the  scar  tissue, 
keeping  my  bearings  by  means  of  a  sound  in  the  bladder, 
and  soon  had  the  satisfaction  of  striking  the  loose  cellular 
tissue,  when  the  volsella  was  applied,  and  from  then  on  I 
had  plain  sailing. 

I  prepare  my  patient  for  the  operation  by  having  the 
bowels  cleared  and  a  vaginal  injection  of  four  or  five  gal¬ 
lons  of  warm  (not  hot)  water.  This  not  only  cleanses  the 
parts  thoroughly,  but  produces  a  relaxation  that  facilitates 
the  subsequent  steps  of  the  operation.  The  bladder  being 
emptied,  the  patient  is  placed  on  the  table  in  the  lithotomy 
position.  Before  the  speculum  is  introduced  the  vagina  is 
thoroughly  mopped  out  with  absorbent  cotton  saturated 
with  a  1-to- 5,000  solution  of  mercuric  chloride.  The  Sims 
speculum  and  two  retractors — one  on  either  side — being  in¬ 
troduced,  the  cervix  is  seized  with  tenacula  or  volsellae  or 
transfixed  by  strong  cords  and  drawn  down.  Now  with  the 
knife  a  rather  free  incision  is  made  at  the  cervico-vaginal 
junction  into  the  submucous  connective  tissue.  This  cut 
must  completely  surround  the  cervix,  but  should  be  ex¬ 
tended  on  either  side  to  afford  room  for  clamping  the  broad 
ligaments.  Now  with  the  finger,  scalpel  handle,  and  scis¬ 
sors  separate  the  bladder  from  the  uterus,  keeping  close  to 
the  latter  and  doing  as  little  cutting  as  possible.  Having 
arrived  at  the  peritonaeum,  which  is  evidenced  by  a  lack  of 
resistance,  Douglas’s  cul-de-sac  is  exposed  in  like  manner, 
and  opened  by  a  stroke  of  the  knife  or  snipped  by  the  scis¬ 
sors.  Introducing  a  finger  over  the  broad  ligament  into  the 
vesico-uterine  space,  the  peritonaeum  is  opened  on  it. 

I  have  usually  disregarded  this  rule  and  pushed  my  fin¬ 
ger  through  from  below,  as  it  is  rather  an  advantage  than 
otherwise  to  have  the  peritonaeum  stripped  from  the  ante¬ 
rior  surface  of  the  uterus  as  far  as  it  will  go.  The  openings 
are  now  enlarged  by  pressure  with  the  fingers  until  the  uterus 
is  cleared  from  side  to  side  and  the  broad  ligaments  made 
freely  accessible.  One  or  two  sponges  properly  prepared 
and  with  cords  attached  are  now  introduced  into  the  peri¬ 
toneal  cavity  to  absorb  the  blood  and  to  keep  the  bowels 
and  other  parts  out  of  harm’s  way.  During  all  this  time 
bleeding  points  are  taken  up  by  pressure  forceps  as  they  are 
exposed,  sometimes  as  many  as  a  dozen  or  more  being 
needed,  at  others  none. 

The  finger,  or,  if  tense  and  unyielding,  a  steel  hook,  is 
now  placed  over  the  left  broad  ligament  under  guidance  of 
the  finger,  and  the  latter  drawn  down.  Following  Reamy’s 
suggestion,  I  habitually  use  the  obstetric  crotchet-hook  for 
this  purpose,  and  it  answers  admirably.  The  broad-liga¬ 
ment  forceps  is  now  passed  up  alongside  and  near  to  the 
uterus  and  slid  outward  on  the  ligament,  bearing  in  mind  the 


proximity  of  the  ureter  and  not  attempting  to  take  too  big 
a  bite,  lest  this  be  included.  If  the  uterus  is  well  drawn 
down,  there  is  much  less  risk  of  catching  up  the  ureters  than 
if  it  be. left  near  its  normal  situation.  With  a  finger  at  the 
distal  end  of  the  forceps  blade  in  the  peritoneal  cavity  the 
forceps  is  closed  so  as  to  take  in  the  entire  depth  of  the 
ligament  and  not  include  anything  else.  Should  the  liga¬ 
ment  be  too  much  crumpled  or  rounded  by  reason  of  trac¬ 
tion  on  the  hook,  this  must  be  relaxed  while  the  forceps  is 
being  adjusted.  I  prefer  a  forceps  with  a  central  longitudi¬ 
nal  groove,  like  the  Wathens,  as  the  tissues  bulging  into 
the  groove  gives  a  firmer  hold  and  there  is  less  danger  of 
slipping.  It  is  better  also  that  the  blades  when  closed  should 
not  touch  their  entire  length,  but  that  one  should  be  able 
to  see  light  through  that  part  nearest  the  handle,  as  the  base 
of  the  broad  ligament  is  a  little  thicker  than  the  upper  part, 
and  equalized  pressure  is  better  secured  thereby.  Some 
time  since  I  got  a  set  of  forceps  from  Tiemann,  one  of  which 
I  considered  defective  by  reason  of  this  non-parallelism  of 
the  blades,  but  in  using  them  I  found  it  the  most  perfect 
instrument  I  had.  Having  secured  the  ligament,  sever  the 
uterus  by  scissors,  being  careful  not  to  cut  too  close  to  the 
forceps.  The  uterus  may  now  be  drawn  down  and  the  other 
forceps  adjusted  under  the  eye.  The  uterus  is  now  cut  away, 
and,  after  looking  carefully  for  bleeding  vessels,  the  vagina 
is  again  mopped  out  with  the  bichloride  solution,  the  sponges 
withdrawn,  the  vagina  packed  loosely  with  iodoform  gauze, 
and  the  patient  put  to  bed.  I  do  not  sew  up  the  perito¬ 
naeum,  for  the  reason  that  if  no  obstacle  exists  it  quickly  falls 
together  and  heals.  On  the  other  hand,  should  antagonistic 
conditions  prevail,  the  demands  for  free  drainage  will  be 
better  subserved  by  leaving  a  free  opening.  The  tampon  is 
left  in’ from  two  to  four  days,  owing  to  the  degree  of  foul¬ 
ness  which  develops,  or,  should  the  patient’s  condition  sug¬ 
gest  infection,  it  is  immediately  withdrawn,  and,  after  gentle 
swabbing  with  the  bichloride,  a  fresh  one  introduced.  All 
except  the  broad-ligament  forceps  are  removed  at  the  expi¬ 
ration  of  twenty-four  hours.  The  latter  are  left  on  forty- 
eio-ht  hours.  It  is  better  not  to  disturb  the  tampon  for 
twenty-four  hours  after  removal  of  the  forceps,  for  the  rea¬ 
son  that,  in  separating  the  blades  to  withdraw  them,  an  open¬ 
ing  may  be  made  into  the  peritoneal  cavity  through  which 
germs  or  extraneous  matter  may  gain  entrance.  I  have  made 
it  a  rule  to  open  the  bowels  on  the  second  day,  whereby  in¬ 
testinal  adhesions  may  be  averted.  There  are  no  hard  rules 
to  follow,  however,  as  this  very  day  I  have  violated  one  of 
the  injunctions  laid  down  above.  It  is  now  the  second  day 
since  operating,  and  consequently  time  to  remove  the  last 
forceps.  I  found  her  very  foul,  and  consequently  swabbed 
her  out  and  introduced  a  fresh  tampon  coincidently  with 
the  withdrawal  of  the  forceps.  This  case  taught  me  another 
lesson  :  The  first  steps  of  the  operation  were  almost  blood¬ 
less.  Just  as  I  was  in  the  act  of  severing  the  last  broad 
ligament  the  forceps  slipped,  and  the  field  was  deluged  in 
blood.  This  being  secured,  a  great  many  vessels  from  the 
hidden  recesses  of  the  retracted  tissues  began  to  spout,  and 
when,  after  a  half  hour’s  hard  work,  the  haemorrhage  was 
stanched,  the  vagina  was  literally  packed  with  pressure 
forceps. 


380 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jocr., 


the 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  OCTOBER  4,  1890. 

THE  MEDICAL  SERVICE  OF  THE  NATIONAL  GUARD  OF 
THE  STATE  OF  NEW  YORK. 

The  Annual  Report  of  the  Adjutant- General  for  the  year 
1889,  transmitted  to  the  Legislature  on  February  20,  1890,  fur¬ 
nishes  noteworthy  evidence  of  the  continued  efficiency  of  the 
medical  corps  of  the  National  Guard.  At  the  date  of  the  re¬ 
port  the  force  comprised  fourteen  regiments,  one  battalion,  and 
forty-five  separate  companies  of  infantry,  five  batteries  of  artil¬ 
lery,  one  troop  of  cavalry,  and  two  signal  corps,  amounting  on 
the  30th  of  September,  1889,  to  14,222  officers  and  men,  and 
being  divided  into  four  brigades.  The  medical  corps  includes 
the  surgeon-general  (Dr.  Joseph  D.  Bryant,  of  New  York),  four 
brigade  surgeons  (Dr.  Robert  V.  McKirn,  of  New  York;  Dr. 
George  R.  Fowler,  of  Brooklyn  ;  Dr.  Herman  Bendell,  of  Al¬ 
bany;  and  Dr.  Roswell  Park,  of  Buffalo),  and  a  surgeon  and 
assistant  surgeon  for  each  regiment.  In  his  own  report  Sur¬ 
geon-General  Bryant  speaks  in  high  praise  of  the  medical  offi¬ 
cers  serving  under  him  and  of  the  sanitary  condition  of  the 
State  Camp,  but  he  deprecates  the  lack  of  punctuality  and  full¬ 
ness  characterizing  the  reports  of  some  of  the  regimental  medi¬ 
cal  officers.  As  an  example  of  what  they  would  do  well  to 
emulate,  he  gives  the  report  made  to  him  by  Surgeon  E.  T.  T. 
Marsh,  of  the  Seventy-first  Regiment,  within  three  weeks  of 
the  time  when  that  regiment  began  its  week’s  encampment. 
Dr.  Marsh,  who  acted  as  post  surgeon  during  his  regiment’s 
encampment,  furnished  certain  recommendations  to  the  com¬ 
manding  officer  of  his  regiment  at  the  outset,  and  at  the  same 
time  some  bits  of  advice  to  the  men— all  intended  to  further 
the  preservation  of  the  men’s  health  while  in  camp.  For  the 
most  part  the  advice  given  by  Dr.  Marsh  was  such  as  every  ex¬ 
perienced  medical  officer  would  undoubtedly  urge,  and  none  of 
it  was  what  such  an  officer  would  regret. 

In  concluding  his  report,  Dr.  Marsh  makes  certain  recom¬ 
mendations  with  regard  to  the  management  of  the  camp — among 
them,  that  the  number  of  bath-houses  be  at  least  doubled;  that 
the  main  street  be  put  in  a  condition,  by  means  of  concrete  or 
brick,  to  enable  it  to  withstand  the  constant  sweeping  to  which 
it  is  necessarily  subjected  in  rainy  weather,  which  now  leads  to 
the  formation  of  hollows  and  consequent  puddles;  that  the 
high  underbrush  and  lower  limbs  of  the  trees  on  the  edge  of 
the  bluff  and  the  borders  of  the  camp  be  cut  away  so  as  to 
allow  of  a  freer  circulation  of  air  in  and  about  the  camp  ;  and 
that  the  members  of  the  ambulance  corps  be  allowed  to  wear 
the  brassard  at  all  times  when  they  are  on  duty,  inasmuch  as 
some  of  them  were  fired  on  during  a  sham  battle,  and  one  had 
his  face  burned  with  gunpowder.  The  surgeon-general  does 
not  seem  to  agree  with  Dr.  Marsh  as  to  the  utility  of  cutting 


away  the  underbrush  and  low  branches  of  trees;  indeed,  he 
affirms  anew  that  there  should  be  larger  and  taller  trees,  and 
more  of  them,  on  the  top  and  the  incline  of  the  bluff,  not  only 
to  afford  shade  during  the  heat  of  the  day,  but  also  to  aid  in 
warding  off'  any  malarial  influences  that  may  emanate  from  the 
neighboring  marshy  ground. 

During  the  past  few  years  a  point  has  been  made  in  the 
National  Guard  of  instructing  details  of  men  in  the  elements  of 
the  art  of  rendering  prompt  and  well-directed  aid  to  the 
wounded  and  disabled.  This  is  one  of  many  manifestations  of 
Surgeon-General  Bryant’s  devotion  to  the  good  of  the  service. 
Of  its  great  value  examples  have  been  abundant,  but  it  is  none 
the  less  gratifying  to  see  that  Colonel  Loder,  of  the  Fifth  United 
States  Artillery,  the  officer  deputed  to  report  upon  the  New 
York  State  Camp  of  Instruction  at  Peekskill,  makes  particular 
mention  of  it  and  gives  Dr.  Bryant  special  credit  for  its  intro¬ 
duction.  “The  idea,”  says  Colonel  Loder,  “ contemplates  the 
extending  of  aid  to  the  unfortunate  citizen  who  may  suffer 
from  the  effects  of  physical  violence  received  in  the  daily  walks 
of  life,  as  well  as  to  the  National  Guardsman  who  may  fall 
while  on  his  special  duty.  Trained  National  Guardsmen  may 
thus  aid  the  citizen  in  other  ways  than  as  a  ‘  man  under 
arms.’  ” 

Surgeon-General  Bryant  properly  protests  against  the  prac¬ 
tice  of  issuing  disused  uniforms  to  recruits.  The  use  of  second¬ 
hand  uniforms,  he  remarks,  is  never  ennobling,  especially  when 
they  are  soiled  and  out  of  repair — perhaps  the  cast-off  garments 
of  those  who  have  been  dropped  for  dereliction  of  duty.  He 
calls  attention  again  to  the  necessity  of  remedying  the  pro¬ 
longed  and  profound  saturation  of  the  soil  beneath  and  around 
the  present  kitchen  in  the  camp.  Although  no  case  of  disease 
traceable  to  any  such  agency  occurred  during  the  year,  it  may 
well  play  havoc  in  the  future  if  it  is  not  dealt  with  energetical¬ 
ly.  All  his  recommendations  seem  to  us  such  as  ought  to  be 
carried  out. 


AN  EPIDEMIC  OF  GHOSTS. 

Those  who  are  interested  in  the  manias  of  the  middle  ages 
will  be  somewhat  amazed  to  hear  that  in  the  last  decade  of  the 
nineteenth  century  a  nervous  epidemic  of  an  hallucinatory 
kind  should  have  made  itself  prevalent  among  such  very  mat¬ 
ter-of-fact  people  as  the  citizens  of  Berlin.  Our  energetic  and 
persevering  friends  in  the  bacteriological  laboratory  have  not 
yet  found  a  microbe  to  account  for  the  contagion  of  bodily 
fear,  that  uncomfortable  sensation  about  the  epigastrium  which 
attacks  individuals  first  and  rapidly  extends  itself  to  large  num¬ 
bers  of  people,  resembling  in  its  onset  the  work  of  the  most 
active  microbe.  We  must,  therefore,  assume  the  existence  of 
a  mental  contagion  to  explain  the  occurrence  of  the  extraordi¬ 
nary  psychical  disturbances  of  which  we  read  in  history  and  of 
which  to-day  we  witness  an  example. 

Berlin  was  a  few  weeks  ago  the  scene  of  a  most  extraordi¬ 
nary  demonstration  of  the  contagious  effect  of  fear.  In  one  of 
the  public  schools,  a  silly  young  girl,  frightened  by  the  flapping 
of  a  window  curtain,  imagined  that  she  had  seen  a  ghost,  and 


Oct.  4,  1890.] 


MINOR  PARAGRAPHS. 


communicated  her  dread  to  the  rest  of  the  scholars  until  some¬ 
thing  like  a  panic  ensued.  Not  only  did  the  scholars  in  this 
one  school  begin  to  see  ghosts,  but  rapidly  ghost-seeing  became 
prevalent  in  other  schools,  until  now  the  moral  contagion  has 
involved  many  of  the  schools  of  the  suburbs,  as  well  as  those  of 
the  capital  itself.  The  force  of  example,  acting  upon  minds 
weakened  by  overwork,  operates  with  a  morbid  activity,  and 
cases  of  hysterical  outbreaks  in  factories,  convents,  and  schools 
have  very  frequently  been  reported.  The  educational  forcing 
system,  what  Charles  Dickens  would  call  the  production  of 
mental  green  peas  at  Christmas  and  intellectual  asparagus  all 
the  year  round,  of  which  our  German  friends  are  so  fond,  may 
play  an  important  r61e,  to  borrow  one  of  their  expressions,  in 
the  aetiology  of  these  contagious  moral  epidemics.  There  is 
not  much  change  in  the  world  after  all.  The  intense  religious 
fervor  of  the  middle  ages  is  replaced  by  the  witchcraft  craze 
and  the  convulsionnaire  movement  of  the  last  century,  and 
now  these  give  place  in  our  time  to  religious  revivals  of  the 
wildly  emotional  type,  the  howling  and  writhing  of  the  camp 
meeting,  the  strange  tongues  of  Irvingism,  and  the  dancing 
parade  of  the  salvation  soldiers.  All  such  movements  have  a 
strong  family  resemblance  the  one  to  the  other,  and  their  gro¬ 
tesqueness  is  proportionate  to  the  degree  of  education  preva¬ 
lent  at  the  period  in  which  they  occur. 

With  the  ghost  mania  it  is  reported  that  the  Berlin  authori¬ 
ties  have  adopted  vigorous  measures,  but  what  form  these  have 
taken  we  have  not  yet  been  informed.  Perhaps  the  paternal 
government  of  Germany  will  employ  the  treatment  recom¬ 
mended  by  Paracelsus  for  the  dancers  of  his  time,  namely, 
total  immersion  of  each  patient  in  cold  water.  The  American 
spank-cure,  as  described  by  a  contemporary,  might  also  prove 
serviceable.  The  prompt  application  of  the  old-fashioned 
calorifacient  slipper  to  the  next  child  announcing  itself  as  a 
seer  of  ghosts  might  aid  in  putting  an  end  to  what  appears  to 
be  really  a  very  serious  mania. 


MINOR  PARAGRAPHS. 

A  TARDY  ACKNOWLEDGMENT. 

Several  years  ago  Dr.  Lewis  A.  Stimson  presented  before 
the  New  York  Surgical  Society  an  account  of  certain  elaborate 
experiments  that  he  had  performed  for  the  purpose  of  testing 
the  efficiency  of  germicides  in  the  form  of  spray  as  destroyers 
of  atmospheric  germs.  This  was  at  a  time  when  everybody 
who  believed  in  antisepsis  at  all  trusted  implicitly  to  the  spray. 
Dr.  Stimson’s  experiments  convinced  him  that  the  common  be¬ 
lief  was  fallacious,  and  he  stated  this  conviction  without  re¬ 
serve,  a  procedure  that  showed  his  entire  confidence  in  the 
methods  he  had  employed  in  the  investigation.  His  paper  was 
published  in  a  Philadelphia  journal,  and  he  soon  found  himself 
the  subject  of  English  criticism  of  considerable  severity,  not  un¬ 
mingled  with  scorn.  But  in  Germany  his  experiments  were  re¬ 
peated  and  corroborated,  and  fort  mit  dem  Spray  !  became  the 
cry.  The  spray  fell  into  general  disuse,  but  we  are  not  aware 
that  its  promoter,  Sir  Joseph  Lister,  ever  formally  acknowl¬ 
edged  that  he  had  erred  in  advocating  its  employment  until  he 
did  so  in  his  address  at  the  recent  Berlin  meeting  of  the  Inter¬ 
national  Medical  Congress. 


381 


MtTLLER’S  symptom  in  aortic  insufficiency. 

According  to  the  Gazette  hebdomadaire  de  medecine  et  de 
chirurgie ,  Dr.  Matthieu,  in  a  recent  Paris  thesis,  states  his  be¬ 
lief  that  the  symptom  is  occasionally  presented  under  the  triad 
of  visible  capillary  pulse,  carotid  beating,  and  puhation  of  the 
uvula  and  soft  palate.  The  second  and  third  of  these  pecul¬ 
iarities  are  most  often  associated,  and  constitute  the  visible  pulse 
of  the  isthmus  of  the  pharynx.  Exceptionally  the  pharynx  is 
agitated  by  the  pulsations  to  the  exclusion  of  the  tonsils  and 
pillars  of  the  fauces.  The  appearance  of  the  symptom  depends 
upoD  :  1.  A  very  energetic  cardiac  impulse.  2.  A  considerable 
volume  of  the  systolic  wave.  3.  The  loss  of  elasticity  of  the 
peripheral  arteries,  either  by  spasm  or  by  degeneration.  The 
symptom  was  only  encountered  in  patients  affected  with  simple 
or  complicated  aortic  insufficiency,  and  only  in  about  fifty  per 
cent,  of  those  examined.  The  symptom  may  be  useful  in  mak¬ 
ing  a  diagnosis  when  a  pulmonary  affection  renders  auscultation 
of  the  heart  difficult,  or  when  it  is  impossible  to  distinguish  be¬ 
tween  the  bruit  of  aortic  insufficiency  and  certain  extracardiac 
murmurs  of  pulmonary  origin  or  pericardial  friction  sounds,  or 
when  a  systolic  murmur  at  the  base  may  be  attributed  to  aortic 
stenosis  or  aortitis  deformans. 


POISONS  FOR  THE  BACILLUS  TUBERCULOSIS. 

Professor  Kooh  says,  according  to  the  British  Medical 
Journal ,  that  he  has  tested  a  very  great  number  of  substances 
to  ascertain  the  influence  that  they  exerted  on  the  tubercle 
bacilli  in  pure  cultures.  The  following  substances,  even  in  small 
quantities,  hindered  the  growth:  A  number  of  ethereal  oils; 
of  the  aromatic  compounds,  /3-naphthylamine,  paratoluidine, 
xylidine;  the  aniline  dyes,  fuchsine,  gentian  violet,  methyl 
blue,  quinoline  yellow,  aniline  yellow,  auramine;  mercury  in 
vapor,  and  silver  and  gold  compounds.  A  compound  of  cyano¬ 
gen  and  gold,  even  in  a  dilution  of  one  to  two  millions,  checked 
the  growth  of  the  bacillus.  These  substances  had  no  effect  on 
tuberculous  animals.  Light  was  as  potent  as  chemicals,  sun¬ 
light  killing  a  layer  of  tubercle  bacilli  in  a  few  minutes  or  hours, 
according  to  the  thickness  of  the  layer.  Ordinary  daylight 
will  exercise  the  same  effect  in  from  five  to  seven  days. 


CAMPHORIC  ACID  AS  AN  ANTHIDROTIC. 

Lyon  medical  gives  an  abstract  of  an  article  by  M.  Leu,  pub¬ 
lished  in  the  Bulletin  medical ,  setting  forth  the  results  of  cer¬ 
tain  trials  of  camphoric  acid,  given  internally,  to  control  the 
profuse  sweats  of  phthisical  patients.  It  was  usually  given  at 
bedtime,  in  doses  of  thirty  grains;  sometimes  that  dose  was 
given  in  the  afternoon  and  a  slightly  larger  one  in  the  evening. 
It  often  happened  that  the  anthidrotic  effect  was  not  shown 
until  the  third  day,  but  generally  the  effect  of  a  single  dose 
lasted  for  several  days.  Out  of  sixty-five  trials  on  thirteen  pa¬ 
tients,  sixty  per  cent,  were  completely  successful,  and  in  twenty- 
two  per  cent,  the  sweating  was  moderated,  lhe  drug  is  soluble 
with  difficulty  in  water,  but  dissolves  more  readily  in  alcohol. 
Its  taste  is  said  not  to  be  disagreeable.  Some  trials  of  an  alco¬ 
holic  solution  in  the  form  of  a  lotion,  for  localized  sweating, 
proved  satisfactory. _ 

MR.  HUTCHINSON  ON  CIRCUMCISION. 

In  the  Archives  of  Surgery  Mr.  Jonathan  Hutchinson  sums 
up  his  experience  in  regard  to  the  sanitary  advantages  of  the 
rite  of  circumcision.  After  premising  that  it  is  not  needful  to 
go  on  a  search  for  any  recondite  motive  for  the  origin  of  the 
practice,  he  says:  “No  one  who  has  seen  the  superior  cleanli- 


382 


MINOR  PA  RA  GRA  PITS.— ITEMS. 


[N.  Y.  Med.  Jour., 


ness  of  a  Hebrew  penis  can  have  avoided  a  very  strong  impres¬ 
sion  in  favor  of  the  removal  of  the  foreskin.  If  not  removed 
it  constitutes  a  harbor  for  filth,  and  is,  in  many  persons,  a  con¬ 
stant  source  of  irritation.  It  conduces  to  masturbation  and 
adds  to  the  difficulties  of  sexual  continence.  It  increases  the 
risk  of  syphilis  in  early  life  and  of  cancer  in  the  aged.  I  have 
never  seen  cancer  of  the  penis  in  a  Jew,  and  chancres  are  rare.” 


A  PROJECT  TO  INCREASE  THE  FISH  SUPPLY  OF  NEW 

YORK  STATE. 

A  number  of  gentlemen  living  in  Rochester  have  undertaken 
to  procure  funds  for  restocking  Lake  Ontario  with  whitefish, 
and  legislation  to  prevent  the  extermination  of  the  new  stock. 
They  have  the  support  of  the  local  newspapers  and  the  ap¬ 
proval  of  their  member  of  the  State  Fish  Commission.  The 
undertaking  is  most  commendable,  and  we  have  no  doubt  that 
the  physicians  of  the  State  will  gladly  aid  in  its  accomplishment 
by  whatever  influence  they  may  have  with  legislators  and  with 
persons  who  may  be  looked  to  for  contributions. 


MEDICAL  DRAWINGS. 

Dr.  Henry  Macdonald,  whose  change  of  address  we  record 
elsewhere  in  this  issue,  informs  us  of  his  willingness  to  devote 
a  portion  of  his  time  to  making  anatomical  and  other  drawings 
for  members  of  the  profession.  We  have  published  many  en¬ 
gravings  from  Dr.  Macdonald’s  drawings,  and  others  have  ap¬ 
peared  in  various  medical  hooks.  His  work  is,  indeed,  so  well 
known  as  to  stand  in  no  need  of  commendation.  We  will  sim¬ 
ply  express  the  hope,  therefore,  that  his  otherwise  unoccupied 
time  may  be  sufficient  to  enable  him  to  do  all  the  drawing  that 
he  is  called  on  to  do. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York.— We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  September  30,  1890: 


DISEASES. 

Week  ending  Sept.  23- 

Week  ending  Sept.  30. 

Cases. 

Deaths. 

Oases. 

Deaths. 

Typhoid  fever . 

39 

13 

61 

11 

Scarlet  fever . 

17 

7 

27 

3 

Cerebro-spinal  meningitis . 

1 

0 

3 

3 

Measles . 

46 

6 

26 

2 

Diphtheria . 

42 

17 

64 

14 

Small-pox . 

0 

0 

1 

0 

Whooping-cough . 

0 

0 

2 

0 

Mount  Sinai  Hospital. — There  is  a  vacancy  in  the  eye  department 
of  the  dispensary.  Applicants,  who  must  be  proficient  in  the  German 
language,  may  address  Mr.  S.  L.  Fatman,  chairman  of  the  dispensary 
committee,  at  the  hospital,  Lexington  Avenue  and  Sixty-sixth  Street. 

Reed  &  Carnrick’s  Foods. — The  recent  destruction  of  one  of  Messrs. 
Reed  &  Carnrick’s  factories  by  fire  will  not,  we  learn  from  the  Dietetic 
Gazette ,  prevent  the  firm  from  filling  orders  pending  the  completion  of 
the  new  building,  as  their  stock  on  hand  in  New  York  is  large. 

The  State  Board  of  Medical  Examiners  of  New  Jersey  will  meet  in 
the  Senate  Chambers  at  the  Capitol  in  Trenton,  on  Thursday,  October 
9th,  at  nine  o’clock  in  the  morning,  for  the  purpose  of  examining  candi¬ 
dates  presenting  themselves  for  a  license  to  practice  medicine  in  the 
State.  Under  the  present  medical  law  of  the  State  every  person  desir¬ 
ing  to  practice  medicine  or  surgery,  in  any  of  its  branches  or  in  any 
way,  who  was  not  legally  registered  previously  to  July  4,  1890,  must 
first  obtain  a  license  from  the  board.  Any  further  information  will  be 
furnished  by  the  secretary.  Dr.  William  Perry  Watson,  of  Jersey  City. 

The  American  Rhinological  Association  will  hold  its  eighth  annual 
meeting  in  Louisville  on  Monday,  Tuesday,  and  Wednesday,  the  6th, 


7th,  and  8th  inst.,  under  the  presidency  of  Dr.  Arthur  G.  Hobbs,  of 
Atlanta,  Ga.  The  programme  announces  the  president's  address  and 
papers  or  remarks  in  discussions  by  Dr.  A.  B.  Thrasher,  of  Cincinnati; 
Dr..T.  H.  Stucky,  of  Louisville;  Dr.  E.  R.  Lewis,  of  Indianapolis;  Dr. 
L.  B.  Gillette,  of  Omaha ;  Dr.  J.  G.  Carpenter,  of  Stanford,  Ky. ;  Dr. 
John  North,  of  Toledo,  0.;  Dr.  C.  T.  McGahan,  of  Chattanooga;  Dr. 
C.  II.  von  Klein,  of  Dayton ;  Dr.  E.  C.  Painter,  of  Pittsburgh ;  Dr.  J. 
H.  Coulter,  of  Peoria;  Dr.  Emmett  Walsh,  of  Grand  Rapids;  Dr.  A. 
De  Vilbiss,  of  Toledo  ;  Dr.  R.  S.  Knode,  of  Omaha ;  and  Dr.  T.  F.  Rum- 
bold,  of  San  Francisco. 

The  Woman’s  Medical  College  of  the  New  York  Infirmary.— Dr. 

George  Thomas  Jackson  has  been  appointed  professor  of  dermatology 
in  this  institution. 

The  New  York  Academy  of  Medicine. — At  the  next  meeting  of  the 
Section  in  Pediatrics,  on  Thursday  evening,  October  9th,  Dr.  W.  L. 
Stowell  will  present  a  Study  of  One  Hundred  Cases  of  Pneumonia  in 
Children.  The  meeting  will  be  held  in  the  Academy’s  new  building  in 
West  Forty-third  Street. 

The  Tri-State  Medical  Association  of  Alabama,  Georgia,  and  Ten¬ 
nessee  will  hold  its  next  meeting  in  Chattanooga  on  Tuesday,  the  14th 
inst.,  under  the  presidency  of  Dr.  J.  B.  Cowan. 

The  Paris  Pasteur  Institute.— According  to  the  British  Medical 
Journal ,  Professor  Metschnikoff,  of  Odessa,  the  distinguished  Russian 
bacteriologist,  has  been  appointed  head  of  the  Pasteur  Institute  in 
Paris,  under  the  general  direction  of  M.  Pasteur. 

Changes  of  Address.— Dr.  F.  Irving  Disbrow,  to  No.  139  West  One 
Hundred  and  Fourth  Street ;  Dr.  Henry  Macdonald  and  Dr.  Belle  Mac¬ 
donald,  to  No.  261  West  Fifty-second  Street. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Armg,  from  September  1J/.  to  September  27,  1890 : 

I 

By  direction  of  the  Acting  Secretary  of  War,  the  following  changes  in 
the  stations  of  officers  of  the  medical  department  are  ordered: 
Spencer,  William  G.,  Captain  and  Assistant  Surgeon,  will,  upon 
the  abandonment  of  Fort  Bridger,  Wyoming  (his  present  station), 
report  in  person  to  the  commanding  officer  of  Omaha,  Nebraska, 
for  duty  at  that  station,  relieving  Bradley,  Alfred  E.,  First  Lieu¬ 
tenant  and  Assistant  Surgeon.  Lieutenant  Bradley,  on  being  re¬ 
lieved  by  Captain  Spencer,  will  report  in  person  to  the  commanding 
general,  Department  of  the  Platte,  for  duty  as  attending  surgeon  at 
the  headquarters  of  that  department.  Par.  16,  S.  0.  214,  A.  G.  0., 
Washington,  D.  C.,  September  12,  1890. 

By  direction  of  the  Acting  Secretary  of  War,  the  leave  of  absence  grant¬ 
ed  Suter,  William  N.,  First  Lieutenant  and  Assistant  Surgeon,  in 
Special  Orders  No.  149,  June  26,  1890,  from  this  office,  is  extended 
fourteen  days.  Par.  6,  S.  0.  214,  A.  G.  0.,  Washington,  D.  C.,  Sep¬ 
tember  12,  1890. 

By  direction  of  the  Acting  Secretary  of  War,  the  leave  of  absence  for 
seven  days  heretofore  granted  McElderry,  Henry,  Major  and  Sur¬ 
geon,  by  the  Superintendent  of  the  U.  S.  Military  Academy,  is  ex¬ 
tended  to  November  10,  1890,  on  account  of  sickness.  Par.  5,  S.  0. 
214,  A.  G.  0.,  Washington,  D.  C.,  September  12,  1890. 

By  direction  of  the  Acting  Secretary  of  War,  Cochran,  John  J.,  Captain 
and  Assistant  Surgeon,  now  on  duty  at  Fort  Adams,  Rhode  Island, 
will  proceed  to  Mount  Vernon  Barracks,  Alabama,  and  report  in 
person  to  the  commanding  officer  of  that  post  for  temporary  duty, 
and  on  completion  of  the  duty  contemplated,  he  will  return  to  his 
proper  station.  Par.  2,  S.  0.  214,  A.  G.  0.,  Washington,  D.  C.,  Sep¬ 
tember  12,  1890. 

By  direction  of  the  Acting  Secretary  of  War,  leave  of  absence  for  three 
months,  commencing  about  October  1,  1890,  is  granted  Ives,  Frank 
J.,  Captain  and  Assistant  Surgeon,  provided  one  of  the  Acting 
Assistant  Surgeons  serving  in  the  Department  of  the  Missouri  can 
be  assigned  to  duty  in  his  stead,  at  Fort  Sill,  Oklahoma  Territory, 
during  that  time.  Par.  26,  S.  0.  213,  A.  G.  0.,  Washington,  D.  C., 
September  11,  1890. 


Oct.  4,  1890.] 


ITEMS.— PROCEEDINGS  OF  SOCIETIES. 


383 


Kimball,  J.  P.,  Major  and  Surgeon,  is,  in  view  of  the  early  abandon¬ 
ment  of  Fort  Elliot,  Texas,  to  which  post  he  is  at  present  assigned 
for  station,  rpfieved  from  duty  at  that  post,  and  will,  upon  the  expira¬ 
tion  of  his  present  sick  leave  of  absence,  proceed  to  Fort  Supply, 
Indian  Territory,  and  report  to  the  commanding  officer  for  duty. 
Par.  2,  S.  0.  132,  Department  of  the  Missouri,  September  24,  1890. 

Under  the  provisions  of  General  Orders  No.  43,  c.  s.,  Headquarters  of 
the  Army,  Adjutant-General’s  Office,  the  post  of  Little  Rock  Bar¬ 
racks,  Arkansas,  will  be  abandoned,  to  take  effect  not  later  than  Oc¬ 
tober  1,  1890. 

Brown,  Paul  R.,  Captain  and  Assistant  Surgeon,  will  accompany  Com¬ 
pany  E  to  Fort  Supply,  Indian  Territory,  and  there  take  station  un¬ 
til  further  orders.  G.  0.  15,  Headquarters  Department  of  the  Mis¬ 
souri,  St.  Louis,  Mo.,  August  11,  1890. 

Ewing,  C.  B.,  Captain  and  Assistant  Surgeon,  is  granted  leave  of  ab¬ 
sence  for  one  month,  to  take  effect  the  1st  proximo.  Par.  5,  S.  O. 
131,  Department  of  the  Missouri,  September  22,  1890. 

Appel,  Aaron  H.,  Captain  and  Assistant  Surgeon.  The  leave  of  ab¬ 
sence  for  seven  days  granted  by  the  commanding  officer,  Fort  D.  A. 
Russell,  Wyoming,  is  extended  twenty-three  days.  Par.  3,  S.  0.  70, 
Department  of  the  Platte,  September  17,  1890. 

Middleton,  Johnson  V.  D.,  Major  and  Surgeon,  is  relieved  from  duty 
at  David’s  Island,  N.  Y.,  and  will  report  in  person  to  the  command¬ 
ing  officer,  Fort  Columbus,  New  York  city,  for  duty  at  that  station, 
relieving  Major  Joseph  R.  Gibson,  Surgeon,  and  reporting  by  letter 
to  the  commanding  general,  Division  of  the  Atlantic.  Par.  1,  S.  0. 
219,  A.  G.  0.,  Washington,  September  18,  1890. 

Gibson,  Major,  on  being  relieved  by  Major  Middleton,  will  report  in  per¬ 
son  to  the  commanding  officer,  David’s  Island,  N.  Y.,  for  duty  at  that 
station,  and  by  letter  to  the  superintendent  of  the  recruiting  service. 
Par.  1,  S.  0.  219,  A.  G.  0.,  Washington,  September  18,  1890. 

Society  Meetings  for  the  Coming  Week: 

Monday,  October  6th :  American  Rhinological  Association  (Louisville — 
first  day);  New  York  Academy  of  Sciences  (Section  in  Biology); 
German  Medical  Society  of  the  City  of  New  York ;  Morrisania 
Medical  Society  (private) ;  Brooklyn  Anatomical  and  Surgical  So¬ 
ciety  (private) ;  Utica,  N.  Y.,  Medical  Library  Association  ;  Boston 
Society  for  Medical  Observation  ;  St.  Albans,  Vt.,  Medical  Asso¬ 
ciation  ;  Providence,  R.  I.,  Medical  Association  ;  Hartford,  Conn., 
City  Medical  Association  ;  Monmouth,  N.  J.,  County  Medical  Society 
(Freehold) ;  Chicago  Medical  Society. 

Tuesday,  October  7th:  American  Rhinological  Association  (second  day) ; 
New  York  Obstetrical  Society  (private) ;  New  Yrork  Neurological 
Society;  Elmira  Academy  of  Medicine;  Buffalo  Medical  and  Surgical 
Association;  Ogdensburgh  Medical  Association;  Medical  Societies 
of  the  Counties  of  Broome  (annual),  Columbia  (annual — Hudson), 
Orange  (semi-annual — Goshen),  and  Schoharie  (semi-annual),  N.  Y. ; 
Medical  Association  of  Northern  New  York  (annual — Malone) ; 
Hudson,  N.  J.  (Jersey  City),  and  Union,  N.  J.  (quarterly),  County 
Medical  Societies;  Chittenden,  Vt.,  County  Medical  Society;  Andro¬ 
scoggin,  Me.,  County  Medical  Association  (Lewiston) ;  Baltimore 
Academy  of  Medicine. 

Wednesday,  October  8th:  Mississippi  Valley  Medical  Association  (first 
day — Louisville) ;  American  Rhinological  Association  (third  day) ; 
New  York  Surgical  Society  ;  New  York  Pathological  Society ;  Ameri¬ 
can  Microscopical  Society  of  the  City  of  New  York ;  Medical  Society 
of  the  County  of  Albany  ;  Tri- States  Medical  Association  (Port  Jervis, 
N.  Y.);  Pittsfidd,  Mass.,  Medical  Association  (private);  Franklin 
(quarterly — Greenfield),  Hampshire  (quarterly — Northampton),  Mid. 
dlesex  South  (Cambridge),  and  Plymouth  (special),  Mass.,  District 
Medical  Societies ;  Philadelphia  County  Medical  Society  ;  Kansas 
City  Ophthalmological  and  Otological  Society. 

Thursday,  October  9th:  Vermont  State  Medical  Society  (annual — Mont¬ 
pelier);  Mississippi  Valley  Medical  Association  (second  day);  New 
York  Laryngological  Society ;  New  York  Academy  of  Medicine 
(Section  in  Paediatrics);  Society  of  Medical  Jurisprudence  and  State 
Medicine ;  Brooklyn  Pathological  Society ;  Medical  Society  of  the 
County  of  Cayuga,  N.  Y. ;  South  Boston,  Mass.,  Medical  Club  (pri¬ 
vate);  Pathological  Society  of  Philadelphia. 


Friday,  October  10th :  Vermont  State  Medical  Society  (second  day) ; 
Mississippi  Valley  Medical  Association  (third  day);  New  Y"ork  Acad¬ 
emy  of  Medicine  (Section  in  Neurology);  Yorkville  Medical  Associa¬ 
tion  (private) ;  German  Medical  Society  of  Brooklyn ;  Medical  So. 
ciety  of  the  Town  of  Saugerties  (anniversary). 

Saturday,  October  11th:  Obstetrical  Society  of  Boston  (private); 
Worcester,  Mass.,  North  District  Medical  Society. 


^rotccbings  of  Sorietws. 


MEDICAL  SOCIETY  OF  VIRGINIA. 

Twenty -first  Annual  Session ,  held  at  Rockbridge  Alum  Springs , 
on  Tuesday ,  Wednesday,  and  Thursday,  September 
2,  3,  and  4,  1890. 

The  President,  Dr.  Oscar  Wiley,  of  Salem,  in  the  Chair. 

Tiie  proceedings  were  opened  by  a  prayer  by  the  Rev.  Dr. 
E.  F.  Garrison,  of  Philadelphia,  and  an  address  of  welcome  by 
Dr.  J.  Edgar  Chancellor,  resident  physician  at  the  Springs. 

The  Hunter  McGuire  Prize  of  one  hundred  dollars,  offered 
for  the  best  essay  on  the  diagnosis,  pathology,  and  treatment 
of  chronic  cystitis  in  the  male,  was  awarded  to  Dr.  R.  M. 
Slaughter,  of  the  Theological  Seminary  of  Virginia.  After  the 
award,  Dr.  McGuire  stated  that  he  would  award  another  prize 
of  one  hundred  dollars,  at  the  next  annual  session  of  the  so¬ 
ciety,  to  any  practitioner  residing  in  Virginia,  West  Virginia, 
or  North  Carolina,  who  would  present  the  best  essay  upon  some 
subject  soon  to  be  determined  upon  and  announced  by  the  secre¬ 
tary  of  the  society. 

The  President’s  Address. — The  President  delivered  an  ad¬ 
dress,  which  was  full  of  wit  and  good  suggestions,  and  of  special 
interest  to  the  profession  of  Virginia. 

The  Summer  Diarrhoea  of  Children.— A  lengthy  discus¬ 
sion  was  held  on  this  subject,  in  which  the  old  doctrines  were 
maintained,  with  additions  of  whatever  was  valuable  as  the  re¬ 
sults  of  recent  observation  and  research. 

Officers  for  the  Ensuing  Year  were  elected  as  follows: 
President,  Dr.  William  W.  Parker,  of  Richmond ;  vice-presi¬ 
dents,  Dr.  J.  W.  Dillard,  of  Lynchburg,  Dr.  Jacob  Michaux,  of 
Richmond,  and  Dr.  H.  M.  Patterson,  of  Staunton;  recording 
secretary,  Dr.  Landon  B.  Edwards,  of  Richmond ;  correspond¬ 
ing  secretary,  Dr.  J.  F.  Winn,  of  Richmond ;  treasurer,  Dr. 
Richard  T.  Sty  11 ,  of  Hollins;  chairman  of  executive  committee, 
Dr.  Hunter  McGuire,  of  Richmond.  To  deliver  the  address  to 
the  public  and  profession  during  the  session  of  1891,  to  be  held 
in  Lynchburg  some  time  in  October,  Dr.  Charles  M.  Blackford, 
of  Lynchburg.  Leader  of  a  discussion  on  acute  dysentery  during 
the  session  of  1891,  Dr.  P.  B.  Green-,  of  Wytheville.  Dr.  Alfred 
C.  Palmer,  of  Norfolk,  was  elected  to  fill  a  vacancy  from  his  con¬ 
gressional  district  on  the  Medical  Examining  Board  of  Virginia. 

Report  on  Ophthalmology,  Otology,  and  Laryngology. 
— Dr.  Robert  L.  Randolph,  of  Baltimore,  chairman  of  the  Sec¬ 
tion,  reviewed  two  important  articles  which  had  appeared  in 
recent  numbers  of  Graefe’s  Archives  of  Ophthalmology  on  anti¬ 
sepsis  in  the  operation  for  cataract.  The  reviewer  concluded, 
from  the  opposite  views  held  by  the  two  authors — von  Graefe, 
of  Halle,  and  StefFan,  of  Frankfort — that  the  former  was  cor¬ 
rect,  and  that  antisepsis,  in  spite  of  the  doubt  cast  upon  its 
value  by  the  able  paper  of  Steffan,  was  indispensable  in  cataract 
operations.  The  reporter  referred  to  the  suturing  of  the  cor¬ 
nea  after  cataract  operations,  and  gave  the  opinions  of  French 
ophthalmic  surgeons.  He  alluded  to  the  recent  treatment  of 


384 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Joor., 


detachment  of  the  retina  by  injection  of  tincture  of  iodine, 
lie  spoke  of  the  value  of  a  solution  of  fluorescein  as  a  means 
of  diagnosticating  corneal  lesions,  and  concluded  with  a  short 
review  of  the  experiments  of  Kolinski  and  himself  upon  the 
lower  animals — namely,  the  production  of  cataract  by  feeding 
the  animals  on  naphthalin. 

Advance  in  Laryngology  and  Otology.— Dr.  William  F. 
Mercer,  of  Richmond,  in  reporting  on  this  subject,  called  atten¬ 
tion  to  the  conclusions  of  Lemon  in  his  investigation  in  regard 
to  the  transformation  of  benign  growths  of  the  larynx  in  con¬ 
sequence  of  intralaryngeal  operations ;  the  early  treatment  of 
naso-pharyngeal  and  throat  affections  in  young  growing  children 
as  a  cure  or  prevention  of  certain  derangements  of  the  nervous 
system  and  impairment  of  the  intellectual  power  existing  or 
shown  later  in  life  ;  nasal  intubation  as  an  easy  and  ready  mode 
of  cure  in  hypertrophy  of  the  soft  intranasal  tissues,  deviations 
of  the  cartilaginous  septum,  fractures,  etc. ;  the  easy  and  cer¬ 
tain  means  of  diagnosis  of  empyema  of  the  antrum  of  Highmore 
by  the  illumination  of  the  maxillary  bones  by  an  electric  lamp 
introduced  into  the  mouth  ;  and  the  importance  of  perfectly 
free  drainage  in  otology.  He  called  special  attention  to  the 
great  importance  of  the  early  recognition  of  and  treatment  for 
acute  suppurative  otitis  media  following  scarlatina,  thereby 
greatly  reducing  the  high  percentage  of  deaf-mutism  from  this 
cause. 

When  shall  we  operate  for  Cataract  and  Strabismus 
in  Children  ? — Dr.  Charles  M.  Shields,  of  Richmond,  read  a 
paper  with  this  title.  He  said  that  the  text-books  seemed  to 
ignore  the  question,  and  that  as  a  large  proportion  of  the  cases 
of  cataract  in  children  were  of  the  zonular  variety,  allowing 
some  vision,  the  operation  was  generally  put  off  until  they  were 
from  ten  to  thirteen  years  old,  an  age  at  which  the  retina  had 
often  lost  its  functional  activity  from  disuse.  His  last  five  cases 
were  cited  in  support  of  the  argument  for  early  operation. 
Three  of  them  were  in  children  between  the  ages  of  ten  and 
thirteen,  and,  although  the  operation  was  successful  in  obtain¬ 
ing  a  clear  pupil,  the  visual  results  were  not  very  satisfactory. 
The  two  others  of  the  series  were  much  younger — one  three 
years  old,  the  other  six  months.  Both  were  needled  and  gave 
the  most  satisfactory  results.  The  reader  thought  the  earlier 
the  operation  for  cataract  in  children,  the  better  the  result,  for 
the  following  reasons:  First,  in  the  young  the  eye  was  more 
tolerant  of  surgical  procedures ;  second,  the  child  was  given  all 
the  benefit  in  gaining  education  that  vision  secured  ;  and  thirdly, 
the  permanent  visual  results  were  better  than  would  be  obtained 
at  a  later  age.  As  to  the  age  for  operation  in  strabismus,  he 
thought  that  usually  suggested  (six  or  seven  years)  early  enough 
in  alternating  squint,  as  vision  in  either  eye  did  not  suffer  from 
delay;  but  where  the  strabismus  was  confined  to  one  eye,  the 
unilateral  form,  the  earlier  the  patient  was  operated  on  the  bet¬ 
ter.  In  this  form  of  squint,  vision  was  constantly  suppressed  in 
one  eye,  and  amblyopia  from  disuse  resulted,  making  the  eye 
useless.  The  operation  should  be  performed  in  the  monolateral 
variety  as  early  as  it  was  recognized. 

The  Modern  Treatment  of  Strabismus.— Dr.  Alexander 
Duane,  of  Norfolk,  presented  a  paper  on  this  subject,  in  which 
he  insisted  upon  the  necessity  of  careful  testing  before,  during, 
and  after  the  operation.  Adopting  Mauthner’s  classification 
of  squint  into  spastic,  accommodative,  concomitant,  and  para¬ 
lytic,  he  pointed  out  that  in  the  first  two  varieties  the  indication 
for  treatment  was  mainly  causal,  while  in  the  last  two  only 
was  there  the  question  of  an  operation.  In  concomitant  squint 
he  insisted  strongly  upon  the  difference  between  cases  with  ten¬ 
sion  and  with  relaxation  of  the  tendons,  and  cited  a  remarkable 
case  of  the  latter,  in  which  an  operation  totally  opposed  to  that 
called  for  by  the  appearances  in  the  case  had  led  to  very  strik¬ 


ing  good  results.  In  paralytic  squint  he  adopted  v.  Graefe’s 
treatment — viz.,  in  paralysis  of  a  lateral  rectus  or  an  oblique 
muscle,  tenotomy  of  the  associated  antagonist  (sometimes  in  the 
former  case  re  enforced  by  tenotomy  of  the  direct  antagonist 
or  by  advancement  of  the  paretic  muscle),  and  in  paralysis  of 
the  superior  or  inferior  rectus,  advancement  of  the  affected 
muscle. 

Otitis  Furunculosa. — A  paper  was  presented  by  Dr.  John 
Herbert  Claiborne,  Jr.,  of  New  York,  in  which  he  summed 
up  his  conclusions  in  the  following  way :  1.  Furunculosis  of 

the  outer  ear  is  a  local  disease.  2.  The  cause  is  the  transmission 
by  rough  means  beneath  the  skin  of  pyogenic  microbes.  3.  The 
prognosis  is  good,  both  as  to  the  life  and  hearing  of  the  indi¬ 
vidual.  4.  The  treatment  consists  in  local  antisepsis  (solutions 
of  boric  acid,  carbolic  acid,  etc.),  moist  heat,  and  incision  of  the 
furuncles  when  they  point. 

Catarrhal  Otitis  Media,  or  Aural  Catarrh.— Dr.  Laurence 
Turnbull,  of  Philadelphia,  who  had  been  invited  to  attend  the 
session,  read  a  paper  which  treated  mostly  of  the  results  of  the 
disease.  He  said,  in  passing,  that  most  of  the  so-called  hearing- 
restorers  acted  most  injuriously  upon  the  sensitive  ear,  and 
were  of  no  benefit  except  to  those  having  a  hole  or  perforation 
of  the  drum  membrane,  or  to  those  who  suffered  relaxation  of 
the  small  bones  of  the  ear  which  became  sometimes  separated 
from  the  membrana  tympani.  In  many  instances  they  had  acted 
as  a  foreign  body ;  and  when  they  had  a  metal  stem,  as  was 
often  the  case,  they  were  sure  to  set  up  a  “  running  ear.”  The 
only  form  of  artificial  covering  to  the  diseased  perforation  of 
the  drum  membrane  should  be  a  delicate  gauze  or  rubber, 
charged  with  an  antiseptic  solution,  to  protect  the  ear  from  the 
floating  microbes  in  the  air  and  from  temperature  changes.  He 
then  detailed  at  length  a  correspondence  with  a  patient  who 
had  tried  to  use  some  of  the  artificial  aids  referred  to. 

A  New  Method  of  lifting  the  Epiglottis.— Dr.  C.  M. 
Blackford,  of  Lynchburg,  presented  a  paper  describing  a 
method  devised  by  Dr.  Samuel  P.  Preston,  of  Lynchburg. 
The  instrument  used  consisted  of  an  ordinary  laryngeal  silver 
probe,  with  the  last  half  inch  bent  so  as  to  make  a  right  angle 
with  the  remainder.  Rings  were  soldered  on  the  shaft  of  the 
probe  through  which  the  third  and  fourth  fingers  of  the  left 
hand  were  passed.  The  probe  was  introduced  and  the  bent 
portion  pressed  down  on  the  glosso-epiglottidean  ligaments. 
This  pressure  tightened  the  ligaments  and  thus  lifted  the  epi¬ 
glottis.  This  instrument  was  used  in  the  Throat  Clinic  in  Vi¬ 
enna.  By  holding  the  laryngeal  mirror  with  the  thumb  and 
forefinger  of  the  left  hand,  with  this  elevator  between  the  third 
and  fourth  fingers  of  the  same  hand,  the  right  hand  was  left 
free  for  use.  The  pressure  of  the  probe  was  not  great  enough 
to  cause  retching,  and  did  not  cause  special  inconvenience  to 
the  patient. 

Palpo-traction. — Dr.  Alfred  C.  Palmer,  of  Norfolk,  intro¬ 
duced  in  a  short  paper  a  new  form  of  treatment  akin  to  mass¬ 
age  which  he  called  by  this  title.  He  stated  that  many  distor¬ 
tions  of  the  lids  might  be  improved  resulting  in  lasting  benefits 
by  this  conservative  plan.  He  alleged  no  good  results  unless 
used  in  infancy  when  the  tissues  were  pliable  and  easily  molded 
by  manipulation.  He  asked  the  obstetricians  to  pay  strict  at¬ 
tention  to  the  formation  of  the  lids  of  the  new-born,  and  in  all 
forms  of  entropion,  ptosis,  contracted  palpebral  fissures,  etc.,  to 
begin  at  once  and  shape  the  lids  and  retract  them  to  their 
proper  forms  and  positions.  He  also  asked  ophthalmologists  to 
pay  attention  to  this  subject. 

Advances  in  Materia  Medica  and  Therapeutics.— Dr.  L. 

II.  Keller,  of  Luray,  presented  the  report,  in  which  he  called 
attention  to  forty-three  newly  introduced  drugs  or  prepara¬ 
tions. 


Oct.  4,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


385 


The  Diagnosis  of  Pelvic  Disease,  or  when  to  operate.— 

Dr.  I.  S.  Stone,  of  Lincoln,  read  a  paper  with  this  title,  in 
which  he  urged  the  importance  of  early  recognition  of  cases 
suitable  for  operative  treatment.  He  maintained  that  the  pro¬ 
fession  was  practically  a  unit  as  to  the  early  removal  of  large 
tumors,  and  also  as  to  the  treatment  of  pyosalpinx  and  extra- 
uterine  pregnancy,  as  the  electricians  evidently  had  the  worst 
of  the  argument.  There  were  also  many  cases  which  were  not 
so  easy  to  diagnosticate,  but  required  prompt  attention  or  they 
might  be  fatal.  The  salpingitis  of  rural  districts  might  easily 
become  pyosalpinx  by  infection  with  the  poison  of  gonorrhoea. 
The  author  maintained  that  pyosalpinx  was  rare  in  the  country 
for  the  reason  given  above — the  comparative  rarity  of  gonorrhoea. 
Salpingitis  did  occur  frequently  following  puerperal  diseases, 
but  often  ran  its  course  and  left  no  trace  afterward.  Its  symp¬ 
toms  were  those  of  pelvic  peritonitis  and  might  result  in  grave 
and  alarming  symptoms.  The  writer  illustrated  the  diagnosis 
of  some  rather  obscure  cases  of  pelvic  disease  by  citing  cases 
and  commenting  on  them,  showing  how  often  these  cases  were 
allowed  to  run  an  indefinite  course  when  they  could  be  prompt¬ 
ly  cured  by  resort  to  abdominal  section.  He  also  plainly  called 
attention  to  the  importance  of  recognizing  the  cases  of  neuras¬ 
thenia  which  simulated  so  closely  cases  of  real  pelvic  disease, 
but  did  not  require  any  operative  treatment  whatever.  The 
importance  of  recognizing  tubercular  disease  of  the  appendages 
was  also  urged,  which,  according  to  the  writer’s  views,  were  not 
infrequent. 

Honorary  Fellow  Dr.  George  T.  Harrison,  of  New  York, 
in  opening  the  discussion  of  Dr.  Stone’s  paper,  said  there  were 
only  one  or  two  points  in  it  that  he  thought  the  subject  of 
criticism,  for  in  general  it  was  an  excellent  presentation  of  the 
subject  of  diagnosis  of  pelvic  diseases  and  when  to  operate.  Dr. 
Stone  had  seemed  to  treat  puerperal  malarial  fever  as  a  disease 
of  minor  importance.  He  remarked  that  Dr.  Fordyce  Barker 
had  been  the  first  to  draw  prominent  attention  to  this  disease, 
which  was  not  a  rare  one  in  certain  communities.  In  New  York, 
for  instance,  it  was  quite  a  common  complication  or  sequel  of 
labor.  But  it  was  not  always  easy  to  trace  the  development  of 
the  disease  to  its  proper  cause.  It  undoubtedly  belonged  to  the 
puerperium.  He  reported  a  case  recently  under  his  observation 
in  which  the  delivery  had  been  conducted  under  the  most  per¬ 
fect  aseptic  principles,  and  yet  about  a  week  after  labor  puer¬ 
peral  malarial  fever  had  set  in  and  lasted  seven  weeks.  Rheu¬ 
matism,  by  the  way,  was  a  frequent  sequel  of  this  fever,  accord¬ 
ing  to  his  observation. 

As  to  the  operation  of  removal  of  the  uterine  appendages,  it 
had  of  recent  months  or  years  been  very  much  abused.  Novices, 
and  specialists  of  high  standing  as  well,  were  performing  lapa¬ 
rotomies  with  a  recklessness  that  demanded  the  cry  of  “  Stop !  ” 
He  related  the  case  of  a  lady  who  had  been  urged  by  a  promi¬ 
nent  laparotomist  to  have  her  ovaries  removed  for  some  trouble 
which  he  told  her  would  render  her  an  invalid  for  life.  She 
declined  the  operation,  however,  and  a  year  later  became  a 
mother.  The  speaker  did  not  deny  the  value  of  the  operation 
in  certain  selected  cases,  but  he  opposed  this  popular  wholesale 
removal  of  the  ovaries  and  appendages,  and  thought  their 
causeless  removal  should  be  rebuked  as  severely  as  Baker 
Brown’s  wholesale  removal  of  clitorides  had  been  years  ago. 
It  should  be  remembered  that  some  cases  of  mental  derange¬ 
ment  even  had  followed  the  removal  of  these  sexual  organs  of 
the  female.  It  was  a  difficult  matter  to  decide  when  to  operate, 
and  no  one  should  undertake  the  operation  until  after  the  ex¬ 
haustion  of  every  other  possible  means  of  relief — unless,  of 
course,  it  was  apparent  that  the  ovaries  or  appendages  were 
structurally  diseased. 

The  matter  of  extra-uterine  pregnancy  was  about  the  most 


important  subject  that  claimed  the  attention  of  the  obstetrician 
as  well  as  the  laparotomist.  The  condition  was  too  often  over¬ 
looked  until  it  was  too  late  to  give  to  the  patient  the  benefit  of 
surgical  art.  The  diagnosis  should  be  made  early  in  order  that 
an  operation  might  save  life.  Tait’s  pathology  of  extra-uterine 
pregnancy  was  all  wrong.  He  confounded  hfematocele  and  hee- 
matoma  with  extra-uterine  pregnancy.  Hasmatocele  was  an 
effusion  of  blood  into  the  peritoneal  cavity  about  Douglas’s  cul- 
de-sac.  Hsematoma  was  an  escape  of  blood  into  the  folds  of  the 
broad  ligament  alone.  But  in  extra-uterine  pregnancy  of  the 
tubal  variety,  after  the  probable  cessation  of  one  or  more  men¬ 
strual  periods,  there  was  often  an  irregular  haemorrhagic  dis¬ 
charge  per  vaginam ,  which  very  generally  preceded  rupture  of 
the  tube  for  several  days. 

Dr.  Joseph  Price,  of  Philadelphia,  present  by  invitation, 
wished  to  emphasize  all  that  Dr.  Harrison  had  said  as  to  reck¬ 
less  operations.  Laparotomies  had  been  too  much  overdone 
by  those  who  had  not  a  sufficient  purpose  in  view.  They 
should  be  undertaken  only  for  an  objective  disease — not  for  a 
subjective  one.  More  of  this  kind  of  work  had  been  done  in 
New  York  than  anywhere  else  on  this  continent,  and  there  the 
operation  had  undoubtedly  been  abused.  Furthermore,  many 
operations  had  been  undertaken  without  having  been  at  all  well 
done ;  and  such  imperfect  operations  had  brought  discredit  upon 
pelvic  surgery.  The  time  had  come  when  simply  opening  the 
abdomen  should  not  cause  death.  This  was  proved  by  the  results 
of  Dr.  McGuire’s  operation  of  suprapubic  cystotomy.  Even  the 
mortality  resulting  from  laparotomies  for  the  removal  of  ova¬ 
rian,  tubal,  or  uterine  diseases  had  now  become  reduced  to  about 
two  per  cent.  The  speaker  then  exhibited  some  drawings  of 
suppurating  tubes  by  Dr.  Coe,  only  to  condemn  them  ;  they  were 
very  unfortunate  and  misleading.  If  pus  could  be  diagnosticated 
in  the  female  pelvic  cavity  anywhere,  cut  for  it  as  you  would  do 
for  a  pus-cell  anywhere  else  in  the  body.  Extirpation  of  the 
ovaries,  etc.,  should  have  no  less  an  object  in  view  than  to  save 
life.  The  day  of  so-called  “  normal  ovariotomy  ”  was  past.  But 
he  would  advise  that  all  forms  and  sizes  of  fibroids  be  extir¬ 
pated  as  soon  as  recognized.  He  also  insisted  upon  the  exer¬ 
cise  of  the  greatest  degree  of  caution  as  to  intra-uterine  exami¬ 
nations  and  medications.  Dr.  Emmet  said  that  he  had  not 
passed  a  uterine  sound  for  years.  He  had  been  called  upon  a 
hundred  times  to  do' abdominal  sections  to  cure  the  results  of 
electrical  uterine  applications;  and  the  same  might  be  said  of 
the  results  of  forcible,  rapid  dilatations  of  the  uterine  neck,  and 
other  intra-uterine  procedures.  Of  course  there  were  some  dis¬ 
eases  that  required  intra-uterine  medications,  but  we  should  be 
very  cautious  in  resorting  to  such  methods  of  treatment.  He 
never  dilated  a  cervix,  nor  would  he  pass  a  uterine  sound — he 
was  afraid  to  do  so.  More  attention  should  also  be  given  to  the 
occurrence  of  gonorrhoea  in  wives  who  were  innocent  of  the 
thought  of  a  wrong  on  the  part  of  their  husbands.  The  ravages 
of  this  disease  among  women  were  twice  as  great  as  those  of 
small-pox.  As  to  extra-uterine  pregnancy,  Virginia  had  a  right 
to  be  proud  of  her  gifts  to  the  army  of  obstetrical  surgeons. 
Bingham,  of  this  State,  about  a  hundred  years  before,  had  done 
the  first  scientific  operation  for  extra-uterine  pregnancy,  and 
about  nine  years  later  a  second  one. 

Honorary  Fellow  Dr.  Hunter  McGuire,  of  Richmond,  re¬ 
marked  that  Dr.  Harrison  had  said  that  Dr.  Fordyce  Barker 
had  been  the  first  to  call  attention  to  and  name  puerperal  malarial 
fever.  But  it  was  the  late  Dr.  Otis  F.  Manson,  of  Richmond, 
who  had  first  described  and  designated  the  condition,  and  now 
Dr.  Barker  recognized  this  claim  of  priority.  Dr.  Price  had 
said  that  the  man  who  employed  a  sound  or  made  intra-uterine 
medications  ought  to  have  his  head  shaved.  If  the  speaker  had 
had  a  strand  of  hair  removed  for  every  one  he  had  made,  he 


386 


PROCEEDINGS  OF  SOCIETIES . 


[N.  Y.  Med.  Jour., 


said  that  he  would  be  bald-headed.  Dr.  Battey  was  a  good  man 
and  a  great  surgeon,  and  was  the  pioneer  in  important  gynae¬ 
cological  work ;  but  Battey’s  operation  of  normal  ovariotomy 
would  become  obsolete.  In  the  speaker’s  opinion,  it  was  a 
crime  to  take  out  normal  ovaries  for  any  nervous  or  hysterical 
condition.  Some  years  ago  he  had  done  it,  but  he  regretted  it; 
it  did  no  permanent  good.  When  there  was  some  pathological 
change  in  the  ovaries  or  tubes,  then,  after  failures  by  other 
means,  the  operation  should  be  done;  but  all  other  means 
should  be  first  exhausted.  He  himself  had  obtained  much  good 
in  such  cases  from  the  use  of  galvanism.  He  did  not  agree  with 
Dr.  Price  that  all  fibroids  should  be  removed.  In  nine  out  of 
ten  cases  that  came  to  him,  he  advised  the  patient  to  let  the 
tumor  alone.  If  the  growth  was  stationary  or  nearly  so,  giving 
rise  to  no  pain  or  mechanical  obstruction,  he  would  let  it  alone. 
If  the  gentleman  knew  how  common  fibroids  were  among  ne¬ 
groes,  and  how  many  negro  women  were  working  to-day  with 
fibroids  of  the  uterus,  in  no  way  disabled  for  work  by  the  tu¬ 
mor,  he  would  not  advise  operation  in  all  cases. 

Dr.  Joseph  Hoffman,  of  Philadelphia,  present  by  invitation, 
remarked  that  not  many  years  ago  every  surgeon  was  sewing 
up  perinseuras  and  uterine  cervices.  But  Emmet  arose  and 
protested  against  such  procedures.  The  speaker  said  that  Bat¬ 
tey’s  operation  had  been  given  a  fair  test  and  had  failed,  and 
should  hereafter  he  done  away  with.  Others  thought  that  all 
diseases  of  women  were  essentially  cellulitis ;  but  in  ninety-nine 
cases  out  of  a  hundred  this  was  a  mistake.  Tait  had  only  re¬ 
vised  the  pathology  of  forty  years  ago,  and  evidently  got  it 
from  Nonat,  who  fully  discussed  the  subject  as  a  circumuterine 
and  lateral  phlegmon  about  1846.  Surgery  ought  to  be  resorted 
to  in  these  cases  only  for  the  purpose  of  relieving  pain  or  else 
to  save  life.  Many  had  punctured  pelvic  abscesses  in  the  hope 
of  curing  them,  but  they  had  never  been  thus  cured.  To  open 
one  pus  cavity  in  the  tubes  did  not  empty  all  the  reservoirs  of 
pus,  because  these  tubal  pus  cavities  were  like  links  of  sau¬ 
sage.  Ilaamatocele  was  very  rare.  Mr.  Tait  said  when  it  did 
occur  it  was  often  mistaken  for  extra  uterine  pregnancy.  Ex¬ 
ploratory  incisions  should  be  used  only  as  guides  to  the  surgeon 
to  see  whether  or  not  he  could  cure  a  given  case.  One  should 
never  cut  down  upon  an  abscess  or  a  tumor  in  the  abdomen,  and 
half  finish  the  operation.  Such  half-finished  operations  injured 
surgery  in  the  esteem  of  the  profession  as  well  as  the  people. 
Scraping  the  mucous  surface  of  the  uterus  with  curettes,  etc., 
was  bad  practice.  Laparotomies  had  been  shown  to  be  com¬ 
paratively  devoid  of  danger  under  modern  modes  of  procedure; 
so  when  such  operations  were  required,  operate  early.  Un¬ 
doubtedly  the  surgeon  should  exercise  common  sense  in  select¬ 
ing  his  cases  for  laparotomies  as  for  other  operations,  and  there 
could  be  no  question  as  to  the  abuse  of  this  operation  by  many 
surgeons — by  some,  even,  of  great  eminence.  But  because  an 
operation  was  abused  by  some  it  was  not  totally  unjustifiable  in 
certain  cases. 

Dr.  Edwin  S.  Ricketts,  of  Cincinnati,  present  by  invita¬ 
tion,  confined  his  remarks  to  a  review  of  the  history  of  ovari¬ 
otomy  and  abdominal  sections  generally — suggested  by  the  fact 
that  the  society  was  now  meeting  within  a  few  miles  of  the 
birthplace  of  the  immortalized  McDowell  in  this  (Rockbridge) 
county.  Bringing  his  subject  down  to  the  present  time,  he 
thought  that  now  the  operations  of  opening  the  female  pelvic 
abdomen  were  too  hastily  undertaken  by  surgeons  who  sought 
rather  to  make  reputations  for  daring  than  to  save  the  lives  of 
their  patients.  Discredit  came  upon  surgery  whenever  an  oper¬ 
ation  was  undertaken  without  a  previous  diagnosis  and  a  con¬ 
sideration  of  the  points  which  determined  prognosis.  He  hoped 
the  profession  would  frown  down  such  reckless  surgery,  and 
keep  surgery  always  lifted  upon  the, platform  of  humanity,  such 


as  had  prompted  McDowell  to  undertake  the  first  ovariotomy, 
and  such  as  would  ever  make  the  profession  commend  it  to 
their  patients. 

Dr.  Isaiah  H.  White,  of  Richmond,  spoke  of  the  importance 
of  an  early  diagnosis  and  prompt  removal  of  an  extra-uterine 
pregnancy.  The  doctor  generally  knew  nothing  about  the  dan¬ 
ger  just  ahead  until  the  sudden  collapse  and  other  evidences  of 
rupture  of  the  tube  indicated  too  plainly  that  his  patient  was 
dying  from  rupture  of  an  extra-uterine  gestation  sac  into  the 
peritoneal  cavity.  But  if  such  a  state  of  things  passed  by  and 
the  woman  rallied  and  got  well  of  the  effects  of  such  a  rupture, 
or  if  gradual  extrusion  of  the  foetus  from  the  tube  so  occurred 
as  never  to  lead  the  surgeon  to  know  where  rupture  was,  and 
if  the  foetus  became  encapsulated  in  a  new  sac,  etc.,  the  extra- 
uterine  pregnancy  might  remain  for  years  in  a  quiescent  state, 
the  foetus  being  dead,  and  no  apparent  risk  of  life  of  the  patient 
occurring  by  reason  of  such  extra-uterine  pregnancy.  He  had 
known  a  case  where  an  extra-uterine  pregnancy  had  remained 
indolent  for  years,  until  finally  a  normal  intra-uterine  impregna¬ 
tion  occurred.  Many  cases  were  reported  where  the  diagnosis  of 
extra-uterine  pregnancy  had  been  first  made  by  the  ulceration  of 
foetal  bones  through  the  rectum,  etc.,  the  pregnant  condition 
years  before  not  having  been  more  than  suspected  at  the  time, 
and  the  idea  dismissed  by  both  patient  and  friends  because  of 
the  recurrence  of  the  apparently  normal  menstrual  function. 
Such  cases  suggested  that,  in  cases  of  supposed  or  diagnosticat¬ 
ed  extra-uterine  pregnancy,  before  rupture  of  the  tubes  into 
the  peritoneal  cavity,  if  the  mother  would  not  consent  to  oper¬ 
ation,  the  foetus  should  be  killed  by  galvanism  ;  then  the  ovum 
might  remain  in  its  sac  simply  as  an  innocent  foreign  body. 
The  known  laws  of  accommodation  on  the  part  of  nature  to 
gradually  developed  abnormal  conditions  might  lead  to  the 
final  safe  removal  of  the  foetus  piecemeal,  by  self-protective 
ulcerations  through  the  rectum,  etc.  Hence  it  was  yet  a  field 
for  discussion  as  to  the  propriety  of  always  insisting  upon  an 
operation  for  an  old  extra-uterine  pregnancy.  But  when  an 
operation  was  decided  on,  what  were  known  as  the  “  rem¬ 
nants  ”  of  an  extra-uterine  conception,  excluding  the  foetus 
itself,  were  most  probably  altogether  the  products  of  the  in¬ 
flammatory  action  set  up  at  the  time  of  the  passage  of  the  foetus 
through  the  tube  into  the  peritoneal  cavity.  The  strictured 
portions  of  the  pus-tube,  which  gave  that  canal  the  appearance 
of  rolled  sausage,  were  due  to  adhesive  perimetric  bands 
formed  around  the  tube.  As  to  the  so-called  “  normal  ovari¬ 
otomy,”  Dr.  McGuire  had  deplored  the  results  obtained  by  him. 
Undoubtedly  he  was  correct.  In  fact,  it  might  not  be  too  much 
to  say  that  some  of  the  survivors  of  the  operation  regretted  that 
they  were  alive. 

Dr.  Landon  Garter  Grat,  of  New  York,  present  by  invita¬ 
tion,  said  that  the  further  resort  to  “  Battey’s  operation  ”  and  the 
pke  for  the  cure  of  nervous  diseases  would  be  a  crime.  Years  agoi 
Baker  Brown  had  properly  been  expelled  from  the  profession 
because  of  his  useless  clitoi’idectomies.  The  great  name  of  Dr. 
Sayre,  a  short  while  ago,  had  given  authority  for  unnecessary 
circumcisions  for  the  relief  of  some  nervous  troubles.  Stevens’s 
wholesale  cutting  of  eye  muscles  for  the  treatment  of  chorea 
and  other  nervous  diseases  should  likewise  be  condemned. 
No  such  operations  should  ever  be  considered  panaceas,  and 
they  should  not  be  undertaken  except  when  there  was  a  clearly 
defined  requirement  for  them  other  than  the  simple  nervous 
trouble.  In  almost  all  the  cases  where  such  mutilations  had 
even  apparently  done  good,  such  relief  was  of  only  temporary 
duration,  showing  that  the  supposed  cure  was  in  reality  the  re¬ 
sult  of  a  psychological  action.  “  Normal  ovariotomies  ”  had  utd 
questionably  appeared  to  do  good  in  a  small  proportion  of  in¬ 
stances  upon  this  very  principle  ;  but  in  all  the  cases  so  operated 


Oot.  4,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


387 


on  that  had  come  under  his  observation,  the  attacks  had  re¬ 
turned  with  even  greater  severity  than  the  original  sickness. 
As  long  ago  as  1828  this  principle  of  mental  impression  was  put 
to  a  thorough  therapeutic  test  by  Esquirol,  and  the  results  of 
his  experiments  should  be  kept  ever  before  those  of  the  profes¬ 
sion  who  still  insisted  upon  experimental  operations.  He  di¬ 
vided  his  cases  of  epilepsy,  etc.,  into  groups.  To  one  group  he 
gave  one  class  of  remedies,  with  the  addition  of  strong  mental 
encouragement.  To  another  group  he  gave  another  class  of 
medicines,  with  the  same  encouragement  as  to  the  benefit  to 
come  from  the  “  new  treatment.”  To  another  group  he  gave 
another  class  of  remedies,  etc. ;  while  to  6till  another  group  he 
gave  simply  colored  water,  etc.  Each  group  of  cases  did 
equally  well  for  a  season,  but  relapses  soon  began  to  occur,  and 
all  the  patients  fell  back  to  the  former  degrees  of  sickness.  Up 
to  the  present  time  no  remedy  *had  stood  the  test  of  prolonged 
experience  in  epileptic  forms  of  diseases,  unless  it  was  the  bro¬ 
mides.  Undoubtedly  operations  had  been  most  beneficial  when 
performed  upon  the  strongly  impressionable  class  of  patients; 
but  this  very  fact  confirmed  the  suggestion  that  most  probably 
one  operation  would  do  about  as  well  as  another.  If  this  was 
so,  then,  in  the  name  of  humanity,  whatever  might  be  the 
amount  of  impression  that  you  wished  to  leave  upon  your  pa¬ 
tient,  perform  that  operation  w’hich  was  least  serious  in  its  pos¬ 
sible  results  of  unsexing  the  individual,  or  otherwise  mutilating 
her.  To  make  a  simple  incision  somewhere,  and  yet  let  the 
patient  believe  that  a  severe  operation  bad  been  performed, 
would  do  as  much  good  in  most  cases  as  the  real  operation. 

Dr.  William  W.  Parker,  of  Richmond,  could  not  understand 
why  all  this  hue  and  cry  had  been  raised  of  late  years  about  the 
danger  of  ordinary  uterine  treatment,  unless  it  was  another  case 
of  the  cry  of  authority  against  every-day  experience.  Of  course, 
judgment  and  gentleness  were  as  essential  in  such  treatment  as 
anywhere  else.  He  believed  intra-uterine  injections  were  per¬ 
fectly  safe,  if  the  precautions  usually  recommended  were  faith¬ 
fully  observed.  In  a  large  practice  daily  since  the  war  he  had 
used  them  without  ever  hearing  of  harm  resulting. 

Dr.  Harrison  said  that  he  would  not  have  himself  recorded 
as  in  toto  opposed  to  Battey’s  operation,  for  there  were  troubles 
of  a  serious  nature  that  he  had  seen  relieved,  if  not  cured,  by 
‘‘Battey’s  operation”  for  apparently  moderately  diseased  ova¬ 
ries.  But  Dr.  Battey’s  original  error — which,  however,  had 
since  been  corrected — consisted  in  naming  his  operation  “nor¬ 
mal  ovariotomy.”  He  thought  Dr.  Battey  justly  entitled  to 
the  credit  of  having  pointed  out  a  new  and  important  gyneco¬ 
logical  field  for  thorough  study. 

Dr.  Stone,  in  closing  the  discussion,  thought  it  proper  to 
remark  that  Dr.  Barker’s  puerperal  malarial  fever  was  often 
nothing  but  the  evidence  of  the  existence  of  pus  in  the  Falloppian 
tubes.  He  would  not,  however,  undertake  to  deny  that  there 
was  a  pure  puerperal  malarial  fever,  as  Dr.  Manson  had  de¬ 
scribed  prior  to  Dr.  Barker’s  mention  of  the  subject.  As  to 
Battey’s  operation,  he  had  never  done  but  one,  and  the  result 
was  unsatisfactory.  Hence  he  stood  simply  as  an  interested 
listener  of  the  remarks  that  had  been  made  by  practitioners  of 
such  large  experience  and  extensive  reputation,  whose  dicta 
would  go  far  in  shaping  or  establishing  subsequent  professional 
opinion  on  the  subject. 

Vertigo  was  the  title  of  a  paper  read  by  invitation  by  Dr. 
Landon  Carter  Gray,  of  New  York.  He  stated  that  there 
was  a  vertigo  due  to  organic  disease  and  a  vertigo  of  functional 
nature.  An  important  generic  distinction  between  these  two 
was  that  organic  vertigos  were  accompanied  by  less  irritabil¬ 
ity  and  apprehension  on  the  part  of  the  patient  than  were  the 
functional  ones.  If  of  organic  origin,  the  vertigo  must  proceed 
from  disease  of  some  one  or  more  of  the  abdominal  or  thoracic 


viscera,  the  spinal  cord,  the  intracranial  organs,  or  the  ear. 
Examine  the  urine  always  repeatedly  both  chemically  and  mi¬ 
croscopically  for  albumin  and  casts  and  test  the  arterial  press¬ 
ure  by  sphygmographic  tracings.  But  the  speaker’s  observation 
showed  that  kidney,  heart,  and  organic  liver  troubles  caused 
slight  vertigo,  lasting  only  a  short  time.  In  renal  vertigo  there 
was  usually  a  headache  that  had  at  times  a  tendency  to  hebe¬ 
tude  or  coma;  occasionally  there  were  convulsions  and  general 
or  local  oedema.  In  hepatic  vertigo  there  would  usually  be 
some  degree  of  hebetude  or  jaundice  or  dropsy.  Almost  all 
intracranial  lesions  would  cause  vertigo,  which,  in  certain  of 
them,  would  be  pathognomonic.  For  instance,  cerebellar  lesion 
would  produce  a  swajing,  staggering  gait,  called  titubation, 
or  the  patient  would  stagger  markedly  to  one  side,  or  he  was 
suddenly  whirled  in  a  semicircle.  If  Dr.  Dana’s  observations 
proved  correct,  temporal-lobe  lesions  might  produce  similar 
symptoms.  Spinal-cord  diseases  were  not  apt  to  cause  more 
than  slight  vertigo,  with  the  exception  of  certain  cases  of  loco¬ 
motor  ataxia,  where  dizziness  was  common  when  the  patient 
was  standing  with  his  eyes  closed.  Aural  diseases,  especially 
of  the  middle  ear  or  labyrinth,  also  often  caused  vertigo. 

But  the  form  of  vertigo  which  caused  most  distress  was 
chronic,  coming  on  in  sudden  paroxysms,  varying  from  a  sud¬ 
den,  uneasy  sensation  of  loss  of  equilibrium  to  such  uncertainty 
of  gait  as  to  make  the  patient  dread  going  out  in  the  street  and 
frequently  accompanied  by  symptoms  of  other  nervous  disturb¬ 
ance,  such  as  furriness  and  tingling  of  the  extremities,  a  feeling 
of  distention  or  fullness  about  the  head,  usually  at  the  vertex, 
with  slight  ringing  in  the  ears,  a  certain  irritability  and  nerv¬ 
ousness,  and  often  a  mild  degree  of  insomnia.  It  was  rare  in 
children,  not  infrequent  in  the  elderly,  but  was  most  frequent 
in  young  and  middle-aged  adults.  This  vertigo  was  extremely 
obstinate,  often  lasted  for  years  after  the  attending  nervous 
symptoms  had  disappeared,  or  it  might  be  the  only  symptom 
throughout.  It  was  prone  to  occur  in  northern  climates  in 
the  first  warm  months  of  the  year,  and  severe  cases  occurring 
at  this  time  did  not  begin  to  recover  until  after  cold  weather 
had  set  in.  It  was  made  worse  by  heat  and  temperature  alterna¬ 
tions;  in  extreme  cases,  even  going  from  a  cold  into  a  heated 
room  would  cause  attacks.  Nervous  prostration  was  common 
— a  form  of  neurasthenia.  Generally  the  tongue  was  unaf¬ 
fected.  The  urine  usually  contained  uric  acid  or  oxalate  of  cal¬ 
cium.  The  cause  of  this  symptom-group  was  a  matter  of  discus¬ 
sion.  The  older  writers  treated  of  it  as  a  stomach  vertigo,  but 
Murchison  thought  it  due  to  liver  derangement,  producing  ex¬ 
cess  of  uric  acid;  hence  the  name  he  gave  it — lithasmia.  The 
speaker  was  not  satisfied  with  this  explanation,  for  many  cases 
did  not  present  a  tangible  evidence  of  hepatic  derangement,  nor 
had  we  ever  established  a  standard  by  which  we  could  say  what 
was  an  excess  of  uric  acid  ;  besides,  in  some  cases,  the  uric  acid 
had  been  extremely  small  in  amount;  and  again  cholagogues, 
such  as  calomel,  aggravated  the  vertigo,  and  often  the  nervous 
symptoms  also.  He  had  cow  come  around  to  adopt  the  old 
theory,  that  the  vertigo  was  of  gastric  origin,  including  the  en¬ 
tire  digestive  track.  The  majority  of  cases  of  this  peculiar 
form  of  vertigo  were  due  to  some  chronic  and  persistent  error 
of  digestion,  either  of  the  nitrogenized  or  starchy  elements  of 
food,  or  of  both.  Constipation  without  coated  tongue  or  foul 
breath  was  common  in  this  error  of  digestion.  It  occurred  in 
those  personally  or  hereditarily  predisposed  to  gout  or  rheuma¬ 
tism.  The  exciting  causes  were,  however,  mental  or  physical 
overwork,  great  anxiety,  malaria,  or  a  very  sedentary  lite.  For 
therapeutic  purposes  he  grouped  his  cases  with  this  form  of 
vertigo  into  (1)  those  in  whom  the  general  neurasthenia  was 
slight,  and  (2)  those  in  whom  it  was  severe.  In  the  non-neur¬ 
asthenic  cases,  begin  with  twenty  drops  of  dilute  nitromuriatic 


38S 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


acid  before  meals  in  a  wine-glass  of  water  and  one  drachm  of 
fluid  extract  or  two  grains  of  solid  extract  of  cascara  sagrada 
three  times  daily.  Take  this  amount  of  cascara  continuously, 
reducing  it  if  it  produces  more  than  two  feculent  actions  a  day. 
During  the  same  period  interdict  the  red-meat  diet  entirely. 
The  patient  would  feel  less  dull,  have  less  of  the  sense  of  dis¬ 
tention  of  the  head,  and  feel  generally  better,  although  the  ver¬ 
tigo  would  probably  be  unaltered.  After  about  ten  days  stop 
the  acid  and  give  pepsin  and  pancreatin,  the  pepsin  imme¬ 
diately  after  meals  and  the  pancreatin  an  hour  and  a  half  after. 
This  treatment  would  more  generally  relieve  the  vertigo  than 
anything  else  he  had  tried.  After  a  time  gradually  restore  the 
meat,  but  only  once  a  day.  In  the  neurasthenic  cases  his 
treatment  was  the  same,  with  the  addition  of  rest,  in  rare  cases 
putting  the  patient  to  bed  for  two  or  three  weeks.  It  was  bet¬ 
ter  to  err  on  the  side  of  enforcing  too  much  rather  than  too 
little  rest.  In  differing  so  radically  from  others  on  this  point, 
he  had  only  to  say  that  his  experience  had  taught  him  to  so 
differ. 

Dr.  William  W.  Parker  agreed  with  Dr.  Gray  that  the 
chronic  vertigo  described  was  of  dyspeptic  origin,  and  hence 
recommended  rigid  diet. 

Dr.  Hunteb  McGuire  said  that  the  cases  of  vertigo  so  well 
defined  by  Dr.  Gray  were  due  to  lithaemia,  and  originated  in  some 
derangement  of  the  portal  system.  If  the  liver  acted  well — 
to  use  the  common  expression— the  vertigo  did  not  occur.  But 
inactivity  or  a  deranged  action  of  the  liver  was  not  always 
shown  by  a  furred  tongue,  etc.,  for  that  might  be  red  and  moist, 
while  the  faecal  discharges  were  grayish  or  puttyish.  But 
there  was  always  some  evidence  of  gastric  or  bowel  fermenta¬ 
tion,  as  shown  by  greater  or  less  eructations  an  hour  or  two  after 
eating.  Acting  upon  the  suggestion  thus  derived,  he  had  got 
benefit  from  the  following  plan  of  treatment :  Use  a  good  cho- 
lagogue  for  two  weeks  or  so,  so  as  to  get  one  or  two  feculent 
actions  a  day  ;  and  then  give  for  about  a  month,  three  times 
daily,  just  after  meals,  minute  doses  of  corrosive  sublimate — 
from  one  sixtieth  to  one  eightieth  of  a  grain — in  solution  or  pill. 
Afterward  give  a  perfectly  neutral  solution  of  the  hypophos- 
phites  of  lime  and  soda  after  each  meal.  The  syrups  of  the  hy- 
pophosphites  as  found  in  the  shops  were  injured  by  the  amount 
of  sugar  they  contained. 

Dr.  Isaiah  H.  White  was  satisfied  that  the  form  of  vertigo 
described  was  due  to  lithsemia  or  to  some  of  the  waste  products 
of  digestion  that  were  not  properly  eliminated.  Possibly  pto¬ 
maines  developed. 

Mr.  Hugh  Blair,  of  Richmond,  fraternal  delegate  from  the 
Virginia  Pharmaceutical  Association,  had  long  since  come  to 
the  conclusion  that  this  was  a  lithaemic  vertigo.  Evidences  of 
impaired  portal  circulation  and  function  were  always  found  in 
such  cases.  Lithsemia  was  but  another  expression  for  the  gouty 
disposition,  and  was  due  to  disordered  or  fermentative  diges¬ 
tion. 

Permanent  Drainage  of  the  Male  Bladder  by  a  Retained 
Cannula  introduced  above  the  Pubes. — This  was  the  title  of 
a  paper  read  by  Dr.  George  Ben.  Johnston,  of  Richmond.  He 
said  that  Dr.  Van  Buren  had  devised  the  best  instrument  for 
the  purpose  that  he  knew  of — consisting  of  an  outer  cannula,  an 
inner  tube,  and  a  trocar.  After  quoting  descriptions  of  these, 
Dr.  Johnston  stated  that  he  had  added  to  the  instrument  a  steel 
guide,  of  double  the  length  of  the  trocar,  over  which  the  outer 
cannula  might  be  easily  drawn  out  of  the  bladder  and  replaced 
without  fear  of  losing  its  course.  After  describing  the  simple 
operation  of  opening  the  bladder  above  the  pubes,  and  how  to 
retain  the  instruments,  he  remarked  that  both  acute  and  chronic 
cases  were  benefited  by  the  proposed  treatment.  Conditions  so 
benefited  were  urinary  retention,  injuries  of  the  urethra  or  pros¬ 


tate,  acute  prostatitis,  perineal  abscess,  urinary  extravasation, 
coagula  in  the  bladder,  chronic  cystitis,  enlarged  prostate,  or 
cancer  of  this  gland,  or  of  the  bladder,  urinary  fistulae,  saccula- 
tions,  adynamia,  etc. 

The  Present  Status  of  Abdominal  Surgery. — Dr.  Joseph 

Price,  of  Philadelphia,  Pa.,  read  a  paper  on  this  subject. 

Early  Exploratory  Incision  as  an  Aid  to  the  Diagnosis 
of  some  Surgical  Diseases  of  the  Abdominal  Cavity.— Dr. 
Edwin  Ricketts,  of  Cincinnati,  read  a  paper  on  this  subject. 
He  had  found  it  difficult  in  many  cases  to  make  a  diagnosis  pre¬ 
vious  to  exploratory  incision.  To  open  the  abdomen  was  easy 
enough,  but  afterward  to  do  always  the  best  thing  and  that 
promptly,  knowing  when  to  end  at  exploration,  bearing  in  mind 
that  half-completed  surgical  procedures  are  rarely  ever  excusa¬ 
ble  ;  these  were  of  greatest  consideration. 

Nervous  Disorders  following  Organic  Stricture  of  the 
Urethra. — Dr.  Hunter  McGuire  read  a  paper  thus  entitled. 
He  related  a  number  of  cases  in  which  paralysis,  apoplexy,  or 
cerebral  disease  of  some  kind  had  followed  long-standing  strict¬ 
ure.  In  none  of  these  cases  was  there  renal  disease.  In  his  prac¬ 
tice  he  had  seen  sclerosis  of  the  lower  portion  of  the  spinal  cord 
follow  old  strictures.  He  concluded  the  paper  thus  :  Are  all  of 
these  cases  mere  coincidences?  Urethral  strictures  are  so  com¬ 
mon,  and  diseases  of  the  nervous  center  so  frequent  after  middle 
life,  and  the  interval  of  years  between  the  formation  of  the 
strictures  and  the  appearance  of  nervous  troubles  so  great,  that 
it  is  difficult  to  say  that  one  is  dependent  upon  the  other.  As 
it  is,  however,  I  can  not  help  thinking  that  long-existing  ure¬ 
thral  strictures  may  set  up  reflex  irritation  in  one  or  more  of  the 
nervous  centers,  and,  this  persisting,  ends  in  pathological  change 
in  one  form  or  another. 

The  Salient  Points  in  Appendicitis ;  its  Diagnosis  and 
Treatment,  was  the  subject  of  a  paper  read  by  Dr.  Joseph 
Hoffman,  of  Philadelphia. 

Remarks  upon  Anteflexion  of  the  Uterus  was  the  title 

of  a  paper  read  by  Dr.  George  Tucker  Harrison,  of  New 
York.  The  normal  position  of  the  uterus  in  the  erect  woman, 
when  the  bladder  and  rectum  were  empty,  was  that  of  ante- 
versio-flexio,  the  place  of  flexion  being  at  the  junction  of  the 
cervix  and  body.  But  when  the  bladder  was  distended,  the 
uterus  was  lifted  up  physiologically  and  its  posterior  wall  lay  in 
juxtaposition  with  the  anterior  wall  of  the  rectum  ;  it  was 
both  retroposed  and  retroverted.  While  the  bladder  was  being 
emptied,  the  fundus  uteri  described  an  arc  which  corresponded 
to  an  angle  of  from  45°  to  60°.  The  characteristic  feature  of 
pathological  anteflexion  was  simply  the  stability  of  the  flexion. 
The  causes  which  made  the  flexion  permanent  were  either  in 
the  organ  itself  or  operated  on  it  from  without.  Metritis  or 
infarction  belonged  to  the  first  class  of  causes,  while  parame¬ 
tritis  posterior,  parametritis  chronica  atrophica,  and  perime¬ 
tritis  belonged  to  the  second  and  more  frequent  class  of  causes, 
and  were  more  permanent  in  effect.  When  metritis  attacked 
an  anteflexed  uterus,  the  angle,  which  up  to  that  time  had  been 
variable,  became  fixed.  The  symptoms  usually  associated  with 
anteflexion  were  dysmenorrhoea  and  sterility.  This  painful 
dysmenorrhoea  was  not  mechanical,  but  was  due  to  the  asso¬ 
ciated  metritis.  The  sterility  also  was  attributable  to  the  ac¬ 
companying  endometritis,  oophoritis,  and  perimetritis.  If  these 
inflammations  were  removed,  and  if  the  perimetritis  had  left 
no  permanent  pathological  changes,  conception  might  ensue, 
notwithstanding  the  existence  of  parametric  cicatricial  tissue 
or  permanent  anteflexion.  The  diagnosis  of  this  pathological 
anteflexion  depended  alone  on  the  demonstration  of  the  sta¬ 
bility  of  the  flexion.  Bimanual  palpation,  or  the  establish¬ 
ment  of  the  fact  that  the  anteflexion  persisted  even  when 
the  bladder  was  distended,  or  the  discovery  that  the  folds  of 


Oct.  4,  1890.] 


PROGEEDINOS  OF  SOCIETIES. 


389 


Douglas’s  sac  were  shortened  or  thickened,  were  the  means  for 
deciding  as  to  the  stability  of  the  flexion.  As  to  treatment,  it 
was  of  prime  importance  to  try  to  remove  the  parametritis  pos¬ 
terior,  or  perimetritis  and  results.  If  the  uterus  was  supersensi¬ 
tive.  scarify  it  just  prior  to  menstruation,  and  the  dysmenorrhcea 
would  be  moderated.  For  the  persistent  uterine  catarrh,  wash 
•out  the  uterine  cavity  with  a  solution  of  carbolic  acid  after  dila¬ 
tation  with  aseptic  laminaria  tents,  followed  by  steel  dilators. 
Lately  he  had  been  very  much  pleased  with  ichthyol,  incorpo¬ 
rated  with  lanolin,  applied  around  the  portio  vaginalis,  in  clear¬ 
ing  up  old  perimetric  and  parametric  adhesions. 

Epilepsy. — Dr.  M.  D.  Hoge,  Jr.,  read  the  Report  on  Ad¬ 
vances  in  Neurology,  confining  his  remarks  more  especially  to 
this  disease.  We  were  perhaps  more  indebted  to  Hughlings 
Jackson  for  the  clearest  explanation  of  convulsions  than  to  any 
medical  writer  of  recent  date.  Three  classes  of  convulsions 
were  made,  corresponding  to  the  three  levels  of  the  nervous 
system.  An  epileptoid  seizure  was  due  to  the  high  instability  of 
certain  cortical  cells,  produced  by  the  nutrient  fluid  bathing  the 
cells  becoming  comparatively  stagnant,  and  in  consequence  there 
was  inferior  nutrition,  a  “substitution  nutrition,”  whereby  the 
phosphorus  compounds  became  more  nitrogenous,  or  viceversa. 
What  was  the  best  form,  then,  of  food  for  the  nerve  cells?  Se-‘ 
guin  had  stated  that  the  central  nervous  system  and  peripheral 
nerves  were  largely  made  up  of  fatty  substances.  In  the  ash 
of  the  cerebral  substance  the  phosphates  existed  to  the  extent 
of  93'5  per  cent. 

Dr.  J.  D.  Eggleston,  a  fellow  of  the  society,  had  come 
nearest  to  the  question  of  a  cure  for  epilepsy,  and  to  him  the 
writer  was  largely  indebted  for  the  following  method  :  The 
treatment  was  a  combined  one,  partly  direct  and  partly  symp¬ 
tomatic.  The  first  step  was  to  supply  the  brain  with  proper 
food  ;  this  could  best  be  accomplished  by  the  use  of  cod-liver 
oil,  combined  with  the  hypophosphites  of  calcium  and  sodium, 
and  a  diet  consisting  largely  of  fatty  food  was  enjoined.  Every 
source  of  external  irritation  must  be  carefully  looked  into  and 
corrected;  it  might  be  eye-strain,  nasal  polypi,  malpositions  of 
the  uterus,  or  phimosis.  Remove  these  sources  of  constant 
irritation,  which  were  continually  sending  nervous  impressions 
to  an  anaemic  brain,  and,  there  accumulating,  it  became  sur- 
-charged,  its  equilibrium  was  disturbed,  and  a  nervous  explosion 
— an  epileptic  fit — took  place. 

No  specific  power  could  be  ascribed  to  atropine.  The  chief 
benefit  to  be  derived  from  its  use  was  the  paralyzing  effect  it 
had  on  the  whole  muscular  system.  The  spasmodic  contraction 
at  the  throat  and  the  violent  movements  of  the  body  during  a 
convulsion  were,  in  a  great  measure,  controlled.  Another  im¬ 
portant  effect  produced  by  its  use  was  the  time  between  the 
aura  and  the  convulsion  itself  was  long  enough  to  allow  the  pa¬ 
tient  to  lie  down  or  take  some  sedative. 

The  use  of  bromides  could  not  be  dispensed  with  entirely  at 
first.  The  patient  must  carry  in  a  convenient  pocket  by  day, 
or  under  the  pillow  at  night  ready  for  instant  use,  a  solution  of 
bromide  of  sodium  ten  grains,  chloral  hydrate  five  grains,  to  the 
drachm.  It  should  be  immediately  swallowed  whenever  the 
aura  was  felt,  a  slight  fainting  sensation,  or  any  vague  fear  of 
an  impending  attack. 

The  treatment  which  gave  the  best  results  in  epilepsy  was  a 
combined  one,  nutritive,  antispa-modic,  and  sedative,  repre¬ 
sented  by  cod-liver  oil,  atropine,  and  bromides. 

Removal  of  a  Large  Vesical  Calculus  per  Vaginam.— 
Dr.  E.  M.  Magruder,  of  Charlottesville,  reported  a  case.  The 
stone  was  about  two  inches  by  three  inches,  and  had  caused  a 
fistulous  opening  of  about  five  eighths  of  an  inch  in  diameter 
in  the  vaginal  wall.  He  reported  the  steps  of  the  operation 
adopted  for  its  removal  by  enlarging  the  vesico-vaginal  opening, 


and,  as  the  stone  seemed  adherent,  pieces  of  it  had  to  be  re¬ 
moved  at  a  time,  instead  of  by  lifting  it  out  of  its  pouch. 

Honorary  Fellows. — Dr.  L.  Astiton,  of  Falmouth,  received 
the  unique  and  unanimous  compliment  of  election  as  honorary 
fellow  of  the  society  without  ever  having  been  president.  In 
numerous  ways  he  had  rendered  most  valuable  services  to  the 
society,  and,  as  he  was  about  to  leave  for  Dallas,  Texas,  it  was 
a  fitting  expression  of  the  esteem  in  which  he  was  held  by  the 
Virginia  profession  to  so  elect  him. 

The  retiring  president,  Dr.  Oscar  Wiley,  was  also  elected  an 
honorary  fellow. 

RICHMOND,  VA.,  ACADEMY  OF  MEDICINE  AND 

SURGERY. 

Meeting  of  September  9 ,  1890. 

The  President,  Dr.  W.  W.  Parker,  in  the  Chair. 

{Reported  by  Dr.  J.  W.  Henson ,  Richmond.') 

Simple  Ulcer  of  the  Rectum  was  the  subject  for  discussion, 
in  the  opening  of  which  Dr.  Louis  C.  Bosher  read  a  paper  in 
which  he  said  that  he  had  selected  this  subject,  not  with  the 
intention  of  writing  a  lengthy  paper,  but  simply  to  report  a 
very  interesting  and  troublesome  case  of  this  disease  that  had 
fallen  into  his  hands  last  year.  In  October  last  he  was  called 
to  see  a  young  married  lady  who  was  suffering  intensely  from  a 
persistent  diarrhoea  and  nervous  prostration.  She  had  become 
very  much  emaciated  and  was  very  anaemic.  He  had  learned 
that  she  had  been  a  sufferer  for  eight  or  ten  months  from  diar¬ 
rhoea,  and  during  that  time  had  lost  some  forty  or  fifty  pounds 
in  weight.  She  had  told  him  that  she  had  received  treatment 
from  a  number  of  physicians,  one  of  whom  had  informed  her 
that  she  had  a  chronic  diarrhoea  and  was  beyond  the  control  of 
medicine,  and  another  that  she  had  consumption  of  the  bowels, 
and  intimated  that  it  was  only  a  question  of  time. 

When  the  speaker  saw  her  she  had  just  returned  from  one 
of  our  alum  spring-,  where  she  had  been  constantly  under  the 
care  of  a  physician.  To  complicate  mat:ers,  a  pelvic  abscess 
had  formed  during  her  stay  at  the  springs,  and  had  brokeu  be¬ 
fore  she  reached  home.  Under  this  double  drain  on  her  sys¬ 
tem  she  had  wasted  to  almost  a  skeleton,  and  had  become  com¬ 
pletely  bedridden.  The  abscess  had  discharged  quite  freely  per 
vaginam ,  but  finally,  under  active  treatment,  had  ceased  with 
an  improvement  in  her  general  health.  The  diarrhoea,  how¬ 
ever,  had  continued  off’  and  on,  notwithstanding  the  free  use  of 
remedies.  The  patient  had  now  begun  to  complain  of  a  slight 
protrusion  and  of  a  smarting,  with  an  unsatisfied  feeling  when¬ 
ever  she  went  to  stool.  She  had  also  complained  of  a  dull,  ach¬ 
ing  pain  at  the  end  of  the  backbone.  After  the  development  of 
the  above-named  symptom  the  speaker  had  made  an  examina¬ 
tion  of  the  rectum  with  the  rectal  speculum.  When  the  sphinc¬ 
ter  was  slightly  dilated  there  was  a  slight  discharge  of  pus  and 
mucus  from  the  bowel.  On  withdrawing  the  blades  of  the 
speculum  somewhat,  an  ulcer  was  discovered,  about  an  inch  and 
a  half  in  diameter,  occupying  the  anterior  wall  of  the  rectum 
just  above  the  internal  sphincter.  The  speculum  was  then  re¬ 
moved,  and,  by  inserting  the  finger  into  the  vagina,  the  bowe 
was  turned  outward,  bringing  the  ulcer  fully  into  view.  After 
cocainizing  the  ulcer  and  slightly  scraping  it,  he  had  made  an 
application  of  nitrate  of  silver. 

When  be  saw  the  patient  on  the  following  day  he  was  in¬ 
formed  that  the  dull  pain  in  the  lower  end  of  the  backbone 
was  very  much  improved,  and  that  there  had  been  only  one 
movement  from  the  bowels  in  twenty-tour  hours,  and  this  one 
had  been  unaccompanied  with  the  usual  rectal  tenesmus.  Pre¬ 
vious  to  the  discovery  of  the  ulcer  and  the  application  of  silver, 


39o 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Joor., 


there  had  been  from  three  to  six  movements  in  twenty-four 
hours.  This  treatment  was  repeated  at  intervals  of  five  or  six 
days  for  some  little  time  before  the  ulcer  healed.  The  diar¬ 
rhoea  had  now  been  absent  for  some  six  or  eight  months,  and, 
although  she  was  very  emaciated  and  amemic,  she  was  doing 
very  nicely  and  was  enjoying  a  stay  in  the  mountains. 

He  had  reported  this  case  for  two  reasons — firstly,  to  em¬ 
phasize  the  importance  of  diarrhoea  as  a  persistent  symptom  in 
some  forms  of  rectal  ulcer;  secondly,  to  call  attention  to  the 
long  train  of  nervous  symptoms  which  had  followed  its  pres¬ 
ence,  and  which,  with  the  diarrhoea,  had  been  entirely  relieved 
by  removal  of  the  cause. 

During  her  confinement  to  bed  this  patient  had  been  the 
subject  of  constant  attacks  of  hysteria.  She  was  now  compara¬ 
tively  free  from  all  hysterical  symptoms. 

Allingbam,  in  his  work  on  the  rectum,  said  :  ‘*  Ulceration 
of  the  rectum  is  not  an  uncommon  disease.  It  inflicts  great 
misery  upon  the  patient,  and,  if  neglected,  leads  to  conditions 
quite  incurable.  As  the  earlier  manifestations  are  fairly  amen¬ 
able  to  treatment,  it  is  of  the  utmost  importance  that  the  dis¬ 
ease  should  be  recognized  early.  Unfortunately,  it  rarely  is  so, 
the  symptoms  are  obscure  and  insidious,  the  suffering  at  first 
but  slight,  and  thus  the  patient  deceives  not  only  himself  but* 
his  medical  attendant.” 

Now,  what  were  the  symptoms  of  this  affliction  and  what 
the  causes  producing  it?  Diarrhoea  was  an  early  symptom,  oc¬ 
curring  early  in  the  morning — frequently  as  soon  as  the  pa¬ 
tient  got  out  of  bed.  There  was  a  most  urgent  desire  with  an 
unsatisfied  feeling,  requiring  the  patient  to  remain  long  at  stool. 
A  dull,  aching  pain  located  at  the  end  of  the  backbone  was 
another  symptom. 

Blood,  sometimes  mixed  with  pus  and  mucus,  often  escaped 
from  the  rectum.  When  the  ulcer  was  complicated  with  a  fis¬ 
sure  in  the  anus  the  most  intense  suffering,  often  lasting  for 
hours,  would  occur,  especially  after  stool.  Pruritus  ani  caused 
by  the  ichorous  discharge  from  the  ulcer  was  another  very 
annoying  symptom.  So  blood  poisoning  of  the  different  organs 
of  the  body  might  occur  when  the  ulcer  had  begun  to  break 
down,  and,  in  its  destruction  of  tissue,  pus,  mucus,  and  impure 
blood  were  excreted. 

Prominent  among  the  causes  of  rectal  ulceration  was  catarrh 
of  the  rectum,  or  proctitis,  which  might  be  brought  on  by  ex¬ 
posure  to  cold,  sitting  on  cold  surfaces,  etc.  So  the  lodgment 
in  the  bowel  of  fish  or  chicken  bones,  fruit  stones,  buttons, 
seeds,  pins,  etc.,  which  had  been  accidentally  swallowed,  might 
set  up  severe  forms  of  ulceration.  Operations  for  htemorrhoids 
and  accidents  in  childbirth,  too,  might  be  numbered  as  among 
the  causes.  Constipation,  the  faecal  masses  tearing  the  delicate 
mucous  membrane  of  the  rectum,  was  not  an  infrequent  cause 
of  ulceration.  In  the  first  edition  of  Kelsey  On  Diseases  of  the 
Rectum  and  Anus ,  he  said  :  u  it  is  much  easier  to  give  a  lady  a 
diarrhoea  mixture  and  trust  in  Providence  for  a  cure  than  to 
gain  her  consent  to  take  ether  and  be  thoroughly  examined, 
and  for  this  reason  many  a  case  of  curable  disease  has  been 
allowed  to  reach  an  incurable  stage  before  its  existence  has 
been  certainly  determined.  The  existence  of  a  chronic  diar¬ 
rhoea  or  of  a  discharge  of  any  kind  from  the  rectum  is  always  a 
good  and  sufficient  reason  for  a  thorough  physical  examination, 
and  with  ether,  a  dilated  sphincter,  and  a  good  speculum  no  one 
need  be  in  doubt  as  to  the  existence  of  ulceration  in  the  lower 
part  of  the  rectum.” 

Would  it  not,  then,  be  well  in  chronic  forms  of  diarrhoea, 
failing  to  be  relieved  by  the  usual  recognized  treatment,  to 
make  an  examination  of  the  rectum  with  a  speculum  and  ex¬ 
clude  ulceration  before  pronouncing  our  patients  the  subjects 
of  incurable  forms  of  diarrhoea? 


% 

The  President  mentioned  a  woman  who  had  recovered  from 
a  rectal  ulcer  three  inches  long. 

Dr.  J.  S.  Wellfokd  thought  that  Dr.  Boslier  had  made 
a  good  suggestion.  He  was  sure  that  many  cases  of  chronic 
diarrhoea  and  so-called  chronic  dysentery  with  great  prostra¬ 
tion  were  due  to  rectal  ulceration  and  could  be  cured  by  the 
line  of  treatment  suggested.  As  illustrative  he  reported  two 
cases  of  abscess  about  the  rectum  and  one  case  of  rectal  ulcer. 
One  of  the  former  had  been  particularly  interesting  because  the 
patient  had  lost  five  or  six  ounces  of  tissue,  the  anus  had  been 
completely  denuded,  and  the  end  of  the  rectum  detached  and 
hanging  out,  yet  he  had  recovered.  In  one  of  these  cases  the 
speaker  had  been  struck  with  the  fact  that  the  bismuth  which 
had  been  given  for  the  diarrhoea  had  continued  to  pass  ten  days 
or  two  weeks  after  its  administration  had  been  stopped.  He 
therefore  had  no  confidence  in  bismuth  except  as  a  protective 
in  irritation,  since  it  merely  adhered  to  the  bowel  and  was  not 
absorbed.  He  also  stated  that  it  was  not  necessary  to  dilate  in 
females,  particularly  if  the  parts  were  relaxed  from  age  or 
often-repeated  parturition  ;  the  finger  in  the  vagina  could  read¬ 
ily  turn  out  the  rectum.  Dilatation  was  best  in  the  male  to 
paralyze  the  sphincter. 

Dr.  Landon  B.  Edwards  was  desirous  that  other  remedies 
be  suggested  for  simple  ulcer  of  the  rectum  in  case  the  caustic 
treatment  failed,  as  it  sometimes  did.  He  suggested  bismuth 
and  iodol  (or  iodoform)  in  equal  parts.  He  had  relieved  a  man 
bv  that  treatment  in  about  a  month  and  a  half  or  two  months 
when  he  had  run  the  gantlet  of  twenty- six  doctors  before 
reaching  him.  He  stated  that  simple  ulcer  of  the  rectum  was 
not  common. 

The  President  had  seen  Dr.  Hunter  McGuire  cure  a  case 
absolutely  by  diet. 

Dr.  T.  J.  Moore  had  gained  a  valuable  hint  from  the  last- 
named  case  in  the  treatment  of  two  cases  of  his  own.  The  first 
was  a  mau  who,  being  told  he  had  cancer  of  the  rectum,  had 
become  positive  that  his  bowel  was  so  constricted  that  he  could 
not  get  up  a  simple  enema  and  that  he  only  passed  at  stool  a 
few  drops  of  mucus  through  the  muscular  action  of  the  bowel. 
He  really  had  fourteen  to  twenty  actions  a  day,  and,  while  faecal 
matter  was  there,  yet  the  consistency  was  for  the  most  part 
blood  and  mucus. 

The  speaker  had  convinced  him  of  the  absence  of  the  con¬ 
striction  by  injecting  a  quart  of  water,  though  the  man  had 
imagined  it  was  running  back  into  the  basin.  An  examination 
had  showed  the  whole  of  the  lower  part  of  the  rectum  exco¬ 
riated.  By  a  diet  of  stale  bread  and  milk,  and  bismuth  and 
salicin  (internally)  as  medicines,  he  had  been  cured.  He  men¬ 
tioned  another  case,  a  constriction  complicated  by  an  ulcer  just 
above  it.  Dilatation  and  diet  had  effected  a  cure.  He  recom¬ 
mended  (in  males)  salicin  and  bismuth  internally  and  no  local 
interference  as  a  rule.  Where  the  trouble  involved  the  internal 
sphincter,  dilatation  by  tbe  thumbs  was  indicated.  Here  nitrate 
of  silver  seemed  almost  specific  in  healing  and  relieving  pain. 
Iodoform  very  frequently  relieved  pain  and  spasm  for  a  few 
hours.  He  mentioned  a  case  in  which  for  that  purpose  he  had 
used  it  with  marked  success  in  suppositories. 

Continued  Fever. — Tbe  President  stated  that  the  young 
man  whose  case  he  had  reported  at  the  last  meeting  as  resem¬ 
bling  typhoid  was  still  sick.  He  had  complained  of  severe  head¬ 
ache  all  along,  and  he  had  a  dull  look  about  the  eye.  The 
speaker  was  afraid  of  head  trouble.  The  temperature  had  kept 
up  from  101°  to  103°.  Dr.  John  R.  Wheat,  in  whose  charge 
the  patient  had  been  left  for  a  while,  had  given  full  doses  of 
quinine  every  morning,  but  without  relieving  the  fever.  His 
pulse  was  weak,  but  the  skin  was  always  moist  and  cool, 
tongue  clean  and  moist;  also  he  had  a  good  appetite.  At  his 


Oct.  4,  1890.] 


MISCELLANY. 


391 


request  be  had  been  allowed  some  soft  eggs  on  Tuesday  last,  but 
they  had  acted  on  bis  bowels  and  had  to  be  stopped.  There  had 
been  for  some  days  a  too  free  discharge  of  high-colored  urine — 
one  quart  in  six  or  eight  hours.  It  was  aeid,  but  contained  no 
albumin  or  bile.  There  had  been  no  tympanites  from  first  to 
last,  n«>r  any  approach  to  it.  The  prostration  and  emaciation 
were  marked. 

He  took  plenty  of  liquid  food,  large  quantities  of  milk 
among  other  things,  to  keep  up  his  strength.  Was  this  ty¬ 
phoid  ?  The  speaker  thought  it  was. 

Dr.  Edwards  had  searched  the  literature  to  get  light  upon 
the  above  class  of  fever.  In  volume  i,  Pepper’s  System  of 
Medicine ,  he  had  found  it  described  as  “  simple  continued  fever  ” 
by  Hutchinson.  There  was  not  the  dry  tongue,  the  eruption, 
the  decided  tympanites,  or  the  other  characteristic  symptoms  of 
typhoid  fever.  Any  solid  food  whatever  would  raise  the  tem¬ 
perature.  Purging  could  be  done  without  damage.  He  had  a 
case  now  which  had  run  sixty  days.  First  the  patient  had 
typho  malarial  fever,  recovering  in  about  fifteen  days.  Later 
on  this  continued  fever  had  begun.  He  was  now  convalescing, 
but  had  a  considerable  urethritis,  for  which  no  cause  could  be 
assigned. 

Dr.  Wellkord  thought  the  amount  of  fever  would  account 
for  the  highly  colored  and  acid  urine  as  well  as  its  high  specific 
gravity  (referring  to  Dr.  Parker’s  report),  and  the  amount  of 
milk  and  other  liquids  taken  would  account  for  the  quantity  of 
urine. 

The  speaker  called  this  continued  fever  typhoidal  because, 
while  it  lacked  most  of  the  characteristic  symptoms  of  typhoid, 
yet  it  resembled  the  latter  in  the  prostration  present  and  the 
continuous  fever.  He  believed  it  was  typhoid.  It  reminded 
him  of  typhoid  in  children  where,  owing  to  the  non-develop¬ 
ment  of  Peyer’s  patches,  etc.,  most  of  the  characteristic  symp¬ 
toms  were  lacking.  Dr.  Coleman  had  said  that  any  fever  in 
children  running  over  twenty-five  or  thirty  days  and  not  con¬ 
trolled  by  quinine  was  typhoid. 

Dr.  Moore  thought  the  nature  of  this  fever  would  the  sooner 
and  better  be  learned  if  every  doctor  would  arrange  to  obtain 
the  temperature  of  such  patients  twice  a  day,  say  between  7 
and  9  a.  m.  and  between  4  and  6  p.  m.  The  more  general  knowl¬ 
edge  of  the  thermometric  variations  in  this  fever  thus  gained 
would  materially  assist  in  the  diagnosis  of  it. 

The  President  suggested  that,  as  the  greatest  prostration 
always  occurred  between  2  and  4  a.  m.,  the  temperature  should 
be  taken  then  as  well  as  at  the  hours  suggested  by  Dr.  Moore. 


*  Jilts  r*II ang. 


The  Mississippi  Valley  Medical  Association  will  hold  its  sixteenth 
annual  meeting  in  Louisville  on  Wednesday,  Thursday,  and  Friday, 
October  8th,  9th,  and  10th,  under  the  presidency  of  Dr.  J.  M.  Mathews, 
of  Louisville.  Besides  the  president’s  address  and  an  address  by  Dr. 
J.  A.  Wyeth,  of  New  York,  the  programme  contains  the  following 
items :  On  Infectious  Dyspepsia  and  its  Rational  Treatment  by  the 
Antiseptic  Method,  by  Dr.  Frank  Woodbury,  of  Philadelphia;  Help 
and  Hindrance  to  Medical  Progress,  by  Dr.  John  H.  Hollister,  of  Chi¬ 
cago;  Therapeutic  Uses  of  Cardiac  Sedatives  in  Inflammation,  by  Dr. 
H.  A.  Hare,  of  Philadelphia ;  Mechanical  Obstruction  in  Diseases  of  the 
Uterus,  by  Dr.  George  Hulbert,  of  St.  Louis ;  The  Construction  of  Bac¬ 
teria,  by  Dr.  J.  T.  Whittaker,  of  Cincinnati;  A  Fatal  Case  of  Vomiting 
after  Laparotomy,  by  Dr.  T.  A.  Reamy,  of  Cincinnati ;  The  Surgical 
Treatment  of  Uterine  Fibroids,  by  Dr.  R.  Stansbury  Sutton,  of  Pitts¬ 
burgh;  Fracture  of  the  Lower  End  of  the  Radius,  by  Dr.  P.  S.  Conner, 


of  Cincinnati;  Coffee,  its  Use  and  Abuse,  by  Dr.  I.  N.  Love,  of  St. 
Louis;  Treatment  of  Fracture  of  the  Forearm  by  Extension,  Counter¬ 
extension,  and  Fixed  Supination,  by  Dr.  X.  C.  Scott,  of  Cleveland; 
Flint’s  Doctrine  of  the  Self-limitation  of  Phthisis,  by  Dr.  William 
Porter,  of  St.  Louis  ;  Cough,  its  Relation  to  Intra-nasal  Diseases,  by  Dr. 
A.  B.  Thrasher,  of  Cincinnati ;  A  Case  of  Rhinoplasma — Operation,  by 
Dr.  A.  H.  Ohtnann-Dumesnil,  of  St.  Louis  ;  Chronic  Diseases  of  the 
Joints,  by  Dr.  Joseph  Ransohoff,  of  Cincinnati ;  Cases  of  Penetrating 
Stab  Wounds  of  the  Abdomen,  Laparotomy  Results,  by  Dr.  H.  C.  Dalton, 
of  St.  Louis ;  Gastro-enterostomy,  by  Dr.  George  Cook,  of  Indianapolis  ; 
Torsion  of  Arteries  as  a  Means  for  the  Arrest  of  Haemorrhage,  by  Dr. 
J.  B.  Murdock,  of  Pittsburgh ;  The  Psychic  Sequences  of  an  Entailed 
and  Chronically  Acquired  Alcoholism,  by  Dr.  C.  H.  Hughes,  of  St. 
Louis ;  A  Resumd  of  Experience  to  Date  all  over  the  World  in  the  Vari¬ 
ous  Operations  for  Cystitis  from  Prostatic  Hypertrophy,  by  Dr.  W.  T. 
Belfield,  of  Chicago  ;  Fevers  and  their  Treatment,  by  Dr.  C.  G.  Comegys, 
of  Cincinnati ;  Bromide  Eruptions  resembling  Syphilitic  Lesions,  by  Dr. 
W.  T.  Corlett,  of  Cleveland ;  Original  Investigation  in  Medicine  in  the 
United  States,  by  Dr.  Frank  S.  Billings,  of  Chicago ;  Acute  Ascending 
Paralysis,  by  Dr.  Joseph  Eichberg,  of  Cincinnati;  Inguinal  Colotomy, 
with  Report  of  a  Case,  bv  Dr.  Arch  Dixon,  of  Henderson,  Ky. ;  One 
Danger  that  Threatens  the  Physical  Deterioration  of  the  Whites  in 
America,  by  Dr.  E.  A.  Wood,  of  Pittsburgh;  Urea  and  Serous  Mem¬ 
branes,  by  Dr.  C.  S."  Bond,  of  Richmond,  Ind. ;  Hypnotism  in  its  Rela¬ 
tion  to  Surgery,  by  Dr.  Emory  Lamphear,  of  Kansas  City ;  Certainty  in 
the  Diagnosis  of  Tuberculosis,  by  Dr.  Theodore  Potter,  of  Indianapolis  ; 
Bunions,  by  Dr.  Robert  T.  Morris,  of  New  York ;  The  Hypodermatic  Use 
of  Arsenic,  by  Dr.  Harold  M.  Moyer,  of  Chicago  ;  Fractures  of  the 
Lower  End  of  the  Humerus,  their  Results  and  Medical  Relations,  by 
Dr.  Reuben  A.  Vance,  of  Cleveland  ;  A  Review  of  the  Treatment  of 
Varicocele,  with  Cases,  by  Dr.  G.  Frank  Lydston,  of  Chicago ;  Ar- 
throtomy  in  Old  Dislocations  of  the  Elbow,  with  the  Report  of  a  Case, 
by  Dr.  Joseph  W.  Marsee,  of  Indianapolis  ;  Perineal  versus  Suprapubic 
Cystotomy,  by  Dr.  H.  0.  Walker,  of  Detroit;  Herniotomy,  with  Re¬ 
ports  of  Three  Novel  Cases,  by  Dr.  B.  Merrill  Ricketts,  of  Cincinnati ; 
What  a  Doctor  should  not  Expect,  by  Dr.  A.  N.  Ellis,  of  Cincinnati ; 
An  Examination  of  the  Pupils  of  the  Kentucky  Institute  for  the  Blind, 
with  Special  Reference  to  Causation,  by  Dr.  J.  M.  Ray,  of  Louisville ; 
Myopia,  by  Dr.  A.  R.  Baker,  of  Cleveland ;  Some  Remarks  on  the  Pre¬ 
vention  of  Myopia,  by  Dr.  Francis  Dowling,  of  Cincinnati ;  Malnutri¬ 
tion  in  Eye  Diseases,  by  Dr.  J.  E.  Harper,  of  Chicago ;  Absence  of  the 
Chorioidal  Blood-vessels  and  Pigment,  affecting  both  Eyes,  by  Dr.  M. 
M.  Cowgill,  of  Paducah,  Ky. ;  Two  Cases  of  Tubal  Pregnancy,  Opera¬ 
tion,  Recovery,  by  Dr.  Edwin  Walker,  of  Evansville,  Ind. ;  Treatment 
of  Organic  Stricture  of  the  Urethra,  by  Dr.  Seaton  Norman,  of  Evans¬ 
ville,  Ind. ;  Exercises  in  the  Treatment  of  Lateral  Curvature  of  the 
Spine,  by  Dr.  G.  W.  Ryan,  of  Cincinnati ;  Antipyretics,  by  Dr.  F.  C. 
Woodburn,  of  Indianapolis  ;  The  Difficulty  in  Diagnosticating  a  Twisted 
Ovarian  Pedicle  in  Uterine  Myoma,  by  Dr.  Edwin  Ricketts,  of  Cincin¬ 
nati  ;  The  Treatment  of  Organic  Stricture  of  the  Urethra,  with  Special 
Reference  to  Perineal  Urethrotomy,  by  Dr.  Jacob  Geiger,  of  St.  Joseph, 
Mo.  ;  Summer  Complaint  in  Children,  by  Dr.  Lyman  Beecher  Todd,  of 
Lexington,  Ky;  Neurasthenia  Foeminea,  a  Fashionable  Disease,  by  Dr. 
Amos  Sawyer,  of  Hillsboro,  Ill. ;  Treatment  of  Epilepsy,  by  Dr.  Philip 
Zenner,  of  Cincinnati ;  Internal  Urethrotomy,  with  Cases,  by  Dr.  J.  V. 
Prewitt,  of  West  Point,  Ky. ;  Lacerated  Wound  of  the  Axilla  from  a 
Barbed  Wire,  by  Dr.  G.  N.  Rowe,  of  Randall,  Kansas ;  Three  Cases  of 
Intestinal  Obstruction,  with  Remarks,  by  Dr.  David  Barrow,  of  Lex¬ 
ington,  Ky. ;  Was  it  Relapsing  Fever  ?  by  Dr.  A.  D.  Barr,  of  Calamine 
Springs,  Ark. ;  When  to  Operate  in  Cases  of  Rupture  in  Ectopic  Preg¬ 
nancy,  by  Dr.  C.  A.  L.  Reed,  of  Cincinnati ;  Extra-uterine  Pregnancy, 
with  the  Report  of  a  Case  of  Four  Years  and  Three  Months’  Duration, 
complicated  with  Entero-uterine  Fistula,  by  Dr.  R.  R.  Kime,  of  Peters¬ 
burg,  Ind. ;  Dermoid  Cysts  of  the  Ovary,  with  Reports  of  Cases,  by  Dr. 
W.  H.  Wathen,  of  Louisville;  The  Application  of  the  Antiseptic 
Method  in  Midwifery  Practice,  by  Dr.  L.  S.  MeMurtry,  of  Louisville ; 
Inflation  with  Hydrogen  Gas  for  Diagnosis,  versus  Exploratory  Lapa¬ 
rotomy,  in  Intestinal  Obstruction  and  Wounds  of  the  Abdominal  Vis¬ 
cera,  by  Dr.  J.  G.  Carpenter,  of  Stanford,  Ky.  ;  Cerebral  Syphilis,  with 
the  Report  of  a  Case,  by  Dr.  Frank  R.  Norbury,  of  Jacksonville,  Ill. ; 


392 


MISCELLANY. 


|N.  Y.  Mkd.  Jopr. 


Simple  Ovariotomy,  by  Dr.  Orange  G.  Pfaff,  of  Indianapolis ;  The 
Treatment  of  Intermittent  Fever,  by  Dr.  Robert  C.  Kenner,  of  Louis¬ 
ville  ;  Tuberculosis,  Syphilis,  Rheumatism,  and  Pelvic  Hyperaesthesia, 
by  Dr.  J.  A.  Cutter,  of  New  York;  Treatment  of  Gonorrhoeal  Rheu¬ 
matism,  by  Dr.  Ap  Morgan  Vance,  of  Louisville;  The  Advantages  of 
attending  Medical  Societies  and  of  reading  Medical  Journals,  by  Dr. 
T.  B.  Greenley,  of  West  Point,  Ky.  ;  Cerebro-spinal  Concussion,  by  Dr. 
J.  F.  Barbour,  of  Louisville;  and  The  Tonsil,  by  Dr.  G.  V.  Woolen,  of 
Indianapolis. 

Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  September  26th  : 


CITIES. 

Week  ending — 

Estimated  popu¬ 
lation. 

Total  deaths  from 
all  causes. 

Cholera. 

|  Yellow  fever. 

Small-pox. 

DE 

"o 

S 

«3 

> 

AT 

A 

"3 

o 

« 

Typhus  fever.  c n 

Enteric  fever. 

50 

Scarlet  fever.  2 

- -  l 

Diphtheria. 

V 

8 

O) 

s 

Whooping- 

cough  . 

New  York,  N.  Y . 

Sept.  20. 

1,642,298 

660 

17 

q 

20 

6 

Chicago,  III . 

Sept.  20. 

1,100,000 

365 

‘>3 

3 

16 

A 

Philadelphia,  Pa . 

Sept.  13. 

1,064,277 

349 

10 

4 

5 

3 

Brooklyn,  N.  Y . 

Sept.  20. 

871,852 

350 

i 

2 

13 

3 

4 

Baltimore,  Md . 

Sept.  2 ). 

500,343 

169 

9 

4 

Q 

St.  Louis,  Mo  . 

Sept.  13. 

460,000 

147 

i 

3 

1 

Bostog,  Mass . 

Sept.  20. 

446,507 

169 

3 

1 

1 

Cincinnati,  Ohio . 

Sept.  19. 

325,000 

107 

3 

11 

.... 

Washington,  I).  C _ 

Sept.  15. 

250,000 

125 

7 

3 

Cleveland,  Ohio . 

Aug.  9. 

240.310 

140 

3 

Cleveland,  Ohio . 

Aug.  16. 

240,310 

87 

7 

i 

Cleveland,  Ohio . 

Aug.  23. 

240,310 

103 

8 

1 

2 

Pittsburgh,  Pa . 

Sept.  15. 

240,000 

85 

19 

9 

o 

Detroit,  Mich . 

Sept.  13. 

230,000 

77 

1 

8 

Louisville,  Kv . 

Sept.  20. 

227|000 

75 

Milwaukee,  Wis . 

Sept.  20. 

220,000 

73 

2 

1 

3 

1 

Minneapolis,  Minn... 

Sept.  20. 

200,000 

40 

i 

5 

Rochester,  N.  Y . 

Sept.  20. 

135,000 

51 

2 

1 

Providence,  R.  1 . 

Sept.  20. 

132,043 

55 

2 

] 

Richmond,  Va . 

Sept.  13. 

100,000 

37 

4 

2 

Richmond,  Ya . 

Sept.  20. 

100,000 

42 

1 

2 

1 

Nashville,  Tenn . 

Sept.  20. 

76,309 

28 

Pall  River,  Mass . 

Sept.  20. 

75,000 

39 

3 

Charleston,  S.  C . 

Sept.  20. 

60,145 

28 

1 

Portland,  Me . 

Sept.  20. 

42.000 

19 

Galveston,  Texas  — 

Sept.  5. 

40.000 

15 

Binghamton,  N.  Y . . . 

Sept.  20. 

35,000 

15 

O 

1 

Altoona,  Pa . \ - 

Aug.  23. 

34,397 

13 

*  * 

1 

Altoona,  Pa . 

Aug.  30. 

34,397 

11 

1 

Altoona,  Pa . 

Sept.  6. 

34,397 

6 

Yonkers,  N.  Y . 

Sept.  12. 

32,000 

8 

Yonkers,  N.  Yr . 

Sept.  19. 

32,000 

10 

Auburn,  N.  Y . 

Sept.  20. 

26.000 

7 

Newton,  Mass . 

Sept.  13. 

22,011 

10 

Newton,  Mass . 

Sept..  20. 

22,011 

7 

Newport,  R.  I . 

Sept.  18. 

20,000 

7 

Rock  Island,  Ill . 

Sept.  14. 

16,000 

5 

Pensacola,  Fla . 

Sept.  13. 

15,000 

6 

1 

An  Opium  Pill  for  Dysentery. — Dr.  N.  M.  Geer,  of  Toronto,  0., 
sends  us  the  following  formula  : 


K  Pulv.  opii .  gr.  xx  ; 

Pulv.  resinae .  gr.  xxx; 

Pulv.  acaciae .  gr.  xx ; 

Aquae . q,  s. 


M.,  fiat  massa  in  pilulas  No.  xxv  dividenda. 

S.  One  pill  every  four  hours  until  relief  is  obtained.  Dr.  Geer  says 
that  he  uses  this  pill  with  great  success  in  obstinate  cases  of  dysentery, 
and  that  the  resin  prevents  the  pill  from  dissolving  before  it  has  been 
carried  low  in  the  intestine.  Old  opium  pills,  that  have  become  diffi¬ 
cult  of  solution,  are  used  by  some  practitioners  with  the  same  idea  in 
view. 

Aristol  in  Acne  Indurata. — Dr.  William  Wickham,  of  Youngstown, 
0.,  writes  as  follows  :  The  therapeutical  agents  recommended  in  cuta¬ 
neous  affections  are  numerous,  but  many  of  those  used  locally  are  ob¬ 
jectionable  for  reasons  well  known  to  the  dermatologist.  Good  local 
applications  are  very  necessary,  and  in  almost  all  cases,  owing  to  their 
parasitic  origin,  are  indispensable  adjuncts  to  the  general  treatment. 
Among  the  best,  according  to  my  experience,  is  aristol.  Having  a  case 
of  acne  indurata  which  stubbornly  resisted  the  usual  treatment,  I  con¬ 
cluded  to  use  the  new  remedy,  aristol,  prescribing  it  in  the  form  of  an 
ointment  of  the  strength  of  ten  per  cent,  made  with  benzoated  lard. 
It  was  applied  at  bedtime  after  having  washed  the  surfaces  affected — 
i.  e .,  the  face  and  neck — with  strong  soap  and  hot  water.  In  the  morn¬ 


ing  the  surfaces  were  again  washed  for  the  purpose  of  cleanliness.  The 
ointment  was  applied  every  night  as  at  first,  and  in  about  two  weeks 
I  dismissed  the  patient  as  cured.  It  is  now  several  months  since,  and 
no  return  of  his  old  trouble  has  occurred.  I  would  add  that  I  am  now 
using  aristol  in  the  treatment  of  chronic  eczema  with  gratifying  re¬ 
sults. 

The  Poisoned  Arrows  of  the  African  Pygmies. — “  From  the  pages 
of  In  Darkest  A  frica  we  learn  that  the  poisoned  arrows  of  the  pygmies 
in  the  forest  often  made  great  havoc  among  Stanley’s  followers  and 
produced  intense  suffering,  and  sometimes  death  by  tetanus.  Some¬ 
times,  however,  death  was  more  rapid,  and  one  instance  is  given  of 
death  within  one  minute  from  a  mere  pin-hole  wound.  Mr.  Stanley  is 
not  able  to  give  the  scientific  names  of  the  plants  or  animals  from 
which  these  poisons  are  extracted,  but  states  that  one  of  a  pitch-like 
consistency  and  color  is  made  out  of  a  species  of  arum ;  another  is  de¬ 
cocted  from  ants,  which  are  crushed  into  a  fine  powder  and  mixed  with 
palm-oil.  The  treatment  found  successful  in  combating  the  poison  was 
to  suck  and  wash  out  the  wound  and  inject  a  strong  solution  of  carbo¬ 
nate  of  ammonium,  and  to  control  the  tetanic  convulsions  by  hypo¬ 
dermic  injections  of  morphine.” — British  and  Colonial  Druggist. 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “■ original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  alivays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (i)  when  a  manuscript  is  sint  to  this  jour¬ 
nal ,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified, 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of— we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  an) 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors ,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long ,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters ,  whether  intended  for  publication  or  not ,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  prroperly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
t  to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  HEW  YORK  MEDICAL  JOURNAL,  October  11,  1890. 


#vigtnal  Commiwmxticms. 


A  CLINICAL  STUDY  OF 

FORTY-SEVEN  CASES  OF  PARALYSIS  AGITANS.* 
By  FREDERICK  PETERSON,  M.  D., 

CHIEF  OF  CLINIC,  NERVOUS  DEPARTMENT,  VANDERBILT  CLINIC,  AND 
LECTURER  ON  NERVOUS  AND  MENTAL  DISEASE  AT  THE  NEW  YORK  POLYCLINIC. 

This  study  is  based  upon  the  careful  observation  of 
twenty-nine  cases  of  paralysis  agitans  in  Dr.  Starr’s  depart¬ 
ment  of  the  Vanderbilt  clinic  ;  six  cases  from  the  nervous 
department  of  the  polyclinic  in  charge  of  Dr.  Sachs,  and 
five  cases  from  my  wards  in  the  New  York  Hospital  for 
Nervous  Diseases  on  Blackwell’s  Island.  Besides  these,  Dr. 
Starr  has  kindly  furnished  me  the  notes  of  seven  additional 
cases  from  his  private  records.  Only  forty  of  the  total  num¬ 
ber  of  cases,  therefore,  have  been  personally  examined  by 
me. 

For  the  purpose  of  practical  study  and  easy  survey,  I 
have  grouped  the  facts  adduced  from  the  cases  under  sepa¬ 
rate  small  headings — setiological,  symptomatic,  pathologi¬ 
cal,  and  therapeutic. 

^Etiology. 


Age  at  Onset. — The  period  of  life  at  which  the  tremor 
began  may  be  seen  from  the  following  table  : 


AGE  AT  ONSET. 

Males. 

Females. 

Total. 

30  to  40 . 

2 

1 

3 

40  to  50 . 

7 

2 

9 

50  to  60 . 

12 

11 

23 

60  to  70 . 

7 

3 

10 

70  to  80 . 

1 

1 

2 

Total . . 

29 

18 

47 

In  the  majority,  then,  it  developed  between  the  ages  of 
fifty  and  sixty,  while  forty-two  of  the  forty-seven  cases  were 
between  forty  and  sixty  years  of  age  at  the  onset,  thus  agree¬ 
ing  with  the  statistics  of  other  observers. 

Sex. — The  fact  that  men  are  more  frequently  affected 
by  this  disease  than  women  is  borne  out  by  my  figures.  Of 
the  forty-seven  cases,  twenty-nine  were  males  and  eighteen 
females. 

Heredity. — It  is  a  moot  question  whether  a  hereditary 
taint  plays  any  particularly  important  role  in  the  develop¬ 
ment  of  paralysis  agitans.  In  only  two  of  these  cases  could 
any  such  factor  be  suspected.  They  were  the  cases  of  a 
brother  and  sister.  In  the  former  it  is  still  mild  in  its  mani¬ 
festations,  while  in  the  sister  the  disorder  has  led  to  irre¬ 
mediable  contractures  in  both  hands  and  both  feet  and  to 
such  general  rigidity  that  locomotion  is  almost  impossible, 
and  even  speech  difficult.  At  the  same  time  this  may  have 
been  an  instance  of  a  communicated  functional  disease, 
analogous  to  folie  a  deux,  which  is  usually  a  communicated 
insanity,  and  to  imitated  chorea  and  to  hysteria  major. 
The  sister  had  the  disease  for  many  years  previously.  The 

*  Read  before  the  New  York  Neurological  Society,  May  6,  1890. 
See  also  a  study  of  twenty-two  cases  of  paralysis  agitans  in  Professor 
Starr’s  book  Familiar  Forms  of  Nervous  Disease,  1890. 


brother  had  become  nervous  through  overwork,  and  had 
some  intention  tremor  of  his  fingers  when  first  seen  by  me. 
The  paralysis  agitans  has  developed  in  him  under  my  ob¬ 
servation,  and  there  has  always  been  constant  anxiety  upon 
his  part  lest  he  should  be  afflicted  like  his  sister.  Possibly 
his  continual  observation  of  her  and  comparison  of  his  own 
symptoms  have  actually  induced  them  in  himself.  Some 
support  is  given  to  this  idea  by  the  cases  of  a  husband  and 
wife  who  are  also  of  the  forty  I  have  studied. 

Mrs.  M.  is  now  fifty-seven  years  of  age  and  has  the  typi¬ 
cal  symptoms  of  Parkinson’s  disease.  The  tremor  began 
four  years  ago  in  her  left  hand.  Mr.  M.  is  sixty-seven  years 
of  age,  and  about  a  year  ago  noticed  some  tremor  in  his 
hands  which  may  have  been  simply  senile  ;  but  within  two 
months  last  past  a  rhythmical  tremor,  precisely  like  his  wife’s, 
has  appeared  in  his  right  hand.  He  has  also  been  fearful 
of  becoming  a  victim  to  shaking  palsy. 

Occupation. — All  the  patients  were  from  the  common 
walks  of  life,  but  a  few  of  them  followed  pursuits  in  which 
they  were  especially  subjected  to  exposure  to  extremes  of 
heat  or  cold.  Thus,  one  was  a  night-watchman,  one  a  coach¬ 
man,  one  a  messenger,  one  an  engineer,  and  one  an  out-of- 
door  laborer,  and  one  worked  as  a  tobacconist  in  a  damp 
basement  for  thirty  years. 

Exposure  to  Cold  and  Wet  as  a  Cause. — In  eight  cases 
the  immediate  cause  given  for  the  tremor  was  working  in 
the  wet  and  cold.  Two  of  these  patients,  both  men,  date  the 
onset  of  the  disease  from  the  famous  “blizzard”  of  March 
14,  1888,  when  New  York  was  snowed  in  to  such  an  extent 
that  all  travel  was  suspended  for  a  day  or  two,  and  several 
people  were  lost  and  frozen  to  death  in  the  streets.  These 
two  men  were  both  out  in  the  storm,  and  the  tremor  fol¬ 
lowed  almost  immediately  upon  the  exposure  to  the  cold 
and  the  exertion  required  to  reach  their  homes. 

Moral  Causes  (worry,  anxiety,  grief,  excitement,  and 
fright). — One  of  my  patients  was  an  illicit  distiller  of  whisky, 
and  the  disease  appeared  soon  after  his  discovery  and  trial 
and  the  confiscation  of  all  his  property.  In  three  cases  do¬ 
mestic  infelicity  was  an  setiological  factor.  One  woman  de¬ 
veloped  it  during  an  anxious  period  of  nursing  a  dying 
mother,  and  another  during  a  period  of  worry  over  her 
drunken  son.  One  woman  gave  as  a  cause  a  sudden  fright. 
In  one  man  the  tremor  appeared  soon  after  great  excitement 
incident  to  a  religious  discussion. 

Traumatic  Causes. — In  one  woman  the  tremor  began  in 
the  right  arm  subsequently  to  a  fall  from  a  step-ladder,  and 
in  another  it  followed  a  fall  down  stairs.  A  beautiful  ex¬ 
ample  of  trauma  as  an  exciting  cause  was  that  of  a  man 
who  at  the  age  of  fifty-twm  was  driving  a  refractory  horse. 
The  horse  ran  away  and  threw  him  out  upon  his  left  shoul¬ 
der.  No  immediate  harm  was  done,  but  paralysis  agitans 
soon  became  manifest,  the  tremor  beginning  in  the  left  arm. 
Fright  must  have  also  had  a  share  in  its  production. 

Miscellaneous  Causes. — In  one  case  fever  and  ague  of 
three  months’  duration  immediately  preceded  the  develop¬ 
ment  of  Parkinson’s  disease.  In  another,  articular  rheuma¬ 
tism  in  the  left  foot  was  antecedent  to  the  development  of 
tremor  in  that  extremity.  One  case,  examined  very  recent- 


394 


PETERSON:  A  CLINICAL  STUDY  OF  PARALYSIS  AGITANS. 


[N.  Y.  Med.  Joub., 


ly,  has  followed  closely  upou  an  attack  of  la  grippe.  Among 
causes  given  by  other  authors  are  to  be  mentioned  gout  by 
Lhirondel  ( These  de  Paris,  1883),  and  typhoid  fever  by 
Berger. 

Symptoms. 


Tremor. — This  is  one  of  tbe  most  important  symptoms 
of  paralysis  agitans,  although,  paradoxical  as  it  may  seem,  a 
number  of  cases  have  been  observed  of  true  Parkinson’s  dis¬ 
ease  without  the  tremor.  Thus,  Charcot  observed  two  such 
cases,  Berger  and  Wienskowitz  two,  Buzzard  one,  Hardy 
one,  Amidon  one  ( N .  Y.  Med.  Record ,  Nov.  24,  1883),  and 
Beevor  has  lately  described  four  [Med.  Soc.  Proceed .,  1889, 
vol.  viii,  p.  8).  Rigidity,  however,  is  always  present  when 
tbe  tremor  is  wanting. 

This  symptom  was  present  in  all  of  tbe  forty-seven 
cases.  The  extremities  in  which  it  first  originated,  as  re¬ 
lated  by  tbe  patients,  are  tabulated  as  follows : 

Cases 


Tremor  began  in  right  hand  in .  18 

“  “  left  hand  in .  20 

“  “  left  foot  in .  5 

“  “  both  hands  (?)  in .  3 

“  “  both  feet  (?)  in .  1 

Total . 47 


Tbe  extent  of  tbe  tremor  at  tbe  time  of  examination 
may  be  gathered  from  the  following : 


Cases 


Tremor  present  in  all  four  extremities  of . 12 

“  “  all  four  extremities  and  head  of .  3 

“  “  all  four  extremities  and  lips,  tongue,  and  head 

of .  3 

“  “  both  upper  extremities  of .  4 

“  “  both  upper  extremities  and  head  of .  2 

“  “  both  upper  extremities  and  face  of .  1 

“  “  both  upper  extremities  and  head  and  face  of. .  1 

“  “  both  upper  extremities  and  left  lower  of .  3 

“  “  both  lower  extremities  and  left  upper  of .  2 

“  “  left  upper  extremity  only  of .  3 

“  “  left  upper  and  left  lower  extremities  of .  6 

“  “  right  upper  extremity  only  of . 3 

“  “  right  upper  and  right  lower  extremity  of .  4 

Total . 47 


Charcot’s  statement  that  tbe  bead  never  takes  part  in 
the  tremor,  but  is  only  moved  by  tbe  contiguous  move¬ 
ments-  of  the  upper  extremities,  lias  been  proved  to  be  un¬ 
founded  in  fact.*  It  will  be  observed  that  there  was  tre¬ 
mor  of  tbe  bead  in  nine  of  my  forty-seven  cases,  and  in 
all  of  these  it  was  possible  to  determine  tbe  participation 
of  tbe  neck  musculature  in  the  tremor. 

With  the  exception  of  the  shivering  from  cold  or  ter¬ 
ror,  the  tremor  of  paralysis  agitans  is  almost  the  only  one 
developed  when  the  body  is  in  a  condition  of  rest.  Almost 
all  others  belong  to  the  class  of  intention  tremors,  or  to 
such  as  are  originated  when  the  limbs  are  extended  without 
support.  Furthermore,  the  tremor  varies  greatly  in  extent 


*  The  following  are  some  of  the  authorities  who  have  disproved 
Charcot’s  assumption:  Oppolzer,  Spital  Zeitung,  Nos.  17,  18,  1861. 
Clement,  Lyon  medical ,  No.  26,  1869.  Jones,  British  Med.  Journal, 
1873.  Westphal,  Charlie  Annalen ,  iii.  u.  iv.  Jahrg.  Demange,  Revue 
d.  mid.,  ii,  1882.  Buzzard,  Clinical  Lectures  on  Dis.  of  the  Nerv.  Syst., 
1882.  Huber,  he.  cit.  Gowers,  loc.  cit.  (8  out  of  37  cases). 


and  rate  of  rhythm  at  different  times  and  even  in  different 
parts  of  the  body  of  the  same  individual.  We  note  in 
some  cases  that  there  may  be  a  cessation  of  the  tremor  com¬ 
pletely  for  an  hour  or  two  daily,  or  in  others  great  diminu¬ 
tion  or  increase  for  an  indefinite  period.  Although  usually 
an  effort  of  the  will  can  cause  it  to  cease  at  least  momen¬ 
tarily,  yet  occasionally  it  is  uncontrollable.  By  means  of 
an  Edwards  sphygmograph  numerous  tracings  of  tremors 
in  various  diseases  have  been  taken  by  me  at  the  Vander¬ 
bilt  Clinic,  some  of  which  were  made  the  subject  of  a  short 
contribution  on  muscular  tremor  read  before  the  American 
Neurological  Association  at  Washington,  September  20, 
1888.*  I  determined  the  average  rate  of  vibration  of  this 
tremor  to  be  from  3‘7  to  5-6  per  second,  agreeing  writb  all 
other  investigators  (except  Goweys),  as  will  be  seen  from 
the  following  table : 


Author. 

PUBLICATION. 

Bate  to  the  second. 

Marie . 

Contrib.  d  l' etude,  etc . 

5 

Charcot . 

Mai.  du  systeme  nerv . 

4-5 

Ewald . 

Berl.  klin.  Wo  cit. ,  1883,  No.  32 . 

5 

Grashly . 

Arch,  fur  Psych.,  1885 . 

414-5-34 

Huber . 

Yirchow’s  Arch.,  vol.  108,  p.  45 . 

3-43-5-57 

Gowers . 

Dis.  of  the  Nerv.  Syst.,  1888,  p.  1001. 

4-8-7 

Wolfenden  & 

Brit.  Med.  Jour.,  May  19,  1888 . 

51 

Williams  . . 
Peterson  .... 

Jour. of  Nerv.  andMent. Dis.,  Feb. ,1889. 

S-7-5-6 

It  is  probable  that  all  tremors  are  a  modification  of  the 
rhythmic  discharges  of  energy  from  the  cortex,  which,  as  is 
well  known,  take  place  at  the  rate  of  ten  in  a  second.  Con¬ 
sequently,  when  there  are  fewer  to  the  second,  it  is  because 
of  the  fusion  of  two  or  three  impulses.  The  dicrotic  charac¬ 
ter  of  the  oscillations  in  paralysis  agitans  has  been  demon¬ 
strated  by  Wolfenden  and  Williams  by  means  of  specially 
constructed  myographic  apparatus.]-  Illustrations  of  the 
tremor  of  paralysis  agitans  taken  from  various  portions  of 
the  body,  and  also  a  series  of  myograms  from  different  dis¬ 
eases,  are  here  inserted  for  comparison. 

Rigidity. — This  symptom  was  present  in  forty-one  cases, 
although  more  marked  in  some  than  in  others.  In  three  it 
was  absent  and  in  three  unnoted.  As  is  well  known,  the 
rigor  musculorum  manifests  itself  in  the  extremities,  trunk, 
neck,  and  face.  The  muscles  of  the  eyes  are  extraordi¬ 
narily  seldom  affected.  Debove  has  reported  cases  where 
there  was  rigidity  of  the  ocular  muscles  [Le  progres  medical, 
1878).  In  one  case  of  mine  the  orbicularis  oris  was  so  in¬ 
flexible  that  the  patient  had  no  control  over  it,  and  she 
driveled  constantly.  Rigidity  of  the  lingual  musculature 
was  observed  in  a  few  cases,  and  probably  a  certain  amount 
of  stiffness  of  the  muscles  concerned  in  articulation  and 
phonation  accounts  for  the  peculiarities  of  speech  noted  in 
some. 

In  two  cases  with  a  hemiplegic  type  of  paralysis  agitans 
affecting  the  left  side  the  rigidity  was  limited  with  re¬ 
markable  precision  to  the  muscles  of  the  left  side  of  the 
head  and  neck,  left  arm  and  left  leg,  and  even  to  the  left 
sides  of  the  tongue  and  orbicularis  oris.  There  was  no 
history  or  symptom  of  hemiplegia.  We  find  commonly 

*  See  Journal  of  Nervous  and  Mental  Disease,  February,  1889. 

f  Loc.  cit. 


Oct.  11,  1890.] 


PETERSON:  A  CLINICAL  STUDY  OF  PARALYSIS  AGITAN8. 


395 


loss  of  power  or  an  actual  paresis  in  connection  with  the 
rigidity  of  the  muscles. 

Contractures. — Over  eighty  per  cent,  of  the  cases  pre¬ 
sented  the  typical  position  of  Parkinson’s  disease  as  figured 


TEN  SECONDS. 


an  extremely  exaggerated  type.  They  could  move  their 
thighs  when  placed  in  a  standing  position,  so  that  they 
could  walk  when  supported  by  another;  but  it  was  impos¬ 
sible  for  them  to  turn  in  bed  or  rise  from  a  chair. 

Muscular  Wasting. — It  is  not  uucommon  to  observe 
some  wasting  of  the  muscles  in  cases  of  long  standing,  but 
this  is  not  always  apparent  unless  the  disease  is  of  the  uni- 


TEN  SECONDS. 


1.  Tremor  of  extensors  of  carpus  of  right  hand, 

2(  u  it  tt 

3.  Tremor  of  head  while  hands  held  a  chair, 

4  tt  tt  tt 

5.  Tremor  of  head,  no  effort  with  hands  to  keep  steady, 

6.  Tremor  of  Interossei, . 


5‘3  per  second. 
5-1 

44  “ 

4-6 

4-8  “ 

4-5 

4-9  “ 


A  Comparative  Series  of  Myograms  of  Various  Tremors. 


1.  Paralysis  agitans, 

. 4-7 

per  second. 

2.  Morbus  Basedowii,  . 

. 117 

U 

3.  Multiple  sclerosis, 

. ’  5-4 

tt 

4.  Hysterical  tremor, 

. 7-7 

tt 

5.  Neurasthenic  tremor, 

. 7-4 

tt 

6.  Delirium  tremens, 

. 56 

tt 

in  the  text-books.  The  bowed  head,  flexed  elbows  and 
knees,  and  flexed  metacarpo-phalangeal  joints  are  to  be 
looked  upon  as  species  of  contractures.  Often  the  flexors 
of  the  forearm  were  so  contracted  that  complete  extension 
could  not  be  made,  and  almost  always  an  attempt  to  stretch 
them  was  painful. 

Two  patients,  both  women,  were  completely  helpless  with 
the  most  advanced  degree  of  contracture  that  I  have  ever 
seen  in  this  disease.  They  both  had  double  talipes  equino- 
varus  and  absolute  ankylosis  of  all  the  joints  of  the  hands 
in  the  characteristic  postures  of  fingers  and  wrists,  but  of 


lateral  type.  A  patient  now  under  my  care  at  the  New 
York  Hospital  for  Nervous  Diseases  exhibits  this  phenome¬ 
non  to  a  remarkable  degree.  R.  B.,  aged  sixty,  admitted 
February  27,  1890,  has  for  nine  months  past  suffered  from 
a  typical  tremor  and  a  gradually  increasing  weakness  and 
stiffness  confined  to  the  left  side.  It  began  in  the  hand 
and  now  involves  the  left  face,  arm,  and  leg.  The  middle 
and  ring  fingers  are  strongly  contracted  into  the  palm. 
There  is  also  now  some  tremor  in  the  right  arm  and  leg. 
It  is  very  marked  in  the  tongue  and  lower  facial  muscles. 
There  is  a  striking  atrophy  of  the  left  arm  and  leg  as  com- 


396 


PETERSON:  A  CLINICAL  STUDY  OF  PARALYSIS  A  GITA  NS. 


[N.  Y.  Mkd.  Jouk., 


pared  with  the  right  extremities,  hut  it  is  especially  marked 
in  the  abductor  and  opponens  pollicis,  abductor  indicis 
and  minimi  digiti,  interossei,  and  adductors  of  the  thigh 
on  the  left  side.  The  measurements  of  the  circumferences 
are  as  follows  : 


Showing  the  amount  of  wasting  in  a  case  of  paralysis  agitans  where  the 
disease  was  limited  to  the  left  side. 


CIRCUMFERENCE  OF— 

Right. 

Left. 

Difference. 

Arms  :  18  cm.  below  shoulders. 

25-5-23 

22-5-20-5 

2-5-3 

Forearms :  15  cm.  below  elbows 

21  -19 

18  -16-5 

2-5-3 

Thighs:  15  cm.  above  patellae. 

37  -34-6 

35-5-33 

1-5 

Legs :  1 5  cm.  below  patellae . . 

29  -27 

28  -26 

1 

The  faradaic  reaction  in  the  wasted  muscles  was  nor¬ 
mal. 

His  rigidity  was  so  great  that  he  could  not  be  photo¬ 
graphed  in  good  position,  but  the  accompanying  photo¬ 
graph  shows  the  wasting  and  contractures  in  the  elbow 
and  fingers. 


Propulsion ,  Retropitlsion ,  Lateropulsion. — Fifteen  cases 
presented  no  peculiarity  of  gait  as  evidenced  by  “running 
after  the  center  of  gravity.”  Propulsion,  or  festination, 
alone  was  observed  in  twelve,  and  retropulsion  alone  in 
three.  Both  propulsion  and  retropulsion  were  of  frequent 
occurrence  in  nine  cases,  and  lateropulsion  remarked  in  but 
one.  Anton  Heimann,  who  reports  in  detail  nineteen  cases 
of  Parkinson’s  disease  in  his  exhaustive  monograph  ( TJeher 
Paralysis  agitans ,  Berlin^  1888),  noted  the  occurrence  of 
lateropulsion  also  in  but  one  case.  Gowers  speaks  of  one. 
A  tabular  view  of  the  relations  of  these  phenomena  of  loco¬ 
motion  in  forty  cases  where  they  were  inquired  into  is  here 
appended : 


Males. 

Females. 

Total. 

Propulsion  only . 

7 

5 

12 

Retropulsion  only . 

Both  propulsion  and  retropul- 

1 

2 

3 

sion . 

5 

4 

9 

Lateropulsion . 

1 

•  • 

1 

No  peculiarity  of  gait . 

9 

6 

15 

Total . 

23 

17 

40 

Tendon  Reflexes. — In  only  nine  cases  were  the  knee, 
wrist,  and  elbow  jerks  exaggerated.  In  six  they  were  hy¬ 
pertypical  and  in  all  the  rest  normal.  The  exaggeration 
was  never  so  marked  as  in  cases  of  organic  disease  of  the 
cerebro-spinal  segment  of  the  motor  tract,  and  indeed  no 
greater  than  is  commonly  observed  in  people  of  advanced 
age,  where  we  ordinarily  expect  an  increase  of  the  deep  re¬ 
flexes.  In  one  of  Dr.  Starr’s  private  cases  where  tremor  was 
limited  to  the  left  hand,  the  left  knee-jerk  was  exaggerated 
and  the  right  absent.  Ankle  clonus  was  not  obtained  in 
any. 

Electrical  Changes. — In  one  case  of  eight  years’  stand¬ 
ing  with  the  disease  limited  wholly  to  the  left  side  I  was 
enabled  to  demonstrate  conclusively  diminished  neuro-mus- 
cular  contractility  to  faradism  upon  the  affected  side.  This 
corroborates  Benedikt,  who  noted  many  years  ago  a  diminu¬ 
tion  of  electrical  irritability  in  affected  extremities  of  old 
cases.  His  further  statement  that  neuro-muscular  contrac¬ 
tility  is  markedly  increased  in  such  parts  in  recent  cases  I 
had  no  opportunity  to  confirm. 

The  Voice  and  Speech. — Buzzard,  in  a  clinical  lecture 
on  shaking  palsy  ( Brain ,  January,  1880),  called  attention  to 
the  high  pitch  and  piping  quality  of  voice  in  some  cases  of 
the  disease,  and  other  authors  have  mentioned  the  occa¬ 
sional  peculiarity  of  a  sort  of  halting  ejaculation  of  words. 
There  were  distinctive  characteristics  of  articulation  and 
plionation  in  no  less  than  thirteen  of  the  forty-seven  cases. 
There  is  probably  no  question  that  these  changes  depend 
almost  wholly  upon  a  certain  amount  of  rigidity  in  muscles 
concerned  in  speech  and  vocalization.  The  especial  feat¬ 
ures  I  have  noted  in  the  thirteen  cases  are,  firstly,  a  condi¬ 
tion  of  monotonia,  as  though  there  were  difficulty  in  ad¬ 
justing  the  vocal  cords  for  the  purposes  of  varying  the 
pitch;  secondly,  a  high  pitch  and  piping  quality  of  tone, 
which  may  possibly  depend  upon  a  certain  minute  degree 
of  contracture  in  the  crico-thyreoid,  posterior  crico-arytse- 
noid,  and  internal  thyreo-arytaenoid  muscles.  A  laryngolo¬ 
gist  might  make  an  interesting  study  of  vocalization  in  this 
disease.  Thirdly,  there  is  often  what  has  been  well  termed 
a  species  of  festination  in  speech.  There  is  some  difficulty 
in  starting  a  sentence,  a  hesitation  upon  the  first  word,  but, 
that  word  having  been  articulated,  the  patient  rapidly  re¬ 
peats  the  whole  sentence  if  a  short  one ;  if  it  be  long,  ho 
pronounces  quickly  five  or  six  words,  and  then  stops  to  re¬ 
adjust  his  muscles  apparently  before  ejaculating  another 
series.  There  are  points  of  analogy  between  the  festination 
of  gait  and  that  of  speech. 

Thermal  Parcesthesia. — An  excessive  feeling  of  heat  over 
the  whole  body,  or  more  rarely  in  limited  areas,  has  been 
mentioned  by  various  writers  as  frequent  in  Parkinson’s 


PETERSON:  A  CLINICAL  STUDY  OF  PARALYSIS  AG  I  TANS. 


397 


Oct.  11,  1890.] 


disease.  Charcot  found  no  alteration  of  temperature  in 
such  cases,  while  a  later  observer,  Berger,  maintained  that 
while  the  general  temperature  was  normal  there  might  be  a 
marked  peripheral  increase.  This  subjective  sensation  of 
heat  I  noted  in  seven  of  my  cases — in  six  general,  in  one 
limited  to  the  abdominal  surface.  This  last  patient,  a  man 
(C.  D.)  aged  sixty,  had  continually  such  a  feeling  of  intense 
heat  over  his  abdomen  that  he  was  constrained  to  keep  con¬ 
stantly  lifting  his  clothing  from  that  surface.  I  placed  an 
Immisch  thermometer  carefully  covered  upon  his  abdomen 
for  seven  minutes,  and  an  ordinary  clinical  thermometer 
under  his  tongue  for  the  same  length  of  time  simultaneous¬ 
ly.  The  abdominal  surface  had  a  temperature  of  97°,  the 
mouth  98#5°. 

At  the  summer  meeting  of  the  French  Society  for  the 
Progress  of  Sciences  ( Ctrlbl .  fur  Nervenheilk .,  Nov.  15, 
1889),  Mosse,  of  Montpellier,  reported  his  observations 
upon  this  matter  in  two  cases  of  the  disease.  He  found  no 
actual  increase  of  peripheral  temperature.  In  one  case  the 
thermal  panesthesia  was  coincident  with  broad  patches  of 
superficial  redness  on  the  back  of  the  hands  and  under  sur¬ 
faces  of  the  forearms.  He  regards  this  sensation  of  heat, 
as  well  as  the  exanthema  and  oedema  sometimes  observed 
in  shaking  palsy,  as  phenomena  due  to  disturbance  in  vaso¬ 
motor  centers. 

Parcesthesia  of  Cold. — This  symptom  was  present  in  five 
of  the  forty-seven  cases.  One  woman  (R.  M.),  aged  sixty- 
five,  whose  tremor  began  in  the  left  arm,  has  always  had  a 
subjective  sensation  of  cold  in  that  arm.  A  man  (T.  F.), 
aged  sixty-eight,  who  has  the  disease  confined  to  both 
arms,  complains  of  a  feeling  of  great  cold  in  those  ex¬ 
tremities.  I  observed  no  particular  coldness  of  the  arms 
upon  examination. 

Miscellaneous  Parcesthesice. — Patients  often  complain  of 
numbness  and  prickling,  sometimes  of  rheumatoid  or  neu¬ 
ralgic  pains  in  the  extremities.  One  man  had  shooting 
pains  in  his  legs  ;  another  a  dull,  aching  pain  in  the  three 
extremities  affected ;  another  numbness  in  the  hands  and 
soles  of  the  feet;  another  much  pain  in  his  two  arms,  which 
were  the  seat  of  the  disease  ;  still  another  had  burning  pains 
in  his  limbs.  Two  women  also  complained  of  pains  in  the 
affected  members.  Anaesthesia  has  never  been  noted. 

Hyper idrosis. — This  symptom,  if  it  is  present,  is,  as  a 
rule,  associated  with  thermal  parsesthesia,  and  in  all  likeli¬ 
hood  depends  upon  the  vascular  relaxation  which  seems  to 
give  rise  to  the  feeling  of  heat.  Hyperidrosis  existed  in 
but  four  of  the  forty-seven  cases,  and  in  these  the  perspira¬ 
tion  was  very  profuse  and  the  sensation  of  heat  extreme. 

Restlessness. — Very  many  cases  have  a  feeling  of  gen¬ 
eral  discomfort,  a  species  of  anxietas  tibiarum ,  only  distrib¬ 
uted  over  the  whole  body.  It  makes  them  exceedingly  rest¬ 
less,  especially  at  night.  Seven  of  the  forty-seven  patients 
made  particular  mention  of  this  trying  symptom. 

Tachycardia. — Although  Marie  and  Azonlav  ( Progres 
med.,  1885,  No.  49)  speak  of  the  frequency  of  this  symp¬ 
tom  in  cases  of  paralysis  agitans,  it  existed  in  but  one  of 
the  cases  here  collected,  a  man,  aged  fifty-four,  with  a  pulse 
of  120. 

Mental  State. — In  many  cases  diminished  intelligence 


or  veritable  psychoses  have  been  described  in  connection 
with  Parkinson’s  disease,  but  there  was  only  one  thus  af¬ 
fected  out  of  my  forty-seven  cases.  The  exception  was  a 
woman  who  developed  first  an  acutely  melancholic  condi¬ 
tion  with  auditory  and  visual  hallucinations,  and  is  now  con¬ 
siderably  demented.  Many  patients  are  more  or  less  de¬ 
pressed  by  their  hopeless  and  uncomfortable  state,  and  in 
many  there  are  present  loss  of  memory  and  mental  weak¬ 
ness  which  should  be  considered  merely  senile  in  character. 

Pathology. 

I  have  had  no  autopsy  in  any  of  these  cases.  Post¬ 
mortem  examination  has  thus  far  failed  to  discover  any 
lesion  to  account  for  the  disease.  It  is  doubtless  one  of 
those  so-called  “functional”  diseases  of  the  motor  areas  of 
the  cortex  due  to  nutritive  changes  of  a  degenerative  char¬ 
acter.  The  weakness,  clonic  movements  of  the  muscles, 
rigidity,  contractures,  and  unilateral  development  of  the 
disease  point  to  the  cortex  as  its  seat.  The  postures  of  the 
hands  and  feet  are  similar  to  those  of  hemiplegia,  epilepsy, 
and  tetany.  The  unilateral  development  is  like  that  of 
monoplegia,  hemiplegia,  and  chorea.  Yet,  though  the  rigid¬ 
ity  is  also  like  that  of  the  paralyses  of  cerebral  origin,  it  is 
difficult  to  explain  the  absence  of  spasticity,  the  deep  re¬ 
flexes  being  usually  normal.  The  vaso-motor  symptoms, 
o-ivino-  rise  to  sensations  of  heat  or  cold,  unilateral  sweating, 

o  O 

general  hyperidrosis,  and  sometimes  oedema  and  the  rlieu- 
matoid  pains,  are  not  easily  explicable  on  any  acceptable 
hypothesis.  But  it  is  possible  that  changes  in  the  periph¬ 
eral  nerves  may  some  time  be  discovered,  which  would  ac¬ 
count  for  some  of  these  peripheral  disturbances,  and  per¬ 
haps  also  for  the  more  than  ordinary  wasting  occasionally 
observed  in  these  cases. 

Treatment. 

The  exact  pathology  of  the  disease  not  yet  having  been 
determined,  all  treatment  has  thus  far  been  more  or  less 
symptomatic,  and  directed  in  particular  toward  diminish¬ 
ing  the  tremor.  The  following  is  a  list  of  some  of  the  more 
important  therapeutic  agents  that  have  been  employed,  and 
if  they  have  no  other  interest,  they  have  at  least  some  pes¬ 
simistic  significance '.  Potassium  bromide  and  iodide,  tinct¬ 
ure  of  veratrum,  veratrin  (Feris),  chloride  of  barium 
(Brown-Sequard),  carbonate  ol  iron  (Elliotson),  strychnine 
(Trousseau),  ergotine,  Calabar  bean  (Ogle),  chloral  hydrate, 
opium,  morphine  (Heimann),  atropine,  belladonna,  gelsem- 
ium,  curare,  hyoscyamine  (Charcot),  Fowler’s  solution 
(Eulenburg,  hypodermically),  coniine  (Berger),  and  eserine 
(Riess). 

Hydrobromide  of  hyoscine  was  first  used  in  paralysis 
agitans  by  Hr.  Langdon,  of  the  Hudson  River  State  Hospi¬ 
tal,  and  myself.  In  a  paper  on  the  employment  of  this 
drug  in  cases  of  insanity,  published  in  the  Medical  Record 
in  1885,  we  called  attention  to  a  case  of  paralysis  agitans  in 
which  the  tremor  ceased  entirely  while  the  patient  was  under 
its  influence.*  In  a  discussion  upon  the  treatment  of  this 

*  Hydrobromate  of  Hyoscine.  Its  Use  in  Forty-eight  Cases  of  In¬ 
sanity  and  Epilepsy.  By  Frederick  Peterson,  M.  D.,  and  Charles  H. 
Langdon,  M.  D.  Case  XXVIII,  Medical  Record ,  Sept.  19,  1885. 


398 


BOS  WORTH:  PARALYSIS  OF  THE  ABDUCTORS  OF  THE  LARYNX.  [N.  Y.  Med.  Joub., 


disease  before  this  society  about  a  year  and  a  half  ago  I  also 
spoke  of  the  efficacy  of  this  drug  in  diminishing  the  tremor. 

Heimann  is  an  enthusiast  as  regards  the  use  of  mor¬ 
phine  iu  these  cases.  He  says  (loc.  cit.) :  “It  is  the  only 
remedy  which  can,  for  at  least  a  short  time,  make  the  pa¬ 
tient  comfortable.” 

Recognizing  the  value  of  opiates  for  overcoming  the 
feelings  of  discomfort  and  restlessness  which  serve  to  make 
the  lives  of  patients  with  Parkinson’s  disease  continually 
miserable,  I  have  latterly  employed  codeine  with  considera¬ 
ble  benefit,  especially  when  combined  in  the  form  of  a  pill 
with  hydrobromide  of  hyoscine  (codeine,  gr.  ss.-ij ;  hyos- 
cine  hydrobromide,  gr.  y^-),  and  administered  twice  or 
thrice  daily.  While  codeine  possesses  many  of  the  useful 
attributes  of  morphine,  it  is  less  deleterious  in  its  influence 
upon  the  system. 

201  West  Fifty-fourth  Street. 


A  CASE  OF  UNILATERAL  PARALYSIS 
OF  THE  ABDUCTORS  OF  THE  LARYNX, 

THE  RESULT  OF  AN  ATTACK  OF  BULBAR  DISEASE  WITH 
UNUSUAL  SYMPTOMS,  AND  WHICH  WAS  APPARENTLY  CAUSED 
BY  SUPPURATIVE  DISEASE  OF  THE  ANTRUM.* 

By  F.  H.  BOSWORTH,  M.  D. 

The  interesting  series  of  experiments  on  the  functions 
of  the  larynx  made  by  Hooper  (Trans,  of  the  Amer.  Laryng. 
Assoc.,  1 885,  p.  9  ;  1886,  p.  22  ;  1887,  p.  41;  1888,  p.  163), 
I.  Donaldson,  Jr.  (Trans,  of  the  Amer.  Laryng.  Assoc., 
1886,  p.  213;  1887,  p.  80),  Semon  and  Horsley  (British 
Med.  Jour.,  1886,  August  28th  and  September  4th,  pp.  405 
and  445),  Krause  (Arch.  f.  Anat.  und  Physiol.,  phys.  Ab- 
theil,  1884),  Onodi  (Ctrlbl.  fur  d.  med.  Wissenschaft., 
1889,  vol.  xxvii,  pp.  258  and  289),  and  Simanowski  (Geschen. 
Min.  Gaz.,  No.  26,  1887)  have  rendered  the  question  of 
laryngeal  paralyses  one  of  no  small  interest.  As  contribut¬ 
ing  somewhat  to  our  knowledge  of  the  subject  from  a  clini¬ 
cal  point  of  view,  I  bring  before  you  the  following  case: 

J.  W.  M.,  a  member  of  the  judiciary  in  one  of  our  Western 
States,  consulted  me  on  March  27,  1890,  with  the  following 
history : 

In  August,  1889,  he  suffered  with  an  ulcerated  second  molar 
tooth,  which  gave  rise  to  an  attack  of  facial  neuralgia,  involv¬ 
ing  the  whole  of  the  left  side  of  the  face.  The  tooth  was  ex¬ 
tracted,  with  relief  to  the  pain,  but  an  offensive  purulent  dis¬ 
charge,  which  had  set  in  from  the  left  nasal  passage,  coincident 
with  the  attack  of  toothache,  persisted.  He  felt  and  thought 
this  was  an  accumulation  in  the  antrum.  This  latter  system 
has  continued  ever  since — an  ill-smelling,  yellowish  discharge, 
which  passes  into  the  fauces  and  is  discharged  through  the  nos¬ 
tril.  When  lying  down,  the  flow  of  pus  into  the  larynx  is  a 
source  of  especial  annoyance.  He  is  a  man  of  large  physique, 
and  has  always  enjoyed  perfect  health. 

On  November  20th  he  retired  in  his  usual  health.  He  was 
awakened  suddenly  in  the  early  morning  hours  by  something 
happening  which  he  could  not  describe.  On  attempting  to  rise 
in  bed,  he  found  that  he  fell  over  to  the  right  side.  There  was 

*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


considerable  nausea,  and,  to  allay  this,  he  attempted  to  drink  a 
little  water,  but  this  he  found  to  be  an  absolute  impossibility. 
He  got  out  of  bed  with  considerable  difficulty  and  got  down 
stairs,  but  be  found  himself  walking  with  very  great  effort  and 
unconsciously  turning  to  the  right.  He  was  also  very  dizzy, 
and  the  nausea  continued.  On  further  questioning  himself  as 
to  his  symptoms,  he  found  that  he  was  partially  paralyzed  as  to 
motion  over  the  whole  of  the  right  side  from  the  crown  of  the 
head  to  the  soles  of  the  feet.  On  the  left  side  there  was  paraly¬ 
sis  of  sensation  to  this  extent:  that  while  the  tactile  sense  was 
not  destroyed,  his  appreciation  of  heat  and  cold  was  absolutely 
gone.  There  was  also  some  slight  dyspnoea,  although  his  voice 
was  unimpaired  as  far  as  he  knew,  except  that  the  vocal  tones 
were  somewhat  peculiar.  This  latter  symptom,  of  course,  was 
due  to  paralysis  of  the  palate. 

There  was  no  facial  paralysis  as  far  as  he  knew — that  is,  the 
face  was  not  drawn,  yet  it  felt  heavy  and  stiff  over  the  right 
side.  There  was  also  some  impairment  of  sight,  in  that,  as  he 
expressed  it,  the  eyes  did  not  focus  well.  He  could  neither 
sneeze  nor  cough,  although  he  could  clear  his  throat  with  some 
little  difficulty.  The  tongue  was  protruded  slightly  to  the  right 
side.  Articulation  was  not  impaired.  The  sense  of  taste  was 
notably  impaired  on  the  left  side  of  the  tongue  and  the  whole 
of  the  fauces.  As  he  expressed  it,  the  loss  of  sensation  of  taste 
on  the  left  side  extended  down  to  his  stomach.  He  declined  to 
consider  himself  a  sick  man  and  kept  about  the  house,  although 
it  was  no  small  effort  to  move.  The  power  of  deglutition  was 
lost  for  two  days,  but  he  commenced  to  swallow  on  the. third 
day.  This,  however,  was  accomplished  but  slowly  for  some 
weeks.  The  motor  impairment  gradually  disappeared,  and  on 
the  twelfth  day  he  walked  down  the  street,  though  still  with 
some  effort.  According  to  his  own  story,  the  impairment  of 
motion  lasted  only  two  months,  although  at  the  time  of  his  visit 
to  my  office,  four  months  after,  I  could  detect  still  some  evi¬ 
dence  of  motor  weakness.  While  this  feature  of  his  paresis 
improved  rapidly,  the  sensory  paresis  of  the  left  side  seemed  to 
improve  quite  slowly,  and  at  the  end  of  four  months  there  was 
still  a  notable  failure  to  appreciate  the  sensations  of  heat  and 
cold. 

When  I  first  saw  this  patient  he  consulted  me  on  account  of 
his  antrum  disease,  and  he  seemed  to  think  that  all  his  other 
symptoms  had  completely  disappeared,  and  really  described 
them  to  me  as  a  curious  experience  which  had  happened  to  him 
some  months  before.  I  found  him  to  be  a  man  in  almost  per¬ 
fect  health,  in  whom  a  close  examination  failed  to  reveal  any 
departure  from  the  normal  condition,  with  the  exception  of 
the  symptoms  above  noted  of  slight  sensory  paresis  of  the  left 
side.  He  went  through  the  ordinary  muscular  tests  of  spinal 
and  bulbar  disease  without  revealing  any  impairment  of  power. 
There  were  the  eharacteristicjsymptoms  of  disease  of  the  left 
antrum,  and  this  was  successfully  operated  upon  by  opening 
the  antrum  through  the  alveolus.  A  large  amount  of  pus  was 
discharged  and  a  Bordenave  tube  inserted. 

An  examination  of  the  larynx  showed  the  right  cord  lying 
motionless  in  the  median  line — in  other  words,  there  was  com¬ 
plete  paralysis  of  abduction  of  the  right  vocal  cord. 

It  would  have  been  interesting  to  have  noted  in  this 
case  whether  there  was  an  anaesthetic  condition  of  the  mu¬ 
cous  membrane  of  the  larynx.  This,  however,  was  not  elicit¬ 
ed,  owing  to  a  somewhat  irritable  condition  of  the  fauces. 

The  first  question  that  arises  here  is  as  to  the  cause  of 
the  bulbar  disease  and  its  possible  connection  with  the  sup¬ 
purative  disease  of  the  antrum.  This  man,  as  I  have  said, 
was  in  the  enjoyment  of  perfect  health,  and  there  was  no 


Oct.  11,  1890.] 


BOSWORTH:  PARALYSIS  OF  TEE  ABDUCTORS  OF  TEE  LARYNX. 


obvious  physical  trouble  which  should  have  led  to  the  de¬ 
velopment  of  bulbar  disease  other  than  the  suppurating 
process  in  the  antrum. 

Dr.  M.  A.  Starr,  who  sawr  this  case  with  me,  was  dis¬ 
posed  to  agree  with  me  in  the  idea  that  there  was  a  throm¬ 
bosis  of  one  of  the  small  arteries  of  the  medulla,  and  that 
this  thrombosis  led  to  some  meningeal  disturbance  extend¬ 
ing  to  the  cerebellum,  which  would  account  for  the  loss  of 
co-ordination,  with  the  motor  and  sensory  impairment 
which  characterized  the  early  days  of  his  attack. 

The  rapid  disappearance  of  symptoms  can  be  accounted 
for  by  the  early  re-establishment  of  the  circulation.  I 
think,  without  question,  this  patient  had  an  attack  of  bul¬ 
bar  disease,  in  which  the  symptoms  disappeared  with  un¬ 
usual  rapidity,  and  at  the  end  of  four  months  the  only 
condition  which  remained  was  right  abductor  paralysis. 
This  seems  to  have  become  permanent.  The  case,  there¬ 
fore,  is  interesting  as  one  of  bulbar  disease,  due  probably 
to  a  suppurating  process  in  the  antrum  of  Highmore.  It  is 
further  interesting  as  lending  weight  to  the  proclivity  the¬ 
ory  of  Semon  (Arch,  of  Laryngology,  vol.  ii,  p.  197),  and 
yet  it  seems  to  me  quite  clear  that  in  this  case  the  laryngeal 
paralysis  was  the  result  of  a  disease  of  the  nerve  centers 
alone.  The  ganglionic  center  which  presides  over  the  res¬ 
piratory  movements  of  one  side  of  the  larynx  lay  in  the 
area  of  distribution  of  the  artery  which  was  occluded.  The 
motor  center  of  the  larynx  in  the  medulla  has  not  as  yet 
been  practically  isolated.  The  diseased  process  in  my  pa¬ 
tient,  however,  seems  to  have  isolated  the  ganglion  which 
presides  over  the  respiratory  function  of  one  side  of  the 
larynx  whose  fibers  pass  through  the  recurrent  laryngeal 
nerve;  and  yet  it  seems  to  me  there  is  no  evidence  what¬ 
ever  that  any  other  fibers  of  the  recurrent  laryngeal  nerve 
were  in  any  way  disturbed. 

Why,  therefore,  does  the  paralysis  of  abduction  become 
permanent,  while  this  patient  recovers  both  motion  and 
sensation  of  the  other  parts  involved?  There  are  but  two 
answers  to  this :  either  the  ganglion  presiding  over  the 
respiratory  function  of  one  side  of  the  larynx  is  perma¬ 
nently  destroyed,  or  there  is  an  essential  proclivity  on  the 
part  of  the  abductor  muscles  to  become  the  seat  of  paraly¬ 
sis.  This  undoubtedly  exists,  and  is  shown  clinically  by 
the  fact  that  when  their  function  is  abolished  they  become 
the  seat  of  a  rapid  degenerative  process,  under  which  they 
lose  their  power  of  responding  to  the  stimulus  of  motor 
innervation. 

This  latter  view,  as  before  stated,  seems  to  be  largely 
established,  not  only  by  clinical  observation,  but  is  promi¬ 
nently  the  teaching  of  the  very  elaborate  series  of  physio¬ 
logical  experiments  alluded  to  at  the  commencement  of  this 

paper. 

As  I  understand  Semon’s  article  on  the  proclivity  the¬ 
ory,  this  condition  lies  in  the  fibers  of  the  recurrent  laryn¬ 
geal  nerves  rather  than  in  the  muscles.  It  certainly  seems 
to  me  that  the  weight  of  evideuce  is  in  favor  of  the  view 
that  this  proclivity  manifests  itself  in  the  muscular  fibers  of 
the  posticus  muscle  rather  than  in  the  nerve.  The  point  is 
certainly  an  interesting  one,  but  is  scarcely  to  be  entered 
upon  at  length  here.  Another  interesting  point  in  this 


399 

connection  is  as  regarding  the  question  of  intrinsic  and  ex¬ 
trinsic  paralysis.  I  have  reported  here  a  case  of  paralysis 
of  undoubted  central  origin. 

About  the  time  that  this  patient  came  under  observa¬ 
tion  another  gentleman  called  on  me  with  the  following 
history  : 

J.  W.  0.,  aged  fifty-six,  broker.  He  was  of  fine  physique 
and  apparently  in  the  enjoyment  of  perfect  health,  and  yet  was 
one  wrho  was  always  exceedingly  nervous  and  sensitive  about 
his  own  physical  health.  About  six  weeks  before  he  had  con¬ 
sulted  a  physician,  who,  as  I  understood,  made  a  diagnosis  of 
recurrent  laryngeal  paralysis  due  to  aneurysm.  This  diagnosis 
so  completely  unnerved  him  that  he  was  practically  confined  to 
his  house  in  a  state  of  nervous  prostration  for  from  four  to  five 
weeks.  As  soon  as  he  was  able  he  came  to  New  York.  On 
examination,  I  found  his  left  vocal  cord  moving  in  about  one 
half  its  normal  excursion ;  in  phonation  it  was  approximated 
nearly  to  the  median  line,  while  in  inspiration  it  was  abducted 
to  perhaps  a  little  more  than  one  half  the  normal  extent.  Its 
movement  was  somewhat  sluggish,  hut  there  was  unquestion¬ 
able  movement  both  in  the  cord  and  in  the  arytenoid  car¬ 
tilage. 

I  made  an  examination  and  found  nothing  abnormal  in  the 
thorax.  This  patient,  at  my  suggestion,  consulted  Dr.  Loomis, 
who  pronounced  him  absolutely  sound,  as  to  both  heart  and 
lungs.  My  own  diagnosis  already  made  was  that  of  partial 
ankylosis  of  the  crico-arytaenoid  joint,  due  probably  to  the  rheu¬ 
matic  habit.  The  diagnosis  was  given  with  absolute  positive¬ 
ness  and  the  patient  returned  to  his  home  reassured,  and,  as 
far  as  I  know,  has  had  no  return  of  his  neurasthenic  symptoms. 
The  local  symptoms  in  the  fauces  had  never  been  other  than  of 
a  mild  form  of  naso-pharyngeal  catarrh. 

Here  was  a  case  pronouced  one  of  paralysis  by  a  very 
competent  observer,  and  yet,  in  my  opinion,  was  one  which 
should  not  be  regarded  as  either  intrinsic,  myopathic,  or 
any  other  form  of  paralysis. 

I  make  this  assertion  deferentially  and  not  polemically, 
but  mainly  on  the  ground  that  it  seems  to  me  our  nomen¬ 
clature  will  be  very  greatly  cleared  up  by  relegating  a  very 
large  proportion  of  our  cases  of  so-called  intrinsic  paralysis 
to  a  totally  different  classification,  and  confining  the  word 
“paralysis”  to  those  cases  which  are  due  to  a  diseased 
condition  either  of  the  nerve  trunk  or  of  the  ganglionic 
centers. 

Coming  back  now  to  the  question  of  central  paralyses,  I 
find  a  number  of  cases  of  recurrent  laryngeal  paralysis,  in¬ 
volving  one  or  both  sides,  reported  by  the  following  observ¬ 
ers  as  due  to  bulbar  disease  :  In  a  case  reported  by  Hugh- 
lings  Jackson  (Lond.  Hosp.  Reports ,  1864,  vol.  i,  p.  361)  there 
was  paralysis  of  the  right  recurrent  laryngeal.  In  a  second 
case  by  the  same  author  ( loc .  cit.,  p.  368)  there  was  paralv- 
sis  of  both  cords.  In  a  third  case  by  the  same  observer 
(Lond.  Hosp.  Reports ,  1867,  vol.  iv,  p.  314)  there  was  pa¬ 
ralysis  of  the  left  cord.  In  a  fourth  case  by  this  writer 
(op.  cit.,  p.  318)  there  was  paralysis  of  the  right  recurrent 
laryngeal.  In  a  case  reported  by  Proust,  cited  by  Hallo- 
peau  (Des  paralyses  bulbaires ,  Paris,  1875,  history  23),  there 
was  paralysis  of  both  cords.  In  a  case  reported  by  Sena¬ 
tor  (Arch.  f.  Psychiatrie,  vol.  xi)  there  was  paralysis  of  both 
cords.  Eisenlohr  (Deut.  med.  Woch.,  1886,  p.  363,  also 
Arch.  f.  Psych.,  1887  and  1888,  vol.  xix,  p.  314)  reports 


400 


EDEBOHLS:  A  MODIFIED  ALEXANDER-ADAMS  OPERATION. 


[N.  Y.  Med.  Jour., 


three  cases,  in  two  of  which  there  was  recurrent  paralysis 
on  both  sides,  while  in  the  third  there  was  recurrent  pa¬ 
ralysis  of  the  left  side.  Sokaloff  also  ( Deut .  Arch,  fur 
klin.  Med.,  vol.  xli,  p.  458)  reports  a  case  of  left  recurrent 
paralysis. 

All  these  cases  resulted  in  a  fatal  termination,  and  post¬ 
mortem  examinations  were  made  in  all,  with  the  exception 
of  Husfhliuo-s  Jackson’s  first  two  cases.  The  lesion  in  every 
case  was  found  to  be  extensive  destruction  of  the  medulla, 
in  volving  the  pyramids,  olivary  bodies,  restiform  bodies, 
floor  of  the  fourth  ventricle,  etc.  In  other  words,  we  find 
here  a  series  of  cases  in  which  the  bulbar  disease  was  of 
such  an  extensive  character  as  to  produce  a  fatal  termination  ; 
and,  furthermore,  that  where  the  local  disease  was  so  exten¬ 
sive  it  resulted  in  the  completest  possible  paralysis  of  the 
muscles  of  the  larynx — viz.,  recurrent  laryngeal  paralysis  of 
one  or  both  sides.  In  the  third  of  Eisenlohr’s  cases,  above 
alluded  to,  the  post-mortem  examination  showed  the  left 
recurrent  nerve  involved  in  a  thickened  pleura,  which  might 
possibly  have  been  considered  as  causing  the  laryngeal  pa¬ 
ralysis;  yet  there  was  also  an  extensive  degeneration  of  the 
medulla,  and,  furthermore,  the  laryngeal  symptoms  ante¬ 
dated  the  pulmonary  disease  by  about  two  years. 

In  addition  to  the  foregoing,  Oppenheim  ( JBerl .  klin. 
Woch .,  1886,  No.  40,  p.  675)  and  Kehler  (Zeil.f.  Heilk.,  1881, 
p.  440)  report  cases  of  recurrent  laryngeal  paralysis,  the  for¬ 
mer  involving  the  right  cord  and  the  latter  the  left,  as  oc¬ 
curring  in  connection  with  locomotor  ataxia.  Wegner  ( An¬ 
nual  of  the  Universal  Med.  Sciences,  vol.  i,  p.  89)  takes  the 
ground  that  the  laryngeal  paralysis  in  cases  of  tabes  usually 
takes  the  form  of  paralysis  of  the  abductor  muscles,  citing 
two  of  his  own,  and  making  a  compilation  of  a  number  of 
other  instances.  This  certainly  is  not  the  rule,  in  view  of 
the  cases  just  instanced,  although,  in  addition  to  Wegner’s, 
we  find  Krause  ( Berl .  klin.  Woch.,  1886,  No.  20,  p.  651), 
Ross  (Brain,  London,  1888),  and  Saundby  (Birming.  Med. 
Review,  December,  1886)  reporting  cases  of  tabes  in  which 
there  was  bilateral  abductor  paralysis;  while,  in  a  case  re¬ 
ported  by  Semon  ( loc .  cit.)  of  double  abductor  paralysis, 
the  patient  subsequently  developed  tabes.  In  a  case  of 
tabes  reported  by  myself  (Laryngeal  and  Pharyngeal  Pa¬ 
ralyses,  Journal  of  Nervous  and  Mental  Diseases,  1889, 
Case  I)  there  was  bilateral  paralysis  of  the  laryngeal  ab¬ 
ductors.  Hubbard  (Toledo  Med.  and  Surg.  Reporter,  1889, 
vol.  ii,  p.  576)  reports  a  case  of  tabes  in  which  there  was 
recurrent  laryngeal  paralysis  of  the  left  side. 

Of  course  there  is  no  special  clinical  deduction  from 
the  laryngeal  paralysis  in  locomotor  ataxia  other  than  that 
the  extent  and  direction  which  the  sclerosis  takes  dominate 
the  form  and  extent  of  laryngeal  paralysis. 

In  addition  to  the  foregoing,  I  find  cases  of  double  ab¬ 
ductor  paralysis  reported  by  Ollivier  d’Angers,  cited  by 
Gottstein  (Die  Krank.  des  Kehlkopfes ,  1888,  p.  309),  Krause 
(Neurol.  Centralblatt,  1885,  p.  543),  and  Penzoldt  (von 
Ziemssen’s  Cyclop.,  vol.  vii,  p.  962),  in  all  of  which  the 
autopsy  showed  extensive  lesion  of  the  medulla,  while  in  a 
case  reported  by  Smith  (Brit.  Med.  Jour.,  July  13,  1878) 
there  was  evident  central  lesion,  although  no  autopsy  was 
made. 


This  would  seem  rather  a  small  proportion  of  cases  of 
bilateral  abductor  paralysis  in  which  the  central  lesion  was 
established,  and  yet  it  must  be  borne  in  mind  that  a  very 
large  proportion  of  cases  of  this  disease  have  clearly  been 
traced  to  local  morbid  processes,  while  in  others  the  mere 
insertion  of  a  tube  has  so  far  prolonged  life  that  the  origin 
of  the  disease  has  remained  obscure. 

As  regards  unilateral  paralysis  of  the  abductor  muscle, 
the  number  of  cases  reported  in  literature  is  not  large; 
moreover,  this  affection  gives  rise  to  comparatively  trivial 
symptoms,  and  undoubtedly  in  many  cases  escapes  observa¬ 
tion.  Of  this  form  of  unilateral  paralysis  of  abduction  in 
the  larynx  cases  have  been  reported  by  Gerhardt,  cited  by 
Gottstein  (op.  cit.,  p.  310),  McBride,  cited  by  Gottstein  (p. 
311),  Nothnagel  (  Wien.  med.  Blatter,  1884,  No.  9),  Mar- 
tius  (Chari  te  Annalen,  1889,  vol.  xiv,  p.  315),  and  Delavan 
(Med.  Record,  Feb.  14,  1885,  p.  178).  In  all  of  these  cases 
an  autopsy  revealed  lesion  of  the  medulla  or  base  ot  the 
brain.  In  Delavan’s  case  it  should  be  stated  that  the  form 
of  paralysis  is  reported  as  complete  paralysis,  the  cord  lying 
in  the  median  line,  which  seems  to  leave  it  somewhat  un¬ 
certain  whether  this  is  abductor  or  recurrent  laryngeal 
paralysis.  In  a  case  reported  by  Wright  (N.  Y.  Med. 
Jour.,  1889,  vol.  1,  p.  345)  the  observer  considered  the  dis¬ 
ease  of  central  origin,  although  no  autopsy  was  made. 

From  this  category  there  is  omitted  quite  a  number  of 
cases  in  which  the  disease  is  attributed  to  local  causes. 

The  object  of  my  paper  is  fulfilled,  therefore,  in  the  re¬ 
port  of  the  case  which  is  the  text  of  my  remarks,  and  the 
further  suggestion  that  we  have  completed  our  duty  in  no 
case  of  laryngeal  paralysis  unless  we  have  either  thoroughly 
eliminated  or  established  the  question  of  a  central  lesion 
as  the  source  of  the  morbid  condition.  In  other  words,  I 
am  disposed  to  think  that  a  central  lesion  is  responsible  for 
a  genuine  paralysis  of  the  vocal  cords  in  a  somewhat  larger 
proportion  of  cases  than  is  usually  believed. 

26  West  Forty-sixth  Street. 


A  MODIFIED 

ALEXANDER- AD  AMS  OPERATION* 

By  GEORGE  M.  EDEBOHLS,  A.  M.,  M.  D., 

GYNAECOLOGIST  TO  ST.  FRANCIS  HOSPITAL,  NEW  YORK. 

The  operation  for  shortening  the  round  ligaments  has 
established  itself  in  the  favor  of  comparatively  few  gynae¬ 
cologists.  This  I  believe  to  be  due  in  very  great  part  to 
the  difficult  and  unsatisfactory  technique  of  the  operation 
as  usually  practiced,  leading  to  disappointment  and  morti¬ 
fication  and  rendering  it  unpopular  with  operators. 

During  my  earlier  experience  with  the  operation,  em¬ 
bracing  five  cases,  I  shared  the  general  unfavorable  im¬ 
pressions,  and  was  on  the  point  of  practically  abandoning 
the  operation  in  favor  of  ventro-fixation  of  the  uterus  in  all 
cases  of  retroflexion  and  version  where  the  symptoms  and 
the  failure  of  milder  methods  to  relieve  called  for  operative 
interference. 

*  Read  before  the  Gynaecological  Section  of  the  Tenth  International 
Medical  Congress. 


Oct.  11,  1890.] 


EDEBOELS:  A  MODIFIED  ALEXANDER- AD  AMS  OPERATION. 


401 


In  a  paper  entitled  Aus  dcr  gynakologischen  Abtheilung 
des  St.  Francis  Hospitals  in  New  York:  Die  Laparotomien 
des  Jahres  1889,*  I  reported  four  hysterorrhaphies,  of 
which  three  were  performed  for  retroversion,  one  for  retro¬ 
flexion  of  the  uterus.  All  of  the  patients  were  seen  be¬ 
tween  six  and  twelve  months  after  operation,  and  remained 
completely  relieved  of  their  former  symptoms.  In  all,  the 
uterus  remained  in  anteversion.  I  quote  from  the  paper  : 

Notwithstanding  these  favorable  results,  I  shall  in  the  future 
perform  laparotomy  for  ventro-fixation  of  the  uterus  only  in 
case  the  latter  be  adherent,  or  when  other  intra-abdominal  con¬ 
ditions  calling  for  operation  complicate  retroversion  of  the 
uon-adherent  uterus.  The  hysterorrhaphies  just  described 
were  performed  at  a  period  when  I  was  dissatisfied  with  the 
Alexander- Adams  operation  for  shortening  the  round  liga¬ 
ments.  This  dissatisfaction  was  grounded  chiefly  on  the  diffi¬ 
culty  of  really  shortening  the  ligaments,  when  found,  in  their 
intra  abdominal  course.  Since  December,  1889,  I  have  per¬ 
formed  the  operation  for  shortening  the  round  ligaments  eight 
(at  present  thirteen)  times  after  a  modification  of  my  own, 
which  I  intend  shortly  to  publish.  In  every  case  I  easily  suc¬ 
ceeded  in  shortening  the  ligaments  from  three  to  four  inches  in 
their  intra-abdominal  course.  The  immediate  results  have  been 
perfectly  satisfactory;  the  final  results  remain  to  be  tested  by 
time.  In  case  the  good  results  prove  permanent,  I  shall  proba¬ 
bly  never  again  perform  laparotomy  for  uncomplicated  retro¬ 
version  of  the  uterus,  but  shall,  in  such  cases,  resort  to  shorten¬ 
ing  of  the  round  ligaments,  or  perhaps  to  a  modification  of  the 
operation  of  vaginal  ligature  after  Schuecking. 

This  quotation  defines  my  present  attitude,  which  I  have 
found  no  occasion  to  change  since  writing  the  foregoing 
In  the  latter  part  of  1889,  as  a  result  of  some  thought  relat¬ 
ing  to  the  difficulties  to  be  overcome  and  of  study  upon  the 
cadaver,  I  elaborated  for  myself  a  modification  of  the  tech¬ 
nique  of  Alexander’s  operation.  This  I  have  since  prac¬ 
ticed  in  thirteen  cases — seven  times  for  retroversion  or  retro¬ 
flexion,  and  six  times  for  prolapse.  These  cases  I  have  here¬ 
with  tabulated,  as  likewise,  for  purposes  of  comparison,  five 
cases  in  which  I  operated  after  the  usual  method.  These 
eighteen  cases  include  my  entire  experience  in  the  operation 
of  shortening  the  round  ligaments.  In  all  of  the  thirteen 
cases  an  immediate  anatomical  success  was  achieved.  The 
retroverted  uterus  was  brought  into  and  held  in  normal 
anteversion;  the  prolapsed  uterus,  with  the  added  aid  of 
plastic  operations  performed  at  the  same  sitting,  was  sus¬ 
tained  at  its  proper  level  in  the  pelvis. 

About  the  permanent  results  it  is  as  yet  too  early  to 
speak.  I  have  seen  all  of  the  patients  at  greater  or  less  in¬ 
tervals  since  the  operation,  and  thus  far  know  of  no  case 
where  the  uterus  has  again  become  prolapsed  or  retroverted. 
Lp  to  the  time  of  my  latest  knowledge,  an  anatomical  and 
a  therapeutical  success  has  been  the  result  in  every  case. 
I  shall  on  a  future  occasion  report  the  final  results  as  far 
as  I  may  be  able  to  ascertain  them.  The  present  paper  is 
concerned  chiefly  with  the  technique  of  the  operation 
which  I  shall  now  attempt  to  describe. 

On  the  day  preceding  operation  the  patient  receives  a 
purgative,  a  pubic  and  vulvar  shave,  and  a  full  bath.  After 


*  New  Yorker  medizinische  Monatsschrift,  May,  1890. 


being  anaesthetized  and  placed  upon  the  table,  the  site  of 
operation  and  the  surrounding  parts  are  thoroughly  cleansed 
with  soap  or  mollin  and  water,  irrigated  with  bichloride 
solution  (1  to  3,000),  dried,  washed  with  ether,  and  again 
irrigated  with  the  sublimate  solution. 

The  spine  of  the  pubes  is  located  by  the  index  finger. 
The  incision  begins  just  above  it,  over  the  site  of  the  ex¬ 
ternal  abdominal  ring,  extending  upward  and  outward,  paral¬ 
lel  to  Poupart’s  ligament,  for  two  inches  and  a  half  to  three 
inches,  according  to  the  amount  of  adipose  tissue.  The  adi¬ 
pose  tissue  is  divided  by  clean  cuts  and  without  the  aid  of 
retractors  until  the  glistening  aponeurosis  of  the  external 
oblique  is  laid  bare.  In  the  use  of  retractors  there  is  dan¬ 
ger  of  drawing  too  much  upon  one  side  or  other  of  the 
wound  and  of  dislocating  its  center,  so  that  after  cutting 
through  the  adipose  tissue  we  may  find  ourselves  upon  the 
muscular  aponeurosis  at  quite  a  distance  from  the  external 
ring. 

If  there  is  much  subcutaneous  fat,  it  is  advisable,  while 
cutting  through  it,  occasionally  to  feel  for  the  spine  of  the 
pubes,  so  that  the  inner  and  lower  end  of  the  incision  may 
bear  directly  down  upon  it.  After  exposing  the  fibers  of 
the  external  oblique,  the  external  abdominal  ring,  its  pillars, 
and  the  intercolumnar  fibers  are  readily  distinguished. 

Up  to  this  stage  the  operation  is  identical  with  the  one 
usually  practiced;  here  the  divergence  begins.  A  grooved 
director  is  inserted  into  the  external  ring,  just  beneath  its 
outer  and  upper  margin.  It  is  advanced  along  the  inguinal 
canal,  hugging  closely  its  anterior  wall,  to  a  point  opposite 
the  internal  ring.  The  anterior  wall  of  the  canal,  along  its 
whole  length,  is  now  divided  on  the  director,  observing  care 
to  cut  as  nearly  as  possible  in  the  exact  direction  of  the 
course  of  the  aponeurotic  fibers.  The  internal  ring  is 
gently  felt  for  but  not  dilated,  and  sometimes  the  ligament 
can  be  distinctly  felt  emerging  therefrom.  Generally,  how¬ 
ever,  it  is  not  easy  to  be  sure  of  feeling  the  ligament.  A 
blunt  hook  is  next  passed  down  to  the  ring  and  its  point 
made  to  sweep  across  the  bottom  of  the  wound  from  above 
and  within  along  the  posterior  and  inferior  walls  of  the 
canal.  The  ligament  is  found  in  the  inferior  and  outer  part 
of  the  canal  nestling  close  behind  Poupart’s  ligament.  It 
is  brought  out  by  the  hook  and  liberated  from  its  cellular 
attachments.  The  fibers  of  insertion  into  the  canal  are 
likewise  separated  from  the  walls  of  the  latter.  It  will  be 
found  that  the  ligament,  at  its  emergence  from  the  internal 
ring,  constitutes  a  well-marked,  oval,  strong  band  of  fibers; 
that  it  immediately  begins  to  spread  out  and  attenuates 
rapidly  as  it  proceeds  inward  and  downward  in  the  direction 
of  the  external  ring. 

The  only  difficulty  in  performing  the  operation  is  likely 
to  be  encountered  here.  If  the  ligament  is  picked  up  in 
the  canal  at  a  distance  from  the  internal  ring,  it  fails  to 
present  its  peculiar  ligamentous  sheen,  owing  to  its  sepa¬ 
ration  into  fibers  for  insertion  into  the  walls  of  the  canal. 
The  operator  has  the  ligament  upon  his  hook,  but  fails  to 
recognize  it.  From  its  resemblance  to  muscular  fibers  he  is 
liable  to  mistake  it  for  the  latter.  If  the  seized  bundle, 
however,  is  made  tense  by  traction,  it  can  be  traced  by  the 
finger  directly  to  the  internal  ring.  Recollecting  that  the 


402 


EDEBOELS:'  A  MODIFIED  ALEXANDER- AD  AMS  OPERATION. 


[N.  Y.  Med.  Joor., 


canal  contains  nothing  but  the  ligament  and  the  accom¬ 
panying  small  ilio-inguinal  nerve,  the  operator  draws  con¬ 
fidently  upon  the  seized  tissues  and  finds  the  round  liga¬ 
ment,  in  propria  forma,  emerging  with  its  peritoneal  invest¬ 
ment. 

The  broad  ligament  covering  the  round  ligament  is 
•drawn  out  in  the  form  of  an  inverted  funnel.  With  one 
hand  pulling  on  the  round  ligament  in  a  direction  at  right 
angles  to  the  plane  of  the  aperture  of  the  ring,  two  fingers 
of  the  other  hand  strip  or  peel  back  the  peritonaeum  of  the 
broad  ligament  from  the  round  ligament,  until  three  to  four 
inches  of  the  latter  have  been  pulled  out  and  bared.  In 
doing  this  the  reflection  of  the  peritonaeum  should  be  dis¬ 
tinctly  kept  in  view.  It  is  easily  recognized  as  a  white  line 
running  transversely  across  the  round  ligament,  anteriorly 
and  posteriorly,  and  all  but -meeting  at  the  sides. 

In  three  of  the  twenty-six  ligaments  thus  treated,  I  have 
torn  and  opened  the  peritonaeum  in  stripping  it  back.  The 
resultant  little  holes  gave  no  trouble.  By  spending  a  little 
time  over  the  work,  and  stripping  the  peritonaeum  back 
gently  and  slowly,  this  accident  can  be  avoided. 

The  wound  is  now  protected  with  bichloride  gauze  and 
the  operation  performed  in  the  same  manner  on  the  oppo¬ 
site  side.  The  next  step  in  the  operation  consists  in  stitch¬ 
ing  the  drawn-out  parts  of  the  shortened  round  ligaments 
securely  in  the  inguinal  canal.  The  ligament  is  pulled  out 
as  far  as  it  will  go.  I  have  never  failed  to  draw  it  out 
three  inches,  nor  ever  secured  a  shortening  of  more  than 
four  inches. 

One  who  has  done  the  operation  in  the  usual  manner, 
drawing  upon  the  ligament  at  the  external  ring  with  fear 
and  trembling  lest  it  at  any  moment  break,  will  be  agreea¬ 
bly  surprised  at  the  firm  traction  which  can  be  exerted  upon 
it  at  the  internal  ring  without  the  sensation  of  impending 
stretching  or  rupture.  Of  the  twenty-six  ligaments  thus 
drawn  out,  not  one  has  ruptured,  although  in  several  in¬ 
stances  they  were  so  slender  in  structure  that  from  my  pre¬ 
vious  experience  I  felt  certain  the  risk  of  tearing  at  the  ex¬ 
ternal  ring  would  have  been  considerable. 

The  drawn-out  ligament,  still  attached  at  the  pubes,  is 
now  handed  to  the  assistant,  who,  by  means  of  the  blunt 
hook,  exerts  sufficient  traction  to  hold  it  taut. 

This  traction  is  made  in  the  direction  of  the  opened  ca¬ 
nal  ;  so  that  a  portion  of  the  ligament  which,  previous  to 
operation,  was  situated  within  the  abdominal  cavity,  now 
occupies  the  space  along  the  course  of  the  canal  formerly 
filled  by  the  extra-abdominal  portion  of  the  ligament.  In 
this  situation  it  is  secured  by  sutures  of  silk-worm  gut  passed 
in  the  following  manner  :  The  first  suture  traverses  the 
wound  at  the  level  of  the  internal  ring.  It  is  introduced 
through  one  lip  of  the  wound,  embracing  skin,  superficial 
fascia,  and  the  aponeurosis  of  the  external  oblique,  into  the 
inguinal  canal.  Here  the  taut  ligament,  as  it  emerges  at 
the  internal  ring,  is  pierced  transversely  by  the  needle^ 
which  then  traverses  the  other  lip  of  the  wound,  penetrat¬ 
ing  in  succession  the  cut  fascia  of  the  external  oblique,  the 
subcutaneous  fat,  and  the  skin. 

Although  very  partial  to  the  Hagedorn  needle  in  most 
of  my  operative  work,  I  here  prefer  the  ordinary  surgical 


needle  curved  on  the  flat.  The  Hagedorn,  in  traversing  the 
ligament,  cuts  the  longitudinal  fibers,  which  the  ordinary 
needle  merely  crowds  between  and  separates. 

Three  to  five  sutures  are  passed  in  a  similar  manner 
through  all  the  tissues  on  either  side  of  the  wound,  into  and 
across  the  canal,  in  their  course  through  the  latter  piercing 
the  ligament.  These  sutures,  when  tied  upon  the  skin,  close 
the  opening  in  the  anterior  wall  of  the  canal  by  bringing 
into  juxtaposition  the  divided  edges  of  the  fibrous  aponeu¬ 
rosis  of  the  external  oblique,  as  well  as  of  the  more  superfi¬ 
cial  structures,  while  at  the  same  time  they  moor  the  short¬ 
ened  ligaments  safely  inside  of  the  canal,  where  they  prop¬ 
erly  belong. 

The  operation  is  completed  by  cutting  away  the  excess 
of  ligament  projecting  beyond  the  lower  angle  of  the  wound. 
Drainage  is  effected  by  three  or  four  strands  of  silk-worm 
gut  running  along  the  bottom  of  the  wound  along  its  entire 
course  and  emerging  at  either  end.  I  take  care  that  these 
silk-worm  gut  drains  reach  into  the  inguinal  canal  at  one 
point  by  passing  them  beneath  the  deepest  portion  of  one 
of  the  wound  sutures. 

I  consider  this  matter  of  drainage  very  important,  as 
considerable  serum  is  apt  to  be  effused.  If  no  vent  he 
given  to  it  externally,  it  may  burrow  along  the  tissue  planes 
in  various  directions  and  even  suppurate.  Indeed,  this  hap¬ 
pened  in  two  among  my  first  cases  in  which  I  endeavored 
to  dispense  altogether  with  drainage  in  any  form  and  closed 
the  wound  tightly.  Pus  formed  and  burrowed  in  various 
directions  between  the  subcutaneous  fat  and  the  fascia  of 
the  external  oblique,  and  even  through  the  internal  ring 
into  the  subperitoneal  areolar  tissue,  necessitating  free  incis¬ 
ions  and  secondary  drainage  of  these  parts.  It  is  but  fair 
j.o  state  that  both  of  these  cases  were  operated  upon  during 
the  height  of  the  epidemic  of  “  la  grippe,”  and  both  were 
attacked  by  the  disease  after  operation.  The  convalescence 
in  both  cases  was  tedious,  though  the  anatomical  success  of 
the  operation  was  fortunately  not  impaired. 

Although  in  two  of  the  first  six  cases  I  obtained  primary 
union  without  the  employment  of  drainage,  the  experience 
in  the  other  four  led  me  to  adopt  drainage  systematically  in 
all  of  my  subsequent  cases.  An  attempt  was  first  made 
with  rubber  tubing,  then  with  catgut,  and  finally,  and  with 
the  most  completely  satisfactory  results,  with  silk- worm  gut. 
The  smooth  surfaces  of  the  latter  act  as  excellent  conveyers 
outward  of  the  pent-up  fluids.  On  their  withdrawal  the 
tissues  come  together,  closing  and  immediately  obliterating 
their  tracks.  The  wounds  are  dressed  with  pads  of  bichlo¬ 
ride  gauze  laid  across  the  lower  part  of  the  abdomen  and 
kept  in  place  by  a  double  spica  bandage.  This  latter  is  se¬ 
curely  pinned,  and,  unless  wound  complications  occur,  the 
dressing  is  allowed  to  remain  undisturbed  for  nine  to  twelve 
days.  At  the  end  of  this  time  the  sutures  and  the  silk-worm 
gut  drains  are  removed  and  the  wound  is  redressed. 

As  to  support  of  the  uterus  after  operation,  I  have  de¬ 
signedly  avoided  it,  as  far  as  possible.  One  patient  with 
retroflexion  wore  a  pessary  for  a  month  after  operation.  In 
the  other  cases  of  retroversion  the  uterus  was  sustained  for 
two  or  three  days  by  a  tampon  of  iodoform  gauze  placed  in 
the  vagina  on  the  completion  of  operation.  Whenever  a 


let.  11,  1890.] 

lastic  operation  upon  the  vagina  or  perinseum  was  simul- 
ineously  performed — i.  e.,  in  all  cases  of  prolapse  and  in 
>me  of  version — absolutely  no  support  of  the  uterus  after 
peration  was  practiced.  The  round  ligaments  were  thus 
werely  tested  as  to  the  security  of  their  new  anchorages 
nd  as  to  their  ability  to  sustain  the  uterus  in  normal  posi- 
on.  They  successfully  stood  the  test  in  every  case. 

I  believe,  however,  with  Alexander,  that  in  every  case 
here  the  operation  is  performed  for  retroflexion  a  glass 
itra-uterine  stem  should  be  worn  during  convalescence,  in 
ie  first  place  to  counteract  the  recoil  influence  of  the  flex- 
>n  upon  the  round  ligaments,  and  secondly  to  establish 
onditions  favorable  to  the  cure  of  the  flexion.  The  only 
ne  of  my  cases  that  has  given  me  any  anxiety  in  regard  to 
he  anatomical  success  was  one  of  retroflexion  in  which  I 
id  not  insert  a  stem.  For  three  or  four  months  after  op- 
ration  the  anatomical  condition  was  one  of  retroflexion 
f  the  anteverted  uterus.  When  last  seen,  the  retroflexion 
;as  growing  less,  while  the  anteversion  was  securely  main- 
ained. 

No  one  can  seriously  dispute  the  fact  that  shortening 
he  round  ligaments  in  their  intra-abdominal  course  really 
hortens  the  distance  between  the  fundus  uteri  and  the  ab- 
ominal  walls,  and  thus  holds  the  uterus  in  the  position  of 
ormal  anteversion  and  of  suspension  at  the  proper  height 
q  the  pelvis.  The  objections  to  the  operation  are  really 
ased,  not  on  theoretical,  but  on  technical  grounds — i.  e ., 
he  technique  has  heretofore  not  been  satisfactory. 

The  principal  difficulties  in  the  performance  of  Alexan- 
er’s  operation,  which  have  stood  in  the  way  of  its  popu- 
irity,  are  experienced,  first,  in  finding  the  round  ligament, 
nd,  secondly,  in  drawing  it  out  when  found.  The  following 
uotation  from  Munde*will  serve  to  emphasize  the  first 
ifticulty  : 

My  great  objection  to  the  operation  when  I  first  attempted 
:  was  the  doubt  whether  the  ligaments  could  always  be  found, 
heard  this  doubt  expressed  by  experienced  gynaecological  sur- 
eons  who  had  tried  and  succeeded,  and  again  tried  and  failed ; 
nd  I  myself  had  passed  through  this  experience,  being  easily 
uccessful  in  my  first,  failing  on  one  side  in  my  second,  and  on 
oth  sides  in  my  third  case.  I  may  say  that  it  was  with  fear 
nd  trembling  that  I  approached  each  Alexander’s  operation, 
lever  feeling  sure  that  I  would  not  disgrace  myself  by  failing 
o  find  the  ligaments,  etc. 

This  difficulty  of  finding  the  ligament  may  also  serve 
o  explain  the  frequency  with  which  the  ligaments  have 
ieen  reported  absent  or  wanting.  In  my  eighteen  opera- 
ions  I  have  found  thirty-six  ligaments. 

My  own  difficulties  have  been  experienced  in  drawing 
>ut  the  ligament  when  found,  or  in  causing  it  to  run  satis- 
actorily. 

Of  ten  ligaments  in  five  operations  performed  after  the 
isual  method,  four  ran  out  satisfactorily  to  the  extent  of 
wo  inches  or  more  ;  three  ran  out  partially  ;  in  one  instance 
desisted  from  further  traction,  warned  by  the  sense  of  im- 
>ending  rupture;  and  twice  the  ligament  tore. 


*  The  Value  of  Alexander’s  Operation  for  Shortening  the  Round 
■igaments.  Am.  Jour,  of  Obst.,  November,  1888,  p.  1123 


403 

A  brief  consideration  of  the  anatomy  of  the  ligament 
will,  I  believe,  serve  to  explain  these  results.  Immediately 
after  passing  out  of  the  abdomen,  through  the  internal 
ring,  as  a  compact,  rounded  cord,  the  fibers  of  the  liga¬ 
ment  separate,  the  greater  number  diverging  to  be  inserted 
into  the  inner  surface  of  the  walls  of  the  inguinal  canal 
throughout  its  entire  length.  Comparatively  few  of  the 
fibers  pass  out  through  the  external  ring  to  be  inserted  into 
the  structures  adjacent  to  the  pillars  of  the  latter. 

In  operating  after  the  usual  manner,  it  is  this  smaller 
bundle  of  the  fibers  of  the  ligament  which  is  grasped  and 
pulled  upon  in  the  attempt  to  draw  the  ligament  out  through 
the  external  ring.  This  minority  of  the  fibers  of  the  liga¬ 
ment  is  frequently  not  strong  enough  to  stand  the  traction 
necessary  to  draw  out  the  ligament  from  within  the  abdo¬ 
men,  especially  as  the  firm  attachment  of  the  larger  num¬ 
ber  of  the  fibers  within  the  inguinal  canal  adds  to  the  diffi¬ 
culty. 

Another  element  to  be  taken  into  consideration  in  this 
connection  is  the  direction  of  traction,  which  is  manifestly 
most  unfavorable.  The  abdominal  part  of  the  ligament 
runs  outward  to  the  internal  ring;  the  part  within  the  in¬ 
guinal  canal  runs  inward  and  forward.  The  two  form  a 
very  acute  angle  with  each  other  at  the  internal  ring.  In 
drawing  upon  its  outer  end,  the  ligament  must  be  drawn 
over  the  sharp  margin  of  the  inner  pillar  of  the  internal 
ring  at  a  very  great  mechanical  disadvantage. 

All  these  disadvantages  are,  to  a  great  extent,  overcome 
in  my  method  of  performing  the  operation.  By  laying 
open  the  inguinal  canal,  the  round  ligament  is  readily  found 
and  picked  up.  By  picking  it  up  as  it  emerges  from  the 
internal  ring,  the  entire  ligament  is  secured  before  any  of 
its  fibers  are  given  off.  This  gives  us  in  all  instances  a 
ligament  sufficiently  strong  to  stand  the  traction  necessary 
to  draw  out  efficiently  its  intra-abdominal  portion.  This 
more  especially  since  we  are  at  liberty,  by  reason  of  free 
access  to  the  internal  ring,  to  draw  in  the  direction  of  the 
intra-abdominal  portion  of  the  ligament. 

Another  great  advantage  presented  is  the  certainty  of 
really  shortening  that  portion  of  the  ligament  (the  intra¬ 
abdominal),  to  shorten  which  is  the  prime  object  of  the 
operation.  As  already  stated  above,  upon  traction  being 
made  upon  the  round  ligament,  the  peritoneal  folds  of  the 
broad  ligament  embracing  it  are  drawn  out  through  the  in¬ 
ternal  ring  in  the  shape  of  an  inverted  funnel.  Under  guid¬ 
ance  of  the  eye  the  broad  ligaments  are  gently  stripped 
back  from  the  round  ligament,  until  the  intra-abdominal 
portion  of  the  latter  is  seen  to  have  been  liberated,  for  three 
or  four- inches  of  its  length,  from  the  embrace  of  the  former. 
This  denuded  intra-abdominal  portion  of  the  ligament  is 
converted  into  the  extra-abdominal  portion  by  being  sutured 
into  the  inguinal  canal. 

The  distinctive  features  of  the  method  of  operation 
advocated  in  this  paper,  briefly  recapitulated,  are  as  fol¬ 
lows  : 

1.  The  inguinal  canal  is  laid  open  along  its  entire 
length. 

2.  The  round  ligament  is  sought  for  and  picked  up  at 
its  point  of  emergence  from  the  internal  ring. 


EDEB0IIL8:  A  MODIFIED  ALEXANDER-ADAMS  OPERATION. 


404 


GLEITSMANN:  PRIMARY  TUBERCULOSIS  OF  TEE  PHARYNX.  [N.  Y.  Med.  Joue., 


3.  The  ligament  is  drawn  out  approximately  in  the  di¬ 
rection  of  its  intra-abdominal  portion. 

4.  The  ligament  is  drawn  out  from  its  peritoneal  invest¬ 
ment  by  aid  of  the  sense  of  sight.  The  shortening  of  its 
intra-abdominal  portion  is  thus  rendered  a  matter  of  abso¬ 
lute  certainty. 

5.  The  method  of  suture,  which,  while  it  closes  the 
canal,  at  the  same  time  secures  the  ligament  within  it. 

6.  The  method  of  drainage  by  silk-worm  gut. 

Many  and  various  are  the  modifications  of  Alexander’s 
operation  which  have  from  time  to  time  been  proposed  by 
different  surgeons  and  gynaecologists.  I  am  not  aware, 
however,  that  the  combination  of  procedures  above  de¬ 
scribed  has  ever  been  advocated.  The  nearest  approach  to 
it  which  I  have  found  recorded  is  in  a  paper,  read  before 
the  Gynaecological  Society  of  Chicago,  by  Dr.  Henry  P. 
Newman,  entitled  Alexander’s  Operation,  with  Report  of 
Cases,*  to  which  I  must  refer  for  the  details  of  Dr.  New¬ 
man’s  technique. 

An  objection  that  may  be  urged  against  the  plan  of 
operation  herewith  presented,  as  compared  with  the  original 
method,  is  the  apparently  greater  probability  of  a  resultant 
hernia.  While  I  do  not  believe  that  the  operation,  care¬ 
fully  performed  after  either  method,  predisposes  to  hernia, 
I  think  a  little  reflection  will  show  that  the  liability  to  this 
accident  is  really  diminished  in  my  modification. 

In  describing  the  technique  of  Alexander’s  operation, 
Munde  f  says  :  “  The  operator  need  not  be  afraid  to  pass  his 
finger  or  the  scalpel  handle  along  the  ligament  into  the  in¬ 
guinal  canal  and  break  up  these  adhesions.”  Add  to  this 
dilatation  of  the  canal  the  subsequent  drawing  down  into 
it  of  the  peritoneal  pouch  which  follows  the  round  liga¬ 
ment,  and  we  certainly  have  established  conditions  not  un¬ 
favorable  to  the  formation  of  hernia.  These  conditions 
were  clearly  in  the  mind  of  Dr.  W.  L.  Reid  when  he  wrote :  \ 
u  I  also  believe  it  wise  to  pass  one  or  two  deep  sutures 
across  the  inguinal  canal  in  order  to  occlude  the  pouch  of 
peritonaeum  which  is  dragged  down  into  it.” 

In  my  method  the  peritonaeum  is  well  stripped  back 
from  the  round  ligament  and  returned  fully  within  the  ab¬ 
domen.  The  round  ligament,  denuded  of  its  peritoneal 
coat,  is  in  a  condition  most  favorable  to  firm  union  with 
the  internal  wall  of  the  canal,  likewise  denuded  by  the  de¬ 
tachment  of  the  fibers  of  insertion  of  the  round  ligament. 
The  method  of  suture  insures  retention  of  the  round  liga¬ 
ment  within  the  inguinal  canal  along  its  whole  length.  The 
walls  of  the  canal  are  adjusted  snugly  around  the  contained 
ligament,  and  the  lumen  of  the  canal  is  now  probably  smaller 
than  before  operation. 

As  already  stated,  the  object  of  this  paper  is  to  call  at¬ 
tention  to  a  method  of  shortening  the  round  ligaments 
which  I  have  thus  far  found  easy  of  performance,  and  de¬ 
lightfully  certain  in  its  immediate  anatomical  results.  That 
it  constitutes  a  somewhat  more  serious  procedure  than  the 
original  operation  I  am  free  to  admit.  This  is,  however, 
more  than  counterbalanced  by  the  greatly  increased,  I  might 

*  American  Journal  of  Obstetrics ,  December,  1888,  p.  1291. 

f  Ibid.,  November,  1888,  p.  1127. 

X  Trans,  of  the  Ninth  Internat.  Med.  Congress,  vol.  ii,  p.  763. 


almost  say  absolute,  certainty  of  finding  the  ligaments,  and 
the  positiveness  with  which  they  can  be  really  shortened 
when  found.  The  hesitancy  and  lack  of  confidence  with 
which  I  formerly  approached  the  operation  have  given  way 
to  a  feeling  of  assurance  based  upon  the  certainty  of  ac¬ 
complishing  that  for  which  the  operation  is  undertaken. 


A  CASE  OF 

PRIMARY  TUBERCULOSIS  OF  THE  PHARYNX 

TERMINATING  IN  CURE* 

By  J.  W.  GLEITSMANN,  M.  D., 

PROFESSOR  OF  LARYNGOLOGY  AND  RHINOLOGY  IN  THE  NEW  YORK  POLYCLINIC, 
LARYNGOLOGIST  AND  OTOLOGIST  TO  THE  GERMAN  DISPENSARY. 

The  following  history  of  a  case  of  tubercular  pharyn¬ 
gitis  is  presented  to  this  learned  assembly  for  two  reasons. 
First,  the  successful  treatment  of  cases  of  a  similar  nature 
is  mainly  due  to  the  labors  of  two  men,  both  of  whom  are 
members  of  this  section,  viz. :  the  introduction  of  lactic 
acid  in  the  treatment  of  laryngeal  phthisis  by  Krause,  and 
its  surgical  treatment  by  Heryng.  Secondly,  the  last  ex¬ 
amination,  made  more  than  two  years  after  the  commence¬ 
ment  of  the  disease,  showed  that  the  patient  remained  per¬ 
fectly  well  and  that  the  cure  had  been  complete: 

The  patient  when  presenting  herself  for  treatment,  May  14, 
1888,  was  thirty-eight  years  of  age,  well  built,  weight  one  hun¬ 
dred  and  eighty  pounds,  no  hereditary  tendency.  She  called 
on  account  of  pain  in  deglutition  on  the  left  side  during  the 
last  two  weeks.  Inspection  revealed  an  ulceration  of-the  size 
of  a  pea,  covered  with  grayish-white  secretion,  situated  at  the 
base  of  the  tongue  on  the  left  side.  The  examination  of  the 
lungs  at  that  time  and  at  all  subsequent  periods  showed  them 
to  be  in  perfectly  healthy  condition.  Syphilis  had  to  be  ex¬ 
cluded,  as  the  patient  had  never  had  any  symptoms  of  the  dis¬ 
ease;  she  was  happily  married  and  had  given  birth  to  six  chil¬ 
dren,  two  of  whom  died  from  croup,  and  four  were  living  and 
healthy. 

The  suspicious  aspect  of  the  ulceration  tempted  me  to  cu¬ 
rette  it  thoroughly  with  the  sharp  spoon  at  her  second  visit. 
The  specimens  examined  under  the  microscope  by  two  inde¬ 
pendent  observers  contained  numerous  tubercle  bacilli.  The 
same  condition  was  found  one  month  later,  when  a  piece  of  tis¬ 
sue  removed  from  the  edge  of  an  ulceration  was  subjected  to 
the  microscopic  test.  The  treatment  during  the  entire  course 
of  the  disease  was  confined  to  curettement  of  the  ulcers  and 
energetic  application  of  lactic  acid  and  at  times  use  of  the 
galvano-cautery.  I  kept  purposely  aloof  from  all  alterative 
remedies  in  order  not  to  obscure  the  case  in  any  manner,  the 
nutrition  only  being  supported  by  tonics,  good  food,  wine,  etc. 

The  main  features  in  the  history  of  the  case  are  the  follow¬ 
ing,  minor  details  being  omitted :  The  primary  ulceration  im¬ 
proved  in  the  beginning,  but  the  latter  part  of  June  the  destruc¬ 
tive  process  extended  along  the  base  of  the  tongue  toward  the 
right  side.  Energetic  treatment  also  arrested  it  in  this  locality, 
but  in  the  beginning  of  August  a  deep  ulcer  was  discovered  in 
the  posterior  portion  of  the  left  tonsil.  The  ulceration  v'as 
hidden  by  a  flap  of  healthy  tissue,  and  could  only  be  seen  by 
pushing  the  latter  aside  with  a  suitable  forceps.  A  few  days 
later  the  lingual  surface  of  the  epiglottis  became  intensely  hy- 
peraamic  and  uniformly  thickened,  resembling  oedema.  But  on 

*  Read  before  the  Laryngological  Section  of  the  Tenth  International 
Medical  Congress,  Berlin,  August,  1890. 


Oct.  11,  1890.  J 


OLEITSMANN:  PRIMARY  TUBERCULOSIS  OF  THE  PHARYNX. 


405 


application  of  a  probe  no  impression  wus  produced,  showing 
that  a  true  infiltration  existed.  This  condition  remained  station¬ 
ary  during  the  following  month,  but  when  returning  from  my 
summer  vacation  I  found  that  the  patient  had  lost  ten  pounds 
in  weight  and  suffered  from  severe  dysphagia.  In  trying  to 
swallow  liquids,  the  greater  part  passed  through  the  nose.  The 
lungs  were  again  found  to  be  intact.  Scarifications  of  the  infil¬ 
trated  epiglottis  were  next  attempted,  but  without  giving  relief. 

By  the  end  of  September,  after  a  most  thorough  cleansing  of 
the  diseased  parts,  which  I  always  found  to  be  covered  with 
copious  and  tenacious  secretion,  the  -whole  infiltration  of  the 
lingual  surface  of  the  epiglottis  proved  to  have  melted  away, 
and  a  large  ulceration  was  visible  instead,  leaving  only  a  small 
area  of  healthy  tissue  on  the  free  border  of  the  cartilage.  On 
October  1st,  ulceration  set  in  on  the  left  palatine  pillar;  on  the 
15th  of  the  same  month  the  remaining  portion  of  the  epiglottis 
was  also  transformed  into  an  ulcer,  and  on  the  20th  the  left 
arytfeno-epiglottic  ligament  became  involved.  Although  I  had 
up  to  this  time  always  entertained  strong  hopes  of  being  able  to 
combat  the  disease  successfully,  the  condition  of  the  patient  was 
now  certainly  very  discouraging,  and  I  almost  despaired  of  her 
ultimate  recovery.  Feeling  that  the  last  measures  were  justi¬ 
fied,  I  scraped  away  all  the  diseased  tissue  most  energetically 
without  regard  to  the  subsequent  haemorrhage  and  rubbed  in 
undiluted  lactic  acid.  The  patient  felt  relief  from  pain  the  fol¬ 
lowing  day,  and  three  days  later  cicatricial  tissue  appeared 
everywhere.  Again  three  days  later,  October  29th,  the  patient 
felt  perfectly  well,  and  on  the  31st  the  last  eschar  disappeared. 
The  patient  now  weighed  but  one  hundred  and  sixty-seven 
pounds. 

During  the  last  week  of  November  (1888)  the  patient  was 
shown  at  a  meeting  of  the  laryngological  section  of  the  New 
York  Academy  of  Medicine  and  examined  by  its  members. 
They  all  confirmed  the  devastation  made  by  the  ulcerative  pro¬ 
cess  and  the  subsequent  cicatrization.  Ulceration  could  no¬ 
where  be  detected  at  that  time. 

In  regard  to  the  treatment  here  pursued  and  its  ulti¬ 
mate  good  result,  it  must  be  conceded  that  it  was  only  pos¬ 
sible  owing  to  the  great  endurance  and  will-power  shown 
by  the  patient  throughout  the  whole  time.  Although  the 
clearing  of  the  ulceration  was  made  with  cocaine  spray,  all 
other  proceedings  only  after  application  of  the  strongest 
solutions,  necessarily  the  measures  adopted  and  their  after, 
effect  were  often  very  painful.  Nevertheless,  they  were 
borne  by  the  patient  with  the  greatest  patience  and  without 
the  slightest  objection.  Another  point  which  appeared  to 
be  of  importance  in  the  treatment  deserves  mention.  It 
has  already  been  observed  by  other  writers  that  rubbing 
with  the  cotton-carrier  over  suspicious  places  aids  in  dis¬ 
tinguishing  between  ulceration  and  cicatrization.  It  some¬ 
times  happens  that  a  slight  haemorrhage  occurs  when  we 
rub  over  apparent  cicatricial  tissue  with  a  cotton-carrier, 
and  that  after  a  thorough  cleansing  an  ulcer  is  discovered. 
If,  however,  after  repeated  rubbing,  no  change  of  suspicious 
places  took  place,  I  felt  justified  in  considering  them  healed. 

The  further  progress  of  the  case  was  much  simpler.  In 
the  beginning  of  December  there  appeared  two  discolored, 
whitish  spots,  corresponding  to  the  posterior  insertion  of 
the  ventricular  bands,  which  remained  visible  during  two 
weeks.  Six  weeks  later  the  same  observation  was  made  at 
both  processus  vocales.  Although  first  uncertain  as  to  their 
nature,  I  had  to  consider  them  as  the  result  of  local  anae¬ 


mia,  because  the  application  of  spray  and  cotton  carrier 
proved  them  to  be  neither  deposits  of  mucus  nor  ulcera¬ 
tions.  A  true  ulcer  formed  in  the  latter  part  of  December 
in  the  midst  of  the  dense,  hyperaemic  left  anterior  palatine 
pillar.  When  treated  with  the  sharp  spoon,  it  proved  to  be 
of  considerable  depth.  Its  upper  edge  was  cut  away  with 
a  pair  of  scissors,  and  lactic  acid  was  rubbed  in.  In  the 
beginning  of  January,  1889,  it  became  necessary  to  scoop 
out  the  freshly  ulcerated  left  tonsil,  and,  two  weeks  later,  a 
lobulated,  suspicious-looking  mass  of  the  tonsil  was  removed 
with  my  irido-platinum  wire.  These  two  ulcers  of  the  pil¬ 
lar  and  tonsil  were  the  last  ones  to  appear,  and  later  on 
no  more  ulceration  took  place. 


The  two  drawings  of  the  pharynx  and  larynx,  which  I 
beg  to  present  to  the  Section,  date  from  this  time  (spring, 
1889).  The  loss  of  substance  at  the  left  tonsil  and  the  soft 
palate  in  one  picture  and  at  the  epiglottis  in  the  other  are 


plainly  visible  and  require  no  further  explanation.  It  is 
only  proper  to  state  here  that  already  at  that  time  the  cica¬ 
tricial  tissue  had  to  a  great  extent  lost  its  irregular  and 
contracted  appearance,  whereas  previously  the  uvula  was 
still  more  deviated  to  the  left  aud  the  zigzag  condition  of 
the  pillar  considerably  more  developed. 

In  March,  1889,  there  appeared,  as  the  last  intercurrent 
affection,  a  tumefaction  of  the  left  sterno-clavicular  articu¬ 
lation,  which  yielded  to  two  months  treatment  with  simple 
remedies.  In  the  beginning  of  this  year  the  patient  be¬ 
came  pregnant,  and  was  delivered  of  a  healthy  boy  after  iny 

return  from  Europe  in  the  fall. 

I  saw  the  patient  and  her  well-developed,  healthy  child 
the  last  time  on  May  28,  1890.  After  the  last  two  ulcera¬ 
tions  (January,  1889)  had  healed,  nothing  abnormal  could 


406 


WHITMAN :  PERSISTENT  ABDUCTION  OF  THE  FOOT. 


[N.  Y.  Med.  Jottk., 


be  detected  in  the  patient’s  pharynx  or  larynx,  her  weight 

had  increased  to  two  hundred  and  four  pounds  (twenty-four 
pounds  more  than  at  the  beginning  of  the  treatment),  and 
she  felt  well  in  every  respect. 

I  expressed  it  as  my  opinion,  when  I  showed  the  patient 
before  the  New  \  ork  Academy  and  also  in  the  introductory 
iemarks  to  this  paper,  that  I  considered  the  successful  result 
obtained  in  this  case  entirely  due  to  the  application  of  lactic 
acid  and  the  surgical  treatment,  in  conjunction  with  the 
galvano-cautery.  It  is  my  firm  belief  that,  with  the  neces¬ 
sary  perseverance  on  the  part  of  the  physician  and  the  cor¬ 
responding  energy  on  the  part  of  the  patient,  such  cases  will 
not  remain  isolated  in  the  future,  and  thus  the  statement 
made  by  a  well-known  author  only  a  few  years  ago — “  It  is 
beyond  doubt  that  up  to  this  time  no  actually  cured  case  of 
pharyngeal  tuberculosis  has  been  reported  ” — can  not  be 
considered  an  axiom  any  longer. 


THE  TREATMENT  OF 

PERSISTENT  ABDUCTION  OF  THE  FOOT, 

COMMONLY  KNOWN  AS  CHRONIC  SPRAIN  OF  THE  ANKLE.* 

By  ROYAL  WHITMAN,  M.  D.,  M.  R.  0.  S. 

The  successful  treatment  of  any  chronic  affection  de¬ 
mands  a  personal,  persistent  attention  to  details  on  the  part 
of  the  surgeon.  This  is  particularly  true  of  the  treatment 
of  what  are  known  as  minor  injuries,  and  therefore  neg¬ 
lected. 

One  of  this  class,  to  which  I  propose  to  call  your  atten¬ 
tion,  is  commonly  known  as  chronic  sprain  of  the  ankle,  an 
affection  which  may  entail  years  of  discomfort  and  disabili¬ 
ty,  with  permanent  impairment  of  the  functions  of  the  foot. 

The  usual  history  of  such  cases  is  as  follows :  Long- 
continued  weakness  and  discomfort,  following  an  injury  to 
the  ankle,  treated  by  various  physicians  with  liniments, 

,  nd  bandages  until  the  discouraged  patient  is  told 
that  nothing  more  can  be  done,  but  that  his  symptoms 
will  wear  away  in  time.”  A  year  or  two  later  he  pre¬ 
sents  himself,  usually  for  the  purpose  of  procuring  a  brace, 
01  for  some  peculiar  shoe  which  he  thinks  may  be  of  serv¬ 
ice  to  him. 

lie  complains  principally  of  weakness,  stiffness,  and  in¬ 
security,  of  fatigue  and  pain  in  the  foot  and  ankle  on  any 
overexertion.  lie  walks  with  a  somewhat  awkward  gait, 
the  foot  everted  to  avoid  flexion  at  the  ankle,  with  a  very 
noticeable  limp  when  fatigued  ;  in  fact,  he  walks  as  little  as 
possible.  On  examination,  one  finds  that  the  foot  is  ab¬ 
ducted — that  is,  turned  outward  in  its  relation  to  the  leg— 
that  forced  adduction  and  extension  are  resisted  and  are 
very  painful  to  the  patient.  There  may  be  some  swelling, 
often  of  the  dorsum  of  the  foot,  or  in  front  and  below  the 
external  malleolus.  In  other  cases  the  ankle  appears  per¬ 
fectly  normal.  The  arch  is  not  markedly  diminished,  but 
there  is  a  prominence  on  the  inner  aspect  of  the  foot,  at  the 
astragalo-scaphoid  joint,  caused  by  its  abducted  position. 
Thus,  although  in  a  well-marked  case  all  the  movements  at 

*  Read  before  the  American  Orthopaedic  Association  at  its  fourth 
annual  meeting. 


the  ankle  and  at  the  medio-tarsal  joint  are  somewhat  re¬ 
stricted,  those  of  adduction  and  extension  are  almost  lost, 
there  being  a  spasmodic  contraction  of  the  peroneii  and 
extensor  longus  digitorum,  with  shortening  of  ligaments 
and  fascia  on  the  outer  side,  varying  according  to  the  time 
the  foot  has  been  held  in  its  improper  position.  The 
amount  of  abduction  varies.  In  many  cases  there  is  sim¬ 
ply  a  slight  limitation  of  adduction  and  almost  no  spasm 
of  muscles.  In  others,  usually  in  young  subjects,  there  is 
a  tonic  contraction  of  the  abductors,  raising  the  outer  bor¬ 
der  of  the  foot  and  throwing  it  into  a  position  of  marked 
deformity,  presenting  the  appearances  of  what  is  sometimes 
called  spasmodic  valgus. 

In  making  the  diagnosis  of  this  condition,  it  is  impor¬ 
tant,  as  a  preliminary  measure,  to  test  the  movements  of 
the  foot — (1)  in  relation  to  its  fellow;  (2)  to  the  normal 
range  of  motion.  This  varies  considerably  with  the  age  or 
personal  peculiarity  of  the  patient,  but,  according  to  a 
number  of  measurements,  the  average  is  about  as  follows  : 

korced  flexion,  70°  to  80°.  Forced  extension,  140°  to 
150°. 

Adduction  is  much  more  difficult  to  determine,  but  it 
may  be  said  that  a  person  sitting,  holding  the  leg  perpen¬ 
dicular  to  the  floor,  the  foot  being  somewhat  extended, 
should  be  able  to  raise  its  inner  border  until  the  sole  forms 
an  angle  with  the  floor  of  about  60°  to  40°. 

In  this  position  the  patient  with  persistent  abduction  of 
the  foot  is  usually  unable  to  raise  the  inner  border  at  all. 

I  wish  to  call  your  attention  particularly  to  the  fact  that 
a  foot  with  persistently  restricted  motion  in  any  direction, 
especially  in  that  of  adduction,  is  in  no  condition  to  re¬ 
cover  under  treatment  by  blisters,  bandages,  or  rest,  un¬ 
aided  by  other  means.  Sprains  of  the  character  we  are 
considering  are  usually  caused  by  a  fall  from  a  height,  or 
by  the  body  turning  outward  over  the  foot,  straining  and 
rupturing  the  internal  lateral  ligaments,  a  more  sudden 
violence  producing  in  the  same  manner  a  Pott’s  fracture. 
Either  as  the  direct  result  of  the  accident,  or  from  the  sub¬ 
sequent  weakness  of  the  internal  ligaments,  a  subluxation  of 
the  astragalus  takes  place  downward  and  inward,  while  the 
remainder  of  the  foot  is  thrown  outward,  so  that  a  dis¬ 
turbance  of  the  muscular  equilibrium  results.  The  adduc¬ 
tors,  working  at  a  disadvantage,  are  unable  to  perform  their 
functions,  while  the  abductors,  the  peroneii,  and  extensor 
longus  digitorum,  in  the  effort  to  hold  and  steady  the  foot, 
are  thrown  into  a  state  of  spasmodic  contraction,  so  that  it 
is,  as  has  been  described,  rigidly  held  in  abduction,  while 
the  power  of  adduction  is  limited  or  lost. 

Abduction  of  the  foot  is  the  position  of  weakness;  ad¬ 
duction,  that  of  strength  and  activity. 

In  other  words,  the  usefulness  of  the  foot  depends  upon 
the  preponderance  of  power  of  the  adductor  muscles. 
A  hen  this  is  lost,  weakness  and  pain  ensue.  If  this  propo¬ 
sition  is  accepted,  the  treatment  becomes  simple  : 

1.  To  overcome  the  contraction  and  spasm  of  the  ab¬ 
ductors. 

2.  To  strengthen  the  adductors. 

I  his  can  best  be  accomplished  as  follows: 

The  patient  being  etherized,  the  affected  foot  is  forcibly 


Oct.  11,  1890.] 


WHITMAN:  PERSISTENT  ABDUCTION  OF  THE  FOOT. 


407 


extended  and  adducted — that  is,  the  heel  and  toes  are 
both  turned  inward,  so  that  the  inner  border  of  the  foot  is 
bent  like  a  bow  ;  it  is  then  forced  inward  under  the  leg  to 
a  position  of  extreme  equino-varus,  the  operation  being  at¬ 
tended  with  audible  cracking  of  adhesions  in  all  the  dis¬ 
used  articulations.  In  this  position  a  well-fitting  plaster 
bandage  is  applied,  with  the  object  of  persistently  over¬ 
stretching  the  shortened  ligaments  and  contracted  muscles 
and  holding  the  foot  firmly  in  its  new  position. 

The  pain  after  the  operation  is  much  less  than  might  be 
supposed  from  the  violence  that  is  often  necessary  to  accom¬ 
plish  the  result. 

The  bandage  may  remain  on  a  variable  length  of  time 
according  to  the  subsequent  pain  and  the  difficulty  that  has 
been  experienced  in  the  reposition.  From  one  to  three 
weeks  is  the  average  time.  When  it  is  removed,  the  foot, 
though  in  good  position,  is  usually  somewhat  swollen,  sen¬ 
sitive  to  pressure,  and  all  its  movements  are  limited  and 
often  painful.  Now  a  course  of  massage  is  necessary, 
gentle  at  first,  followed  by  bandaging  and  complete  rest. 
In  two  or  three  days,  when  the  swelling  has  subsided,  the 
patient  begins  voluntary  exercises,  assisted  by  the  surgeon, 
the  attempt  being  made  to  place  the  foot  in  the  position  of 
adduction — that  is,  to  regain  the  motion  that  was  lost. 
Thus,  the  patient  contracts  the  adductors  and  flexors, 
while  the  surgeon  aids,  by  gently  pressing  at  the  same  time 
on  the  dorsum  of  the  foot.  At  the  conclusion  of  the  exer¬ 
cise  the  surgeon,  holding  the  foot  firmly,  turns  it  slowly 
inward  toward  the  position  of  equino-varus,  and  retains  it 
there  until  the  involuntary  resistance  diminishes.  This 
movement  is  usually  accompanied  by  a  very  painful  sensa¬ 
tion  of  stretching  in  the  muscles  and  ligaments  of  the  outer 
border  of  the  foot,  which  gradually  diminishes  as  the  foot 
returns  to  its  normal  condition.  This  portion  of  the  treat¬ 
ment,  described  by  the  patients  as  “  twisting,”  is  by  far  the 
most  important.  Patients  strongly  object  to  it  at  first,  but 
afterward  submit  to  it  willingly,  as  it  relieves  the  sensation 
of  painful  stiffness,  while  the  gain  in  range  of  motion  after 
each  application  is  very  evident.  When  the  pain  and  stiff¬ 
ness  have  diminished,  usually  in  from  one  to  three  weeks, 
the  patient  is  allowed  to  use  the  foot. 

As  the  foot  was  formerly  everted  in  walking,  he  now 
walks  with  the  toes  directly  in  front  of  the  body,  so  that  the 
flexors  and  adductors  must  be  exercised  with  every  step. 
He  is  to  wear  a  Waukenphast  shoe,  as  its  inward  twist  aids 
in  holding  the  foot  in  proper  position.  If  necessary,  its  in¬ 
ner  border  may  be  built  up,  after  the  method  of  Thomas.  I 
invariably  use  the  foot  brace,  which  has  already  been  shown 
the  society,  to  support  the  foot  and  prevent  abduction  until 
the  patient  by  constant  exercises  and  avoidance  of  improper 
positions  has  allowed  the  foot  to  return  to  its  normal  con¬ 
dition.  These  exercises  are  very  simple  : 

1.  The  movements  of  adduction  and  extension  which 
have  been  described. 

2.  Raising  the  body  on  the  bare  toes  twenty  to  thirty 
times  morning  and  night,  as  recommended  by  Ellis. 

3.  And  most  important,  a  correct  walk,  by  which  the 
body  must  be  raised  upon  the  foot  at  every  step,  as  de¬ 
scribed  in  Yol.  1  of  the  Orthopcedic  Transactions. 


The  successful  treatment  of  this  class  of  cases  may,  I  ap¬ 
prehend,  be  summed  up  as  follows  : 

Discover  what  movements  of  the  foot  are  restricted,  with 
the  apparent  causes. 

Then  a  persistent  endeavor  to  overcome  such  restric¬ 
tion — 

1.  By  forcible  reposition  to  break  up  adhesions  and  to 
overstretch  the  contracted  muscles  and  ligaments. 

2.  A  long-continued  massage  intelligently  applied  by 
the  surgeon. 

It  is  not  sufficient  to  order  rubbing  of  the  foot — this  has 
been  done  by  the  patient  for  months — but  a  manipulation 
diligently  carried  out  with  the  purpose  of  stretching  the 
shortened  ligaments  and  overcoming  the  contraction  and 
spasm  of  muscles. 

3.  A  re-education  of  the  patient  as  to  the  proper  posi¬ 
tions  and  movements  of  the  foot. 

This  course  of  treatment  is  often  long,  tedious,  and  pain¬ 
ful,  but  it  is,  I  believe,  the  only  one  which  may  restore  the 
injured  member  to  strength  and  usefulness,  and  if  the  patient 
and  surgeon  are  not  prepared  to  carry  it  out,  it  is  better  for 
both  that  the  attempt  should  not  be  made. 

Having  spoken  of  the  treatment  of  this  affection,  we 
may  now  consider  how  such  a  condition  may  be  avoided. 

The  surgeon  called  upon  to  treat  a  recent  injury  to  the 
ankle  should  remember  that  the  subsequent  disability  is 
almost  invariably  the  result  of  abduction,  because  the  origi¬ 
nal  injury  is  usually  to  the  internal  lateral  ligament  and 
those  of  the  medio-tarsal  joint. 

Consequently,  it  seems  reasonable,  in  a  sprain  of  any 
severity,  to  place  the  foot  for  several  days  in  a  well-fitting 
plaster  bandage  in  the  position  of  adduction,  to  guard 
against  a  possible  subluxation  of  the  astragalus,  and  to  re¬ 
lax  the  injured  ligaments  and  muscles  ;  then  a  course  of  mas¬ 
sage  until  the  swelling  has  subsided  and  all  the  movements 
of  the  ankle  and  foot  have  been  regained  and  are  painless, 
with  the  temporary  use  of  a  foot-brace  if  necessary. 

In  conclusion,  the  history  of  many  of  these  patients 
would  seem  to  show  a  very  discreditable  ignorance  among 
physicians  as  to  the  appearance  of  a  normal  foot  and  of  the 
injuries  and  diseases  to  which  it  is  liable.  A  sufferer  from 
non-deforming  club-foot,  persistent  abduction  of  the  foot, 
or  flat-foot,  usually  goes  from  physician  to  physician  only 
to  receive  a  prescription  for  a  new  liniment  or  antirrheu- 
matic  medicine. 

Even  when  a  correct  diagnosis  is  made,  surgeons  are 
too  often  content  with  temporary  relief,  rather  than  insist¬ 
ing  on  the  persistent  treatment  which  may  result  in  cure. 

Note. — The  term  “persistent  abduction”  is  used  simply  to  describe 
the  actual  condition  of  an  affection  which  is  not  flat-foot,  yet  nearly  al¬ 
lied  to  it.  At  the  reading  of  this  paper  it  was  suggested  that  there  were 
two  distinct  classes  of  cases  presenting  the  appearances  described,  one 
of  which  was  purely  neurotic  and  might  be  cured  without  reference  to 
the  local  condition  of  the  foot.  Such  cases  must  be  extremely  rare. 
Disordered  reflexes  may  increase  the  effect  of  a  local  trouble,  and  a  poor 
general  condition  must  be  treated  as  well  as  the  local  affection  ;  but, 
other  things  being  equal,  the  writer  believes  that  the  best  way  to  treat 
neuroses,  if  such  exist,  producing  the  symptoms  above  described,  will 
be  to  break  up  the  adhesions,  to  replace  the  foot  in  normal  position, 
to  strengthen  and  re-educate  its  muscles  in  the  manner  already  de¬ 
scribed. 


408 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jock., 


the 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  OCTOBER  11,  1890. 

THE  BACTERIOLOGY  OF  ACUTE  CROUPOUS  PNEUMONIA. 

Dr.  William  H.  Welch  has  reported  to  the  Johns  Hopkins 
Hospital  Medical  Society  some  of  the  results  of  his  investiga¬ 
tions  regarding  the  bacteriology  of  acute  croupous  pneumonia. 
He  has  been  able  to  discover  the  Diplococcus  pneumonia  in  ten 
cases,  all  that  were  examined  by  him  in  this  research,  and  to 
isolate  the  micro-organism  in  a  pure  culture.  From  a  summary 
of  Dr.  Welch’s  remarks,  given  in  the  Journal  of  the  American 
Medical  Association,  we  learn,  further,  that  he  is  inclined  to 
accept  the  views  of  Fraenkel  and  others  who  teach  that  the 
diplococcus  is  the  specific  cause  of  the  disease.  In  regard  to 
Dr.  Welch’s  culture  experiments  it  may  be  said  that  he  prefers 
the  gelatin-agar  medium,  prepared  according  to  the  formula  of 
Guarnieri ;  in  that  substance  the  growth  of  the  pneumococcus 
was  particularly  luxuriant.  He  used  other  media,  such  as  nu¬ 
trient  agar  and  glycerin-agar,  making  his  cultures  from  the  af¬ 
fected  parts  of  the  lungs,  from  the  spleen,  from  the  blood,  and 
from  various  complicating  lesions.  In  addition,  mice  and  rab¬ 
bits  were  inoculated  with  pieces  of  hepatized  lung  and  of  the 
spleen.  In  no  instance  was  he  able  to  produce  pneumonia  in 
the  dog  by  means  of  any  pneumococcus  culture  obtained  by 
him;  others,  however,  have  attained  to  positive  results  by 
methods  similar  to  those  which  failed  in  his  hands.  Dr.  Welch 
observed  in  one  instance  that  the  presence  of  the  organism 
would  have  been  overlooked  if  he  had  not  taken  the  precau¬ 
tion  to  make  inoculations  with  bits  of  the  tissues.  He  believes 
that  the  diplococcus  should  not  be  said  to  be  absent  simply  on 
the  ground  of  negative  results  from  cultures;  these  results  must 
be  supplemented  by  the  inoculation  of  susceptible  animals. 
Moreover,  the  fact  of  failure  to  kill  mice  and  rabbits  by  inocu¬ 
lations  of  the  diplococcus  from  the  human  body  is  not  conclu¬ 
sive  evidence  of  the  absence  of  the  organism,  since  it  may  be 
found  in  man  in  a  form  that  is  incapable  of  destroying  those 
animals.  In  some  cases  the  pneumococcus  did  not  kill  rabbits, 
but  did  kill  mice,  making  it  evident  that  the  latter  are  more 
highly  susceptible  and  are  to  be  preferred  for  the  inoculation 
of  tissues  taken  from  the  lungs  in  cases  of  croupous  pneumonia. 
In  three  cases  rabbits  survived  inoculation  for  more  than  five 
days,  the  longest  duration  being  twelve  days.  When  rabbits 
were  inoculated  with  the  exudation  present  in  the  bronchi  or 
trachea,  a  speedily  fatal  result  was  sometimes  obtained,  even 
when  the  hepatized  lung  yielded  a  pneumococcus  of  diminished 
virulence. 

The  inference  is  very  strong  that  the  most  virulent  forms 
of  the  organism  are  to  be  found  in  the  sputum,  in  the  freshly 
hepatized  lung,  and  at  the  margin  of  an  advancing  pneumonia, 
whereas  the  cocci  present  in  advanced  stages  of  hepatization 


and  in  the  spleen  are  likely  to  be  less  virulent.  In  five  of  his 
cases  there  was  a  pleuritic  exudate  accompanying  the  croupous 
pneumonia,  and  this  was  examined  by  means  of  culture  meth¬ 
ods,  revealing  the  pneumococcus  in  every  instance.  The  organ¬ 
ism  has  also  been  found  in  other  cases  of  empyema  following 
that  disease.  The  pneumobacillus  of  Friedlander  was  not  found 
in  any  case.  These  studies  by  Dr.  Welch  appear  to  confirm 
Fraenkel’s  statements  as  to  the  behavior  of  the  Diplococcus 
pneumonia  in  artificial  culture  media,  its  susceptibility  to  slight 
changes  in  the  composition  and  reaction  of  the  medium,  and  its 
brief  vitality.  The  frequent  presence  of  the  pneumococcus  in 
health  in  the  human  saliva  is  an  occurrence  which,  on  the 
whole,  must  be  of  assistance  in  explaining  the  various  factors 
that  are  concerned  in  the  causation  of  croupous  pneumonia. 
Dr.  Welch  deals  with  the  history  of  the  question  briefly,  giving 
to  Dr.  Sternberg  the  credit  of  the  discovery,  in  1880,  of  the 
salivary  coccus,  which  he  derived  from  his  own  buccal  secre¬ 
tions  and  with  which  he  inoculated  rabbits  at  that  time,  pro¬ 
ducing  fatal  results.  Dr.  Welch  does  not  adopt  the  term  Micro¬ 
coccus  Pasteuri ,  given  to  the  organism  by  Dr.  Sternberg,  and 
he  does  not  appear  to  accept  that  which  is  more  commonly  used 
by  European  bacteriologists,  for  he  speaks  of  it  as  “the  so- 
called  Fraenkel-Weichselbaum  pneumococcus.”  These  re¬ 
searches  of  Dr.  Welch’s  have  been  made  with  great  care  and 
many  precautions  against  possible  error,  and  will  convince  not 
a  few  doubtful  minds  that  the  aetiology  of  croupous  pneumonia 
is  largely  influenced  by  the  Diplococcus  pneumonia. 


FURTHER  ADVANCES  IN  CEREBRAL  SURGERY. 

Last  winter  we  referred  to  the  work  of  Dr.  T.  Claye  Shaw 
in  treating  general  paralysis  of  the  insane  by  trephining.  At 
the  recent  meeting  of  the  International  Medical  Congress  Mr. 
Victor  Horsley  spoke  of  the  value  of  the  operative  treatment 
of  certain  neuroses  and  psychoses.  In  a  ca«e  of  athetosis,  a 
symptom  of  which  the  pathology  is  obscure,  though  he  believes 
it  is  always  a  sign  of  cortical  lesion,  the  limbs  had  been  pro¬ 
gressively  invaded,  beginning  with  the  thumb;  he  accordingly 
removed  the  thumb  center.  A  paralysis  of  motion  followed, 
lasting  forty-eight  hours ;  then  the  spasm  returned  in  a  meas¬ 
ure  in  the  parts  supplied  by  the  cortex  bordering  upon  the  ex¬ 
cised  portion.  It  was  therefore  necessary  to  remove  the  cen¬ 
ter  for  the  whole  limb ;  the  operation  was  intended  to  relieve 
only  the  spasm  and  not  the  paralytic  condition. 

When  operative  interference  in  general  paralysis  and  alien¬ 
ation  is  considered,  Horsley  believes  that  recovery  from  the 
disease  is  possible,  though  he  has  not  had  personal  experience 
bearing  on  the  point.  His  sanction  of  the  potentialities  of  the 
operation  was  confirmed  by  the  unique  experience  of  Dr. 
Burckhardt,  who  has  operated  in  six  cases  of  psychoses.  In 
two  cases  his  aim  was  to  intercept  the  paths  of  cortical  associa¬ 
tion  that,  in  his  opinion,  transmitted  pathological  impressions 
arising  in  sensorial  and  ideogenous  portions  of  the  brain;  he 
has  thus  removed  bands  of  the  frontal  and  parietal  cortex,  an¬ 
terior  and  posterior  to  the  ascending  convolutions.  In  one 


Oct.  11,  1890.] 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


409 


case  the  result  had  been  most  satisfactory ;  in  the  second,  that 
was  still  under  treatment,  the  improvement  had  been  only  par¬ 
tial.  The  four  other  cases  were  accompanied  with  more  or 
less  acute  hallucinatory  delirium.  The  indication  was  to  abolish, 
or  reduce  at  least,  the  verbal  hallucination  as  much  as  possible. 
But  Dr.  Burckhardt  thought  that  the  auditory  verbal  halluci¬ 
nations  could  only  be  produced  when  the  logogenic  centers  in 
the  brain  were  in  action.  Verbal  deafness  and  aphasia  have 
acquainted  us  with  two  cortical  centers  for  the  formation  of 
words,  and  Burckhardt  believed  that  these  centers  were  indis¬ 
pensable  for  the  genesis  of  verbal  hallucination.  To  cure  the 
hallucinations  it  is  therefore  necessary  to  attack  the  centers 
directly  and  to  excise  portions  of  the  first  temporal  and  of 
the  third  frontal  convolutions  of  the  left  cerebral  hemisphere. 
In  three  cases  the  result  was  satisfactory,  perhaps  not  final ; 
but  in  case  of  a  relapse  it  is  intended  to  excise  a  portion  of 
these  convolutions  again.  In  the  fourth  case,  in  which  a  very 
satisfactory  result  was  expected,  the  patient  died  on  the  sixth 
day  of  cerebral  vascular  paralysis,  due  without  doubt  to  the 
use  of  the  scissors.  But  for  this  disaster  the  actual  results  were 
encouraging  during  the  two  years  in  which  the  work  had  been 
prosecuted. 

These  results  are  remarkable,  and  must  be  considered  by 
those  having  the  treatment  of  such  cases  within  their  hands. 
But  cerebral  surgery  to-day  affords  the  promise,  both  of  success 
and  of  failure,  that  abdominal  surgery  has  offered  during  the 
past  decade;  and  a  similar  furor  secandi  will  probably  be 
manifested  for  some  years,  until  larger  experience  teaches  sur¬ 
geons  when  to  be  bold  and  when  to  refrain. 


CLOSTRIDIAL  NEPHRITIS. 

Dr.  F.  V.  Hopkins,  of  San  Francisco,  has  made  a  bacterio¬ 
logical  study  of  a  fatal  case  of  renal  disease,  which  has  been  re¬ 
ported  in  the  Pacific  Medical  Journal.  The  patient  suffered 
with  a  chronic  affection  of  the  kidneys  and  other  organs,  char¬ 
acterized  by  albuminuria,  dropsy,  nervousness,  insomnia,  flatu¬ 
lent  dyspepsia,  dyspnoea,  and  heart  failure.  Oasts  were  pres¬ 
ent,  which,  in  part,  were  made  up  of  bacteria  occurring  in  the 
form  of  rods  with  rounded  ends.  To  this  micro-organism  Dr. 
Hopkins  has  given  the  name  Clostridium  renale ,  and  he  regards 
it  as  the  cause  of  a  peculiar  form  of  chronic  nephritis,  which  he 
would  distinguish  from  the  common  forms  of  Bright’s  disease, 
under  the  term  “  clostridial  nephritis.”  The  bacterium  occurs 
as  circular  cocci,  as  rods  with  rounded  ends,  and  as  filaments, 
in  some  cases  tapering,  and  in  others  having  the  same  thick¬ 
ness  throughout  their  whole  length.  It  is  non-motile  and  in¬ 
fests  the  blood  ;  from  which  it  passes  into  the  capillaries  of  the 
principal  organs,  which  it  obstructs.  The  organism  is  obtained 
in  the  urine,  free  and  in  casts,  and  is  pathognomonic  of  clos¬ 
tridial  nephritis.  Dr.  Hopkins’s  research  included  some  cultiva¬ 
tions  of  these  bacteria,  under  proper  precautions,  and  inocula¬ 
tions  of  rabbits  were  made,  with  the  result  of  invariably  caus¬ 
ing  in  them  a  fatal  dropsy  and  albuminuria,  with  the  kidneys 
and  other  organs  occupied  by  the  germs. 


Whether  Dr.  Hopkins’s  discovery  of  a  new  form  of  Bright’s 
disease  is  confirmed  by  future  observations  or  not,  his  work  in 
this  particular  instance  is  instructive  and  exemplifies  the  im¬ 
portance  of  a  bacteriological  examination  of  the  urine  and 
casts.  He  has  assumed  that  the  renal  affection  in  his  patient 
was  the  primary  and  significant  disease,  whereas  it  may  have 
been  a  secondary  manifestation,  due  to  a  systemic  bacterial  in¬ 
fection,  capable  of  invading  the  kidneys  in  common  with  vari¬ 
ous  other  structures.  Dr.  Hopkins  makes  bibliographical  ref¬ 
erence  to  the  work  of  other  observers  who  have  reported  cases 
of  bacillar  nephritis.  Among  these  was  Letzerich,  who  de¬ 
scribed  in  1887  a  series  of  twenty-five  young  persons  who  suf¬ 
fered  from  an  acute  renal  dropsy  which  he  called  nephritis 
bacillosa  interstitial  is  primaria.  This  disease  is  due  to  bacilli, 
which  swarm  in  the  urine,  and  may  last  from  four  to  six 
weeks.  Pure  cultures  of  these  organisms  were  made  and  rab¬ 
bits  were  inoculated  therefrom,  causing  ascites  in  about  two 
weeks.  The  bacilli  were  found  at  the  junction  of  the  pyram¬ 
idal  and  cortical  portions  of  the  kidneys. 


MINOR  PARAGRAPHS. 

THE  SUCCESSFUL  REMOVAL  OF  A  PANCREATIC  CYST. 

In  the  Lancet  for  September  27th,  Mr.  Frederick  Treves  re¬ 
ports  the  case  of  a  man,  aged  forty,  who  was  healthy  until  eight 
months  preceding  treatment,  when  a  throbbing  sensation  was 
noticed  in  the  umbilical  region  with  subsequent  pains,  and  gen¬ 
eral  fatigue.  A  physician  who  was  consulted  discovered  a 
swelling  in  the  abdomen,  so  the  man  sought  relief  in  a  hospital. 
His  expression  was  melancholic,  his  complexion  was  of  a  dirty- 
brown  color,  his  pupils  were  contracted,  and  he  showed  great 
lassitude.  The  abdominal  tumor  extended  from  three  inches 
above  the  umbilicus  to  the  pubes,  and  laterally  it  occupied  al¬ 
most  the  entire  front  of  the  abdomen  The  growth  felt  smooth, 
and  was  firm,  elastic,  painless,  and  fixed  ;  it  could  not  be  reached 
through  the  rectum.  A  space  existed  between  it  and  the  liver, 
and  respiratory  movements  did  not  affect  it.  The  pigmentation 
of  the  face  and  contraction  of  the  pupils  were  ascribed  to  press¬ 
ure  on  the  solar  plexus;  the  rapid  growth  suggested  a  sarcom¬ 
atous  tumor.  The  patient  requested  that  an  operation  be  at¬ 
tempted,  and  an  infra-umbilical  incision  revealed  a  reddish- 
brown,  smooth,  retroperitoneal  cyst.  An  incision  into  the  cyst 
let  out  about  a  hundred  ounces  of  thick,  opaque,  brownish-red 
fluid.  The  margins  of  the  cyst  wall  were  attached  to  the  parie¬ 
tal  wound  by  fourteen  sutures,  and  a  drainage-tube  was  inserted 
in  the  cavity.  The  discharge  from  the  cyst  was  copious  at  first, 
but  soon  became  thin  and  pale;  it  did  not  irritate  the  integu¬ 
ment.  The  stitches  were  removed  by  the  tenth  day,  but  the 
patient  remained  in  bed  for  almost  six  weeks.  For  two  weeks 
after  the  operation  he  was  apathetic  and  in  the  semi-somnolent 
condition  of  a  person  under  the  influence  of  morphine.  \\  hen 
he  was  discharged,  two  months  after  the  operation,  a  sinus  still 
remained  that  did  not  close  until  a  month  later.  Two  years 
after  the  operation  the  patient  was  in  excellent  health. 


LUNACY  IN  IRELAND. 

On  the  1st  of  January  last  there  were  held  in  district  and 
private  asylums,  jails,  poorhouses,  and  criminal  asylums  in  Ire¬ 
land  16,159  lunatics,  being  an  increase  amounting  to  474  as 
compared  with  those  on  the  1st  of  January,  1889.  This  increase 


410 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Jodr., 


is  greater  than  at  first  sight  it  appears,  inasmuch  as  the  popula¬ 
tion  of  Ireland  has  of  late  years  decreased  considerably  in  con¬ 
sequence  of  emigration.  As  regards  the  condition  of  the  insane 
scattered  through  the  various  workhouses,  it  can  not  be  regarded 
as  satisfactory,  and  the  only  plea  for  their  detention  at  present- 
is  that  they  are  destitute  persons.  As  no  legal  power  exists  for 
their  detention  and  safe-keeping,  it  is  not  to  be  wondered  at 
that  the  provision  for  the  proper  care  and  maintenance  of  harm¬ 
less  lunatics  and  idiots  in  these  institutions  does  not  meet  the 
requirements  of  this  helpless  class.  The  Inspectors  of  Asylums 
intend  at  an  early  date  to  report  on  the  condition  of  the  insane 
in  the  various  licensed  houses  in  Ireland,  as  they  are  of  opinion 
that,  with  a  few  exceptions,  they  are  not  entirely  satisfactory. 
Many  contain  but  two  or  three  patients,  whose  contributions 
toward  their  support  will  hardly  admit  of  due  provision  being 
made  for  their  proper  care.  The  extension  in  Ireland  of  public 
hospitals  supported  by  public  grants,  or  charitable  institutions 
for  the  reception  of  the  insane  whose  friends  are  able  to  con¬ 
tribute  only  a  small  sum  for  their  support,  appears  to  be  a  want 
urgently  felt. 


A  DEMONSTRATION  OF  THE  AMCEBA  COLI  IN  DYSENTERY. 

In  the  Johns  Hophins  Hospital  Bulletin  for  September  there 
is  a  note  on  a  case  of  dysentery  in  a  seaman,  aged  twenty-seven 
years,  who  had  not  been  in  the  tropics  since  1880,  but  had  been 
attacked  with  bloody  stools  a  week  before  his  admission  into 
the  hospital.  A  microscopical  examination  of  the  stools  by 
Dr.  Lafleur  showed  numerous  actively  moving  amoeboid  bodies 
of  from  five  to  seven  times  the  size  of  a  leucocyte ;  they  were 
of  a  pale  bluish-green  color,  and  contained  one  or  more  small 
vacuoles  surrounded  by  fine  and  often  highly  refracting  granu¬ 
lar  particles,  each  body  being  invested  by  a  homogeneous  outer 
zone  looking  like  finely  ground  glass.  The  outer  layer  would 
be  slowly  projected  from  some  part  of  the  surface  in  the  form 
of  a  hemispherical  knob,  and  the  granular  center  of  the  body 
would  then  flow  into  this  with  a  rapid  motion.  To  detect  these 
bodies,  first  described  by  Losch  in  1875,  the  stools  should  be 
passed  into  a  bed- pan  previously  warmed  with  hot  water  and 
an  examination,  of  the  discharge  made  at  once.  They  are  most 
abundant  in  the  grayish-yellow  pus  collections.  This  was  the 
first  time  they  had  been  demonstrated  to  a  medical  society  in 
this  country. 


THE  NEW  ST.  FRANCIS  HOSPITAL  IN  JERSEY  CITY. 

The  new  building  adjoining  the  original  hospital,  in  East 
Hamilton  Place,  was  opened  on  Saturday,  the  4th  inst.,  with 
the  ecclesiastical  ceremonies  customary  with  the  Pvoman  Catho¬ 
lic  Church  on  such  occasions,  with  the  co-operation  of  the  medi¬ 
cal  staff,  the  architect,  and  representatives  of  the  clerical  and 
medical  professions  in  several  neighboring  cities.  The  hospital 
is  under  the  care  of  the  Sisters  of  St.  Francis,  and  that  fact  of 
itself  insures  the  excellence  of  its  management.  Its  stand¬ 
ing  with  the  medical  profession  is  correspondingly  high  ;  by 
many  it  will  long  be  remembered  as  the  scene  of  much  of 
the  good  work  done  in  surgery  by  the  late  Dr.  Varick.  The 
additional  building  now  completed  makes  the  hospital  prac¬ 
tically  a  new  institution — one  thoroughly  equipped  with  the 
requisites  of  a  modern  hospital,  including  a  medical  and  sur¬ 
gical  staff  of  exceptional  efficiency,  enthusiasm,  and  singleness 
of  purpose. 

THE  ACTION  OF  STROPHANINE. 

According  to  the  Lancet ,  Dr.  Eothziegel  finds  that  stro- 
phanine,  the  active  principle  of  strophanthus,  in  doses  of  one 


three-hundredth  to  one  two-hundredth  of  a  grain  daily,  improves 
the  circulation,  strengthening  the  pulse,  and  attaining  its  full 
effect  in  two  or  three  days.  It  relieved  the  dyspnoea,  palpita¬ 
tion,  and  other  symptoms  occurring  in  organic  heart  disease; 
in  time  increased  the  flow  of  urine  without  irritating  the  kid¬ 
neys;  it  did  not  produce  gastric  symptoms ;  it  had  no  cumu¬ 
lative  effects;  and  it  only  indirectly,  but  favorably,  improved 
the  nervous  symptoms.  It  acted  most  rapidly  when  given  sub¬ 
cutaneously,  and  it  is  said  to  be  indicated  in  valvular  disease 
with  or  without  affection  of  the  myocardium,  while  in  Bright’s 
disease  it  produces  diuresis.  Strange  to  report,  the  tincture  of 
strophanthus  acted  more  certainly  and  more  quickly  than  the 
alkaloid. 

CREOLIN  IN  THE  TREATMENT  OF  CHANCROID. 

The  Bulletin  general  de  therapeutique  for  July  15th  pub¬ 
lishes  an  account  of  the  experience  of  Dr.  JosǤ  Busque,  of  Pe- 
lotas,  Brazil,  in  the  use  of  creolin  as  an  application  to  soft 
chancres.  It  was  used  in  the  proportion  of  from  twelve  to 
twenty  parts  of  creolin  to  a  thousand  parts  of  water,  and  is 
stated  to  have  caused  the  sores  to  heal  rapidly  even  in  cases  in 
which  the  action  of  corrosive  sublimate  and  that  of  iodoform 
had  been  tardy.  However,  the  most  rapid  healing  was  secured 
by  employing  creolin  and  iodoform  together. 


METHYLENE  BLUE  AS  AN  ANODYNE. 

The  Practitioner  cites  from  the  Pharmaceutical  Journal 
and  Transactions  an  account  of  the  results  of  the  use  of  methy¬ 
lene  blue  as  an  anodyne  in  the  Moabit  Hospital  in  Berlin.  Its 
employment  in  this  way  was  suggested  by  its  remarkable  affin¬ 
ity  for  nerve-tissue,  and  especially  for  the  axis-cylinder,  in  his¬ 
tological  staining.  When  administered  internally,  even  in  the 
smallest  doses,  it  could  be  detected  in  the  urine  in  a  quarter  of 
an  hour.  It  was  found  to  act  as  an  anodyne  in  various  painful 
local  diseases,  such  as  neuritis  and  rheumatic  affections  of  the 
muscles,  joints,  and  tendon-sheaths. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  Gases 
and  deaths  reported  during  the  two  weeks  ending  October  7,  1890: 


DISEASES. 

Week  ending  Sept.  30. 

Week  ending  Oct.  7. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

61 

11 

39 

3 

Scarlet  fever . 

27 

3 

28 

1 

Cerebro-spinal  meningitis. . 

3 

3 

2 

2 

Measles . 

•25 

2 

43 

4 

Diphtheria . 

54 

14 

57 

13 

Small-pox . 

1 

0 

0 

0 

Whooping-cough . 

2 

0 

0 

0 

The  Kings  County  Medical  Association  will  meet  on  October  14th, 
at  Kunzler’s  Hall,  near  the  Post-Office,  Brooklyn.  The  paper  of  the 
evening  will  be  read  by  Dr.  Nelson  L.  North,  on  The  Medical  and  Sur¬ 
gical  Treatment  of  Tuberculosis. 

The  District  Medical  Society  of  Northwest  Missouri  held  a  meeting 
in  St.  Joseph  on  Thursday,  the  9th  inst.,  under  the  presidency  of  Dr. 
.Tames  W.  Heddens,  of  St.  Joseph.  The  following  were  among  the 
papers  presented :  When  and  how  to  use  the  Obstetric  Forceps,  by 
Dr.  A.  Goslin,  of  Oregon,  Mo. ;  The  Most  Frequent  Cause  of  Death 
after  Abdominal  Section,  and  its  Prevention,  by  Dr.  George  Nash,  of 
Maryville ;  A  Function  of  the  Colon,  by  Dr.  M.  Rhodes,  of  Graham ; 
The  Eye  in  General  Diseases,  by  Dr.  P.  I.  Leonard,  of  St.  Joseph  ; 


Oct.  11,  1890.  J 


ITEMS.— LETTERS  TO  THE  EDITOR. 


(pri\  ate) ;  New  Bedford,  Mass.,  Society  for  Medical  Improvement 


Pudendal  Thrombus — History  of  a  Case,  by  Dr.  F.  G.  Thompson,  of  St. 
Joseph ;  Paraldehyde  as  a  Hypnotic,  by  Dr.  F.  C.  Hoyt,  of  St.  Joseph ; 
Excision  of  the  Breast,  by  Dr.  J.  A.  McKinnon,  of  Maysville. 

The  Medical  Society  of  the  State  of  New  York.— The  eighty-fifth 
annual  meeting  will  be  held  in  Albany  on  Tuesday,  Wednesday,  and 
Thursday,  February  3,  4,  and  5,  1891.  The  Business  Committee  has 
been  appointed  and  is  composed  of  the  following-named  gentlemen  :  Dr. 
Herman  Bendell,  178  State  Street,  Albany,  chairman;  Dr.  Seneca  D. 
Powell,  12  West  Fortieth  Street,  New  York;  and  Dr.  James  D.  Spen¬ 
cer,  Watertown.  The  president,  Dr.  W.  W.  Potter,  of  Buffalo,  says 
that  all  who  intend  to  present  papers  should  send  the  titles  thereof  to 
any  member  of  the  Business  Committee  not  later  than  December  15, 
1890,  as  the  programme  will  be  made  up  and  issued  early  in  January. 

The  Medical  Society  of  the  County  of  Ontario. — At  the  meeting  to 
be  held  on  Tuesday,  the  14th  inst.,  in  the  Court  House  in  Canandaigua, 
at  10.30  a.  m.,  Dr.  Charles  H.  Richmond,  of  Livonia  Station,  will  report 
a  case  of  intestinal  anastomosis  for  fmcal  fistula,  and  reports  of  other 
cases  of  interest  are  expected. 

The  New  Tariff  and  Medical  Books. — Some  of  our  readers  may  not 
be  aware  that  under  the  new  tariff  law  foreign  medical  books  printed 
in  any  other  language  than  English  are  admitted  without  the  payment 
of  duty. 

Changes  of  Address. — Dr.  Charles  H.  Chetwood,  to  No.  120  East 
Thirty-fourth  Street;  Dr.  H.  Newton  Heineman,  to  No.  60  West 
Fifty-sixth  Street ;  Dr.  George  A.  Peters,  to  No.  45  West  Thirty-fifth 
Street;  Dr.  Royal  Whitman,  to  No.  126  West  Fifty-ninth  Street. 

The  Death  of  Dr.  Montrose  A.  Pallen  took  place  on  Wednesday, 

the  1st  inst.  He  had  long  been  in  poor  health,  and.  his  death  was  not 
unexpected.  The  deceased  was  for  a  time  a  member  of  the  faculty  of 
the  Medical  Department  of  the  University  of  the  City  of  New  York, 
and  previously  of  that  of  one  of  the  St.  Louis  colleges.  During  his 
active  professional  career  he  was  a  prominent  gynaecologist. 

The  Death  of  Dr.  Cosmo  Brailly,  of  New  York,  occurred  on  Sunday, 
the  5th  inst.,  at  Hazlet,  N.  J.,  where  he  had  been  spending  the  summer. 
He  was  a  native  of  France,  but  had  practiced  medicine  in  New  York 
for  nearly  fifty  years. 

Society  Meetings  for  the  Coming  Week  : 

Monday,  October  13th :  New  York  Academy  of  Medicine  (Section  in 
Surgery);  New  York  Ophthalmological  Society  (private);  New  York 
Medico-historical  Society  (private) ;  New  York  Academy  of  Sciences 
(Section  in  Chemistry  and  Technology);  Lenox  Medical  and  Surgical 
Society  (private) ;  Boston  Society  for  Medical  Improvement ;  Gyne¬ 
cological  Society  of  Boston  ;  Burlington,  Yt ,  Medical  and  Surgical 
Club;  Norwalk,  Conn.,  Medical  Society  (private) ;  Baltimore  Medi¬ 
cal  Association. 

Tuesday,  October  llfh:  Tri-State  Medical  Association  (first  day — 
Chattanooga);  New  York  Medical  Union  (private);  Kings  County, 
N.  Y.,  Medical  Association  (Brooklyn) ;  Medical  Societies  of  the 
Counties  of  Albany  (annual),  Chenango  (tri-annual),  Greene  (semi¬ 
annual — Cairo),  Jefferson  (quarterly— Watertown),  Oneida  (quar¬ 
terly— Utica),  Ontario  (quarterly— Canandaigua),  Rensselaer,  Scho¬ 
harie  (semi-annual),  Tioga  (quarterly — Owego),  and  Wayne  (semi¬ 
annual),  N.  Y. ;  Newark,  N.  J.,  and  Trenton  (private),  N.  J.,  Medi¬ 
cal  Associations;  Bergen,  N.  J.,  and  Cumberland  (semi-annual), 
N.  J.,  County  Medical  Societies ;  Litchfield,  Conn.,  County  Medical 
Society  (annual);  Baltimore  Gynaecological  and  Obstetrical  Society. 
Wednesday,  October  15th:  Tri-State  Medical  Association  (second  day); 
Harlem  Medical  Association  of  the  City  of  New  York  ;  Northwest¬ 
ern  Medical  and  Surgical  Society  of  New  York  (private) ;  Medico- 
.  legal  Society  ;  Medical  Society  of  the  County  of  Allegany  (quarterly), 
N.  Y. ;  New  Jersey  Academy  of  Medicine  (Newark) ;  Philadelphia 
County  Medical  Society. 

Thursday,  October  16th :  Tri-State  Medical  Association  (third  day) ; 
New  York  Academy  of  Medicine;  Metropolitan  Medical  Society 


(private). 

Friday,  October  17th:  New  York  Academy  of  Medicine  (Section  in 
Orthopaedic  Surgery);  Chicago  Gynaecological  Society  (annual); 
Baltimore  Clinical  Society. 

Saturday,  October  18th  :  Clinical  Society  of  the  New  York  Post¬ 
graduate  Medical  School  and  Hospital. 


fetters  to  tljc  (^bitur. 


MASSAGE  IN  SWEDEN. 

Stockholm,  September  15 ,  1890. 

To  the  Editor  of  the  New  Yoric  Medical  Journal : 

Sik:  This  attractive  and  picturesque  city  in  the  North,  built 
on  several  islands  on  Lake  Malar  and  an  arm  of  the  Baltic 
Sea  at  the  point  where  the  two  meet,  and  laying  claim  to  the 
titles  of  u  The  Venice  ”  and  “  The  Paris  of  the  North,”  is  rapidly 
making  good  another  claim,  “The  Mecca  for  Gynaecologists ” ; 
for  since  some  four  years  ago,  when  Major  Thure  Brandt  went 
to  Jena  at  the  invitation  of  Professor  Scluiltze,  of  that  place,  and 
subjected  his  method  of  treating  cases  of  pelvic  affections  to  the 
close  scrutiny  and  criticism  of  that  distinguished  gynaecologist, 
physicians  in  great  numbers,  from  Germany,  Austria,  Russia, 
and  a  few  from  other  countries,  have  flocked  here  to  see  and  ac¬ 
quire  the  method.  When  we  reached  Norway  about  three 
months  ago,  we  wrote  to  Major  Thure  Brandt  expressing  our 
desire  of  working  under  him  for  a  time.  The  reply  was  courte¬ 
ous,  short,  and  prompt  in  making  its  appearance.  It  stated  a 
condition  of  having  to  agree  to  remain  two  months  should  he 
think  it  necessary.  Having  accepted  the  condition,  we  according¬ 
ly  presented  ourselves  on  the  morning  of  the  1st  of  September, 
and  were  shown  into  a  large  and  artistically  furnished  parlor  to 
await  the  master.  In  a  few  minutes  a  man  well  advanced  in 
years  (seventy-one),  but  with  a  firm  and  elastic  step,  military 
bearing,  a  fine  physique,  and  a  finely  shaped  head  well  poised 
on  broad  shoulders,  entered  and  extended  to  us  a  cordial  wel¬ 
come  with  a  warm  shake  of  the  hand. 

Every  morning  (excepting  Sunday)  at  eleven  o’clock  the  pa¬ 
tients  present  themselves  for  treatment.  They  congregate  in  a 
large  waiting-room,  devoid  of  carpet,  and  around  the  three 
sides  of  which  are  ranged  a  number  of  low  couches  and  cane- 
bottom  chairs,  with  high,  straight  backs.  Here  they  are  put 
through  a  number  of  gymnastic  movements  by  a  bright,  intelli¬ 
gent  little  woman  —  Miss  Johnsson,  Brandt’s  assistant.  On 
watching  these  manipulations  for  the  first  time,  as  each  patient 
in  turn  was  subjected  to  a  certain  manoeuvre,  then  let  alone  for 
five  or  ten  minutes,  to  be  taken  up  again  for  a  different  exer¬ 
cise,  the  impression  produced  was  rather  comical.  One  re¬ 
called  Lord  Dundreary’s  system  of  “  taking  exercise  in  compart¬ 
ments.”  But  a  longer  observation  revealed  the  facts  that  each 
patient  was  provided  with  a  formula  of  the  movements  to  be 
carried  out,  that  each  movement  had  a  distinct  object  in  view 
relative  to  the  disease  with  which  the  patient  was  suffering, 
and  that,  in  accordance  with  an  old  law  in  medical  gjmnastics, 
a  certain  interval  must  intervene  between  the  execution  of  the 
different  exercises. 

Major  Thure  Brandt  always  applies  the  special  treatment  of 
the  pelvic  contents  himself  in  a  separate  room — i.  <?.,  he  never 
intrusts  it  to  his  assistant.  One  is  not  here  long  before  he  is 
fully  convinced  of  the  utter  futility  of  trying  to  learn  the  meth¬ 
od  from  books  and  articles — a  fact  insisted  upon  by  every  one 
who  has  written  on  the  subject  after  having  seen  Brandt  work. 


412 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


Another  point  which  one  soon  learns,  and  which  also  has  been 
freely  expressed  by  the  same  writers,  is  that  this  non-medical 
man  possesses  a  diagnostic  skill  which  would  put  to  shame 
many  an  eminent  gynaecologist.  His  knowledge  of  the  anatomy 
of  the  contents  of  the  abdomen  and  pelvis  is  extensive,  and  in 
the  main  correct.  This  is  not  the  time  or  place  to  express  an 
opinion  on  his  method,  which  also  requires  a  fuller  acquaint¬ 
ance  and  a  longer  observation  than  we  have  as  yet  gained.  But 
so  much  we  can  venture  to  say,  that  the  impression  so  far  is 
extremely  favorable,  and  that  much  more  can  be  accomplished 
with  it,  in  a  certain  class  of  cases,  than  we  had  thought  it  pos¬ 
sible  before  coming  here.  Whether  this  layman  will  prove  to 
be  another  veritable  Preissnitz  is,  perhaps,  at  this  stage,  too 
early  to  predict.  But  too  much  praise  can  not  be  bestowed 
upon  him  for  his  conscientiousness,  his  earnestness,  his  gener¬ 
osity,  his  sacrifices,  and  his  self-disinterested  desire  to  propagate 
his  system  and  to  relieve  suffering  womankind. 

This  city,  as  is  well  known,  is  the  home  of  medical  gymnas¬ 
tics  and  massage.  A  visit,  therefore  (in  fact,  we  have  already 
made  many),  to  the  Central  Gymnastic  Institute  is  not  only  in¬ 
teresting  but  profitable.  At  our  first  visit  wTe  were  conducted 
through  the  building  by  the  genial,  courteous,  and  highly  cult¬ 
ured  Professor  L.  M.  Torngren,  the  chief  of  the  institute.  Every 
part  and  contrivance  was  shown  and  fully  explained  in  excel¬ 
lent  English  by  the  professor.  On  entering  one  of  the  rooms, 
we  took  by  surprise  a  number  of  bright-looking  girls,  each  por¬ 
ing  studiously  over  a  work  on  anatomy  and  some  bone  of  the 
human  frame.  The  number  of  very  fine  human  skeletons  and 
bones  in  this  room  surprised  us  in  turn,  as  did  also  the  informa¬ 
tion  that  the  students  had  to  follow  the  dissection  of  six  whole 
bodies  each  session  for  two  sessions.  How  many  of*>ur  medi¬ 
cal  schools  call  for  as  much  from  their  students?  The  students 
are  also  given  a  good  grounding  in  physiology  and  in  the  diag¬ 
nosis  and  pathology  of  those  diseases  amenable  to  treatment 
by  medical  gymnastics  and  massage.  Before  receiving  a  di¬ 
ploma  the  student  must  have  attended  two  full  sessions  of  eight 
months  each,  and  have  passed  a  creditable  examination  in  the 
foregoing  subjects.  But,  for  fear  some,  of  your  readers,  who  are 
sending  patients  to  Swedish  masseurs  and  masseuses,  on  reading 
this  will  fall  into  a  false  security,  I  hasten  to  add  that  Professor 
Torngren  assures  me  that  there  are  only  three  of  their  graduates 
in  the  whole  of  the  United  States,  and  that  not  one  of  these  is 
living  in  New  York  city.  Of  course,  New  York  may,  neverthe¬ 
less,  have  some  very  competent  masseurs  and  masseuses,  but  it 
is  well  to  bear  in  mind  the  foregoing  circumstance  when  sub¬ 
jecting  one’s  patient  to  treatment  by  massage.  This  treatment, 
which  has  grown  so  much  in  fashion  with  us  lately,  as  it  is  wit 
nessed  here,  though  capable  of  doing  much  good  in  certain 
cases,  is  certainly  capable  of  inflicting  much  harm  when  done 
injudiciously  or  by  untrained  persons. 

H.  N.  Vineberg,  M.  D. 


EXTRACT  OF  PiNUS  PALUSTRIS  AS  A  VULNERARY. 

Charleston,  S.  C. 

To  the  Editor  of  the  New  York  Medical  Journal: 

Sir  :  I  wish  to  call  the  attention  of  the  profession  to  a  treat¬ 
ment  which,  so  far  as  I  know,  is  original,  and  with  which  I  have 
had  marked  success  in  the  treatment  of  fistula  in  ano. 

After  the  proper  surgical  procedures  have  been  carried  out, 
a  strong  extract  of  lightwood  ( Pinus  palustris )  in  alcohol  is 
applied.  This  very  adhesive  preparation  glues  together  the 
edges  of  the  wound  and  thus  insures  quick  and  healthy  union. 
The  advantages  alleged  for  this  treatment  are:  1.  That  the  di¬ 
vided  tissues  are  kept  firmly  held  together,  and  thus  their  union 
is  quickly  attained.  2.  The  extract  of  lightwood  acts  as  a  heal¬ 


ing  agent,  stimulating  to  just  such  a  degree  as  is  necessary  to 
bring  about  quick  and  healthy  union.  The  utility  of  this  mode 
of  treatment,  I  am  quite  sure,  will  be  very  evident  to  all  who 
give  it  a  fair  trial,  and  it  will,  I  am  equally  sure,  supersede  the 
time-honored  use  of  styptics  in  these  cases.  The  extract  may 
be  used  either  with  a  syringe  or  else  applied  directly  by  a  suit¬ 
able  instrument  when  the  tract,  sinus,  or  broken  tissues  are  in 
view.  Of  course,  the  application  should  be  made  daily,  or  so 
loner  as  the  parts  do  not  appear  firmly  united.  The  extract  of 
lightwood  is  simply  made  by  placing  in  a  small  quantity  of  alco¬ 
hol  a  number  of  shavings  of  fat  lightwood,  gauging  the  quantity 
so  as  to  get  an  extract  of  a  syrupy  consistence. 

Whenever,  then,  the  close  apposition  of  surfaces  after  sur¬ 
gical  procedures  is  necessary  to  bring  about  healthy  union,  the 
application  of  this  extract  will  meet  the  indication  and  will,  in¬ 
deed,  take  the  place  of  sutures  in  those  parts  of  the  body  where 
they  are  inapplicable.  Allard  Memminger,  M.  D. 

***  In  a  supplementary  letter,  Professor  Memminger  in¬ 
forms  us  that  the  extract  is  made  from  only  those  parts  of 
the  tree  that  have  been  converted  into  “lightwood,”  and  from 
which  much  rosin  is  exuding,  such  as  the  knots  of  the  trunk  of 
a  tree  that  has  been  felled  for  some  time  and  is  elsewhere  un¬ 
dergoing  decay. 


JJroceubinjgs  of  Sodeties* 


RICHMOND  ACADEMY  OF  MEDICINE  AND  SURGERY. 

Meeting  of  August  26,  1890. 

The  President,  Dr.  W.  W.  Parker,  in  the  Chair. 

*  ( Reported  by  Dr.  J.  W.  Henson ,  Richmond .) 

Symptoms  of  Cocaine  Poisoning  from  Half  a  Drachm 

(per  rectum)  of  a  Three-per-cent.  Solution _ Dr.  Ramon  D. 

Garcin  reported  that  six  weeks  or  two  months  since  he  had 
been  called  to  see  Mr.  F  ,  who  had  been  operated  upon  by  an 
irregular,  who  was  out  of  the  city  when  the  speaker  was  called. 
When  he  had  reached  the  man  he  was  suffering  intensely,  and 
morphine  hypodermatically  not  relieving  him,  half  a  drachm  of 
a  three-per-cent,  solution  of  cocaine  was  administered  per  rec¬ 
tum.  No  relief  of  pain  had  ensued,  but  in  a  short  time  breath¬ 
ing  had  become  quickened,  extremities  cold,  pulse  rapid  and 
weak.  The  man  had  described  his  flesh  as  tingling  like  the  sen¬ 
sation  felt  upon  first  grasping  the  poles  of  a  galvanic  battery. 
By  the  use  of  stimulants  he  had  soon  rallied. 

Dr.  J.  P.  Roy  asked  if  the  muscles  of  deglutition  were  af¬ 
fected. 

Dr.  Garoin  replied  that  they  were  not. 

A  Case  for  Diagnosis.— On  July  8,  1890,  Dr.  Garcin  said 
that  he  had  been  called  to  see  Mr.  M.,  aged  nineteen  years,  who 
had  complained  of  intense  nausea  and  pains  resembling  cramps 
in  the  region  of  the  epigastrium.  The  history  of  the  case  be¬ 
fore  this  was  negative.  He  had  been  to  work  up  to  the  day 
before  taking  his  bed,  although  a  week  previously  there  bad 
been  a  slight  diarrhoea  fora  few  days;  but  when  the  doctor 
was  called  the  man  had  said  that  his  bowels  were  in  a  normal 
condition.  His  tongue  was  very  slightly  furred,  temperature 
(by  mouth)  98-5°  F.,  and  the  abdomen,  especially  about  the  um¬ 
bilical  region,  was  very  tympanitic.  A  distinct  gurgling  (ex¬ 
actly  resembling  that  of  typhoid  fever)  was  present  in  both 
iliac  fossaa.  The  bowels  had  been  moved  once  that  day. 

The  speaker  had  given  a  simple  anodyne  for  the  cramps, 
which  had  soon  afforded  relief,  and  dilute  hydrochloric  acid, 
fifteen  drops  every  four  hours. 


Oct.  11,  1890.  J 


413 


PROCEEDINGS 

July  9th  and  10th. — Patient  about  the  same;  bowels  acting 
once  daily.  A  mixture  of  equal  parts  of  turpentine  and  sweet 
oil  was  ordered  applied  over  the  iliac  region.  lie  had  from  the 
first  ordered  liquid  diet.  The  temperature  was  normal ;  taken 

once  that  day. 

12th. —  The  characteristic  diarrhoea  of  typhoid  “pea-soup” 
discharges;  temperature  normal,  morning  and  evening.  Tym¬ 
panites  being  more  decided,  fifteen  drops  of  turpentine  in  emul¬ 
sion  every  six  hours  was  ordered. 

18th,  llfth ,  and  15th. — Tympanites  decidedly  diminished. 
Diarrhoea  worse  toward  evening;  three,  four,  and  sometimes 
five  discharges  from  3  p.  m.  to  6  or  7  p.  m.  The  speaker  ordered 
fifteen  drops  of  dilute  hydrochloric  acid  and  ten  grains  each  of 
lactopeptine  and  bismuth  subnitrate  every  four  hours. 

16th  and  17th. — Patient  seen  for  the  speaker  by  Dr.  R.  T. 
Ellis. 

18th,  19th,  20th,  and  21st. — Bowels  not  so  bad  ;  tympanites 
had  disappeared;  slight  gurgling  in  right  iliac  fossa;  no 

fever. 

22d. — Pulse  and  temperature  normal;  bowels  moved  once; 
tongue  healthy. 

The  interesting  features  of  this  case,  said  the  speaker,  were 
(1)  entire  absence  of  fever,  morning  and  evening;  (2)  absence 
of  the  typhoid  tongue;  and  (3)  absence  of  coma,  the  man  being 
conscious  throughout  the  attack.  The  after-treatment  had  been 
a  tonic  of  vin  Mariani.  The  patient  was  out  by  August  1st. 

The  President  asked  if  there  was  any  history  of  phthisis? 

Dr.  Garoin  replied  No. 

Dr.  J.  M.  Winfree — Any  pain,  mucus,  or  blood? 

Dr.  Garoin — Some  pain  ;  no  mucus  or  blood. 

Dr.  T.  J.  Moore — How  long  was  the  man  sick? 

Dr.  Garoin — About  three  weeks. 

Dr.  Moore — Did  Dr.  Garoin  see  him  when  first  taken  ? 

Dr.  Garoin — Yes,  when  he  first  took  to  bed ;  but  he  had 
been  complaining  before,  although  at  work  up  to  the  day  be¬ 
fore  the  first  visit. 

Dr.  Moore — What  was  his  work? 

Dr.  Garoin — Apprenticed  lithographer. 

Dr.  Moore — Did  he  work  in  lead? 

Dr.  Garoin — Yes;  a  little  in  mixing  paints. 

Dr.  Moore  stated  that  the  symptoms  were  so  obscure  it  was 
impossible  to  make  anything  like  an  accurate  diagnosis. 

When  a  person  was  subjected  to  the  gradual  and  prolonged 
absorption  of  lead,  there  occurred  sometimes  a  condition  where 
there  was  no  manifestation  of  colica  pictonum  proper,  but  a 
certain  degree  of  constipation  followed  by  an  irritative  diar¬ 
rhoea.  Possibly  this  patient  was  so  affected.  The  diurnal  nor¬ 
mal  temperature  excluded  typhoid  fever.  There  was  sometimes 
a  condition  of  bowel  where  a  local  irritation  of  a  diarrlioeic  char¬ 
acter  congested  and  caused  ulceration  of  Peyer’s  patches ;  this 
might  give  the  characteristic  pultaceous  stools  with  the  fcetor 
of  typhoid  actions,  accompanied  by  tympanites.  Mere  tym¬ 
panites  occurred  in  so  many  conditions  that  it  was  not  calcu¬ 
lated  to  lead  up  to  a  diagnosis.  Tenderness  in  the  ileo-cascal 
region  was  more  directly  prognostic. 

Abscess  of  the  Parotids  complicating  Typhoid  Fever. — 
The  President  had  seeD,  in  a  boy  aged  sixteen  years,  abscess 
of  each  parotid  gland  as  a  complication  of  typhoid  fever.  Each 
abscess  had  discharged  from  the  ear  before  being  lanced,  the 
discharge  through  the  ear  ceasing  after  the  lancing.  The  point 
was  that  the  boy  had  recovered,  though  some  one  had  stated 
that  all  cases  of  typhoid  fever  with  abscess  about  the  parotid 
gland  proved  fatal. 

Dr.  Moore  said  that  several  years  since  Dr.  R.  M.  0.  Page, 
of  New  York,  had  written  an  article  on  secondary  parotiditis  in 
which  he  had  stated  that  when  suppuration  of  the  parotid  gland 


OF  SOCIETIES. 


arose  as  a  complication  of  typhoid  fever,  nearly  all  cases  so  af¬ 
fected  proved  fatal. 

Dr.  Roy  had  had  a  similar  case  to  Dr.  Parker’s  last  autumn 
occurring  in  about  the  third  week  of  typhoid.  As  in  Dr.  Par¬ 
ker’s  case,  each  abscess  had  discharged  from  the  ear.  There  had 
also  been  an  accompanying  cancrum  oris— a  spot  of  gangrene 
of  the  size  of  a  silver  dollar  appearing  on  the  outside  of  one 
cheek  before  death,  which  had  followed  soon. 

Aneurysm  of  the  Arch  of  the  Aorta.— Dr.  Lewis  0.  Bosher 
had  been  called  in  consultation  with  Dr.  Jones  to  see  a  colored 
woman  who  was  suffering  from  the  effects  of  a  pulsating  tumor 
occupying  the  upper  part  of  the  left  side  of  the  thorax.  He  had 
found  a  patient  about  thirty-five  years  of  age  who  was  exceed¬ 
ingly  emaciated  and  suffering  greatly  from  pain,  dyspnoea,  and 
extreme  debility.  She  had  little  or  no  appetite.  On  examina¬ 
tion,  the  tumor,  which  had  measured  about  three  inches  by  three 
inches  and  a  half  at  every  point,  had  given  a  distinct  pulsation 
corresponding  to  the  cardiac  systole.  The  stethoscope  gave  only 
an  indistinct  bruit.  The  sternum  had  appeared  to  project  for¬ 
ward,  and  there  was  a  complete  dislocation  of  the  left  clavicle 
at  the  left  sterno-clavicular  articulation.  He  diagnosticated  the 
tumor  as  an  aneurysm  of  the  arch  of  the  aorta,  which  had  pro¬ 
jected  forward,  pressing  against  the  sternum,  ribs,  and  clavicle, 
and  causing  absorption  of  the  former  and  dislocation  of  the 
latter.  On  Saturday  night  last  this  patient  had  died,  and  yes¬ 
terday,  with  the  assistance  of  Dr.  0.  A.  Blauton,  Dr.  Daniel  J. 
Coleman,  Dr.  Jones,  and  others,  a  post-mortem  was  made  which 
had  confirmed  the  diagnosis.  A  sacculated  aneurysm,  springing 
from  the  arch  of  the  aorta  and  projecting  forward  and  upward, 
had  dislocated  the  left  clavicle  at  its  sternal  end  and  had  caused 
absorption  of  some  of  the  upper  ribs  as  well  as  the  sternum  at 
the  junction  of  the  manubrium  and  gladiolus.  There  was  a 
slight  rupture  in  the  sac  from  which  there  had  been  probably  a 
slow  leakage  of  blood,  thus  accounting  for  the  gradual,  rather 
than  the  sudden,  death,  such  as  results  from  sudden  rupture  and 
copious  haemorrhage.  The  left  side  of  the  thorax  was  filled  with 
blood. 

A  Limit  to  Life  in  Organic  Heart  Disease  should  be  set 
with  Caution. — The  President  had  reported,  two  or  three  years 
ago,  the  case  of  a  man,  aged  about  seveDty-five  years,  with  en¬ 
larged  and  valvular  disease  of  the  heart.  Pulse  had  been  24 
per  minute  for  months  at  a  time.  While  under  his  observation 
— a  period  of  about  two  months — he  had  apparently  died  tum¬ 
or  five  times  a  day.  At  the  end  of  two  months  he  had  left  town 
— now  over  two  years  since.  He  had  just  died  a  few  days  ago. 

A  doctor  should  be  careful  how  he  limited  life  in  a  per-on 
with  organic  heart  trouble.  As  illustrative,  the  speaker  told  of 
a  man  named  Shook,  the  action  of  whose  heart  (from  hypertro¬ 
phy)  had  been  so  violent  as  to  shake  the  bed.  After  being  in 
bed  several  months,  he  had  got  up  and  walked  about  for  one  or 
two  years. 

Mastoiditis  in  the  Negro — Dr.  W.  F.  Mercer  asked  if  any¬ 
body  had  ever  seen  mastoiditis  in  a  full-blooded  negro.  Dr.  T. 
E.  Murrell,  of  Little  Rock,  Arkansas,  had  stated  that  mastoiditis 
was  never  seen  in  a  full-blooded  negro.  In  a  dispensary  prac¬ 
tice  of  six  years  (the  majority  of  the  patients  negroes  too)  the 
speaker  had  never  seen  a  case  in  a  full-blooded  negro  until  within 
the  last  two  months — one  case  occurring  in  a  man.  His  only 
evidence  that  he  was  full-blooded  was  his  appearance  and  state¬ 
ment. 

The  President  had  had  a  case  in  a  mulatto.  This  had  been 
operated  upon  by  Dr.  J.  A.  White,  but  death  had  occurred  in 
three  or  four  weeks  afterward. 

Continued  Fevers. — The  President  had  seen  some  time 
ago  a  case  of  fever  with  Dr.  O.  A.  Crenshaw,  who,  a  great  be¬ 
liever  in  typhoid  fever,  had  insisted  that  this  was  typhoid  for 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mbd.  Jour., 


414 

some  time  ;  but  it  was  not.  The  woman  had  been  badly  treated 
by  her  husband.  The  speaker  thought  it  an  irritative  fever.  It 
had  terminated  favorably  after  three  or  four  weeks’  duration. 
It  was  not  usual,  though,  to  see  a  continued  fever  unless  it  be 
typhoid.  He  had  seen  numbers  of  cases  of  slow-pulse  typhoid 
before  the  war.  The  amount  of  prostration,  however,  proved 
them  to  be  typhoid  to  his  mind.  He  was  now  attending  a  young 
lady  who  had  had  typhoid  fever  in  Charlottesville.  Supposed 
to  be  decidedly  convalescent,  she  had  been  brought  here  two 
weeks  ago  to  escape  diphtheria.  Moving  had  done  a  great  deal 
of  harm.  Her  temperature  was  now  108°  F.  She  could  not 
walk  five  steps  now  without  help.  He  had  been  called  on  Sat¬ 
urday  night  to  see  a  young  man  in  the  same  house  with  the 
young  lady.  His  temperature  was  103°,  and  he  bad  presented 
the  symptoms  of  cold — flushes  and  steams  alternating  with  cold 
chills.  The  speaker  thought  it  a  general  inflammatory  fever  or 
a  sort  of  general  rheumatism.  He  had  given  him  calomel  and 
soda  then,  and  on  Sunday  quinine,  five  grains  every  four  hours. 
On  Monday  he  was  in  a  profuse  cold  sweat,  pulse  feeble,  no 
fever  from  symptoms,  bowels  and  tongue  pretty  good,  appetite 
bad  except  for  liquids.  He  thought  he  would  soon  be  better. 
Tuesday  (to-day)  his  temperature  was  103°.  Perspiration  gone. 
Skin  hot. 

The  speaker  had  forgotten  to  say  that  he  had  had  two  hfem- 
orrhages  from  the  nose  on  Monday  night.  He  thought  the  case 
peculiar,  and  was  uncertain  whether  it  was  typhoid  or  not. 

Dr.  M.  D.  IIoge,  Jr.,  asked  if  there  was  any  cough  ? 

The  President  replied,  None. 

Dr.  David  MoOaw — Had  the  patient  been  given  any  anti- 
pyrine  ? 

The  President — None.  Had  Dr.  Moore  seen  any  cases  of 
continued  fever  not  typhoid? 

Dr.  Moore  replied,  Yes. 

The  President — What  was  the  pathology  of  them? 

Dr.  Moore  stated  that  every  fever  was  continued  in  which 
there  was  no  intermission  —  for  example,  remittent  malarial 
fever.  What  was  the  president’s  idea  of  continued  fever? 

The  President  thought  typhoid  and  typhus  continued  fevers, 
but  not  malarial  fever. 

Dr.  Moore  stated  that  he  had  seen  a  form  of  fever  this  sea¬ 
son  that  had  corresponded  neither  in  type  nor  characteristics 
to  either  remittent  or  typhoid  fever. 

He  thought  the  lines  were  too  sharply  drawn  by  the  writ¬ 
ers  concerning  the  continued  fevers  common  to  various  sec¬ 
tions  of  the  United  States.  We  saw  occasionally  in  this  part  of 
Virginia  a  form  of  fever  congestive  in  type  (attributable  to  heat 
and  the  peculiar  atmospheric  conditions),  with  high  and  irregu¬ 
lar  diurnal  thermometric  ranges,  great  rapidity  of  pulse,  con¬ 
gestion  and  tenderness  of  spleen  and  liver,  congestion  of  kid¬ 
ney,  a  certain  amount  of  tympanites,  and  of  uncertain  duration, 
lasting  often  from  ten  days  to  two  weeks.  It  did  not  yield  to 
quinine,  while  alterative  doses  of  mercury  modified  the  disease 
and  shortened  the  duration  of  the  fever.  It  was  accompanied 
by  a  bilious  diarrhoea,  yielding  best  to  bismuth  and  opium.  Ty¬ 
phoid  existed  in  all  parts  of  the  United  States.  It  was  most 
prevalent  and  violent  in  type  in  high  altitudes.  It  hugged  the 
mountains  and  a  belt  of  Piedmont  country  contiguous  thereto. 
It  was  also  found  in  the  low  country  and  in  Tertiary  formations. 
It  was  modified  in  many  of  its  symptoms  by  the  effect  of  pro¬ 
longed  heat  and  the  structural  alterations  of  the  glandular 
organs,  particularly  the  spleen  and  liver,  by  malarious  influ¬ 
ences.  The  speaker  was  not  referring  now  to  the  disease  called 
typho-tnalarial  fever.  The  cause  of  typhoid  fever  had  never 
been  ascertained.  Scientific  men  had  offered  many  suggestions 
without  definite  results.  Sewer-gas  was  often  mentioned  as 
the  vehicle  by  which  the  specific  poison  was  conveyed.  In 


many  places,  especially  mountainous  sections,  both  sewers  and 
sewer-gas  were  unknown.  Running  and  well  water  were  both 
frequently  thought  to  contain  the  specific  poison.  He  did  not 
believe  a  specific  cause  or  germ  had  been  definitely  ascertained. 
He  related  how  an  old  Tennessee  doctor,  unlettered  but  experi¬ 
enced,  at  some  convention  had  stated  that  he  knew  nothing  of 
germs  and  the  other  new-fangled  notions  in  regard  to  the  cause 
of  typhoid  fever,  but  that  whenever  he  could  induce  any  of  his 
families  to  locate  their  stables  and  hog-pens  at  a  sufficient  dis¬ 
tance  from  their  houses,  and  remove  their  chip-piles  at  the 
proper  seasons,  he  noticed  that  such  families  were  not  troubled 
with  typhoid  fever.  Typhoid  differed  markedly  in  regard  to 
the  severity  of  attacks,  embracing  from  the  walking  cases  upon 
the  one  hand  to  the  malignant  upon  the  other.  In  regard  to 
the  perspiration  mentioned  by  the  president,  he  had  seen  fre¬ 
quently  profuse  sweats  in  the  first  week  of  conception  of  ty¬ 
phoid  fever,  but  usually  there  was  a  dry  skin. 

The  President  remarked  that  in  some  parts  of  East  Ten¬ 
nessee  the  people  forty  years  ago  had  never  heard  of  sewers  or 
sewer-gas,  or  of  typhoid  fever.  But  he  spoke  of  an  old  gentle¬ 
man,  owning  about  seventy-five  negroes,  and  who  had  lived 
seven  miles  from  bis  nearest  neighbor,  and  the  fact  that  awhile 
later  typhoid  broke  out  among  his  slaves,  though,  as  stated 
before,  it  had  not  been  heard  of  previously. 


MEDICO-CHIRURGICAL  SOCIETY  OF  MONTREAL. 

Meeting  of  May  30,  1890. 

The  President,  Dr.  G.  Armstrong,  in  the  Chair. 

Sudden  Death  from  Rupture  of  a  Gummatous  Tumor  of 
the  Heart-wall. — Dr.  John  A.  Hutchinson  exhibited  the  heart 
of  a  young  man  who  had  died  suddenly.  He  had  not  known 
him  at  all  during  life,  but  had  good  reason  to  believe  that  he 
had  been  under  treatment  for  syphilis.  The  heart  had  been 
removed  by  order  of  the  coroner,  and  a  caseous  tumor,  proba¬ 
bly  a  gumma,  had  been  found  in  the  wall  of  the  right  ventricle. 
This  had  broken  down  on  its  inner  side,  and  its  contents,  which 
were  almost  liquid,  had  escaped  into  the  ventricle. 

Obstruction  of  the  Bowel  by  a  Gall-stone  followed  by 
Spontaneous  Relief. — Dr.  Bell  exhibited  a  gall-stone  of  a 
round  outline  as  large  as  a  walnut  which  had  been  passed  per 
anum  under  the  following  circumstances:  The  patient,  a  spin¬ 
ster  aged  sixty-seven,  had  enjoyed  good  health,  with  the  ex¬ 
ception  of  an  obscure  illness  somewhat  resembling  typhoid 
fever  three  years  ago.  The  present  illness  had  begun  with  ab¬ 
dominal  pain  and  discomfort,  and  it  had  soon  become  evident 
that  an  acute  obstruction  was  present.  Abdominal  section  bad 
been  proposed  but  obstinately  objected  to  by  the  patient.  Sub¬ 
sequently  repeated  enemata  had  been  employed.  On  the  sixth 
day  the  bowels  had  moved  spontaneously  and  this  huge  gall¬ 
stone  had  been  found  in  the  faaces. 

Enormous  Vesical  Calculus. — Dr.  Hingston  exhibited  an 
enormous  stone,  weighing  a  few  grains  over  five  ounces,  which 
he  had  that  day  removed  from  the  bladder  of  an  elderly  man 
by  the  lateral  method.  He  compared  it  with  a  stone  nearly  as 
large  which  he  had  removed  by  the  same  method  sixteen  years 
ago. 

The  Distribution  of  the  Lesions  in  Chronic  Phthisis.— 

Dr.  I.  G.  McCarthy  read  the  paper  of  the  evening  with  this 
title.  After  rapidly  reviewing  the  advances  made  in  the  study 
of  tuberculosis,  he  explained  the  theory  of  localization  of  the 
tubercular  lesions  of  the  lung  enunciated  in  1888  by  Dr.  I. 
Kingston  Fowler,  of  the  Brompton  Hospital  for  Consumption, 
and  related  his  own  experiences  of  many  chest  cases  examined 
,n  that  hospital,  while  he  was  attending  Dr.  Fowler’s  clinic, 


Oct.  11,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


415 


where  he  lmd  opportunities  of  verifying  the  doctrines  of  liis 
teacher.  He  had  found,  too,  that  “the  disease  in  its  onward 
progress  through  the  lungs,  in  the  majority  of  cases,  followed 
a  distinct  route  from  which  it  was  only  turned  aside  by  the  in¬ 
troduction  of  some  disturbing  element.”  This  doctrine  was 
based  upon  numerous  post-mortem  examinations  and  an  exten¬ 
sive  clinical  experience.  It  had  been  long  established  that  the 
apex  of  the  upper  lobe — that  was,  the  apex  of  the  lung — was 
the  usual  site  of  deposit,  and  that  it  was  generally  the  part  to 
be  first  affected.  Fowler  had  defined  two  points  as  the  sites  of 
the  primary  lesion.  The  one  most  frequently  found  was  situ¬ 
ated  from  an  inch  to  an  inch  and  a  half  from  the  summit  of  the 
lung  and  nearer  the  posterior  than  the  anterior  surface.  On 
the  chest  this  corresponded  to  a  point  above  the  clavicle,  or 
immediately  below  the  center  of  that  bone ;  posteriorly  it  was 
in  relation  with  the  supraspinous  fossa.  Hence,  the  examina¬ 
tion  of  the  supraspinous  region  was  of  the  utmost  importance. 
The  disease  next  tended  to  spread  downward  at  about  three 
fourths  of  an  inch  from  the  surface  of  the  lung  anteriorly,  and 
Avas  mapped  out  on  the  chest-wall  by  a  line  corresponding  to 
an  inch  and  a  half  from  the  inner  ends  of  the  first,  second,  and 
third  interspaces.  The  disease  here  was  made  up  of  new  foci 
occurring  in  nodules,  with  normal  lung-tissue  intervening.  As 
the  disease  progressed,  a  time  would  come  when,  by  the  soften¬ 
ing  and  extension  of  these  nodules,  there  would  be  physical 
signs  of  extensive  disease  anteriorly.  But  this  did  not  take 
away  from  the  fact  that  the  disease,  in  the  first  instance,  oc¬ 
curred  nearer  the  posterior  surface  and  tended  to  spread  back¬ 
ward. 

The  other  and  less  frequent  site  of  the  primary  lesion  was 
in  relation  with  the  first  and  second  interspaces,  below  the 
outer  third  of  the  clavicle.  It  spread  downward,  and  an  oval 
portion  of  lung  was  involved.  The  middle  lobe  was  rarely  pri¬ 
marily  affected.  The  next  point  at  which  the  disease  showed 
itself  was  situated  in  the  apex  of  the  lower  lobe  of  the  side  pri¬ 
marily  affected.  The  disease  occurred  here  early,  long  before 
there  was  extensive  disease  at  the  apex  of  the  lung.  It  was 
possible  that  there  was  special  vulnerability  at  these  two  points, 
the  apices  of  the  upper  and  lower  lobes.  This  secondary  lesion 
was  situated  about  an  inch  and  a  half  below  the  upper  and  pos¬ 
terior  extremity  of  the  lower  lobe,  and  about  the  same  distance 
from  its  posterior  border,  which  corresponded  on  the  chest- 
wall  to  a  point  situated  midway  between  the  fifth  dorsal  spine 
and  the  border  of  the  scapula;  from  this  focus  the  disease 
spread  along  the  interlobar  septum.  A  rough  surface  mark 
of  this  line  of  invasion  was  obtained  by  making  the  patient 
place  his  hand  upon  the  opposite  shoulder,  when  the  vertebral 
border  of  the  scapula  in  its  new  position  would  indicate  ap¬ 
proximately  the  line  of  the  disease.  Tubercles  next  appeared  at 
the  apex  of  the  lung  heretofore  free,  and  next  at  the  apex  of  its 
lower  lobe. 

As  regarded  the  exceptional  cases  where  the  base  was  first 
attacked,  the  reader  inclined  to  the  theory  that  such  cases  were 
not  really  basic  phthisis,  but  were  the  outcome  of  some  non- 
tubercular  affection  which  had  weakened  this  part  of  the  lung 
and  left  therein  a  suitable  nidus  for  the  bacillus. 

Wound  of  the  Scrotum  with  Protrusion  of  the  Testis  — 
I)r.  J.  A.  Hutchinson  related  the  history  of  an  accident  which 
had  happened  to  one  of  his  patients  who  had  been  riding,  when 
the  horse  had  reared  and  fell  on  him.  The  scrotum  had  become 
crushed  between  the  thigh  and  the  pommel  of  the  saddle.  The 
pain  and  sickness  produced  had  been  intense.  The  speaker 
had  found  the  man  in  a  condition  of  collapse.  After  an  anaes¬ 
thetic  had  been  administered  it  was  found  that  the  testis  had 
been  pushed  through  the  scrotal  tissues  and  protruded  through 
a  button-hole  opening,  which  had  to  be  enlarged  so  as  to  per¬ 


mit  of  the  replacement  of  the  viscus.  The  subsequent  course 
of  the  case  was  satisfactory. 


CANADIAN  MEDICAL  ASSOCIATION. 

Twenty-third  Annual  Meeting ,  held  at  Toronto ,  September  9, 

10 ,  and  11 ,  1890. 

( Concluded  from  page  358.) 

Spinal  Syphilis.— Dr.  Finley,  of  Montreal,  read  a  paper  on 
this  subject.  Allusion  was  made  to  the  various  diseases  of  the 
cord  following  syphilis,  such  as  locomotor  ataxia,  Landry’s  pa¬ 
ralysis,  and  myelitis.  Gummatous  formations  were  next  dealt 
with.  It  was  pointed  out  that  in  these  cases  only  could  brill¬ 
iant  results  be  looked  for  from  the  use  of  antisyphilitic  reme¬ 
dies.  An  early  diagnosis  was  essential  for  successful  treatment, 
before  destruction  of  the  nerve  tissue  had  occurred.  Permanent 
damage  not  infrequently  was  a  result  of  disease  in  this  region, 
and  in  certain  cases  remedies  had  but  little  effect.  Three  cases 
were  reported  illustrating  different  phases  of  the  disease. 

The  first  was  that  of  a  female,  aged  thirty-four,  who  had 
previously  been  under  treatment  for  headaches,  and  who  had 
presented  syphilitic  scars,  was  seen  in  January,  1889,  with  an 
ataxic  gait,  weakness  of  the  legs,  girdle  sensations,  and  irregu¬ 
larly  distributed  areas  of  hyperaesthesia  and  anaesthesia  on  the 
trunk  and  legs.  She  had  also  had  formication  in  the  legs  and 
occasional  incontinence  of  urine.  Under  the  influence  of  mer¬ 
curial  inunctions  and  iodide  of  potassium  these  symptoms  had 
completely  disappeared,  with  the  exception  of  the  girdle  sensa¬ 
tion.  In  this  case  it  was  believed  that  a  gumma  pressed  on  the 
cord,  and  that  the  ataxia  was  due  to  involvement  of  the  poste¬ 
rior  columns.  The  iris  reflexes  were  normal  and  there  was  no 
change  in  the  optic  discs. 

A  second  case  occurred  in  a  man  aged  twenty-three,  who 
had  acquired  syphilis  three  years  previously.  Pains  and  weak¬ 
ness  in  all  the  limbs  had  come  on  within  a  fortnight.  There 
were  weakness  of  all  the  limbs,  a  girdle  sensation,  and  anaesthesia 
of  the  greater  part  of  the  trunk  and  limbs  to  touch  and  pain. 
With  the  same  treatment  the  sensory  symptoms  had  disappeared, 
but  the  paresis  still  persisted.  A  subacute  diffuse  myelitis  had 
probably  existed  which  was  not  greatly  influenced  by  treatment. 
The  rapid  disappearance  of  the  sensory  symptoms  might  be  ac¬ 
counted  for  by  disappearance  of  an  accompanying  gummatous 
outbreak. 

The  third  case,  in  a  man  aged  thirty-four,  was  also  a  mye¬ 
litis,  and  was  chiefly  interesting  as  coming  on  within  eight 
months  of  acquiring  primary  syphilis,  and  was  followed  shortly 
afterward  with  a  right-sided  hemiplegia  due  to  thrombosis. 

Pernicious  Anaemia.— The  paper  of  Dr.  A.  MoPhedran,  of 
Toronto,  contained  the  histories  of  five  cases  of  pernicious 
anaemia  which  he  had  had  under  observation.  In  the  first  case 
there  were  delirium,  high  temperature,  chills,  and  gastrointes¬ 
tinal  disturbance.  The  red  blood-corpuscles  were  typical — 
731,000  to  the  cmm.  Arsenious  acid  to  the  extent  of  a  quarter 
of  a  grain  a  day  was  taken  for  two  months.  Recovery  was  com¬ 
plete  in  seven  or  eight  months.  In  his  second  case  the  symp¬ 
toms  were  moderate — 606,000  corpuscles  to  the  cmm.  The  ad¬ 
ministration  of  arsenic  had  to  be  suspended  every  few  days  on 
account  of  epigastric  pain,  and  in  four  months  was  stopped  alto¬ 
gether,  when  the  corpuscles  had  reached  2,600,000.  Recovery 
was  complete  in  ten  months.  In  the  third  case  the  disease  was 
followed  by  parturition  and  was  not  very  severe.  Insanitary  sur¬ 
roundings  were  a  probable  cause.  In  six  months  recovery  was 
complete.  The  fourth  case  was  complicated  by  la  grippe,  and 
in  its  main  features  simulated  malignant  disease  of  the  stomach- 
Arsenic,  even  in  minute  doses,  could  not  be  tolerated.  No  im- 


416 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Joor., 


provement  as  yet.  In  the  fifth  ease  there  appeared  to  have 
been  a  previous  attack,  the  same  symptoms  having  been  present 
two  years  previously.  This  patient  was  now  taking  arsenic  and 
making  considerable  progress  toward  recovery. 

In  all  five  cases  there  was  gastro-intestinal  disturbance,  with 
high-colored  acid  urine,  not  increased  in  volume,  and  of  low 
specific  gravity.  These  characters  were  specially  marked  dur¬ 
ing  exacerbations  of  the  disease,  when  in  one  case  (the  fourth) 
renal  casts  were  found.  These  had  contained  much  pigment, 
as  well  as  yellowish  pigment  masses  which  had  disappeared  as 
the  exacerbation  passed  off.  No  microscopic  examination  was 
made  in  the  first  three  cases,  and  no  pigment  was  found  in  the 
urine  in  the  fifth  case,  but  the  patient  had  had  no  paroxysm  of 
the  disease  since  he  came  under  observation. 

The  works  of  Hunter,  Mott,  and  others  showed  that  the  dis¬ 
ease  was  characterized  by  excessive  haemolysis  occurring  in  the 
portal  system,  due  probably  to  some  poison,  possibly  a  ptomaine 
or  some  of  the  many  organic  compounds  that  might  be  absorbed 
from  the  intestinal  tract.  The  treatment  advised  consisted 
essentially  in  intestinal  disinfection — thymol,  /3-naphthol,  and 
naphthalin  being  the  most  effective  agents.  The  administration 
of  arsenic  in  minute  doses  at  short  intervals,  and  a  diet  of  the 
haematogenous  foods,  were  also  recommended. 

Hemiatrophy  of  the  Tongue  of  Peripheral  Origin.— In 
the  course  of  a  paper  upon  this  subject  Dr.  H.  S.  Birkett,  of 
Montreal,  related  the  history  of  a  male  patient,  aged  twenty- 
three,  who,  on  examination,  had  presented  the  following  con¬ 
ditions :  The  right  half  of  the  tongue  was  markedly  atrophied, 
but  tactile  sense  and  the  sense  of  taste  were  not  impaired. 
The  right  side  of  the  soft  palate  was  paralyzed,  and  sensation 
was  diminished  in  the  buccal  mucous  membrane  and  the  naso¬ 
pharynx.  Adduction  and  abduction  of  the  right  vocal  cord 
were  very  limited.  There  was  persistent  myosis  of  the  right 
pupil.  There  was  a  thickened  and  infiltrated  area,  situated  on 
the  right  side  of  the  neck,  just  in  front  of  the  anterior  border 
of  the  sterno-mastoid  muscle,  and  at  a  level  of  a  line  drawn 
backward  from  the  angle  of  the  lower  jaw  on  the  same  side, 
pressure  on  which  produced  Hushing  and  sweating  of  the  right 
side  of  the  face,  with  dryness  of  the  throat,  which  all  passed 
off  when  the  pressure  was  removed.  There  was  never  any  diffi¬ 
culty  in  deglutition,  but  speech  was  at  first  interfered  with,  es¬ 
pecially  for  words  containing  the  letter  “  r  ”  ;  pulse,  98.  Phys¬ 
ical  signs  negative.  The  nerves  involved  were  the  hypoglossal, 
the  vagus,  accessory,  the  branches  of  the  pharyngeal  plexus, 
and  the  superior  cervical  ganglion  of  the  sympathetic.  These 
nerves  appeared  to  have  been  involved  in  a  large  and  painful 
swelling  at  the  angle  of  the  lower  jaw  on  the  right  side,  which 
had  come  on  during  convalescence  from  an  attack  of  mumps 
nine  years  ago.  The  speaker’s  deductions  were  as  follows:  1. 
The  hypoglossal  was  the  motor  and  trophic  nerve  of  the  tongue. 
2.  The  glossopharyngeal  nerve  was  concerned  in  the  function 
of  taste.  3.  The  branches  of  the  pharyngeal  plexus  supplied 
the  mucous  membrane  of  the  buccal  and  nasal  pharynx  with 
sensation.  4.  That  the  motor  nerve  of  the  levator  palati  and 
azygos  uvulae  muscles  was  probably  the  accessorius.  5.  That 
the  superior  cervical  ganglion  of  the  sympathetic  contained  (a) 
dilator  fibers  to  the  iris  of  the  same  side,  ( i )  vaso-motor,  (c) 
sweat,  and  ( d )  special  secreting  nerve  fibers. 

Peri-urethral  Cellulitis.— Sir  James  Grant,  of  Ottawa, 
narrated  the  history  of  the  case  of  a  man,  aged  forty,  who  had 
suffered  from  an  extravasation  of  urine  in  1879.  He  had  pre¬ 
viously  developed  a  stricture  following  a  gonorrhoea.  A  large 
portion  of  the  integument  of  the  scrotum  had  sloughed  in  con¬ 
sequence  of  the  extravasation,  and  a  fistulous  opening  had  re¬ 
mained  in  the  perinseum,  leading  down  to  the  membranous  ure¬ 
thra,  through  which  urine  had  flowed  freely.  The  parts  had 


granulated  readily.  An  attempt  was  made  to  pass  a  catheter 
into  the  bladder  by  the  urethra,  and  this  had  rather  unexpected¬ 
ly  succeeded.  The  catheter  was  secured  in  the  bladder  and  left 
in  situ  for  three  days,  during  which  time  the  urine  had  flowed 
freely  through  the  instrument,  none  escaping  through  the  peri¬ 
neal  fistula.  At  the  end  of  the  third  day  the  catheter  was  re¬ 
moved  and  the  urine  had  subsequently  flowed  through  the  nat¬ 
ural  channel;  healing  had  rapidly  occurred  in  the  perinaeum. 
The  case  was  cited  to  demonstrate  the  marvelous  reparative 
power  of  granulation  tissue  even  under  the  most  adverse  cir¬ 
cumstances. 

Dr.  Shepherd  did  not  think  that  three  days  was  sufficient 
time  for  healing  by  granulation  to  take  place  in  an  old-standing 
fistula,  although  it  might  occur  in  a  recent  case.  He  consid¬ 
ered  Dr.  Grant  very  fortunate  in  the  result  he  had  obtained. 

Cholecystotomy. — Dr.  Shepherd,  of  Montreal,  read  a  paper 
on  this  subject.  After  giving  a  short  account  of  the  history  of 
the  operation,  he  stated  that,  although  it  was  frequently  per¬ 
formed  in  Europe,  it  had  been  but  seldom  performed  in  Ameri¬ 
ca.  The  difficulties  of  the  operation  varied  greatly  in  different 
cases.  When  the  gall-bladder  was  distended  and  could  be 
brought  up  to  the  abdominal  walls  the  operation  was  compara¬ 
tively  easy ;  but  when  the  gall-bladder  was  shrunken  and  small 
or  altered  by  the  products  of  inflammation,  the  operation  of 
cholecystotomy  might  become  one  of  the  most  difficult  in  sur¬ 
gery.  He  also  spoke  of  the  great  difficulty  of  diagnosis  of  gall¬ 
stones  in  some  cases,  and  how,  until  an  exploratory  operation 
was  performed,  no  positive  diagnosis  could  be  given.  He  gave 
the  history  of  a  case  in  which  he  had  performed  the  operation 
and  in  which  the  diagnosis  was  very  obscure :  The  patient,  a 
lady  aged  fifty-one,  had  been  in  failing  health  for  a  year,  suf¬ 
fering  from  pain  in  the  epigastrium  and  great  discomfort  after 
eating.  Six  weeks  before  consulting  Dr.  Shepherd  she  had 
been  suddenly  seized  with  a  severe  pain  in  the  abdomen,  with 
incessant  vomiting  and  great  tenderness ;  there  had  also  been 
elevation  of  temperature.  Her  medical  attendant  had  now  for 
the  first  time  discovered  a  tumor  to  the  right  of  the  umbilicus, 
which  was  teuder  on  pressure  and  freely  movable.  During  the 
next  few  weeks  the  patient  had  had  several  similar  attacks,  and 
since  the  first  attack  had  never  been  free  from  pain  and  dis¬ 
comfort  about  the  abdomen,  especially  after  eating  or  moving 
about  much.  When  the  speaker  first  saw  her  there  was  a  well- 
defined  tumor  of  about  the  size  of  a  foetal  head  to  the  right  of 
and  beneath  the  umbilicus;  it  was  smooth  on  the  surface,  but 
deeper  down  was  hard  and  irregular;  it  was  freely  movable, 
dull  on  percussion,  and  tender  to  the  touch.  After  a  careful 
examination  of  the  case  and  consultation  with  colleagues,  it 
was  thought  probable  the  case  was  one  of  malignant  disease  of 
the  bowel,  and  an  exploratory  incision  was  advised  and  con¬ 
sented  to.  On  opening  the  peritoneal  cavity  in  the  median  line 
over  the  tumor,  an  elongated  portion  of  liver  was  first  met  with, 
and  beneath  this  a  large,  hard,  nodular  mass  covered  by  omen¬ 
tum  and  bowel.  The  gall-bladder  could  not  be  found,  so  the 
liver  was  carefully  separated  from  this  mass,  and,  although 
there  was  free  haemorrhage,  the  connection  was  not  very  firm. 
A  gush  of  fluid  from  the  tumor  had  disclosed  a  small  cavity  in 
which  were  situated  two  large  gall-stones  joined  together;  these 
were  extracted  and  the  finger  pushed  in  through  a  constriction 
into  a  space  in  which  was  another  large  stone,  which  was  with 
difficulty  removed.  The  edges  of  the  cavity  which  contained 
the  gall-stones  consisted  of  inflammatory  tissue,  and  were  so 
friable  that  they  could  not  be  brought  to  the  abdominal  parie- 
tes.  However,  the  space  between  the  abdominal  walls  and  al¬ 
tered  gall-bladder  was  filled  in  by  omentum  and  a  portion  of 
the  elongated  liver  lobe.  A  rubber  drain  was  introduced  into 
the  bottom  of  the  cavity,  the  liver  replaced,  and  the  abdominal 


Oct.  11,  1890.] 


BOOK  NOTICES. 


417 


wound  closed.  The  patient  rallied  well  from  the  operation  and 
had  no  vomiting;  the  temperature  was  normal  throughout. 
For  some  days  there  was  a  profuse  discharge  of  bile  through 
the  tube,  but  this  had  ceased  altogether  on  the  fifteenth  day 
after  operation.  The  patient  was  out  driving  daily  in  the  second 
week,  and  went  home  in  less  than  a  month  without  any  sinus, 
and  feeling  better  than  she  had  for  years. 

The  speaker  drew  attention  to  the  fact  that  even  after  the 
abdomen  was  opened  it  was  a  difficult  thing  to  say  whether 
the  tumor  consisted  of  new  growth  or  inflammatory  tissue;  the 
gall-bladder  was  so  altered  as  to  be  unrecognizable.  In  this 
case  the  elongated  portion  of  liver  represented  what  had  been 
called  the  lacing  lobe,  the  lacing  furrow  being  over  the  region 
of  the  cystic  duct  and  neck  of  the  gall-bladder;  pressure  here 
caused  stagnation  of  bile  and  the  formation  of  gall-stones.  The 
writer  concluded  by  saying  that  the  result  in  his  case  pointed 
strongly  to  the  advantage  of  exploratory  incision  in  doubtful 
and  apparently  hopeless  cases. 

Dr.  Chown,  of  Winnipeg,  in  discussing  Dr.  Shepherd’s  paper, 
mentioned  a  case  of  long-standing  jaundice  where  an  explora¬ 
tory  incision  was  made.  The  pancreas  was  irregularly  enlarged 
and  was  occluding  the  common  bile  duct  by  direct  pressure. 
The  gall-bladder  was  pushed  to  the  right  of  the  tumor.  The 
central  incision  was  closed  and  a  second  one  made  over  the 
gall-bladder  on  the  right.  The  bladder  was  stitched  to  the 
edges  of  the  incision  and  opened,  when  bile  escaped.  Six  weeks 
had  now  passed  since  the  operation,  and  the  patient  continued 
to  pass  all  the  bile  through  the  fistulous  opening.  The  jaundice 
had  disappeared,  but  there  was  no  change  in  the  tumor. 

Appendicitis. — Dr.  George  Armstrong,  of  Montreal,  read 
a  paper  upon  this  subject,  dealing  especially  with  the  important 
question  as  to  the  time  at  which  an  operation  should  be  per¬ 
formed.  He  urged  upon  all  practitioners  to  bring  forward  and 
publish  their  cases,  both  successful  and  unsuccessful,  in  order 
that  we  might  be  placed  in  a  position  to  decide  upon  an  estab¬ 
lished  procedure,  and  he  assumed  that  on  the  following  points 
all  were  agreed  :  1.  That  the  caecum  and  appendix  were  entirely 
surrounded  by  serous  membrane  and  were  intraperitoneal.  2. 
Primary  infiltration  of  cellular  tissue  in  the  right  iliac  fossa  was 
unknown.  3.  There  was  no  evidence  of  the  existence  of  an 
infiltration  of  the  walls  of  the  caecum  other  than  that  caused 
by  a  catarrhal  infiltration  or  ulceration  of  its  mucous  mem¬ 
brane,  the  most  common  forms  of  ulcer  being  stercoral,  typhoid, 
tubercular,  and  perhaps  syphilitic.  4.  The  symptoms  of  a  ca¬ 
tarrhal  infiltration  of  the  mucous  membrane  of  the  caecum  were 
those  of  a  colitis  rather  than  typhlitis,  and  ulceration  of  the 
caecum  did  not  give  rise  to  symptoms  of  typhlitis  unless  the 
peritoneal  covering  became  involved. 

The  reader  dwelt  upon  the  importance  of  early  recognition 
of  the  disease,  and  upon  the  fact  that  every  one  of  the  symp¬ 
toms  might  be  very  slight.  A  little  pain  on  pressure  might  be 
the  only  symptom  present  to  indicate  the  presence  of  a  pint  of 
stinking  pus.  A  case  was  cited,  that  of  a  girl  of  twenty-one, 
in  whom  the  symptoms  had  been  very  mild  and  there  had  been 
apparent  improvement  until  the  fifth  day  of  the  illness,  when 
symptoms  of  general  peritonitis  had  been  observed.  Abdomi¬ 
nal  section  had  been  performed.  The  appendix  had  been  found 
to  be  perforated.  The  patient  had  died  a  few  hours  afterward. 

In  a  second  group  of  cases  the  inflamed  appendix  was  com¬ 
pletely  surrounded  by  the  products  of  inflammation,  so  that 
further  changes  in  the  tissue  were  prevented  from  contaminat¬ 
ing  the  general  peritonaeum,  at  least  for  a  time.  In  such  cases 
the  use  of  an  exploring  needle  had  been  recommended,  but  the 
speaker  had  had  little  experience  of  its  use.  A  distended  gut 
could  not  be  pierced  with  impunity.  With  regard  to  medi¬ 
cal  treatment,  the  amount  of  opium  used  should  be  the  smallest 


quantity  that  would  insure  a  fair  degree  of  comfort  to  the  pa¬ 
tient,  lest  the  symptoms  be  masked  and  the  true  condition  of 
affairs  not  be  rendered  evident  to  the  friends  of  the  patient. 
Purgatives  should  be  avoided.  A  mild  enema  was  all  that 
could  safely  be  used.  Under  such  treatment  recovery  might 
ensue.  It  was  probable  that  merely  a  catarrhal  appendicitis 
had  been  present.  But  apparent  recovery  was  no  certain  indi¬ 
cation  that  the  appendix  was  whole,  and  in  proof  of  this  a  case 
was  cited  where,  after  complete  recovery,  a  second  peritonitis 
had  occurred.  Here  the  abdomen  had  been  opened  and  a  quan¬ 
tity  of  pus  removed,  the  patient  making  a  complete  recovery. 
In  a  third  case  the  appendix  was  removed  successfully  during 
the  period  of  quiescence.  The  paper  was  brought  to  a  close  by 
an  earnest  appeal  for  early  operation. 


§0ok  Notices. 


Familiar  Forms  of  Nervous  Disease.  By  M.  Allen  Starr 
M.  D.,  Ph.  D.,  Professor  of  Diseases  of  the  Mind  and  Nerv¬ 
ous  System,  College  of  Physicians  and  Surgeons,  New  York. 
With  Illustrative  Diagrams  and  Charts.  New  York  :  Will¬ 
iam  Wood  &  Co.,  1890.  Pp.  xii-339. 

This  is  a  most  practical  book  and  one  of  great  value  to  the 
student  and  general  practitioner.  Chapters  of  interest  and  mo¬ 
ment  are  by  Dr.  Frederick  Peterson,  Dr.  Walter  Yought,  Dr. 
Winslow  W.  Skinner,  Dr.  Edwin  Swift,  and  Dr.  M.  L.  Good- 
kind.  Thus  it  will  be  perceived  that  to  the  author’s  trained 
comprehension  of  his  subject  are  added  the  earnest  thoughts  and 
conclusions  of  other  well-endowed  medical  observers.  There 
is  not  a  word  too  much  in  the  entire  work.  Dr.  Starr’s  com¬ 
mand  of  English  is  especially  felicitous,  and  his  style  forcible 
and  clear — qualities  of  great  importance  in  the  exposition  of 
nervous  disease.  The  chapters  on  localization,  cerebral  func¬ 
tion,  and  the  motor  area  are  instructive  to  a  degree.  Whoever 
reads,  learns,  marks,  and  inwardly  digests  this  book  will  recog¬ 
nize  familiar  forms  of  nervous  disease  and  know  how  to  treat 
them  within  given  limits. 

Les  anesthesiques :  physiologie  et  applications  chirurgicales. 
Par  A.  Dastre,  professeur  de  physiologie  a  la  Sorbonne. 
Paris  :  G.  Masson,  1890.  Pp.  xi-306.  [Prix,  5  fr.] 

In  this  work  an  attempt  is  made  to  survey  the  field  of  anaes¬ 
thetics  critically  and  analytically,  and  from  a  brief  reference  to 
ancient  anaesthetics — including,  of  course,  a  reference  to  that 
French  pioneer  in  scientific  discoveries,  Denis  Papin — the  au¬ 
thor  reviews  the  history  of  the  discovery  of  laughing-gas,  ether, 
and  chloroform.  These  common  anaesthetics  are  then  taken  up 
and  considered  at  length,  physiologically  and  therapeutically. 
Chapters  are  devoted  to  chloral,  bromide  of  ethyl,  chloride  of 
methylene,  the  chloride,  acetate,  and  benzoate  of  ethyl,  amy- 
lene,  and  methyl  chloroform,  cocaine,  mixed  antesthesia,  and 
local  anaesthesia. 

We  note  that  the  chapters  on  chloroform  were  written  be¬ 
fore  the  report  of  the-  Hyderabad  commission  was  published, 
and  the  author’s  conclusions  regarding  the  toxic  effect  of  chlo¬ 
roform  are  directly  opposite  to  the  results  obtained  by  that 
body.  In  summing  up  between  ether  and  chloroform,  he  con¬ 
cludes  that  the  former  should  be  given  when  the  condition  of 
the  patient  or  other  causes  presage  the  possibility  of  secondary 
syncope,  or  when  a  lesion  of  the  right  heart  consequent  upon 
chronic  lung  disease  exists.  But  in  prolonged  operations,  in 
cases  of  lesion  of  the  left  heart,  and,  lastly,  in  children,  chloro- 


418 


MISCELLANY. 


[N.  Y.  Mkd.  Jour., 


form  is  preferable.  We  can  commend  the  volume  to  all  desirous 

of  information  regarding  the  various  anaesthetics. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

A  Text-book  of  Comparative  Physiology  for  Students  and  Practi¬ 
tioners  of  Comparative  (Veterinary)  Medicine.  By  Wesley  Mills,  M.  A., 
M.  D.,  D.  V.  S.,  Professor  of  Physiology  in  the  Faculty  of  Human  Medi¬ 
cine  and  the  Faculty  of  Comparative  Medicine  and  Veterinary  Science 
of  McGill  University,  Montreal.  With  476  Illustrations.  New  York : 
D.  Appleton  &  Company,  1890.  Pp.  xix-636.  [Price,  $3.] 

Ihe  Philosophy  of  Tumor  Disease:  a  Research  for  Principles  of  its 
Treatment.  By  C.  Pitfield  Mitchell,  Member  of  the  Roval  College  of 
Surgeons,  England.  London :  Williams  &  Norgate,  1890.  Pp.  xi-3  to 
263. 

The  Science  and  Art  of  Obstetrics.  By  Theophilus  Parvin,  M.  D., 
LL.  D.,  Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in 
Jefferson  Medical  College,  Philadelphia.  Second  Edition,  revised  and 
enlarged.  Illustrated  with  Two  Hundred  and  Thirty-nine  Woodcuts 
and  a  Colored  Plate.  Philadelphia:  Lea  Brothers  &  Co.,  1890.  Pp. 
xv-21  to  704. 

Influenza  or  Epidemic  Catarrhal  Fever:  An  Historical  Survey  of 
Past  Epidemics  in  Great  Britain  from  1510  to  1890.  Being  a  New  and 
Revised  Edition  of  “Annals  of  Influenza,”  by  Theophilus  Thompson, 
M.  D.,  F.  R.  C.  P.,  F.  R.  S.  By  E.  Symes  Thompson,  M.  D.,  F.  R.  C.  P., 
etc.,  Brompton.  London :  Percival  &  Co.,  1890.  Pp.  xv-490.  [Price, 
21  shillings.] 

Transactions  of  the  Royal  Academy  of  Medicine  in  Ireland.  Vol. 
VII.  Edited  by  William  Thomson,  M.  A.,  F.  R.  C.  S.,  etc.  Dublin: 
Fannin  &  Company,  1889.  Pp.  xxxix-402. 

Hypodermic  Medication  in  Diseases  of  the  Eye.  By  Charles  J. 
Lundy,  A.  M.,  M.  D.,  Detroit. 

Diphtheria,  Follicular  Tonsillitis,  and  Membranous  Sore  Throat,  and 
their  Relations  to  each  other,  with  Cases.  By  0.  T.  Osborne,  M.  D., 
New  Haven,  Conn.  [Reprinted  from  the  Proceedings  of  the  Connecticut 
Medical  Society.  ] 

On  the  Radical  Cure  of  Hernia,  with  Results  of  One  Hundred  and 
Thirty-four  Operations.  By  William  T.  Bull,  M.  D.,  New  York.  [Re¬ 
printed  from  the  Medical  News.\ 

Deformity  from  Prominent  Ears  cured  by  a  New  Method  of  Operat¬ 
ing.  By  W.  W.  Keen,  M.  D.,  Philadelphia.  .[Reprinted  from  the 
Transactions  of  the  Philadelphia  County  Medical  Society.  ] 

Two  Suggestions  in  Surgical  Technique.  I.  A  New  Method  of  com¬ 
pressing  the  Subclavian  Artery.  II.  A  New  Method  of  ascertaining 
whether  the  Bladder  is  or  is  not  Ruptured.  By  W.  W.  Keen,  M.  D., 
Philadelphia.  [Reprinted  from  the  Transactions  of  the  Philadelphia 
County  Medical  Society.  ] 

Dupuytren’s  Finger  Contraction.  Operation  by  Removal  of  the 
Contracting  Band  by  Open  Wound.  Immediate  Cure  without  Reaction 
or  Pain.  By  W.  W.  Keen,  M.  D.,  Philadelphia.  [Reprinted  from  the 
Transactions  of  the  Philadelphia  County  Medical  Society.] 

Longevity  and  Climate.  Relations  of  Climatic  Conditions  to  Lon¬ 
gevity,  History ,  and  Religion.  Relations  of  Climate  to  National  and 
Personal  Habits.  The  Climate  of  California  and  its  Effects  in  Relation 
to  Longevity.  By  P.  C.  Remondino,  M.  D.,  San  Diego. 

De  la  laryngite  tuberculeuse  k  forme  sclereuse  et  v^getante.  Par 
MM.  le  Dr.  Gouguenheim  et  J.  Glover.  [Extrait  des  Anncdes  des  mala - 
dies  de  Voreille  et  du  larynx.] 

Die  Behandlung  des  chronischen  Trachoms  vermittelst  der  Trans¬ 
plantation  die  Schleimhaut,  Conjunctiva  perstica.  Von  K.  Noiszewski. 
[Separat-Abdruck  aus  dein  Centralblatt  fur  praktische  Augenheilkunde.] 


Whitehead’s  Operation  for  Haemorrhoids. — At  a  recent  meeting  of 
the  Philadelphia  County  Medical  Society,  Dr.  Charles  B.  Penrose  read 
the  following  paper : 


My  object  in  presenting  this  paper  is  to  urge  the  more  general  use 
of  Whitehead’s  operation  of  excision  in  the  treatment  of  certain  cases 
of  haemorrhoids. 

In  1887,  Mr.  Whitehead,  of  Manchester,  reported*  three  hundred 
consecutive  cases  of  haemorrhoids  which  had  been  successfully  treated 
by  the  method  of  excision  and  suture.  His  operation  is  performed  in 
the  following  manner:  1.  The  patient  is  placed  on  a  table  in  the  lithot¬ 
omy  position,  with  the  hips  well  elevated.  2.  The  anal  sphincters  are 
then  thoroughly  paralyzed  by  digital  stretching.  3.  The  mucous  mem¬ 
brane  of  the  rectum  is  divided  at  its  junction  with  the  skin  around  the 
entire  circumference  of  the  bowel.  4.  The  mucous  membrane,  with 
the  attached  haemorrhoids,  is  dissected  from  the  submucous  tissue,  and 
the  cuff  or  cylinder  thus  formed  is  dragged  below  the  skin  margin.  5. 
The  mucous  membrane  above  the  haemorrhoids  is  then  divided  trans¬ 
versely,  thus  removing  the  pile-bearing  area,  and  the  operation  is  com¬ 
pleted  by  suturing  the  upper  margin  of  the  severed  membrane  to  the 
free  margin  of  the  skin. 

The  advantages  alleged  by  Whitehead  for  this  method  of  treatment 
are  based  on  pathological  and  on  surgical  reasons.  He  considers  that 
internal  haemorrhoids,  which  are  generally  regarded  as  localized  distinct 
tumors,  amenable  to  individual  treatment,  are,  as  a  matter  of  fact,  com¬ 
ponent  parts  of  a  diseased  condition  of  the  entire  plexus  of  veins  sur¬ 
rounding  the  lower  rectum,  each  venous  radicle  being  similarly,  if  not 
equally,  affected  by  an  initial  cause,  constitutional  or  mechanical.  The 
operation  of  excision  is  the  only  one  which  removes  this  whole  diseased 
area.  It  is,  therefore,  demanded  for  this  pathological  reason.  It  is  in 
addition  surgically  more  perfect  than  any  other  method  of  treatment, 
because  it  provides  for  the  readjustment  of  healthy  tissues  with  the 
object  of  securing  primary  union  and  rapid  convalescence.  It  does  not 
leave  the  sluggish  ulcer  of  the  cautery,  nor  is  it  attended  with  the  pain 
and  slow  convalescence  of  the  ligature. 

My  experience  with  this  operation  is  limited  to  ten  selected  cases. 
Only  those  cases  were  selected  in  which  there  existed  a  complete  circle 
of  hiemorrhoidal  tumors  surrounding  the  lower  margin  of  the  rectum, 
since  for  such  cases  Whitehead’s  treatment  of  excision  seems  to  be 
most  particularly  adapted. 

The  details  of  the  operation  are  simple  and  easy  to  execute.  In  di¬ 
viding  the  mucous  membrane  from  the  skin  it  is  best  to  begin  at  the 
posterior  margin  of  the  anus  in  order  to  prevent  the  blood  from  obscur¬ 
ing  the  field  of  operation.  No  skin  should  be  sacrificed,  even  though 
there  appear  to  be  redundant  tags  around  the  margin  of  the  anus.  The 
skin  always  retracts  somewhat  and  the  tags  shrivel  and  disappear  be¬ 
fore  firm  union  has  taken  place.  Failure  to  observe  this  rule  may  re¬ 
sult  in  subsequent  serious  trouble.  Kelsey  f  reports  the  case  of  a 
woman  who  had  been  subjected  to  a  so-called  Whitehead  operation 
and  who  presented  herself  to  him  with  a  complete  circle  of  excori¬ 
ated  mucous  membrane,  extending  for  one  inch  outside  the  anus. 
It  is  probable  that  in  this  case  the  operator  had  sacrificed  too  much 
skin. 

On  the  other  hand,  the  upper  section  of  the  mucous  membiane 
should  be  made  in  the  same  horizontal  plane  throughout,  in  order  to 
prevent  subsequent  ectropion  ani. 

The  dissection  of  the  mucous  membrane  from  the  underlying  tissue 
is  exceedingly  easy  except  >in  some  cases  of  old — or  long-standing — 
piles.  I  he  attachment  of  the  submucous  tissue  is  very  loose,  and  sepa¬ 
ration  can  be  effected  with  the  finger  or  with  the  handle  of  the  scalpel. 

It  is  not  always  possible  to  dissect  the  piles  completely  from  the  under¬ 
lying  structures,  as  they  may  involve  not  only  the  mucous  but  the  sub¬ 
mucous  tissues,  and  in  such  cases  it  is  necessary  to  cut  partly  through 
the  piles  until  the  healthy  mucous  membrane  above  is  reached.  Re¬ 
peated  attacks  of  inflammation  of  course  render  closer  the  adhesion  of 
the  pile  area  to  the  underlying  structures.  In  one  of  my  own  cases, 
where  the  piles  had  existed  for  forty  years,  and  had  frequently  been 
inflamed,  the  adhesions  to  the  two  sphincters  were  so  close  that  a  few 
muscular  fibers  were  cut  away  during  the  removal. 

The  amount  of  blood  lost  during  the  operation  is  surprisingly  small. 
Whitehead  states  that  he  has  often  operated  on  severe  cases  and  not 


*  British  Medical  Journal ,  February  6,  1887. 
f  New  York  Medical  Journal ,  October  5,  1889. 


Oct.  11,  1890.| 

found  it  necessary  to  twist  a  single  vessel.  In  five  of  my  cases  no 
haemostasis  was  necessary.  Bleeding  is  avoided  by  adhering  closely 
to  the  mucous  membrane  in  the  dissection,  as  the  larger  arterioles  lie 
beneath  the  submucous  tissue.  The  arterial  bleeding  occurs  in  those 
cases  of  old  piles  which  have  been  subjected  to  previous  operation  or 
to  attacks  of  inflammation,  and  in  which  dilatation  of  the  rectal  and 
anal  arteries  has  taken  place  secondary  to  dilatation  of  the  h hemor¬ 
rhoidal  veins.  The  bleeding  from  the  upper  divided  edge  of  the  mu¬ 
cous  membrane  can  be  reduced  to  a  minimum  by  following  White¬ 
head’s  method  of  inserting  the  sutures  as  each  portion  is  divided,  or  by 
adopting  Marcy’s  plan  of  introducing  a  circle  of  shoemaker  stitches  of 
catgut  around  the  mucous  membrane  above  the  piles  before  cutting  the 
mass  away. 

Whitehead’s  advice  is  in  all  cases  to  remove  the  complete  cylinder 
of  mucous  membrane,  whether  or  not  the  whole  of  this  area  appears  to 
be  diseased.  He  gives  this  advice  for  the  reason  which  I  have  already 
stated,  that  he  considers  the  individual  piles  as  but  part  of  a  general 
pathological  condition,  involving  all  the  lower  htemorrhoidal  veins  of 
the  rectum. 

Whether  wre  accept  this  pathological  view  or  not,  it  is  best  to  follow 
this  plan,  and  to  make  a  complete  circular  division  of  the  mucous  mem¬ 
brane,  as  by  this  method  the  best  surgical  results  are  obtained,  and 
ectropion  ani  prevented.  I  have  seen  a  case  in  which  only  one  half 
of  the  circumference  of  the  mucous  membrane  of  the  rectum  was  re¬ 
moved,  and  a  few  hours  after  the  operation  an  oedematous  swelling 
formed  in  the  other  half,  which  has  now  resulted  in  a  haemorrhoidal 
tumor  almost  as  annoying  as  the  one  for  which  the  operation  was  per¬ 
formed. 

In  attaching  the  mucous  membrane  to  the  skin,  Whitehead  uses  the 
interrupted  silk  suture.  He  never  removes  the  sutures,  but  allows  them 
to  ulcerate  through — a  process  which  is  very  easily  accomplished.  In 
my  own  cases  I  have  used  the  continuous  catgut  suture. 

The  treatment  of  these  cases  after  operation  is  very  simple.  It  is 
rarely  necessary  to  use  opium  or  the  catheter.  An  opium  and  bella¬ 
donna  suppository,  introduced  immediately  after  the  operation,  is  in 
most  cases  all  that  is  required.  The  bowels  can  be  moved  in  from 
twenty-four  hours  to  four  days,  and  with  very  little  pain.  Absence  of 
pain  after  Whitehead’s  operation  is  due  to  the  thorough  paralysis  of 
the  sphincters  and  to  the  fact  that  no  source  of  irritation  is  left  beyond 
that  of  a  clean  linear  incision,  united  without  tension  and  without  stran¬ 
gulation  of  tissue. 

A  glance  at  the  histories  of  my  own  cases  shows  that  they  were  all 
cases  of  aggravated  haemorrhoids  in  which  the  piles  covered  the  whole 
circumference  of  the  lower  part  of  the  rectum.  In  all  the  cases  the 
disease  had  existed  for  many  years,  and  two  had  been  subjected  to  pre¬ 
vious  operation  by  the  ligature. 

In  only  one  case  was  there  anything  like  free  bleeding  during  the 

operation. 

In  all  the  cases  a  suppository  of  half  a  grain  of  extract  of  opium 
and  half  a  grain  of  extract  of  belladonna  was  introduced  immediately 
after  the  operation,  and  this  was  all  the  opium  required  except  in  three 
cases,  in  which  one  sixth  of  a  grain  of  morphine  was  subsequently  ad¬ 
ministered. 

The  catheter  was  used  in  only  three  cases,  and  in  these  for  a  period 
not  longer  than  twenty-four  hours.  The  length  of  time  that  the  patient 
is  confined  to  bed  depends  to  a  great  degree  upon  his  social  standing 
and  disposition.  In  my  cases  it  varied  from  two  to  ten  days.  Every 
patient  should  be  able  to  sit  up  in  four  or  five  days,  and  to  resume 
work  in  ten  days  or  two  weeks. 

The  bowels  were  opened  without  pain  in  from  twenty-four  hours  to 
four  days  after  the  operation. 

No  complications  of  any  kind  followed  these  operations.  Union 
takes  place  quickly,  and  generally  one  dressing,  taken  off  when  the 
bowels  are  moved,  is  all  that  is  necessary.  In  no  case  was  there  incon¬ 
tinence  from  paralysis  of  the  sphincters,  or  any  tendency  to  stricture, 
from  contraction  of  the  scar. 

Since  the  publication  of  Whitehead’s  paper  his  method  of  operating 
has  been  tested  by  many  surgeons.  The  operation  can  not  be  criticised 
on  surgical  grounds,  as  it  is  certainly  the  most  perfect  plan  of  treat¬ 
ment,  surgically  speaking,  which  has  been  proposed. 


419 

The  immediate  removal  of  the  tumors,  the  coaptation  of  healthy 
tissues,  and  primary  union,  are  substituted  for  slow  strangulation  by  the 
ligature,  or  removal  by  the  cautery  and  healing  by  granulation. 

The  applicability,  or  the  necessity,  of  this  operation  in  all  cases  of 
haemorrhoids,  is,  however,  open  to  criticism.  If  we  accept  Whitehead’s 
views  in  regard  to  the  pathology  of  piles,  and  believe  that  the  whole 
venous  plexus  surrounding  the  anus  and  the  lower  end  of  the  rectum  is 
in  a  pathological  condition  in  every  case  of  haemorrhoids,  even  though 
there  may  be  present  only  one  or  two  isolated  tumors,  then,  of  course, 
the  complete  removal  of  this  area  is  indicated. 

But  that  this  view  is  not  true  is  proved  by  the  thousands  of  cases 
which  have  been  permanently  cured  by  the  ligature  and  the  clamp.  The 
method,  however,  is  indicated  in  all  cases  of  aggravated  haemorrhoids 
where  the  vascular  tumors  cover  the  whole  or  the  greater  part  of  the 
circumference  of  the  bowel.  In  such  cases  the  operation  presents  no 
great  difficulties.  Statistics  show  that  it  is  at  least  as  safe  as  operation 
by  the  ligature  or  the  clamp,  and  it  is  certainly  followed  by  a  more 
rapid  convalescence,  and  much  less  pain  and  discomfort. 

Pulmonary  Consumption  and  the  Board  of  Health. — An  Open  Let¬ 
ter  to  the  Board. — Gentlemen  :  The  Board  of  Health  has  seen  fit  to 
issue  rules  to  be  observed  for  the  prevention  of  the  spread  of  con¬ 
sumption.  If  this  proclamation  had  been  intended  for  the  medical 
profession  it  might  be  looked  upon  as  harmless,  but  the  nine  com¬ 
mandments  are  distinctly  addressed  to  the  public  at  large. 

The  chief  points  in  this  remarkable  document  may  be  summed  up 
as  follows : 

1.  “  Consumptives  are  respectfully  requested  not  to  spit  on  the  floor 
or  on  cloths,  but  into  a  solution  of  corrosive  sublimate.” 

This  is  laudable  as  far  as  it  goes. 

2.  “  Do  not  sleep  in  a  room  occupied  by  a  person  who  has  consump¬ 
tion.  The  living-room  of  a  consumptive  patient  should  have  as  little 
furniture  as  practicable.  Hangings  should  be  especially  avoided.  The 
use  of  carpets  and  rugs  ought  always  to  be  avoided.” 

This  is  cheerful,  to  say  the  least. 

3.  “  Do  not  fail  to  wash  thoroughly  the  eating-utensils  of  a  person 
who  has  consumption  as  soon  after  eating  as  possible,  using  boiling 
water  for  the  purpose.” 

The  effect  of  this  is  to  make  it  painfully  plain  to  the  patient  that  he 
is  an  outcast  and  an  object  of  well-merited  disgust. 

4.  “  Do  not  mingle  the  unwashed  clothing  of  a  consumptive  person 
with  similar  clothing  of  other  persons.  The  soiled  clothing  of  a  con¬ 
sumptive  person  should  be  removed  at  once,  put  in  boiling  water  for 
forty-five  minutes,  or  otherwise  disinfected.” 

In  other  words,  the  family  of  the  patient  are  told  to  look  upon  him 
as  a  leper.  This,  too,  is  refreshing. 

5.  “  Do  not  fail  to  catch  the  bowel  discharges  of  a  consumptive 
person  with  diarrhoea  in  a  vessel  containing  corrosive  sublimate  one 
grain  to  water  one  pint.” 

This  paragraph  is  commendable  on  the  grounds  of  common 
decency. 

8.  “  Household  pets  (animals  or  birds)  are  quite  susceptible  to  tu¬ 
berculosis  ;  therefore, 

“  Do  not  expose  them  to  persons  afflicted  with  consumption ;  also,  do 
not  keep,  but  destroy  at  once,  all  household  pets  suspected  of  having 
consumption,  otherwise  they  may  give  it  to  human  beings.” 

This  is  laughable,  because  it  is  not  true.  It  is  the  comedy  part  of 
this  otherwise  very  serious  melodrama. 

Before  submitting  to  your  honorable  Board  a  few  questions,  let  me 
say  that  I  am  far  from  believing  that  in  issuing  this  remarkable  docu¬ 
ment  you  were  actuated  by  other  than  the  best  of  motives.  And  now 
will  you  kindly  tell  me — 

1.  Do  you  not  know  that  there  are  many  forms  of  so-called  con¬ 
sumption,  ranging  from  pleuritic  adhesions,  peribronchitis,  and  other 
connective-tissue  processes  to  suppurative  conditions  and  the  invasion 
of  the  tubercle  bacillus  ?  Do  you  not  know  that  all  of  these  conditions 
are  accompanied  by  more  or  less  cough  and  expectoration — an  expecto¬ 
ration  free  from  the  much-dreaded  bacillus  in  over  seventy  per  cent,  of 
all  cases  of  so-called  consumption  ? 

2.  And  if  you  did  know  it,  how  came  you  to  address  a  circular  to 


MISCELLANY. 


420 


MISCELLANY. 


the  general  public  advising  them  to  shun  as  nuisances  all  persons  who 
cough  and  expectorate  ? 

3.  Upon  what  evidence  do  you  base  your  belief  that  it  is  dangerous 
to  sleep  in  the  same  room  with  any  one  “  suspected  ”  of  being  a  con¬ 
sumptive  ? 

4.  Who  told  you  that  the  clothing  of  a  consumptive — let  it  be  a 
bacillus  consumptive  this  time — was  a  source  of  infection  to  persons  in 
good  health  ? 

5.  How  in  the  world  did  you  learn  that  even  the  tubercle  bacillus 
itself  ever  infected  any  one  except  by  direct  inoculation?  You  will  tell 
me  it,  is  a  fair  inference.  I  know  that.  An  inference  is  on  a  par  with 
a  possibility,  a  possibility  is  not  a  probability,  and  even  a  probability  is 
several  removes  from  a  fact. 

Laboratory  experiments  have  produced  tubercular  consumption  by 
artificial  inoculation  in  animals,  not  in  man.  If  you  want  to  find  out 
that  clinical  experience  does  not  justify  you  in  assuming  that  consump¬ 
tion — not  even  tubercular  consumption — is  contagious,  be  good  enough 
to  consult  the  Transactions  of  the  Medical  Society  of  the  State  of  Penn¬ 
sylvania  (June,  1890),  and  look  for  the  Address  in  Hygiene,  by  Thomas 
J.  Mays,  M.  D.,  of  Philadelphia.  On  page  8  of  the  reprint  of  this  ex¬ 
cellent  address  you  will  find  this :  “  Now,  in  converging  the  evidence 
of  the  two  sides  of  this  question,  there  appears  to  be  an  irreconcilable 
contradiction.  The  experimental  testimony  points  decidedly  toward 
contagion,  while  the  clinical  testimony  just  as  decidedly  opposes  such 
an  opinion.  It  must  be  remembered,  however,  that  the  first  kind  of 
evidence  pertains  only  to  experiments  on  the  lower  animals,  and,  in  so 
far  as  it  applies  to  the  human  body,  rests  entirely  on  a  theoretical 
basis.”  And  again :  “  All  that  they  (the  experiments)  show  is  that  the 
disease  may  be  transplanted  by  a  certain  method,  after  it  has  been 
called  into  existence  by  other  causes.”  * 

Again  I  quote  from  page  10  of  the  same  pamphlet :  “  Take  away 
the  inoculation  experiments  on  animals  and  you  destroy  the  corner¬ 
stone  on  which  those  who  believe  in  the  communication  of  consump¬ 
tion  from  man  to  man  repose  their  belief.” 

And  on  page  11 :  “  Moreover,  the  contagiousness  of  consumption  is 
an  old  idea,  and  all  the  measures  of  prevention  which  are  receiving 
serious  consideration  from  those  who  believe  in  it  at  the  present  time 
were  tested  with  disastrous  results  by  the  inhabitants  of  Naples  more 
than  a  hundred  years  ago.  They  reasoned  as  follows  :  If  consumption 
is  contagious,  then  the  separation  of  the  afflicted  from  the  well  is  the 
only  logical  remedy;  and  for  sixty-six  years — from  1782  to  1848 — they 
enacted  and  enforced  the  most  rigorous  laws  that  have  ever  been  intro¬ 
duced  for  the  suppression  of  any  disease.” 

What  you  have  published  as  a  well-intended  warning  to  the  public 
will  do  no  good,  but  a  great  deal  of  mischief.  So  far  as  the  public  is 
concerned,  it  will  create  a  far-reaching  and  permanent  panic  in  the 
minds  of  people  who  were  well  and  happy  before  they  read  your  un¬ 
timely  announcement.  A  family  with  consumption  in  its  midst  will  be 
shunned.  So  far  as  the  sufferers  from  chronic  coughs  are  concerned — 
and  your  circular  includes  all  of  them  under  the  heading  of  “suspect¬ 
ed  ” — they  will  be  regarded  as  a  public  pest,  and  will  be  forced  to  un¬ 
dergo  a  degree  of  social  ostracism  hitherto  experienced  only  by  the 
victims  of  leprosy. 

In  conclusion,  I  can  not  withhold  an  opinion  shared  by  many  of 
my  colleagues,  and  it  is  this  :  It  strikes  me  that  occasional  petty  tor¬ 
tures  are  invented  by  the  Board  of  Health  for  lack  of  something  else 
to  do. 

All  of  which  is  respectfully  submitted. 

J.  Hilgard  Tyndale,  M.  D. 

Thunder  and  Sour  Milk. — “  The  effect  of  thunder-storms  in  turning 
milk  sour  is  a  matter  of  constant  observation  in  every  household.  It 
is  not  certainly  known  to  what  element  in  the  air  this  souring  action  on 
milk  is  to  be  directly  attributed,  and  most  people  are  content  to  ascribe 
it  to  1  electricity  in  the  air.’  An  Italian  savant ,  Professor  G.  Tolomei, 
has  lately  made  some  experiments  with  the  view  of  elucidating  this 
question.  He  found  that  the  passage  of  an  electric  current  directly 
through  the  milk  not  only  did  not  hasten,  but  actually  delayed  acidula- 


[N.  Y.  Mkd.  Joub. 

tion,  milk  so  treated  not  becoming  sour  until  from  the  sixth  to  the  ninth 
day,  whereas  milk  not  so  electrified  became  markedly  acid  on  the  third 
day.  When,  however,  the  surface  of  a  quantity  of  milk  was  brought 
close  under  the  two  balls  of  a  Holtz  machine  the  milk  soon  became 
sour,  and  this  effect  he  attributes  to  the  ozone  generated,  for  when  the 
discharge  was  silent  the  milk  soured  with  greater  rapidity  than  when 
the  discharge  was  explosive,  in  the  former  case  more  ozone  being  formed  j 
than  in  the  latter.  The  souring  of  milk  is  generally  attributed  to  the 
growth  of  a  ferment  (bacterium),  which  converts  the  milk  sugar  into 
lactic  acid.  It  is  possible,  then,  that  the  presence  of  ozone  in  the  air 
overlying  the  milk  hastens  the  growth  and  multiplication  of  the  bacte¬ 
rium.  The  first  observation — namely,  the  retardation  of  souring  by  the 
passage  of  a  current  through  the  milk — may  be  a  point  of  practical  im¬ 
portance  to  milk  traders.  Any  methods  of  preserving  milk  from  its  ( 
first  retrogressive  changes,  which  does  not  involve  the  addition  of  ex¬ 
traneous  substances  (antiseptics)  to  the  milk,  and  which  is  at  the  same 
time  cheap,  effective,  and  not  likely  to  prove  injurious  to  the  consumer, 
is  sure  to  be  welcomed  at  a  time  when  milk  is  sent  long  distances  to  i 
market,  and  is  often  stored  for  a  considerable  time  before  it  reaches 
the  consumer.” — British  Medical  Journal. 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purjme 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti-  \ 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  ( 1 )  when  a  manuscript  is  sent  to  this  jour¬ 
nal ,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors ,  are 
not  suitable  for  publication  in  this  journal ,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histones  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  ivhen  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and , 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


*  Deutsche  Medizinal-Zeitung,  April  3,  7,  10,  and  14,  1890. 


THE  NEW  YORK  MEDICAL 


futures  anb  sses  4 


DIATHESIS  AND  CACHEXIA. 

A  CLINICAL  LECTURE, 

DELIVERED  AT  THE  PHILADELPHIA  HOSPITAL. 

By  ERNEST  LAPLACE,  M.  D., 

PROFESSOR  OF  PATHOLOGY  AND  CLINICAL  SURGERY  IN  THE  MEDICO-CI1IRURGICAL 
COLLEGE  OF  PHILADELPHIA  ;  VISITING  SURGEON  TO  PHILADELPHIA  HOSPITAL, 

ETC. 

Leotuke  III. 

Reported  by  WILLIAM  BLAIR  STEWART,  M.  D. 

There  are  two  words — diathesis  and  cachexia — which 
are  used  frequently  by  all  of  us,  which  for  a  long  time  rep¬ 
resented  something  that  was  very  obscure  to  our  minds;  it 
is  often  several  years  before  an  accurate  knowledge  of  these 
two  terms  is  attained  by  the  average  medical  student.  Al¬ 
though  not  defined  in  the  same  way  by  all  medical  authori¬ 
ties,  it  is  well  to  have  a  definite  idea  of  every  subject  about 
which  we  talk.  It  may  be  that  in  time  what  we  talk  about 
now  will  be  modified  somewhat. 

Therefore,  from  the  very  first,  the  meaning  of  diathesis 
is  an  inherited  condition  or  predisposition  to  get  a  disease, 
while  a  cachexia  is  an  acquired  condition  when  the  body  has 
ceased  to  be  in  its  normal  state  by  having  passed  through 
some  pathological  condition.  We  speak  of  the  malarial 
cachexia  in  a  person  who,  once  perfectly  well,  had  malaria, 
but  who  recovered  with  the  malarial  appearance  remaining. 
A  child  born  of  tuberculous  parents,  coming  into  the  world 
with  its  physiological  condition  below  par,  is  born  with  the 
tubercular  diathesis.  From  time  immemorial  it  was  evident 
that  parentage  had  something  to  do  with  health  and  disease. 
Such  is  the  case  among  animals  that  are  affected  according 
to  the  condition  of  their  parents  or  species.  Since  that  is 
the  case  in  lower  animals,  how  much  more  forcibly  must 
this  be  in  man  !  In  fact,  civilization  is  to  man  what  domes¬ 
tication  is  to  animals.  Having  drawn  clear  lines  of  dis¬ 
tinction  between  diathesis  and  cachexia,  and  having  a  posi¬ 
tive  notion  on  this  subject,  let  me  clear  up,  as  far  as  is  in  my 
power  to  do,  those  points  that  are  not  clear  in  your  mind. 

The  word  diathesis  you  hear  indiscriminately  used  in 
connection  with  scrofulosis  and  tuberculosis.  A  child  is 
born  of  tuberculous  parents.  The  child  need  not  have  any 
evidence  of  the  actual  existence  of  tuberculosis  in  his  sys¬ 
tem.  This  fair-haired,  bright-skinned,  blue-eyed  child,  the 
wonder  of  the  neighborhood,  who  is  not  strong,  grows 
in  a  puny  condition,  has  a  delicate  appetite,  grows  with 
other  children — this  child  has  a  tuberculous  diathesis,  and 
is  only  waiting  to  develop  tuberculosis  when  a  favorable 
opportunity  presents  itself.  Two  children  fall  and  each 
receives  an  injury.  The  one  is  laid  up  for  one  or  two  days 
and  is  all  right  again.  The  other,  our  fair-haired  child, 
from  the  injury  to  its  knee  develops  tuberculosis  in  that 
joint.  Both  of  these  children  from  birth  had  been  breath¬ 
ing  the  germs  of  tuberculosis,  and  were  apparently  none 
the  worse  for  it,  but  both  fell  and  received  a  contusion  in 
the  knee  joint.  One  recovered.  This  fall  formed  that  un¬ 
known  something  that  was  wanting  to  develop  tuberculosis 


JOURNAL,  October  18,  1890. 

in  the  fair-haired  child,  otherwise  it  would  have  developed 
the  same  in  the  other.  What  do  we  understand  when  we 
say  a  child  has  scrofula?  A  child  suffering  with  scrofula 
has  tuberculosis  of  the  lymphatic  glands.  From  the  time 
the  glands  begin  to  manifest  themselves  by  enlargement 
they  ai e  tuberculous  and  the  bacilli  are  growing  there. 
White  swelling  is  tuberculosis  of  the  knee  joint.  There 
are  no  reliable  cases  on  record  to  warrant  the  fact  that  a 
child  has  been  born  with  fully  developed  tuberculosis  in  its 
system.  A  child  is  born  with  the  tubercular  diathesis,  and, 
sooner  or  later,  develops  tuberculosis,  manifesting  itself 
either  in  the  glands  as  scrofulosis;  in  the  meninges  of  the 
brain  as  tuberculous  meningitis,  or  abscesses  of  different 
kinds;  or,  later  in  life,  tuberculosis  of  the  lungs,  the  most 
fatal  form.  All  these  are  acquired  because  the  child  has 
been  born  with  the  tuberculous  diathesis. 

There  are  many  among  us  who,  if  they  lived  up  to  the 
laws  of  hygiene,  would  not  become  tuberculous  ;  but  there 
are  few  of  us  who,  if  imprisoned  in  a  damp  place,  with  im¬ 
proper  food  and  poor  light,  would  resist  the  germs  of  tuber¬ 
culosis  that  we  now  breathe  with  impunity.  It  is  not  pos¬ 
sible  for  us  to  acquire  tuberculosis  until  we  acquire  a  con¬ 
dition  suitable  to  it,  and  that  condition  is  cachexia.  Leav¬ 
ing  tuberculosis,  we  take  up  syphilis ;  that  is  an  affection  in 
which  a  diathesis  appears,  but,  unlike  tuberculosis,  the  child 
may  be  born  with  the  affection  fully  developed.  Cancer  is 
exactly  in  the  same  state  as  syphilis,  for  children  are  born 
with  fully  developed  cancer  in  the  mesentery.  .  Most  of  the 
affections  that  we  acquire,  such  as  small-pox,  syphilis,  etc. — 
all  diseases  that  start  as  cachexia — may  manifest  themselves 
as  diatheses  in  our  children.  Here  is  a  person  in  perfect 
health  who  acquires  tuberculosis;  he  has  the  cachexia,  but 
will  give  the  diathesis  to  his  children.  That  point  being 
established,  let  us  see  what  can  be  done  from  a  remedial 
standpoint. 

The  question  that  naturally  presents  itself  is,  What  is  the 
difference  between  a  person  who  has  the  tubercular  diathe¬ 
sis  and  one  who  has  not  ?  It  is  purely  a  chemical  differ¬ 
ence,  modified  by  temperature,  possibly.  Since  we  know 
that  tuberculosis  is  due  to  a  peculiar  seed  (the  Bacillus  tu¬ 
berculosis)  that,  falling  on  suitable  ground,  develops,  so  I 
tell  you  the  reason  it  will  not  develop  in  that  soil — a  healthy 
man — is  that  the  soil  is  unsuited  to  it.  The  only  difference 
between  the  two  is  in  the  soil,  and  that  difference  is  of  a 
chemical  nature.  Plant  a  seed  in  one  soil  and  it  grows. 
Plant  it  in  another  and  it  will  not  grow.  In  the  one  soil 
there  is  more  of  this  salt  or  another,  and  hence  the  reason 
or  growth  is  that  the  soil  is  chemically  suited  to  it.  So  in 
the  body  there  is  a  chemical  difference  in  the  albuminoids 
that  is  not  appreciable  to  us.  Gentlemen,  remember  that 
this  is  no  hypothesis  and  we  are  not  guessing  at  it,  but  what 
I  have  said  can  be  as  clearly  demonstrated  as  two  and  two 
are  four.  Pasteur,  a  man  of  deep  thought  and  research  in 
bacteriology,  took  agar-agar,  a  medium  in  which  to  cultivate 
germs,  and  added  four  per  cent,  of  glycerin  to  it  and  found 
that  the  Bacillus  tuberculosis  grew  beautifully,  showing  that 
it  was  a  suited  soil.  He  took  the  same  auar-ao'ar,  under 
the  same  conditions,  and  added  eight  per  cent,  of  glycerin, 


422 


LAPLACE:  DIATHESIS  AND  CACHEXIA. 


[N.  Y.  Med.  Joub., 


and  the  germs  would  not  grow  in  it  any  more  than  they 


would  on  this  table.  The  two-per  cent,  solution  represents 
the  child  with  the  tubercular  diathesis,  while  the  eight-per¬ 
cent.  solution  represents  us  in  whom  the  germs  would  not 
grow.  Therefore  remember  these  things  are  not  spoken  to 
you  as  they  might  have  been  twenty  years  ago,  for  all  this 
can  be  demonstrated  in  a  pathological  laboratory.  This 
example  took  place  in  a  prepared  test  tube,  and  if  it  takes 
place  here  under  favorable  conditions  of  temperature  and 
moisture,  will  not  the  same  thing  take  place  in  the  body  ? 
The  germs  of  disease  are  different,  just  as  the  seeds  of 
grain;  and  diseases  are  different,  just  as  the  causes  that 
produce  them.  To  illustrate,  let  me  relate  an  incident  that 
occurred  in  Paris  a  few  years  ago. 

Pasteur  had  found  a  method  of  inoculation  against 
splenic  fever  in  sheep.  He  found  that  the  disease  would 
not  attack  fowls,  but  it  would  man.  He  found  that  when 
the  germs  were  grown  at  the  degree  of  temperature  coiie- 
sponding  to  the  temperature  of  man  (98-5°  F.)  and  cattle, 
it  was  very  deadly  ;  but  if  raised  three  degrees  higher,  it 
became  innocent.  Then  it  struck  him  to  investigate  the 
temperature  of  the  fowl  that  was  101°  F.  Thinking  this 
high  temperature  to  be  the  cause  of  his  failure,  he  put  the 
fowl  in  cold  water  until  its  temperature  fell  to  98*5°  F.,and 
then  introduced  the  germ.  It  grew  and  killed  the  fowl, 
whereas  before  it  was  inert.  This  illustrates  that  tempera¬ 
ture  predisposes  to  disease.  Two  men  go  out  hunting; 
their  temperature  is  lowered  ;  the  one  gets  pneumonia  and 
the  other  does  not,  because  he  is  hearty  and  strong  and 
perhaps  suffered  no  disturbance  in  the  body  temperature. 

The  first  one  who  directed  our  minds  toward  a  rational 
treatment  was  Jenner,  who  observed  the  facts  that  led  us  to 
vaccination.  What  is  vaccination  ?  It  is  the  introduction 
of  a  certain  amount  of  chemical  substance  or  living  sub¬ 
stance  that  develops  in  the  body,  and  alters  the  chemis¬ 
try  of  the  body  so  that  the  person  will  not  develop  the  dis¬ 
ease  that  he  would  have  taken  otherwise.  That  being  the 
case,  what  a  great  field  lies  before  us,  seeing  that  these  af¬ 
fections  are  due  to  living  organisms  that  develop  and  may 
be  prevented  by  altering  the  chemical  condition  of  the  soil ! 
What  great  opportunities  are  given  to  the  investigation  of 
the  growth  and  development  of  germs !  But,  when  the 
ways  of  each  of  these  germs  come  to  be  understood ;  the 
nature  of  the  soil  and  how  to  alter  it  to  prevent  it  from 
growing  germs — pathological  germs ;  then  will  the  vision 
of  Mirza  be  a  dream  indeed.  Instead  of  seventy  arches  with 
innumerable  pitfalls  and  broken  columns  to  entrap  man  on 
his  way  through  life,  there  will  be  one  hundred  perfect 
arches  over  which  man  will  travel  happy  and  healthy  to  the 
Elysian  fields  beyond. 

Gangrene. — The  cases  that  I  shall  bring  before  you  this 
morning  are  cases  of  gangrene.  Gangrene  is  always  due  to 
some  trouble  in  the  circulation,  and  may  be  arterial,  venous, 
or  both.  Arterial  obstruction  causes  dry  gangrene  ;  venous 
obstruction  causes  moist  gangrene;  when  due  to  both,  we 
have  capillary  gangrene,  that  comes  from  severe  bruises, 
old  age,  diseased  arteries,  or  ergot  and  allied  drugs.  The 
first  patient  is  this  old  woman,  suffering  with  senile  gan¬ 
grene,  due  to  the  fact  that  her  heart  is  too  weak  to  carry  the 


blood  to  her  extremities.  A  few  days  ago  I  outlined  on 
her  foot,  with  ink,  the  limit  between  the  healthy  and  dis¬ 
eased  tissue,  and  in  three  days  the  gangrene  had  spread 
beyond  this  line.  In  a  condition  of  this  kind,  where  septi¬ 
caemia  has  started,  it  is  best  to  amputate  far  away  from  the 
diseased  tissue,  if  the  patient  can  stand  it.  I  think  it 
would  be  safe  to  amputate  in  this  case  just  below  the  knee. 
Her  condition  was  explained  to  her,  but  she  refused  to 
have  any  operation  done,  and,  as  a  consequence,  she  is  now 
laboring  under  a  septic  pneumonia  from  septic  absorption. 
I  think  now  it  would  be  too  late  to  operate,  but,  if  she 
would  consent,  it  would  be  well  to  do  so  to  give  her  a 
chance  for  life.  Gangrene  starts  from  a  cessation  of  the 
flow  of  blood  to  a  part,  and  a  focus  of  decomposition  is 
started.  The  black  condition  is  due  to  fermentation  and 
decomposition  from  the  presence  of  germs.  The  smell  is 
due  to  sulphureted  hydrogen  and  carbon-dioxide  gas  com¬ 
ing  from  the  decomposing  parts. 

Here  is  another  patient  that  had  gangrene  when  she 
came  into  the  hospital.  She  had  a  hard  fall  on  her  buttock 
and  the  parts  around  the  anus  were  very  much  contused 
and  the  blood  supply  was  impaired.  As  a  consequence, 
there  was  a  sloughing,  which  is  nothing  but  a  condition  of 
gangrene.  The  spot  is  limited  to  the  extent  of  the  injury. 
When  this  slough  comes  off  it  is  called  sphacelus.  Here 
are  healthy  granulations  forming,  and,  to  facilitate  the  pro¬ 
cess  of  healing,  a  few  sutures  will  be  put  in  to  draw  the 
parts  together. 

The  next  patient  is  the  one  that  I  brought  before  you  at 
another  time  when  I  spoke  of  the  metastasis  of  cancer.  I 
bring  him  in  to  show  another  case  of  gangrene  and  to  op¬ 
erate  on  him.  He  is  a  young  man,  and  we  will  make  an 
effort  to  destroy  the  cancerous  process  if  possible.  You 
notice  the  gangrenous  spots  around  this  cancerous  ulcer  on 
his  thigh  that  are  due  to  the  poison  that  is  developing  and 
interfering  with  the  circulation,  just  as  ergot,  carbolic  acid, 
and  such  drugs.  Remember  that  micro-organisms  may  be 
the  cause  of  gangrene  just  as  they  are  the  cause  of  carbun¬ 
cles  and  anthrax.  In  operating  on  this  mass,  in  the  left 
groin,  we  must  take  great  care  not  to  wound  the  femoral 
artery  or  vein,  as  they  will,  in  all  probability,  be  exposed 
in  cutting  away  this  dead  material.  The  gangrenous  por¬ 
tions  were  thoroughly  removed  and  parts  dressed  antiseptic- 
ally.  The  cure  of  cancer  should  not  be  considered  a  hope¬ 
less  aim.  At  the  last  medical  congress,  held  in  Berlin,  six 
cases  of  cure  of  epithelioma  were  reported.  About  twenty 
years  ago  a  French  surgeon  had  a  case  of  cancer  of  the 
breast  in  which  he  neglected  to  operate.  As  he  was  not 
cleanly  and  did  not  believe  in  the  modern  ways  of  treat¬ 
ment,  the  patient  got  erysipelas  in  her  breast  and  nearly 
died.  Fortunately,  she  recovered,  but  was  seized  with 
another  attack.  The  cancerous  growth  assumed  a  benign 
appearance  and  an  entire  recovery  resulted.  Two  surgeons 
in  Berlin  prepared  pure  cultures  of  the  germs  of  erysipelas 
and  inoculated  a  number  of  cancerous  patients  with  the 
pure  culture,  and,  as  a  result,  they  report  the  cure  of  six 
patients  that  were  'undoubtedly  laboring  under  the  can¬ 
cerous  process.  This  opens  up  to  us  a  newr  field  in  the 
cure  of  cancer. 


Oct.  18,  1890.] 


01  BIER :  A  NEW  THEORY  ABOUT  TEMPERAMENTS. 


423 


#rtgmal  Communications. 


A  NEW  THEORY  ABOUT  TEMPERAMENTS .* 

By  PAUL  GTBIER,  M.D., 

FORME  ULY  INTERNE  OF  PARIS  HOSPITALS 
AND  ASSISTANT  IN  PATHOLOGY  AT  THE  PARIS  MUSEUM  ; 

*  DIRECTOR  OF  THE  NEW  YORK  PASTEUR  INSTITUTE. 

Great  importance  was  attached  by  the  ancients  to  the 
study  of  temperaments.  In  this  connection  it  is  well  to 
observe  that  certain  schools  distinguished  in  special  form 
four  principal  temperaments  more  or  less  susceptible  of 
affiliation,  viz.,  “the  sanguine,  the  nervous,  the  bilious,  and 
the  lymphatic.”  Nowadays — while  recognizing  that  the 
physiological  basis  varies  with  individuals,  as  is  shown  by 
the  unequal  distribution  of  maladies,  or,  in  other  words,  the 
differences  of  susceptibility  to  infection — sufficient  impor¬ 
tance  does  not  seem  to  be  attached  to  what  was  formerly 
designated  as  “  the  composition  of  humors.” 

Were  it,  nevertheless,  demonstrated  that  a  difference 
in  composition,  however  slight,  was  capable  of  preventing 
the  development  of  certain  ailments,  and  were  it  possible 
for  the  medical  man  to  bring  about  such  a  modification  in 
the  quality  of  the  humors  of  the  human  body,  or,  to  use  a 
more  modern  phraseology,  in  the  chemical  composition  of 
the  center  of  development  of  the  germs  of  these  ailments, 
would  it  not  be  of  advantage  in  a  great  number  of  cases 
to  know  in  a  temperament — i.  e.,  from  this  our  special  point 
of  view — the  “composition”  of  a  patient? 

More  remains  to  be  said  on  this  score,  for  if,  in  a  cura¬ 
tive  sense,  this  knowledge  could  be  utilized,  how  much 
more  valuable  would  it  not  be  in  the  preventive  sense  ?  The 
knowledge  of  a  temperament  once  acquired,  notably  by  the 
study  of  its  ancestry — for,  in  my  opinion,  the  human  body 
inherits  to  a  large  extent  the  basis  from  which  a  malady 
takes  its  development  rather  than  the  malady  itself — a  tem¬ 
perament,  I  repeat,  having  been  once  determined,  would  it 
not  be  possible  by  an  appropriately  specified  diet  to  prevent 
the  growth  of  cancer,  of  tuberculosis,  of  nervous  ailments, 
of  acute  or  chronic  rheumatism,  and  so  forth  ? 

Recent  studies  made  in  connection  with  infectious  germs 
enable  one  to  answer  this  question  in  the  affirmative.  Do 
we  not  know,  for  instance,  that  an  infinitesimal  proportion 
of  chloride  of  silver  is  sufficient  to  check  the  development 
of  certain  inferior  organisms  (Raulin),  that  glycerin  intro¬ 
duced  into  a  culture  medium  otherwise  inert  renders  it 
capable  of  giving  nourishment  to  the  Bacillus  tuberculosis 
(Roux  and  Nocard)  ?  Do  we  not,  moreover,  know  that 
when  we  have  neglected  to  slightly  alkalinize,  or  at  least  to 
neutralize,  an  acid  culture  medium,  the  majority  of  patho¬ 
genic  microbes  decline  to  develop,  even  when  but  traces  of 
acidity  exist  ? 

If  it  needs  so  little  to  cause  an  inert  medium  to  become 
unfit  for  the  development  of  infectious  germs,  what  may  we 
not  expect  from  our  cellular  tissues,  which  are  struggling 
actively,  and  I  venture  to  say  intelligently,  for  the  preserva- 

*  Read  before  the  Tenth  International  Medical  Congress,  Berlin, 

August,  1890. 


tion  of  their  collective  existence  which  constitutes  our  own 
as  a  whole  ? 

I  do  not  intend  to  dwell  on  this  point.  It  is  in  order 
to  place  my  theory  on  record  that  I  make  the  present  com¬ 
munication.  It  must  necessarily  be  short,  and  I  must  be 
forgiven  if  what  follows  savors  of  a  somewhat  absolute  form. 
I  must,  however,  state  that  for  the  time  being  I  merely  sub¬ 
mit  my  theory  as  a  simple  hypothetical  one  which  requires 
confirmation,  although  the  results  obtained  by  me  in  its 
practical  application  are  most  satisfactory.  I  am  fully  aware 
that  the  distance  between  a  theory  of  this  nature  and  the 
facts  to  be  established  >s  great;  but  he  who  sows  or  plants 
must  not  look  for  a  crop  the  next  day. 

Numerous  observations  made  upon  my  patients,  and  ex¬ 
periments  made  both  at  my  clinic  and  in  my  laboratory, 
allow  me  to  advance  the  statement  that  there  exist  three 
temperaments  or  constitutions  of  the  animal  body  : 

1.  The  alkaline  temperament. 

2.  The  acid  temperament. 

3.  The  neutral  temperament. 

As  may  be  observed,  I  am  comparing  the  chemical  com¬ 
position  of  the  animal  organism  to  that  of  all  other  com¬ 
posite  bodies  which  we  study  in  nature. 

All  substances,  from  a  chemical  standpoint,  are  alkaline, 
acid,  or  neutral ;  why  should  not  the  same  hold  good  of 
those  living  animal  substances  whose  functions  are  so  va¬ 
ried?  The  blood  is  alkaline,  and  yet  do  not  the  cells  of 
the  glands,  the  muscles,  and  other  tissues  secrete  liquids 
that  are  more  or  less  acid  according  to  individuals?  These 
liquids  are  taken  up  again  by  the  blood  and  eliminated  by 
the  sudoriparous  glands,  by  the  kidneys,  etc.,  or  partly  de¬ 
posited  within  the  organs.  But  the  limits  of  this  note  do 
not  allow  of  my  carrying  this  point  any  further. 

And  now  let  us  study  temperaments: 

1.  The  Alkaline  Temperament. — People  who  are  pos¬ 
sessed  of  this  temperament  are  hut  slightly  or  not  at  all 
predisposed  to  so-called  arthritic  affections ;  they  have  no 
eczema,  no  psoriasis,  varices  but  seldom,  and  rarely  any  vas¬ 
cular  or  cardiac  affections.  They  are  not  subject  to  cancer 
in  its  various  forms.  Their  secretions  are  but  slightly  acid 
and  they  never  or  seldom  suffer  from  sourness  of  the  stomach 
(pyrosis).  The  women  are  more  fertile. 

Rheumatism,  especially  in  the  chronic  form,  as  well  as 
gout,  is  unknown  among  the  alkaline.  On  the  other  hand, 
they  are  apt  to  acquire  other  maladies  easily,  and  although, 
in  case  they  have  the  chance  to  live  far  from  populous  cen¬ 
ters,  they  may  give  instances  of  exceptional  longevity,  they 
commonly,  when  living  in  cities,  show  a  peculiar  aptitude 
for  the  acquisition  of  chest  troubles,  and  more  especially  of 
pulmonary  tuberculosis.  This  is  especially  the  case  when 
their  means  do  not  allow  them  to  “acidify”  themselves  by 
indulgence  in  animal  food.  They  are  also  subject  to  all 
forms  of  tuberculosis,  and  notably  to  scrofulosis. 

Among  the  many  tubercular  subjects  I  have  examined  I 
have  as  yet  met  with  none  who  presented,  in  their  persona} 
and  family  history,  the  unmistakable  signs  of  “acidism,” 
which  I  shall  describe  further  on.  Pertinent  to  this,  I  will 
here  state  that,  considering,  as  I  do,  that  in  animal  food 
and  moderate  quantities  of  spirituous  liquors  we  hava  a 


424 


GOLDENBERG:  HUTCHINSON'S  “ VARICELLA  PRURIGO .” 


[N.  Y.  Mkd.  Jour., 


potent  means  toward  the  acidifying  of  tissues,  I  do  not 
hesitate  to  affirm  that,  in  my  opinion,  a  vegetarian  diet 
(which,  on  the  other  hand,  tends  to  alkalinize),  together 
with  a  complete  avoidance  of  fermented  drinks,  jeopardizes 
the  life  of  alkaline  subjects  who  live  in  populous  cen¬ 
ters,  where  the  germs  of  tuberculous  contagion  are  so  nu¬ 
merous. 

Among  alkaline  animals  are  the  herbivora,  the  vaccine 
race  especially,  and  it  is  well  known  how  easily  horned 
cattle  become  tubercular  when  stabled  in  large  cities. 

2.  The  Acid  Temperament. — This  may  be  observed  in 
people  who  do  not,  any  more  than  the  alkaline  subjects, 
present  any  external  characteristic  appearance ;  everything 
at  first  takes  place  within  the  body.  It  is  but  at  a  later 
period  that  special  deformities  of  certain  articulations,  or 
that  certain  apparent  cutaneous  affections,  may  lead  to  their 
easy  recognition.  Yet  during  youth  acid  subjects  may 
have  facial  acne.  Their  gastric  juice  is  markedly  acid,  and 
more  especially  during  adolescence  they  frequently  com¬ 
plain  of  pyrosis.  Hence,  under  careful  hygienic  direction, 
they  are  less  apt  than  the  other  class,  during  cholera  epi¬ 
demics  or  in  yellow-fever  districts,  to  acquire  these  mala¬ 
dies;  the  marked  acidity  of  their  gastric  juice  causes  the 
destruction  of  the  infecting  bacilli  prior  to  their  passage 
into  the  intestines. 

Acid  subjects  are  not  in  danger  of  tuberculosis  or  of 
scrofula,  but,  according  as  their  peculiarity  of  temperament 
is  more  or  less  marked,  they  may  suffer  from  eczema  or 
any  of  the  eruptions  or  cutaneous  affections  which  to-day 
are  still  tei*med  arthritic  and  herpetic.  According  to  the 
mode  of  life  their  affections  vary  :  the  acidism  may  be 
manifested  in  the  form  of  a  subacute  rheumatism,  with  re¬ 
peated  attacks,  or  of  a  chronic  variety  of  this  disease.  A 
meat  diet  added  to  a  liberal  use  of  alcoholics  is  rapidly 
productive  of  gout  in  acid  temperaments  (more  especially 
when  exercise  is  not  taken  in  order  to  increase  the  secre¬ 
tions)  whenever  heredity  has,  as  it  were,  polarized  the  acid 
tendency  in  that  direction. 

It  is  especially  among  the  subjects  of  “  acidism  ”  that 
we  observe  haemorrhoids,  varices,  and  the  eczema  of  the 
legs  which  so  frequently  accompanies  them.  In  these  peo¬ 
ple  we  also  find  headaches  (migraine)  and  the  neuralgic 
affections  depending  upon  a  cellular  development  of  the 
central  nervous  system  (general  paralysis,  scleroses,  loco¬ 
motor  ataxia,  etc.),  together  with  neuropathic  affections* 
hysteria,  etc. 

“  Acidism  ”  would  seem  to  develop  asthma,  pulmonary 
emphysema,  chronic  dry  coryza,  etc.,  in  the  respiratory  sys¬ 
tem,  while  it  appears  to  lead  to  aneurysms,  to  cerebral 
luemorrhages,  arterial  scleroses,  atheroma,  angina  pectoris, 
etc.,  in  the  circulatory  apparatus. 

“  Acidism  ”  constitutes  a  favorable  soil  for  the  develop¬ 
ment  of  cancer  and  malignant  epithelial  productions  in 
general.  The  organs  which  are  most  frequently  attacked 
are  the  stomach,  a  viscus  whose  contents  are  usually  acid, 
and  the  uterus,  which  occasionally  secretes  an  acid  mucus; 
uterine  cancer  is  frequently  observed  in  nulliparae.  On  the 
other  hand,  we  know  that  acidity  of  the  uterine  mucus  is 
a  common  cause  of  sterility. 


Among  the  animals  that  are  of  an  acid  temperament  we 
must  class  the  carnivora  (in  a  general  manner),  and  particu 
larly  the  dog. 

It  may  be  for  this  reason  that  the  blood  of  this  animal, 
when  injected  into  the  system  of  herbivora  (which  are  alka¬ 
line)  that  have  previously  been  inoculated  with  tubercular 
material,  has  appeared  to  retard  the  infection  and  the  death 
of  the  subjects  of  the  experiment  (Richet).  The  dog  is  one 
of  the  rare  domestic  animals  in  which  rheumatism  may  be 
observed. 

3.  The  Neutral  Temperament. — According  to  my  the¬ 
ory,  this  would  correspond  to  the  temperate  temperament 
of  the  ancients.  Persons  gifted  with  it  show  no  marked 
signs  belonging  to  the  two  other  classes  (alkaline  and  acid), 
and  their  state  is  really  the  normal  one.  They  may  ap¬ 
proach  either  of  them  according  to  their  alimentation  and 
their  mode  of  life.  According  to  my  observations,  these 
people  are  more  easily  cured  than  the  “  acids”  when  they 
are  attacked  by  certain  “  acidic  ”  affections.  This  is  equally 
true  of  the  alkaline  affections.  This  must  be  due  to  the 
ease  with  which  their  temperament  may  be  modified. 

Each  one  of  these  temperaments  (alkaline,  acid,  neutral) 
may  be  met  with  among  those  whom  the  ancient  humoralists 
were  wont  to  term  bilious,  atrabiliary,  sanguine,  lymphatic, 
nervous,  athletic,  etc.  These  definitions  describe  rather  the 
external  appearance,  and  even  the  moral  character,  than  the 
true  temperament — that  is  to  say,  the  internal  constitu¬ 
tion. 

Temperaments  are  inherited  in  various  degrees  accord¬ 
ing  to  ancestors  and  the  combinations  of  breeding.  The 
marked  alkaline  and  acid  dispositions  are  difficult  to  correct 
and  modify.  The  neutral,  on  the  other  hand,  may  be 
altered  in  either  direction  according  to  the  mode  of  life  of 
its  possessor. 

I  do  not  wish  to  insist  at  present  upon  the  practical  de¬ 
ductions  which  may  be  drawn  from  what  precedes.  This 
will  allow  me  to  hope  for  a  little  more  indulgence  in  case  I 
have  wandered  upon  a  false  track.  It  is,  however,  a  matter 
that  may  be  studied  more  thoroughly  in  time. 


A  CASE  OF 

HUTCHINSON’S  “VARICELLA  PRURIGO:” 

By  HERMAN  GOLDENBERG,  M.  D., 

ATTENDING  PHYSICIAN  TO  THE  MOUNT  SINAI  HOSPITAL, 

ASSISTANT  PHTSICIAN  TO  THE  NEW  YORK  HOSPITAL,  OUTDOOR  DEPARTMENTS 

FOR  SKIN  DISEASES. 

In  his  Clinical  Lectures  on  Rare  Skin  Diseases ,  Hutch¬ 
inson  describes,  under  the  name  of  “varicella  prurigo,”  a 
disease  which  affects  infants  and  children,  and  which  he 
maintains  to  be  a  kind  of  persistent  chicken-pox.  The  pro¬ 
cess  begins  as  a  bona  fide  varicella,  the  fresh  crops  consist¬ 
ing  of  elevated,  pointed  papules,  feeling  very  firm,  and  each 
surmounted  by  a  small  vesicle. 

Its  peculiarity  consists  in  that  the  eruption,  instead  of 
disappearing  in  a  few  days,  is  indefinitely  prolonged  by  the 
succession  of  fresh  crops,  and  that  the  spots  ulcerate  and 
scab,  sometimes  becoming  large  sores.  The  eruption  is  ac¬ 
companied  by  intense  itching,  and  may  last  for  months  or 


Oct.  18,  1890.] 


GOLDENBERG :  HUTCHINSON'S  “ VARICELLA  PRURIGO .” 


425 


years,  lie  thinks  the  disease  has  nothing  to  do  with  vac¬ 
cination,  but  considers  it  to  be  a  true  varicella. 

I  am  not  able  to  find  anything  in  dermatological  litera¬ 
ture  pertaining  to  this  subject,  except  that  Trousseau  men¬ 
tions  an  epidemic  of  varicella  which  occurred  in  the  Necker 
Hospital,  in  which  some  cases  lasted  for  six  weeks,  becoming 
ulcerative  in  character  and  resembling  pemphigus.  He  does 
not,  however,  mention  intense  irritation  as  accompanying 
the  disease. 

Radcliffe  Crocker  also  relates  in  his  work  the  occurrence 
of  cases  similar  to  those  described  by  Hutchinson. 

Some  months  ago  I  treated  a  patient  in  the  Outdoor 
Department  of  the  New  York  Hospital  (Dr.  Bulkley’s  serv¬ 
ice),  who  presented  the  symptoms  of  the  varicella  prurigo 
of  Hutchinson.  The  history  given  at  the  time  was  as  fol¬ 
lows  : 

M.  L.,  two  years  old,  had  always  been  healthy.  In  May, 
1889,  she  was  vaccinated ;  the  vaccination  took,  but  was  not 
followed  by  any  eruption.  Since  August,  1889,  she  had  suffered 
frequently  from  attacks  of  diarrhoea.  In  February,  1890,  a  rash 
appeared  on  the  wrists  and  palms  which  resembled  chicken- 
pox.  Intense  itching  was  the  only  subjective  symptom,  and 
there  was  no  fever  or  general  malaise.  The  mother,  who  brought 
the  child  to  the  dispensary,  stated  that  a  physician  who  saw 
the  patient  declared  the  eruption  to  be  the  ‘‘itch,”  while  she 
and  her  friends  regarded  it  as  chicken-pox,  the  doctor’s  diag¬ 
nosis  seeming  improbable  on  account  of  the  lesions  resembling 
those  of  varicella,  and  because  the  interdigital  spaces  were  not 
affected.  In  the  course  of  the  following,  weeks  the  eruption 
appeared  on  the  trunk  and  extremities,  covered  the  entire  scalp, 
aDd  also  affected  the  soles.  As  the  lesions  underwent  involu¬ 
tion  and  disappeared,  they  left  scars. 

There  was  no  specific  history  obtainable. 

The  mother  stated,  furthermore,  that  there  was  a  certain 
succession  and  regularity  in  the  appearance  of  the  symptoms, 
inasmuch  as  every  new  lesion  began  as  a  small,  red,  hard  lump, 
on  top  of  which  a  small  vesicle  appeared  in  the  course  of  a  few 
hours.  Its  contents  were  clear  at  the  outset,  but  soon  became 
purulent  in  character.  About  six  hours  after  its  appearance 
spontaneous  rupture  would  occur,  and  a  crust  would  form, 
which  left  a  scar  after  it  had  fallen  off.  The  itching  was  at  its 
worst  while  the  lump  was  present,  and  would  diminish  after 
the  lesion  became  a  pustule.  Simultaneously  with  the  appear¬ 
ance  of  the  lesions  there  would  be  a  swelling  of  the  eyelids  to 
such  an  extent  that  the  eyes  would  be  closed  for  a  day,  the  lids 
having  a  purplish  color.  From  the  beginning  of  the  trouble 
the  hands  were  puffed. 

Status  prwsens. — Child  well  developed,  blue  eyes,  dark  hair. 
Formation  of  the  bones,  head,  and  teeth  perfect.  On  the  face 
there  were  many  small,  slightly  pigmented,  depressed  scars. 
On  the  left  lower  eyelid  a  small,  fresh,  umbilicated  pustule  was 
situated,  and  surrounded  by  a  red  areola.  There  were  likewise 
a  number  of  older  lesions,  formerly  pustules,  but  now  repre¬ 
sented  by  crusts.  On  the  back  there  were  a  great  number  of 
small,  pigmented,  brown  spots,  round  and  oval  in  shape,  uni¬ 
form  in  size,  and  some  of  them  slightly  depressed.  The  abdo¬ 
men  and  chest  were  symmetrically  affected,  and  likewise  the 
extensor  surfaces  of  the  extremities.  On  these  latter  the  pust¬ 
ular  lesions  and  the  scars  already  described  were  met  with  in 
abundance.  The  depression  in  the  centers  of  these  cicatrices 
was  much  more  pronounced  than  in  those  on  the  back,  nearly 
every  single  lesion  showing  it.  The  flexor  surfaces  of  the  ex¬ 
tremities  were  normal.  There  were  no  new  lesions  on  the 
scalp,  the  soles,  or  the  palms,  but  a  number  of  more  or  less 


pigmented  scars  indicated  their  former  presence.  There  was 
nowhere  any  marked  thickening  of  the  skin.  The  hands  were 
very  much  swollen  and  of  a  white  color,  the  swelling  being 
oedematous  in  nature,  since  it  disappeared  under  pressure. 
Polyadenitis.  The  mucous  membranes  were  normal.  The  urine 
was  free  of  albumin  and  sugar. 

At  the  second  visit,  three  days  later,  there  remained  a  pig¬ 
mented,  depressed  scar  on  the  site  of  the  pustular  lesion  pre¬ 
viously  observed.  On  the  forehead  were  a  number  of  newt 
small,  umbilicated  pustules  with  a  red  areola,  but  not  seated  on 
an  elevated  base.  The  development  of  these  pustules  was,  ac¬ 
cording  to  the  mother,  preceded  by  red,  hard  lumps,  and  accom¬ 
panied  by  a  swelling  of  the  eyelids,  in  the  same  manner  as  had 
occurred  in  previous  eruptions. 

I  impressed  upon  the  mother  the  necessity  of  my  seeing  the 
lesions  when  they  first  appeared,  and  a  few  days  later  I  was 
able  to  observe  the  process,  so  to  speak,  in  statu  nascente.  The 
right  eyelid  was  swollen.  On  the  left  side  of  the  forehead  there 
was  a  sharply  circumscribed  red  lump,  of  the  size  of  a  marble, 
elevated  about  an  eighth  of  an  inch  above  the  surface,  movable, 
very  firm,  and  painful  to  the  touch.  It  was  very  similar  to  the 
lesion  occurring  in  erythema  nodosum.  On  top  of  this  nodular 
lesion  there  was  a  small  vesicle  with  clear  contents.  This 
later  became  an  umbilicated  pustule  and  subsequently  a  crust, 
which,  when  it  fell  off,  left  a  depressed  cicatrix.  There  was 
considerable  itching  while  the  lump  was  there.  The  latter  dis¬ 
appeared  as  soon  as  the  formation  of  the  pustule  occurred. 

While  under  observation,  the  child  had  a  number  of  similar 
attacks  at  different  times  of  the  day  or  night,  and  seemingly 
not  brought  on  by  any  particular  cause.  The  lesions  were  lo¬ 
cated  on  different  parts  of  the  body,  and  very  itchy.  Pigmented 
spots,  and  more  or  less  pigmented,  pitted  scars,  remained  after 
their  disappearance. 

The  internal  treatment  with  tonics  and  arsenic  in  increased 
doses  was  of  no  benefit.  Castor-oil  relieved  the  diarrhoea  and 
the  offensive  odor  of  the  bowels  for  the  time  being.  Local  ap¬ 
plications  of  soothing  lotions  and  baths  eased  the  little  patient, 
but  had  likewise  no  marked  effect  on  the  disease.  Although 
there  was  no  indication  for  a  specific  treatment,  I  yet  gave  it 
with  the  same  negative  result.  I  was  therefore  not  surprised 
that  the  mother  ceased  her  visits,  being  disappointed  by  the  in¬ 
efficacy  of  the  treatment. 

In  resume ,  we  had  to  deal  with  a  chronic  skin  disease, 
manifesting  itself  in  hard  lesions,  on  top  of  which  there  de¬ 
veloped,  after  a  few  hours’  duration,  small  vesicles,  which  lat¬ 
ter  became  pustular  and  umbilicated,  then  crusting,  and  finally 
leaving  a  scar  mostly  resembling  that  of  varicella.  The  erup¬ 
tion  was  an  extremely  itchy  one,  unaccompanied  by  any  general 
disturbance,  except  the  slight  affection  of  the .  bowels.  It 
avoided  the  flexor  surfaces,  but  affected  the  soles,  palms,  the 
face,  and  extensor  surfaces  of  the  extremities.  The  primary 
hard  lesion  disappeared  as  soon  as  the  bullous  lesion  became 
pustular. 

These  symptoms  are  exactly  the  same  as  those  of  Hutch¬ 
inson’s  varicella  prurigo.  There  may  he  a  difference  in  the 
size  of  the  initial  lesion,  as  in  the  majority  of  his  cases  he 
states  they  were  hard  papules.  Of  some  of  them,  however, 
he  says  himself  they  were  like  urticaria  wheals. 

What  is  it  that  made  the  celebrated  English  author  call 
his  disease  varicella  prurigo  ? 

Let  us  take  either  of  these  terms  separately. 

As  to  the  “  varicella,”  it  is  indeed  difficult  to  say  why 
he  affixed  this  term  to  the  disease,  for  while  on  one  page 
he  regards  it  as  a  kind  of  persistent  chicken-pox,  on  another 


426 


GOLDENBERG:  HUTCHINSON'S  “ VARICELLA  PRURIGO .” 


[N.  Y.  Med.  Joub., 


/ 


he  seems  to  express  a  different  opinion  by  saying  “  that  it 
ought  to  be  regarded  as  sequel®  of  the  exanthema  ”  (id 
est  varicella)  “  and  not  in  any  strict  sense  a  continuation 
of  it.” 

If  the  disease  were  a  kind  of  persistent  chicken-pox, 
which  I  shall  try  to  prove  not  to  be  the  case,  there  would 
be  no  reason  to  criticise  this  term  ;  but  as  Hutchinson  him¬ 
self  declares  it  an  after-disease  of  the  varicella,  he  divests 
himself  of  the  right  of  calling  it  “  varicella”  ;  for  we  are 
not  justified  in  using  here  the  “post  hoc,  ergo  propter  hoc," 
and  calling  the  disease  varicella,  because  it  sets  in  after 
chicken-pox,  just  as  we  do  not  think  of  calling  it  morbilli 
or  scarlatina,  when  it  appears  after  these  diseases,  as  it  some¬ 
times  does. 

In  reality  the  disease  is  not  a  persistent  chicken-pox, 
and  I  do  not  speak  only  of  my  case,  but  I  likewise  include 
Hutchinson’s  cases.  In  going  through  his  elaborate  article, 
I  can  not  help  thinking  that  the  latter  have  very  little  in 
common  with  varicella.  We  have  a  chronic  disease  with¬ 
out  fever,  of  which  the  principal  symptom,  because  it  is 
the  initial  one,  is  the  result  of  a  transudation — that  is,  an 
oedematous  swelling — whether  in  the  form  of  a  papule  or 
wheal,  for  both  are  only  different  stages  of  the  same  pro¬ 
cess.  This  is  a  symptom  we  never  find  in  varicella.  I  can 
not  see  why  we  should  overlook  this  first  and  principal  sign 
of  the  disease. 

On  the  other  hand,  there  is  some  resemblance  to  vari¬ 
cella,  but  only  in  the  later  stage  of  our  disease — viz.,  when 
the  lesions  have  become  pustular.  They  then  resemble 
those  of  varicella,  and  are  indeed  so  much  alike  that  the 
physician  who  sees  the  patient  for  the  first  time  and  is  not 
informed  in  regard  to  the  steps  in  the  process  will  readily 
be  deceived.  No  wonder,  then,  that  mothers  who  are  nat- 
urally  unable  to  distinguish  between  the  two  diseases  will 
state  that  a  child  had  chicken-pox.  To  speak  of  my  pa¬ 
tient,  her  mother  was  sure  that  it  was  chicken-pox,  although 
I  know  that  the  nodular  lesions  were  present  in  the  begin¬ 
ning  in  the  same. way  as  they  were  in  the  later  periods  of 
the  disease.  They  were  simply  overlooked  or  regarded  as 
unimportant,  for  the  reason  that  they  did  not  belong  to  the 
symptomatology  of  chicken-pox. 

The  resemblance  of  the  pustular  lesions  of  our  disease 
and  those  of  varicella  is  for  us  actually  without  any  great 
importance  and  can  not  influence  our  diagnosis,  for  we  find 
vesicular  or  pustular  umbilicated  lesions  leaving  more  or 
less  depressed  cicatrices  in  several  other  skin  diseases. 
They  have  been  termed  varioliform  on  account  of  the  re¬ 
semblance  they  bear  to  variola  lesions  in  their  clinical  symp¬ 
toms;  but  that  does  not  make  them  integral  parts  of  variola. 
By  the  same  mode  of  reasoning,  we  can  say  also  that  be¬ 
cause  a  lesion  objectively  resembles  a  chicken-pox  lesion,  it 
is  not  by  any  means  on  that  account  chicken-pox. 

As  to  the  scars,  they  are  to  be  regarded  as  nothing  else 
but  sequel®  of  the  scratching,  for  I  found  them  much  more 
pronounced  on  the  face  and  extremities  than  on  the  back. 
Naturally  on  the  former  surfaces  the  little  patient  had  full 
power  of  her  hands  for  scratching  purposes. 

In  order  to  understand  the  term  “prurigo,”  I  must  state 
that  Hutchinson  does  not  acknowledge  prurigo  as  a  disease 


sui  generis.  He  applies  this  term  to  all  diseases  in  which 
excessive  itching  is  the  first  and  principal  feature,  “  whether 
beginning  from  lice,  from  fleas,  from  woolen  clothing,  from 
half-cured  scabies,  or  from  some  internal  cause.”  The  name 
varicella  prurigo  is  therefore  meant  to  express  varicella  pru- 
ritica. 

Having  thus  demonstrated  that  the  process  is  neither 
varicella  nor  prurigo,  let  us  now  consider  what  the  dis¬ 
ease  is : 

When  the  individual  lesions  were  observed,  we  found  a 
papule  or  a  wheal,  precisely  the  same  as  is  met  with  in 
urticaria,  and  this  represents  the  primary  lesion,  or  the  one 
characterizing  the  process.  During  the  life  history  of 
this  primary  lesion,  however,  it  was  seen  that  an  inflamma¬ 
tory  bulla,  becoming  later  pustular,  arose  upon  the  primary 
wheal  as  a  base  and  lasted  longer  than  the  latter.  This  is 
an  occurrence  which,  in  my  opinion,  must  be  considered  as 
secondary  and  independent  of  the  original  process.  Now, 
when,  in  addition  to  the  character  of  the  primary  lesion  (that 
is,  its  clinical  identity  with  those  of  urticaria),  we  take  the 
sudden  appearance  of  the  wheals  and  the  excessive  itching, 
the  conclusion  which  I  arrived  at — viz.,  that  the  varicella 
prurigo  is  primarily  and  essentially  an  urticaria — is  certainly 
justifiable,  and  this  view  I  am  glad  to  find  corroborated  by 
T.  C.  Fox  in  an  article  on  Urticaria  in  Infancy  and  Child¬ 
hood.  The  results  of  his  observations  agree  with  mine, 
notwithstanding  that  our  line  of  reasoning  was  different. 

But  how  are  we  to  explain  the  bullous  and  pustular  le¬ 
sions  which  form  on  the  wheals?  I  have  already  said  that  I 
considered  them  to  be  secondary  to  the  original  disease,  and 
I  can  not  confirm  the  statement  made  by  T.  C.  Fox,  that 
urticaria  pustulosa  is  the  urticaria  /car’  e^oxgv  of  infants 
and  children,  for,  according  to  my  experience  here  and  in 
Germany,  pure  cases  of  pustular  urticaria  are  of  rare  occur¬ 
rence  ;  but  when  they  are  met  with  they  are  usually  the  re¬ 
sult  of  secondary  infection  from  without — that  is,  the 
Staphylococcus  is  brought  in  contact  with  the  wheal  by 
scratching  and  other  means,  and  then  a  pustule  appears. 
In  my  case  there  could  be  no  question  of  the  pustule  be¬ 
ing  due  to  any  external  agent  or  cause,  as  there  were  no 
evidences  about  the  primary  lesions  which  would  suggest 
that  they  had  been  in  any  way  infected  from  without.  The 
type  was  perfectly  pure;  each  lesion  was  primarily  a  wheal, 
and  within  a  very  short  time  the  further  development  was 
that  of  a  distinct  pustule,  and  in  consequence  it  seemed  to 
me  that  when  we  could  exclude  external  infection  we  must 
look  for  some  source  of  infection  in  the  body.  In  my  opin¬ 
ion,  this  is  to  be  found  in  the  fermentative  processes  of  the 
intestines,  which  are  very  important  ®tiologieal  factors,  in¬ 
asmuch  as  they  may  have  a  twofold  effect.  In  the  first 
place,  they  may  produce  wheals  through  reflex  action  ;  in 
the  second  place,  ptomaines  may  be  formed  which,  taken 
up  by  the  circulation,  may  act  as  irritants  upon  the  walls 
of  the  vessels,  thus  causing  an  inflammatory  exudation  into 
the  tissues,  where  the  wheal  is  situated,  as  there  exists  in 
that  situation  a  locus  minoris  resistentice.  These  ptomaines 
‘may,  furthermore,  be  pus-forming  elements,  and  conse¬ 
quently  the  contents  of  the  vesicle  will,  under  those  circum¬ 
stances,  become  purulent  and  lose  their  simple  serous  char- 


Oct.  18,  1890.] 


MAJOR:  AN  INTERESTING  CASE  OF  ANEURYSM. 


427 


actor;  for,  as  Brieger  has  shown  in  his  elaborate  work  on 
ptomaines,  the  intestinal  tract  may  be  considered  as  a  favor¬ 
able  location  for  the  formation  of  chemical  alkaloid  prod¬ 
ucts  called  ptomaines,  caused  under  the  influence  of  germs 
during  the  process  of  decomposition  and  of  fermentation. 
These  noxious  products  which  are  being  continually  formed 
are  generally  rendered  harmless  by  the  influences  of  certain 
products  of  digestion,  such  as  indol,  phenol,  and  skatol, 
for  instance,  in  their  chemical  combination  with  sulphuric 
acid.  Should  the  formation  of  these  products  of  digestion 
be  interfered  with,  owing  to  pathological  conditions  in  the 
intestinal  tract,  it  is  evident  that  the  influence  of  these  nox¬ 
ious  substances,  normally  produced,  will  no  longer  be  con¬ 
trolled  by  their  chemical  antidotes. 

There  is  one  point  that  may  seem  to  speak  against 
Hutchinson’s  “varicella  prurigo”  being  considered  an  urti- 
caiia  viz.,  the  multiplicity  of  cases  in  one  family  ;  for 
Hutchinson  observed  in  some  of  his  cases  several  children 
of  the  same  family  affected  simultaneously.  One  may  think 
that  this  proves  the  contagious  nature  of  the  disease,  but 
such  is  not  necessarily  the  case.  It  is  not  uncommon  to 
find  several  children  of  the  same  family  affected  at  the 
same  time  with  urticaria.  This  fact  is  not  surprising  con¬ 
sidering  that  every  one  of  them  may  be  or  may  have  been 
exposed  to  the  same  external  or  internal  noxse.  In  fact, 
this  multiplicity  is  of  such  frequent  occurrence  that  I  have 
been  asked  more  than  once  if  the  hives  were  contagious. 

107  East  Fifty-ninth  Street. 


NOTES  ON 

AN  INTERESTING  CASE  OF  ANEURYSM* 

By  GEORGE  W.  MAJOR,  M.  D., 

MONTREAL. 

M.  K.,  male,  German,  aged  thirty-four,  while  walking  in  the 
street  was  suddenly  seized  with  intense  dyspnoea,  and  as  he 
was  in  the  vicinity  of  the  Montreal  General  Hospital  he  made 
immediate  application  for  relief.  Dr.  Richard  L.  MacDonnell, 
one  of  the  physicians,  was  in  the  building  at  the  time  and  ad¬ 
mitted  the  man  into  one  of  his  wards.  As  suffocation  was  im¬ 
minent,  I  was  summoned  in  consultation,  and  intubation  of  the 
larynx  was  decided  upon.  When  I  saw  the  patient,  a  few  min¬ 
utes  after  his  arrival,  his  condition  was  desperate  in  the  ex¬ 
treme  and  most  painful  to  witness.  He  was  unable  to  speak, 
his  face  was  purple  and  swollen  with  blood,  and  he  forced  his 
finger  tips  into  his  ears  in  his  efforts  to  relieve  the  pressure  on 
the  drum  heads.  I  introduced  an  O’Dwyer  tube  of  large  size 
into  the  larynx,  which  afforded  sensible  but  gradual  relief.  Af¬ 
ter  the  severity  of  the  paroxysm  had  somewhat  subsided  I 
withdrew  the  tube,  and  succeeded  in  making  a  laryngoscopic 
examination,  to  which  reference  shall  be  made  hereafter.  When 
able,  the  patient  stated  that  he  had  served  in  the  Franco-Prus- 
sian  war.  He  denied  ever  having  had  syphilis;  had  been  mar¬ 
ried  seven  years;  his  wife  had  one  child  and  had  not  miscar¬ 
ried.  He  was  employed  as  a  storeman,  and  was  in  the  habit  of 
lifting  very  heavy  weights.  He  had  not  suffered  from  cough 
or  pain  in  the  chest.  During  the  last  two  months  he  had  sev¬ 
eral  attacks  of  dyspnoea,  but  always  found  relief  in  the  appli¬ 

*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


cation  of  mustard.  He  was  a  large,  well-built  man,  with  a 
splendid  development  of  chest,  covered  deeply,  however,  with 
a  thick  layer  of  fat.  The  pupils  were  of  equal  size,  the  radial 
pulses  were  equal,  and  there  was  no  tracheal  tugging. 

Physical  examination  of  the  chest  revealed  simply  dimin¬ 
ished  respiration  over  the  left  side.  No  dullness  on  percussion 
was  at  any  time  established,  due,  doubtless,  to  the  great  thick¬ 
ness  of  the  thoracic  walls. 

The  patient  survived  six  days,  and  in  that  time  was  never 
quite  free  from  dyspnoea.  Intubation  and  catheterism  were 
practiced  twice  during  his  residence  in  hospital,  when  death  ap¬ 
peared  imminent,  but  always  with  but  modified  relief.  Finally, 
termination  was  by  syncope.  There  was  no  doubt  at  any  time 
existing  in  our  minds  as  to  the  character  of  the  case. 

At  the  autopsy  the  clinical  diagnosis  of  aneurysm  was  fully 
confirmed. 

A  saccular  dilatation  in  the  transverse  and  descending  arch, 
about  the  size  of  a  small  orange,  was  found.  The  left  bronchus’ 
which  passed  immediately  behind  the  sac,  was  almost  obliter¬ 
ated.  The  rupture  occurred  at  this  point  of  constriction,  and  a 
number  of  nerve  fibers  connected  with  the  pneumogastric  and 
left  recurrent  laryngeal  nerves  were  involved  in  the  extrava¬ 
sation.  The  rupture  took  place  into  the  posterior  mediastinum, 
and  there  was  secondary  haemorrhage  into  the  stomach.  Haem¬ 
orrhagic  infarction  of  the  pneumogastric,  but  particularly  of 
the  left  recurrent,  was  observed  at  the  post-mortem  examina¬ 
tion. 

From  the  laryngologist’s  point  of  view,  this  case  presents 
a  number  of  interesting  features  and  suggests  a  variety  of 
considerations.  Intubation  did  not  afford  the  immediate 
and  complete  relief  that  one  would  expect  in  a  ease  of  pure¬ 
ly  glottic  obstruction.  The  laryngoscopic  examination 
showed  the  left  vocal  cord  fixed  at  the  middle  line,  left  ab¬ 
ductor  paralysis  with  adductor  spasm.  The  right  vocal  cord, 
though  moving  through  its  field,  underwent  intermittent 
spasmodic  movements  ;  the  tendency  was,  however,  decided¬ 
ly  in  the  direction  of  adduction.  In  this  particular  case  the 
laryngeal  image  proved  of  great  value  as  a  means  not  only 
of  assisting  in  the  diagnosis  of  aneurysm,  but  also  in  esti¬ 
mating  the  part  the  larynx  played  in  producing  the  dysp¬ 
noea.  We  might  even  go  further  and  say  that  (taking  into 
consideration  concomitant  circumstances,  of  course)  the 
image  was  characteristic  of  pressure  on  the  left  vagus,  or,  at 
all  events,  pointed  in  that  direction.  Pressure  on  the  vagus 
will  produce  abductor  paralysis  of  the  same  side  with  ad¬ 
ductor  reflex  spasm  of  the  laryngeal  muscles  of  the  opposite 
side.  In  deciding  these  points,  due  allowance  must  be  made 
for  the  stage  of  advancement  of  the  aneurysm  at  the  time 
of  examination.  If  the  pressure  had  been  on  the  left  recur¬ 
rent  nerve  only,  the  vocal  cord  of  the  left  side  would  have 
been  affected  and  the  dyspnoea  would  have  been  intermittent 
instead  of  having  the  permanent  character  it  exhibited. 
Pressure  on  one  recurrent  nerve  does  not  affect  phonation 
and  is  not  likely  to  give  rise  to  troublesome  dyspnoea  ;  but 
pressure  on  one  vagus,  inducing  double  adductor  spasm,  as 
it  does,  will  produce  serious  results  thereby. 

I  stated  a  moment  ago  that  the  position  of  the  vocal 
cords  depended  somewhat  on  the  duration  of  the  disease 
and  on  the  amount  of  pressure  exerted.  I  have  occasion¬ 
ally  observed  in  the  course  of  an  aneurysm  that  the  image 
so  varied  from  time  to  time,  after  a  considerable  interval, 


428 


MAJOR:  AN  INTERESTING  CASE  OF  ANEURYSM. 


[N.  Y.  Med.  Joik., 


that  I  was  led  to  doubt  the  accuracy  of  a  previous  delinea 
tion  in  my  register.  This  change  is  more  readily  observed 
in  a  case  of  pressure  on  one  recurrent  nerve.  For  instance, 
in  recurrent  pressure  there  may  be  early  in  the  case  some 
dyspnoea,  but  rarely  any  voice  affection ;  on  examination, 
we  find  the  vocal  cord  on  the  side  of  pressure  at  the  middle 
3ine — abductor  paralysis.  Later  on  the  dyspnoea  disap¬ 
pears,  but  the  voice  is  impaired.  The  laryngoscope  shows 
the  cord  of  the  same  side  at  the  cadaveric  position — com¬ 
plete  paralysis ;  the  adductor  fibers  have  become  involved. 
The  patient  now  suffers  from  phonatory  leakage.  He  can 
inspire  freely  enough,  but  he  can  not  economize  his  air  and 
is  easily  put  out  of  breath  in  consequence;  his  cough  also 
is  difficult;  the  mechanism  of  cough  is  interfered  with.  At 
a  still  later  stage  the  voice  may  improve;  this  is  the  result 
not  of  local  improvement  in  the  case,  but  of  the  compensating 
.action  of  the  vocal  cord  of  the  opposite  side  approaching  its 
fellow  to  produce  vocal  effect.  The  same  state  of  things  no 
doubt  may  occur  in  vagus  pressure  modified  by  the  differ¬ 
ence  in  the  conditions.  Personally,  I  have  not  had  an  op¬ 
portunity  of  following  vagus  pressure  for  a  sufficiently  long- 
period  to  speak  with  any  authority.  The  late  Professor 
Elsberg,  of  New  York,  formulated  a  law  with  the  object 
and  intention  of  explaining  these  somewhat  curious  facts. 
He  maintained  that  “  the  abductor  filaments  of  the  nerve 
are  more  prone  to  be  affected  than  the  adductor  filaments, 
and  that  if  in  a  given  case  in  which  both  the  abductors  and 
adductors  are  affected,  recovery  takes  place,  the  adductors 
are  apt  to  recover  first  or  exclusively  and  to  be  affected 
with  abnormal  contraction,  so  that  the  patient  during  the 
progress  of  recovery  is  in  danger  of  a  dyspnoea  which  may 
necessitate  a  tracheotomy  in  order  to  prevent  death.”  In 
practice  this  law  has  received  abundant  confirmation, 
and,  in  the  absence  of  any  satisfactory  explanation  of 
a  theoretical  nature,  we  can  not,  I  think,  do  better  than 
accept  it. 

In  the  case  I  report,  the  laryngeal  condition  was  due 
either  to  pressure  on  the  left  vagus  or  to  pressure  on  the 
recurrents  of  both  sides.  In  either  case  great  dyspnoea 
would  be  present,  and  in  the  comparative  absence  of  physi¬ 
cal  signs  it  became  a  nice  question  of  diagnosis.  The  case 
was  not  seen  until  pressure  on  the  vagus  had  been  set  up,  but, 
from  the  history  given  by  the  patient  himself,  pressure  on 
the  left  recurrent  laryngeal  had  preceded  it  for  some  months. 
The  obstruction  offered  to  the  entrance  of  air  into  the  left 
lung,  and  the  altogether  greater  frequency  of  aneurysmal 
pressure  on  the  left  side,  were  valuable  considerations  in 
arriving  at  a  correct  diagnosis.  In  the  present  instance 
there  were  no  physical  signs  of  any  value  present  excepting 
the  pressure  on  the  left  bronchus.  The  laryngeal  indications 
were  therefore  paramount,  and,  when  associated  with  certain 
collateral  indications,  a  diagnosis  was  not  difficult.  In  every 
case  of  loss  or  impairment  of  voice,  and  in  every  case  of 
dyspnoea,  an  expert  laryngoscopic  examination  should  be 
made  ;  it  no  doubt  would  often  clear  up  obscure  symptoms 
and  enable  us  to  properly  estimate  their  true  value.  In  the 
course  of  this  case  there  is  no  doubt  that  the  attacks  of 
dyspnoea  of  the  greatest  severity  were  the  result  of  pressure 
exerted  by  the  succession  of  haemorrhages  that  took  place. 


We  have  no  direct  proof  of  this,  but  we  made  tolerably  cer¬ 
tain  by  intubation  that  the  larynx  was  not  entirely  at  fault. 
The  question  of  tracheotomy  was  raised  at  different  times 
for  the  relief  of  the  dyspnoea,  but  was  negatived  for  the  fol¬ 
lowing  reasons:  In  the  first  place,  intubation  failed  to  give 
the  instantaneous  relief  it  should  have  afforded  in  a  case  of 
purely  laryngeal  obstruction.  In  the  second  place,  there 
was  a  general  absence  of  the  usual  signs  of  laryngeal  dysp¬ 
noea — for  example,  the  larynx  was  stationary  in  the  throat; 
it  did  not  descend  during  inspiration.  There  was  no  supra¬ 
sternal  depression  and  no  diaphragmatic  retraction.  The 
voice  was  weak,  the  cough  and  inspirations  were  asthenic, 
and  the  muscles  of  the  chest  were  quiescent.  The  abdomi¬ 
nal  walls  were,  however,  in  a  state  of  great  and  continued 
activity,  especially  during  expiration.  Had  the  dyspnoea 
been  of  a  laryngeal  nature  I  should  not  have  hesitated  to 
perform  tracheotomy,  not  only  for  the  relief  of  breathing, 
but  also  as  a  means  of  delaying  the  rupture  of  the  sac. 

1  mentioned  the  absence  of  tracheal  tugging  in  this  case, 
and,  as  it  is  a  symptom  of  aneurysm  but  little  known,  will 
say  a  few  words  concerning  it  before  closing.  Tracheal 
tugging  was  first  described  as  a  symptom  of  aneurysm  of 
the  arch  by  Dr.  W.  S.  Oliver*  (surgeon-major  in  II.  B- 
M.’s  regular  army,  retired),  of  Halifax,  Nova  Scotia.  It 
has  been  recognized  in  the  practice  of  the  Montreal  General 
Hospital  ever  since,  hut  there  has  seemed  to  exist  some 
doubt  as  to  the  exact  way  in  which  the  “tugging”  was 
brought  about. 

When  the  aneurysmal  sac  is  immediately  over  the 
bronchus  the  direct  pressure  downward  produces  this  symp¬ 
tom,  which  is  synchronous  with  the  pulse,  whereas  if  the 
sac  is  behind  or  before  there  is  no  effect  produced.  Dr. 
MacDonnell,  Professor  of  Clinical  Medicine  in  McGill  Uni¬ 
versity,  first  gave  me  this  explanation  of  the  phenomenon, 
which  I  have  since  proved  by  reference  to  case  reports. 
To  detect  this  symptom  the  patient  is  placed  seated  upright 
in  a  chair  with  the  mouth  closed.  The  trachea  is  drawn 
upward  by  traction  on  the  cricoid,  and  if  “tugging”  is  felt 
you  can  be,  in  so  far  as  my  knowledge  and  experience  goes, 
pretty  certain  of  an  aneurysmal  sac  pressing  downward  on 
the  left  bronchus. 

The  autopsy  in  this  case  was  made  by  Dr.  Wyatt  John¬ 
ston,  pathologist  to  the  hospital,  and  my  short  report  of 
the  appearances  was  abstracted  from  the  hospital  register. 


Operation  for  Distichiasis.  —  “  Dr.  Landolt  has  lately  devised  a  new 
operation  for  this  troublesome  affection.  He  splits  the  lid  into  two 
portions  by  an  incision  carried  right  along  the  intermarginal  space. 
The  anterior  flap  contains  the  skin,  loose  tissue,  and  cilia,  the  posterior 
the  tarsus  and  muscle.  He  then  divides  the  anterior  flap  into  two  parts 
by  a  longitudinal  incision.  The  lower  part,  which  is  made  very  small, 
contains  the  cilia.  This  part  is  shoved  right  up  under  the  upper  part 
of  the  anterior  flap,  so  that  it  reaches  to  a  level  above  or  at  the  superior 
margin  of  the  tarsus.  The  upper,  larger  part  falls  down  by  its  own 
weight,  and  its  edge  is  united  to  the  inferior  edge  of  the  posterior  flap. 
As  soon  as  these  two  edges  are  firmly  adherent  one  with  the  other,  a 
longitudinal  incision  is  carried  along  the  eyelid  at  a  few  millimetres 
from  the  edge  ;  and  the  cilia,  which  have  till  now  been  inclosed  in  a 
sort  of  pouch,  are  liberated.” — Glasgow  Medical  Journal. 

*  Lancet ,  September  21,  1878. 


Oct.  18,  1890.] 


ROBINSON:  THE  RAWHIDE  PLATE. 


THE  RAWHIDE  PLATE. 

A  NEW  PLATE  FOR  INTESTINAL  ANASTOMOSIS. 

By  F.  B.  ROBINSON,  B.  S.,  M.  D., 

TOLEDO,  OHIO, 

PROFESSOR  OF  ANATOMY  AND  CLINICAL  SURGERY  IN  TOLEDO  MEDICAL  COLLEGE. 

Very  little  distinct  surgery  of  the  intestines  was  done 
in  a  systematic  method  until  Travers,  of  London,  pub¬ 
lished  his  investigations  in  1812.  He  entitled  it  An  In¬ 
quiry  into  the  Process  of  Nature  in  repairing  Injuries  of 
the  Intestines ,  illustrating  the  Treatment  of  Penetrating 
Wounds  and  Strangulated  Hernia.  In  this  work  Trav¬ 
ers  demonstrated  remarkable  tact,  ingenuity,  and  judg¬ 
ment.  His  deductions  were  able  and  philosophical  and 
his  experiments  far-reaching  and  practical.  It  was  Trav¬ 
ers  who  showed  that  a  fine  thread  could  be  tightly  tied 
around  a  dog’s  intestine,  and  the  thread  would  cut  through 
and  fall  into  the  gut  lumen,  while  the  dog  would  recover. 
The  faecal  circulation  would  again  assume  its  normal  course. 
The  next  European  experimental  work  on  the  intestines  was 
done  in  France  about  1825,  when  Jobert  gave  the  profes¬ 
sion  his  ingenious  operation,  and  Lembert,  in  conjunction 
with  Jobert,  recorded  the  immortal  Lembert  stitch.  Pro¬ 
fessor  Czerny,  of  Heidelberg,  a  student  of  Billroth’s,  gave 
his  stitch  to  the  profession  a  few  years  ago.  Dupuytren, 
Larrey,  and  Baudens  added  by  practical  work  improvements 
to  intestinal  surgery.  Ledran,  Ramdohr,  Denans,  Reybard, 
Adelmann,  Gegenbaur,  and  other  Europeans  recorded  some 
experiments,  but  not  any  particular  advance  over  Travers, 
Lembert,  and  Jobert.  In  America,  Dr.  T.  Smith,  of  the 
Island  of  St.  Croix,  made  a  dozen  experiments  on  dogs’  in¬ 
testines  to  test  the  sutures  of  Bell  and  others. 

The  report  of  Dr.  Smith’s  experiments  was  published  in 
1805  in  his  Inaugural  Dissertation,  and  placed  before  the 
trustees  and  faculty  of  the  University  of  Pennsylvania.  Dr. 
Smith  mainly  recorded  the  action  of  the  operation  on  the 
animal’s  life,  but  did  not  give  many  practical  views  as  to 
the  nature  of  the  pathology  of  repair.  But  autopsies  then 
and  now  are  different  factors  in  medicine.  Much  silence 
reigned  until  1841,  when  Dr.  Gross,  while  living  at  Louis¬ 
ville,  Ky.,  did  a  very  notable  series  of  experiments  on  sev¬ 
enty  dogs,  extending  over  three  years.  Dr.  Gross  did  all 
known  experiments  on  the  intestines  at  that  time,  and  de¬ 
serves  our  lasting  admiration  for  his  courage,  able  execu¬ 
tion,  and  commendable  spirit  of  progress  in  those  days  of 
no  ansesthetics. 

In  1884  Professor  Charles  T.  Parkes,  of  Chicago,  per¬ 
formed  a  very  valuable  series  of  experiments  on  dogs’  in¬ 
testines,  mainly  with  regard  to  gunshot  wounds.  The  able 
work  of  Professor  Parkes  attracted  widespread  interest  in 
this  country.  Cuts  showing  the  results  of  this  accomplished 
surgeon’s  experiments  may  be  seen  scattered  through  vari¬ 
ous  surgical  works,  and  I  know  personally  that  much  good 
resulted  to  the  profession  from  his  labors. 

Very  little  further  experimental  work  was  done  to  throw 
any  light  on  intestinal  surgery  until  1887,  when  Professor 
Senn,  assisted  by  Dr.  Connell,  carried  out  one  hundred  and 
fifty  systematic  experiments.  In  this  remarkable  series  of 
experiments  the  brilliant  genius  of  Senn,  with  his  untiring 
energy  and  laudable  industry,  erected  to  his  name  a  lasting 


429 

monument  of  benefaction  to  humanity.  Professor  Senn’s 
book  is  the  best  sample  of  the  vigorous  spirit  of  modern 
progress  yet  presented  in  this  department  of  surgery.  The 
essential  idea  which  will  be  of  lasting  value  in  Professor 
Senn’s  experiments  is  that  of  anastomosis  by  approximat¬ 
ing  perforated  discs.  Professor  Senn  notes  that  Dr.  Con¬ 
nell  first  suggested  their  use.  In  1887  I  began  systematic 
experiments  on  the  intestines  of  dogs,  assisted  by  Dr.  D.  D. 
Bishop,  now  of  Rush  College.  The  work  was  continued 
here  mainly  with  the  aid  of  Dr.  C.  S.  Miller.  Dr.  Gillette 
also  shared  in  it.  Carefully  recorded  work  has  been  carried 
on  from  then  until  the  present.  We  have  now  over  one 
hundred  and  sixty  systematic  experiments,  besides  many 
irregular  ones.  As  a  result  of  these  experiments,  we  have 
several  new  things  to  present  to  the  profession.  One  of  the 
new  things  is  a  rawhide  plate  for  intestinal  anastomosis. 

It  would  be  very  neglectful  if  I  did  not  say  that  Dr. 
Brokaw,  of  St.  Louis,  Dr.  Davis,  of  Birmingham,  Ala.,  and 
Dr.  Matas,  of  New  Orleans,  have  done  extensive  and  splen¬ 
did  work  in  experiments.  Dr.  Davis  presents  the  catgut 
mats,  Dr.  Matas  his  solid  catgut  ring,  and  Dr.  Brokaw  his 
very  valuable  segmented  rubber  ring.  The  advance  in  in¬ 
testinal  work  is  unparalleled  in  any  age.  The  progress  and 
revolutions  of  the  past  eighteen  months’ intestinal  work  are 
absolutely  marvelous.  And  it  still  continues,  for  Dr.  A.  C. 
Bernays,  of  St.  Louis,  writes  me,  on  his  return  from  Berlin 
in  September,  that  the  medical  men  there  were  talking  of 
giving  up  all  aids  to  intestinal  anastomosis,  such  as  plates 
and  rings ;  that  they  got  better  results  from  the  simple  Lem¬ 
bert  suture.  We  hope  the  Lord  will  forgive  all  such  sin¬ 
ners.  This  idea  reminds  us  of  Daniel  Webster  in  Congress 
giving  up  the  idea  of  telegraphy  as  a  failure. 

In  1889  I  began  to  look  around  for  a  more  convenient 
material  for  intestinal  anastomosis  than  Professor  Senn’s 
decalcified  perforated  bone  plate.  His  plate  does  the  work 
quite  well,  but  it  requires  some  ten  to  fourteen  days  to  pre¬ 
pare  the  plates,  and  they  cost  a  dollar  a  pair.  As  the  subject 
was  then  quite  new,  one  had  to  rely  on  his  own  resources. 
At  that  time  I  had  never  known  of  cartilage  being  used, 
and,  in  daily  passing  a  large  butcher-shop,  the  non-ossified 
or  cartilaginous  part  of  a  young  beef  attracted  my  atten¬ 
tion.  I  used  that  with  success  in  the  form  of  perforated 
plates  with  four  to  six  sutures.  But  I  lost  some  dogs  from 
too  rapid  absorption  of  the  cartilage  plates,  so  I  abandoned 
it.  For  cartilage  to  resist  absorption  in  the  upper  alimen¬ 
tary  passage  it  requires  a  large,  thick  plate.  For  months  I 
tried  all  kinds  of  material,  chiefly  leathers.  The  healing  of 
the  anastomosis  was  nearly  always  good,  but  an  inabsorb- 
able  plate  is  a  possible  source  of  danger.  Finally,  to  put  a 
long,  tedious  number  of  experiments  into  a  short  story,  I 
began  the  use  of  rawhide  plates.  These  proved  to  be  a  re¬ 
markable  success  in  living  experiments  from  the  simple  re¬ 
covery  of  so  many  of  the  animals.  The  rawhide  plate  is 
made  by  shaving  the  hair  from  the  green  hide  of  an  ox. 
Then  cut  the  hide  into  strips  an  inch  wide  and  two  inches 
and  a  half  long.  Perforate  the  plate  by  a  diamond-shaped 
aperture  (half  an  inch  by  three  quarters  of  an  inch).  Then 
apply  four  to  six  sutures  to  the  plate,  armed  with  four  to 
six  needles,  and  it  is  ready  for  use.  The  plate  can  be  used 


430 


ROBINSON:  THE  RAWHIDE  PLATE . 


[N.  Y.  Med.  Jocr., 


dried  or  green.  We  have  tried  both  ways  many  times.  If 
the  hair  is  shaved  from  the  green  hide  and  then  the  hide  is 
dried,  it  thickens  and  stiffens  it  so  that  almost  any  kind  of 
plates  suitable  to  any  part  of  the  alimentary  canal  can  be 
obtained.  The  features  of  these  rawhide  plates  are — they 
are  eminently  suitable  for  the  operation  of  intestinal  anas¬ 
tomosis  ;  they  are  easily  prepared,  quite  accessible,  and  very 
convenient ;  they  are  suitably  absorbable  and  can  be  well 
adapted  to  the  character  and  quality  of  the  intestinal  tract. 

After  a  very  large  number  of  experiments,  I  am  fully  con¬ 
vinced  that  a  plate  should  not  be  absorbed  too  soon.  One 
can  not  rely  on  any  definite  period  of  healing  from  perito¬ 
neal  plastic  exudates.  The  exudate  may  be  rapid  in  its 
formation  or  much  delayed.  A  plate  should  hold  intact  for 
about  five  days  to  insure  success.  The  superiority  of  plates 
over  all  rings  is  in  the  amount  of  serous  surface  held  in  con¬ 
tinuous  approximation.  Rings  hold  only  a  limited  serous 
surface  in  approximation,  and  they  are  apt  to  contuse  or 
cause  sloughing.  A  plate  produces  equable  and  uniform 
pressure  in  all  directions,  and  thus  causes  no  sloughing  or 
gangrene.  Its  edges  are  round  and  smooth,  and  no  promi¬ 
nences  project  against  the  gut  wall  to  cause  gangrene  of  its 
tissues,  forming  faecal  fistula,  and  inviting  the  demon  peri¬ 
tonitis  to  end  the  scene.  The  rawhide  plates  produce  ex¬ 
cellent  fixation  of  the  anastomosed  parts,  and  consequent 
mechanical  and  physiological  rest,  which  is  required  for  suf¬ 
ficient  cell  proliferation  and  definite  healing.  The  plate  is 
not  large  or  bulky,  is  easily  inserted,  and  is  very  convenient 
for  rapid  execution — a  prime  necessity  in  all  intestinal  op¬ 
erations. 

Anastomosis  means  the  opening  of  one  mouth  into  an¬ 
other,  the  communicating  of  one  vessel  with  another.  In¬ 
testinal  anastomosis  means  the  communicating  of  the  lumen 
of  one  gut  with  the  lumen  of  another  through  its  walls.  It 
is  an  artificial  fistula  in  which  the  mucous  membrane  is  con¬ 
tinuous  through  a  new  channel  which  passes  through  the 
contiguous  bowel  walls.  It  is,  in  short,  a  bimucous  fistula, 
which  disease  must  have  frequently  been  established  shortly 
after  intestines  were  created.  Yet  the  idea  of  forming  an 
artificial  bowel  fistula  arose  not  long  ago  among  the  French. 
The  original  genius  who  conceived  the  idea  did  some  un¬ 
successful  operations  on  human  beings,  and  the  vacillating 
French  doctors  covered  the  poor  operator  with  such  violent 
storms  of  abuse  and  indelicate  opposition  that  he  dared  not 
advocate  his  project  or  publish  his  writings.  Curiously 
enough,  the  French  were  in  this  one  thing  conservative. 
Thus  Dr.  Maisonneuve’s  valuable  conceptions  lay  dormant 
in  the  bowels  of  oblivion  for  years,  to  be  acted  on  by  a  few 
unheeded  and  unnoticed  progressive  men,  until  actively  re¬ 
vived  by  the  bold  and  skillful  surgeon,  Dr.  Hahn,  of  Berlin. 
The  ground  of  opposition  of  the  French  medical  society  to 
intestinal  anastomosis  was,  that  faeces  would  accumulate  in 
the  excluded  bowel  loop  and  finally  kill  the  patient.  Our 
experiments,  which  are  now  over  a  hundred  and  sixty, dem¬ 
onstrate  definitely  that  the  faeces  will  not  accumulate  in  the 
excluded  loop,  but  will  take  the  shortest  route  through  the 
bimucous  or  artificial  fistula.  Experience  teaches  that  the 
physiologically  excluded  gut  will  simply  atrophy.  Peri¬ 
stalsis  drives  the  faeces  out.  There  is  a  tendency  in  the 


artificial  fistula  to  contract  while  healing,  so  that  the  original 
incision  should  be  liberal  in  size.  I  he  artificial  fistula  as 
it  heals  often  acquires  a  sphincter-like  condition  from  the 
periodical  contraction  and  dilatation  of  the  fistula,  due  to 
the  irregular  passage  of  fiatus  and  faeces.  Among  the  es¬ 
sential  elements  to  insure  rapid  union  of  parts  in  intestinal 
operations  is  scarification  of  the  serous  surface  coaptated. 
We  have  proved  often  that  any  abraded,  denuded,  or  raw 
surface  in  the  abdominal  cavity,  if  retained  approximated, 
will  unite.  It  does  not  matter  whether  it  is  denuded  mu¬ 
cous  or  serous  surface.  On  this  principle  I  have  a  new  op¬ 
eration  to  present  to  the  profession.  It  is  simply  the  prin¬ 
ciple  of  denuding  a  mucous  surface  and  placing  it  in  fixed 
approximation  to  a  scarified  serous  surface.  Denuded  or 
raw  surfaces  heal  universally.  Another  very  important  aid 
in  the  healing  of  intestinal  wounds  is  the  application  of  a 
peritoneal  or  omental  graft  to  the  parts  operated  on.  The 
surface  of  the  graft  and  the  surface  to  which  it  is  applied 
should  be  scarified  with  a  needle  point  and  held  in  position 
by  a  few  fine  sutures.  The  grafts  should  be  large  enough  to 
completely  cover  the  whole  wound.  If  the  wound  is  ex¬ 
tensive,  one  or  more  grafts  could  be  applied.  Grafts  two 
bv  four  inches  live  well  and  retain  remarkable  vitality.  The 
grafts  are  best  obtained  from  the  omentum.  Grafts  are 
used  in  two  ways.  One  is  to  apply  the  omentum  (the  edge 
or  any  part)  around  the  parts  operated  on,  fix  it  in  position 
with  sutures,  and  leave  it  unsevered  from  the  omentum.  It 
is  not  cut  away  from  the  original  attachments.  I  have  used 
the  graft  in  this  manner  about  a  hundred  times  and  never 
saw  a  bad  result.  The  objection  to  raise  against  it  is,  that 
it  will  create  an  arch  under  which  intestines  will  slide  to 
and  fro  and  may  become  herniated.  Wandering  guts  may 
be  caught  and  strangulated.  This  may  happen,  but  in  a 
hundred  and  fifty  post-mortems  made  by  myself  no  such 
thing  has  been  found.  The  autopsies  were  made  from  one 
to  eighty  days  after  the  operation.  This  method  of  graft 
application  is  very  certain  in  its  healing,  and  many  times  I 
have  found  distinct  faecal  fistufe  which  were  arrested  by 
the  thickened  graft.  In  these  cases  the  graft  absolutely  is 
the  means  of  saving  life. 

The  other  method  of  using  peritoneal  or  omental  grafts 
is  to  completely  sever  them  from  some  part  of  the  perito¬ 
naeum  or  omentum,  and  then  to  apply  them  over  the  parts 
operated  on,  fixing  them  in  position  by  sutures.  I  have  tried 
this  method  many  times  with  success,  and  used  grafts  from 
the  omentum  as  large  as  three  inches  by  five  inches  with¬ 
out  a  sign  of  loss  of  vitality.  I  have  tried  the  grafts  in  all 
ways,  severed  and  unsevered,  scarified  and  unscarified,  and 
am  convinced  that  few  bowel  operations  should  be  done 
without  the  application  of  a  graft.  I  wish  to  suggest  that, 
if  omental  grafts  are  used,  they  should  be  taken  from  the 
edge  (cut  or  torn),  and  not  from  the  center  or  interior. 
We  did  this  a  few  times,  tearing  an  omental  graft  out  of 
the  interior  of  the  omentum,  leaving  a  hole  varying  from 
two  inches  by  four  inches  to  three  inches  by  six  inches  in 
this  membrane.  The  autopsy  of  several  of  those  cases 
rewarded  us  with  very  instructive  information.  In  a  case 
of  gastro-enterostomy  an  aperture  was  torn,  and  at  the  au¬ 
topsy,  weeks  after,  six  feet  to  eight  feet  of  small  intestine 


Oct.  18,  1890.] 


ROBINSON:  TEE  RAWHIDE  PLATE. 


431 


were  found  prolapsed  through  the  hole  in  the  omentum. 
The  edges  of  the  aperture  had  become  rounded  and  thick¬ 
ened,  and  might  strangulate  the  prolapsed  intestines  at  any 
moment  from  mechanical  or  pathological  causes. 

In  another  case  a  similar  occurrence  was  found  at  the 
autopsy  when  the  animal  was  killed  to  obtain  the  specimen. 
The  abdomen  was  closed  by  some  three  sutures  to  an  inch, 
including  skin,  fascia,  muscles,  theca  or  fascia,  and  perito¬ 
naeum.  Hernia  occurred  in  about  three  per  cent,  of  the 
cases.  But  in  every  instance,  as  far  as  could  be  seen,  the 
hernia  was  caused  by  the  failure  to  secure  the  theca  wel 
(the  combined  fascia  or  aponeurosis  of  the  oblique  and  trans- 
versalis  abdominal  muscles).  I  believe  this  is  precisely  the 
condition  in  the  human  subject.  In  human  laparotomy, 
hernia  is  nearly  always  caused  by  the  failure  to  secure  the 
combined  fascia  or  tendon  of  the  oblique  and  transverse 
abdominal  muscles  well  and  close  it  with  sutures.  The 
limits  of  this  article  forbid  further  discussion. 

The  following  experiments  will  illustrate  the  technique, 
methods,  convenience,  absorbability,  and  general  use  and 
worth  of  the  rawhide  plate,  which,  I  hope,  will  be  useful 
in  future  intestinal  surgery.  I  will  select  at  random  cases 
of  operation  in  different  parts  of  the  alimentary  canal  with 
the  plate  : 


Experiment  No.  18. — Dog,  male;  weight,  twenty  pounds; 
operation,  gastro-enterostomy.  In  this  case  I  used  belt  leath¬ 
er,  or  raw  hide  slightly  tanned.  Abdomen  opened  and  omen¬ 
tum  pushed  to  left,  and  loops  of  small  intestine  drawn  out 
and  incised  on  its  convex  border  an  inch.  In  this  incision  was 
inserted  a  rawhide  plate  (an  inch  by  two  inches  and  a  half), 
armed  with  four  sutures,  and  a  needle  attached  to  each  lateral 
one.  The  two  lateral  needles  were  pushed  from  inside  the  gut 
outward,  penetrating  the  entire  bowel  wall  a  third  of  an  inch 
from  margin  of  wound.  An  incision  was  made  in  the  stomach 
(an  inch  and  a  half)  after  it  was  drawn  out,  and  a  plate  was 
similarly  introduced.  The  serous  surface  over  the  plates  was 
scarified,  and  a  continuous  Lembert  suture  stitched  the  gut  and 
stomach  together,  and,  as  the  continuous  suture  coapted  the 
scarified  serous  surface,  the  corresponding  sutures  on  the  plates 
were  tied,  first  the  lower  lateral,  then  the  two  end  ones,  and 
finally  the  upper  lateral  one.  A  few  over-sutures  were  applied. 
A  scarified  graft  (omental)  was  applied  over  the  scarified  anas 
tomosis  and  sutured  in  position  by  a  few  fine  sutures.  The  dog 
made  an  uninterrupted  recovery.  Eighteen  days  after,  the  dog 
was  killed.  Abdominal  organs  found  healthy.  The  omen¬ 
tal  graft  had  formed  firm  and  strong  adhesions.  The  anas¬ 
tomosis  was  well  established.  Water  turned  into  the  stom¬ 
ach  passed  equally  through  the  new  and  old  channel.  The 
artificial  or  biinucous  fistula  had  contracted  to  about  half  its 


original  size.  It  admitted  the  index  finger,  and  had  the  appear¬ 
ance  and  feel  of  a  distinct  sphincter.  Plates  entirely  gone. 
I  wo  threads  of  linen  were  hanging  in  the  edge  of  the  fistula. 
In  approaching  the  stomach,  instead  of  pushing  the  omentum 
to  the  left,  as  in  securing  the  bowel,  the  great  omentum  was  torn 
through,  making  an  aperture  about  three  inches  by  five  inches. 
Through  this  hole  some  seven  feet  of  small  intestine  had  pro¬ 
lapsed.  It  looked  very  suggestive  to  see  that  roll  of  viscera 
hanging  in  front  of  the  omentum,  and  teaches  us  not  to  make 
such  holes  or  to  resuture  them.  It  would,  no  doubt,  strangulate 
the  intestines  by  some  mechanical  condition  in  the  future.  The 
plates  should  be  kept  in  alcohol.  The  anastomosis  was  done 
four  feet  below  the  stomach.  I  did  not  intend  to  do  that,  but 
supposed  I  had  the  duodenum.  This  is  dangerous,  as  marasmus 
will  frequently  follow  from  the  excluded  gut.  The  early  advice 
of  Luecke  and  Lauenstein,  though  of  high  authority,  must  be 
discarded.  It  was  to  sejze  the  first  appearing  loop  of  bowel 
(distended).  That  is  not  justifiable,  as  it  might  be  the  lower 
end  of  the  ileum — a  mistake  Lauenstein  made,  killing  his  pa¬ 
tient  in  a  few  weeks  from  marasmus.  To  find  the  duodenum, 
introduce  the  index  and  middle  fingers  and  feel  for  the  pylorus, 
and  especially  the  end  of  the  pancreas,  of  course  pushing  the 
omentum  to  the  left.  The  four  feet  of  excluded  bowel  did  not 
accumulate  faeces,  but  assumed  a  condition  of  atrophy.  Any 
anastomosis  on  the  stomach  should  be  done  from  its  most  de¬ 
pendent  portion,  so  that  the  secretion  and  food  can  pass  out 
with  no  hindrance,  and  also  so  that  the  continual  passage  of 
material  will  keep  the  bimucou3  fistula  patent.  This  dog  ate 
voraciously,  but  lost  flesh.  Our  experiments  demonstrated  that 
the  physiological  exclusion  of  four  feet  of  bowel  was  often  fol¬ 
lowed  by  marasmus. 


Experiment  No.  21f,. — Dog,  male;  weight,  twenty  pounds; 
operation,  gastro-colostomy  ;  material,  rawhide  plates.  The  in¬ 
tention  was  to  anastomose  the  colon  (transverse)  to  the  stomach. 
The  stomach  incision  was  an  inch  and  a  half,  and  the  bowel  an 
inch  long.  The  plates  were  inserted,  and  the  lateral  needles 
ousbed  from  within  outward,  the  serous  surface  was  scari¬ 
fied,  the  plates  were  placed  vis  d  vis ,  and  the  corresponding 
sutures  were  tied — first  the  lower,  then  the  end,  and  finally 
the  upper.  No  Lembert  sutures  employed,  and  no  graft. 
Time  of  operation,  twenty  minutes.  Dog  made  a  good  re¬ 
covery.  He  was  chloroformed  to  death  in  eleven  days.  Au¬ 
topsy  showed  all  abdominal  organs  healthy.  The  autopsy 
also  showed  that  the  transverse  colon  was  not  disturbed,  but 
the  rectum  was  anastomosed  to  the  stomach.  Hence  the  dog  had 


432 


ROBINSON:  THE  RAWHIDE  PLATE. 


[N.  Y.  Med.  Jour., 


just  enough  stomach  and  gut  to  reach  from  mouth  to. anus  for 
an  alimentary  canal.  It  dragged  and  dilated  the  stomach  about 
a  quarter  larger  than  normal.  Water  turned  into  the  stomach 
passed  almost  entirely  through  the  new  artificial  fistula,  which 
had  contracted  to  half  its  original  size,  and  felt  precisely  like  a 
natural  sphincter.  It  admitted  the  index  finger.  Though  the 
dog  had  nearly  all  the  bowels  excluded  physiologically,  he  did 
not  have  marasmus.  The  plates  were  entirely  absorbed.  No 
fcecal  accumulation  occurred  in  the  excluded  bowels.  Without 
large  practice,  one  can  not  seize  the  bowel  at  a  desired  point 
unless  eventration  is  resorted  to,  passing  the  bowel  before  the 
eye  and  through  the  fingers. 

Professor  Madelung,  of  Rostock,  made  crucial  tests  to 
show  the  difficulty  of  diagnosis  of  points  of  the  intestines 
which  are  familiar  to  most  abdominal  surgeons.  They 
demonstrate  that  practice  alone  insures  accuracy  in  diag¬ 
nosticating  disease  of  the  intestines. 


Fig.  3. 


Experiment  No.  22. — Dog,  female,  weight  fifteen  pounds. 
Operation,  ileo-ileostomy ;  material,  rawhide  plates;  animal 
chloroformed,  belly  shaved,  and  through  a  two-inch  abdominal 
incision  a  loop  of  small  intestine  wa9  drawn  out  along  the  right 
side  of  the  omentum.  The  bowel  was  completely  severed  and 
its  two  ends  invaginated  each  an  inch  and  held  in  position  by 
four  to  six  continuous  Lembert  sutures.  On  the  convex  surface 
of  each  gut  (the  part  most  distant  from  the  mesentery)  incisions 
an  inch  long  were  made.  Rawhide  plates  (an  inch  by  two 
inches  and  a  half)  were  inserted  in  the  bowel.  The  six  needles 
armed  with  linen  sutures  were  passed  from  the  inside  of  the  gut 
lumen  through  the  entire  bowel  wall  one  third  of  an  inch  from 
wound  margin.  The  serous  surface  over  the  plates  was  scarified 
with  a  needle  point,  the  plates  were  approximated,  and  the  six 
corresponding  sutures  were  tied.  A  few  continuous  over-sutures 
were  added.  An  unsevered  omental  graft  was  applied  to  the 
anastomosis  and  held  in  position  by  four  fine  sutures.  Ten 
inches  of  the  ileum  was  excluded.  Dog  recovered  excellently,  ate, 
drank,  played,  and  appeared  bappy.  She  had  slight  marasmus. 
She  was  chloroformed  to  death  fifteen  days  after.  The  autopsy 
showed  healthy  viscera.  A  very  circumscribed  local  peritonitis 
had  arisen  and  subsided.  The  graft  was  solidly  and  firmly 
grown  to  the  parts.  The  severed  gut  ends  were  well  healed,  but 
one  had  continued  to  invaginate  two  inches  and  the  other  an 
inch  and  a  half.  This  is  a  danger  I  have  frequently  observed, 
but  have  never  found  it  recorded  by  other  writers.  I  have  lost 
eight  to  ten  dogs  from  this  cause.  The  invagination  continues, 
and  it  finally  mechanically  occludes  the  gut  lumen  or  the  arti¬ 
ficial  fistula.  The  plates  were  entirely  absorbed.  In  the  ab¬ 
sence  of  hydrogen  gas  at  the  autopsy  I  filled  a  four-gallon  rub¬ 
ber  balloon  with  air  and  inserted  its  nozzle  into  the  rectum. 
The  abdominal  wall  was  then  removed.  Slight  pressure  on  the 
balloon  soon  forced  the  gas  with  an  audible  noise  through  Bau- 
hin’s  valve,  through  the  pylorus,  and  out  at  the  nose.  The  anas¬ 


tomosis  did  not  leak.  If,  however,  one  attempts  to  force  the 
air  or  gas  from  mouth  to  rectum,  it  will  generally  rupture  or 
lacerate  the  tissues,  especially  the  peritonaeum. 

Experiment  No.  40. — Dog,  male,  weight  twelve  pounds.  Op¬ 
eration,  ileo  ileostomy;  material,  green,  soft  rawhide  plates.  A 
loop  of  intestine  was  drawn  out  and  anastomosed.  No  over-sut¬ 
ures,  but  an  unsevered  omental  graft  was  well  applied  over  the 
parts  and  sutured  in  position.  As  dogs  were  occasionally  scarce,- 
we  operated  several  times  on  the  same  one  at  different  dates,  so, 
nine  days  after,  circular  enterorrhaphy  was  performed  on  this 
dog.  He  did  well,  ate,  drank,  and  played.  Twenty  two  days 
after  the  first  and  nine  after  the  second  operation  the  dog  was 
killed.  The  organs  were  found  healthy  at  the  autopsy.  Two 
points  showed  the  rise  and  subsidence  of  a  local  peritonitis  at 
the  enterorrhaphy  and  anastomosis.  The  graft  had  healed;  it  was 
strong  and  firm.  The  anastomosis  was  well  established,  conduct¬ 
ing  nearly  all  of  the  foacal  circulation.  The  artificial  fistula  had 
contracted  to  half  its  size  and  was  distinctly  sphincter-like.  The 
fistula  is  generally  larger  when  all  the  faeces  and  flatus  are  com¬ 
pelled  to  go  through  it.  Here  it  had  two  routes.  Rawhide 
plates  entirely  absorbed.  All  the  sutures  (six)  were  still  hang¬ 
ing  in  the  edge  of  the  artificial  fistula.  The  circular  enteror¬ 
rhaphy  had  contracted  to  a  third  of  its  original  size  and  was 
beginning  to  cause  obstruction. 


Fig.  4. 


Experiment  No.  66. — Dog,  male,  weight  twenty-five  pounds. 
The  usual  preparations  and  a  loop  of  intestine  drawn  out.  Ten 
inches  was  resected.  The  two  divided  ends  were  invaginated 
an  inch,  and  so  sutured  in  position  with  six  continued  Lembert 
sutures.  Rawhide  plates  were  introduced  into  the  incisions  in 
the  bowel  and  approximated  and  tied.  A  graft  was  applied 
over  the  parts  and  sutured  in  position.  The  dog  made  an  unin¬ 
terrupted  recovery,  ate,  drank,  and  played.  He  escaped,  un¬ 
fortunately,  on  the  ninth  day,  hale  and  hearty. 

Experiment  No.  67. — Dog,  male,  weight  ten  pounds.  Opera¬ 
tion,  resection  of  an  inch  and  a  half  of  bowel,  and  canal  restored 
by  anastomosis  with  rawhide  plates.  After  the  resection  the 
two  bowel  ends  were  invaginated  an  inch  each  and  sutured  in 
position,  then  anastomosed.  Graft  applied.  The  rawhide 
plates  were  very  thin.  The  dog  was  killed  on  the  ninth  day. 
Graft  was  well  healed,  anastomosis  well  established,  and  artifi¬ 
cial  fistula  of  good  size.  Plates  entirely  absorbed.  A  very  im¬ 
portant  point  was  again  observed  in  regard  to  the  invaginated 
bowel  ends  which  had  proceeded  beyond  the  point  of  the  arti¬ 
ficial  fistula,  causing  danger  of  mechanical  obstruction  at  any 
moment.  What  is  to  be  done  to  avoid  it?  Invaginate  only 
half  an  inch,  so  that  the  muscles  of  the  gut  do  not  get  any  pur¬ 
chase  power  in  peristalsis. 

Experiment  No.  43. — Dog,  male,  weight  forty  pounds.  The 
dog’s  intestine  was  drawn  out  and  invaginated  four  inches  by 
forcing  the  upper  segment  of  the  bowel  into  the  lower  or  draw¬ 
ing  the  lower  over  the  upper.  The  invagination  was  sutured 
in  position  by  four  sutures;  belly  closed.  Forty-eight  hours 
after,  abdomen  reopened.  The  gut  had  so  violently  disinvagi- 


Oct.  18,  1890.J 


KENNEDY:  GONORRUCEA  AND  RENAL  DISEASE. 


nated  itself  that  it  had  torn  out  two  sutures  and  insinuated  itself 
out  between  the  other  two.  The  whole  disinvaginated  loop  was 
excluded  by  anastomosing  the  gut  above  to  the  gut  below  with 
rawhide  plates  (green  and  soft).  Graft  applied.  Dog  died 
nine  days  after  from  progressive  fibrino-purulent  peritonitis. 
The  peritonaeum  showed  at  the  autopsy  a  wonderful  variety  of 
pathology — pyogenic  membrane,  pus  puddles  which  Nature  had 
tried  to  hem  in,  and  local  fields  of  tortuous  impacted  blood¬ 
vessels  meandering  like  golden  threads  over  dusky  mottled 
membrane.  The  excluded  gut  was  contracted  and  only  had  a 
little  mucus  left  in  it.  Two  invagination  sutures  still  existed  in 
the  bowel.  The  anastomosis  was  well  established  and  the  arti¬ 
ficial  fistula  was  large.  No  sign  or  trace  of  the  plates  was  seen. 
The  graft  was  solidly  and  firmly  healed.  The  dog  was  killed 
by  infection  at  one  of  the  operations. 

Experiment  (not  numbered). — Dog,  male  pup,  weight  eight 
pounds.  Operation,  ileo-ileostomy  ;  material,  rawhide  plates, 
very  thin.  A  loop  of  intestine  was  drawn  out,  and,  through 
incisions  in  the  bowel,  the  plates  were  inserted,  coaptated,  and 
tied.  The  dog  ate,  drank,  and  played  the  next  day,  and  con¬ 
tinued  in  this  manner  until  he  was  killed,  two  weeks  later. 
Autopsy  :  Abdominal  organs  healthy.  Graft  well  grown.  An¬ 
astomosis  established;  but  here  again  the  faecal  circulation  had 
two  directions  to  travel,  and  hence  the  artificial  fistula  was 
small.  Plates  entirely  gone. 

Many  more  examples  might  be  adduced  out  of  over  a 
hundred  and  sixty  experiments,  but,  no  doubt,  sufficient 
have  been  given.  The  cuts  will  illustrate  the  technique  and 
methods  of  using  the  plates. 


THE  RELATION  OF 

GONORRHCEA  TO  RENTAL  DISEASE. 

By  JAMES  KENNEDY,  M.  D., 

SAN  ANTONIO,  TEXAS. 

In  a  case  of  urethral  stricture  where  I  performed  the 
operation  of  external  urethrotomy  the  patient  died  within 
five  hours,  and  post-mortem  examination  revealed  the  exist¬ 
ence  of  a  chronic  suppurative  nephritis.  The  patient  hav¬ 
ing  given  a  history  of  gonorrhoeal  infection,  followed  by 
gleet  and  subsequent  interference  with  micturition,  the  in¬ 
quiry  naturally  suggested  was,  What  relation  did  the  gonor¬ 
rhoeal  infection  bear  to  the  renal  lesion  ? 

The  history  of  the  case  in  which  I  operated  is  briefly  as 
follows : 

The  patient,  who  was  thirty-eight  years  of  age,  had  con¬ 
tracted  gonorrhoea  some  two  or  three  years  previously,  had  used 
various  injections,  and,  after  several  months  of  this  self-treat¬ 
ment,  considered  himself  cured. 

Within  the  past  year  he  bad  experienced  pain  in  the  region 
of  the  bladder,  and  had  noticed  that  his  urine  would  often  be 
of  an  unnatural  appearance,  being  sometimes  milky,  and  expe¬ 
rienced  considerable  difficulty  and  often  pain  in  emptying  the 
bladder.  But  only  within  the  past  month  did  he  deem  it  neces¬ 
sary  to  send  for  a  physician,  and  then  only  because  of  the  ur¬ 
gency  of  his  symptoms,  being  unable  to  empty  bis  bladder,  and, 
in  consequence  of  the  overdistention,  suffered  intense  pain. 

I  attempted  to  relieve  his  condition  by  means  of  a  flexible 
catheter,  but  found  it  would  not  pass  the  deeper  stricture  (there 
being  two).  I  then  resorted  to  a  metallic  instrument,  and  suc¬ 
ceeded  in  emptying  his  bladder  of  its  foul  contents,  which  con¬ 
sisted  of  decomposed  urine,  pus,  and  blood. 


433 

I  believed  from  the  history  and  symptomatology  that  I  was 
dealing  with  a  bad  case  of  chronic  cystitis,  and  that  relief,  if 
any  was  to  be  obtained,  must  be  found  in  the  creation  of  an 
artificial  urethra  and  the  removal  of  the  stricture  by  means  of 
an  external  urethrotomy,  which,  in  addition  to  draining  the 
bladder,  would  also  enable  us  to  wash  it  out  with  antiseptic 
solutions,  by  which  means  I  hoped  to  arrest  the  inflammatory 
process  and  ameliorate  the  patient’s  condition. 

In  reference  to  the  operation  I  need  only  say  that  I  operated 
according  to  the  usual  method,  and,  after  an  opening  had  been 
made  into  the  urethra,  a  cannula  was  introduced.  Chloroform 
was  used  as  an  anaesthetic,  and  the  operation  completed  in  ten 
minutes.  The  patient  rapidly  recovered  from  the  anaesthesia 
and  was  not  unconscious  more  than  twenty  minutes. 

I  left  him  at  12  m.,  and  instructed  to  give  him  stimulants  in 
moderate  quantity.  When  I  returned  at  5  p.  m.  his  pulse  was 
feeble  and  so  rapid  that  it  could  not  be  counted.  On  examina¬ 
tion,  I  found  that  no  urine  had  passed  through  the  cannula,  and 
suspected  some  obstruction  in  the  instrument.  This  proved  to 
be  not  the  case,  however,  for,  on  removing  the  instrument  and 
exploring  with  the  finger,  the  bladder  was  found  empty.  There 
was  acute  suppression  of  the  renal  function. 

The  pulse  grew  more  feeble  and  more  rapid,  and  respiration 
became  labored  and  interrupted.  I  administered  whisky  hypo- 
dermatically,  but  to  no  avail.  I  sent  for  digitalis,  but  the  pa¬ 
tient  sank  rapidly  and  died  before  it  arrived. 

Post-mortem. — The  bladder  showed  evidence  of  chronic  in¬ 
flammation,  being  four  or  five  times  its  normal  thickness.  The 
ureters  showed  similar  evidence  of  having  participated  in  the 
inflammatory  process. 

The  kidneys  were  about  three  times  their  normal  size,  and, 
on  section,,  exhibited  a  number  of  abscesses  of  various  sizes, 
some  containing  as  much  as  two  or  three  drachms  of  thick, 
greenish-yellow  pus.  Each  abscess  had  a  distinct  wall  of  con¬ 
siderable  thickness,  and  many  of  them  communicated. 

These  organs  were  literally  nothing  more  than  suppurating 
masses  of  tissue,  and  how  they  managed  to  perform  their  im¬ 
portant  functions  in  their  extremely  disabled  condition,  as  they 
had  been  doing  for  months,  I  do  not  understand. 

Relation  between  Gonorrhoea  and  Renal  Disease. — There 
is  no  doubt  in  my  mind  that  if  this  patient  had  not  con¬ 
tracted  gonorrhoea  he  would  not  have  died  of  suppurative 
nephritis.  I  believe  that  gonorrhoea  is  a  frequent  causative 
factor  in  renal  disease,  and  that  among  the  sequelse  of  this 
lesion  nephritis  is  not  rare. 

The  ways  in  which  gonorrhoea  may  induce  disease  of  the 
kidneys  appear  to  me  to  be  as  follows  : 

1.  By  direct  extension  of  the  inflammatory  process  by 
virtue  of  continuity  of  structure. 

2.  By  interference  with  escape  of  urine,  as  in  stricture. 
The  bladder,  becoming  filled,  causes  the  urine  to  collect  in 
the  pelvis,  calyces,  and  tubules  of  the  kidney,  and  inter¬ 
feres  with  the  process  of  secretion,  causing  congestion, 
which,  if  prolonged,  the  succeeding  stages  of  inflammation 
follow  and  a  nephritis  is  established. 

3.  By  reflex  irritation.  The  urethral  irritation  may  re- 
flexly  disturb  the  renal  function  and  cause  hypersemia  and 
congestion. 

4.  By  diuretics.  The  excessive  or  injudicious  adminis¬ 
tration  of  copaiba,  cubehs,  etc.,  so  commonly  used  for  the 
cure  of  gonorrhoea,  may  induce  disease  of  the  kidneys  by 
overstimulation  of  these  organs. 


434 


LEADINO  ARTICLES. 


[N.  Y.  Med.  Jocb., 


the 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  OCTOBER  18,  1890. 


PAWLIK’S  OPERATION  FOR  CANCER  OF  THE  CERVIX 

UTERI. 

The  Medical  News  gives  an  interesting  estimate  of  Pawlik’s 
recently  proposed  operation  for  the  free  extirpation,  by  the 
vaginal  method,  of  the  neck  of  the  uterus  when  cancerously 
diseased,  and  of  the  perimetric  connective  tissue  along  with  the 
diseased  part  of  the  uterus.  This  procedure  is  dignified  by  the 
somewhat  ambitious,  possibly  misleading,  title  of  “the  radical 
cure  of  cancer  of  the  cervix  uteri.”  The  “radical”  feature 
consists  in  the  free  use  of  the  knife  upon  those  lateral  tissues  in 
which  the  disease  usually  spreads  before  it  extends  from  the 
cervix  to  the  body  of  the  organ.  Incidental  to  this  operation 
are  Pawlik’s  studies  in  regard  to  catlieterism  of  the  ureters, 
which  confirm  the  view  already  pronounced  by  that  surgeon 
that  the  free  removal  of  the  infiltrated  tissues  may  be  accom¬ 
plished  without  injuring  the  ureters.  This  confirmation  has  been 
found,  the  writer  believes,  in  the  fact  that  the  ureters  are  rare¬ 
ly  involved  in  the  cancerous  infiltration.  In  four  cases  of  can¬ 
cel  of  the  cervix  he  inserted  a  catheter  into  the  ureters  and 
proceeded  to  remove  the  diseased  organ  and  its  adjacent  con¬ 
nective  tissue.  The  results  thus  far  obtained  appear  to  justify 
the  inductions;  two  of  the  patients  are  now  alive  and  without 
a  recurrence  of  the  trouble,  a  year  and  more  having  elapsed 
since  the  operation;  in  a  third  case  cystitis  with  uretero-vagi- 
nal  fistula  has  been  an  unfortunate  sequel,  but  the  patient’s 
general  health  has  continued  good.  One  patient  has  passed  out 
of  observation  and  can  not  at  present  be  reported  on. 

This  is  a  small  series  of  cases  upon  which  to  build  any  broad 
generalizations,  but  we  are  confident  that  it  will  enlist  the  at¬ 
tention  of  surgeons.  The  writer  in  the  News  has  evidently 
been  under  the  immediate  influence  of  Pawlik,  since  that  part 
of  his  article  which  relates  to  catlieterism  of  the  ureters  reveals 
the  fact  that  “  under  his  eye  we  have  successfully  followed  his 
example  ”  in  regard  to  the  delicate  manipulation.  He  therefore 
writes  with  a  full  appreciation  of  the  requisites  of  the  opera¬ 
tion  under  discussion.  Catlieterism  of  the  ureters,  while  not 
exceedingly  difficult,  requires  constant  practice,  and  Pawlik 
himself  embraces  every  opportunity  to  practice  this  explora¬ 
tion,  tor  he  finds  that  only  in  that  way  can  he  maintain  his  re¬ 
markable  dexterity.  It  is  evident  from  this  that  the  average 
operator  may  not  at  once  succeed  in  following  his  example. 
TV  ithout  a  guide  in  the  ureter  it  would  certainly  be  unsafe  to 
attempt  the  radical  removal  of  connective  tissue  surrounding 
the  diseased  cervix,  and  impossible  to  determine  whether  the 
ureters  were  not  themselves  involved  in  the  disease.  To  one 
who  has  diligently  built  himself  up  in  manipulations  of  this 
delicacy  this  so-called  radical  cure  will  appear  worthy  of  a 


trial,  whereas  the  less  expert  and  dexterous  will  approach  the 
practice  with  diffidence.  The  class  of  cases  to  which  it  will 
probably  be  found  best  applicable  will  be  those  in  which  the 
perimetric  tissue  is  only  partially  invaded,  as  shown  by  a  re¬ 
maining  mobility  of  the  uterus,  and  in  which  the  disease  has 
not  extended  to  the  fundus;  in  other  words,  the  early  employ¬ 
ment  of  the  operation  will  give  the  greatest  promise  of  success. 


THE  ADIRONDACK  SANITARIUM. 

This  institution,  at  Saranac  Lake  village,  has  now  reached 
such  a  point  of  popular  approval  and  grateful  recognition  that 
gifts  begin  to  flow  in  upon  it,  and  its  permanent  endowment 
may  be  looked  forward  to  as  a  very  probable  event.  Dr.  Tru¬ 
deau  is  no  longer  alone  there  as  attending  physician,  but  is  now 
assisted  by  Dr.  C.  F.  Wicker.  The  present  accommodations  are 
for  fifty  patients,  but  two  new  cottages  are  now  being  built, 
which,  with  other  proposed  changes,  will  make  them  sufficient 
for  about  sixty ;  as  it  is,  the  room  is  all  taken  up,  and  applicants 
are  awaiting  their  turn  as  vacancies  occur.  A  benevolent  New 
York  lady  has  given  the  means  necessary  to  the  erection  of  a 
recreation  hall,  or  pavilion,  which  will  contain  billiard  tables 
and  other  apparatus  for  gentle  exercise  in  inclement  weather; 
also  about  it  there  will  be  promenades  which  can  be  shut  in 
with  glass  when  the  midwinter  cold  prevents  the  patieots  from 
going  into  the  open  air  to  the  same  extent  as  in  other  seasons. 
There  are  a  few  free  beds  for  recommended  patients,  for  the 
benefit  of  those  who  can  not  defray  the  almost  nominal  charge 
of  five  dollars  a  week.  The  cottages  are  small,  being  commonly 
designed  to  hold  not  more  than  from  two  to  five  beds.  Out-of- 
door  life  being  one  of  the  cardinal  principles  of  the  Adirondack 
regimen,  facilities  are  provided  for  riding,  walking,  and  other 
suitable  diversions.  In  regard  to  admissions,  it  is  the  aim  of 
Dr.  Trudeau  to  restrict  them  to  cases  of  phthisis  in  its  incip¬ 
ient  stage  and  to  persons  of  the  res  angusta  domi  type,  and 
thus  to  restore  to  their  occupations  the  productive  and  indus¬ 
trious  members  of  society;  he  thus  acts  on  the  principle  that 
Mr.  Jonathan  Hutchinson  has  given  recent  expression  to  as 
being  the  fundamental  idea  of  the  modern  hospital — namely, 
that  it  is  an  institution  for  the  prevention  of  orphanage.  No 
single  generation  measures  the  bounds  of  influence  for  good 
of  the  modern  institutions  of  charity.  Dr.  Trudeau  himself 
and  some  of  his  most  interested  supporters  have  been  restored 
to  health  and  useful  activity  by  the  Adirondack  air  and  regi¬ 
men,  and  they  know  the  extent  as  well  as  the  limitations  that 
pertain  to  the  work  they  have  so  carefully  and  beneficently 
undertaken. 


KOCH’S  BERLIN  ADDRESS. 

The  statements  made  by  Koch  in  his  notable  address  at  the 
Berlin  Congress  have  received  confirmation  in  two  important 
points.  To  one  of  these  we  have  already  referred — namely,  to 
the  work  done  byGrancher  and  Martin,  of  Paris,  in  the  produc¬ 
tion  and  arrest  of  inoculated  tuberculosis  in  rabbits.  This  work 
is  confirmatory  of  Koch’s  experiments  on  the  guinea-pig,  with 


Oct.  18,  1890.] 


MINOR  PARAORAPES. 


435 


an  agent  not  yet  named,  for  the  reason  that  tlie  series  is  yet  in¬ 


complete  and  under  observation.  The  second  point  wherein 
Koch’s  observations  have  been  corroborated  is  that  regarding 
the  antitubercular  properties  of  gold  and  silver  compounds. 
This  we  learn  from  an  article  in  the  Lancet  for  August  30th, 
which  describes  the  almost  synchronous  discovery  of  an  Aus¬ 
trian  official  in  regard  to  the  apparent  prevention  of  phthisis 
among  workmen  who  have  to  handle  and  work  with  “cyan- 
gold.  ’  This  observer,  Herr  Reuter,  read  a  paper  in  April  last 
before  the  Industrial  Union  of  Lower  Austria,  showing  how 
his  position  as  director  of  several  great  workshops  of  metallic 
wares,  at  home  and  abroad,  had  led  him  to  notice  the  relative 
infrequency  of  consumption  among  his  operatives,  and  to  be¬ 
come  inquisitive  as  to  the  agencies  at  work  among  this  class  of 
workmen.  He  paid  particular  attention  to  works  in  which  the 
artisans  were  engaged  in  galvanizing  articles  with  gold  and  sil¬ 
ver,  and  the  inquiries  that  were  made  by  him  gave  him  the  im¬ 
pression  that  a  healing  virtue  resided  in  prussic  acid,  the  use  of 
which  is  essential  in  those  workshops  where  the  “cyan-metals” 
dissolved  in  potassium  cyanide  are  used.  Herr  Reuter  obtained 
much  confirmatory  testimony  from  the  workmen  in  these 
works.  Not  only  did  they  agree  that  consumption  was  ex¬ 
tremely  rare  among  them,  but  that  many  of  those  who  came 
into  the  works  from  other  places,  and  who  had  diseases  of  the 
respiratory  organs,  were  greatly  benefited,  and  some  entirely 
cured.  Since  the  adjournment  of  the  Berlin  Congress,  the  Vi¬ 
enna  Medical  Association  has  begun  the  consideration  of  Herr 
Reuter’s  observations,  and  has  already  indicated  that  they  ap¬ 
pear  to  be  reliable  and  valuable. 

We  commend  to  our  readers  a  full  perusal  of  Koch’s  great 
paper,  for,  if  we  mistake  not,  it  will  hereafter  take  rank  with 
the  epoch-making  essays  of  Harvey,  Boerhaave,  Hunter,  Jen- 
ner,  and  Pasteur.  It  is  too  early  yet  to  know  positively  facts 
which  Koch  himself  announces  apologetically  and  in  part  only; 
still  it  is  a  significant  and  hopeful  sign  that,  almost  immediately 
upon  the  adjournment  of  the  great  Congress,  there  should  come 
from  different  sources,  and  with  different  ends  in  view,  these 
various  voluntary  confirmations. 


MINOR  PARAGRAPHS. 

RUPTURE  OF  THE  VAGINA. 

Dr.  Himmelfarb,  of  Odessa,  and  others  are  quoted  in  the 
Pi  itish  Medical  Journal  regarding  the  causation  of  this  injury. 
He  has  carefully  studied  the  literature  of  this  comparatively  un- 
exploied  subject,  and  presents  cases  of  his  own.  He  concludes 
that,  while  the  major  part  of  the  cases  reported  have  been  an 
accident  of  parturition,  there  are  some  cases  that  have  been  due  to 
the  introduction  of 'foreign  bodies  and  to  violent  coitus.  The  last- 
named  cause  is  not  always  acknowledged  when  it  should  be. 
The  rupture  of  the  vagina  of  old  subjects  during  coitus  is  a  well- 
recognized  injury.  When  the  accident  occurs  in  young  subjects 
the  explanation  of  its  production  becomes  more  difficult.  Dr. 
Himmelfarb  reports  a  case  in  a  healthy  woman,  aged  twenty- 
four,  in  whose  person  the  posterior  wall  of  the  vagina  was  torn 
through  during  coitus,  and  in  whom  the  rupture  was  followed 
by  parametritis,  peritonitis,  and  fatal  pytemia.  Connection  had 


frequently  taken  place,  after  the  first  occasion  when  the  pain 
was  very  severe,  notwithstanding  the  suffering  that  it  produced. 
Dr.  Himmelfarb  thinks  that  vaginal  rupture  is  more  frequent 
than  is  commonly  supposed  in  those  cases  of  sudden  pain  from 
coitus  where  no  sign  of  injury  to  the  external  parts  exists,  and 
that  coitus  is  then  the  true  cause  of  the  injury.  Dr.  Frank,  of 
Prague,  has  reported  a  case  of  rupture  where  there  was  a  double 
vagina.  The  right  half  ended  in  a  blind  sac,  while  the  left  com¬ 
municated  with  the  uterus;  the  hymen  on  the  right  side  and 
the  septum  were  lacerated  in  coitus.  He  has  also  had  a  case  of 
extensive  laceration  in  a  woman  aged  thirty-two.  She  recov¬ 
ered  from  the  injury,  which  was  certainly  inflicted  during  con¬ 
nection.  The  entire  subject  is  not  without  medico-legal  interest 
and  importance. 


TRICHLORACETIC  ACID  IN  THROAT  DISEASES. 

The  testimony  in  favor  of  the  use  of  trichloracetic  acid  in 
diseases  of  the  throat  is  accumulating.  In  the  Lancet ,  Ehr¬ 
mann,  of  Heidelberg,  is  quoted  in  reference  to  his  results  in  over 
a  hundred  recent  trials.  In  one  hundred  and  forty  cases  of 
chronic  inflammation  and  of  hypertrophic  conditions  of  the  va¬ 
rious  parts  in  the  neighborhood  of  the  pharynx  and  nares  this 
remedy  was  employed  with  marked  success.  In  one  hundred 
and  twenty-two  cases  he  reports  permanent  cure.  The  method 
of  its  employment  is  twofold — :as  an  escharotic  and  as  an  astrin- 

k 

gent.  Hypertrophied  tonsils  and  other  parts  may  be  reduced 
by  rubbing  them  with  a  crystal  of  the  acid,  which  has  the  effect 
of  producing  an  eschar  that  is  white,  dry,  smooth,  and  adher¬ 
ent.  This  eschar  is  thrown  off  much  more  slowly  than  that 
produced  by  chromic  acid.  Ehrmann  observed  no  secondary 
inflammation  or  other  unpleasant  effects  of  any  kind.  If  a 
merely  astringent  effect  is  desired,  the  acid  should  be  dissolved 
in  an  equal  weight  of  glycerin  (or  in  double  its  weight),  with  the 
addition  of  a  little  iodine  and  iodide  of  potassium,  and  the  mixt¬ 
ure  may  be  used  to  paint  the  throat  with.  The  best  results 
were  obtained  in  follicular  amygdalitis  and  chronic  pharyngitis. 
At  the  last  meeting  of  the  New  York  State  Medical  Association, 
Fifth  District  Branch,  Dr.  Gleitsmann,  of  New  York,  reported 
that  he  had  been  pleased  with  the  apparent  results  in  the  treat¬ 
ment  of  tonsillar  disease  with  the  acid,  and  that  it  was  his  pur¬ 
pose  to  extend  his  employment  of  the  drug.  In  regard  to  the 
handling  of  the  crystals  of  the  acid,  Ehrmann  has  found  that  a 
silver  applicator  which  will  hold  the  crystal  firmly  answers  a 
very  good  purpose. 


THE  MURDER  OF  DR.  LLOYD,  OF  FLATBUSH. 

Dr.  George  W.  Lloyd,  assistant  superintendent  of  the 
Kings  County  Asylum  at  Flatbush,  has  been  murdered  by  a  dis¬ 
charged  lunatic,  who  was  at  the  time  in  pursuit  of  the  superin¬ 
tendent,  Dr.  Fleming.  This  took  place  on  the  evening  of 
Thursday,  the  9th  instant.  The  murderer  has  declared  that  he 
had  had  no  feeling  of  special  animosity  against  Dr.  Lloyd  per¬ 
sonally,  but  was  actuated  by  a  revengeful  rage  against  all  who 
had  been  instrumental  in  his  former  confinement,  from  the 
judge  down  to  the  subordinate  attendants.  Both  Dr.  Arnold 
and  Dr.  Fleming  probably  had  a  narrow  escape  from  the  same 
fate,  since  the  maniac  was  armed  with  two  fully  loaded  revolv¬ 
ers,  and  was  in  search  of  them  when  Dr.  Lloyd  was  encoun¬ 
tered  and  slain,  a  guiltless  martyr,  while  engaged  in  the  round 
of  his  professional  duty.  Dr.  Lloyd  was  a  painstaking  and 
efficient  official.  The  obvious  reason  why  he  was  slain  was 
that  the  men  marked  out  for  slaughter  were  not  found  conven¬ 
iently  at  hand  in  the  places  of  their  customary  resort,  but  the 
real  reason  was  that  somebody  had  blundered  in  allowing  a 
violent  lunatic  to  remain  at  large. 


436 


MINO  R  PA  RA  ORA  PBS.— ITEMS. 


[N. 


Y.  Med.  Jour. 


THE  INDIGENT  INSANE  OF  TIIE  STATE  OF  NEW  YORK. 

It  was  to  be  expected  that  the  State  Commission  in  Lunacy 
would  take  all  necessary  measures  for  properly  administering 
the  new  law  committing  the  indigent  insane  to  the  care  of  the 
State,  hut  it  is  none  the  less  gratifying  to  meet  with  tangible 
evidence  of  the  commission’s  activity.  Elsewhere  we  publish 
the  order  issued  by  the  president,  Dr.  Carlos  F.  MacDonald,  re¬ 
garding  the  transportation  of  the  insane  poor  to  the  State  hos¬ 
pitals,  and  we  will  mention  an  order  by  the  commission  to  the 
effect  that  hereafter  private  patients  in  the  State  hospitals  are 
not  to  be  treated  differently  from  public  patients  in  respect  to 
the  care  and  accommodations  furnished  them. 


THE  CONVICTION  OF  AN  ABORTIONIST. 

The  prompt  conviction  of  Dr.  McGonegal  on  the  charge  of 
having  caused  a  young  woman’s  death  by  criminal  abortion, 
and  his  sentence  to  imprisonment  for  fourteen  years,  are  reas¬ 
suring  signs  that  the  machinery  of  the  courts  is  not  wholly  un¬ 
trustworthy  as  a  means  of  curbing  a  crime  that  too  often  goes 
unpunished.  Their  significance  is  tempered,  however,  when 
we  reflect  that  it  was  not  so  much  the  crime  itself  that  seemed 
to  be  presented  to  the  jury  as  the  peculiarly  heartless  way  in 
which  the  accused  was  shown  to  have  carried  out  his  measures. 


A  RUSSIAN  INSTITUTE  OF  BACTERIOLOGY. 

It  is  announced  that  a  Pasteurian  Institute  is  to  be  estab¬ 
lished  at  St.  Petersburg,  through  the  generosity  of  Prince  Peter 
Oldenbourg.  The  building,  on  Apothecary  Island,  is  nearly 
completed,  and  will  be  known  as  the  Institute  of  Experimental 
Medicine.  The  conduct  of  the  studies  in  regard  to  rabies  and 
contagious  diseases  generally  will  be  intrusted  to  specialists  in 
bacteriology,  chemistry,  biology,  and  veterinary  science. 


“SUNDOWN  DOCTORS.” 

This  is  the  appellation  said  to  be  applied  in  the  city  of 
Washington  to  a  class  of  practitioners  who  are  clerks  in  the 
Government  offices,  and  who  have  taken  a  medical  degree  with 
a  view  to  practicing  after  the  hours  of  their  official  work  are 
over. 


A  MISSIONARY  HOSPITAL  IN  SITKA. 

Dr.  Clarence  Tiiwing,  of  Brooklyn,  has  accepted  an  invi¬ 
tation  to  establish  one  or  more  missionary  hospitals  in  Alaska, 
beginning  at  Sitka.  He  was  graduated  about  three  years  ago, 
since  which  time  he  has  been  engaged  in  special  courses  that 
will  fit  him  for  his  new  and  responsible  berth.  His  father,  also 
a  physician  and  a  clergyman  as  well,  has  become  known  through 
his  advocacy  of  the  establishment  at  Hong  Kong  of  an  asylum 
for  the  insane,  which,  if  he  succeeds,  will  be  the  first  of  its 
kind  on  Chinese  soil. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  October  14,  1890: 


DISEASES. 

Week  ending  Oct.  7. 

Week  ending  Oct.  14. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

39 

3 

45 

16 

Scarlet  fever . 

28 

1 

25 

5 

Cerebro-spinal  meningitis . 

2 

2 

0 

0 

Measles . 

43 

4 

79 

6 

Diphtheria . 

57 

13 

46 

15 

Alleged  Danger  in  Artificial  Celluloid  Eyes. — “  Dr.  Meurer,  of 

Lyons,  warns  physicians  against  the  use  of  artificial  eyes  made  of  cellu¬ 
loid.  They  are  cheap  and  of  good  appearance,  and  for  the  first  three 
or  four  months  render  good  service.  After  this,  however,  they  undergo 
chemical  changes,  and  set  up  a  high  degree  of  irritation.  Meurer  has 
repeatedly  overcome  the  resultant  inflammation  by  antiseptic  treatment 
and  suspending  the  use  of  the  artificial  eye.  So  soon  as  the  old  eye  was 
again  used  the  inflammation  returned,  but  on  using  a  glass  eye  the  parts 
remained  normal.” — Druggist's  Circular  and  Chemical  Gazette. 

Change  of  Address. — Dr.  P.  Flewellen  Chambers,  to  No.  26  West 

Forty-seventh  Street. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army ,  from  September  27  to  October  11,  1890 : 

Phillips,  John  L.,  Captain  and  Assistant  Surgeon.  By  direction  of 
the  Secretary  of  War,  the  leave  of  absence  granted  in  S.  0.  164,. 
July  16,  1890,  from  this  office,  is  extended  two  months.  Par.  3, 
S.  0.  228,  A.  G.  0.,  Washington,  September  29,  1890. 

Owen,  W.  0.,  Jr.,  Captain  and  Assistant  Surgeon,  in  view  of  the  aban¬ 
donment  of  Fort  Gibson,  Indian  Territory,  to  which  post  he  is  at 
present  assigned  for  station,  is  relieved  from  duty  at  that  post,  and 
will,  upon  the  expiration  of  his  present  leave  of  absence,  proceed 
to  Fort  Sill,  Indian  Territory,  and  report  to  the  commanding  officer 
for  duty.  S.  0.  165,  Department  of  the  Missouri,  September  2V, 
1890. 

Phillips,  J.  L.,  Captain  and  Assistant  Surgeon,  in  view  of  the  aban¬ 
donment  of  Fort  Crawford,  Colorado,  to  which  post  he  is  at  present 
assigned  for  station,  is  relieved  from  duty  at  that  post,  and  will, 
upon  the  expiration  of  his  present  leave  of  absence,  proceed  to 
Fort  Logan,  Colorado,  and  report  to  the  commanding  officer  for 
duty.  Par.  4,  S.  0.  166,  Department  of  the  Missouri,  September  27, 
1890. 

Tesson,  Louis  S.,  Captain  and  Assistant  Surgeon,  Fort  Sidney,  Nebras¬ 
ka.  Leave  of  absence  for  twenty  days,  to  take  effect  when  his 
services  can  be  spared  by  bis  post  commander,  is  granted.  S.  0. 
72,  Department  of  the  Platte,  September  25,  1890. 

Crampton,  Louis  W.,  Captain  and  Assistant  Surgeon  (Fort  Sheridan, 
Illinois).  Leave  of  absence  for  one  month,  to  take  effect  about  Oc¬ 
tober  1,  1890,  is  granted.  Par.  2,  S.  0.  80,  Division  of  the  Mis¬ 
souri,  September  30,  1890. 

Byrne,  Charles  C.,  Lieutenant-Colonel  and  Surgeon,  is  relieved  from 
duty  as  attending  surgeon  at  the  Soldiers’  Home,  near  this  cityr 
and  will  report  in  person  to  the  commanding  officer,  Fort  Sam  Hous¬ 
ton,  Texas,  for  duty  at  that  station.  Par.  8,  S.  0.  232,  A.  G.  0., 
Washington,  D.  C.,  October  3,  1890. 

Baily,  Joseph  C.,  Lieutenant-Colonel  and  Assistant  Medical  Purveyor, 
Medical  Director  of  the  Department,  is  granted  leave  of  absence 
for  one  month.  Par.  3,  S.  0.  86,  Department  of  Texas,  October  3, 
1890’. 

Reed,  Walter,  Captain  and  Assistant  Surgeon,  is,  by  direction  of  the 
Secretary  of  War,  relieved  from  further  duty  at  Mount  Vernon  Bar¬ 
racks,  Alabama,  and  assigned  to  duty  as  Attending  Surgeon  and 
Examiner  of  Recruits  at  Baltimore,  Md.  Par.  7,  S.  0.  233,  A.  G.  0 
Washington,  D.  C.,  October  4,  1890. 

Gibson,  Robert  J.,  Captain  and  Assistant  Surgeon,  is,  by  direction  of 
the  Secretary  of  War,  granted  leave  of  absence  for  three  months, 
to  take  effect  on  being  relieved  from  duty  at  Fort  Trumbull,  Con¬ 
necticut,  by  Major  Henry  M.  Cronkhite,  Surgeon.  Par.  12,  S.  0. 

232,  A.  G.  0.,  Washington,  D.  C.,  October  3,  1890. 

Macauley,  C.  N.  Berkeley,  Captain  and  Assistant  Surgeon,  is,  by  di¬ 
rection  of  the  Secretary  of  War,  relieved  from  duty  at  Fort  Supply, 
Indian  Territory,  and  will  report  in  person  to  the  commanding  offi¬ 
cer,  Fort  Lewis,  Colorado,  for  duty  at  that  station.  Par.  2,  S.  0. 

233,  A.  G.  0.,  Washington,  D.  C.,  October  4,  1890. 

Benham,  Robert  B.,  Captain  and  Assistant  Surgeon,  will,  by  direction 
of  the  Secretary  of  War,  proceed  from  Fort  Hamilton,  New  York, 
to  Mount  Yernon  Barracks,  Alabama,  and  report  in  person  to  the 
commanding  officer  of  that  post  for  temporary  duty,  relieving  Cap- 


Oct.  18,  1890.] 


ITEMS . 


437 


tain  John  J.  Cochran,  Assistant  Surgeon,  who  will  return  to  his 
proper  station.  Par.  8,  S.  0.  232,  A.  G.  0.,  Washington,  D.  C.,  Oc¬ 
tober  3,  1890. 

Ebert,  Rudolph  G.,  Captain  and  Assistant  Surgeon,  is,  by  direction  of 
the  Secretary  of  War,  relieved  from  duty  at  Angel  Island,  Califor¬ 
nia,  to  take  effect  upon  the  arrival  at  that  post  of  Major  William  II. 
Gardner,  Surgeon,  and  will  then  proceed  to  Vancouver  Barracks, 
Washington,  and  report  for  duty  to  the  commanding  officer  of  that 
post  for  duty.  Par.  15,  S.  0.  232,  A.  G.  0.,  Washington,  D.  C.,  Oc¬ 
tober  3,  1890. 

Gardner,  William  H.,  Major  and  jSurgeon,  is,  by  direction  of  the  Sec¬ 
retary  of  War,  relieved  from  duty  at  Washington  Barracks,  D.  C., 
to  take  effect  on  the  arrival  of  Major  Joseph  K.  Corson,  Sur¬ 
geon,  and  will  report  in  person  to  the  commanding  officer,  Angel 
Island,  California,  for  duty  at  that  station.  Par.  8,  S.  0.  232, 
A.  G.  0.,  Washington,  D.  C.,  October  3,  1890. 

Wood,  Leonard,  First  Lieutenant  and  Assistant  Surgeon.  The  leave 
of  absence  granted  in  S.  0.  74,  August  30,  1890,  Department  of 
California,  is,  by  direction  of  the  Secretary  of  War,  extended  one 
month.  Par.  7,  S.  0.  232,  A.  G.  0.,  Washington,  D.  C.,  October  3, 
1890. 

Hubbard,  Van  Buren,  Major  and  Surgeon,  is,  by  direction  of  the  Sec¬ 
retary  of  War,  relieved  from  duty  at  Columbus  Barracks,  Ohio,  and 
will  report  in  person  to  the  commanding  officer,  Fort  Spokane,  Wash¬ 
ington,  for  duty  at  that  station,  relieving  Captain  Henry  S.  Purrill, 
Assistant  Surgeon.  Captain  Purrill,  on  being  relieved  by  Major 
Hubbard,  will  report  in  person  to  the  commanding  officer,  Madison 
Barracks,  New  York,  for  duty  at  that  station,  relieving  Major  John 
D.  Hall,  Surgeon.  Major  Hall,  on  being  relieved  by  Captain  Purrill, 
will  report  in  person  to  the  commanding  officer,  Fort  Canbv,  Wash¬ 
ington,  for  duty  at  that  station.  Par.  8,  S.  0.,  232,  A.  G.  0.,  Wash¬ 
ington,  D.  C.,  October  3,  1890. 

By  direction  of  the  Secretary  of  War,  the  following  changes  in  the  sta¬ 
tions  and  duties  of  officers  of  the  Medical  Department  are  ordered : 

Sternberg,  George  M.,  Major  and  Surgeon,  is  relieved  from  duty  as 
Attending  Surgeon  and  Examiner  of  Recruits  at  Baltimore,  Md., 
and  as  a  member  of  the  Army  Medical  Board  appointed  to  meet 
in  New  York  city,  N.  Y.,  and  will  repair  to  San  Francisco,  Cal.,  and 
take  charge  of  the  Medical  Purveying  Depot  at  that  place,  as  Act¬ 
ing  Assistant  Medical  Purveyor,  relieving  Colonel  B.  J.  D.  Irwin, 
Surgeon.  Colonel  Irwin,  on  being  thus  relieved,  will  report  in 
person  to  the  commanding  general,  Department  of  the  Columbia,  for 
assignment  to  duty  as  Medical  Director  of  that  department  and  as 
Post  Surgeon,  Vancouver  Barracks,  Washington,  relieving  Major 
William  E.  Waters,  Surgeon,  now  Post  Surgeon,  and  temporarily 
in  charge  of  the  Medical  Director’s  office.  Major  Waters,  on  being 
thus  relieved,  will  report  in  person  to  the  commanding  officer,  Fort 
Custer,  Montana,  for  duty  at  that  station.  Par.  8,  S.  0.  232, 
A.  G.  0.,  October  3,  1 890. 

Munn,  Curtis  E.,  Major  and  Surgeon,  is,  by  direction  of  the  Secretary 
of  War,  relieved  from  duty  at  Angel  Island,  California,  and  will  re¬ 
port  in  person  to  the  commanding  officer,  Fort  Monroe,  Virginia, 
for  duty  at  that  station,  relieving  Major  John  Brooke,  Surgeon. 
Major  Brooke,  on  being  relieved  by  Major  Munn,  will  report  in  per¬ 
son  to  the  commanding  officer,  Fort  Leavenworth,  Kansas,  for  duty 
at  that  station,  relieving  Major  Alfred  A.  Woodhull,  Surgeon. 
Major  Woodhull,  on  being  relieved  by  Major  Brooke,  will  report  in 
person  to  the  commanding  officer,  Fort  Sherman,  Idaho,  for  duty  at 
that  station.  Par  8,  S.  0.  232,  A.  G.  0.,  Washington,  D.  C.,  Octo¬ 
ber  3,  1890. 

Borden,  William  C.,  Captain  and  Assistant  Surgeon,  is,  by  direction 
of  the  Secretary  of  War,  relieved  from  duty  at  Fort  Sam  Houston, 
Texas,  upon  the  arrival  of  Lieutenant-Colonel  C.  C.  Byrne,  Surgeon, 
and  will  report  in  person  to  the  commanding  officer,  Fort  Davis, 
Texas,  for  duty  at  that  station,  relieving  Captain  Peter  R.  Egan, 
Assistant  Surgeon.  Captain  Egan,  on  being  relieved  by  Captain 
Borden,  will  report  in  person  to  the  commanding  officer,  Fort  War¬ 
ren,  Massachusetts,  for  duty  at  that  station,  relieving  Captain  George 
McCreery,  Assistant  Surgeon.  Captain  McCreery,  on  being  relieved 
by  Captain  Egan,  will  report  in  person  to  the  commanding  officer, 


Fort  Clark,  Texas,  for  duty  at  that  station,  relieving  Captain  Charles 
M.  Gandy,  Assistant  Surgeon.  Captain  Gandy,  on  being  relieved  by 
Captain  McCreery,  will  report  in  person  to  the  commanding  officer, 
Fort  Shaw,  Montana,  for  duty  at  that  station.  Par.  8,  S.  0.  232, 
A.  G.  0.,  Washington,  D.  C.,  October  3,  1890. 

I  inley,  James  A.,  Captain  and  Assistant  Surgeon,  is,  by  direction  of 
the  Secretary  of  War,  relieved  from  duty  at  Fort  Totten,  North  Da¬ 
kota,  and  will  report  in  person  to  the  commanding  officer,  Jefferson 
Barracks,  Missouri,  for  duty  at  that  station,  relieving  Captain 
William  D.  Crosby,  Assistant  Surgeon.  Captain  Crosby,  on  being 
relieved  by  Captain  Finley,  will  report  in  person  to  the  command¬ 
ing  officer,  Fort  Pembina,  North  Dakota,  for  duty  at  that  station. 
Par.  8,  S.  0.  232,  A.  G.  0.,  Washington,  D.  C.,  October  3,  1890. 

Taylor,  Arthur  W.,  Captain  and  Assistant  Surgeon,  is,  by  direction 
of  the  Secretary,  relieved  from  duty  at  Fort  Wingate,  New  Mexico,, 
to  take  effect  on  the  expiration  of  his  present  sick  leave  of  absence, 
and  will  report  in  person  to  the  commanding  officer,  Fort  Adams, 
Rhode  Island,  for  duty  at  that  station,  relieving  Captain  J.  J.  Coch¬ 
ran,  Assistant  Surgeon.  Captain  Cochran,  on  being  relieved  by 
Captain  Taylor,  will  report  in  person  to  the  commanding  officer,. 
Camp  Eagle  Pass,  Texas,  for  duty  at  that  station,  relieving  First 
Lieutenant  Paul  Clendenin,  Assistant  Surgeon.  Lieutenant  Clen- 
denin,  on  being  relieved  by  Captain  Cochran,  will  report  in  person 
to  the  commanding  officer,  Fort  Brady,  Michigan,  for  duty  at  that 
station.  Par.  8,  S.  0.  232,  A.  G.  0.,  Washington,  D.  C.,  October  3r 
1890. 

Smith,  Allen  M.,  First  Lieutenant  and  Assistant  Surgeon,  is,  by  direc¬ 
tion  of  the  Secretary  of  War,  relieved  from  duty  at  Fort  Snelling,, 
Minn.,  and  will  report  in  person  to  the  commanding  officer,  Fort 
Assinniboine,  Mont.,  for  duty  at  that  station,  relieving  Assistant 
Surgeon  Paul  Shillock.  Lieutenant  Shillock,  upon  being  relieved, 
will  report  in  person  to  the  commanding  officer,  Fort  Custer,  Mont., 
for  duty  at  that  station,  relieving  Captain  William  R.  Hall,  Assist¬ 
ant  Surgeon.  Captain  Hall,  upon  being  relieved  by  Lieutenant 
Shillock,  will  report  in  person  to  the  commanding  officer,  Fort 
Schuyler,  N.  Y.,  for  duty  at  that  station,  relieving  Captain  Norton 
Strong,  Assistant  Surgeon.  Captain  Strong,  on  being  relieved  by 
Captain  Hall,  will  report  in  person  to  the  commanding  officer  at 
Fort  Meade,  South  Dakota,  for  duty  at  that  station.  Par.  8,  S.  0. 
232,  A.  G.  0.,  Washington,  D.  C.,  October  3,  1890. 

Cronkhite,  Henry  M.,  Major  and  Surgeon,  is,  by  direction  of  the  Sec¬ 
retary  of  War,  relieved  from  duty  at  Fort  Lewis,  Colo.,  and  will 
report  in  person  to  the  commanding  officer,  Fort  Trumbull,  Conn., 
for  duty  at  that  station,  relieving  Captain  Robert  J.  Gibson,  As¬ 
sistant  Surgeon.  Captain  Gibson,  on  being  relieved  from  duty  by 
Major  Cronkhite,  will  report  in  person  to  the  commanding  officer, 
Fort  Sam  Houston,  Texas,  for  duty  at  that  station.  Par.  8,  S.  0. 
232,  A.  G.  0.,  Washington,  D.  C.,  October  3,  1890. 

Appointment. 

\  ollum,  Edward  P.,  Colonel  and  Surgeon,  to  be  chief  medical  pur¬ 
veyor  with  the  rank  of  colonel.  August  28,  1890. 

Promotions. 

Morris,  Edward  R.,  Assistant  Surgeon,  September  17,  1890,  to  be  As¬ 
sistant  Surgeon,  U.  S.  Army,  with  the  rank  of  Captain,  in  accord¬ 
ance  with  the  act  of  June  23,  1874. 

Irwin,  Bernard  J.  D.,  Lieutenant  Colonel  and  Assistant  Medical  Pur¬ 
veyor,  to  be  surgeon  with  the  rank  of  colonel.  August  28,  1890. 

Fryer,  Blencowe  E.,  Major  and  Surgeon,  to  be  assistant  medical  pur¬ 
veyor  with  the  rank  of  lieutenant  colonel.  August  28,  1890. 

Cowdrey,  Stevens  G.,  Captain  and  Assistant  Surgeon,  to  be  surgeon 
with  the  rank  of  major.  August  28,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 

of  the  United  States  Navy  for  the  week  ending  October  11,  1890 : 

Braisted,  William  C.,  Detroit,  Mich.,  appointed  an  assistant  surgeon 
in  U.  S.  Navy. 

Wales,  P.  S.,  Medical  Director.  Detached  from  temporary  duty  as 
member  of  Medical  Examining  Board. 

Ames,  H.  E.,  Passed  Assistant  Surgeon.  Detached  from  temporary 
duty  as  member  of  Medical  Examining  Board. 


438 


ITEMS.— LETTERS  TO  THE  EDITOR. 


[N.  Y.  Med.  Joor., 


Herndon,  C.  G.,  Surgeon.  Ordered  to  Naval  Hospital,  New  York. 

Persons,  R.  C.,  Surgeon.  Detached  from  Naval  Hospital,  New  York, 
and  to  wait  orders. 

Scott,  H.  B.,  Passed  Assistant  Surgeon.  Ordered  before  the  Retiring 
Board. 

Price,  A.  F.,  Surgeon.  Detached  from  Naval  Dispensary,  Washington, 
D.  C. 

Anderson,  Frank,  Passed  Assistant  Surgeon.  Ordered  to  Naval  Dis¬ 
pensary,  Washington,  D.  C. 

White,  C.  H.,  Medical  Inspector.  Ordered  to  hold  himself  in  readiness 
for  duty  on  U.  S.  Steamer  San  Francisco. 

Braisted,  W.  C.,  Assistant  Surgeon.  Ordered  to  Army  and  Naval 
Hospital,  Hot  Springs. 

Spratling,  L.  W.,  Assistant  Surgeon.  Ordered  to  hold  himself  in  readi¬ 
ness  for  orders  to  the  U.  S.  Steamer  San  Francisco. 

Siegfried,  C.  A.,  Surgeon.  Ordered  to  the  U.  S.  Training-ship  New 
Hampshire. 

Blackwood,  N.  P.,  Assistant  Surgeon.  Detached  from  duty  in  the 
Bureau  of  Medicine  and  Surgery,  and  granted  leave  of  absence. 

Stone,  L.  H.,  Assistant  Surgeon.  Detached  from  the  U.  S.  Steamer  New 
Hampshire  and  to  wait  orders. 

Edgar,  John  M.,  Passed  Assistant  Surgeon.  Ordered  to  hold  himself 
in  readiness  for  duty  on  the  U.  S.  Steamer  San  Francisco. 

Gardner,  J.  E  ,  Passed  Assistant  Surgeon.  Detached  from  the  Alba¬ 
tross  and  to  wait  orders. 

Marine-Hospital  Service. — Official  List  of  Changes  of  Stations  and 

Duties  of  Medical  Officers  of  the  United  States  Marine-Hospital  Service 

from  September  8,  1890 ,  to  October  J,  1890 : 

Hutton,  W.  H.  H.,  Surgeon.  Detailed  as  chairman  Board  of  Exam¬ 
iners.  October  2,  1890. 

Long,  W.  II.,  Surgeon.  Detailed  as  member  Board  of  Examiners. 
October  2,  1890. 

Purviance,  George,  Surgeon.  Granted  leave  of  absence  for  thirty 
days.  September  10,  1890. 

Godfrey,  John,  Surgeon.  Detailed  as  recorder  Board  of  Examiners. 
October  2,  1890. 

Wheeler,  W.  A.,  Passed  Assistant  Surgeon.  To  proceed  to  New  Or¬ 
leans,  La.,  for  temporary  duty.  October  3,  1890. 

Banks,  C.  E.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  twenty  days.  October  3,  1890. 

Ames,  R.  P.  M.,  Passed  Assistant  Surgeon.  To  proceed  to  New  Or¬ 
leans,  La.,  for  duty.  September  13,  1890. 

Pettus,  W.  J.,  Passed  Assistant  Surgeon.  To  proceed  to  Vineyard 
Haven,  Mass.,  for  temporary  duty.  October  1,  1890. 

Hussey,  S.  H.,  Assistant  Surgeon.  To  proceed  to  New  Orleans,  La., 
for  temporary  duty.  September  19,  1890.  To  proceed  to  Norfolk, 
Va.,  for  temporary  duty.  October  3,  1890. 

Wertenbaker,  C.  P.,  Assistant  Surgeon.  Granted  leave  of  absence 
for  twenty  days.  September  12,  1890. 

Perry,  J.  C.,  Assistant  Surgeon.  Upon  expiration  of  leave  to  rejoin 
station  at  Mobile,  Ala.  September  29,  1890. 

Young,  G.  B.,  Assistant  Surgeon.  To  proceed  to  Memphis,  Tenn.,  for 
temporary  duty.  September  13,  1890.  To  rejoin  station,  St.  Louis, 
Mo.,  when  relieved  at  Memphis,  Tenn.  October  3,  1890. 

Society  Meetings  for  the  Coming  Week: 

Monday,  October  20th:  New  Yrork  Academy  of  Medicine  (Section  in 
Ophthalmology  and  Otology) ;  New  York  County  Medical  Associa¬ 
tion;  Hartford,  Conn.,  City  Medical  Association ;  Chicago  Medical 
Society. 

Tuesday,  October  21st :  New  York  Academy  of  Medicine  (Section  in 
Theory  and  Practice  of  Medicine);  New  York  Obstetrical  Society 
(private) ;  Medical  Societies  of  the  Counties  of  Kings,  St.  Lawrence 
(semi  annual),  and  Westchester  (White  Plains),  N.  Y. ;  Ogdens- 
burgh,  N.  Y.,  Medical  Association ;  Hunterdon,  N.  J.,  County  Medical 
Society  (Flemington) ;  Baltimore  Academy  of  Medicine. 

Wednesday,  October  22d :  New  York  State  Medical  Association  (first 
day — New  York);  New  York  Surgical  Society;  New  York  Patho¬ 
logical  Society ;  American  Microscopical  Society  of  the  City  of  New 


York  ;  Medical  Society  of  the  County  of  Albany,  N.  Y. ;  Philadelphia 
County  Medical  Society. 

Thursday,  October  23d :  New  York  State  Medical  Association  (second 
day) ;  New  Yrork  Academy  of  Medicine  (Section  in  Obstetrics  and 
Gynaecology);  New  York  Orthopmdic  Society  ;  Brooklyn  Pathologi¬ 
cal  Society ;  Roxbury,  Mass.,  Society  for  Medical  Improvement  (pri¬ 
vate). 

Friday,  October  21fth :  New  York  State  Medical  Association  (third 
day);  Yorkville  Medical  Association  (private) ;  New  York  Society 
of  German  Physicians  ;  New  York  Clinical  Society  (private);  Phila¬ 
delphia  Clinical  Society ;  Philadelphia  Laryngological  Society. 

Saturday,  October  25tli :  New  York  Medical  and  Surgical  Society  (pri¬ 
vate). 


Jettfrs  to  %  (Sbitor. 


THE  VIRGINIA  STATE  MEDICAL  SOCIETY. 

221  West  Twenty-third  Street,  New  York,  October  8,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  Will  you  kindly  permit  me  to  correct  several  errors 
made  by  your  reporter  in  his  abstract  of  my  remarks  before 
the  Virginia  State  Medical  Society  which  are  found  on  page 
385  of  the  Journal  ?  I  am  no  doubt  partly  responsible  for  these 
errors,  as  I  failed  to  make  my  meaning  plain  in  extempore  dis¬ 
course.  In  the  first  place,  I  did  not  intend  to  convey  the  idea 
that  rheumatism  was  a  frequent  sequel  of  puerperal  malarial 
fever.  What  I  did  say  was,  in  an  illustrative  case  of  puerperal 
malarial  fever  which  I  narrated,  that  acute  articular  rheuma¬ 
tism  developed  subsequently,  and  that  a  number  of  times  I  had 
observed  this  latter  disease  as  a  complication  of  the  puerperal 
state,  but  not  frequently.  Secondly,  in  speaking  of  Mr.  Tait’s 
views  upon  the  subject  of  extra-uterine  pregnancy,  I  insisted 
that  this  surgeon  had  introduced  elements  of  confusion  by  not 
distinguishing  between  retro-uterine  hsematocele  properly  so 
called  and  a  free  effusion  of  blood  into  the  peritoneal  cavity, 
and  that  what  he  called  an  intrap eritoneal  hcematocele  was  not 
an  hcematocele  at  all,  but  simply  an  escape  of  blood  into  the 
peritoneal  cavity.  Again.  I  insisted  that  the  term  extraperi- 
toneal  hcematocele  ought  to  be  discarded,  and  the  name  hcema- 
toma  used  for  the  escape  of  blood  into  the  connective  tissue  of 
the  broad  ligaments;  and  that  these  distinctions  were  of  the 
utmost  importance  in  order  to  understand  the  relations  of 
tubal  pregnancy  to  hcematocele  or  hcematoma. 

George  Tucker  Harrison,  M.  D. 


DOBISCH’S  LOCAL  ANAESTHETIC. 

Home  for  Habitues,  Brooklyn,  October  8,  1890. 
To  the  Editor  of  the  New  York  Medical  Journal : 

Sir  :  The  new  local  anaesthetic  first  commended  hyDobiscb, 
of  Zwittau,  has  served  me  so  well  that  I  think  the  Journal  read- 

f 

ers  may  be  glad  to  know  of  it.  Its  make-up  is  : 

Menthol .  1  drachm  ; 

Chloroform .  10  drachms; 

Ether .  15  “ 

Used  as  spray. 

Though  never  pushed  to  complete  anaesthesia,  it  is  said  to 
freeze  the  part  in  a  minute.  I  have  found  it  very  effective  in 
superficial  neuralgia,  especially  about  the  head  ;  and  if,  added 
to  its  local  use,  a  thin  kerchief  is  placed  over  the  face  and  the 
spray  thrown  on  the  nose  and  mouth,  enough  general  effect — 
yet  quite  within  a  safe  limit — can  be  got  to  add  not  a  little  to 
the  local  good.  J.  B.  Mattison,  M.  D. 


Oct.  18,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


439 


proceedings  of  Societies. 


AMERICAN  GYNAECOLOGICAL  SOCIETY. 

Fifteenth  Annual  Meeting ,  held  in  Buffalo,  September  16,  17, 

and  18,  1890. 

The  President,  Dr.  John  P.  Reynolds,  of  Boston,  in  the  Chair. 

The  Diagnosis,  Pathology,  and  Treatment  of  Extra- 

uterine  Pregnancy. — Dr.  A.  W.  Johnstone,  of  Danville,  Ky., 
opened  a  discussion  of  this  subject  with  an  elaborate  paper.  He 
stated  that  the  amoeboid  state  was  the  first  picture  in  the  life  of 
all  viviparous  animals.  Immersed  in  a  properly  tempered  and 
proportioned  nutrient  fluid,  all  alike,  from  the  first  segmenta¬ 
tion,  went  on  to  the  formation  of  the  hypoblast,  the  epi blast,  and 
finally  the  mesoblast.  All  after  the  same  plan,  with  slight 
modifications,  progressed  in  the  formation  of  their  envelopes 
and  temporary  organs  necessary  to  intramaternal  existence; 
but,  up  to  a  certain  point,  all  that  was  required  of  the  mother 
was  that  she  should  furnish  this  properly  conditioned  fluid. 
The  writer’s  studies  in  comparative  anatomy  had  forced  him  to 
the  conclusion  that,  in  the  lower  animals,  excepting  the  anthro¬ 
poids,  at  no  time  but  when  the  “rut”  was  on  could  this  nour¬ 
ishing  lymph  be  furnished,  and,  without  this,  pregnancy  was  out 
of  the  question.  In  the  human  being  and  in  certain  monkeys 
the  “rut ”  was  sempiternal,  and,  as  a  matter  of  fact,  the  endo¬ 
metrium  was  ever  ready  to  furnish  the  necessary  nutrient  fluid. 
Pregnancy  might,  therefore,  occur  at  any  time.  This  nutrient 
fluid  came  from  the  adenoid  tissue  lining  the  uterine  cavity  and 
the  Falloppian  tubes.  Even  the  most  remote  fimbria  was  pos¬ 
sessed  of  this  lining.  Stiip  off  the  cilia  from  the  epithelium  of 
the  tube,  and  there  was  left  a  condition  quite  analogous  to  that 
of  the  lining  of  the  uterus.  These  cilia  were  extremely  delicate. 
He  could  not  believe  that  ectopic  pregnancy  could  occur  unless 
there  was  some  abnormity  in  the  genital  tract.  Anything  with¬ 
in  or  without  the  tube  that  caused  loss  of  the  epithelium,  and 
consequently  of  the  cilia,  was  sufficient  to  produce  a  spot  to 
which  the  ovum  might  adhere.  Ovarian  pregnancy,  if  there 
was  such  a  thing,  must  arise  from  a  peculiar  condition.  The 
practical  question  was,  Gould  ectopic  pregnancy  be  diagnosti¬ 
cated  before  rupture?  The  patient  did  not  seek  the  physician 
before  the  occurrence  of  severe  pain,  and  every  colicky  pain 
meant  a  giving  way  of  some  part  of  the  tube.  Sometimes  the 
first  rupture  broke  a  blood-vessel,  but  the  rule  was  that  haemor¬ 
rhage  did  not  occur  until  the  second  or  third  attack.  After 
the  discovery  of  an  extra- uterine  pregnancy,  laparotomy  was 
the  only  procedure  in  any  sense  warrantable.  The  growth  of 
the  gestation  sac  could  not  be  arrested  until  the  placenta  was 
killed,  and  the  death  of  the  child  did  not  necessarily  insure  the 
death  of  the  placenta.  Electrical  treatment,  once  so  much  ad¬ 
mired,  was  wrong  in  principle,  dangerous  in  practice,  and  dis¬ 
astrous  in  its  final  results. 

Dr.  Matthew  D.  Mann,  of  Buffalo,  stated  that  the  view 
that  union  of  the  male  and  female  elements  of  generation  must 
take  place  in  the  uterus  was  erroneous.  In  ectopic  pregnancy 
the  union  must  occur  in  or  beyond  the  tube,  and  most  of  these 
pregnancies  were  primarily  tubal.  So  far  as  abdominal  preg¬ 
nancies  were  concerned,  the  subject  was  still  sub  judice.  There 
was  no  rational  doubt  as  to  the  existence  of  ovarian  gestation. 
Electricity  was  of  great  value  ordinarily,  for,  if  the  embryo  was 
destroyed,  rupture  would  not  occur.  After  rupture,  laparotomy 
was  clearly  indicated. 

Dr.  J.  M.  Baldy,  of  Philadelphia,  stated  that  it  must  be  con¬ 
sidered  that  he  based  bis  arguments  on  the  supposition  that 
conception  had  taken  place  in  the  tube.  He  did  not  wish  to 


place  himself  on  record  as  denying  the  possibility  of  an  ovarian 
or  an  abdominal  gestation,  but,  whatever  the  condition  might 
be  in  the  earlier  stages,  the  symptoms  were  so  similar  that  their 
distinction  was  quite  out  of  the  question.  The  following  symp¬ 
toms  might  be  classified  as  significant  or  strongly  suggestive  of 
ectopic  pregnancy:  1.  A  spurious  flow,  simulating  menstrua¬ 
tion,  which  was  at  first  lighter  and  afterward  darker  than  the 
normal  menstrual  discharge,  and  which  contained  clots  and 
shreds.  2.  Pain,  intermittent  and  cramp-like,  and  becoming 
more  severe  and  more  frequent.  The  situation  of  this  pain  was 
invariably  in  the  pelvis  and  low  in  the  abdomen,  and  it  might 
be  sufficiently  severe  to  produce  syncope.  It  was  usually  the 
symptom  that  caused  the  patient  to  seek  her  physician,  aud,  in 
conjunction  with  the  pseudo-menstrual  flow,  might  be  accepted 
as  pointing  strongly  toward  the  existence  of  extra-uterine  preg¬ 
nancy.  3.  The  discharge  of  shreds  of  decidua,  with  or  without 
clots.  4.  The  general  signs  of  pregnancy.  5.  Occasionally  the 
history  of  a  sterility  following  normal  labor  or  a  miscarriage. 
6.  The  vaginal  discoloration  as  in  normal  pregnancy.  7.  The 
cervix  was  sometimes  appreciably  enlarged  and  the  os  uteri 
patulous,  but  this  was  not  invariably  the  case.  8.  The  fundus 
of  the  uterus  was  enlarged  and  softened  and  crowded  either  for¬ 
ward  against  the  pubic  bone  or  to  one  side.  It  was  more  or 
less  immovable  and  had  a  feeling  of  softness.  As  in  the  case 
of  the  cervix,  these  conditions  were  not  constant.  9.  The  uter¬ 
ine  appendages  sometimes  showed  a  cyst  on  one  side,  while  an 
inspection  of  the  other  side  gave  a  negative  result.  The  cyst, 
even  if  pulsating,  was  not  a  positive  diagnostic  sign.  10.  The 
patient’s  belief  as  to  whether  she  was  or  was  not  pregnant  was 
quite  important  in  making  a  diagnosis.  11.  In  some  cases  an 
elevated  temperature  and  an  accelerated  pulse.  12.  At  the 
period  of  rupture  great  pain,  collapse,  and  all  the  signs  of  in¬ 
ternal  haemorrhage.  The  speaker  stated  that  three  propositions 
were  justified  by  his  experience  and  that  of  other  gynaecolo¬ 
gists:  1.  In  a  certain  proportion  of  cases  of  extra-uterine  preg¬ 
nancy,  in  the  early  stages,  the  diagnosis  was  easy  and  unmis¬ 
takable.  2.  In  a  certain  (quite  large)  proportion  of  cases  suffi¬ 
cient  symptoms  were  present  to  lead  to  a  diagnosis  of  extra- 
uterine  pregnancy,  although  such  a  pregnancy  was  not  present. 
3.  In  a  certain  proportion  of  cases  the  symptoms,  until  rupture 
had  occurred,  were  entirely  wanting  or  of  such  dubious  char¬ 
acter  as  in  no  wise  to  warrant  a  diagnosis  of  ectopic  preg¬ 
nancy. 

A  very  large  number  of  cases  terminated  fatally,  which  ren¬ 
dered  expectant  treatment  somewhat  hazardous  and  made  active 
measures  essential.  When  the  diagnosis  was  reasonably  certain, 
laparotomy  was  indicated.  It  was  a  noticeable  fact  that  many 
of  the  physicians  who,  a  year  ago,  had  been  among  the  most 
ardent  admirers  of  electrical  treatment  for  extra-uterine  preg¬ 
nancy,  now  seemed  to  support  laparotomy. 

A  case  of  tubal  gestation  with  rupture  was  reported  by  Dr. 
Charles  Jewett,  of  Brooklyn,  as  having  occurred  in  the  prac¬ 
tice  of  Dr.  F.  A.  Jewett. 

Dr.  A.  J.  C.  Skene,  of  Brooklyn,  believed  that  it  was  highly 
important  that  a  diagnosis  should  be  made  in  all  cases  of  extra- 
uterine  pregnancy  with  equal  certainty,  whether  the  treatment 
contemplated  was  that  by  electricity  or  by  laparotomy,  in  order 
that  patients  in  extremis  might  be  cared  for  intelligently.  He 
was  firmly  convinced  that  extra-uterine  pregnancy  was  as  easily 
diagnosticated  as  any  known  affection  of  the  female  pelvic  or¬ 
gans,  if  there  was  no  complication  of  other  pelvic  disease.  In 
regard  to  the  treatment  with  electricity,  the  speaker  expressed 
the  regret  that  it  should  have  been  so  heatedly  and  doubtfully 
discussed,  and  that  it  should  have  received  such  merciless  con¬ 
demnation  from  the  advocates  of  laparotomy,  and  he  believed 
that  such  acrimonious  discussions  would  never  lead  to  deter- 


440 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


mining  the  true  value  of  either  method  of  treatment.  He  had 
seen  no  evidence  that  electricity  was  especially  dangerous,  and 
believed  that  it  could  he  employed  with  entire  safety,  and  its 
failing  to  cure  did  not  prejudice  in  the  least  the  resort  to  lapa¬ 
rotomy.  The  laparotomists  said  that  their  operation  must  be 
done  by  “  competent  hands.”  Considering  that  the  cases  for 
laparotomy  were  emergency  cases,  perhaps  if  they  examined 
the  histories  of  the  cases  that  bad  been  operated  upon  by  pre¬ 
sumably  “  competent  hands,”  they  would  not  be  so  ready  to 
condemn  electricity. 

Dr.  W.  W.  Jaggard,  of  Chicago,  was  sure  that  the  existence 
of  ovarian  pregnancy  had  been  proved.  A  great  many  cases  of 
so-called  tubal  pregnancy  were  simply  bsematoma  of  the  tubes, 
and  many  cases  of  so-called  hematosalpinx  were  really  tubal 
pregnancies. 

Tubal  pregnancy  bad  three  terminations:  1.  Death  before 
rupture.  2.  Rupture.  3.  Going  on  to  term.  When  the  tube 
ruptured,  the  following  subterminations  might  be  observed:  1. 
Rupture  into  the  broad  ligament,  with  the  formation  of  liasma- 
toma  of  the  broad  ligament.  2.  After  rupture,  the  ovum  might 
remain  in  situ  and  plug  up  the  opening.  3.  Rupture  with  the 
formation  of  a  retro-uterine  hematocele.  4.  Rupture  into  the 
abdomen  with  iutraperitoneal  hemorrhage.  With  the  excep¬ 
tion  of  the  last,  all  these  were  favorable  terminations,  and  as  a 
rule  tubal  pregnancy  with  rupture  would  end  in  recovery  if  left 
alone.  He  agreed  perfectly  with  Dr.  Skene  in  regard  to  the 
diagnosis  being  easy  in  uncomplicated  cases.  It  should  be  noted 
that  the  typical  cases  of  extra-uterine  pregnancy  occurred  in 
old  multiparse  with  a  long  interval  between  pregnancies,  or  in 
primiparse  who  had  been  sterile  for  a  long  time.  The  evidence 
in  favor  of  laparotomy,  where  the  diagnosis  was  made  before 
rupture,  was  conclusive. 

There  were  the  following  objections  to  the  use  of  electrici¬ 
ty  :  1.  Danger  of  rupturing  the  sac.  2.  Uncertainty  in  diag¬ 
nosis.  3.  After  the  eighth  week  it  was  hopeless  to  expect  re¬ 
sorption  of  the  foetus  or  the  placenta.  He  agreed,  however, 
with  Dr.  Skene  that  it  was  well  to  be  temperate  in  the  condem¬ 
nation  of  electricity.  The  proposition  that  every  case  of  tubal 
pregnancy  with  rupture  called  for  laparotomy  was  erroneous, 
and  had  proved  most  disastrous  in  practice.  The  principal  in¬ 
dication  for  laparotomy  was  free  intraperitoneal  haemorrhage. 
In  the  event  of  haematoma  of  the  broad  ligament  or  of  rupture 
of  the  tube,  the  clot  acting  as  a  tampon,  the  indications  were  all 
strongly  against  laparotomy. 

Dr.  Howard  A.  Kelly,  of  Baltimore,  beliered  it  was  pos¬ 
sible  to  recognize  the  following  forms  of  extra-uterine  preg¬ 
nancy:  1.  Interstitial.  2.  Tubal.  3.  Tubo-ovarian  (doubtful). 
4.  Ovarian  (proved  beyond  a  doubt).  5.  Primary  abdominal 
(remaining  to  be  proved).  Tubal  gestation  might  be  divided 
into  isthmial,  isthmio-ampullar,  and  ampullar,  according  to  the 
relative  position  of  the  tube.  The  criterion  of  ovarian  preg¬ 
nancy  was  an  extra  uterine  foetal  sac,  which  must  have  the  same 
relation  to  the  uterus  as  the  ovary  had,  the  tube  remaining  in¬ 
tact  and  the  ovarian  ligament  connecting  the  side  of  the  sac 
with  the  uterus  being  present.  A  positive  diagnosis  of  extra- 
uterine  pregnancy  could  be  made  if  the  following  symptoms 
were  present:  1.  Cessation  of  menstruation  followed  by  its  ir¬ 
regular  recurrence.  2.  Pain  in  the  lower  part  of  the  abdomen. 
3.  A  fluctuating  tumor.  4.  Enlarged  uterus  (not  always  pres¬ 
ent).  5.  A  discharge  of  membrane,  which  was  very  character¬ 
istic.  6.  Milk  in  the  breasts.  7.  A  tumor  diminishing  in  size 
under  observation,  a  pathognomonic  sign  rarely  present,  unless 
electricity  was  used,  which  of  course  implied  the  death  of  the 
foetus.  There  was  a  class  of  doubtful  cases  where  some  of  the 
symptoms  were  present,  and  there  was  still  another  class  of 
uncertain  cases  where  there  were  no  signs,  and  they  were  gen¬ 


erally  discovered  accidentally.  If  he  found  a  freely  movable 
tumor  in  the  abdomen,  he  would  perform  laparotomy;  but,  if 
the  tumor  had  ruptured  into  the  broad  ligament,  he  would  use 
electricity  and  wrait  for  results  up  to  the  end  of  the  third  month. 
He  would  not  consider  the  life  of  the  foetus  to  the  detriment 
of  the  life  of  the  mother,  but  consider  the  foetus  simply  as  a 
malignant  foreign  body.  If  there  was  a  living  foetus  at  term, 
he  would  open  the  abdomen,  and  if  it  proved  to  be  an  unrupt¬ 
ured  tube,  with  the  placenta  enucleated  in  the  sac,  the  latter 
could  be  removed  and  the  life  of  the  foetus  saved.  If  the  pla¬ 
centa  was  attached  to  the  intestines,  he  would  remove  the  foetus 
and  drop  the  funis  back  into  the  abdominal  cavity,  and  after¬ 
ward  perform  laparotomy  if  necessary. 

Dr.  Hunter  Robb,  of  Philadelphia,  believed  that  the  tubes 
were  the  most  frequent  site  of  fecundation,  but  that  ovarian 
pregnancies  did  take  place,  and  agreed  with  Dr.  Jaggard  that 
microscopical  examination  was  alone  reliable  in  determining 
this  condition.  He  believed  the  diagnosis  as  easy  as  that  of 
fibroid  or  parovarian  cyst. 

Dr.  Joseph  Taber  Johnson,  of  Washington,  remarked  that 
a  paper  of  Dr.  Hanks’s,  read  before  the  society  in  1888,  had 
given  the  histories  of  eleven  cases,  with  the  statement  that  a 
diagnosis  ought  to  be  possible  in  ninety  or  ninety-five  per  cent, 
of  all  cases;  that  he  believed  in  electricity  in  the  beginning  and 
operation  afterward  if  necessary.  He  thought  electricity  would 
kill  the  foetus,  and  that  in  all  cases  of  rupture  laparotomy  should 
be  done  at  once. 

Dr.  A.  H.  Buckmaster,  of  Brooklyn,  thought  it  would  be  a 
fatal  blow  to  the  use  of  electricity  in  these  csfses  if  it  should  be 
proved  that  it  could  not  accomplish  the  destruction  of  the 
foetus. 

Dr.  J.  A.  Temple,  of  Toronto,  related  a  case  of  extra-uteriue 
gestation  in  which  he  had  removed  the  tumor  and  tube  without 
rupture.  The  patient  made  a  good  recovery  and  the  stitches 
were  taken  out  on  the  sixth  day.  On  the  eighth  day  she  had  a 
severe  attack  of  mania;  on  the  twelfth  day  she  became  semi- 
comatose  and  did  not  recover  consciousness ;  and  on  the  twenty- 
third  day  she  died  perfectly  insensible.  He  was  confident  that 
sbe  did  not  die  from  septicaemia  or  any  similar  affection  as  the 
result  of  the  operation. 

Dr.  Mann  reiterated  the  views  expressed  in  his  paper  in  re¬ 
gard  to  the  specimen  which  he  presented  two  years  ago,  and 
still  held  the  case  to  have  been  one  of  true  ovarian  pregnancy. 
His  opinion  in  regard  to  the  use  of  electricity  in  properly  elected 
cases  was  also  unchanged. 

Under  what  Conditions  can  Electricity  be  of  Positive 
Service  to  the  Gynecologist  ? — A  paper  on  this  subject,  by 
Dr.  Andrew  F.  Currier,  of  New  York,  was  read  by  title.  We 
are  indebted  to  the  author  for  the  following  abstract  of  the 
paper : 

The  testimony  upon  this  subject  is  conflicting.  Some  have 
opposed  it  from  prejudice  and  bias,  and  others  have  advocated 
it  with  an  enthusiasm  which  revealed  indiscretion  and  unwis¬ 
dom.  Satisfactory  knowledge  can  be  gained  only  by  experi¬ 
ence,  and  this  necessitates  no  little  expense  for  the  apparatus 
and  time  and  labor  in  order  to  comprehend  the  physical  laws 
governing  electricity.  As  in  religion,  art,  science,  and  politics, 
success  only  comes  as  a  rule  to  those  who  follow  up  the  sub¬ 
ject  persistently  and  thoroughly.  The  patient  also  must  sub¬ 
mit  to  such  conditions  as  will  permit  of  a  fair  test  of  the  agent. 
The  subject  is  considered  under  three  headings: 

A.  Necessary  outlay  and  apparatus. 

B.  Indications. 

C.  Contra-indications,  cautions,  and  objections. 

The  faradaic  current  is  indicated  when  one  desires  in¬ 
creased  muscular  tone  or  contractile  force.  Incidentally  will 


Oct.  18,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


come  improved  vascularity  and  nerve  energy.  The  galvanic 
current  is  indicated  as  an  astringent,  haemostatic,  denutrient, 
adnutrient,  or  sedative.  For  some  conditions,  for  example 
pain,  either  current  may  be  effective.  All  battery  currents  are 
based  upon  Ohm's  law  that  the  available  battery  force  equals 
the  entire  force  generated  by  all  the  cells  divided  by  the  resist¬ 
ance  offered  by  the  wires,  the  fluid  in  the  cells— in  fact,  every¬ 
thing  which  hinders  the  passage  of  the  current.  The  unit  of 
usable  current  in  electro  therapeutics  is  the  milliampere.  The 
requirements  for  a  faradaic  battery  are  that  it  be  small,  simple, 
clean,  and  cheap.  Gaiffe’s  costs  but  a  few  dollars  and  is  per¬ 
haps  the  best  there  is.  The  requirements  for  a  galvanic  battery 
are  steadiness  of  current,  cleanliness,  simplicity  of  construction, 
and  durability.  The  writer  has  never  found  a  portable  battery 
that  answered  these  requirements,  but  does  not  assert  that  they 
do  not  exist.  To  answer  the  conditions  mentioned  there 
should  be  a  large  number  of  large  cells  in  continuous  connec¬ 
tion.  Either  the  Law  or  the  Leclanche  cells  will  give  satisfac¬ 
tion,  the  former  being  more  cleanly  and  more  durable.  A 
rheostat  and  a  milliamperemeter  are  indispensable,  and  the 
writer  is  well  pleased  with  the  Bailey  rheostat  and  the  Bar¬ 
rett  meter  graduated  to  250.  The  connecting  cords  from  bat¬ 
tery  to  patient  should  be  long  enough  for  the  patient  to  be 
moved  about  without  danger  of  breaking  the  circuit  and  giving 
a  shock.  For  an  abdominal  electrode  Martin’s  is  the  best. 
There  are  many  varieties  of  vaginal  and  uterine  electrodes, 
those  designed  by  Apostoli  being  very  good  ones.  The  writer 
has  designed  one  of  aluminium,  with  a  cylindrical  removable 
platinum  tip,  the  shaft  being  covered  with  thin  rubber  tubing. 
It  is  light,  cheap,  and  flexible. 

The  rheostat  and  meter  may  rest  upon  a  portable  base  fur¬ 
nished  with  suitable  binding  posts  and  a  switch  for  changing 
polarity.  Ihe  character  and  effect  of  the  current  at  the  two 
poles  are  essentially  different.  The  positive  pole  will  check 
haemorrhage  and  glandular  secretion;  the  negative  will  not- 
the  positive  pole  will  corrode  all  but  the  noble  metals;  the 
negative  will  not.  The  positive  pole  is  acid;  the  negative  al¬ 
kaline.  At  the  positive  pole  oxygen  is  liberated  in  the  elec¬ 
trolysis  of  water  ;  at  the  negative,  hydrogen. 

The  writer’s  paper  contains  an  analysis  of  twenty-three  cases 
in  which  the  indications  for  treatment  were:  1.  Pain.  2. 
Hemorrhage.  3.  Inflammatory  exudate.  4.  Sterility.  5.  Dys- 
menorrboea.  6.  Supersecretion.  7.  Hysteria.  8.  Uterine 
subinvolution.  9.  Uterine  subnutrition. 

For  pain  the  positive  pole  should  be  within  the  vagina  or 
uterus,  and  a  weak  current  is  better  than  a  strong  one.  A  good 
average  is  30  milliamperes,  used  from  five  to  eight  minutes. 
The  intervals  of  application  should  depend  upon  the  duration  of 
the  periods  in  which  pain  is  absent.  Pain  was  relieved  in  two 
cases  in  which  it  persisted  after  removal  of  the  uterine  annexa, 
m  one  each  of  uterine  myoma,  pyosalpinx  with  ovarian  apo¬ 
plexy  and  endometritis,  and  two  of  pelvic  peritonitis  with  exu. 
dation.  For  hemorrhage  the  positive  pole  is  believed  to  be  un- 
sui  passed.  It  was  used  in  a  case  of  interstitial  myoma,  and  in 
One  of  malignant  disease  of  the  uterus  and  omentum.  Four 
cases  were  treated  for  inflammatory  exudate,  and  in  three  the 
exudate  was  disintegrated  and  absorbed.  But  as  the  diseased 
organs  which  had  been  confined  by  it  became  more  mobile  they 
also  became  larger  and  more  sensitive.  In  five  cases  sterility 
was  treated  with  the  faradaic  current.  Impregnation  andde- 
livery  resulted  in  two.  Dysmenorrhoea  may  be  relieved  by 
either  the  positive  galvanic  pole  or  faradism.  Three  cases  are 
narrated,  but  in  only  one  was  the  result  decidedly  favorable. 
For  supersecretion  the  positive  pole  is  preferable  to  the  power¬ 
ful  caustics  and  escharotics,  and  yielded  good  results  in  three 
•cases.  In  two  cases  hysterical  symptoms  were  much  modified 


441 

in  addition  to  benefit  which  was  derived  for  more  palpable 
lesions. 

Subinvolution  was  successfully  treated  in  one  case,  the 
uterus  contracting  firmly  upon  the  bipolar  electrode  of  Apos¬ 
toli,  and  with  the  faradaic  current.  Uterine  subnutrition  in 
connection  with  hard  anteflexed  uteri  and  usually  associated 
with  amenorrhcea,  dysmenorrhoea,  or  sterility  will  be  benefited 
by  the  faradaic  current.  Five  patients  were  treated,  and  all 
but  one  received  positive  benefit.  Under  the  head  of  cautions, 
contra-indications,  and  objections,  nausea  resulted  in  one  case' 
and  this  observation  has  frequently  been  made  by  others.  The 
passage  of  the  galvanic  current  may  cause  faintness,  which  may 
be  slight  or  profound,  and  dizziness.  In  a  case  of  exophthalmic 
goitre  with  rapid  heart  action  collapse  was  imminent  on  two 
occasions..  An  irritable  heart,  such  as  is  usually  present  in  the 
last-mentioned  disease,  and  certain  chronic  gastric  disorders 
contra-indicate  the  use  of  electricity.  Malignant  disease  within 
the  abdomen  is  a  contra-indication,  or  at  least  proved  so  in  one 
case.  Small,  dry  electrodes  should  not  be  applied  to  the  ab¬ 
domen,  but  large,  wet  ones.  The  former  will  invariably  pro¬ 
duce  burning.  The  method  of  rapid  reversals  of  the  galvanic 
current  is  of  limited  usefulness,  and  should  not  be  used  with 
nei  vous  women.  The  shocks  may  be  exceedingly  harmful.  The 
electro-puncture  of  fibroid  tumors  means  possible  sepsis  with 
its  consequences.  If  it  is  electricity  and  not  inflammation  and 
sloughing  which  reduce  the  nutrition  of  a  tumor,  it  would  seem 
to  be  unnecessary.  Galvano-cauterization  of  the  uterine  mu¬ 
cous  membrane  seems  to  furnish  the  advantages  of  puncture 
without  the  danger.  Electro-puncture  is  also  disapproved  of 
for  hsematoma  and  hsematocele  as  dangerous,  tedious,  and  in¬ 
efficient  as  to  its  results.  Electricity  is  the  handmaid  and  not 
the  mistress  of  surgery,  a  valuable  assistant  and  increasing  in 
value  with  experience,  but  one  which  demands  rational,  care¬ 
ful,  and  intelligent  use. 

(To  be  continued.') 


MEDICAL  SOCIETY  OF  THE  COUNTY  OF  NEW  YORK. 

Meeting  of  September  22,  1890. 

The  President,  Dr.  A.  S.  Hunter,  in  the  Chair. 

The  Initiation  Fee.-Dr.  0.  II.  Avert  withdrew  his  motion 
to  reduce  the  initiation  fee  from  five  dollars  to  one  dollar  in 
favor  of  an  amendment  to  the  By-laws  recommended  by  the 
Comitia  Minora  to  reduce  the  fee  to  two  dollars.  The  Comitia 
also  recommended  that  the  editor  of  the  Medical  Directory  be 
ex  officio  a  member  of  the  Comitia  Minora. 

Nominations.— Nominations  were  made  as  follows:  For 
president,  Dr.  Andrew  F.  Currier,  Dr.  O.  B.  Douglas,  Dr.  J.  L. 
Corning;  for  vice-president,  Dr.  J.  L.  Corning,  Dr.  A.  M.  Ja¬ 
cobus  ;  for  secretary,  Dr.  Charles  H.  Avery  ;  for  assistant  secre¬ 
tary,  Dr.  W.  E.  Bullard;  for  treasurer,  Dr.  John  S.  Warren; 
for  censors  (five  to  be  elected),  Dr.  George  E.  Abbott,  Dr.  Will¬ 
iam  McLaury,  Dr.  A.  S.  Hunter,  Dr.  R.  Van  Santvoord,  Dr.  E. 
A.  Maxwell,  Dr.  G.  T.  Jackson,  Dr.  S.  O.  Vander  Poel,  Dr.  N. 
G.  McMaster,  Dr.  W.  C.  Jarvis,  Dr.  W.  Washburne,  Dr.  C.  F." 
Milne,  Dr.  G.  F.  Carey. 

The  Diagnosis  and  Treatment  of  Certain  Abdominal  Dis- 
eases  principally  characterized  by  Symptoms  of  Peritonitis. 

Dr.  H.  T.  Hanks  based  a  paper  on  this  subject  on  experience 
gained  within  the  past  ten  years,  during  which  time  the  treatment 
of  diseases  characterized  principally  by  symptoms  of  peritonitis 
had  undergone  considerable  change,  while  much  progress  had 
been  made  in  their  diagnosis.  He  thought  it  wise  to  interro¬ 
gate  the  viscera,  one  after  another,  in  arriving  at  a  diagnosis  in 
not  perfectly  clear  cases.  Conjoined  manipulation  per  rectum 


442 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  JocR.r 


et  vaginam  was  often  necessary,  and  might  be  aided  by  a  few 
whiffs  of  an  anaesthetic.  Experience  had  taught  us  that  many 
cases  which  formerly  would,  have  been  regarded  as  primary 
peritonitis  could  now  be  made  out  as  secondary.  He  believed 
that  only  three  cases  of  idiopathic  peritonitis  had  ever  come 
under  his  own  observation,  and  in  those  the  diagnosis  had  not 
been  confirmed  by  an  autopsy.  The  symptoms  which  formerly 
would  have  been  regarded  as  diagnostic  of  peritonitis — pain  in 
the  abdomen,  tympanites,  rapid  pulse,  pinched  face,  etc. — it  was 
now  known  might  be  due  to  perihepatitis,  metritis,  gastritis, 
acute  congestion  of  the  kidneys,  etc.,  and  the- important  ques¬ 
tion  arose  whether  the  former  treatment  of  peritonitis  (by 
opium)  would  cure  such  cases.  Evidently  it  would  not  in  many 
instances.  How,  for  instance,  could  it  be  expected  that  large 
doses  of  opium  would  cure  twisting  of  an  ovarian  pedicle,  of 
which  condition  the  chief  symptoms  might  be  those  of  perito¬ 
nitis? 

Where  the  surgical  indications  had  not  become  clear,  the 
author  would  treat  a  case  characterized  by  symptoms  of  perito¬ 
nitis  with  saline  cathartics,  sufficient  codeine  to  give  comfort 
(opium  was  objected  to  as  being  constipating  in  its  effects),  the 
ice  coil  where  fever  was  high,  and  leeches;  perhaps  enerhata 
might  have  to  take  the  place  of  salines.  The  case  should  be  con¬ 
stantly  watched,  since  the  abdominal  surgeon  might  have  to  be 
called  at  any  time.  These  remarks  applied  in  a  general  way  to 
appendicitis  as  well  as  to  other  conditions,  and  he  could  say  that 
if  the  case  was  seen  early  an  appendicitis  could  thus  be  made  to 
undergo  resolution  ;  if,  however,  an  abscess  formed,  an  opera¬ 
tion  should  be  resorted  to,  although  the  mortality  in  operative 
cases  had  been  very  large. 

Dr.  A.  Jaoobi  discussed  the  subject  as  applied  to  children, 
and  said  that  peritonitis  in  the  infant  was  about  the  same  ana¬ 
tomically  and  pathologically,  and  largely  setiologically,  as  in  the 
adult.  He  thought  a  large  number  of  cases  were  mistaken  for 
peritonitis  which  were  of  some  other  nature,  while  a  still  larger 
number  were  in  reality  peritonitis  mistaken  for  some  other  con¬ 
dition.  This  had  been  shown  in  a  paper  he  had  once  read  be¬ 
fore  the  Virginia  State  Medical  Society.  Many  cases  of  so 
called  stomach-ache  in  infants  and  adults  were  new  or  recurrent 
attacks  of  peritonitis.  Agglutinations  between  the  intestines 
were  often  found  at  autopsy  which  had  not  been  suspected  dur¬ 
ing  life;  they  meant  peritonitis.  Old  typhoid  ulcers  sometimes 
perforated  and  caused  peritonitis.  In  many  instances  repeated 
belly-ache  in  children  was  due  to  perityphlitis.  In  chronic 
peritonitis,  with  acute  or  subacute  attacks,  the  bowels  should 
be  supported  by  a  snug  bandage  covering  the  whole  abdomen. 
Regarding  the  old  treatment  by  opium  and  the  modern  by  pur¬ 
gation,  there  seemed  a  wide  difference,  which  might  perhaps 
be  accounted  for  by  different  elates  of  cases.  And  where  laxa¬ 
tives  proved  beneficial,  was  not  a  narcotic  for  rest  demanded 
subsequently  ?  He  gave  a  laxative,  followed  it  by  opium,  but 
admitted  that  he  was  sometimes  unable  to  tell  whether  the 
stage  had  yet  passed  for  a  saline,  and  opium  was  demanded. 

Dr.  W.  H.  Thomson  spoke  of  purulent  peritonitis  at  the 
terminal  stage  of  Bright’s  disease,  which  was  so  often  over¬ 
looked  until  the  body  reached  the  post-mortem  room.  Among 
its  indications  was  a  rapid,  small,  incompressible  pulse,  with 
little  or  no  elevation  of  the  temperature.  The  incompressibility 
of  the  pulse  was  different  from  that  pertaining  to  the  kidney 
disease  itself.  He  also  mentioned  the  fact  that  in  perforation 
during  typhoid  fever  there  was  frequently  no  rise,  perhaps  a 
fall,  of  the  temperature,  which  was  due  to  sudden  shock.  The 
surgeon  alone  could  here  give  relief.  The  pain  in  cirrhosis  of 
the  liver,  common  in  alcoholics,  was  oftener  due  to  peritonitis 
than  to  gastritis  or  gastro-duodenitis.  He  further  said  in  con¬ 
nection  with  diagnosis  that  sudden  pain  followed  by  symptoms 


of  general  peritonitis  was  very  different  from  steadily  increas¬ 
ing  pain,  and  pointed  to  perforation  of  a  hollow  viscus. 

Dr.  0.  0.  Lee  said  his  remarks  would  be  based  chiefly  on 
surgical  experience.  There  were  three  classes  of  cases:  1. 
Those  of  septic  nature,  in  which  the  cause  of  sepsis  should  be 
removed.  When  peritonitis  of  this  nature  developed  alter  an 
abdominal  operation  there  was  likely  to  be  remarkable  absence 
of  severe  pain,  due,  he  supposed,  to  the  obtunding  of  the  nerve 
centers  by  septic  matter  covering  a  large  surface,  the  symptoms- 
simulating  malarial  conditions.  Many  such  cases  were  now 
saved  by  re-opening  the  abdomen  while  formerly  they  died.  2. 
What  might  be  called  acute  traumatic  peritonitis.  In  this  class 
of  cases  abdominal  surgeons  were  responsible  for  what  he- 
thought  was  a  heresy  in  announcing  that  salines  would  be  likely 
to  result  uniformly  successfully.  He  had  treated  cases  in  that 
way  vigorously,  and  had  yet  to  see  one  do  well  in  which  the- 
treatment  was  kept  up,  except  there  were  obstruction  by  gas 
or  faecal  accumulation.  Now  he  began  with  a  saline  cathartic, 
then  gave  opium  to  quiet  the  bowels.  He  admitted  the  argu¬ 
ments  in  favor  of  codeine.  The  ice  coil  was  useful  only  during 
the  formative  stage,  and  was  contra-indicated  after  plastic  de¬ 
posit.  3.  Secondary  peritonitis.  Here  success  required  re¬ 
moval  of  the  cause.  He  thought  we  would  reach  the  period 
when  there  would  be  less  abdominal  surgery  than  to-day. 

Dr.  E.  H.  Grandin  spoke  of  puerperal  cases,  and  said  that 
during  his  early  professional  career  he  at  once  began  dosing  the 
patient  with  opium,  and  she  died.  Now,  when  he  saw  his  pa¬ 
tients  early  they  got  well,  and  his  treatment  consisted  in  the 
use  of  salines  and  the  avoidance  of  opium  as  far  as  possible. 
The  vagina  and  uterus  should  be  clean;  if  a  pyosalpinx  or  ova¬ 
rian  abscess  had  ruptured,  the  surgeon  would  have  to  act. 

Dr.  Rai.ph  Waldo  had  seen  patients  who  had  been  treated 
successfully  for  an  attack  or  repeated  attacks  of  peritonitis  by 
opiates,  but,  they  being  hypenesthetic,  the  physician  was  led  to 
continue  the  narcotic  too  long,  and-  complications  developed, 
such  as  faecal  impaction  and  digestive  derangement.  This  oc¬ 
curred  so  frequently  that  it  seemed  necessary  to  say  a  word  of 
caution. 

Dr.  R.  A.  Murray  thought  primary  peritonitis  occurred  but 
seldom.  Further,  that  severe  attacks  were  infrequently  recov¬ 
ered  from,  whatever  the  treatment.  Probably  most  of  us  saw 
more  of  puerperal  peritonitis  than  of  any  other  kind,  and  treat¬ 
ment  by  either  opium  or  laxatives  failed  simply  for  the  reason 
that  the  cause  was  not  removed — that  is,  sepsis.  Where  perito¬ 
nitis  was  ushered  in  after  laparotomy,  by  giving  a  saline  one 
certainly  took  away  the  serum  which  furnished  a  nidus  for 
germs;  he  should  then  quiet  the  bowels  and  enhance  digestion 
by  small  doses  of  opium ;  or,  if  there  was  shock,  give  large 
doses,  for  opium  was  a  powerful  heart  stimulant. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Meeting  of  October  2,  1890 - 
The  President,  Dr.  Alfred  L.  Loomis,  in  the  Chair. 

The  New  Building. — The  President,  on  calling  the  meet¬ 
ing  to  order,  explained  that,  while  the  effort  to  have  the  new 
building  ready  for  the  opening  work  of  the  session  had  been 
successful,  the  formal  inauguration  would  not  take  place  until 
the  second  meeting  in  November,  on  the  date  fixed  for  the 
anniversary  oration. 

Skin  Grafting  after  the  Method  of  Thiersch.  —  Dr. 

Charles  MoBurney  read  a  paper  on  this  subject.  After  describ¬ 
ing  Reverdin’s  well-known  method,  the  author  went  fully  into 
the  details  of  skin  grafting  as  practiced  by  Thiersch  and  as- 
modified  by  himself.  According  to  Thiersch,,  all  strong  aDti- 


Oct.  18,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


443 


septics  were  to  be  avoided  in  skin  grafting,  as  the  effect  of 
these  upon  the  cellular  elements,  upon  the  capillaries,  and  upon 
the  blood  itself  was  such  as  to  seriously  endanger  and  even 
prevent  the  immediate  union  between  the  grafts  and  the  sur¬ 
faces  upon  which  they  were  placed.  Thiersch  himself  used 
absolutely  no  solution  except  one  of  common  salt  in  water,  in 
the  proportion  of  six  parts  to  one  thousand.  The  speaker  was 
convinced  of  the  importance  of  sterilizing  this  solution.  It  was 
his  practice  to  use  distilled  water,  boiling  the  solution  before 
using  it,  and  also  to  employ  a  solution  of  bichloride  of  mercury 
freely  in  disinfecting  the  ulcerated  surface,  as  well  as  the  sur¬ 
face  fiom  which  the  grafts  were  to  be  taken,  completely  wash¬ 
ing  away  all  of  this  solution  with  the  saline  one  of  Thiersch 
just  before  operating.  The  parts  should  be  thoroughly  washed 
with  soap  and  water,  and  all  hair  should  be  removed  by  care¬ 
ful  shaving.  In  some  cases  grafts  might  be  placed  with  success 
directly  upon  the  unbroken  surface  of  healthy  granulations, 
but  a  much  more  certain  method  of  insuring  success,  and,  ac¬ 
cording  to  Thiersch,  one  essential  to  the  avoidance  of  subse¬ 
quent  contraction,  was  to  remove,  by  curetting,  the  superficial 
layer  of  granulations,  and  also  the  tough  cicatricial  edge  of  the 
ulcer.  A  bleeding  surface  was  thus  produced  on  which  many 
open  capillaries  existed,  and  which  was  very  favorable  to  im¬ 
mediate  union  of  the  grafts.  The  author  had  found  it  more 
rapid  and  convenient  to  use  the  knife.  With  a  sharp  scalpel 
an  incision  nearly  or  quite  through  the  true  skin  was  rapidly 
made  entirely  around  the  ulcer  just  outside  its  thickened  bor¬ 
der.  With  the  same  instrument  the  whole  area  included  by 
the  incision  was  shaved  off.  A  smooth,  bleeding,  healthy  sur¬ 
face  was  thus  produced.  This  surface  was  immediately  irri¬ 
gated  with  the  sterilized  salt  solution  and  compresses  of  steril¬ 
ized  gauze  were  placed  upon  it  to  control  bleeding. 

The  question  of  haemorrhage  at  this  stage  of  the  operation 
was  one  of  considerable  importance.  If  grafts  were  placed 
while  bleeding  still  went  on,  the  risk  of  failure  was  much  in¬ 
creased.  Accumulations  of  blood,  even  small  ones,  beneath  the 
grafts  frequently  induced  their  necrosis,  and  saturation  of  the 
dressings  with  blood  was  favorable  to  infection.  But  all  ulcer¬ 
ations,  and  particularly  those  on  the  lower  extremities,  when 
shaved,  were  liable  to  bleed  actively  for  a  long  time.  The  use 
of  Esmarch’s  constricting  band  was  found  to  entirely  dispose 
of  the  question  of  hemorrhage,  to  shorten  the  whole  operation 
greatly,  and  not  in  the  least  to  affect  the  vitality  of  the  grafts. 
When,  therefore,  the  situation  of  the  ulcer  was  such  that  the 
band  could  be  applied,  it  was  put  on  above  the  whole  field  of 
operation,  thus  rendering  the  process  a  nearly  bloodless  one.  The 
grafts  might  then  be  immediately  applied  and  the  dressings  put 
on.  The  grafts  themselves  illustrated  most  decidedly  the  origi¬ 
nality  of  the  Thiersch  method.  They  consisted  of  thin  slices  of 
skin,  removed  by  shaving  parallel  with  the  surface.  The  author 
had  found  a  broad  razor  with  a  very  delicate  edge  the  best  instru¬ 
ment  for  this  purpose.  The  most  convenient  points  from  which 
to  take  the  grafts  were  the  front  and  outer  part  of  the  thigh 
and  the  outer  surface  of  the  upper  arm.  Taking  the  razor,  the 
operator  wet  it  in  the  salt  solution,  and,  applying  the  edge  at 
the  most  distant  part  of  the  stretched  skin,  with  a  rapid  sawing 
motion  toward  himself  shaved  off  as  thin,  long,  and  wide  a 
shaving  as  he  could.  Four  or  five  inches  in  length  and  an  inch 
m  width  were  about  the  dimensions  of  a  first-rate  graft.  The 
grafts  might  or  could  be  of  a  variety  of  thicknesses,  but  no 
graft  would  do  well  that  was  thick  enough  to  include  fat  upon 
its  lower  surface.  As  it  was  being  cut  the  graft  piled  up  on  the 
razor.  After  it  was  separated  from  the  skin,  a  few  drops  of 
the  salt  solution  should  be  dropped  on  it,  and  the  razor  be  im¬ 
mediately  carried  to  the  edge  of  the  surface  to  be  covered. 
With  a  probe,  one  end  of  the  graft  was  then  teased  off  the  razor  ' 


to  the  raw  surface,  and  while  it  was  held  there  the  razor  could 
be  slipped  from  under  it  across  the  surface  so  as  to  unfold  the 
graft  and  deposit  it  in  place.  The  graft  could  then  be  readily 
adjusted  with  two  probes.  It  should  be  so  placed  that  its  edge 
would  follow  up  the  perpendicular  edge  of  the  prepared  sur¬ 
face  and  reach  very  slightly  on  to  the  uncut  skin.  In  that  man¬ 
ner  graft  after  graft  was  placed,  great  care  being  taken  that 
the  edges  were  in  neat  apposition  to  one  another,  and  were  at 
no  point  folded  under.  From  time  to  time  a  little  salt  solution 
should  be  sprinkled  on  the  grafts  already  placed  to  prevent  their 
becoming  too  dry,  which  would  destroy  their  vitality.  Strips 
of  Lister  protective  or  of  thin  rubber  tissue,  about  an  inch  wide 
and  long  enough  to  a  little  more  than  cross  the  grafted  surface, 
should  then  be  laid  on  like  shingles,  overlapping  one  another 
over  the  entire  area.  These  strips,  previously  sterilized  in  bi¬ 
chloride  or  carbolic-acid  solution,  just  before  using  should  be 
drawn  through  the  salt  solution.  They  should  be  gently  pressed 
on  the  giafts,  and  then  covered  with  some  soft  sterilized  mate¬ 
rial,  such  as  a  compress.  This  substance  should  be  wet  in  the 
salt  solution  and  piled  up  over  the  protective;  over  this  again 
a  large  piece  of  protective  or  rubber  tissue  should  be  applied  to 
prevent  rapid  evaporation,  and  finally  a  well-applied  gauze 
bandage.  The  surface  from  which  the  grafts  were  taken  did 
well  under  the  salt  solution.  After  wetting  the  surface,  the 
part  was  completely  covered  with  rubber  tissue  and  dressed 
with  sterilized  gauze.  1  his  method  of  dealing  with  the  denuded 
surface  had  given  entire  satisfaction. 

The  variety  of  lesions  to  which  Thiersch’s  method  was 
adapted  was  very  large.  It  included  all  ulcerations  upon  any 
part  of  the  external  surface.  Those  not  familiar  with  the 
method  would  be  surprised  to  see  how  perfectly  and  success¬ 
fully  these  grafts  could  be  applied  to  the  surfaces  produced  by 
extensive  operations  for  the  removal  of  malignant  and  other 
tumors— to  any  raw  surface,  in  fact,  which  could  not  be  cov- 
ei  ed  by  the  adjacent  skin.  It  was  astonishing  to  see  the  variety 
of  tissue  to  which  the  grafts  would  adhere  firmly.  Muscle, 
fascia,  cartilage,  and  even  bone  might  all  be  successfully  grafted. 
The  most  favorable  surface  was  a  clean  muscular  one,  and  the 
least,  the  surface  of  compact  bone. 

In  one  case,  after  the  removal  of  an  extensive  carcinoma 
of  the  face,  a  large  area  of  lower  jaw  was  completely  bared. 
Grafts  laid  over  this  surface  had  adhered  almost  perfectly 
throughout,  and  at  the  end  of  a  week  those  that  covered  the 
bone  were  found  to  be  soundly  attached  to  it.  In  another  case 
a  surface  several  inches  in  diameter  on  the  back  of  the  forearm 
included  a  number  of  extensor  tendons.  The  grafts  applied 
were  more  than  usually  successful,  and  complete  healing  was 
rapidly  attained.  The  breast  cases  were  of  special  interest,  as 
entire  liberty  could  be  taken  in  thorough  removal  of  the  dis¬ 
ease,  for  the  denuded  surface  could  be  covered  without  resort¬ 
ing  to  any  plastic  operation.  Thiersch  advised  that  the  gauze 
placed  immediately  over  the  protective  should  be  kept  con' 
stantly  moist  with  salt  solution,  and  said  that  to  effect  this  it 
was  necessary  to  moisten  the  gauze  every  four  hours.  As  this 
was  very  laborious,  the  author  had  extended  the  time  to  once 
in  two  days,  and  the  cases  treated  in  this  manner  had  done 
very  well.  At  the  end  of  forty-eight  hours  the  dressings  were 
all  removed  except  the  protective,  which  lay  next  to  the  grafts. 

A  fresh  wet  dressing  was  applied  and  changed  again  after  two 
•lays.  By  that  time  there  was  usually  some  formation  of  pus, 
as  it  was  unusual  for  a  case  to  go  on  a  whole  week  writhout 
some  suppuration.  It  should  be  carefully  removed  and  fresh 
dressing  applied.  It  was  the  author’s  practice  to  leave  the 
protective  in  place  from  ten  to  fourteen  days,  as  the  too  early 
application  of  a  dry  dressing  destroyed  the  vitality  of  the  grafts. 
The  author  then  reported  twenty-five  cases  which  represented 


444 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mkd.  Joor., 


a  considerable  variety,  a9  regarded  both  the  size  and  the  char¬ 
acter  of  the  surface  grafted.  The  length  of  time  occupied  in 
attaining  sound  healing  had  varied  from  a  week  to  two  months. 
In  regard  to  the  permanency  of  the  grafts,  his  experience 
showed  it  to  be  remarkably  good.  While  there  was  no  con¬ 
tention  made  that  Thiersch’s  grafting  would  prevent  the  return 
of  malignant  disease,  it  was  certainly  much  to  be  desired  that 
after  all  operations  for  malignant  disease  the  wounds  should  be 
healed  at  the  earliest  possible  moment,  and  the  application  of 
the  method  would  not  fail  to  convince  one  of  its  great  value. 
A  number  of  patients  were  then  presented  for  inspection. 

Dr.  L.  A.  Stimson’s  experience  with  the  method  was,  he 
said,  comparatively  limited.  He  admitted  having  always  felt  a 
certain  want  of  confidence  in  it  until  he  had  learned  of  Dr. 
McBurney’s  recent  successes.  Since  then  he  had  employed  it 
and  had  got  some  good  results.  His  general  experience  with 
the  employment  of  the  method  for  the  treatment  of  ulcers  was 
that,  while  healing  was  often  prompt,  there  existed  a  tendency 
to  return  of  the  trouble.  He  believed,  however,  that  in  cases 
in  which  large  areas  of  surface  were  of  necessity  exposed,  with 
great  loss  of  substance,  the  method  was  destined  to  take  the 
place  of  plastic  operations.  In  inoperable  cases  of  malignant 
disease  in  which  much  destruction  of  substance  existed  he  had 
essayed  the  use  of  grafts  upon  the  freshened  surfaces,  but  so  far 
without  success.  He  thought  if  later  experience  showed  that 
this  could  be  satisfactorily  done  it  would  be  a  most  desirable 
application  of  the  method. 

Dr.  H.  Knapp  explained  that  he  had  witnessed  grafting  in 
Thiersch’s  clinic.  In  his  own  practice  it  was  successful  enough 
in  operation  upon  the  upper  eyelid,  but  not  so  much  so  on  the 
lower.  The  drawback  was  the  enormous  shrinkage  which  fol¬ 
lowed.  It  was  his  custom  to  adopt  Wolfe’s  method. 

Dr.  P.  A.  Morrow  said  that  he  had  used  much  thicker  grafts 
than  the  mere  superficial  layer  of  skin.  He  had  taken  grafts 
that  included  the  entire  derma  and  subcutaneous  tissue.  He 
had  recently  thus  repaired  a  scar  of  long  standing  upon  a  pa¬ 
tient’s  scalp.  He  had  used  a  small  punch  or  trephine  and  had 
taken  buttons  of  material  from  the  opposite  side  and  trans¬ 
planted  them  into  incisions  in  the  scar  tissue,  fitting  them  with 
mathematical  accuracy.  Perfect  union  had  resulted  within  a 
week.  No  dressings  were  used  except  gutta-percha  over  the 
site  of  the  operation.  Then  he  had  taken  portions  of  scalp  a 
quarter  of  an  inch  thick  from  another  individual.  These  also 
had  united  within  a  week,  no  suppuration  ensuing.  The  new 
grafts  had  all  continued  to  bear  hairs  luxuriously.  It  was  usu¬ 
ally  difficult  to  obtain  such  material.  He  did  not  think  that  any 
tissue  had  ever  been  previously  grafted  to  produce  growth  of 
hair.  Such  grafts  had  hitherto  not  been  taken  deep  enough  to 
include  the  essential  elements  of  hair  growth.  In  the  experiments 
he  had  thus  made  there  had  been  no  indication  of  the  breaking 
down  of  tissue.  He  thought  the  method  he  had  described  would 
have  a  range  of  applicability  in  such  cases  as  circumscribed 
lupus,  moles,  warty  growths,  and  so  on.  In  the  case  he  had  de¬ 
scribed  it  had  been  almost  impossible  to  discover  the  line  of  de- 
markation  after  healing.  Of  course  he  had  not  neglected  the 
use  of  antiseptic  precautions,  such  as  the  use  of  bichloride  and 
carbolic  acid. 

Dr.  Bulkley  objected  to  Thiersch’s  method  on  the  ground 
that  the  skin  which  covered  the  ulcer  was  of  such  thinness  as 
to  breakdown  readily.  He  also  thought  that  if  the  whole  thick¬ 
ness  of  the  skin  was  used  a  better  result  would  be  obtained. 
Reverdin’s  method  had  proved  very  satisfactory  in  his  practice. 

Dr.  McBurney  said  that  all  the  methods  that  had  been  men¬ 
tioned  had  their  special  applications.  The  transplantation  of 
buttons  of  skin  seemed  a  very  valuable  plan,  but  of  course  such 
grafts  could  not  be  used  over  surfaces  eight  or  ten  inches  in  di¬ 


ameter  or  on  ulcerated  areas.  He  thought  no  method  could 
equal  Thiersch’s  in  applicability  to  a  wide  range  of  require¬ 
ments.  ■ 

MEDICO-CI1IRURGICAL  SOCIETY  OF  MONTREAL. 

Meeting  of  October  3 ,  1890. 

The  President,  Dr.  George  Armstrong,  in  the  Chair. 

A  Case  of  Hodgkin’s  Disease.— Dr.  R.  L.  MacDonnerl  ex¬ 
hibited  a  young  man,  aged  twenty-five,  a  freight-checker,  who 
was  the  subject  of  Hodgkin’s  disease.  Up  to  four  years  ago  the 
patient  had  enjoyed  good  health,  but  at  about  that  time  he  be- 
ran  to  suffer  from  a  severe  and  prolonged  attack  of  what  was 
called  bronchitis.  There  were  severe  attacks  of  dyspnoea,  which 
came  on  on  exertion  and  when  he  was  at  rest,  and  cough  was 
very  severe  and  brassy.  He  made  a  good  recovery  and  con¬ 
tinued  well  until  two  years  ago,  when  he  began  to  notice  the 
presence  of  lumps  in  his  neck.  These  gradually  increased  in  size 
and  number.  Two  months  ago  the  breathing  became  seriously 
embarrassed,  and  suffocative  attacks  of  the  severest  kind  oc¬ 
curred,  especially  when  he  was  in  the  recumbent  posture.  In 
the  beginning  of  August  he  presented  himself  at  the  Montreal 
General  Hospital  suffering  from  attacks  of  dyspncea  and  from  a 
brassy  cough.  On  August  11th  a  chain  of  glands  was  removed 
from  the  front  of  the  trachea.  These  were  found  to  extend  very 
deep  into  the  chest  and  were  thought  to  be  continuous  with 
other  enlarged  glands  in  the  mediastinum.  He  made  a  good  re¬ 
covery  from  the  operation,  and  since  then  he  had  not  suffered 
from  any  attacks  of  dyspnoea,  though  his  breath  was  short  on 
exertion  and  he  still  suffered  from  cough.  He  remembered  that 
frequently  when  he  was  a  boy  there  were  large  lumps  in  the 
arm-pit.  Epistaxis  had  been  frequent  during  the  last  six  months. 
There  was  no  history  of  any  venereal  disease.  The  glands  in 
the  left  side  of  the  neck  were  all  enlarged,  especially  those  situ¬ 
ated  behind  the  sterno-mastoid.  They  were  prominent,  distinct 
from  each  other,  loosely  attached,  and  of  firm  structure.  There 
were  two  or  three  enlarged  glands  in  each  axilla,  but  none  in 
the  groin.  The  spleen  was  somewhat  enlarged,  but  was  not 
palpable  below  the  ribs.  The  liver  was  of  normal  size.  Ex¬ 
amination  of  the  urine  yielded  a  negative  result.  The  skin  gen¬ 
erally  was  clammy,  but  always  on  the  left  side  of  the  forehead 
and  face  there  was  very  free  perspiration.  The  left  pupil  was 
much  larger  than  the  right.  Physical  examination  of  the  heart 
and  lungs  revealed  nothing.  The  temperature  in  the  afternoon 
had  generally  been  1°  or  P5°  above  normal.  The  pulse  was  al¬ 
ways  between  100  and  110.  No  member  of  the  family  had  ever 
suffered  from  enlarged  glands.  There  wTas  a  large  excess  of 
white  cells  in  the  blood.  For  the  last  month  Fowler’s  solution 
had  been  taken  regularly,  with  an  apparently  good  result. 
About  a  fortnight  ago  the  patient  had  a  severe  syncopal  attack. 

After  the  members  of  the  society  had  fully  examined  the 
patient  Dr.  MaoDonnell  stated  that  the  diagnosis  was  no  mat¬ 
ter  of  doubt.  The  history  of  indolent  enlargement  of  the  glands 
extending  along  the  course  of  the  great  vessels  following  the 
route  described  by  Hodgkin,  involving  first  the  cervical  and 
then  traveling  downward,  together  with  the  altered  composi¬ 
tion  of  the  blood  and  the  enlargement  of  the  spleen,  combined 
to  complete  the  clinical  picture.  But  the  most  interesting  point 
in  the  case  was  the  interference  with  the  cervical  sympathetic, 
as  was  shown  by  the  dilated  pupil,  the  unilateral  sweating  of 
the  face,  and  the  accelerated  pulse.  Interference  with  car¬ 
diac  innervation  probably  accounted  for  the  attacks  of  syncope. 

Dr.  H.  S.  Birkett  had  had  the  patient  under  his  care  pre¬ 
viously  to  his  admission  into  the  Montreal  General  Hospital. 
He  had  examined  him  for  the  first  time  on  the  6th  of  June  last, 
when  he  complained  of  hoarseness,  which  had  been  present  for 


Oct.  18,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


445 


the  preceding  two  weeks.  There  was  also  considerable  dysp¬ 
noea.  Laryngoscopic  examination  proved  the  presence  of  small 
superficial  ulcers  situated  one  on  the  middle  third  of  each  vocal 
cord  and  directly  opposed  to  each  other.  The  base  of  each 
ulcer  was  pale  and  the  surrounding  tissue  slightly  hypenemic. 
The  pharynx  was  decidedly  anaemic.  The  lymphatic  glands  in 
the  neck  were  found  to  be  enlarged,  especially  those  about  the 
sterno-mastoid,  and  so  were  the  three  lobes  of  the  thyreoid. 
Thinking  that  this  was  a  case  of  tuberculosis  with  laryngeal 
manifestations,  Dr.  Birkettliad  examined  the  lungs,  but  a  careful 
examination  failed  to  reveal  any  lesion.  The  temperature  was 
slightly  elevated  (100°)  and  the  pulse  96.  This,  in  conjunction 
with  the  foregoing  laryngeal  condition,  had  led  him  to  regard 
the  case  as  one  of  localized  tuberculosis,  due  probably  to  a 
caseating  degeneration  going  on  in  the  enlarged  glands  in  the 
neck ;  but,  in  order  to  have  more  satisfactory  proof,  the  sputum 
was  examined  by  Dr.  Wyatt  Johnston,  who  reported  absence 
of  both  tubercle  bacillus  and  elastic  tissue.  The  laryngeal  con¬ 
dition  was  then  regarded  as  one  of  chronic  inflammation  in 
which  superficial  ulceration  had  taken  place.  Before  the  report 
of  the  sputum  was  received  the  case  was  treated  as  one  of  tu¬ 
berculosis,  and  lactic  acid  of  varying  strength  was  used.  The 
ulcers  having  healed  rapidly,  Dr.  Birkett  had  thought  he  had 
cured  a  case  of  tuberculosis  of  the  larynx,  but  the  result  of  the 
examination  of  the  sputum  put  this  idea  to  one  side.  About 
the  1st  of  August  the  dyspnoea  began  to  increase,  and  laryngo¬ 
scopic  examination  showed  that  there  was  pressure  on  the  an¬ 
terior  wall  of  the  trachea,  due  undoubtedly  to  an  enlarged  gland 
situated  on  the  middle  lobe  of  the  thyreoid.  As  the  dyspnoea 
continued  to  increase,  surgical  interference  was  advised. 

Dr.  Wesley  Mills  thought  the  case  was  one  that  seemed  to 
teach  some  physiology,  or  at  all  events  to  illustrate  some  of  the 
latest  conclusions  of  that  science.  Was  the  disease  of  the  glands, 
together  with  the  symptoms  referable  to  the  iris  and  sweat 
glands,  consequent  on  a  disease  of  the  nervous  system  express¬ 
ing  itself  through  the  sympathetic  nerves,  or  did  they  all  arise 
from  pressure  or  irritation  of  the  sympathetic  by  the  enlarged 
glands?  Believing  as  he  did  that  the  whole  function  of  nutri¬ 
tion  was  under  the  influence  and  direction  of  the  nervous  sys¬ 
tem,  he  would  not  exclude  the  lymphatic  glands  and  other 
blood-forming  organs.  In  this  instance,  however,  it  was  possi¬ 
ble  to  explain  the  dilatation,  the  localized  sweating,  and  the 
rapid  action  of  the  heart  by  irritation  of  the  sympathetic.  The 
first  and  second  could  be  imitated  experimentally,  and  it  had 
lately  been  shown  by  himself  and  others  that  the  accelerator 
nerves  of  the  heart  had  a  definite  course  in  most  animals.  They 
were  given  off  either  from  the  first  thoracic  or  from  the  two 
lower  cervical  ganglia.  Accelerator  fibers  ran  in  the  vagus  also. 
Possibly  the  syncope  that  had  occurred  had  been  due  to  cardiac 
exhaustion  from  overaction  of  the  sympathetic,  rather  than  to 
cardiac  inhibition  proper.  It  was  likely  that  the  most  impor¬ 
tant  of  the  accelerator  branches  in  man  were  given  off  from  the 
middle  cervical  ganglion. 

Dr.  SnEpnERD  drew  attention  to  the  shape  of  the  patient’s 
neck,  which  he  thought  was  peculiar  to  Hodgkin’s  disease,  and 
described  briefly  the  operation  of  removing  the  glands  from  the 
front  of  the  trachea,  which  he  had  found  a  very  difficult  under¬ 
taking.  The  chain  of  glands  had  extended  so  deep  that  at  the 
bottom  ot  the  incision  the  transverse  arch  of  the  aorta  could  be 
felt. 

Fragilitas  Ossium,— Dr.  Roddick  exhibited  a  boy  of  thir¬ 
teen  who  had  been  the  subject  of  twenty-seven  fractures  of  the 
lower  extremity.  The  first  fracture  was  of  the  right  thigh  and 
occurred  when  the  boy  was  a  year  old.  Union  took  place  after 
each  tracture  with  abundant  new  growth  of  bone,  but  the  more 
recent  fractures  refused  to  unite  readily,  and  at  present  a  false 


joint  existed  in  the  middle  of  the  left  femur.  The  fractures 
were  produced  by  very  slight  violence  and  in  most  instances 
were  quite  painless.  The  cause  of  this  condition  could  not  be 
ascertained.  The  family  history  was  very  good.  The  brothers 
and  sisters  of  the  patient  were  in  excellent  health.  Dr.  Rod- 
dick  proposed  amputation,  as  both  legs  were  utterly  useless  and 
atrophied  to  an  extreme  degree. 

Exhibition  of  Patients  on  whom  Osteotomy  had  been 
performed  • — Dr.  James  Bell  showed  two  children  on  whom, 
he  had  operated  for  the  relief  of  genu  valgum  and  for  the  oppo¬ 
site  condition  of  bow-legs.  The  result  had  been  excellent.  In 
both  patients  the  legs  had  been  perfectly  straightened.  Their 
histories  he  related  as  follows: 

Case  I. — A  healthy,  strong  boy,  five  years  and  a  half  old, 
was  one  of  a  family  of  several  children  all  of  whom  had  suffered 
from  rickets  and  subsequent  bony  deformities,  which,  however, 
bad  all  been  fairly  well  outgrown  and  had  not  required  opera¬ 
tive  or  other  treatment.  The  patient  had  suffered  from  rickets 
when  two  years  and  a  half  of  age,  and,  on  admission  into  the 
hospital  (nearly  three  years  later),  presented  marked  deformity 
of  all  the  long  bones,  the  most  conspicuous  deformity  being  a 
very  pronounced  condition  of  genu  valgum,  so  that  the  knees 
completely  overlapped  in  walking.  On  the  5th  of  May,  1890, 
this  deformity  was  corrected  by  a  double  osteotomy  by  Mac- 
ewen’s  method.  On  section,  the  bones  were  found  to  be  ex¬ 
ceedingly  bard  and  brittle.  No  bad  symptoms  followed,  and 
the  boy  now  walked  without  any  apparent  deformity. 

Case  II. — A  boy,  aged  three  years  and  a  half,  was  brought 
to  the  hospital  with  very  marked  bow-legs.  All  the  long  bones 
were  deformed,  but  the  tibiae  and  fibulae  most  of  all.  There 
was  great  anterior  convexity  of  the  lower  third  of  the  tibiae. 
Double  linear  osteotomy  with  section  of  both  Achilles  tendons 
was  done  on  the  1st  of  June.  On  section,  the  bones  were  very 
soft  and  the  deformities  easily  corrected.  No  bad  symptoms 
followed  and  the  child  now  walked  perfectly  and  without  evi¬ 
dent  deformity.  This  child  had  been  well  and  strong  and  had 
straight,  well-formed  limbs  until  she  was  eighteen  months  old) 
when  she  became  ill.  The  history  was  a  typical  one  of  rickets. 
She  became  unable  to  walk  for  a  time,  and  when  she  was  re¬ 
covering,  the  bony  deformities  occurred. 

Pathological  Specimens. — Dr.  Wyatt  Johnston  exhibited 
a  myoma  of  the  uterus  and  a  myosarcoma  of  the  uterus.  These 
specimens  were  exhibited  for  Dr.  Gardner.  The  first  had  been 
removed  from  a  patient,  twenty-five  years  of  age,  whom  he  had 
had  under  observation  several  years  before,  and  for  whom  he 
had  advised  removal  of  the  uterine  appendages.  The  tumor  was 
very  large  and  very  closely  adherent  to  the  structures,  from 
which  it  was  extremely  difficult  to  separate  it  without  causing 
severe  haemorrhage.  In  the  second  case  the  age  of  the  patient 
was  forty-two.  The  tumor  had  been  of  rapid  growth,  and  was 
removed  without  any  difficulty.  The  third  specimen  was  a 
fibro-cystic  tumor  of  the  ovary.  In  this  case  the  tumor  was  found 
to  be  freely  movable,  hard,  and  painful.  The  pelvis  was  filled 
with  an  immovable  mass.  Abdominal  section  was  performed 
by  Dr.  Shepherd,  who  found  the  tumor  covered  by  intestines 
and  intimately  adherent  to  the  adjacent  structures.  The  recov¬ 
ery  of  the  patient  had  been  uninterrupted.  The  fourth  speci¬ 
men  was  one  of  tuberculosis  of  the  heart.  It  was  from  the 
body  of  a  child  that  had  died  of  general  tuberculosis.  The  heart 
had  become  attacked,  as  was  shown  by  a  small  tubercular  nod¬ 
ule  in  one  of  the  aortic  valves. 

Sudden  Death  in  the  Course  of  Mild  Typhoid  Fever. — 
Dr.  MoGannon,  of  Brockville,  related  the  history  of  a  girl,  four¬ 
teen  years  of  age,  in  whose  family  there  were  other  cases  of 
fever,  but  who,  up  to  within  a  few  days  of  her  death,  had  been 
engaged  in  housework,  though  she  felt  ill.  She  was  feverish 


446 


NEW  IN  YEN  TIONS.— MISCELLANY. 


[N.  Y.  Med.  Jotjb., 


when  seen  by  Dr.  McGannon,  but  no  serious  symptoms  were 
present.  Sudden  death  occurred  by  syncope.  There  was  no 
autopsy. 


Uefo  Jnbcnftons,  etc. 


THE  UNIVERSAL  NEEDLE  FORCEPS. 

By  0.  G.  Pfaff,  M.  D., 

CLINICAL  LECTURER  ON  DISEASES  OF  WOMEN,  MEDICAL  COLLEGE  OF  INDIANA. 

The  Hagadorn  is  without  doubt  the  most  popular  needle  ever  in¬ 
vented,  and  it  has  been  also  heretofore  the  most  difficult  to  manipulate. 
The  very  few  forceps  which  can  be  used  at  all  with  these  needles  almost 
without  exception  compel  the  operator  to  hold  the  needle  at  an  exact 
right  angle  with  his  instrument.  It  is  maintained  by  some  that  nothing 
more  is  required.  In  most  instances  this  is  true,  but  the  demands  of 
the  exceptional  cases  are  imperative,  and  the  comfort  of  the  operator 
promotes  the  patient’s  welfare. 

The  ideal  needle  forceps  should  hold  any  kind  of  needle  whatever, 
of  any  shape  or  size,  in  any  position  which  the  operator  may  find 
most  convenient. 

I  have  devised  such  an  instrument,  which  is  made  by  Tiemann  & 
Co.,  of  New  York.  It  fulfills  all  the  indications.  By  means  of  it  I 
have  been  enabled  to  dispense  with  the  Peaslee  needle  in  laparotomy, 


and  thus  to  simplify  this  operation  by  a  gain  of  some  little  time.  I  hold 
the  properly  curved  Hagadorn  needle  directly  in  the  end  of  and  paral¬ 
lel  to  the  forceps,  introducing  it  like  a  Peaslee  needle,  carrying  it  on 
through  both  walls  and  out,  completing  each  suture  in  one  motion,  as  in 
other  operations. 

The  accompanying  cut  renders  a  detailed  description  of  the  instru¬ 
ment  unnecessary.  The  disc  for  receiving  the  needle  is  the  distinctive 
feature  of  the  instrument.  It  is  a  small  “  turn-table,”  with  an  excavated 
surface  to  accommodate  curved  needles,  and  square-cut  grooves  in  which 
rests  the  needle  when  grasped  for  action.  This  “  turn-table  ”  occupies 
the  extreme  point  of  the  lower  jaw,  while  a  copper  plate  fits  it  neatly 
from  above.  The  handles  are  of  vulcanized  rubber,  baked  into  the 
metal,  and  every  part  of  the  instrument  can  be  easily  removed  for  clean¬ 
ing,  thus  meeting  the  demands  of  antiseptic  surgery. 


ijutII  aitD. 


Certain  Causes  of  .Major  Pelvic  Troubles,  traceable  to  Minor  Gynae¬ 
cology. — At  a  recent  meeting  of  the  Philadelphia  County  Medical  So¬ 
ciety  Dr.  Joseph  Price  read  the  following  paper : 

With  the  present  popular  cry  of  “  conservatism,”  in  reference  to 
operation  in  cases  where  it  is  held  that  all  treatment  should  be  tried 
previous  to  real  surgical  interference,  it  is  worth  while  asking  whether 
this  preliminary  treatment  should  not  itself  be  abandoned  in  the  hands 
of  those  who  plead  most  pathetically  for  it.  Their  cry  is  not  a  scien¬ 
tific  plea,  but  in  most  instances  a  personal  bid  for  indulgence  while  they 
try  to  accomplish  something,  without  acknowledging  on  the  one  hand 
that  there  is  little  or  nothing  to  encourage  them  in  their  work,  so  far 
as  results  are  concerned ;  and  on  the  other,  that  there  are  abundant 


proofs  from  the  cases  that  have  come  out  from  under  their  hands,  with 
one  treatment  or  another,  that  manifold  really  major  surgical  affections 
arise  merely  from  treatment  recognized  as  orthodox  from  the  stand¬ 
point  of  minor  gynaecology.  So  far  as  my  own  experience  is  concerned, 
I  do  not  hesitate  to  put  minor  gynaecology  in  a  causal  relation  with  a 
vast  amount  of  the  necessary  major  pelvic  surgery  coming  under  my 
attention. 

First  among  these  causes  may  be  mentioned  the  Emmet  cervical 
operation.  Like  many  other  surgical  operations,  this,  when  first  ex¬ 
plained  by  its  distinguished  originator,  was  done  in  season  and  out,  by 
every  one,  without  the  least  considpration  of  its  contra-indications.  Very 
many  minor  tears  of  the  cervix,  in  which  a  cosmetic  effect  only  is  ob¬ 
tained  by  operation,  are  made  distinctly  worse  by  operative  interference. 
In  many  cases  the  pain  becomes  insufferable,  from  the  lighting  up  of  a 
dormant  or  unrecognized  pelvic  trouble,  and  operation  is  required  to 
undo  the  mischief  of  an  unnecessary  cervical  closure.  This  fact  has 
been  recognized  by  Emmet  himself,  and  he  has  counseled  the  careful 
selection  of  cases  in  order  to  escape  these  disastrous  results.  It  should 
be  set  down  that  where  there  is  pre-existing  pelvic  disease,  even  though 
slight,  no  cervical  operation  ought  to  be  tried  unless  absolutely  required 
by  the  condition  of  the  patient.  Another  operation  which  has  met  with 
much  approval  in  many  directions,  and  which  some  measure  of  success 
seems  to  follow  in  some  cases,  is  the  forcible  dilatation  of  the  cervix. 
It  is  clear  that  where  there  is  antecedent  inflammation  of  the  pelvic 
viscera — that  is,  of  the  genito-urinary  system — such  an  operation  as  sur¬ 
gical  dilatation  of  the  cervix  can  not  be  free  from  danger.  In  order  to 
relieve  dysmenorrhoea  by  this  procedure,  it  must  evidently  be  due  to 
stenosis  of  the  os  or  cervix.  The  question  here 
arises,  Can  it  be  told,  in  dysmenorrhoea,  wherein 
its  causes  lie  ?  Sometimes,  but  not  infallibly.  The 
fact  is,  that  in  many  women  where  a  stenosis  would 
be  diagnosticated,  there  is  no  difficulty  whatever 
attending  the  menstrual  flux.  This  being  the  case, 
it  is  evident  that  a  diagnosis  can  not  be  made  by 
simple  observation  without  a  careful  study  of  all  the 
symptoms.  Again,  in  many  women  the  causes  for 
this  condition  are  complex.  It  will  not  do  to  lose 
sight  of  this,  and  conclude  that  because  a  flexion  exists,  dilatation 
will  remedy  menstrual  pain.  It  is  to  be  remembered  that  if  there 
]s  co-existing  pelvic  inflammation,  dilatation  will  increase  it,  and, 
under  certain  conditions,  cause  it  if  absent.  Rapid  dilatation  of  the 
cervix  is  a  distinct  traumatism,  and  along  with  it  run  all  the  dangers 
incident  to  septic  absorption  that  attend  any  other  violent  procedure, 
and  where  traumatism  incident  to  natural  causes  is  confessed  to  be  the 
cause  of  so  much  subsequent  mischief,  it  ought  not  to  be  expected  that 
operative  injury  can  be  harmless.  This  conclusion,  reached  inferentially, 
has  been  abundantly  confirmed  practically  on  the  operative  table  by 
much  of  my  later  pelvic  work.  In  a  number  of  cases  with  a  history  of 
preceding  dilatation  the  after-operation  has  exhibited  an  inflammatory 
condition  of  affairs  as  complicated  as  any  other  in  my  experience.  Some 
of  the  dilatations  were  done  with  pre-existing  disease,  which  was  made 
worse  by  this  interference,  while  others  were  done  simply  to  relieve  the 
dysmenorrhoea,  and  resulted  in  the  establishment  of  a  complicated  sur¬ 
gical  disease  in  wdiich  operation  was  necessary  purely  to  save  life.  All 
in  all,  I  believe  that,  judged  simply  by  its  remoter  effects,  the  operation 
of  rapid  dilatation  is  a  dangerous  one,  and  residts  oftener  in  subsequent 
harm  than  in  lasting  good.  The  surgical  injury  to  the  cervix  is,  in 
many  of  these  cases,  more  pronounced  than  the  tears  of  the  cervix 
which  it  is  the  intention  to  remedy  by  Emmet’s  operation.  In  this  case 
there  is  operation  at  each  horn  of  the  dilemma,  and  the  results  are  often 
equally  bad  at  both.  Simple  closure  of  the  cervix  in  cases  of  pelvic 
disorder  almost  certainly  exacerbates  the  symptoms.  The  necessary  in¬ 
flammatory  action  set  up  in  the  suture  tract  is  transferred  along  the 
lymphatic  or  venous  channels  to  the  seat  of  the  earlier  inflammation ; 
this  is  lighted  up  anew,  and  goes  on  in  its  development  until  a  pelvic 
peritonitis  is  kindled  or  rekindled,  which  at  last  entails  a  major  opera¬ 
tion.  The  minor  gynaecologist,  as  such,  who  has  no  regard  for  or  ap¬ 
preciation  of  the  relation  of  the  commonly  advocated  general  closure  of 
perineal  and  cervical  tears  to  major  surgical  complications,  can  not  but 
be  a  great  factor  in  the  causation  of  the  same.  In  Pepper’s  System  of 


Oct.  18,  1890.] 


MISCELLANY. 


447 


Medicine ,  vol.  iv,  there  is  on  record  a  case  in  which  the  operator  hoped 
to  cure  a  pelvic  inflammation  by  the  derivative  effect  of  a  perineal  or 
cervical  operation.  Needless  to  say,  pelvic  operation  was  afterward 
done.  Such  a  cure  is  no  less  ridiculous  than  the  so-called  “faith ”  cure, 
and  is  certainly  more  actively  harmful. 

That  the  inconsiderate  use  of  the  uterine  sound  has  been  responsi 
ble  for  much  inflammatory  pelvic  trouble  is  scarcely  to  be  disputed. 
This  is  not  because  the  sound  is  of  itself  a  dangerous  instrument,  but 
because  it  is  put  into  the  hands  of  every  tyro  as  an  instrument  of  diag 
nosis.  If  used  at  all,  it  should  be  in  the  hands  of  those  with  whom 
its  application,  by  reason  of  their  skill,  will  be  exceptional,  not  usual, 
and  the  rule  should  be  that  in  the  hands  of  a  non-expert  it  should  be 
forbidden.  The  more  expert  and  experienced  the  specialist,  the  more 
rarely  will  the  instrument  be  required.  My  own  rule  is  that,  in  cases 
in  which  it  might  at  first  seem  indicated,  a  little  patience  and  diligence 
will  obviate  the  necessity  of  employing  it.  The  indiscriminate  use  of 
the  sound  and  electrode  is  the  most  serious  mechanical  objection  to  the 
employment  of  electricity.  Every  sitting  for  the  electrical  treatment  is 
prefaced  by  the  use  of  the  sound,  and  followed  necessarily  by  the  in 
troduction  of  an  electrode  of  some  form.  This  is  by  a  class  of  men 
who,  in  the  main,  have  had  no  previous  gynaecological  training  or  educa¬ 
tion  whatever.  In  such  hands  such  methods  can  only  be  harmful,  and 
we  are  now  reaping  the  fruits  of  their  work  in  a  class  of  pelvic  oper 
ations  not  surpassed  in  the  complications  presented.  Along  with  the 
sound  may  be  placed  the  curette  in  the  same  category.  Dilatation  and 
curetting  of  the  uterus  have  placed  to  their  credit  a  long  series  of  major 
operations. 

Another  class  of  cases  coming  under  this  head  are  those  in  which 
there  has  been  a  long  time  during  which  intra-uterine  applications 
have  been  made.  All  the  caustics  in  the  catalogue  have  at  one  time 
or  another  been  in  favor  as  cure-alls  in  intra-uterine  therapeutics — 
nitric  acid,  chromic  acid,  nitrate  of  silver,  and  the  rest.  For  a  woman 
to  have  undergone  a  routine  treatment  with  this  list,  and  to  have  es¬ 
caped  pelvic  inflammatory  trouble,  is  little  short  of  a  miracle.  A  care¬ 
ful  inquiry  into  many  of  the  cases  coming  under  my  care  directly  and 
indirectly  reveals  the  history  that  all  sorts  of  minor  procedures  were 
tried,  only  to  fail  and  apparently  hasten  the  necessity  for  operation.  I 
shall  refer  to  and  illustrate  these  points  by  the  citation  of  cases  in  the 
discussion. 


The  New  York  State  Medical  Association  will  hold  its  seventh  an¬ 
nual  meeting  in  the  Mott  Memorial  Hall,  No.  64  Madison  Avenue,  New 
York,  on  Wednesday,  Thursday,  and  Friday,  the  22d,  23d,  and  24th 
inst.,  under  the  presidency  of  Dr.  John  G.  Orton,  of  New  York.  The 
programme  includes  the  following  items:  An  address  in  medicine. 
Prognostics  in  Medicine,  by  Dr.  John  Cronyn,  of  Erie  Co. ;  The  Mimicry 
of  Animal  Tuberculosis  in  Vegetable  Forms,  by  Dr.  E.  F.  Brush,  of 
Westchester  Co. ;  A  New  Method  of  Surgical  Treatment  in  Certain 
Forms  of  Retro-displacements  of  the  Uterus  with  Adhesions,  by  Dr. 
A.  Palmer  Dudley,  of  New  York  Co.  ;  a  discussion  on  intracranial 
lesions  (to  be  opened  by  Dr.  W.  W.  Keen,  of  Pennsylvania,  with  a 
paper  on  The  Diagnosis  and  Treatment  of  Intracranial  Lesions,  pro¬ 
pounding  questions  under  the  following  divisions :  I.  Localization 
[cerebral  topography]  ;  II.  Nature  of  the  lesions  ;  III.  Indications  for 
operative  treatment ;  IV.  Technique  of  operation  ;  V.  Results.  Ques¬ 
tion  1.  What  are  the  present  means  of  localizing  intracranial  lesions? 
Question  2.  What  is  the  nature  of  the  chief  intracranial  lesions 
(hajmorrhage,  abscesses,  tumors),  and  how  can  they  be  discriminated  ? 
Question  3.  W  hat  are  the  indications  and  contra-indications  of  opera¬ 
tive  interference  in  cases  of  intracranial  lesions  ?  Question  4.  What 
are  the  best  modes  of  operating  in  cases  of  intracranial  lesions  ? 
Question  5.  W hat  are  the  immediate  and  also  the  remote  results 
of  operative  treatment  in  cases  of  incracranial  lesions  ?  These  ques¬ 
tions  wilt  be  discussed  by  Dr.  James  J.  Putnam,  of  Massachusetts; 
Dr.  Charles  K.  Mills,  of  Pennsylvania ;  Dr.  Donald  Maclean,  of  Michi¬ 
gan  ;  Dr.  John  B.  Roberts,  of  Pennsylvania ;  Dr.  Charles  McBurney, 
of  New  York  Co.;  Dr.  Frederic  S.  Dennis,  of  New'  York  Co.;  Dr. 
Stephen  Smith,  of  New  York  Co.;  Dr.  John  A.  Wyeth,  of  New 
"iork  Co. ;  Dr.  Joseph  D.  Bryant,  of  New  York  Co.;  and  Dr.  Thomas 
H.  Manley,  of  New  York  Co.) ;  Hypnotism,  by  Dr.  n.  Ernest  Schmidt, 


of  Westchester  Co.;  Retention  of  Urine  from  Prostatic  Obstruction— 
its  Nature,  Diagnosis,  and  Management,  by  Dr.  John  W.  S.  Gouley,  of 
New  York  Co. ;  The  Specific  Treatment  of  Typhoid  Fever,  by  Dr.  Gus- 
tavus  Eliot,  of  Connecticut;  an  address  in  surgery,  The  Ligature  of 
Arteries,  by  Dr.  Stephen  Smith,  of  New  York  Co.;  The  Death  Penalty. 
Does  the  Garrote  or  Hanging  ever  produce  Instantaneous  Unconscious¬ 
ness  ?  by  Dr.  George  E.  Fell,  of  Erie  Co. ;  The  Therapeutics  of  Exoph¬ 
thalmic  Goitre,  by  Dr.  E.  D.  Ferguson,  of  Rensselaer  Co. ;  The  Tech¬ 
nique  of  Laparo-hysterectomy,  with  Illustrative  Cases,  by  Dr.  Ely  Van 
de  Warker,  of  Onondaga  Co. ;  a  discussion  on  obstetrics  (to  be  opened 
by  Dr.  S.  B.  Wylie  McLeod,  of  New  York  County,  with  a  paper  pro¬ 
pounding  the  following  questions :  Question  1.  How  may  the  present 
prophylactic  measures  in  obstetrics  be  more  extended  and  applied? 
Question  2.  Is  the  present  technique  in  the  management  of  labor 
and  convalescence  in  accordance  with  sound  physiology  ?  Ques¬ 
tion  3.  To  what  extent  have  the  surgical  means  of  treatment  of 
labor  complications  been  successful,  or  should  these  complications 
and  the  process  of  repair  have  been  more  generally  left  to  nature  ? 
Question  4.  What  influence  would  a  more  advanced  obstetric  science 
have  on  the  biological  and  social  condition  of  the  race?  These  ques¬ 
tions  will  be  discussed  by  Dr.  Ira  B.  Read,  of  New  York  Co. ;  Dr. 
Henry  D.  Nicoll,  of  New  York  Co. ;  Dr.  William  McCollom,  of  Kings 
Co.;  Dr.  Joseph  W.  Stickler,  of  New  Jersey;  Dr.  George  T.  Har¬ 
rison,  of  New  York  Co. ;  Dr.  Timothy  J.  McGilicuddy,  of  New  York 
Co. ;  Dr.  Palmer  Dudley,  of  New  York  Co. ;  Dr.  William  II.  Robb, 
of  Montgomery  Co. ;  and  Dr.  Alfred  L.  Carroll,  of  New  York  Co.);  an 
address  in  obstetrics,  by  Dr.  Carlton  C.  Frederick,  of  Erie  Co. ;  an  ad¬ 
dress  on  The  Medicine  of  the  Classics,  by  the  Hon.  Charles  H.  Truax 
LL.D.,  of  New  York;  Expert  Medical  Testimony,  or  the  Physician  as 
a  Witness,  by  Dr.  Martin  Cavana,  of  Madison  Co.  ;  Some  Observations 
on  Bone  and  Skin  Grafting,  by  Dr.  Benjamin  M.  Ricketts,  of  Ohio ; 
Mental  Therapeutics,  by  Dr.  Henry  D.  Didama,  of  Onondaga  Co.  ;  Lep- 
rosy,  by  Dr.  Joseph  C.  Greene,  of  Erie  Co. ;  The  Curability  of  Pulmo¬ 
nary  Tuberculosis,  by  Dr.  Hermann  M.  Biggs,  of  New  York  Co.  ;  Pre¬ 
ventive  Medicine,  by  Dr.  Henry  C.  Van  Zandt,  of  Schenectady  Co.’;  The 
Use  and  Neglect  of  Bloodletting,  by  Dr.  Homer  0.  Jewett,  of  Cortlandt 
Co.;  A  Medico-legal  Study  of  Alcoholic  Daze,  Trance,  or  Hypnotism, 
by  Dr.  Simeon  Tucker  Clark,  of  Niagara  Co. ;  The  Psychical  Aspects  of 
Insanity,  by  Dr.  John  Shrady,  of  New  York  Co. ;  Tumors  of  the  Orbit 
and  Neighboring  Cavities,  by  Dr.  Charles  Stedman  Bull,  of  New  York 
Co. ;  Tesf  of  Dugas  in  Dislocation  of  the  Shoulder,  by  Dr.  Frederick 
W.  Putnam,  of  Broome  Co. ;  Early  Infant  Viability,  with  Management 
of  Cases,  by  Dr.  Henry  C.  Hendrick,  of  Cortlandt  Co. ;  Scarlet  Fever  in 
the  Puerperium  with  Cerebral  Haemorrhage  and  Hemiplegia,  by  Dr  C 
S.  Allen,  of  Rensselaer  Co. ;  Alcoholism  as  a  Vice,  and  as  a  Result  of 
Inherited  or  Acquired  Brain  Disease,  by  Dr.  Isaac  de  Zouche,  of  Fulton 
Co. ;  An  Office  Battery,  by  Dr.  William  H.  Robb,  of  Montgomery  Co. ; 
In  Abortion,  What  of  the  Placenta  after  the  Second  Stage,  by  Dr.  Dar¬ 
win  Colvin,  of  Wayne  Co. ;  Cysts  and  Cystic  Formations— their  Pathol¬ 
ogy,  Diagnosis,  and  Treatment,  by  Dr.  Thomas  H.  Manley,  of  New 
Lork  Co. ;  Functional  Disorders  of  the  Nervous  System  of  Women,  by 
Dr.  Timothy  J.  McGillicuddy,  of  New  York  Co. ;  The  Feeding  of  ’ In¬ 
fants,  by  Dr.  John  P.  Garrish,  of  New  York  Co. ;  and  A  Case  of  Crani¬ 
otomy,  with  Remarks,  by  Dr.  James  W.  Guest,  of  New  York  Co. 


Alcohol  and  Childhood.— “  We  most  decidedly  and  heartily  give  our 
support,”  says  the  lancet,  “to  the  doctrine  that,  as  a  rule,  children  and 
young  people  do  not  need  alcohol,  and  are  much  better  without  it 
Their  appetites  are  good,  their  cares  few,  and  the  more  simply  they  live 
the  better.  Anything  that  can  be  done  in  board  schools,  and  in  public 
schools  too,  for  that  matter,  likely  to  promote  a  thorough  and  intelli¬ 
gent  independence  of  alcohol,  should  be  encouraged.  But  it  should  be 
well  done.  The  more  moderate  and  medical  the  statement  of  the  case 
the  better.  Young  people  resent  intemperance  in  teetotalers  as  well 
as  in  other  people.  It  must  be  remembered,  too,  that  the  real  way  to 
make  children  temperate  is  by  setting  them  a  good  example  at  home. 
If  children  see  alcohol  produced  in  all  shapes,  and  at  all  hours,  and  for 
every  visitor  at  home,  or  if  they  are  sent  out  as  messengers  twice  or 
thrice  a  day  to  the  neighboring  ‘  public,’  all  the  teaching  of  the  schools 
will  go  for  nothing.” 


448 


MISCELLANY. 


[N.  Y.  Mkd.  Jock. 


The  Transfer  of  Public  Insane  Patients  to  State  Hospitals. — The 

statute  having  made  it  the  duty  of  the  president  of  the  State  Commis¬ 
sion  in  Lunacy  to  prescribe  regulations  governing  the  transfer  of  public 
insane  patients  from  their  homes  or  from  poor-houses  to  State  hospitals 
by  Superintendents  of'  the  Poor,  and  concerning  the  clothing  of  said 
patients,  he  has  issued  the  following  order : 

1.  That  all  County  Superintendents  of  the  Poor  or  town,  county,  or 
city  authorities,  before  sending  a  patient  to  any  State  hospital,  see  that 
said  patient  is  in  a  state  of  bodily  cleanliness  and  provided  wdth  the  fol¬ 
lowing  clothing,  to  wit :  (a)  One  full  suit  of  underclothing.  (b)  One 
full  suit  of  outer  clothing,  including  head  wear  and  boots  or  shoes. 

Between  the  months  of  November  and  April,  both  inclusive,  there 
shall  be  provided,  in  addition  to  the  foregoing,  suitable  overcoats  for 
the  men  patients  and  suitable  shawls  or  chaks  for  the  women  patients, 
also  gloves  or  mittens.  Considering  the  great  danger,  always  present, 
of  the  introduction  of  contagious  or  infectious  diseases  into  institutions 
where  large  numbers  of  people  are  congregated,  and  to  avoid,  so  far  as 
possible,  the  introduction  of  such  diseases  by  means  of  wearing  apparel, 
the  clothing  above  provided  for  must  in  all  cases  be  new. 

2.  In  traveling  by  rail,  patients  must  not  be  compelled  to  ride  in 
smoking  or  baggage  cars,  except  in  the  case  of  men  patients  who  may 
be  so  violent,  profane,  or  obscene  as  to  render  their  presence  in  ordi¬ 
nary  passenger  coaches  offensive.  If  any  portion  of  the  route  is  neces¬ 
sary  to  be  traversed  by  team,  a  covered  conveyance  should,  unless  im¬ 
possible,  be  provided.  The  shortest  practicable  route  should  be  se¬ 
lected  ;  the  hour  of  departure  should  be  timed,  so  far  as  possible,  so  as 
to  avoid  the  necessity  of  stopping  over  night  on  the  journey  and  so  as 
not  to  reach  the  hospital  at  an  unseasonable  hour.  Whenever  prac¬ 
ticable,  a  notice  in  advance,  by  writing  or  telegraph,  should  be  sent  to 
the  medical  superintendent  of  the  hospital  of  the  coming  of  the  patient. 
In  cases  of  violent  patients  a  sufficient  number  of  attendants  should  be 
provided  to  control  their  actions  without  resorting  to  the  use  of  me¬ 
chanical  restraints,  such  as  straps,  ropes,  chains,  hand-cuffs,  etc. ; 
quieting  medicines  should  not  be  given  to  such  patients  except  upon 
the  prescription  of  a  physician.  If  it  becomes  necessary  to  remain 
over  night  or  for  a  number  of  hours  at  a  station  on  the  route,  patients 
are  not  to  be  taken  to  jail,  police  station,  or  lock-up.  Food  in  proper 
quantity  and  quality,  and  at  intervals  not  exceeding  five  hours,  should' 
be  provided  for  patients,  but  no  alcoholic  beverages  must  be  given  un¬ 
less  upon  prescription  of  a  physician.  Opportunity  must  be  afforded  for 
attention  to  the  calls  of  nature,  and  the  rules  of  decency  must  be  ob¬ 
served.  In  case  of  the  employment  of  extra  attendants  in  conveying 
violent  patients,  care  must  be  taken  that  they  are  of  adult  age  and  of 
good  moral  character.  The  provisions  of  the  statute  which  require 
that  a  woman  attendant  shall  accompany  women  patients  when  taken 
to  State  hospitals  must  be  strictly  complied  with. 

3.  Any  violation  of  the  requirements  of  this  order  shall  be  prompt¬ 
ly  reported,  so  far  as  known  to  him,  by  the  medical  superintendent  of 
the  hospital  to  the  State  Commission  in  Lunacy. 

4.  This  order  shall  take  effect  on  the  1st  day  of  October,  1890. 

The  New  York  Academy  of  Medicine. — At  the  next  meeting  of  the 
Section  in  Ophthalmology  and  Otology,  on  Monday  evening,  the  20th 
inst.,  Dr.  M.  L.  Foster  will  read  a  paper  on  Cyst  of  the  Lacrymal  Gland, 
Mr.  James  Prentice  will  show  Prentice’s  prismometer,  and  Dr.  H.  D. 
Noyes  will  open  a  discussion  on  Hmmorrhage  into  the  Vitreous  follow¬ 
ing  Operations. 

At  the  next  meeting  of  the  Section  in  Theory  and  Practice  of  Medi¬ 
cine,  on  Tuesday  evening,  the  21st  inst.,  Dr.  G.  R.  Lockwood  will  read 
a  paper  on  Acute  Hsemorrhagic  Purpura. 

At  the  next  meeting  of  the  Section  in  Obstetrics  and  Gynaecology, 
on  Thursday  evening,  the  23d  inst.,  Dr.  Ralph  Waldo  will  read  a  paper 
on  Pregnancy  complicated  by  Circumuterine  Inflammatory  Deposits, 
and  Dr.  G.  M.  Edebohls  will  read  a  paper  on  Exploratory  Puncture  of 
the  Female  Pelvic  Organs. 

At  the  next  meeting  of  the  Section  in  Laryngology  and  Rhinology, 
on  Tuesday  evening,  the  28th  inst.,  Dr.  C.  H.  Knight  will  read  a  paper 
entitled  A  Sequestrum  removed  from  the  Nasal  Fossa  byRonge’s  Meth¬ 
od,  and  Dr.  D.  Bryson  Delavan  will  read  a  paper  on  The  Surgical  Treat, 
ment  of  Tubercular  Laryngitis. 


Prostatic  Hypertrophy. — In  a  paper  presented  to  the  Mississippi 
Valley  Medical  Association  at  the  recent  meeting  in  Louisville,  Dr. 
William  T.  Belfield,  of  Chicago,  collects  133  cases  of  operations  upon 
the  hypertrophied  prostate,  including  8  of  his  own,  as  follows  :  41  by 
perineal  incision,  mortality  9  per  cent. ;  88  by  suprapubic  cystotomy* 
mortality  1 6  per  cent.  ;  4  by  combined  perineal  and  suprapubic  incis¬ 
ion,  none  fatal. 

In  fifty-six  of  these  cases  the  essential  facts  before  and  after  opera¬ 
tion  are  furnished.  The  patients  had  been  the  subjects  of  cystitis  and 
dependent  upon  the  catheter  for  periods  varying  from  one  to  ten  years. 
In  all  the  cystitis  was  cured  ;  in  thirty-eight  (two  thirds)  voluntary  uri¬ 
nation  wras  restored  and  continued  during  the  time  of  observation,  six 
months  to  two  years  and  a  half ;  in  eighteen  this  function  was  not  re¬ 
covered. 

Fifteen  of  these  fifty-six  cases  were  complicated  with  stone ;  ex¬ 
cluding  these — since  it  might  be  objected  that  the  cure  resulted  rather 
from  the  calculus  extraction  than  from  the  prostatic  operation — there 
remained  forty-one  cases  of  uncomplicated  prostate  operations ;  of 
these,  thirty-two  patients  (four  fifths)  recovered  the  power  of  urination* 
and  in  nine  this  ability  was  not  recovered. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  caUed  to  the  follow¬ 
ing : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  ( 1 )  when  a  manuscript  is  sent  to  this  jour¬ 
nal ,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles, 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be- 
published  as  promptly  as  our  other  engagements  will  admit  of — we- 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  ( 3 )  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no> 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors ,  are 
not  suitable  for  publication  in  this  journal ,  either  because  they  are 
too  long ,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases ,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters ,  whether  intended  for  publication  or  not ,  must  contain  the 
writer's  name  and  address ,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter ,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal ,  will  be  answered  by 
number ,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential,  lie  can¬ 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  prof  cssion  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and , 
if  the  space  at  our  command  admits  of  it ,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL 


JOURNAL,  October  25,  1890. 


#rt0tnnl  Commumrations. 


A  CONTRIBUTION  TO 

THE  STUDY  OF  APPENDICITIS* 

By  LEWIS  A.  STIMSON,  M.  D., 

ATTENDING  SURGEON  OF  THE  NEW  YORK  AND  BELLEVUE  HOSPITALS  • 
PROFESSOR  OF  SURGERY  IN  THE  MEDICAL  DEPARTMENT  OF 
THE  UNIVERSITY  OF  THE  CITY  OF  NEW  YORK. 

Inflammation  of  the  vermiform  appendix  is  an  affection 
that  has  received  especial  attention  during  the  last  few 
years  an  attention  that  has  greatly  increased  the  extent  and 
accuracy  of  our  knowledge  of  its  various  forms  and  mode 
of  development,  and  our  ability  successfully  to  deal  with  it. 
A  large  part  of  this  advance  in  our  knowledge  of  the  sub¬ 
ject  is  the  result  of  the  labors  of  American  physicians  and 
surgeons,  and  one  of  the  most  notable  papers  that  have  ap¬ 
peared  of  late  upon  this,  or  indeed  upon  any  surgical  topic, 
is  the  one  read  by  our  associate,  Dr.  McBurney,  before  this 
society,  November  13,  1889,  under  the  title  of  Early  Opera¬ 
tive  Interference  in  Disease  of  the  Vermiform  Appendix, 
and  published  in  the  New  York  Medical  Journal ,  Decem¬ 
ber  21,  1889. 

It  was  not  merely  that  he  presented  an  important  num¬ 
ber  of  cases  successfully  operated  upon  in  the  early  stage, 
and  a  number  much  larger  than  had  been  reported  by  any 
other  surgeon,  but,  much  more  than  that,  he  presented 
new  and  important  information  concerning  the  pathological 
processes  of  the  early  stage,  the  varying  conditions  of  the 
appendix,  the  position  and  time  of  appearance  of  pus,  the 
relation  or  absence  of  relation  between  the  symptoms  and 
the  pathological  conditions,  and,  above  all,  pointed  out  the 
means  by  which  the  presence  of  the  disease  might  be  recog¬ 
nized  at  the  very  outset.  Perhaps  the  most  valuable  result 
of  the  publication  of  Dr.  McBurney’s  paper  has  been  the 
readiness  and  certainty  with  which  the  disease  is  now  rec¬ 
ognized,  and  the  wide  extension  that  has  been  given  to  this 
addition  to  our  diagnostic  resources.  This  is  shown  by  the 
great  increase  in  the  number  of  recognized  cases  and  in 
those  that  are  referred  to  surgeons  for  operation.  This  is 
strikingly  shown  by  a  comparison  of  recent  experience  with 
that  of  the  past.  When  Dr.  Sands  wrote  his  first  paper  on 
appendicitis,  eight  or  ten  years  ago,  he  mentioned  as  a  sur¬ 
prising  fact  that  he  had  seen  twenty-nine  cases  in  the  course 
of  the  preceding  twenty  years;  probably  some  of  us  have 
seen  nearly  an  equal  number  in  the  last  year.  As  there  is 
no  reason  to  suppose  that  the  affection  is  more  frequent  to¬ 
day  than  it  was  in  the  past,  the  inference  is  unavoidable 
that  formerly  many  cases  passed  unrecognized.  The  fatal 
cases  were  called  peritonitis  or  intestinal  obstruction;  the 
mild  ones  were  thought  to  be  gastritis,  or  gastro-enteritis,  or 
intestinal  colic. 

This  increase  in  the  number  of  recognized  cases  is  all 
the  more  valuable  because  it  is  not  merely  a  duplication  of 
past  experience,  but,  on  the  contrary,  is  made  up  of  cases 
observed  in  earlier  stages  and  under  different  conditions. 
For  this  reason,  and  because  of  the  need  of  establishing 

*  Read  before  the  New  York  Surgical  Society,  October  8,  1890. 


principles  of  treatment  based  upon  the  new  knowledge,  it 
is  desirable  that  recent  individual  experience  and  results 
should  be  made  known  in  order  that  enough  material  may 
be  at  our  disposal  to  permit  trustworthy  deduction  and  gen¬ 
eralization. 

I  desire,  therefore,  to  present  this  evening  a  report  of 
the  cases — twenty-one  in  number— that  have  come  under  my 
observation  since  November,  1889.  Four  of  the  thirteen 
operative  cases  have  been  previously  reported  to  the  society. 
For  convenience  of  reference,  the  cases  have  been  arranged 
m  groups  according  to  the  method  of  treatment  instead  of 
chronologically. 

Oases  not  operated  upon. 

Case  I.— John  E.,  thirty  years  of  age,  was  brought  to  the 
Chambers  Street  Hospital,  February  27,  1890.  Four  days 
previously  he  had  a  chill,  followed  by  pain  in  the  abdomen, 
persistent  nausea,  and  fever.  A  physician  had  seen  him  on 
the  third  day  and  found  his  temperature  10U7°.  No  move¬ 
ment  of  the  bowels  since  the  beginning  of  the  attack.  He 
had  had  a  similar  attack  two  or  three  years  previously.  On 
admission,  his  temperature  was  98°  in  the  rectum,  pulse  130 
and  weak,  abdomen  greatly  distended .  and  painful,  especially 
on  the  right  side;  patient  apathetic.  The  question  of  ap¬ 
pendicitis  was  raised  but  not  positively  answered.  The  pa¬ 
tient  s  condition  was  so  desperate  that  no  operative  measure 
was  deemed  justifiable,  except  an  enterotomy  for  the  relief  of 
the  (functional)  obstruction.  It  showed  the  small  intestine 
deeply  congested  and  largely  distended  to  a  point  six  inches 
above  the  ileo-csecal  junction;  below  that  point  it  was  empty; 
no  kink  or  mechanical  obstruction  was  seen.  The  contents  of 
the  intestine  escaped  freely  through  the  incision,  but  the  pa¬ 
tient  died  a  short  time  afterward— February  28th. 

The  autopsy  showed  general  peritonitis  without  liquid  or 
ibrinous  exudation,  the  appendix  deeply  congested  and  appar¬ 
ently  gangrenous  at  its  apex.  Microscopical  examination 
showed  catarrhal  inflammation  of  its  mucosa;  there  was  no 
perforation. 

Case  II.— Od  April  28,  1890,  I  was  called  by  Dr.  Wells,  of 
New  Rochelle,  to  see  Henry  R..  thirty  years  old,  who  had  been 
attacked,  April  23d,  with  violent  pain  in  the  right  iliac  fossa. 
The  diagnosis  of  appendicitis  was  made  and  the  pain  soon  re- 
ieved  by  morphine;  the  apparent  convalescence  had  been 
abi  uptly  interrupted  at  10  a.  m.,  April  28th,  by  a  recurrence  of 
die  pain,  so  severe  that  a  grain  and  a  half  of  morphine  Were 
administered  hypodermically  within  three  hours.  I  saw  him  at 
p.  m.  ;  he  had  then  no  pain  except  on  pressure,  was  cheerful, 
but  his  surface  was  dusky  and  cool,  his  lips  bluish,  his  pulse 
150,  and  his  rectal  temperature  105'5°,  although  in  the  mouth 
it  was  only  99-25°.  The  abdomen  was  tense  and  distended  ;  deep 
resistance  and  pain  on  pressure  in  the  right  iliac  fossa;  a •  soft, 
irregular  mass,  hard  and  tender  on  its  right  side,  could  be  felt 
through  the  rectum  behind  the  bladder.  The  patient  was  clear¬ 
ly  moribund,  and  died  four  hours  later. 

Case  III. — On  May  18th  I  was  called  to  Connecticut  to  see  a 
friend,  a  man  thirty  years  old,  who  had  been  ill  for  nearly  a 
month  with  constant  but  not  severe  pain  in  the  right  iliac  fossa, 
occasional  nausea,  and  some  fever.  I  found  him  free  of  fever 
but  very  weak,  with  marked  tenderness  and  slight  deep  indura¬ 
tion  at  a  point  midway  between  the  umbilicus  and  the  right 
anterior  superior  spine  of  the  ilium.*  For  a  few  days  previ- 

*  For  the  sake  of  brevity,  and  as  a  proper  recognition  of  the  value 
of  this  symptom,  I  shall  speak  of  this  point  as  “McBurney’s  point.” 


450 


[N.  Y.  Mei>.  Joub., 


S  TIMS  ON :  A  P  PEN  DIO  I TIS. 


ously  there  had  been  at  this  poiut  a  swelling  that  distinctly 
raised  the  anterior  abdominal  wall.  The  tenderness  persisted 
at  intervals  until  August,  and  was  increased  by  free  movements 
of  the  right  thigh. 

Case  IV.— James  H.,  aged  twenty-four,  was  attacked  May 
17th  with  nausea'  and  diffuse  abdominal  pain,  followed  by 
fever,  which  persisted  until  May  20th,  when  I  was  asked  to  see 
him.  There  was  marked  tenderness  on  pressure  at  McBurney’s 
point ;  temperature  100°.  There  was  a  clear  history  of  a  very 
sharp  attack,  diagnosticated  as  perityphlitis,  five  years  before. 
Having  in  view  the  possibility  of  an  operation,  I  sent  the  pa¬ 
tient  at  once  to  the  New  York  Hospital.  After  the  condition 
had  been  explained  to  him  he  desired  the  operation,  but,  as  he 
was  improving,  1  advised  delay;  the  next  day  he  was  much 
better,  and  shortly  afterward  was  discharged.  He  declared 
that  if  the  trouble  recurred  “he  would  have  that  thing  out  ’’; 
it  did  recur,  and  he  reappears  in  the  group  of  cases  treated  by 
laparotomy. 

Case  V. — Henry  D.,  aged  twenty-one,  was  admitted  to  the 
Chambers  Street  Hospital,  June  15,  1890,  complaining  of  pain 
in  the  abdomen  and  nausea.  The  McBurney  point  was  well 
marked;  no  deep  induration;  temperature,  101-5°.  He  was 
kept  in  bed  on  low  diet,  and  improved  so  rapidly  that  he  was 
discharged  in  three  days. 

Case  VI. — On  September  23,  1890,  I  was  asked  by  Dr.  Par¬ 
tridge  to  see  Mr.  H.  R.,  twenty-five  years  old,  who  had  been 
attacked  with  abdominal  pain  on  the  preceding  afternoon.  The 
pain  had  become  quite  severe  by  morning,  with  nausea  and  a 
■slight  chill  at  noon.  I  saw  him  at  3  p.  m.  Temperature,  101-75° ; 
pulse,  102;  abdomen  quite  tense  on  the  right  side  and  painful 
•on  pressure  at  and  below  McBurney’s  point.  No  recognizable 
induration.  He  had  had  two  similar  but  less  severe  attacks 
■within  the  preceding  ten  weeks. 

At  9  p.  m.  his  temperature  was  100-25°,  pulse  74.  The  fol¬ 
lowing  day  the  temperature  had  fallen  to  99°,  and  on  the  25th 
it  was  normal  and  the  tenderness  much  less.  He  was  kept  in 
bed  and  on  a  light  diet  for  six  days,  and  then  discharged.  There 
was  still  slight  tenderness  in  the  iliac  fossa  on  pressure. 

Case  VII. — James  G.,  about  forty  years  old,  while  under 
treatment  in  the  New  York  Hospital  for  a  compound  fracture 
of  the  arm,  had  a  rise  of  temperature,  nausea,  and  considerable 
abdominal  pain  ;  McBurney’s  point  well  marked.  The  follow¬ 
ing  day  the  fever  and  nausea  had  ceased;  the  local  tenderness 
had  diminished,  and  it  entirely  ceased  in  a  day  or  two. 

In  the  following  case  the  diagnosis  may  be  questioned. 

Case  VIII. — An  unmarried  lady,  thirty-two  years  old,  has 
been  practically  disabled  for  several  years  by  recurrent  attacks 
of  pain  in  the  abdomen,  especially  on  the  right  side,  accom¬ 
panied  by  nausea,  but  usually  without  fever.  Five  years  ago 
she  was  treated  by  an  eminent  gynaecologist  for  these  attacks, 
which  he  thought  might  be  due  to  an  ovaritis.  An  equally 
eminent  physician,  whom  she  subsequently  consulted,  diagnos¬ 
ticated  an  inflammation  of  the  ascending  colon  and  gave  her 
some  relief.  The  attacks  were  always  severe,  the  pain  begin¬ 
ning  in  the  right  iliac  fossa,  and  sometimes  radiating  up  the 
back  ;  they  lasted  for  days,  and  sometimes  for  weeks  with  less 
severity.  I  saw  her  in  August  during  an  attack  and  found  Mc- 
Burney's  point  perfectly  well  marked.  I  believe  it  to  be  a  case 
of  recurrent  appendicitis,  and  expect  that  before  long  an  opera¬ 
tion  will  demonstrate  it. 

Cases  treated  by  Operation.  Simple  Evacuation  of  an 

Abscess. 

Case  IX. — D.,  ten  years  old,  was  admitted  to  the  New 
York  Hospital  on  November  25,  1889.  Two  weeks  previously 
he  had  been  seized  with  severe  pain  in  the  right  iliac  fossa, 


nausea,  and  fever;  during  the  second  week  a  swelling  was  no¬ 
ticed  in  the  right  iliac  region.  On  admission,  there  was  a  large 
fluctuating  swelling  in  the  right  iliac  fossa,  over  the  center  of 
which  the  skin  was  red  and  adherent.  Temperature,  101  "5°. 
An  incision  was  made  over  the  prominent  part  of  the  swelling 
and  a  large  quantity  of  pus  evacuated.  On  December  28th  dis¬ 
charged  cured.  The  boy  has  been  seen  recently,  and  has  re¬ 
mained  well. 

Case  X. — Mary  K.,  aged  twelve  years,  admitted  to  the  New 
York  Hospital,  in  June,  1890,  with  a  perityphlitic  abscess,  which 
was  opened  by  an  incision  along  the  outer  part  of  Poupart’s 
ligament  and  the  adjoining  crest  of  the  ilium.  The  case  came 
uuder  my  care  July  1st,  and  then  had  a  faecal  fistula  in  the  line 
of  the  incision,  which  still  persists. 

Case  XI. — Dr.  James  E.,  about  thirty  years  old,  was  attacked 
on  April  10,  1890,  with  severe  pain  in  the  right  iliac  fossa  and 
vomiting.  This  was  the  sixth  attack  in  three  years.  The  pre¬ 
vious  attacks  had  been  treated  by  the  internal  administration 
of  castor-oil  and  belladonna,  and  had  lasted  only  one  or  two 
days,  ceasing  promptly  after  the  bowels  moved.  I  saw  him  on 
the  second  day,  when  he  was  feeling  better  and  was  confident 
the  attack  had  passed.  The  evening  of  the  12th,  while  at  stool, 
he  had  the  sensation  of  something  giving  way  in  the  lower 
part  of  the  abdomen.  He  said  it  felt  as  if  something  tore  for  a 
length  of  about  four  inches,  and  this  was  followed  by  great 
rectal  tenesmus.  He  summoned  an  ambulance  to  take  him  to 
the  New  York  Hospital,  and  notified  me  on  the  following  morn¬ 
ing.  Dr.  McBurney  kindly  saw  him  with  me  at  my  request. 
Temperature,  101°,  the  patient  looking  very  ill,  and  quite  dazed 
by  a  small  amount  of  morphine  taken  the  previous  evening. 
Marked  tenderness  and  some  fullness  in  the  right  iliac  fossa  at 
and  below  the  level  of  the  anterior  superior  spine.  The  finger 
in  the  rectum  found  a  bulky  swelling  at  and  above  the  region 
of  the  prostate,  extending  from  side  to  side  of  the  pelvis,  rather 
hard  and  tender  on  the  right  side,  soft  and  depressible  high  up 
in  the  center.  A  hypodermic  needle,  introduced  into  this  swell¬ 
ing,  brought  thin,  offensive  pus. 

Ether,  anus  dilated,  and  an  incision  made  through  the  ante¬ 
rior  wall  of  the  rectum,  evacuating  a  large  amount  of  thin  pus. 
The  finger  introduced  through  the  incision  passed  into  a  cavity 
behind  the  bladder,  undoubtedly  the  cavity  of  the  peritonaeum. 
A  large  drainage-tube  was  inserted  and  retained  for  three  days, 
then  escaping  spontaneously  during  a  movement  of  the  howels 
induced  by  a  saline  purge. 

April  18th. — Patient  returned  to  his  home. 

May  7th. — Some  thickening  can  be  felt  through  the  rectum, 
and  a  very  little  in  the  right  iliac  fossa. 

The  transient  character  of  the  five  previous  attacks  natu¬ 
rally  gave  him  the  impression  that  the  sixth  would  be  as  easily 
recovered  from,  and  yet  it  is  clear  that  the  delay  seriously  im¬ 
periled  the  patient’s  life. 

Oases  treated  by  Laparotomy,  with  Opening  of  the 
General  Peritoneal  Cavity. 

In  all  but  one  of  these  cases  the  incision  was  made 
along  the  outer  border  of  the  rectus  from  the  level  of 
the  umbilicus  nearly  to  the  center  of  Poupart’s  ligament. 
The  appendix  was  tied  with  catgut  close  to  the  caecum 
and  cut  away ;  the  stump  was  cauterized  with  pure  car¬ 
bolic  acid ;  the  adjoining  intestines  were  carefully  pro¬ 
tected  during  the  operation  by  flat  sponges  and  cloths  held 
against  them  by  long,  broad  retractors;  a  drainage-tube 
and  packing  of  iodoform  gauze  were  used  in  all  cases  and 
usually  removed  on  the  fourth  or  fifth  day.  The  external 
wound  was  closed  for  two  thirds  or  three  fourths  of  its 


Oct.  25,  1890.] 


STIMSON:  APPENDICITIS. 


451 


length.  Absolute  diet  was  maintained  for  twenty-four 
hours,  and  then  small  quantities  of  milk  were  given.  The 
microscopical  examination  of  the  removed  appendices  was 
made  by  Dr.  Ferguson  and  Dr.  James  at  the  laboratory  of 
the  New  York  Hospital. 

Case  XII. — John  M.,  twenty-two  years  old,  was  admitted 
to  the  Chambers  Street  Hospital,  October  25,  1889,  complaining 
of  severe  pain  in  the  right  iliac  fossa.  Temperature,  99°.  There 
was  some  rigidity  of  the  abdomen  on  the  right  side,  but  no 
dullness  or  tumor.  McBurney’s  point  well  marked.  He  gave 
a  history  of  two  attacks,  fourteen  months  and  three  years  pre¬ 
viously. 

Operation  forty-eight  hours  after  the  beginning  of  the  at¬ 
tack.  The  appendix  was  closely  adherent  through  its  whole 
length  to  the  mesentery  of  the  ileum,  and  so  completely  im¬ 
bedded  in  new  tissue  that  it  was  found  and  removed  with  much 
difficulty.  There  was  no  pus.  Microscopical  examination 
showed  the  wall  of  the  appendix  studded  writh  small  round  cells, 
and  the  structure  of  the  mucosa  entirely  lost.  Recovery  fol¬ 
lowed  without  incident. 

Case  XIII. — Christopher  H.,  twenty-three  years  old,  admit¬ 
ted  to  Chambers  Street  Hospital,  November  29,  1889,  complain¬ 
ing  of  nausea  and  violent  pain  in  the  abdomen,  especially  on  the 
right  side.  Temperature,  103°.  I  transferred  him  to  the  New 
York  Hospital,  and  operated  fifty-five  hours  after  the  beginning 
of  the  attack.  The  appendix  was  prominent  below  and  behind 
the  caecum,  deeply  congested,  and  about  an  inch  long  and  three 
quarters  of  an  inch  thick  at  its  base.  As  the  caecum  was  raised 
pus  escaped,  to  the  amount  of  about  two  drachms,  from  around 
the  base  of  the  appendix.  It  was  caught  bn  sponges,  and  the 
region  lightly  washed  with  a  bichloride  solution.  The  appen¬ 
dix  was  then  removed.  From  its  apex  a  stout  cord  of  connect¬ 
ive  tissue  extended  upward,  and  was  continuous  with  the  tissues 
of  the  floor  of  the  fossa.  The  patient  made  an  uneventful  re¬ 
covery. 

Case  XIV. — Lorenzo  M.,  twenty-three  years  old,  admitted 
to  the  Chambers  Street  Hospital,  January  21,  1890.  Ten  days 
previously  he  had  been  seized  with  severe  abdominal  pain  and 
nausea,  which  had  persisted  in  less  degree  and  had  been  accom¬ 
panied  by  fever.  A  firm,  very  sensitive  swelling  could  be  felt 
in  the  right  iliac  fossa,  beginning  an  inch  above  Poupart’s  liga¬ 
ment  and  extending  upward  farther  than  it  could  be  followed. 

It  was  dull  on  percussion,  with  resonance  below,  above,  and  on 
its  inner  side.  Temperature,  101-5°.  On  making  the  usual  in¬ 
cision  there  were  found  no  infiltration  of  the  abdominal  wall,  no 
adhesions,  no  injection  of  the  peritonaeum,  no  effusion.  The 
caecum  and  ascending  colon  were  empty  and  raised  upon  a  firm 
mass  attached  to  the  floor  of  the  iliac  fossa  ;  the  ileum  and  its 
mesentery  were  normal,  and  could  be  readily  followed  to  the 
junction  wth  the  caecum,  but  the  appendix  could  not  be  found. 
While  holding  up  the  caecum  I  saw  pus  exude  through  a  minute 
opening  in  the  lower  end  of  the  mass  just  mentioned.  A  sponge 
was  placed  against  it,  the  adjoining  intestines  protected  by  fiat 
sponges,  and  then  the  minute  opening  was  enlarged,  giving  exit 
to  several  ounces  of  foetid  pus  and  gas;  the  finger  could  then 
trace  the  cavity  of  the  abscess  upward  and  backward  behind 
the  colon  as  far  as  the  finger  could  reach.  The  appendix  seemed 
to  be  imbedded  in  the  lower  part  of  the  wall  of  the  abscess  and 
was  not  removed. 

A  drainage-tube  was  introduced  into  the  abscess,  and  the 
portion  lying  between  the  abscess  and  the  parietal  incision  was 
rather  thickly  surrounded  with  a  packing  of  iodoform  gauze. 
Gauze  was  also  packed  over  the  crncum  and  between  it  and  the 
small  intestine,  as  a  protection  in  case  infection  by  the  pus  had 
occurred  at  that^point.  This  gauze  was  removed  after  three 


days,  that  around  the  tube  at  the  end  of  a  week.  The  patient 
made  an  uneventful  recovery. 

Case  XV. — James  R.,  eighteen  years  old,  was  brought  to  me, 
March  31,  1890,  by  Dr.  White,  of  Franklin,  N.  Y.,  with  a  his¬ 
tory  of  four  attacks  of  appendicitis  within  a  year.  The  first 
attack  lasted  four  days;  the  second,  in  September,  1889,  was 
more  severe;  the  third,  in  December,  ltss  severe;  and  the 
fourth,  in  March,  again  more  so.  Dr.  White  had  seen  the  pa¬ 
tient  only  in  the  last  attack. .  His  description  of  the  symptoms, 
which  included  the  McBurney  point,  left  no  doubt  of  the  cor¬ 
rectness  of  the  diagnosis.  I  sent  the  patient  to  Bellevue  Hospi¬ 
tal  and  operated  the  next  day. 

The  appendix  was  adherent  to  the  caecum  and  omentum;  its 
terminal  inch  was  as  large  as  the  end  of  my  little  finger ;  the 
remainder,  an  inch  and  a  half  to  two  inches  long,  was  the  size 
of  a  lead-pencil.  It  was  removed  and  the  patient  was  discharged, 
cured,  at  the  end  of  a  fortnight.  The  appendix  contained  no 
concretion  and  no  pus ;  the  cavity  of  its  dilated  end  was  shut 
off  by  a  tight  stricture;  the  mucosa  was  thickened  and  pulpy. 

Case  XVI. — John  McG.,  seventeen  years  old,  was  admitted 
to  the  Chambers  Street  Hospital,  April  17,  1890,  complaining  of 
severe  pain  in  the  right  iliac  fossa,  which  had  begun  a  few 
hours  before.  In  January,  1887,  he  had  been  in  the  hospital 
for  three  weeks  suffering  with  peritonitis  caused  by  the  passage 
of  the  wheel  of  a  wagon  across  his  abdomen.  Temperature 
102°.  Marked  tenderness  on  pressure  and  some  resistance 
in  the  right  iliac  fossa.  I  operated  the  next  day.  The  sub- 
peritoneal  tissue  in  the  line  of  the  incision  was  oedematous, 
the  omentum  adherent  at  points  to  the  anterior  abdominal 
wall ;  the  free  end  of  the  appendix  was  almost  in  contact 
with  the  anterior  wall,  the  caecum  lay  above  it,  and  a  loop 
of  the  ileum  lay  on  its  inner  side  closely  adherent  to  it,  to  the 
caecum,  and  to  the  floor  of  the  fossa.  These  adhesions  were 
old  and  thick;  the  appendix  was  deeply  congested.  The  re¬ 
moval  of  the  appendix  was  difficult,  because  of  the  adhesions 
and  because  of  its  position  in  the  sort  of  deep,  narrow  pocket 
formed  by  the  adherent  intestines;  it  was  tied  two  inches  be¬ 
yond  its  tip,  apparently  quite  close  to  the  caecum.  Uneventful 
recovery. 

Case  XVII. — Dr.  Charles  W.,  aged  thirty-two,  was  attacked, 
May  26,  1890,  with  nausea,  which  grew  worse  during  the  even¬ 
ing  and  was  accompanied  by  abdominal  pain.  As  there  was  no 
movement  of  the  bowels  and  no  escape  of  flatus  during  the 
night,  he  feared  intestinal  obstruction,  and  sent  for  me  the  fol- 
owiDg  morning.  There  was  pain  on  pressuie  and  dullness  on 
the  left  side  of  the  abdomen;  the  right  iliac  fossa  was  free. 
Temperature  between  101°  and  102°.  A  dose  of  castor-oil  in¬ 
duced  a  copious  movement,  which  contained  a  considerable 
quantity  of  undigested  soft-shell  crabs  that  had  been  eaten  the 
previous  day.  The  nausea  persisting,  I  transferred  the  care  of 
the  case  to  Dr.  J.  W.  McLane. 

A  week  later,  June  3d,  I  was  again  called;  the  fever  had 
jeen  constant,  there  was  marked  pain  and  an  ill-defined  tumor 
in  the  right  iliac  fossa,  and  the  skin  above  the  crest  of  the  right 
ilium  was  red  and  thickened.  The  patient  was  evidently  very 
ill.  Not  wishing,  for  personal  reasons,  to  operate,  I  asked  Dr. 
McBurney  to  do  so.  The  operation  was  done  June  4th.  An 
exploration  of  the  reddened  area  above  the  ilium  showed  that 
the  wall  was  not  invaded  and  not  adherent  to  the  adjoining 
mass;  the  usual  incision  was  then  made  in  front.  A  small 
amount  of  pus  was  found  behind  and  at  the  outer  side  of  the 
caecum,  and  was  carefully  removed  on  sponges.  The  appendix 
was  not  seen,  and  it  was  thought  best  not  to  break  up  adhesions 
to  seek  for  it.  The  operation  was  done  with  the  delicacy  and 
precision  that  characterize  the  operator,  and  no  precaution  was 
neglected  that  might  have  contributed  to  the  safety  of  the  pa- 


452 


STIMSON :  A  PPENDICITIS. 


[N.  Y.  Med.  Jocr., 


tient.  But  the  septicaemia  was  not  checked,  the  discharge  was 
free  aud  very  offensive,  and  he  died  forty-eight  hours  after  the 
operation. 

Case  XVIII. — James  H.,  aged  twenty-four.  The  previous 
history  of  this  patient  has  been  given  above  (Case  IV).  On  June 
29th  he  had  another  attack,  less  severe  than  the  one  in  May, 
and,  as  I  was  temporarily  absent  from  the  city,  he  entered  the 
New  YTork  Hospital  and  sent  me  word  that  he  wished  to  have 
his  appendix  removed.  When  I  saw  him,  July  1st,  the  attack 
had  almost  ceased,  the  temperature  was  normal,  and  the  tender¬ 
ness  on  pressure  slight,  but  he  still  desired  the  operation. 

The  appendix  arose  from  the  autero-lateral  aspect  of  the 
caecum  and  thence  curved  inward  and  backward,  its  apex  being 
closely  adherent  to  the  peritonaeum  of  the  fossa;  the  distal  half 
was  firmly  bound  down  by  adhesions,  and  there  were  some 
recent  ones  along  its  curve.  It  presented  two  constrictions  that 
■divided  it  into  nearly  equal  thirds,  and  was  not  distended ;  it 
contained  no  concretions;  its  mucosa  was  almost  completely 
destroyed  by  round-cell  infiltration.  The  patient  was  discharged, 
cured,  July  15th. 

Case  XIX. — Mrs.  K.  (Stamford,  Conn.),  thirty-five  years 
old,  the  mother  of  seven  children  and  three  months  pregnant, 
was  seized  with  intense  abdominal  pain  on  the  right  side  at  1 
p.  m.,  July  31,  1890;  it  was  so  severe  that  between  three  and 
ten  o’clock  she  received  a  grain  and  a  half  of  morphine  hypo¬ 
dermically.  Tenderness  on  pressure  appeared  to  be  most  marked 
at  McBurney’s  point,  and  extension  of  the  right  thigh  was  some¬ 
what  painful,  but,  as  the  patient  had  lost  blood  rather  freely 
from  the  uterus  three  times  during  her  pregnancy  and  some 
thickening  could  be  felt  through  the  vagina  on  the  right  side, 
her  physician,  Dr.  A.  M.  Hurlbutt,  thought  it  might  be  a  rupt¬ 
ured  extra-uterine-gestation  sac.  I  saw  the  patient  at  1  a.  m. 
She  had  rallied,  the  pain  was  controlled  by  the  morphine,  but 
the  temperature  had  risen  to  101°.  The  abdomen  was  rigid, 
resonant  throughout,  and  moderately  distended.  The  previous 
history  wa3  negative  except  for  several  transitory  attacks  of 
sharp  pain  low  down  in  the  abdomen  during  the  preceding  three 
or  four  years,  none  of  which  had  compelled  her  to  take  to  bed. 

I  did  not  think  it  was  a  case  of  ruptured  extra-uterine  preg¬ 
nancy,  but  the  existence  of  an  acute  spreading  peritonitis  was 
beyond  doubt,  aud  I  advised  immediate  operation  to  remove  the 
cause  if  possible.  I  chose  the  median  incision,  believing  that 
the  appendix  could  be  removed  through  it  if  necessary,  and 
that  it  might  be  of  advantage  if  the  peritonitis  should  prove  to 
be  due  to  some  other  cause. 

The  operation  was  done  at  2  a.  m.,  with  the  assistance  of 
Dr.  Hurlbutt,  Dr.  Pierson,  and  Dr.  Hungerford.  As  soon  as 
the  peritoneal  cavity  was  opened  a  considerable  amount  of  tur¬ 
bid  serum  containing  flakes  of  lymph  escaped,  and,  on  raising 
the  right  side  of  the  incision,  the  appendix  appeared ;  it  was 
brightly  congested  ;  its  apex  was  directed  forward  and  inward 
and  almost  in  contact  with  the  abdominal  wall;  it  lay  behind 
and  in  contact  with  the  right  ovary,  the  point  of  contact  being 
at  the  junction  of  its  basal  and  middle  thirds,  and  at  this  point 
was  a  dark  slough  a  quarter  of  an  inch  in  diameter;  around 
the  slough  and  on  the  adjoining  surface  of  the  ovary  was  a  nar¬ 
row  white  zone  of  fibrin.  The  neighboring  peritoneal  surfaces 
were  congested  ;  there  were  no  adhesions. 

The  appendix  was  tied  at  its  base  and  removed  with  great 
ease,  the  adjoining  peritonmum  lightly  sponged  off1,  a  drainage- 
tube  aod  iodoform  gauze  packing  introduced,  and  the  incision 
closed  in  great  part.  Recovery  followed  without  interruption. 
The  appendix  was  three  inches  long  and  as  large  as  the  little 
finger;  its  wall  was  very  thick,  the  mucosa  in  a  condition  of 
catarrhal  inflammation  ;  it  contained  only  a  small  flake  of  soft 
faeces.  On  the  basal  side  of  the  slough,  which  was  perforated 


at  its  center,  was  a  marked  diaphragmatic  contraction  with  a 
minute  central  opening.  The  mucosa  covering  this  constriction 
was  not  destroyed,  and  it  did  not  appear  to  be  cicatricial. 

Case  XX. — Robert  R.,  aged  twenty-eight,  a  pilot,  was  at¬ 
tacked  with  very  severe  pain  in  the  abdomen  on  the  evening  of 
September  22,  1890,  while  at  sea;  during  the  two  preceding 
days  he  had  had  occasional  slight  pains.  The  pain  continued 
with  nausea  through  the  following  day  and  night,  and  he  was 
brought  to  the  Chambers  Street  Hospital  on  the  morning  of 
September  24th.  I  saw  him  at  12.30  p.  m.  He  gave  the  his¬ 
tory  of  a  similar  attack  in  the  preceding  April.  His  tempera¬ 
ture  was  103°,  pulse  145,  abdomen  tense  and  resonant  through¬ 
out  but  somewhat  dull  in  the  right  flank,  and  was  very  painful 
on  pressure  in  the  right  iliac  region  and  the  left  liypochond  rium. 
His  voice  was  strong,  his  mind  clear  and  calm,  and,  although 
the  condition  seemed  desperate,  yet  I  was  encouraged,  by  the 
success  in  Case  XIX  and  by  the  absence  of  the  signs  of  pro¬ 
found  septic  intoxication,  to  make  the  attempt  to  save  him. 
Other  engagements  compelled  a  delay  until  3.30.  The  pain  in 
the  left  hypochondrium  had  then  ceased;  rectal  temperature, 
104°;  pulse,  165.  As  soon  as  the  peritoneal  cavity  was  opened 
several  ounces  of  thin  pus  escaped,  coming  in  great  part  from 
the  region  of  the  right  flank,  but  also  from  the  mesial  side  of 
the  incision  and  the  floor  of  the  fossa.  There  were  no  limiting 
adhesions,  and  the  distended  intestines  were  held  back  with 
difficulty.  The  appendix  lay  transversely,  its  apex  below  the 
brim  of  the  pelvis;  it  was  much  enlarged  and  was  bound  down 
by  light  adhesions,  which  gave  way  readily  on  slight  traction. 
I  transfixed  its  mesentery  close  to  the  origin  of  the  appendix 
and  passed  two  catgut  ligatures,  one  about  the  narrow  mesen¬ 
tery,  the  other  about  the  appendix,  and  cut  away  the  latter. 
The  pus  was  removed  by  sponging,  a  drainage-tube  was  passed 
upward  on  the  outer  side  of  the  coIod,  and  iodoform  gauze  was 
packed  above,  below,  and  to  the  inner  side.  The  incision  was 
partly  closed  by  a  suture  at  its  center  and  one  at  each  end. 

The  appendix,  two  inches  and  a  half  in  length,  somewhat 
flattened,  and  more  than  an  inch  broad  near  its  free  end,  showed 
three  sloughing  perforations — one  close  to  the  line  of  section, 
one  at  the  apex,  and  one  midway  between  the  others.  Within 
it  and  corresponding  to  the  first  perforation  was  an  enterolith 
a  third  of  an  inch  in  diameter ;  the  wall  was  thick,  the  mucosa 
sloughy,  and  showing  drops  of  pus  at  a  few  points. 

At  10  p.  m.  the  pulse  had  fallen  to  130,  the  temperature  to 
102'5° ;  the  next  morning  the  temperature  in  the  rectum  was 
100‘4°,  pulse  135,  and  the  patient  cheerful  and  apparently  bet¬ 
ter,  but  the  nausea  persisted.  At  6  p.  m.  the  temperature  in 
the  rectum  had  risen  to  104*6°,  the  pulse  to  150  ;  a  saline  purge 
and  enema  had  proved  ineffectual.  Two  hours  later  I  went  to 
him  with  the  intention  of  opening  the  abdomen  in  the  median 
line  and  draining  the  left  side  of  the  cavity  if  the  symptoms 
called  for  it ;  but  I  found  him  easier,  his  temperature  a  little 
lower,  and  no  signs  of  an  effusion  within  the  cavity;  there  was 
some  tenderness  on  pressure  with  the  finger  in  the  rectum.  I 
withdrew  part  of  the  packing;  it  was  moderately  wet  and  odor¬ 
less. 

September  26th. — He  seemed  better  in  the  morning,  but  the 
rectal  temperature  was  104°  and  the  pulse  150  and  very  small. 
At  10.30  the  temperature  was  105 -5°.  During  the  afternoon 
he  was  delirious  at  intervals;  rectal  temperature  at  3  p.  m.  107°. 
He  died  at  6  p.  m.  with  a  temperature  of  107-8°. 

Auptosy  eighteen  hours  after  death.  The  packing  of  the 
wound  had  been  withdrawn  immediately  after  death,  and  the 
incision  closed  by  sutures.  Abdomen  largely  distended.  Od 
opening  the  abdominal  cavity,  liquid  fseces  and  gas  escaped  in 
large  quantities  ;  they  came  from  a  linear  opening  an  inch  long 
near  the  middle  of  the  small  intestine,  the  loop  lying  in  the  right 


Oct.  25,  1890.J 


S  TIM  SON:  APPENDICITIS. 


453 


hypoehondrium,  the  edges  of  which  showed  no  traces  of  inflam¬ 
mation.  As  the  cavity  in  the  loin  occupied  by  the  drainage-tube 
and  the  upper  packing  was  not  shut  oft' from  the  general  cavity 
by  adhesions,  and  as  nothing  came  from  it  when  the  packing 
was  removed  and  the  incision  sewed  up  after  death,  I  can  not 
think  this  rupture  and  effusion  could  have  occurred  beforedeath. 
It  is  barely  possible  that  it  was  a  cut  made  in  opening  the  ab¬ 
domen  at  the  autopsy.  No  pus  could  be  recognized  in  the  liquid, 
and  there  was  no  injection  of  the  general  peritoneal  cavity,  no 
adhesions,  no  coating  of  fibrin  upon  it.  The  stump  of  the  ap¬ 
pendix  was  completely  covered  in  by  adhesions.  In  the  true 
pelvis  on  the  right  side  was  a  closed  collection  of  sweet,  thick 
pus,  estimated  at  two  ounces;  it  surrounded  the  point  on  the 
wall  from  which  the  perforated  apex  of  the  appendix  had  been 
removed.  It  seems  not  improbable  that  if  the  packing  had  been 
pushed  farther  down  in  this  direction,  suppuration  might  have 
been  arrested  there,  as  it  apparently  had  been  elsewhere.  The 
terminal  ten  or  twelve  inches  of  the  ileum  ran  down  into  the 
pelvis,  was  adherent  to  its  wall,  and  formed  part  of  the  wall  of 
the  abscess;  it  was  darkly  congested  and  thickly  coated  with 
fibrin  in  places,  and  empty.  The  ceecum  and  ascending  colon 
contained  only  a  small  amount  of  dark  semi-solid  faeces,  show¬ 
ing  that  something  had  completely' prevented  the  passage  of  the 
contents  of  the  small  intestine  downward.  No  mechanical  ob¬ 
struction  could  be  found. 

Case  XXI. — Hermann  F.,  aged  twenty-two,  admitted  to  the 
Chambers  Street  Hospital,  September  30,  1890.  He  had  been 
ill  for  two  weeks  with  continuous  nausea  and  vomiting  and  se¬ 
vere  pain  in  and  near  the  right  iliac  fossa.  No  history  of  any 
previous  attack.  Temperature  102  4°.  Abdomen  not  distended 
or  rigid.  A  well-marked  swelling  extended  from  the  pubes 
nearly  to  the  umbilicus,  and  from  an  inch  to  the  left  of  the 
median  line  to  three  inches  to  the  right  of  it,  not  reaching  to 
the  right  spine  of  the  ilium  by  more  than  an  inch  ;  maximum 
tenderness  begins  an  inch  below  McBurney’s  point  and  extends 
downward  and  inward.  Under  ether  the  swelling  is  hard,  ir¬ 
regular,  and  slightly  movable  laterally. 

Operation  at  2  p.  m.  The  omentum  covered  the  mass  and 
was  closely  adherent  to  it  and  to  the  anterior  abdominal  wall 
on  the  mesial  side  of  the  incision,  but  not  to  the  caecum.  The 
anterior  longitudinal  bundle  of  the  caecum  ran  inward  to  the 
base  of  the  mass.  On  gently  separating  the  latter  from  the 
floor  of  the  fossa,  exit  was  given  to  a  large  quantity  of  foetid 
pus,  estimated  at  six  ounces,  and  to  a  faecal  concretion  half  an 
inch  long  and  nearly  as  thick  as  a  lead-pencil.  The  bleeding 
from  the  wall  of  the  abscess  was  free.  Large  packing  of  iodo¬ 
form  gauze  ;  the  incision  was  partly  closed  by  a  suture  at  each 
end  and  a  loosely-drawn  central  one.  The  temperature  fell 
that  evening  to  99’6° ;  the  bowels  were  moved  by  enema  Octo¬ 
ber  2d,  and  the  gauze  was  removed  October  3d,  a  light,  fresh 
packing  being  substituted. 

To-day,  October  8th,  the  temperature  is  normal,  the  abdo¬ 
men  flat  and  insensitive,  the  abscess  is  discharging  moderately, 
and  the  incision  is  closing. 

In  eight  of  these  cases  the  removal  of  the  appendix  gave 
the  opportunity  to  examine  it  directly  and  investigate  the 
cause  of  the  morbid  process.  Contrary  to  a  widely  held 
opinion  and  perhaps  to  the  experience  of  others,  in  only 
one  of  them  was  a  foreign  body  or  a  fecal  concretion  of 
sufficient  size  to  have  been  a  factor  in  inducing  the  inflam- 
mation  found.  The  oyster-shell  and  grape-seed  of  tradition 
must  disappear  as  causes,  or  at  least  must  be  freely  supple¬ 
mented  by  others.  But  in  all  cases  we  find  a  marked  in¬ 
flammation  of  the  mucosa,  and  one  that  in  some  cases  had 


almost  obliterated  its  structure  by  studding  it  with  round 
cells.  Total  or  partial  obliteration  of  the  lumen  was  found 
in  three  cases  ;  and  in  another,  in  which  the  appendix  was 
short  and  considerably  distended,  it  seems  probable  that 
there  was  a  constriction  between  the  point  of  excision  and 
the  caecum  ;  in  one  of  these  three  cases  the  stricture  was 
double,  but  not  impervious.  As  the  first  two  gave  a  his¬ 
tory  of  previous  attacks  of  considerable  severity,  I  deemed 
these  strictures  the  result  of  cicatricial  contraction,  but  in 
the  other  one  (Case  XIX)  there  was  a  history  of  many  transi¬ 
tory  attacks  of  pain,  but  of  none  lasting  for  any  length  of 
time  and  accompanied  by  fever,  and  the  stricture  itself  was 
not  cicatricial  but  was  covered  by  a  normal  mucosa.  It 
seems  probable,  therefore,  that  the  cause  may  sometimes  lie 
in  a  congenital  defect,  a  narrowing  due  to  a  developmental 
aberration.  It  would  be  instructive  to  know  in  what  pro¬ 
portion  of  all 'autopsies  such  stricture  of  the  appendix  is 
present. 

It  can  hardly  be  doubted  that  the  combination,  when 
present,  is  an  important  factor  in  provoking  or  increasing 
the  inflammation,  and,  by  preventing  the  escape  of  the  con¬ 
tents  of  the  appendix,  in  inducing  perforation.  Cases  have 
been  reported  in  which  the  appendix  was  literally  a  bag  of 
pus,  an  abscess  upon  the  point  of  breaking,  and  for  such  a 
condition  a  total  occlusion  of  the  lumen  on  the  proximal 
side  is  necessary.  Yet  perforation  is  not  always  due  to  ob¬ 
struction  and  distention  ;  in  Case  XIX  the  obstruction  was 
not  complete,  and  there  was  no  distention,  yet  a  slough  a 
quarter  of  an  inch  in  diameter  had  formed  without  any 
warning  symptoms,  and  the  attack  began  apparently  with 
its  separation. 

In  Case  XVII  the  appendicitis  followed  an  attack  of 
gastro- enteritis  induced  by  an  error  in  diet,  and  the  case  is 
noteworthy  for  the  prompt  appearance  of  septicaemia  and 
its  rapid  advance  to  a  fatal  termination  without  peritonitis 
and  notwithstanding  the  evacuation  and  drainage  of  the 
small  abscess.  In  connection  with  this  apparent  relation 
between  enteritis  and  appendicitis  I  may  refer  to  those  oc¬ 
casional  cases  in  which  an  error  in  diet  is  habitually  fol¬ 
lowed  by  a  transient  attack  of  appendicitis,  one  marked  by 
pain  but  usually  free  from  fever,  and  of  only  a  few  hours’ 
duration.  On  the  hypothesis  of  a  constriction  of  the  ap¬ 
pendix  and  of  a  catarrhal  inflammation  of  the  mucosa  such 
attacks  can  be  readily  explained. 

Remembering  that  the  mucosa  of  the  appendix  contains 
an  exceptionally  large  proportion  of  solitary  and  agminated 
follicles,  it  occurred  to  me  that  appendicitis  might,  theoreti¬ 
cally,  be  expected  sometimes  to  occur  as  a  sequela  of  ty¬ 
phoid  fever.  My  own  experience  contains  only  one  case  in 
which  such  a  connection  might  have  existed — a  case  of  ty¬ 
phoid  fever  the  convalescence  from  which  wras  interrupted 
by  a  return  of  fever  with  abdominal  pain,  followed  after  a 
few  weeks  by  pyaemia  and  death.  The  autopsy  showed  a 
small  collection  of  pus  about  the  appendix,  a  suppurative 
portal  phlebitis,  and  multiple  abscesses  of  the  liver.  Since 
the  possibility  of  such  a  connection  first  occurred  to  me, 
about  a  year  ago,  I  have  noticed  the  report  in  the  journals 
of  two  cases  in  which  appendicitis  immediately  followed  an 
attack  of  typhoid  fever. 


454 


STIMSON:  APPENDICITIS. 


IN.  Y.  Med.  Jour., 


The  course  of  the  affection,  when  not  interrupted  by  op¬ 
eration,  is  shown  or  indicated  in  nineteen  of  my  twenty- 
one  cases,  and  if  to  these  are  added  the  previous  attacks  in 
the  same  patients  (excluding  Cases  VIII  and  XIX),  we 
have  a  total  of  thirty  attacks.  Of  these,  twenty  recovered 
and  two  died,  without  operation  ;  pus  was  found  in  nine  ; 
in  three  of  these  it  formed  a  large  abscess  which  was  opened 
without  exposure  of  the  general  peritoneal  cavity,  and  with 
the  formation  of  a  persistent  faecal  fistula  in  one  ;  in  four 
the  collection  of  pus  was  removed  by  laparotomy,  with  one 
death  ;  in  two,  general  peritonitis  occurred  in  consequence 
of  perforation,  with  one  death  and  one  recovery  after  lapa¬ 
rotomy.  #Pwo  cases  (XII  and  XVI)  throw  no  light  upon 
the  probable  course,  because  the  process  was  cut  short  by 
an  early  removal  of  the  appendix. 

The  pus  in  all  the  cases,  with  possibly  one  exception, 
was  intraperitoneal  ;  in  the  possible  exception  (Case  XIV) 
it  lay  between  the  layers  of  the  mesocolon,  and  it  may  be 
deemed  an  open  question  whether  it  originally  formed  there 
or  reached  that  position  by  perforation  of  the  peritonaeum 
after  having  formed  about  the  appendix  ;  the  latter  organ 
was  not  recognized,  being  apparently  imbedded  in  the  wall 
of  the  abscess. 

It  is  of  interest  to  note  that  in  one  case  certainly  (XII), 
and  in  two  others  probably  (XIII  and  XVI),  pus  formed 
about  the  appendix  without  perforation  or  sloughing  of 
that  organ ;  and  also  that  a  fatal  septic  peritonitis  w^as  set 
up  (Case  I)  without  perforation  of  the  appendix  or  the  pre¬ 
vious  formation  of  pus  about  it.  In  Case  XIII  pus  was 
found,  without  perforation,  at  the  beginning  of  the  third 
day,  and  in  the  same  length  of  time  in  Case  XI  a  large 
abscess  appears  to  have  had  time  to  form  and  rupture. 

The  uncertainty  of  the  course  is  strikingly  shown  in 
Cases  II  and  XIX  ;  in  the  former,  convalescence,  that  had 
apparently  been  progressing  satisfactorily  for  several  days, 
was  suddenly  interrupted  by  a  violent  recurrence  that  proved 
fatal  in  ten  hours ;  in  the  latter,  a  slough  formed  in  the 
wall  ot  the  appendix  without  having  given  rise  to  any 
symptoms  that  attracted  the  patient’s  attention,  and  its  per¬ 
foration  set  up  a  general  peritonitis  that  would,  I  think, 
have  proved  fatal  in  a  few  hours  if  it  had  not  been  arrested 
by  operation. 

Eight  of  the  patients  (exclusive  of  Case  VIII)  had  had 
previous  attacks,  most  of  them  quite  severe.  In  one  (I) 
the  second  attack  proved  fatal  by  septic  peritonitis  without 
perforation  or  suppuration;  in  another  (XX)  the  second 
attack  proved  fatal  by  perforation  ;  in  another  (XIX),  after 
many  slight  attacks,  perforation  took  place  and  nearly 
proved  fatal ;  in  Case  XI,  after  five  previous  attacks,  a  large 
abscess  formed  and  was  opened  through  the  rectum  after 
the  patient’s  life  had  been  gravely  jeopardized.  In  Case 
XV,  operated  upon  after  the  cessation  of  the  fourth  attack, 
the  terminal  inch  of  the  appendix  was  shut  off  by  a  con¬ 
striction  and  so  distended  that  its  ultimate  suppuration,  if 
it  had  been  left  to  itself,  seems  highly  probable.  In  the 
sixth  (XV  III)  there  were  twTo  tight  constrictions  of  the  ap¬ 
pendix,  but  no  distention.  In  the  seventh  (XII)  the  appen¬ 
dix  was  buried  under  adhesions,  and  in  the  eighth  (VI)  no 
operation  was  done.  These  histories  indicate  that  the  dan¬ 


ger  is  greater  in  patients  who  have  had  previous  attacks, 
and  that  the  easy  inference  that  because  they  have  escaped 
once  or  twice  or  thrice  they  may  therefore  be  trusted  to  do 
so  again,  is  not  well  founded. 

The  course  of  an  attack  that  gets  well  under  medical 
treatment  is  ordinarily  as  follows:  It  begins  with  pain  more 
or  less  severe,  at  first  central  or  general,  but  soon  localized 
or  with  maximum  severity  in  the  right  iliac  fossa,  and  ac¬ 
companied  or  soon  followed  by  nausea.  The  temperature 
rises  and  may  reach  102°  at  the  end  of  twenty-four  hours, 
but  during  the  second  day  it  falls,  although  the  tenderness 
on  pressure  or  coughing  persists,  and  by  the  third  or  fourth 
day  the  temperature  is  normal  and  the  tenderness  less. 
Traces  of  the  latter  may  remain  for  a  week  or  two. 

In  cases  that  suppurate,  with  or  without  a  perforation 
protected  by  adhesions,  the  temperature  continues  to  rise, 
or  is  maintained  after  the  second  day,  and  distinct  resist¬ 
ance  or  a  well-defined  tumor  is-recognizable  on  deep  palpa¬ 
tion  in  the  right  iliac  fossa.  This  tumor  is  constituted  at 
first,  not  by  an  abscess,  but  by  agglutinated  loops  of  intes¬ 
tine,  and  exploration  of  it  with  a  hypodermic  needle  is  verv 
unlikely  to  yield. pus. 

Death  may  come  through  septicaemia  after  suppuration, 
by  shock  or  acute  peritonitis  after  perforation  or  rupture  of 
an  abscess,  or  by  a  septicaemia  that  apparently  originates 
in  a  functional  obstruction  of  the  intestines.  Two  of  the 
four  deaths  in  this  list  of  cases  were  apparently  due  to  this 
latter  cause,  and  the  conditions  found  on  autopsy  were 
striking:  the  small  intestine  largely  distended  with  liquid 
yellow  contents  down  to  a  point  within  a  few  inches  of  the 
ileo-caecal  junction  and  empty  beyond,  with  no  recognizable 
mechanical  obstruction  at  the  point  where  the  distention 
ceased.  I  recall  another  case  in  which  the  same  conditions 
existed  :  a  stab-wound  of  the  abdomen,  with  four  cuts  in  the 
intestine,  which  I  closed  by- suture;  the  course  of  the  case, 
until  death  on  the  sixth  day,  was  that  to  which  the  name  of 
intestino-peritoneal  septicaemia  has  been  recently  given,  and 
the  autopsy  showed  the  same  distention  of  the  small  intes¬ 
tine  ending  abruptly  in  the  neighborhood  of  the  healed 
wounds  in  the  bowel.  This  is  a  condition  against  which, 
when  it  is  fully  developed,  we  seem  to  be  at  present  power¬ 
less,  and  which  demands  6ur  most  thoughtful  attention. 

Concerning  the  diagnosis  I  have  but  little  to  add.  The 
localization  of  the  maximum  of  pain,  or  of  the  only  pain, 
on  pressure  at  or  very  near  the  point  indicated  by  Dr.  Mc- 
Burney,  two  inches  from  the  anterior  superior  spine  of  the 
ilium  on  a  line  drawn  from  it  to  the  umbilicus,  has  been 
constant,  and,  in  pointing  out  this  symptom,  Dr.  McBurney 
has  rendered  us  a  service  which  it  is  difficult  to  estimate 
too  highly  ;  it  has  made  the  recognition  of  appendicitis,  in 
its  early  stages  at  least,  easy  for  every  one.  In  several  cases 
I  have  found  the  point  of  tenderness  a  little  lower,  or  that 
it  covered  a  relatively  large  area  downward.  It  may  justly 
be  objected  that  the  appendix  is  not  the  only  organ  in  the 
right  iliac  fossa  that  may  be  the  seat  of  pain,  but,  except  in 
the  case  of  women,  the  objection  appears  to  have  no  prac¬ 
tical  importance,  and  the  disease  is  much  less  common  in 
women  than  in  men.  An  answer  that  seems  to  me  to  be 
entirely  sufficient  to  the  objection  that  the  group  of  syrup- 


Oct.  25,  1890.] 


S TIMSON :  A  PPENDICITIS. 


toms  mentioned  is  not  sufficient  for  the  diagnosis  is  found 
in  the  fact  that  it  has  been  tested  in  a  very  considerable 
number  of  operations  and  no  error  in  diagnosis  has  yet 
been  reported.  It  is,  of  course,  understood  that  the  value 
of  this  symptom  is  greater  in  the  cases  in  which  an  abscess 
of  considerable  size  has  not  formed  or  the  abdomen  is  not 
greatly  distended  and  rigid. 

W  hile  the  diagnosis  is  easy  in  the  early  stage,  and  also 
in  the  late  one  in  which  a  large  fluctuating  tumor  is  present 
in  the  right  iliac  fossa,  it  may  be  surrounded  by  much  un¬ 
certainty  at  other  stages  and  in  other  forms.  The  case 
may  not  be  seen  until  after  the  attack  has  .lasted  several 
days,  and  it  may  be  impossible  to  obtain  an  intelligible  ac¬ 
count  of  the  earlier  symptoms ;  the  abdomen  is  distended 
and  rigid,  vomiting  is  persistent,  the  bowels  have  not  moved. 
Is  it  appendicitis,  or  one  of  the  varied  forms  of  intestinal 
obstruction,  or  a  peritonitis  due  to  some  other  cause?  If 
there  is  a  history  of  a  previous  attack,  and  if  pain  is  found 
especially  at  McBurney’s  point,  we  may,  I  think,  make  the 
diagnosis  with  considerable  confidence,  especially  in  view 
of  the  relatively  great  frequency  of  the  affection.  * 

But  the  recognition  of  the  existence  of  appendicitis  is 
not  all  that  is  needed.  We  must  also  seek  to  know  its 
character  and  probable  development.  Is  it  a  simple  catarrh 
that  will  resolve  in  a  few  days?  will  pus  form,  and,  if  so, 
can  we  safely  await  the  evolution  of  the  abscess?  or  is  an 
unprotected  perforation  or  the  rupture  of  a  small  abscess 
about  to  occur  ?  4  he  aids  to  answering  these  questions  are 

few  and  not  very  helpful,  and  yet  the  questions  are  of 
the  utmost  importance;  upon  the  answer  turns  the  choice 
between  operative  and  expectant  treatment;  the  issue  may 
be  life  or  death. 

Upon  the  question  whether  suppuration  will  or  will  not 
occur,  or  whether  it  has  not  perhaps  already  occurred,  we 
can,  I  think,  find  some  guidance  in  the  height  and  persist¬ 
ence  of  the  fever.  If  the  temperature  is  above  102°  two 
days  after  the  beginning  of  the  attack,  suppuration  is,  I  be¬ 
lieve,  imminent  or  already  present. 

As  to  the  imminence  of  an  unprotected  perforation,  a 
perforation  with  immediate  infection  of  the  general  perito¬ 
neal  cavity,  I  know  of  no  guide.  We  have  seen  it  occur 
abruptly  without  the  slightest  warning  in  one  case  (XIX), 
and  with  only  such  warning  as  was  contained  in  slight 
transitory  pains  during  the  preceding  two  days  in  another 
(XX). 

The  degree  of  the  pain  at  the  onset  tells  us  but  little. 
If  very  severe,  it  may  be  the  sign  of  a  perforation  that  has 
placed  the  patient’s  life  in  the  greatest  danger,  or,  as  in  a 
case  reported  to  this  society  by  Dr.  McBurney  last  May,  in 
which  a  grain  and  a  half  of  morphine  was  required  to  con¬ 
trol  the  pain,  there  may  be  no  perforation,  no  peritonitis, 
no  suppuration  Let  me  add,  however,  that  severe  pain  oc- 
cuiring  in  the  course  of  the  affection  has  very  great  signifi¬ 
cance;  it  means  the  rupture  of  the  appendix  or  of  an  ab¬ 
scess  into  the  general  peritoneal  cavity. 

Grievous  as  the  conclusion  may  be,  it  must  be  admitted 
that  we  are  wholly  unable  to  distinguish  at  the  beginning  the 
case  that  will  end  in  recovery,  even  if  left  to  itself,  from  that 
which  will  put  the  patient’s  lile  in  the  greatest  danger;  we 


455 

are  even  unable  to  assure  the  patient  that  before  the  door 
closes  behind  us  he  may  not  have  passed  into  the  very  jaws 
of  death.  As  Dr.  McBurney  said  in  the  paper  to  which  I 
referred  at  the  beginning,  there  seems  to  be  no  better  way 
of  improving  our  methods  of  diagnosis  than  the  exploratory 
incision  ;  and  he  added :  “  If  it  can  be  shown  by  future  ex¬ 
perience  .  .  .  that  the  exploratory  incision  for  inspection 
of  the  diseased  appendix  is  much  more  free  from  danger 
than  the  expectant  treatment,  then  there  could  be  but  one 
answer  to  the  question,  what  is  the  best  treatment?”  As 
part  of  the  material  to  be  accumulated  for  that  purpose,  my 
list  furnishes  five  operations  in  the  early  and  doubtful  stage 
without  a  death,  and  even  without  a  moment’s  anxiety  be¬ 
yond  that  which  belonged  to  the  taking  of  the  step. 

burning  now  to  the  question  of  treatment ,  we  find,  as 
already  stated,  twenty  attacks  treated  medically,  with  eight¬ 
een  recoveries  and  two  deaths ;  but  if  to  these  we  tdd 
those  in  which  surgical  aid  was  required  at  a  later  period  in 
the  case,  we  have  twenty-eight  attacks  with  four  deaths. 
This  is  the  most  favorable  showing  that  this  group  of  cases 
can  be  made  to  give  for  medical  treatment;  if  previous  at¬ 
tacks  are  excluded,  and  only  those  taken  which  I  saw,  the 
record  stands  sixteen  cases  with  four  deaths,  a  mortality  of 
25  pei  cent.,  and  ultimate  resort  to  surgery  in  eight — exactly 
one  half.  Again,  including  previous  attacks,  in  order  to 
meet  as  far  as  possible  the  objection  that  the  surgeon  natu- 
ially  sees  an  unduly  large  proportion  of  cases  requiring  op¬ 
eration,  we  have  twenty-eight  attacks,  ten  of  which  (add¬ 
ing  the  two  deaths),  or  more  than  one  third,  required  sur¬ 
gical  treatment.  It  is  to  be  remembered  also  that  most  of 
the  surgeon’s  hospital  cases  have  gone  to  the  hospital,  not 
specifically  for  operation,  but  for  treatment,  and  that  to 
that  extent  his  experience  is  the  same  as  that  of  the  gen¬ 
eral  practitioner.  Further,  this  list  contains  cases  to  which 
I  was  called  as  a  surgeon,  but  in  which  no  operation  was 
done. 

In  connection  with  this  I  will  quote  the  statistics  of  a 
physician,  Dr.  Fitz,*  seventy-two  personal  cases,  the  largest 
number  yet  reported.  He  says:  “Seventy-four  percent, 
recovered  and  26  per  cent,  died.  About  one  half  of  them 
were  treated  medically,  the  other  half  receiving  surgical 
treatment  [presumably  in  the  later  stages  of  the  affection]. 
Of  those  treated  surgically,  40  per  cent,  died,  while  of  those 
under  medical  treatment  11  per  cent.  died.  .  .  .  The  per¬ 
centage  of  cases  ending  in  resolution  was  36  per  cent,, 
which  is  practically  the  same  previously  found.  Medical 
treatment  should,  therefore,  be  limited  to  a  little  more  than 
a  third  of  the  cases.”  This,  I  repeat,  is  the  opinion  of  a 
physician.  The  rate  of  mortality  of  Dr.  Fitz’s  list  is  the 
same  as  that  of  mine  ;  its  rate  of  call  for  surgical  aid  even 
higher— two  thirds  as  against  one  half.  To  his  expression 
of  opinion  I  add  that  of  another  physician,  Professor 
Bridge, f  of  Chicago:  “Surgery  is  imperative  in  cases  of 
acute  inflammation  in  the  caecal  region  with  rather  pro¬ 
tracted  high  temperature  that  does  not  show  positive  evi¬ 
dence  of  subsidence  within  two  days,  or  three  or  four  days 


*  Trans,  of  the  Assoc,  of  Amer.  Physicians,  1890,  p.  39. 
f  Ibid.,  p.  34. 


STIMSON :  A  PPENDIC1 TIS. 


[N.  Y.  Mkl>.  Jouk., 


456 

from  the  beginning.”  Dr.  Fitz’s  brief  summary  of  the  in¬ 
dications  for  operating  in  the  early  stage  is  practically  the 
same.  He  advises  it  for  “  urgent  symptoms  (rising  pulse 
and  temperature,  increasing  distention,  and  spreading  pain), 
with  or  without  a  tumor.” 

This  is  about  as  much  as  any  surgeon  has  advocated. 
We  do  not  urge  that  a  laparotomy  should  be  done  in  every 
case  as  soon  as  the  patient  is  seen,  and  we  fully  recognize 
the  fact  that  an  operation  is  a  very  different  thing  to  the 
person  at  the  other  end  of  the  knife — that  the  average  pa¬ 
tient  would  choose  expectant  treatment  with  greater  risk 
rather  than  operative  treatment  with  less  risk.  But  if  death 
or  an  ultimate  resort  to  surgery  is  inevitable  in  from  one 
half  to  two  thirds  of  all  cases,  and  if  from  the  remaining 
one  third  or  one  half  we  exclude  those  in  which  improve¬ 
ment  appears  by  the  third  day,  the  choice  is  more  apparent 
than  real ;  it  is  not  whether  the  patient  will  submit  to  op¬ 
eration,  but  whether  he  will  have  it  at  once  or  later.  And 
if  the  waiting  carries  the  chance  of  a  complication  that  may 
make  interference  hopeless  ;  if  the  late  operation  itself  shows 
a  relatively  enormous  mortality  (40  per  cent,  according  to 
Fitz,  35  per  cent,  in  my  list) ;  if,  as  Fitz  states,  recurrence 
is  as  frequent  in  those  who  undergo  the  late  operation  with 
out  removal  of  the  appendix  as  in  those  who  recover  with¬ 
out  operation  ;  and  if,  as  I  fully  believe,  the  risks  in  an  early 
operation  properly  performed  are  small — can  it  be  doubted 
that  the  early  operation  is  the  wiser  choice? 

By  waiting  a  day  or  two  at  the  very  beginning  to  see  if 
the  attack  may  not  subside  spontaneously,  some  lives  will 
undoubtedly  be  lost — some  of  those,  for  example,  in  which 
unprotected  perforation  takes  place;  but  these  are  the  ex¬ 
ceptions,  the  possibilities,  not  the  probabilities,  and  are  to 
be  classed  with  other  exceptions,  like  those  in  which  recov¬ 
ery  takes  place  by  spontaneous  evacuation  of  an  abscess 
through  the  bowel.  Our  action  must  be  guided,  not  by  the 
possible  one,  but  by  the  probable  nine  or  nineteen  or  nine¬ 
ty-nine.  If  the  patient,  with  a  full  understanding  of  the 
matter,  is  unwilling  to  take  even  that  risk,  then  I  believe 
the  surgeon  is  fully  justified  in  operating  immediately,  ex¬ 
actly  as  he  is  justified  in  operating  after  an  attack  has  ceased 
in  order  to  prevent  recurrence.  But  in  such  cases  the  de¬ 
cision  should  lie  with  the  patient. 

And  in  connection  with  recurrences,  let  me  repeat  that 
the  experience  contained  in  this  list  of  cases  indicates  that 
the  danger  of  a  recurrent  attack  is  greater  than  that  of  a 
first  one,  and  that  in  such  it  is  perhaps  wiser  not  even  to 
wait  to  see  how  the  attack  will  turn,  but  to  operate  at  once. 

A  word  of  caution  as  to  the  operation  itself.  In  all  1 
have  said  in  favor  ot‘  the  early  operation,  1  have  had  in 
mind  its  performance  by  those  who  are  experienced  in  op¬ 
erating,  with  trained  assistants,  and  with  all  possible  care 
and  precautions.  While  the  recognition  and  removal  of 
the  appendix  may  in  some  cases  be  as  simple  and  easy  as 
any  piece  of  abdominal  surgery,  it  is  much  more  likely  to 
present  serious  difficulties  and  to  call  for  the  exercise  of  the 
soundest  judgment  and  the  most  careful  handling. 

In  the  search  for  the  appendix  1  have  found  it  advan¬ 
tageous  to  follow  the  anterior  longitudinal  bundle  of  mus- 
cular  fibers  of  the  caecum  downward  and  inward;  it  ends  at 


the  root  of  the  appendix.  For  the  ligature  of  the  appendix 
I  have  always  used  a  catgut  ligature,  and  have  simply  tied 
it  about  it  as  in  tying  an  artery.  No  ill  result  lias  followed 
in  any  case,  and  I  have  seen  no  reason  to  abandon  this 
simple  method  and  resort  to  the  more  difficult  one  of  turn¬ 
ing  in  the  cut  end  and  suturing  the  opposed  peritoneal  sur¬ 
faces.  In  some  of  my  cases  the  latter  method  would  have 
been  quite  impracticable,  even  if  any  confidence  could  have 
been  felt  that  such  suturing  of  the  inflamed,  softened,  and 
sometimes  suppurating  peritonaeum  would  have  held. 

Free  packing  with  iodoform  gauze  has  seemed  to  be  of 
great  service  in  arresting  suppuration  and  preventing  the 
spread  of  infection.  I  should  be  very  loath  to  dress  a  sup¬ 
purative  case  without  it.  I  have  used  it  not  only  in  the  im¬ 
mediate  field  of  operation,  but  also  and  quite  freely  over 
and  among  the  adjoining  loops  of  intestine,  removing  it 
thence  usually  after  forty- eight  hours. 

The  external  incision  I  have  always  closed  in  great  part, 
bringing  the  drainage-tube  and  packing  out  near  the  lower 
angle  ;  when  the  packing  has  been  used  more  freely,  among 
the  adjoining  loops  of  intestine.  I  have  brought  it  out  in 
two  bundles,  closing  the  incision  between  them.  This  par¬ 
tial  closure  of  the  wound  has  not  interfered  with  drainage, 
and  I  have  thought  it  made  cicatrization  more  prompt  and 
perhaps  diminished  the  chance  of  hernia. 

Finally,  I  may  be  permitted  briefly  to  summarize  the 
views  held  by  those  who  have  accepted  the  principles  ad¬ 
vanced  by  Dr.  Me  Burney  a  year  ago,  so  far  as  I  may  speak 
for  them. 

Inflammation  in  the  caecal  region  is,  in  the  immense 
majority  of  cases,  an  inflammation  in  and  about  the  appen¬ 
dix. 

A  certain  proportion  of  cases  will  resolve  spontaneously 
within  two  or  three  days. 

The  others,  and  they  are  much  the  larger  number,  seri¬ 
ously  endanger  life  in  their  evolution  and  are  liable  at  any 
moment  to  assume  a  condition  that  is  practically  fatal. 

We  have  no  means  of  distinguishing  those  cases  which 
will  go  on  to  the  formation  of  an  abscess  without  accident 
from  those  in  which  this  evolution  will  be  gravely  inter¬ 
rupted. 

Early  laparotomy — that  is,  laparotomy  within  the  first 
three  days — enables  us  to  arrest  the  process  by  removal  of 
the  cause,  and  is  less  dangerous  than  expectant  treatment. 

It  is  maintained  that  such  laparotomy  should  be  done, 
not  in  every  case,  but  only  in  those  which  clearly  do  not 
belong  to  the  first  mentioned,  the  resolving  class. 

34  East  Thirty-third  Street. 


A  New  Method  of  producing  Local  Anaesthesia. —  “Dr.  Voituriez 

recommends  in  the  Moniteur  therapeutique  a  method  of  producing 
local  anaesthesia  which  certainly  possesses  the  merit  yd  simplicity.  It 
is  based  upon  the  ‘  well-known  anaesthetic  properties  of  carbonic  oxide, ? 
and  consists  in  pouring  on  the  place  to  be  anaesthetized  the  contents  of 
two  or  three  bottles  of  Seltzer  water,  preferably  by  means  of  the  siphon, 
which  releases  the  water  in  a  strong  stream.  The  anaesthesia  lasts  five 
minutes  and  then  gradually  disappears.  It  is  difficult  to  see  how  the 
‘  well-known  anaesthetic  properties  ’  of  the  oxide  are  exerted  by  external 
application.  The  effect,  if  any,  is  probably  mechanical.” — Druggist's 
Circular  and  Chemical  Gazette. 


Oct.  25,  1890.]  LSER1DGE: 


NERVOUS  AND  MENTAL  DISEASES  IN  COLORADO. 


457 


NERVOUS  AND  MENTAL  DISEASES 
OBSERVED  IN  COLORADO* 

By  J.  T.  ESKRIDGE,  M.  D., 

DENVER,  COL., 

FORMERLY  POST-GRADUATE  INSTRUCTOR  IN  NERVOUS  DISEASES  IN 
TIIE  JEFFERSON  MEDICAL  COLLEGE  AND  PHYSICIAN  TO  THE 
HOSPITAL  OF  THE  COLLEGE.  ETC. 

In  a  communication  to  the  Philadelphia  Neurological 
Society  in  September,  1887,  I  gave  the  results  of  three 
years’  observation  of  the  climate  of  Colorado  on  nervous 
and  mental  diseases,  together  with  the  views  of  several  phy¬ 
sicians  in  various  portions  of  the  State,  practicing  at  alti¬ 
tudes  varying  from  four  thousand  to  ten  thousand  feet.  In 
the  present  paper  I  can  add  three  years’  additional  observa¬ 
tions  on  the  same  subject.  Two  years  of  this  time  have 
been  spent  in  Denver,  where  the  field  of  observation  has 
been  much  enlarged,  owing  to  the  size  of  the  city  and  the 
hospital  accommodations,  which  have  enabled  me  to  study 
cases  from  nearly  every  portion  of  the  State. 

In  my  former  paper  I  stated  that  “among  the  inhabit¬ 
ants  ot  Colorado  we  find  more  leisure  in  many  places  and 
a  gi eater  tendency  to  keep  late  hours  and  indulge  in  various 
dissipations  than  is  common  farther  east.  Many  go  to 
Colorado  in  search  of  health,  and  the  separation  from  rela¬ 
tives  and  friends,  added  to  the  enforced  idleness,  is  a  source 
of  worry  and  a  certain  amount  of  nervousness.  Some  go 
to  better  their  fortunes,  and,  for  these,  investments  in  mines 
and  vaiious  other  uncertain  speculations  cause  anxiety  and 
unwonted  excitement.  Many  who  had  lived  quiet  lives  and 
kept  regular  hours  for  rest  and  eating  in  the  Eastern  States 
go  to  Colorado,  overindulge  in  the  use  of  alcohol  and  to¬ 
bacco,  and  try  their  nervous  systems  by  late  and  irregular 
hours.  After  allowing  for  all  the  modifying  influences,  ex¬ 
clusive  of  climate,  I  feel  confident  that  by  a  careful  compari¬ 
son  of  certain  nervous  disturbances  at  sea-level  with  those  of 
like  nature  met  with  in  high  and  dry  mountainous  regions  a 
difteienee  will  be  found  to  exist;  but  the  difference  is  much 
less  than  the  exaggerated  statements  made  by  the  laity 
here  concerning  the  influence  of  Colorado  climate  on  the 
nervous  system  would  at  first  lead  us  to  believe.  That 
among  the  people  of  Colorado  we  have  more  of  what  is 
termed  nervousness  than  exists  in  the  same  number  of  in¬ 
habitants  at  sea-level  there  can  be  no  doubt,  but  consump¬ 
tive  invalids  form  a  greater  proportion  of  the  population 
in  Colorado  than  is  found  f  rther  east.” 

Most  of  the  statements  just  quoted  hold  good  to-day  in 
certain  portions  of  Colorado,  especially  in  Colorado  Springs, 
where  I  resided  when  the  observations  were  made.  In 
Denver,  where  I  have  made  my  observations  during  the 
past  two  years,  there  are  less  idleness  and  fewer  consump¬ 
tives  in  proportion  to  the  population,  but  more  business 
woiry  and  hustle,  and  probably  more  irregular  living,  than 
in  places  like  Colorado  Springs  and  Manitou,  where  a  greater 
proportion  of  the  inhabitants  have  gone  more  for  health 
than  for  business.  If  we  take  the  people  of  Denver  and 
compare  them  with  a  similar  number  in  one  of  the  wide¬ 
awake  and  business-going  cities  of  the  East,  such  as  New 

Read  before  the  American  Climatological  Association  at  its  annual 
meeting,  held  in  Denver,  September  2,  3,  and  4,  1890. 


York  or  Chicago,  we  shall  find  their  habits  and  methods  of 
doing  business  so  nearly  alike  that  but  little  difference  in 
influence  on  the  nervous  system,  except  climatal,  will  be 

found  to  exist  in  Denver  that  is  not  active  in  the  Eastern 
cities. 

Most  of  my  observations  on  the  influence  of  Colorado 
climate  on  the  nervous  system  have  not  been  conducted  by 
strictly  scientific  methods,  but  rather  by  comparing  clinical 
observations  made  in  Colorado  with  those  made  in  Phila¬ 
delphia,  extending  over  a  number  of  years.  Jt  must  be 
borne  in  mind  that  conclusions  reached  by  this  method  are 
distorted  more  or  less  by  personal  equation,  the  degree  of 
inaccuracy  depending  largely  upon  the  carefulness  and 
faithfulness  of  the  observer.  A  few  facts,  however,  have 
been  ascertained  by  strictly  scientific  procedure.  While 
practicing  in  Philadelphia  I  devoted  considerable  time  to 
surface-temperature  observation,  both  in  health  and  in  dis¬ 
ease.  The  number  of  observations  amounted  to  several 
thousands,  taken  over  various  portions  of  the  body.  Dur¬ 
ing  the  last  four  or  five  years  I  have  continued  these  obser¬ 
vations  in  Colorado,  limiting  the  area  mainly,  but  not  ex¬ 
clusively,  to  the  surface  of  the  head.  After  allowing  for 
changes  in  the  mercurial  thermometers,  which  time  invaria¬ 
bly  effects,  I  find  that  the  normal  head  temperature  in 
Colorado  is  about  half  a  degree  (F.)  higher  than  in  Phila¬ 
delphia. 

I  have  also  endeavored  to  compare  the  surface  tempera- 
ture  of  the  body  at  various  altitudes,  but  observations  made 
at  high  altitudes,  especially  on  Pike’s  Peak,  owing  to  dan¬ 
ger  to  my  health  in  ascending  high  mountains,  had  to  be 
intrusted  to  others,  and  I  fear  have  but  little  value.  No 
one  unaccustomed  to  making  surface  temperature  observa¬ 
tions  realizes  the  amount  of  care  necessary  to  prevent  inac¬ 
curacies.  Time  and  time  again  I  have  requested  my  assist¬ 
ants  to  make  such  temperature  observations  for  me,  and  I 
have  repeated  the  observations  a  few  minutes  later  and  have 
gotten  different  results,  the  difference  varying  from  a  quar¬ 
ter  of  a  degree  to  a  degree. 

Increased  surface  temperature  in  Colorado  is  what  most 
clinical  observers  had  inferred  long  before  my  observations, 
but  the  supposed  condition,  scientifically  confirmed,  be¬ 
comes  a  fact  and  may  help  to  explain  many  modifying  in¬ 
fluences  the  climate  has  on  the  functions  of  the  organs  of 
the  body. 

Mental  Work. — I  have  often  asked  myself  the  ques¬ 
tion,  and  not  infrequently  propounded  the  query  to  others, 
whether  a  person  is  able  to  do  more  or  less  mental  work  in 
Colorado  than  at  sea-level.  The  kind  of  mental  work  I 
refer  to  is  hard  study  for  several  hours  each  day,  continued 
over  several  weeks.  The  answer  I  have  obtained  from  most 
persons  whom  I  have  interrogated  on  this  subject  is  that 
they  have  not  compared  the  effects  and  were  undecided  as 
to  the  results.  I  have  tried  to  compare  the  effects  on  my 
own  person,  as  I  gave  a  few  hours  each  day  to  hard  mental 
work  for  many  consecutive  weeks  in  each  year  while  prac¬ 
ticing  in  Philadelphia,  and  much  of  the  time  since  coming 
to  Colorado,  when  my  health  would  permit  of  it.  I  have 
devoted  more  or  less  time  each  day  to  mental  work.  I  feel 
that  the  conclusions  at  which  I  have  arrived  from  personal 


45  8 


ESKRIDGE:  NERVOUS  AND  MESTAL  DISEASES  IN  COLORADO.  [N.  Y.  Med.  Jouk., 


experience  may  be  open  to  objection.  My  physical  power 
of  endurance  is  much  lessened  since  I  contracted  lung 
trouble,  for  which  I  came  to  Colorado,  and,  in  consequence, 
mental  effort  sooner  results  in  fatigue.  I  have  found  that 
three  or  four  hours  each  day  devoted  to  continuous  mental 
work  and  extended  over  a  period  of  a  few  weeks  so  weak¬ 
ens  and  prostrates  me  that  I  am  compelled  to  give  up  all 
reading,  except  light  literature,  for  a  time.  When  I  have 
felt  fresh  and  have  had  a  zest  for  study,  I  have  thought  I 
could  accomplish  more  in  a  given  time  than  I  was  able  to 
do  at  a  low  altitude  ;  but  this  is  merely  surmise  on  my  part. 
The  only  persons  who  can  approximate  an  accurate  solution 
of  this  subject  are  those  who,  in  good  health,  accustomed 
to  do  a  regular  amount  of  study  East,  have  come  to  Colo¬ 
rado  in  the  same  state  of  health  to  pursue  similar  studies 
to  those  engaged  in  while  East. 

Sleep  and  Insomnia. — Under  this  heading  in  my  former 
paper,  the  unanimous  opinion  of  the  physicians  was  that 
sleep  was  more  easily  obtained,  more  continuous,  and  more 
refreshing  in  Colorado  than  at  sea-level.  We  have  several 
classes  in  which  to  study  the  effects  of  the  climate  on  the 
production  of  sleep,  or  as  a  cause  of  insomnia.  Among 
these  may  be  mentioned  the  tourist,  including  the  business 
adventurer ;  the  tired  and  overworked,  both  mentally  and 
physically  ;  and  the  health-seeker,  especially  the  consump¬ 
tive  person. 

On  tourists  or  adventurers  the  effects  are  as  varied  as 
the  temperaments  of  the  individuals,  and  are  modified  by 
the  habits  and  life  of  such  persons  while  in  Colorado.  The 
restless  ones  among  this  class,  who  are  never  satisfied,  but 
must  have  continuous  excitement  in  scenery  or  some  other 
diversion,  rarely  get  good  and  refreshing  sleep  in  Colorado 
unless  tired  out  by  physical  exhaustion,  when  they  run  the 
risk  of  developing  a  temporary  irritable  heart,  disturbances 
in  digestion,  and  headache.  Such  persons  frequently  leave 
the  State  complaining  bitterly  of  the  evil  effects  of  the  cli¬ 
mate  on  healthy  individuals. 

Those  of  this  class  who  take  things  leisurely,  more  as  a 
natural  result  of  their  temperaments  than  from  the  warnings 
of  others  who  have  been  indiscreet,  do  not  over-exercise, 
and  allow  themselves  time  for  regular  meals  and  rest,  rarely 
fail  to  get  prolonged  and  refreshing  sleep. 

About  the  only  practical  deductions  to  be  derived  from 
a  study  of  the  experiences  of  the  tourists  in  Colorado  are 
what  to  avoid  in  the  invalid  class. 

The  Overworked. — In  this  class  are  included  the  tired 
business  and  professional  man,  whose  mental  strain  com¬ 
pels  sedentary  habits,  neglect  of  proper  exercise,  and  irregu¬ 
lar  hours  for  eating  and  sleeping,  and  the  lady  of  family 
cares,  as  well  as  she  whose  vigor  has  been  sapped  by  the 
unreasonable  exactions  of  fashionable  life.  To  these  a  visit 
to  Colorado  means,  in  the  majority  of  cases,  if  too  much 
physical  exercise  is  not  indulged  in,  prolonged  and  refresh¬ 
ing  sleep.  Such  persons  coming  here  from  the  East  regain 
their  strength  rapidly ;  but  we  must  not  attribute  all  the 
good  results  to  Colorado  climate.  Habits  and  modes  of 
living  for  the  time  being  are  changed.  The  business  man 
leaves  worry  and  care  behind  ;  the  professional  man,  re¬ 
lieved  of  the  trials,  annoyances,  and  anxious  cares  of  his 


profession,  seeks  rest  amid  new  scenes,  while  she  who  had 
been  sore  pressed  with  family  cares  and  social  obligations 
changes  these  for  a  quiet  life.  Much  of  the  relief  comes 
from  “the  change,”  irrespective  of  climate. 

Having  had  an  opportunity  for  a  number  of  years,  before 
coming  to  Colorado,  of  studying  the  effect  of  sea-shore  re¬ 
sorts  on  this  class  of  persons,  I  found  a  greater  proportion 
unrelieved  from  insomnia  than  I  find  to  be  the  case  with 
those  who  seek  rest  and  change  among  the  mountains  of 
Colorado,  provided  that  a  sufficiently  quiet  life  is  led  here. 
According  to  the  writer’s  experience,  it  is  a  rare  exception 
for  insomnia  to  continue  in  such  persons  after  coming  to 
Colorado,  excluding  a  few  cases  of  supposed  active  hyperse- 
tnia  of  the  brain  or  irritable  heart,  reference  to  which  will 
be  made  later. 

Health-seekers. — I  have  found  no  reasons  for  changing 
the  statements  that  I  made  three  years  ago  :  “  That  for  the 
majority  of  persons,  especially  for  the  consumptive  invalids, 
sleep  is  more  easily  obtained,  more  continuous,  and  more  re¬ 
freshing  in  Colorado  than  in  the  Eastern  States.  The  tired, 
ill-nourished,  and  overworked  person,  who  spent  sleepless 
nights  East,  goes  to  Colorado  and  finds,  as  his  nutrition  im¬ 
proves,  that  sleep  is  prolonged  and  unusually  refreshing. 
Cool  nights  throughout  the  summer  season,  as  a  rule,  en¬ 
able  persons  to  get  much  more  sleep  and  rest  in  Colorado 
than  can  be  obtained  at  sea  level  during  this  portion  of  the 
year.  Some,  on  going  to  Colorado,  are  unable. to  sleep  well 
for  a  few  nights,  or  perhaps  weeks,  while  others  get  pro¬ 
longed  and  refreshing  sleep  from  the  first.  Those  belong¬ 
ing  to  the  latter  group  are  much  the  more  numerous.  Those 
whose  sleep  is  disturbed  on  first  going  to  places  of  consid¬ 
erable  altitude  usually  enjoy  a  sufficient  amount  of  sleep 
for  several  months  after  they  begin  to  rest  well,  but  I  doubt 
whether  these  are  ever  able  to  sleep  as  much  as  those  who  rest 
well  on  first  going  to  high  mountainous  regions.  There  is  a 
popular  and  almost  universal  belief  among  the  laity,  and 
physicians  share  this  opinion,  that  one  wears  out  the  good 
effects  of  the  climate  after  a  few  years’  continuous  residence 
in  Colorado.  I  am  firmly  convinced,  both  from  observa¬ 
tions  and  from  inquiries  among  those  who  have  resided 
here  a  considerable  length  of  time,  that  there  is  a  great 
deal  of  truth  in  this  prevailing  opinion.  Those  who  lead 
idle  or  sedentary  lives  are,  I  think,  more  liable  to  become 
sleepless  after  a  considerable  stay  here  than  those  who 
keep  profitably  employed  in  work  that  requires  more  or  less 
exercise.  Much  severe  mental  work  at  high  altitudes  would 
be,  I  think,  more  likely  to  be  followed  by  sleeplessness  than 
the  same  done  at  sea-level.  Tobacco,  alcohol,  tea,  and 
coffee,  if  indulged  in  immoderately,  apparently  injuriously 
affect  sleep  more  at  high  altitudes  than  the  same  indiscre¬ 
tions  do  at  low  elevations.” 

While  the  majority  of  persons  who  come  to  Colorado 
get  refreshing  sleep  for  a  number  of  months,  and  in  some 
instances  for  years,  yet  there  are  a  few  nervous,  hysterical 
individuals  who  find  great  difficulty  in  getting  refreshing 
sleep  here.  They  are  not  able  to  sleep  a  sufficient  number 
of  hours,  and  the  time  for  repose  is  frequently  spent  in 
broken  sleep.  Cases  of  insomnia  in  the  East,  due  to  active 
hyperaemia  of  the  brain  that  is  not  relieved  by  rest,  sleep 


Oct.  25,  1890.] 


ESKRIDGE:  NERVOUS  AND  MENTAL  DISEASES  IN  COLORADO. 


459 


poorly,  I  think,  in  Colorado.  At  least  this  has  been  my  ex¬ 
perience  with  cases  of  the  kind.  Dr.  Anderson,  of  Colo¬ 
rado  Springs,  and  Dr.  Sears,  of  Leadville,  both  say  that  cases 
of  cerebral  hyperaemia  sleep  well  at  each  of  the  last-named 
places.  I  am  inclined  to  believe  that  they  have  not  distin¬ 
guished,  in  their  communications  to  me,  between  active  and 
passive  hyperaemia.  I  am  led  to  believe,  from  observations, 
that  cases  of  passive  hyperaemia,  or  venous  stasis  of  the 
brain,  due  to  mental  overwork,  worry,  loss  of  sleep,  etc.,  are 
able  to  obtain  abundant  and  refreshing  sleep.  I  believe 
also  that  insomnia  due  to  organic  brain  changes  or  active 
hyperaemia  is  made  worse  in  Colorado.  In  my  former  paper 
I  stated  that  “it  is  very  difficult  to  say  whether  medium 
(4,000  to  6,000  feet)  elevations,  or  the  higher  (7,000  to 
11,000  feet),  are  the  better  for  cases  of  insomnia.”  During 
the  last  three  years  I  have  known  of  a  few  persons  who  have 
come  to  the  medium  elevations,  slept  well  for  a  time,  then, 
becoming  more  or  less  sleepless,  have  gone  to  the  higher 
altitudes,  where  they  again  slept  well.  I  think  such  cases 
are  rare.  But,  on  the  contrary,  we  frequently  find  that  per¬ 
sons  who  become  troubled  with  insomnia  in  the  higher  alti¬ 
tudes,  where  they  had  slept  fairly  well  for  a  length  of  time, 
coming  to  the  medium  elevations  of  Colorado  obtain  refresh¬ 
ing  and  prolonged  sleep.  Pure  air,  good  weather,  and  the 
amount  of  bright  sunshine,  even  in  winter,  inviting  persons 
to  live  outdoors  a  good  portion  of  the  time  and  take  more 
exercise  than  they  were  accustomed  to  do  East,  are  impor¬ 
tant  agents  in  enabling  one  to  get  refreshing  sleep  in  Colo¬ 
rado.  What  lessened  atmospheric  pressure  has  to  do  with 
inducing  sleep,  making  it  more  profound,  as  some  who  re¬ 
side  in  very  high  altitudes  maintain,  has  yet  to  be  deter¬ 
mined.  Those  who  have  had  experience  with  the  pneumatic 
cabinet,  and  have  noted  the  sensations  experienced  by  their 
patients,  may  be  able  to  enlighten  us  on  this  subject. 

Irritable  Nervous  System ,  or  Nervousness. — The  opin¬ 
ions  of  the  physicians  of  Colorado  differ  widely  respecting 
the  influence  of  the  climate  on  a  delicate  and  irritable  nerv¬ 
ous  system,  some  believing  the  influence  is  great,  and  oth¬ 
ers  that  it  is  slight,  if  any  exists. 

An  additional  three  years’  experience  with  nervous  af¬ 
fections  found  in  Colorado  enables  me  to  emphasize  what  I 
said  on  this  subject  three  years  ago  :  “  From  what  l  have 
learned  from  observations  and  inquiry,  I  have  no  hesitation 
in  saying  that  the  inherent  nervous  temperaments — not  those 
who  are  nervous  from  malnutrition,  which  the  climate  may 
and  does  remove  in  many  instances — are  made  worse  by  a 
prolonged  residence  in  Colorado.  Further,  I  believe,  and 
I  think  I  am  expressing  the  opinions  of  a  number  of  phy¬ 
sicians  there,  that  many  who  are  not  usually  considered 
nervous  become  so  after  a  prolonged  residence  in  Colora¬ 
do.”  The  nervousness  may  manifest  itself  by  sleeplessness, 
irritable  heart,  with  a  tendency  to  passive  congestion,  espe¬ 
cially  of  the  gastro-intestinal  mucous  membrane,  by  a  loss 
of  appetite,  failure  of  strength,  lessened  power  of  endur¬ 
ance,  and  considerable  loss  in  body  weight.  Some  suffer 
from  restlessness  and  irritability  of  temper,  and  some  com¬ 
plain  of  inability  to  concentrate  the  mind  long  on  any  sub¬ 
ject.  Persons  thus  affected  and  contemplating  making  their 
home  in  Colorado  should  not  try  to  overcome  their  sensa¬ 


tions  by  a  prolonged  and  uninterrupted  stay  here,  but  they 
should  try  to  spend  a  month  or  two  each  year  at  sea-level, 
which  is  almost  invariably  followed  by  an  improved  condi¬ 
tion  of  the  nervous  symptoms. 

Dr.  Reed,  of  Colorado  Springs,  informed  me  that  he 
had  observed  that  child-bearing  nervous  women,  after  a 
prolonged  stay  in  Colorado,  recover  less  satisfactorily  from 
the  trying  ordeals  of  the  lying-in  room  after  the  birth  of 
the  second  or  third  child  than  they  had  done  after  the  first. 
The  intensely  bright  sunshine,  and  the  great  amount  of  it, 
which  is  the  boast  of  Coloradians,  the  dry  atmosphere,  and 
the  winds,  it  seems  to  me,  are  factors  in  irritating  an  al¬ 
ready  irritable  nervous  system.  Some  have  tried  to  lay 
the  cause  at  the  door  of  lessened  atmospheric  pressure. 
This  may  have  something  to  do  with  it,  but  how  much  it  is 
impossible  to  say. 

Before  beginning  this  paper  I  was  informed  that  Dr.  II. 
A.  Lemen,  who  has  practiced  medicine  in  Colorado  for  a 
number  of  years  and  paid  especial  attention  to  diseases  of 
women,  would  write  on  the  influence  of  climate  on  women. 

I  regret  that  his  engagements  have  been  such  that  he  has 
been  unable  to  contribute  a  paper  on  this  subject.  That 
the  nervous  system  of  woman  is  more  irritable  than  that  of 
man  every  one  will  admit,  and  that  she  in  consequence 
suffers  more  from  the  irritating  effects  of  our  climate  is  self- 
evident.  My  note-book  shows  that  a  large  percentage  of 
those  who  suffer  from  the  irritating  effects  of  this  climate 
is  composed  of  women  ;  but  I  will  not  go  into  details,  hop¬ 
ing  that  Dr.  Lemen,  at  some  future  time,  will  take  up  this 
subject  and  elaborate  it. 

Hysteria. — Three  years  ago  I  was  able  to  give  the  re¬ 
sults  of  the  experience  of  various  physicians  wjth  this  pro¬ 
tean  disease  as  it  occurs  in  the  smaller  towns  in  the  State, 
and  of  my  observations  of  it  in  Colorado  Springs.  My  con¬ 
clusions  were  then  that  it  was  of  lighter  form,  shorter  dura¬ 
tion,  and  much  less  frequent  in  proportion  to  the  popula¬ 
tion  than  observed  in  the  large  Eastern  cities,  but  at  the 
same  time  I  endeavored  to  account  for  the  infrequency  from 
the  habits  of  the  people  and  their  surroundings,  and  ex¬ 
pressed  an  opinion  that  had  we  in  Colorado  all  the  condi¬ 
tions  of  a  large  Eastern  city  favorable  for  the  development 
of  hysteria,  it  would  be  found  more  frequent  here  than  it  is 
in  cities  at  sea-level.  Two  years’  experience  in  Denver, 
where  conditions  favoring  the  development  and  manifesta¬ 
tion  of  the  disease  exist,  convinces  me  that  hysteria  is  not 
infrequent  here,  and  that  it  is  found  in  all  forms,  from  the 
mildest  to  the  severest.  I  have  witnessed  three  cases  in  the 
male.  From  my  present  experience  I  am  unable  to  say  that 
the  disease  is  of  shorter  duration  and  yields  more  readily 
to  treatment  than  is  found  in  the  eastern  portion  of  this 
country. 

Chronic  Alcoholism  and  the  Opium  Habit. — What  must 
impress  itself  on  every  observer  in  Denver  is  the  immense 
number  suffering  from  the  chronic  effects  of  alcohol  and 
opium.  Other  causes  than  climatal  may  account  for  this. 

A  large  proportion  of  those  whom  I  have  had  an  opportu¬ 
nity  to  interrogate  on  this  subject  admit  having  been  ad¬ 
dicted  to  the  habit  before  coming  to  Colorado.  Denver 
during  the  last  f|sw  years  has  been  the  Mecca  sought  by 


460 


ESKRIDGE:  NERVOUS  AND  MENTAL  DISEASES  IN  COLORADO.  [N.  Y.  Med.  Jocr 


those  broken  down  financially,  and  in  this  class  alcoholism 
and  the  opium  habit  are  common.  Whether  there  is  any¬ 
thing  in  the  climate  of  Colorado  tending  to  indulgence  in 
alcohol  and  opium  more  than  what  is  found  at  sea-level  I 
am  unable  to  say.  W  hether  a  larger  proportion  of  the 
population  here  has  begun  the  over-use  of  alcohol,  or  con¬ 
tracted  the  opium  habit,  in  Colorado,  than  is  found  at  sea- 
level,  many  years  of  carefully  studied  statistics  must  an¬ 
swer. 

Chorea. — The  physicians  who’favored  me  with  their  ex¬ 
periences  with  chorea  three  years  ago  were  almost  unani¬ 
mous  in  their  opinions  that  the  disease  is  more  frequent,  se¬ 
verer,  of  longer  duration,  and  less  amenable  to  treatment  in 
Colorado  than  at  sea-level.  I  then  expressed  the  opinion, 
from  an  experience  with  the  disease  in  Colorado  Springs, 
that  it  was  unfavorably  influenced  by  the  climate. 

Some  of  the  physicians  who  were  kind  enough  to  answer 
my  inquiries  stated  that  they  invariably  sent  all  their  cases 
of  chorea  to  lower  altitudes,  with  decided  benefit  to  their 
patients. 

During  the  past  three  years  I  have  had  the  opportunity 
of  treating  and  seeing  in  consultation  numerous  cases  of 
chorea  in  Denver.  So  far,  without  a  single  exception,  they 
have  yielded  to  the  ordinary  treatment  for  this  disease. 
Some  cases  have  developed  at  low  altitudes,  and  from  force 
of  circumstances  have  been  brought  to  this  city.  These 
have  yielded  to  treatment,  but  in  one  case  the  movements 
at  first  seemed  to  be  exaggerated  by  the  change  to  this  alti¬ 
tude.  My  treatment  has  invariably  been,  in  cases  where 
the  choreic  movements  were  great,  full  doses  of  autipyrine 
or  phenacetin  until  the  movements  had  nearly  ceased,  when 
Fowler’s  solution  of  arsenic  has  been  carried  to  the  point  of 
toleration,  the  dose  reached  in  some  cases  being  eio-hteen  or 
twenty  drops  thrice  daily.  My  former  statements  will  have 
to  be  modified  by  saying  that  chorea  at  this  altitude  (about 
five  thousand  feet)  seems  to  yield  about  as  readily  as  at  sea- 
level,  and  with  no  greater  tendency  to  relapses. 

Neuralgia. — A  more  extended  experience  convinces  me 
that  neuralgia  is  a  much  less  troublesome  and  less  frequent 
disease  in  Colorado  than  in  low  malarial  districts.  I  have 
seen  several  cases  of  malarial  neuralgia  rapidly  yield  after 
coming  to  Colorado. 

Migraine  seems  to  be  favorably  modified  on  first  coming 
to  Colorado,  but  the  attacks  are  not  broken  up,  and,  after 
a  few  months,  the  trouble  returns  and  seems  to  be  more 
persistent  than  it  was  at  low  altitudes. 

In  some  of  these  sufferers,  upon  a  return  to  a  low  alti¬ 
tude  after  they  had  spent  some  months  in  Colorado,  long- 
intervals  with  entire  freedom  from  the  disease  have  resulted. 

Multiple  Neuritis. — During  the  last  six  months  I  have 
seen  six  cases  of  this  disease.  So  far  I  have  been  unable 
to  discover  any  points  of  difference  between  the  course, 
severity,  and  duration  of  the  disease  here  and  at  low  alti¬ 
tudes. 

Epilepsy. — In  my  former  communication  the  answers 
of  the  physicians  in  reply  to  my  inquiries  concerning  the 
influence  of  the  climate  on  epilepsy  varied  so  greatly  that 
no  conclusion  could  be  arrived  at ;  some  believed  that  the 
disease  was  unfavorably  influenced  by  a  resort  to  this  cli¬ 


mate,  that  it  quite  frequently  originated  here  and  proved 
rebellious  to  treatment ;  others  thought  it  was  uninfluenced 
by  the  climate,  while  some  thought  it  was  a  very  infre¬ 
quent  disease  in  Colorado. 

I  have  had  an  opportunity  of  personally  studying  twenty- 
one  cases  of  epilepsy  since  coming  to  Colorado.  Sixteen 
of  the  twenty-one  originated  at  low  altitudes  outside  of 
Colorado,  leaving  five  cases  which  began  in  some  portion  of 
the  State.  Of  the  Colorado  group,  the  age  at  which  the 
disease  began  was  at  the  second,  third,  fourth,  seventh,  and 
thirtieth  year,  respectively.  Of  the  imported  cases,  three 
began  at  the  second,  two  at  the  fourth,  six  at  the  tenth, 
three  at  the  sixteenth,  one  at  the  thirty-third,  and  one  at 
the  thirty-seventh  year. 

Causes. — Of  the  Colorado  group,  in  one,  injury  to  head 
from  a  fall ;  in  one,  hydrocephalus,  and  in  three  the  cause  is 
unknown.  Of  the  imported  cases,  gastro-intestinal  disturb¬ 
ances  in  infancy  seemed  to  be  the  exciting  cause  in  four, 
injury  to  head  in  five,  and  unknown  in  eight. 

Sex. — Colorado  group,  three  males,  two  females.  Im¬ 
ported  cases,  there  were  fifteen  males  and  one  female. 

Severe  or  Light  Attacks. — In  the  Colorado  cases  three 
suffered  only  from  the  light  or  petit  mal ,  and  in  two  the 
grand  and  petit  mal  were  found.  In  the  imported  cases  all 
suffered  from  the  severer  manifestations  of  the  disease,  al¬ 
though  a  few  also  had  occasional  petit-mal  attacks. 

Time. — Of  the  Colorado  cases,  in  one  the  seizures  were 
limited  to  the  waking  hours,  and  in  the  other  four  they  oc¬ 
curred  both  diurnally  and  nocturnally.  Of  the  imported 
cases,  in  only  one  were  the  seizures  of  the  diurnal  charac¬ 
ter,  and  in  the  other  fifteen  the  attacks  occurred  indiffer¬ 
ently  both  day  and  night.  So  far  I  have  not  seen  a  case  of 
epilepsy  in  Colorado  in  which  the  attacks  were  limited  to 
the  sleeping  hours.* 

Mental  Effect. — Of  the  Colorado  cases,  there  is  decided 
mental  failure  in  three,  and  in  two  the  mind  seems  unaf¬ 
fected.  Of  the  imported  cases,  insanity  has  developed  in 
four  and  mental  failure  in  ten,  and  in  two  the  mind  seems 
well  preserved.  In  all  of  the  Colorado  cases  treatment  has 
seemed  to  be  attended  with  the  usual  results  found  at  low 
altitudes.  The  result  of  the  climate  on  the  sixteen  im¬ 
ported  patients  is  hard  to  determine.  Two  were  excitable 
and  unmanageable  at  times  before  coming  to  Colorado. 
These  were  soon  decided  to  be  insane  after  coming  to  this 
State,  and  one  has  since  died  in  a  condition  of  status  epi- 
lepticus.  On  the  fourteen  others  the  climate  had  no  appre¬ 
ciable  effect.  It  will  be  observed  that  only  one  female  epi¬ 
leptic  is  found  among  the  sixteen  coming  from  a  distance  to 
Colorado.  This  is  accounted  for  from  the  fact  that  female 
epileptics  rarely  leave  home.  I  have  been  unable  to  perceive 
that  the  climate  of  Colorado,  especially  at  Denver,  materi¬ 
ally  modifies  the  course  of  epilepsy,  except,  it  may  be,  for 
a  short  time  after  the  arrival  of  such  patients  here,  when 
the  disease  is  frequently  benefited  if  the  person  keeps  suffi¬ 
ciently  quiet. 

Insanity. — Since  coming  to  Denver  I  find  it  even  more 

*  Since  this  was  written,  a  case  of  epilepsy  with  attacks  only  in  the 
early  morning  hours  (four  or  five  o’clock)  has  come  under  my  observa¬ 
tion. 


Oct.  25,  1890.] 


ESKRIDGE:  NERVOUS  AND  MENTAL  DISEASES  IN  COLORADO. 


461 


difficult  to  determine  the  influence  of  Colorado  climate  on 
the  insane  and  in  the  causation  of  insanity  than  I  did  while 
practicing  in  Colorado  Springs.  Of  the  one  hundred  cases 
of  insanity  of  which  I  have  records  of  having  seen  during 
the  past  year  in  this  city,  about  fifty  per  cent,  were  insane 
before  coming  to  Colorado,  and  ten  of  the  remaining  fifty 
became  insane  in  other  portions  of  Colorado  than  Denver. 
During  June  of  the  present  year  I  saw  nine  cases  of  in¬ 
sanity,  six  of  which,  so  far  as  could  be  learned,  developed 
in  Colorado,  but  only  four  of  these  in  Denver.  From  the 
1st  to  the  19th  of  August  I  saw  sixteen  cases,  only  seven  of 
which  developed  in  Colorado.  In  July  I  saw  six  cases, 
three  of  which  developed  in  Colorado  and  three  outside 
the  State. 

This  State  has  not  as  yet  made  adequate  provision  for 
the  care  of  her  insane,  and  some  of  the  adjoining  States 
and  Territories  are  behind  Colorado  in  caring  for  their  in¬ 
sane,  and,  in  consequence,  there  is  a  small  insane  nomadic 
population  that  travel  from  State  to  State  and  from  city  to 
city,  as  they  can  succeed  in  obtaining  from  county  commis¬ 
sioners  free  transportation.  As  jury  trials  are  expensive 
to  adjudge  persons  of  unsound  mind  insane,  it  sometimes 
happens  that  the  cheapest  way  to  get  rid  of  such  persons  is 
to  send  them  to  an  adjoining  county  or  State. 

Until  Colorado  succeeds  in  establishing  ample  accom¬ 
modation  for  her  insane,  and  until  we  can  get  the  records 
of  every  case  of  insanity  developing  in  the  State  and  leaving 
it,  it  will  be  impossible  to  ascertain  our  insane  population. 
It  is  evident  that  the  proportion  of  our  insane  population 
in  this  State  is  rapidly  increasing,  but  how  fast  statistics 
give  us  no  idea. 

Some  patients  with  insanity,  especially  of  the  maniacal 
form,  are  benefited  on  being  removed  to  a  lower  altitude. 
The  number  of  cases  of  insanity  developing  in  Colorado 
and  taking  a  depressive  form  far  outnumber  those  of  an  ex¬ 
pansive  nature.  As  yet  there  is  no  private  asylum  in  the 
State  where  the  insane  with  means  to  defray  their  own  ex¬ 
penses  can  be  cared  for,  and  in  consequence  all  such  are  sent 
to  Eastern  asylums. 

Temporary  Effects  of  High  Altitudes. — Many  go  to  the 
summit  of  high  mountains  and  experience  no  inconvenience, 
while  others  at  times  can  perform  such  feats  with  impunity, 
but  at  other  times,  depending  probably  upon  the  condition  of 
their  health,  find  mental  or  physical  symptoms  arc  produced 
thereby,  and  yet  a  third  class  is  almost  invariably  inconve¬ 
nienced  by  high  altitudes.  The  following  case  reported  in 
a  former  paper  is  to  the  point:  “An  intelligent  young  man, 
a  tutor,  in  excellent  health,  started  from  Manitou  early  one 
morning  in  June,  1887,  to  go  on  horseback  to  the  summit 
of  Pike’s  Peak.  The  distance  is  about  twelve  miles.  He 
had  eaten  a  fair  breakfast,  but  took  no  stimulants  that  day, 
either  before  or  during  the  trip.  He  accomplished  the 
ascent  of  the  mountain  in  a  few  hours,  in  company  with 
several  others,  and  experienced  no  inconvenience.  The 
party  remained  on  the  Peak  about  two  hours  before  begin¬ 
ning  the  descent.  Nothing  peculiar  was  noticed  in  the 
young  man  until  he  had  descended  about  two  thousand 
feet,  when  some  of  the  party  observed  his  strange  remarks 
and  absent-minded  condition.  It  was  found  on  inquiry  that 


he  had  forgotten  nearly  everything  that  had  occurred  dur¬ 
ing  the  day.  When  he  reached  Manitou,  late  in  the  after¬ 
noon,  he  did  not  remember  at  what  hotel  he  had  been  stop¬ 
ping.  He  had  paid  for  the  hire  of  his  horse,  and  his  guide 
for  his  services,  in  the  morning  before  starting,  but  on  re¬ 
turning  had  forgotten  all  about  it.  When  he  reached  his 
room  in  his  hotel  he  had  forgotten  what  he  had  done  with 
his  horse,  and  started  to  look  for  him.  Fie  remained  in 
this  confused  and  amnesic  condition  about  thirty-six  hours. 
I  fortunately  had  an  opportunity  to  interview  him  a  few 
days  after  the  strange  occurrence.  At  the  time  of  my  con¬ 
versation  with  him  he  said  that  he  then  remembered  every 
incident  of  the  day’s  journey,  of  which  he  was  oblivious  on 
the  day  of  the  ascent  of  the  Peak.  He  told  me  he  was  not 
conscious  at  the  time  that  anything  was  wrong  with  his 
memory,  but  was  conscious  of  saying  foolish  things  to  which 
he  could  not  help  giving  expression.  He  could  afterward 
recall  his  dazed  condition,  loss  of  memory,  and  the  laughter 
which  he  provoked  among  his  party.  He  stated  that  he 
had  on  previous  occasions  ascended  high  mountains,  some 
as  high  and  some  higher  than  Pike’s  Peak,  but  never  be¬ 
fore  had  had  a  similar  experience  from  mountain  climbing.’’ 

I  have  reported  this  case  in  full,  as  it  illustrates  a  freak 
of  memory  found  in  a  recent  case  of  insanity  which  came 
under  my  experience.  In  July,  1887,  a  gentleman  from 
Boston,  member  of  a  mountain  climbing  club,  went  to  Estes 
Park,  at  an  elevation  of  between  8,000  and  9,0;)0  feet.  At 
the  end  of  a  week  or  two  he  felt,  as  he  expressed  it,  as 
though  he  were  in  a  furnace,  a  sensation  of  intense  heat, 
and  began  to  lose  flesh  rapidly.  In  July  of  the  present 
year  (1890)  I  met  an  Englishman  who  had  been  in  this 
country  only  a  short  time.  He,  in  company  with  a  num¬ 
ber  of  gentlemen,  was  driving  over  some  of  the  high  ranges 
in  the  neighborhood  of  Leadville,  at  an  altitude  of  11,000 
feet.  He  felt  well  and  was  quite  hilarious,  but  suddenly 
became  paretic  in  his  legs  and  was  unable  to  stand  without 
assistance  from  a  person  on  each  side  of  him.  He  experi¬ 
enced  no  pain.  The  paresis  disappeared  as  he  reached  a 
lower  altitude,  and  he  has  had  no  difficulty  in  walking  since. 

I  have  heard  of  one  other  who  was  mentally  confused  in 
making  the  ascent  of  high  mountains  in  Colorado. 

So  far  I  have  had  nothing  interesting  to  report  from 
Professor  Pickering,  of  the  Astronomical  Department  of 
the  Harvard  University,  owing  to  the  fact  that  Pike’s  Peak 
was  abandoned  by  him  and  his  assistants  after  the  first  year 
(1887)  as  a  point  for  observation. 

Inflammatory  Lesions  of  the  Brain  and  Cord. — Under 
this  division  of  my  paper,  read  in  1887,  before  the  Phila¬ 
delphia  Neurological  Society,  I  gave  the  opinions  of  sev¬ 
eral  physicians  of  Colorado  in  respect  to  the  influence  of 
the  climate.  Most  of  them  thought  inflammatory  lesions 
of  the  brain  and  cord  comparatively  rare.  Dr.  Anderson, 
of  Colorado  Springs,  stated  :  “  The  only  lesion  of  the  brain 
with  which  I  have  had  any  experience  here  has  been  soft¬ 
ening,  and  I  would  say,  from  experience,  that  long  resi¬ 
dence  in  high  altitudes  is  one  of  the  most  prolific  sources 
of  this  affection.  A  number  of  cases  in  ‘old  timers’  have 
come  under  my  observation,  and  have  proved  fatal.”  Dr. 
Jacob  Reed,  Jr.,  of  the  same  place,  thought  that  he  had 


462 


ESKRIDGE:  NERVOUS  AND  MENTAL  DISEASES  IN  COLORADO.  [N.  Y.  Med.  Jour., 


met  with  tubercular  meningitis  more  frequently  in  Colorado 


Springs  than  he  had  in  the  same  number  of  children  either 
in  1  hiladel phia  or  Michigan.  So  far  as  I  know,  only  three 
cases  of  tubercular  meningitis  occurred  in  Colorado  Springs 
from  1884  to  1887.  The  population  during  these  years  av¬ 
eraged  about  6,000.  I  do  not  know  the  percentage  of  deaths 
from  tubercular  meningitis  that  occur  in  the  Eastern  towns 
the  size  of  Colorado  Springs.  One  death  annually  in  a 
population  of  6,000  seems  to  me  comparatively  small,  and 
if  we  take  into  consideration  the  large  proportion  of  the 
children  of  Colorado  Springs  born  of  consumptive  parents, 
the  death-rate  is  proportionately  smaller  to  the  consumptive 
population.  It  might  be  that  the  open-air  life  led  by  the 
children,  and  the  bracing  effects  of  the  atmosphere,  together 
with  cool  nights,  even  in  midsummer,  insuring  refreshing 
sleep,  enable  the  issue  of  consumptive  parents  to  overcome 
the  tendency  to  the  development  of  the  disease.  Certainly 
this  seems  to  be  the  case  with  reference  to  the  development 
of  tuberculosis  of  the  lungs  in  children  that  are  born  and 
reside  in  Colorado.  The  dryness  of  the  atmosphere  favor¬ 
ing  free  perspiration  is  evidently  a  factor  in  the  prevention 
of  tuberculous  and  other  inflammation  of  the  central  nerv¬ 
ous  system.  My  experience  in  Denver  leads  me  to  believe 
that  tuberculous  affections  of  the  brain  are  proportionately 
larger  here  than  in  Colorado  Springs.  During  my  fourth 
year  in  Colorado  Springs  I  saw  two  cases  of  infantile  pa¬ 
ralysis;  none  during  the  previous  three  years.  I  have  ob¬ 
served  only  four  such  cases  during  two  years  in  Denver.  I 
did  not  hear  of  a  siugle  case  of  non-traumatic  and  non-tu- 
bercular  meningitis  during  four  years’  residence  in  Colorado 
Springs,  and  have  heard  of  only  one  during  the  past  two 

years  in  Den  ver.  I  have  studied  six  cases  of  acute  myelitis _ 

one  of  tumor  of  the  cord,  five  of  tumor  of  the  brain,  and 
eleven  of  chronic  systemic  degeneration  of  the  cord — dur¬ 
ing  the  past  two  years  in  Denver,  and  have  been  unable  to 
find  any  points  of  difference  in  the  histories  and  progress 
between  these  troubles  here  and  those  of  like  nature  ob¬ 
served  at  sea-level.  Of  their  comparative  frequency  in  this 
altitude  I  am  unable  to  form  an  opinion,  as  most  of  the  cases 
of  gross  lesions  of  the  central  nervous  system  observed  here 
have  been  seen  in  hospitals  in  patients  from  various  portions 
of  the  State.  It  is  probable  that  persons  suffering  from 
chronic  degenerative  conditions  of  the  cord  experience  an 
apparent  improvement  in  their  nervous  conditions  on  com¬ 
ing  to  Colorado,  not,  I  believe,  from  the  direct  influence  of 
the  climate  on  their  nervous  affections,  but,  indirectly,  on 
account  of  improved  condition  resulting  from  the  stimulat¬ 
ing  and  bracing  effects  of  the  atmosphere.  Dr.  Solly  thinks 
he  has  seen  temporary  good  effects  produced  by  a  resi¬ 
dence  in  Colorado  on  chronic  inflammatory  lesions  of  the 
cord. 

Chronic  Degeneration  of  the  Brain. — That  mental  failure 
begins  earlier  in  life  in  persons  who  have  lived  and  strug¬ 
gled  for  many  years  in  Colorado,  and  is  in  many  cases  at¬ 
tended  by  symptoms  of  chronic  degeneration  of  the  brain 
more  frequently  than  is  the  case  in  similar  individuals  East, 
is  recognized  by  the  profession  and  laity  generally.  That 
this  belief  is  correct,  after  six  years’  observation,  I  have  no 
doubt.  The  practical  question  is,  Is  it  due  to 


m  high  altitudes,  as  many  maintf  in,  or  has  it  been  caused  by 
something  peculiar,  or  at  least  prominent,  in  the  lives  and 
business  habits  of  Colorado’s  pioneers?  To  answer  this  in¬ 
quiry  intelligently,  we  must  consider  several  factors  in  the 
lives  of  these  men.  These  persons  lived  in  Colorado  many 
years,  surrounded  by  treacherous  Indians  and  still  more 
treacherous  desperadoes.  The  mining  interests  of  the  State 
from  1859  to  1870  were  her  main  and  almost  her  sole  re¬ 
source  for  those  seeking  wealth.  The  uncertainty  of  for¬ 
tune  and  the  feverish  excitement  in  the  speculative  miner’s 
life-prospective  millions  to-day,  realized  poverty  to-mor¬ 
row— kept  them  under  great  mental  strain.  For  some,  to 
the  prolonged  mental  excitement  and  worry  we  may  add 
irregular  hours  for  eating,  often  insufficient  food  and  sleep 
for  days,  and  no  relaxation  for  years ;  and  for  others  we 
may  still  add  indulgences  in  alcoholic  and  venereal  ex¬ 
cesses;  and  still  for  a  third  class,  gambling.  Are  not  these 
causes  sufficient  to  wear  a  man  out  at  any  altitude  and  in 
any  climate?  What  is  the  cause  of  the  early  mental  and 
physical  wreck  seen  in  so  many  of  the  Wall  Street  brokers 
and  railroad  magnates?  Is  it  altitude?  Certainly  not. 
Then  why  attribute  so  much  to  high  altitude  as  the  factor 
determining  the  early  break-down  of  persons  who  have 
crowded  so  much  worry  and  mental  excitement  into  so 
short  a  space  of  time  ?  Again,  some  of  the  pioneers  brought 
their  wives  to  Colorado  with  them,  and  if  altitude  was  the 
great  cause  of  mental  failure,  these  too  should  suffer  in  a 
similar  manner.  Practically  this  is  not  the  case.  The  fe¬ 
male  often  becomes  nervous  and  sleepless,  but  she  does  not 
suffer  in  Colorado  from  chronic  brain  degeneration  in  the 
same  proportion  as  the  male  sex.  I  fortunately  have  had 
opportunities  to  examine  the  brains  and  blood-vessels  of 
some  who  have  suffered  and  died  in  Colorado,  comparative¬ 
ly  early  in  life,  from  chronic  brain  degeneration.  The 
blood-vessels  have  been  found  diseased  in  every  case,  and 
in  some  slight  chronic  meningitis  has  co-existed.  I  believe 
arteritis  is  the  primary  lesion  in  the  majority  of  cases  of 
early  mental  break-down  in  Colorado.  The  climate  may, 
and  doubtless  does,  play  a  small  part  in  the  matter,  but  not 
nearly  so  great  as  has  been  popularly  attributed  to  it. 

Apoplexy. — Three  years  ago  Dr.  Strickler,  of  Colorado 
Springs,  with  an  experience  of  seventeen  years  there,  and 
Dr.  B.  P.  Anderson,  with  ten  or  twelve  years’  experience 
in  the  same  place,  stated  that  they  had  not  seen  a  case  of 
cerebral  haemorrhagic  apoplexy  in  Colorado.  This  struck 
me  as  being  very  strange,  and  after  referring  to  three  cases 
of  apoplexy  that  I  had  seen,  or  of  which  I  had  personal 
knowledge,  occurring  in  Colorado  Springs  in  1887, 1  added  : 
“I  see  no  reason  why  haemorrhagic  apoplexy  should  not  be 
as  frequent  in  Colorado  as  we  find  it  at  sea-level.”  During 
the  last  eighteen  months  I  have  either  had  under  my  own 
care,  or  seen  in  consultation  with  other  physicians,  seven¬ 
teen  cases  of  apoplexy.  I  doubt  if  the  climate  has  much  to 
do  per  se  in  the  production  of  apoplexy,  but  I  do  believe 
that  violent  exercise  in  high  altitudes  in  persons  with  weak 
cerebral  arteries  is  more  dangerous  than  in  such  persons  at 
low  altitudes. 


Sunstroke  or  heat  stroke  is  almost  unknown  in  Colorado, 
long  lesidence  I  A  few  years  ago  it  was  said  never  to  have  been  known  to  oc- 


Oct.  25,  1890.J  AULDE:  CRUDE  DRUGS  COMPARED  WITH  CHEMICAL  PRODUCTS. 


463 


cur  here.  Its  absence  is  accounted  for  by  the  active  capillary 
circulation  of  the  skin,  by  the  free  evaporation  of  moisture 
from  the  surface  of  the  body,  and  by  the  increased  amount 
of  watery  vapor  given  off  from  the  pulmonary  mucous  mem¬ 
brane  into  the  rarefied  and  dry  air.  During  the  summer  of 
1889  I  saw  a  man  who  had  been  overcome  and  who  died 
from  the  effects  of  the  heat  while  working  in  the  Grant 
Smelter  of  this  city.  The  day  was  warm  and  sultry  for 
Colorado.  The  man  was  working  near  one  of  the  large 
furnaces  in  the  smelter,  and  his  death  was  due  to  artificial 
heat. 

Paresthesia—  Two  cases  of  paresthesia,  one  of  which 
was  seemingly  due  to  high  altitude,  have  recently  come 
under  ray  observation.  After  studying  them  more  fully,  if 
they  should  prove  to  be  as  interesting  as  they  now  seem,  I 
intend  to  publish  a  detailed  account  of  them. 


CRUDE  DRUGS 

COMPARED  WITH  CHEMICAL  PRODUCTS. 

By  JOHN  AULDE,  M.  D., 

PHILADELPHIA. 

The  lack  of  uniformity  in  galenical  preparations  has  re¬ 
sulted  in  the  development  of  two  distinct  classes  of  medical 
practitioners;  on  the  one  hand  must  be  classed  a  large 
number  who,  knowing  the  unreliability  of  our  medicaments, 
prescribe  them  indiscriminately,  not  to  say  recklessly,  while 
others  would  have  us  believe  that  all  remedial  agents  are 
for  practical  purposes  worthless,  sneering  at  any  attempts 
made  with  a  view  to  inaugurate  a  scientific  basis  for  their 
employment.  The  former  are  not  inaptly  referred  to  as 
“plungers,”  and  the  latter  have  long  been  known  as  “thera¬ 
peutic  nihilists.”  It  is  quite  possible  that  in  time  these 
two  extremes  of  the  medical  army  may  be  brought  together 
through  the  exertions  of  those  who  occupy  a  position  mid¬ 
way  between  the  two  factions.  The  solution  of  this  prob¬ 
lem,  however,  will  most  likely  be  attained  by  a  compromise 
which  shall  have  for  a  basis  the  employment  of  definite 
chemical  products,  and,  with  a  view  to  advance  the  interests 
of  the  profession,  I  shall  consider  briefly  some  of  the  com¬ 
parisons  and  contrasts  connected  with  these  two  classes  of 
preparations. 

In  conversation  lately  with  a  physician  who  had  prac¬ 
ticed  for  quite  a  number  of  years  in  the  city  of  London,  I 
was  surprised  to  learn  that  until  recently  a  majority  of  the 
physicians  confined  themselves  to  the  use  of  tinctures,  be¬ 
lieving  that  they  were  far  more  reliable  than  fluid  extracts. 
He  assured  me  that  many  of  the  fluid  extracts  were  prac¬ 
tically  inert  in  respect  to  distinct  physiological  activity,  and 
that  they  were  useful  only  in  proportion  to  the  alcohol  they 
contained  ;  these  preparations,  he  said,  could  be  taken  in 
considerable  quantity  without  other  apparent  effect  than 
that  which  would  naturally  follow  the  ingestion  of  so  much 
alcohol.  Since  the  publication  of  my  paper  on  Assayed 
Galenical  Preparations,  in  this  Journal  (August  30,  1890), 

I  have  received  a  number  of  commendatory  letters,  and  am 
therefore  prompted  to  add  some  further  reasons  for  the 
position  I  have  taken.  One  gentleman  writes  as  follows: 


“  I  have  been  trying  to  follow  your  advice  in  the  adminis¬ 
tration  of  drugs  to  the  letter,  and  in  most  cases  have  had 
phenomenal  success,  but  occasionally  I  have  failed  to  get 
the  desired  results  ;  but,  after  reading  your  last  paper  in  the 
Journal,  I  am  led  to  think  that  my  lack  of  success  was  pos¬ 
sibly  due  to  the  administration  of  drugs  that  were  not  up 
to  the  standard,  although  I  have  tried  to  be  very  careful  in 
that  particular.”  Another  practitioner  writes  me  enthusi¬ 
astically  in  regard  to  the  wants  of  the  physician  in  the  di¬ 
rection  of  standardized  galenicals,  insisting  that  the  physi¬ 
cian  as  well  as  the  patient  suffer  from  this  lack  of  uniformi¬ 
ty.  As  an  evidence  of  the  dangers  connected  with  our 
practice  without  the  proper  safeguards,  he  relates  an  inci¬ 
dent  which  occurred  in  a  hospital  for  the  insane.  It  seems 
that  the  resident  had  been  using  the  fluid  extract  of  conium 
in  teaspoonful  doses  to  lessen  the  excitement  and  produce 
a  calmative  effect  upon  some  of  the  inmates  who  failed  to 
obtain  needed  repose.  A  new  supply  of  the  drug  had  been 
obtained,  and  the  physician  in  charge  was  not  aware  that 
the  product  came  from  a  different  manufacturer,  and,  the 
usual  dose  being  given,  the  following  morning  no  less  than 
seven  patients  were  found  dead.  There  could  be  no  other 
conclusion  than  that  these  deaths  were  due  to  the  greater 
activity  of  the  new  preparation  which  had  been  substituted 
lor  the  old.  With  our  knowledge  of  the  physiological  ac¬ 
tion  of  drugs,  I  doubt  if  such  an  accident  could  occur  at  the 
present  day  ;  our  knowledge  of  the  character  and  qualities 
of  drugs  is  too  thoroughly  diffused,  and  the  general  intelli¬ 
gence  which  pervades  all  classes  of  medical  practitioners 
forbids.  If  this  were  not  the  case,  I  should  be  inclined  to 
believe  that  the  regulation  of  these  preparations  was  not  an 
unmixed  blessing. 

The  foregoing  remarks  will  serve  in  a  measure  to  indi¬ 
cate  the  principles  which  should  govern  us  in  the  selection 
of  galenical  preparations;  at  the  same  time  it  will  show 
that  alkaloids,  or  their  salts,  which  are  true  chemical  prod¬ 
ucts,  might  often  be  used  with  safety,  and  that  they  might 
be  expected  to  supplant  entirely  the  use  of  galenical  prod¬ 
ucts.  It  must  be  remembered,  however,  that  the  crude 
drugs  have  been  used  for  a  long  time,  and  that  by  this 
usage  we  have  become  familiar  with  their  physiological  ac¬ 
tions,  statements  which  do  not  to  any  great  extent  apply  to 
alkaloidal  preparations.  Again,  many  of  these  crude  drugs 
contain  alkaloidal  substances,  as  well  as  resins  and  oils, 
which  exercise  more  or  less  influence  when  taken  into  the 
economy,  and  consequently  the  same  results  can  not  be  ex¬ 
pected  from  the  use  of  a  single  principle  which  has  hereto¬ 
fore  been  obtained  from  the  whole.  It  is  a  well-known 
tact,  too,  that  alkaloidal  substances, in  crude  drugs  often 
counteract  the  effects  of  one  another;  but  I  do  not  care  to 
go  into  a  discussion  of  that  question  at  the  present  time. 

It  will  be  sufficient  to  say  that  although  the  use  of  alkaloids 
is  at  present  subsidiary  to  the  employment  of  crude  drugs, 
the  true  basis  of  medication  rests  upon  this  as  a  foundation, 
and  in  time  I  am  convinced  that,  for  the  most  part,  the  use 
of  crude  drugs  will  become  subsidiary  to  the  administration 
of  the  alkaloids  and  their  salts. 

Unfortunately,  the  method  of  determining  the  physio¬ 
logical  activity  and  chemical  value  of  galenical  preparations 


464 


AULDE:  CRUDE  DRUGS  COMPARED  WITH  CHEMICAL  PRODUCTS.  [N.  Y.  Ukd.  Jouk., 


by  assay  process  has  been  seriously  opposed,  although, 
strange  to  say,  no  one  has  made  objections  to  the  demands 
of  experimental  physiologists  for  reliable  products  as  re¬ 
gards  physiological  activity  for  laboratory  investigations. 
The  necessity  for  integrity  in  laboratory  products  is  freely 
admitted,  but  the  same  rule  applied  to  medicaments  to  be 
used  in  the  treatment  of  disease  is  regarded  with  disfavor. 
The  exact  effect  of  duly  measured  products  upon  dogs, 
rabbits,  and  guinea-pigs  is  esteemed  of  more  importance 
than  the  saving  of  human  life.  Arguments  have  been  ad¬ 
vanced  purporting  to  show  that  the  variations  are  such  that 
it  would  be  impossible  to  accomplish  anything  which  would 
further  the  interests  of  the  practitioner  by  the  methods  pro¬ 
posed.  This  conclusion,  it  will  be  seen,  throws  the  entire 
responsibility  upon  the  physician,  and  compels  him  to  adopt 
what  is  known  among  carpenters  as  the  ‘‘try  rule”;  if  the 
usual  dose  of  the  selected  drug  fails  to  produce  the  re¬ 
quired  effect,  a  larger  quantity  must  be  tried.  The  varia¬ 
tions  occurring  in  the  alkaloidal  purity  of  cinchona  are 
cited  to  prove  the  unwisdom  of  attempting  to  govern  fin¬ 
ished  products  by  the  proportion  of  alkaloids.  Thus,  in 
the  examination  of  a  number  of  specimens  of  cinchona  cali- 
saya,  Eusby  finds  that  they  vary  from  2’2  per  cent,  total 
alkaloids  to  5T  per  cent.;  in  cinchona  red  the  variation 
was  even  greater,  being  as  low  as  5-2  per  cent,  and  as  high 
as  9'8  per  cent.  It  will  be  seen  at  a  glance  that  a  drachm 
of  one  preparation  would  carry  about  four  times  the  quan¬ 
tity  of  alkaloid  found  in  the  least  rich  of  the  crude  drugs 
and  the  use  of  preparations  of  this  class  without  some  ab¬ 
solute  knowledge  of  their  supposed  physiological  powers 
would  be  exceedingly  hazardous.  Instead  of  being  an  argu¬ 
ment  against  standardization,  therefore,  it  proves  bevond 
question  the  absolute  necessity  for  the  adoption  of  some 
such  process  as  a  guide  for  the  practitioner. 

An  explanation  will  serve  to  show  that  the  selection  of 
cinchona  as  a  basis  for  opposition  to  standardization  was 
unfortunate,  because  these  extraordinary  differences  occur 
in  the  products  obtained  from  cultivated  plants.  The  grow¬ 
ers  have  discovered  certain  artificial  means  by  which  the 
alkaloid  quinine  can  be  greatly  increased  at  the  expense  of 
the  cinchonidine  and  other  less  desirable  alkaloids,  and  this 
circumstance  has  been  urged  by  the  opponents  of  standard¬ 
ization,  who  would  have  us  believe  that  the  presence  of  a 
certain  percentage  of  alkaloid  is  no  true  criterion  of  the 
value  of  the  drug.  It  is  alleged,  for  instance,  that  in  the 
case  of  nux  vomica  the  determination  of  the  total  amount 
of  alkaloid  would  furnish  no  indication  of  the  exact  amount 
of  strychnine  contained.  The  sophistry  of  such  argument 
is  easily  unraveled ;  if  the  presence  of  a  larger  or  smaller 
amount  of  alkaloid  does  not  modify  the  action  of  the  drug, 
no  further  investigation  is  required.  If  the  activity  of  the 
drug  is  increased  or  diminished  in  proportion  to  the  total 
amount  of  alkaloid  contained,  the  physician  will  learn  to 
make  due  allowance  for  its  presence,  and  will  not  be  com¬ 
pelled  to  await  the  development  of  the  characteristic  physi¬ 
ological  action  when  prescribing  different  preparations,  or 
when  administering  it  to  different  patients.  How  much 
better  would  it  be  were  each  product  made  to  conform  to 
certain  tests  as  regards  alkaloidal  purity,  thus  relieving  the 


physician  from  the  peculiar  and  trying  position  as  that  in 
which  he  would  be  placed  ! 

A  distinction  must  be  made  between  cultivated  or  do¬ 
mestic  plants  and  natural  plants — i.  e.,  those  found  growing 
wild.  In  deciding  upon  a  preparation  of  digitalis,  this  is  a 
most  important  matter.  Professor  Bartholow,  in  his  lect¬ 
ures  to  students,  has  so  regularly  and  persistently  advised 
them  to  make  sure  that  their  patients  obtain  the  English 
digitalis  instead  of  the  square  packages  put  up  by  the  Shak¬ 
ers,  that  his  ideas  on  this  topic  have  been  disseminated  all 
over  the  world.  These  are  particulars  which  heretofore 
have  not  received  much  attention  at  the  hands  of  practi¬ 
tioners,  but  doubtless  in  the  future  assayed  galenicals  are 
destined  to  occupy  an  important  position  in  the  armamen¬ 
tarium  of  the  physician. 

There  are  several  other  galenical  products  to  which  I 
should  like  to  call  attention,  principally  because  of  the  vaii- 
ations  which  have  been  found  in  the  crude  drug,  as  I  be¬ 
lieve  such  knowledge  should  be  as  widely  disseminated 
as  possible.  An  examination  of  twenty-six  specimens  of 
belladonna  root  showed  that  the  maximum  alkaloidal 
strength  of  the  different  samples  was  about  50  per  cent, 
greater  than  the  minimum  ;  that  is,  a  single  drop  of  the 
tincture  or  fluid  extract  made  from  one  preparation  would 
contain  about  two  thirds  of  the  alkaloidal  strength  of  the 
other.  The  following  are  the  exact  figures :  Minimum 
strength,  0’53  per  cent,  atropine;  maximum  strength,  074 
per  cent,  total  alkaloid.  The  examination  of  twenty-two 
specimens  of  belladonna  leaves  showed  even  a  more  decided 
variation,  being  0-2  per  cent,  and  0-69  per  cent.,  respect¬ 
ively. 

An  examination  of  ten  specimens  of  colchicutn  seeds 
showed  marked  variations  in  alkaloidal  strength,  the  per¬ 
centage  ranging  from  04  per  cent,  to  1*06  per  cent.,  or,  in 
other  words,  one  preparation  was  about  two  and  a  half  times 
stronger  than  the  other.  Eight  specimens  of  ipecac  varied 
from  2  per  cent,  of  emetine  to  4T  per  cent.,  making  one 
preparation  twice  the  value  in  alkaloidal  strength  of  that 
containing  the  minimum  amount.  Nine  specimens  of  nux 
vomica  varied  from  IT  per  cent,  of  total  alkaloid  to  4'86 
per  cent.,  or  we  may  estimate  that  the  best  preparation  v'as 
about  five  times  the  value  of  the  poorest.  Fifteen  speci¬ 
mens  of  stramonium  leaves  varied  from  0’21  per  cent,  of 
alkaloid  to  0‘5  per  cent. ;  or,  to  put  it  in  another  form,  the 
best  was  two  and  a  half  times  more  active  than  the  poorest 
sample.  The  foregoing  memoranda  have  been  extracted 
from  a  paper  by  Dr.  Frank  Woodbury  ( Times  and  Register ), 
and  are  the  actual  records  of  the  scientific  department  of 
Messrs.  Parke,  Davis,  &  Co.,  who  have  shown  a  commenda¬ 
ble  activity  in  bringing  this  question  before  the  profession. 

While  it  is  true  that  the  above  includes  but  a  small  por¬ 
tion  of  the  drugs  in  general  use,  and  while  it  may  be  urged 
that  a  number  of  drugs,  such  as  aconite,  gelsemium,  and 
hyoscyamus,  can  not  practically  be  submitted  to  this  test, 
owing  to  the  very  small  proportion  of  the  alkaloid  and  the 
expense  connected  with  the  operation,  other  methods  which 
answer  our  purpose  have  been  adopted  and  are  found  avail¬ 
able.  Thus  aconite  is  submitted  to  the  physiological  test, 
gelsemium  is  subjected  to  certain  manipulations  with 


Oct.  25,  1890.1 


LEADING  ARTICLES. 


465 


Mayer’s  reagent,  and  a  like  method  lias  been  followed  in 
the  estimation  of  the  qualities  of  hyoscyamus  and  other 

products. 

In  view  of  the  extraordinary  differences  in  alkaloidal 
strength  of  the  crude  drugs  mentioned  above,  it  seems  a 
waste  of  words  to  argue  the  desirability  of  having  some 
definite  standard  adopted  which  shall  enable  manufacturers 
to  give  us  substantially  the  same  product.  The  standard 
should  not  be  so  high  that  it  would  be  difficult  to  conform 
to  the  requirements  when  the  crop  happened  to  be  of  an  in¬ 
ferior  quality  ;  but,  on  the  other  hand,  it  should  be  fixed 
at  a  point  that  would  insure  the  best  results  to  the  patient 
as  viewed  from  the  standpoint  of  the  physician.  At  the 
same  time,  it  would  be  necessary  to  make  a  distinction  be¬ 
tween  certain  kinds  of  crude  drugs,  just  as  is  now  made 
with  reference  to  the  different  brands  of  cinchona,  or  to  the 
two  varieties  of  digitalis  leaves  mentioned.  It  seems  in¬ 
credible  that  any  physician  should  object  to  the  use  of 
preparations  which  had  been  prepared  under  the  supervision 
of  thoroughly  qualified  chemists,  who  aim  to  afford  him 
some  positive  information  concerning  the  value  of  the  drug 
he  employs  when  studied  from  the  chemical  side.  It  is  but 
reasonable  to  suppose  that  such  preparations  would  be  more 
acceptable  to  the  intelligent  physician  than  crude  drugs 
prepared  haphazard  without  any  reference  to  their  active 
principles,  and  which  I  have  shown  may  vary  all  the  way 
from  a  trifling  percentage  to  400  or  500  per  cent.  If  it 
were  a  financial  question,  the  percentages  would  very  quick¬ 
ly  receive  attention. 

1910  Arch  Street. 


Induction  of  Abortion  for  Uncontrollable  Vomiting. — According  to 
the  British  Medical  Journal,  “  Dr.  Pugliatti,  of  Novara,  recommends 
that  in  cases  of  hyperemesis  gravidarum  where  milder  means  have 
failed,  abortion  should  be  induced  in  the  following  manner:  A  bougie 
about  two  fifths  of  an  inch  thick  is  pushed  upward  to  the  extent  of  two 
inches  into  the  uterus.  After  two  or  three  hours  this  bougie  is  re¬ 
placed  by  another  slightly  thicker,  and  after  the  same  space  of  time  a 
third,  thicker  than  the  second,  is  introduced.  This  last  bougie  is  left 
in  until  distinct  uterine  contractions  are  set  up.  This  method,  accord¬ 
ing  to  Dr.  Pugliatti,  is  free  from  danger.  The  membranes  are  not 
damaged,  and  in  the  worst  cases  there  remains  the  great  advantage  that 
the  lower  uterine  segment  has  been  brought  into  a  condition  favorable 
for  further  proceedings.” 

Color  of  Beef  Extract.— “  It  is  not  generally  known  that  pure  beef 
extract  is  of  a  dingy,  unpleasant  gray  color,  and  that  from  its  repulsive 
look,  especially  when  dissolved  or  made  into  beef  tea,  it  would,  unless 
doctored  up  as  is  now  done,  have  very  little  if  any  sale  or  use.  Science 
and  art  come  in  nicely  to  remedy  this  defect  by  furnishing  a  harmless 
4ve  namely,  burnt  sugar  or  caramel.  This  also  improves  the  flavor 
as  well  as  the  appearance.  We  see  no  harm  in  this  apparently  nice 
little  innocent  deception — especially  if  druggists  and  physicians  arc 
fully  acquainted  with  it,  as  they  soon  will  be.” — Druggist's  Circular 
and  Chemical  Gazette. 

Phenacetin  in  Typhoid  Fever— According  to  the  Lancet,  “  Dr.  Som¬ 
mer  has  used  phenacetin  with  great  success  in  the  treatment  of  typhoid 
fever,  thus  confirming  the  favorable  views  of  its  action  which  have  been 
expressed  by  Masius  and  others.  The  dose  employed  for  adults  was 
four  grains,  which  was  repeated  from  two  to  four  times  during  the 
twenty-four  hours.  Children  were  given  only  half  this  dose.  No  less 
than  sixty  cases  were  treated  in  this  way,  with  but  one  fatal  case,  about 
"liich  it  is  noted  that  the  patient  was  not  subjected  to  phenacetin 
treatment  until  three  weeks  from  the  commencement  of  the  attack  In 
no  case  were  there  any  serious  complications.” 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  bv 

D  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  OCTOBER  25,  1890.  . 

RHACHIOTOMY  FOR  PARAPLEGIA. 

In  the  July  number  of  the  Annals  of  Surgery ,  Dr.  F.  X. 
Dercum  and  Dr.  J.  William  White  report  the  result  of  a  rliachi- 
otomy  on  a  German,  aged  tifty-five  years,  who  was  attacked  in 
1887  with  severe  burning  and  shooting  pains  in  the  shoulder 
and  arms.  Shortly  after  the  development  of  these  symptoms 
an  increasing  weakness  of  the  lower  extremities  began  that 
rapidly  resulted  in  paraplegia,  including  the  anal  and  vesical 
sphincters.  Anaesthesia  extended  to  the  level  of  the  nipple; 
trophic  bed-sores  developed  ;  the  deep  and  superficial  reflexes 
became  exaggerated;  and  percussion  over  the  third,  fourth, 
and  filth  dorsal  spinous  processes  caused  pain,  while  percussion 
of  the  head  in  the  direction  of  the  spinal  axis  produced  a  se¬ 
vere  girdle  pain  at  the  level  of  the  nipples.  The  patient  be¬ 
came  worse  during  ten  months  of  internal  medication,  so  the 
first,  second,  third,  fourth,  and  fifth  dorsal  spines  and  laminae 
were  removed,  and  the  exposed  thickened  dura  incised.  The 
dura  was  attached  to  the  pia  by  numerous  adventitious  bands 
that  were  broken  down  ;  nothing  further  was  found  about  the 
spinal  cord.  A  few  hours  after  the  operation  the  girdle  pain 
passed  off,  the  following  day  sensation  in  the  feet  returned,  in 
two  months  voluntary  motion  was  possible,  and  there  was  some 
control  of  the  sphincters.  In  twelve  months  the  patient  had 
normal  control  of  the  sphincters  and  could  walk  about  the 
ward,  though  his  gait  was  a  trifle  spastic,  and  he  had  decided 
lordosis.  The  authors  consider  that  more  relief  was  afforded 
in  this  case  than  was  explicable  by  relieving  pressure,  and  they 
attach  considerable  importance  to  the  rupture  of  the  meningeal 
adhesions  and  the  reaction  of  nutrition  consequent  upon  the 
operation. 

The  authors  are  to  be  congratulated  upon  their  success,  that 
finds  a  parallel  in  a  case  reported  by  Mr.  W.  Arbuthnot  Lane 
in  the  Lancet  for-  July  5,  1890.  A  male,  aged  thirty-two  years, 
noticed  in  1888  a  pain  in  the  middle  of  the  back  while  run¬ 
ning;  six  months  later  a  prominence  appeared  on  the  spine 
that  was  treated  as  a  ganglion,  but  that  soon  developed  into  an 
angular  curvature.  About  March  1st  a  weakness  began  in  the 
right  leg,  and  the  toes  caught  a  little  in  drawing  the  foot  for¬ 
ward  ;  soon  (May  2d)  there  was  complete  paraplegia,  with  anal¬ 
gesia  of  the  extremities,  and  the  superficial  and  deep  reflexes 
were  markedly  present.  There  was  a  sharp  angular  curvature 
at  the  tenth  dorsal  vertebra.  On  May  13th  the  spinous  pro¬ 
cesses  and  laminae  of  the  ninth,  tenth,  and  eleventh  dorsal  ver¬ 
tebrae  were  removed  with  a  bone  forceps,  and  a  large  mass  of 
granulation  tissue,  resembling  tubercular  synovial  membrane, 
was  exposed  in  the  canal.  In  the  center  of  the  neoplasm  were 
about  eighty  minims  of  purulent  material,  that  was  let  out  in 


466 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Jour., 


removing  the  growth.  A  small  portion  of  the  latter  extended 
forward  to  the  right  of  the  dura;  the  meninges  were  healthy. 
Power  of  motion  of  the  extremities  and  diminution  of  the  ex¬ 
aggerated  reflexes  rapidly  ensued,  and  at  the  time  of  the  report 
the  patient  could  use  his  legs  freely  and  with  force. 

The  justifiability  of  surgical  interference  is  demonstrated  by 
the  conditions  found  in  these  cases,  that  suggest  the  resort  to 
operative  measures  in  analogous  conditions. 


NORMAL  PARTURITION  COMPLICATED  BY  AN  EXTRA- 
UTERINE  TWIN  FtETUS. 

Dr.  Harriman,  of  Laconia,  has  reported  to  the  State  Medi¬ 
cal  Society  of  New  Hampshire  a  case  which  he  regards  as  one 
of  twin  pregnancy,  w7ith  one  foetus  intra-uterine  and  the  other 
extra-uterine.  From  his  account  of  the  case,  given  in  the  Bos¬ 
ton  Medical  and  Surgical  Journal  for  August  14th,  it  appears 
that  the  parturition  of  the  intra-uterine  child  took  place  with¬ 
out  much  difficulty  at  full  term.  The  patient  was  a  primipara, 
aged  thirty-two.  The  course  of  gestation  had  been  marked  by 
few  unusual  symptoms,  except  that  at  about  the  fourth  month 
considerable  pain  was  complained  of  in  the  abdomen  ;  the  last 
eight  weeks  were  painful  and  locomotion  was  somewhat  diffi¬ 
cult.  As  seen  at  the  time  of  confinement,  the  abdomen  was 
greatly  enlarged  and  unusually  shaped  ;  just  above  the  pubes 
a  rounded  tumor  or  eminence  presented  itself,  resembling  a 
child’s  cranium,  and  lifting  the  integument  and  underlying 
parts  to  about  the  size  of  a  man’s  hand.  In  the  right  lumbar 
region  a  second,  smaller,  eminence  could  be  seen,  about  on  a 
line  with  the  umbilicus  ;  while  directly  above  the  umbilicus,  at 
the  fundus,  two  smaller  parts  could  be  felt  in  close  proximity. 
These  various  elevated  or  salient  parts  were  believed  to  belong 
to  the  foetuses  of  an  ordinary  case  of  twin  pregnancy,  rendered 
especially  tangible  by  reason  of  an  excessive  thinning  of  the 
abdominal  parietes.  The  duratiou  of  the  labor  was  seven 
hours,  and  it  resulted  in  the  birth  of  a  seven-pound  living  fe¬ 
male  infant,  soon  followed  by  its  placenta  and  membranes. 
All  pain  ceased,  but  there  was  evidently  another  child,  appar¬ 
ently  fully  grown,  and  it  was  in  the  abdomen.  Strong  pains 
were  experienced  on  the  day  after  delivery,  and  it  was  believed 
to  be  necessary  to  examine  the  patient  under  chloroform.  Bi¬ 
manual  manipulation  was  made,  and  it  showed  not  only  that 
the  uterus  was  entirely  emptied,  but  that  a  foetus  presented 
with  its  head  above  the  pubes,  probably  as  large  as  the  one  ex¬ 
pelled.  The  back  of  the  child  was  against  the  abdomen  of  the 
mother,  and  the  limbs,  hands,  and  feet  could  be  easily  outlined 
through  the  thin  intermediate  tissues.  No  signs  of  life  were  at 
any  time  recognized  in  the  abdominal  foetus.  Pains  recurred 
for  several  days  after  the  effects  of  the  anaesthetic  had  passed 
off,  requiring  large  doses  of  opium  to  afford  relief ;  but  at  the 
end  of  twelve  days  very  little  pain  was  complained  of.  With 
the  exception  of  these  pains,  there  were  no  untoward  symp¬ 
toms  during  the  convalescence.  The  size  of  the  ectopic  tumor 
was  gradually  reduced,  under  purely  expectant  treatment,  un¬ 
til,  at  the  end  of  three  months,  it  was  not  larger  than  a  good¬ 


sized  cocoanut.  The  patient  had  been  well  since  delivery,  and 
was  ignorant  of  the  nature  of  her  still  interesting  condition. 
Seven  months  had  elapsed  since  her  confinement  when  the  re¬ 
port  of  the  case  was  made,  as  above  stated,  and  there  had  been 
but  little  further  diminution  in  the  size  of  the  tumor  and  no 
indication  for  surgical  interference  for  the  removal  of  the 
foetus. 


MINOR  PARAGRAPHS. 

EXTRAVAGANCE  IN  THE  NAME  OF  CHARITY. 

Dr.  P.  H.  Tvretzsoiimar,  the  presiding  officer  of  the  Board 
of  Supervisors,  at  Brooklyn,  has  recently  had  occasion  to  write 
a  very  caustic  veto  touching  a  bill  for  repairs  at  the  branch 
asylum  for  the  insane  at  St.  Johnland.  The  branch,  also  called 
the  County  Farm,  is  forty-two  miles  distant  from  the  old  asy¬ 
lum  at  Flatbush,  and  has  proved  an  unexpectedly  heavy  burden 
on  the  taxpayers  on  account  of  “  extras.”  It  seems  likely  to 
cost  the  county  only  a  trifle  less  than  $2,000  per  capita  to  sim¬ 
ply  house  the  pauper  insane  of  that  community,  the  cost  of  the 
land,  chiefly  farm  lands  and  forests  being  included.  There  are 
costly  stone- built  and  fully  equipped  hospitals  in  our  cities  that 
have  cost  not  more  than  $2,000  per  capita,  cost  of  the  land  in¬ 
clusive;  while  some  others,  less  ornate  but  equally  well  adapted 
to  their  purposes,  have  been  constructed  for  $1,000  a  patient. 
From  the  standpoint  of  the  medical  superintendent,  the  effect 
of  the  political  pilfering  of  the  pauper  lunatic  is  deplorable. 
The  medical  men  can  not  be  ignorant  that  their  patients  are 
beingdefrauded,  and  yet  their  own  mouths  must  be  kept  closed  ; 
that  their  “  enthusiasm  of  humanity  ” — be  it  ever  so  bright  and 
noble  at  the  outset — is  tarnished  in  an  atmosphere  of  jobbery; 
and  that  their  best  efforts  for  the  treatment  and  restoration  of 
their  unfortunate  charges  can  not  be  put  forth.  Repression 
takes  the  place  of  encouragement  and  the  sympathy  of  their 
superiors,  and  they  fold  themselves  in  a  mantle  of  routineism. 

If  Dr.  Kretzschmar  has  set  before  himself  the  task  of  de¬ 
fending  the  otherwise  defenseless  county  lunatic,  he  has  not  en¬ 
tered  public  life  in  vain  ;  therefore  he  should  have  the  cordial 
support  of  his  medical  brethren. 


MOUNTAIN  DISEASE. 

In  the  Internationale  /clinische  Rundschau  Dr.  Liebig  pub¬ 
lishes  an  article  in  which  he  describes  a  disease  peculiar  to  great 
altitudes.  At  an  ascension  of  about  1,500  metres  the  first 
physiological  change  noticed  was  an  acceleration  of  therespira* 
tions  and  dyspnoea;  at  a  little  greater  elevation  an  unaccount¬ 
able  weakness  of  the  legs  came  on,  compelling  the  person  to  sit 
down.  At  a  still  greater  height,  from  3,000  to  5,000  metres, 
the  veins  would  become  full  and  the  face  livid,  with  headache, 
blindness,  nausea,  vomiting,  bleeding  from  the  various  mucous 
membranes,  and  stupor.  These  symptoms  seemed  to  have 
caused  no  organic  changes,  and  usually  disappeared  in  from  ten 
to  twelve  days,  only  a  slight  dyspnoea,  showing  itself  on  exer¬ 
tion,  and  depression  of  spirits  remaining.  Various  theories 
have  been  advanced  from  time  to  time  as  to  the  cause  of  these 
phenomena.  The  author  accentuated  the  point  that  many  of 
the  cases  of  so-called  mountain  disease  were  also  found  in  the 
low-lying  lands  of  the  heights,  as  well  as  at  the  great  elevations 
with  rarefied  air ;  also  that  the  disease  was  not  constant,  and 
that  only  under  certain  circumstances  could  the  attack  come 
on.  If  the  rise  was  gradual  and  rest  was  taken  at  frequent  in¬ 
tervals,  the  lungs  could  expand  and  the  breathing  adapt  itself 
to  the  diminished  air-pressure;  but  if  the  strength  gave  out, 


Oct.  25,  1890.] 


MINOR  PARAGRAPHS. 


467 


then  would  follow  a  paroxysm.  Again,  if  there  was  any  lack 
of  elasticity  or  constriction  of  the  lung  motor-power,  the  con¬ 
dition  would  be  unfavorable  for  adaptation  to  the  change  in 
atmospheric  pressure.  The  author  was  convinced,  from  ex¬ 
tended  experimental  research  and  personal  observation,  that 
the  disease  was  not  due  alone  to  the  decrease  of  carbonic-acid 
gas  in  the  air,  nor  to  the  diminished  air-pressure,  but  to  a  pe¬ 
culiarity  of  lung  elasticity  which  in  some  cases  allowed  the  sys¬ 
tem  to  become  surcharged  with  venous  blood. 


ETHEREAL  PREPARATIONS  AS  TOPICAL  REMEDIES. 

Sir  James  Sawyer,  of  the  Queen’s  Hospital,  Birmingham, 
writes  in  the  Lancet  in  high  commendation  of  ethereal  tinctures 
as  topical  application®,  chiefly  on  account  of  the  osmotic  capa¬ 
city  of  ether  and  its  solvent  action  on  the  fatty  constituents  of 
the  sebaceous  secretion  of  the  skin,  whereby  the  most  inrimate 
application  of  remedies  to  the  epidermis  is  facilitated.  He  has 
made  special  use  of  ethereal  preparations  of  belladonna,  iodine, 
menthol,  and  capsicum. 


HYSTEROPEXY. 

Dr.  Pozzi  proposes,  in  the  Annales  de  gynecologic^  a  modi¬ 
fication  of  hysterorrhaphy,  which  he  denominates  “hystero¬ 
pexy,’  or  binding  of  the  uterus.  The  steps  of  the  operation, 
alter  the  uterus  has  been  exposed  and  brought  into  close  prox¬ 
imity  to  the  abdominal  wound,  are  the  employment  of  a  con¬ 
tinuous  silk  suture  passed  from  the  left  side  of  the  patient  to 
the  right  through  the  posterior  sheath  of  the  rectus  muscle,  the 
peritonaeum,  and  the  uterus  in  the  middle  line;  thence  the 
suture  is  passed  outward  through  the  peritonaeum  and  the  sheath 
of  the  rectus  on  the  right  side  of  the  wound.  The  suture  is 
thus  passed  three  times  through  the  uterus,  transfixing  the 
organ  a  short  distance  below  the  serous  covering.  The  suture 
is  tied  and  cut  short.  The  more  superficial  layers  of  the  ab¬ 
dominal  wound  are  then  brought  together  and  closed  by  a  sep¬ 
arate  suturing.  Pozzi  describes  two  cases  of  retroflexion  of 
the  uterus,  with  more  or  less  of  inflammatory  adhesions,  treatec 
by  this  operation.  The  first  case  was  entirely  successful,  anc 
it  was  one  in  which  Alexander’s  operation  had  been  done  with¬ 
out  affording  relief.  The  second  case  was  less  fortunate,  hav¬ 
ing  been  attended  by  suppurative  inflammation  at  the  lower 
part  of  the  wound,  which  was  probably  due  to  an  imperfect 
boiling  of  the  silk  suture;  but  the  uterus  in  both  these  cases 
remained  firmly  fixed  to  the  anterior  abdominal  wall.  Pozzi 
prefers  the  continuous  to  the  interrupted  suture,  passed  outside 
and  through  the  integuments,  as  affording  a  firmer  and  more 
certain  kind  of, adhesion. 


HOW  TO  KEEP  THE  PAQUELIN  CAUTERY  IN  GOOD  ORDER. 

According  to  Le  Praticien ,  quoted  in  Z’ Union  medicate, 
Paquelin’s  cautery  would  never  be  found  out  of  order  if  the 
following  instructions,  given  by  M.  Colin,  were  followed  strict¬ 
ly :  The  benzin  employed  should  be  of  from  700°  to  720°, 
using  the  petroleum  densimeter,  at  a  temperature  of  59°  F.,  that 
is  to  say,  it  should  weigh  from  700  to  720  grammes  to  the  litre. 
At  most,  it  should  not  occupy  more  than  a  third  of  the  capacity 
of  the  reservoir.  In  case  of  need,  the  hand-bulb  may  be  replaced 
by  a  pair  of  bellows.  During  the  whole  operation,  the  temper¬ 
ature  of  the  benzin  should  be  kept  at  from  59°  to  68°  F.,  to  ac¬ 
complish  which  it  is  only  necessary  to  hold  the  reservoir  in  the 
hand  or  carry  it  in  one’s  pocket.  Too  high  a  temperature  hinders 
the  incandescence  of  the  cautery.  The  platinum  point  should 
be  placed  in  the  lateral  portion  of  the  flame,  at  the  level  of  the 
center.  Lse  pure  alcohol  for  the  lamp.  Avoid  heating  the 
platinum  to  the  luminous  point.  If  the  cautery  cools  off,  work 
the  bulb  vigorously,  and  if  necessary  place  the  point  in  the  flame 
again.  When  the  operation  is  finished,  before  allowing  the  cau¬ 
tery  to  become  extinguished,  bring  it  to  a  bright  red  by  a  few 
rapid  insufflations,  and  then,  while  it  is  fully  incandescent,  de- 
Lach  the  rubber  tube  from  the  handle  suddenly.  Let  the  cau¬ 
tery  cool  in  the  open  air.  Cleanse  it  with  a  moistened  rag.  If 
die  instrument  is  not  used  very  often,  it  is  well  to  heat  the  va¬ 
rious  points  from  time  to  time. 


THE  CALIFORNIA  VINTAGE  COMPANY. 

We  have  several  times  spoken  in  commendation  of  the 
wines  and  brandies  furnished  by  the  California  Vintage  Com¬ 
pany.  The  company  has  devoted  great  care  to  the  task  of  pro¬ 
viding  products  of  the  best  character  for  medical  purposes,  and 
has  thus  established  a  reputation  in  the  medical  profession  that 
certain  unscrupulous  persons  seem  disposed  to  profit  by,  espe¬ 
cially  in  the  matter  of  tokay  wine.  The  company  announces 
that  the  trade  name  of  its  “  Royal  Tokay  ”  has  been  copied, 
and  that  inferior  wines  sold  under  that  name  have,  as  might 
have  been  expected,  proved  disappointing  to  physicians  who 
prescribed  the  genuine  article.  On  that  account,  the  company 
asks  physicians  to  prescribe  “  Calvico  Tokay  ”  when  they  mean 
the  wine  heretofore  known  as  “Royal  Tokay.” 


A  HOSPITAL  CENSURED. 

A  coroner’s  jury  in  Kings  County  has  passed  a  vote  of 
censure  against  the  Long  Island  College  Hospital,  in  conse¬ 
quence  of  the  death  of  a  patient  by  suicide.  The  case  was  one 
of  alcoholic  delirium.  The  patient  was  confined  in  a  private 
room,  manacled  by  both  hands  and  feet,  and  fastened  to  the 
bed  with  a  rope,  and  yet  she  managed  to  slip  away  from  her 
fastenings  and  cast  herself  down  from  the  window,  which  was 
not  barred.  Under  the  terms  of  the  jury’s  verdict  “the  authori¬ 
ties  of  the  hospital  are  responsible  for  being  negligent  in  not 
providing  the  proper  care  to  prevent  the  said  patient  from  tak¬ 
ing  her  own  life.”  Alcoholic  delirium  cases  are  not  “interest¬ 
ing”  ones  at  any  hospital,  as  they  entail  extraordinary  vigi¬ 
lance,  care,  and  expense,  but  that  is  no  reason  why  that  class 
of  cases  should  be  overlooked  or  refused  admittance,  as  is  the 
manner  of  some  who  are  in  the  receipt  of  municipal  funds; 
while  it  may  be  a  reason  against  an  attempt  to  treat  the  sufferer 
at  his  home  or  in  any  private  house.  They  are  peculiarly  hos¬ 
pital  cases. 


MALARIAL  GERMS. 

Dr.  F.  Neelsen,  in  the  Centralblatt  fur  kliniscTie  Medicin , 
quoting  from  the  writings  of  Camillo  Golgi,  in  the  Archivio  per 
le  scienze,  says  that  two  distinct  types  of  bacilli  have  been  dem¬ 
onstrated  as  causing  the  tertian  and  quartan  malarial  fevers. 
Biologically,  the  tertian  germ  completes  its  development  in  two 
dajs  and  the  quartan  in  three,  and  the  amoeboid  movements  of 
the  tertian  type  are  much  more  marked  than  those  of  the  quar¬ 
tan.  Clinically,  the  destruction  of  the  hiemoglobin  in  the  red 
corpuscles  is  much  more  rapid  in  the  tertian  than  in  the  quar¬ 
tan.  Morphologically,  the  difference  is  to  be  seen  in  the  first 
stages  of  development;  the  amoeba  of  the  tertian  has  a  more 
delicate  mass  of  protoplasm  and  a  sharper  contour  than  those 
of  the  quartan,  while  the  pigment  granule  and  bacillus  of  the 
quartan  are  larger  and  coarser.  Finally,  segmentation  takes 
place  in  a  less  regular  manner  in  the  tertian  than  in  the  quar¬ 
tan  organism. 


4G8 


ITEMS.— PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jonk., 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  October  21,  1890: 


DISEASES. 

Week  ending  Oct.  14. 

Week  ending  Oct.  21. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

45 

16 

44 

9 

Scarlet  fever . 

25 

5 

25 

1 

Cerebro-spinal  meningitis . 

0 

0 

0 

0 

Measles . 

.  79 

6 

52 

5 

Diphtheria . 

46 

15 

57 

17 

Small-pox . 

0 

0 

1 

0 

Varicella . 

0 

0 

2 

0 

The  District  Medical  Society  of  Central  Illinois  will  hold  its  fif¬ 
teenth  semi-annual  meeting  in  Decatur  on  Tuesday,  the  28th  inst., 
under  the  presidency  of  Dr.  W.  P.  Buck,  of  Moawequa.  The  pro¬ 
gramme  gives  notice  of  the  following  reports  and  essays :  Surgery,  by 
Dr.  G.  N.  Kreider,  of  Springfield ;  Some  Notes  on  Hodgen’s  Splint,  by 
Dr.  W.  J.  Chenoweth,  of  Decatur ;  The  Essential  Oils  in  Surgery,  by 
Dr.  C.  E.  Black,  of  Jacksonville ;  Some  Surgical  Cases,  by  Dr.  W.  M. 
Harsha,  of  Chicago;  Premature  Expulsion  of  the  Ovum,  by  Dr.  L.  P. 
Walbridge,  of  Decatur;  Puerperal  Eclampsia,  by  Dr.  F.  B.  Haller,  of 
Yandalia;  Cervical  Laceration,  by  Dr.  L.  A.  Malone,  of  Jacksonville; 
Neurasthenia  Fceminea,  by  Dr.  Amos  Sawyer,  of  Hillsboro;  and  Alco¬ 
holism  and  Insanity,  by  Dr.  F.  P.  Norbury,  of  Jacksonville. 

The  Brooklyn  Surgical  Society. — At  the  meeting  held  on  Thursday 
evening,  the  16th  inst.,  Dr.  L.  S.  Pilcher  read  a  paper  on  The  Question 
of  the  Propriety  of  Suturing  Recent  Fracture  of  the  Patella. 

The  United  States  Marine-Hospital  Service. — A  board  of  examiners 
will  sit  for  the  examination  of  candidates  for  admission  into  the  serv¬ 
ice,  at  the  Marine  Hospital  at  Stapleton,  Staten  Island,  N.  Y.,  begin¬ 
ning  on  Monday,  the  27th  inst. 

The  New  York  Polyclinic. — Dr.  Dillon  Brown  has  been  appointed 
instructor  in  intubation  of  the  larynx  on  the  cadaver. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army ,  from  October  12  to  October  18,  1890 : 

By  direction  of  the  Acting  Secretary  of  War,  the  retirement  from  active 
service  on  October  12,  1890,  by  operation  of  law,  of  Cherbonnier, 
Andrew  V.,  Captain  and  Medical  Storekeeper,  under  the  provisions 
of  the  act  of  Congress  approved  June  30,  1882,  is  announced.  Par. 
11,  S.  0.  240,  A.  G.  O.,  Washington,  D.  C.,  October  13,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  October  18,  1890 : 
Bright,  George  A.,  Surgeon.  Detached  from  temporary  duty  at  the 
Naval  Academy  and  placed  on  waiting  orders. 

Ayres,  J.  G.,  Surgeon.  Detached  from  temporary  duty  at  the  Naval 
Academy  and  placed  on  waiting  orders. 

Lumsden,  George  P.,  Passed  Assistant  Surgeon.  Detached  from  the 
U.  S.  Steamer  Boston  and  granted  three  months’  leave. 

Anzal,  E.  W.,  Passed  Assistant  Surgeon.  Detached  from  the  Naval 
Academy  and  ordered  to  the  U.  S.  Steamer  Boston. 

Smith,  Howard,  Surgeon.  Ordered  to  appear  before  the  retiring  board 
at  Mare  Island,  Cal. 

Society  Meetings  for  the  Coming  Week  : 

Monday,  October  27th:  Medical  Society  of  the  County  of  New  York  ; 
Boston  Society  for  Medical  Improvement ;  Lawrence,  Mass.,  Medical 
Club  (private) ;  Cambridge,  Mass.,  Society  for  Medical  Improve¬ 
ment  ;  Baltimore  Medical  Association. 

Tuesday,  October  28th:  New  York  Academy  of  Medicine  (Section  in 
Laryngology  and  Rhinology) ;  New  York  Dermatological  Society 
(private);  Buffalo  Obstetrical  Society  (private);  Medical  Societies 
of  the  Counties  of  Queens  (semi-annual — Garden  City)  and  Rock¬ 
land  (semi-annual),  N.  Y. ;  Boston  Society  of  Medical  Sciences  (pri¬ 
vate). 


Wednesday,  October  29th :  Auburn,  N.  Y.,  City  Medical  Association ; 
Berkshire,  Mass.  (Pittsfield)  and  Middlesex,  Mass.,  North  District 
(Lowell)  Medical  Societies ;  Gloucester,  N.  J.,  County  Medical  Soci¬ 
ety  (quarterly). 

Thursday,  October  30th:  Massachusetts  Medical  Benevolent  Society 
( annual ). 

Friday,  October  31st :  New  York  Clinical  Society  (private). 

Saturday,  November  1st :  Clinical  Society  of  the  New  York  Post-gradu¬ 
ate  Medical  School  and  Hospital;  Manhattan  Medical  and  Surgical 
Society  (private);  Miller’s  River,  Mass.,  Medical  Society'. 


IJrocccinnp  of  Societies. 


MISSISSIPPI  VALLEY  MEDICAL  ASSOCIATION. 

Sixteenth  Annual  Meeting ,  held  in  Louisville , 

October  8,  9,  and  10,  1890. 

The  President,  Dr.  J.  M.  Mathews,  of  Louisville,  in  the  Chair. 

Infectious  Dyspepsia  and  its  Rational  Treatment  by  the 
Antiseptic  Method  was  the  title  of  a  paper  by  Dr.  Frank 
Woodbury,  of  Philadelphia,  who  limited  his  consideration  of 
the  subject  to  gastric  dyspepsia.  He  considered  dyspepsia  en¬ 
titled  to  recognition  as  a  distinct  disease.  It  was  characterized 
clinically  by  manifestations  of  nervous  disorder  ;  so  that  Cullen 
had  not  been  very  far  wrong  in  considering  it  as  a  neurosis, 
under  the  class  of  Adynamice.  Its  most  marked  symptoms  were 
produced,  the  author  believed,  by  the  absorption  of  products  of 
parasitic  micro-organisms.  Of  late  years  bacteriology  had  made 
wonderful  advance,  and  especially  in  the  department  of  bacte¬ 
rial  parasiticism,  or  infection,  and  its  relation  to  disease.  Abe- 
]ous,  a  recent  investigator  of  this  subject,  had  found  sixteen 
species  existing  normally  in  his  own  stomach,  of  which  two 
were  micrococci,  thirteen  were  bacilli,  and  one  was  a  vibrio. 
The  presence  of  saprogenic  microbes  in  the  stomach,  therefore, 
being  constant  and  not  incompatible  with  health,  it  became  ne¬ 
cessary  to  inquire  why  fermentation  or  putrefaction  of  the  food 
did  not  occur  after  every  meal.  In  other  words,  how  was  prac¬ 
tical  antisepsis  obtained  by  natural  processes?  Three  things 
were  to  be  considered  in  this  connection  :  (1)  the  food,  (2)  the 
digestive  fluids,  and  (3)  the  physical  conditions  attending  the 
act  of  digestion.  Laborious,  painful,  and  imperfect  digestion 
occurring  habitually,  when  not  symptomatic  of  other  disease, 
constituted  dyspepsia;  and  when  it  was  accompanied  by  fei- 
mentation  of  the  contents  of  the  stomach  and  general  toxic 
symptoms,  the  result  of  microbian  development,  it  might  prop¬ 
erly  be  called  infectious  dyspepsia.  The  disorder  was  sufficiently 
prevalent,  and  gave  rise  to  enough  discomfort  and  actual  suffer¬ 
ing  in  its  victims,  not  only  to  deserve  our  serious  consideration, 
but  also  to  enlist  our  best  therapeutic  skill  in  their  behalf.  The 
excessive  growth  of  micro-organisms  during  digestion  was  fa¬ 
vored  by  slow  movements  of  the  stomach  and  by  defective  quan¬ 
tity  or  quality  of  the  gastric  juice.  Acid  dyspepsia,  or  sour 
stomach,  might  be  due  in  rare  cases  to  excessive  secretion  of 
hydrochloric  acid,  but  was  generally  caused  by  lactic,  acetic,  or 
butyric  fermentation,  due  to  the  presence  of  appropriate  forms 
of  bacteria  in  the  stomach.  The  object  of  treatment  of  infec¬ 
tious  dyspepsia  was  to  prevent  the  excessive  development  of  mi¬ 
cro-organisms  during  digestion.  This  was  sought  to  be  accom¬ 
plished  (1)  by  the  use  of  articles  of  diet  that  were  not  in  a  fer¬ 
menting  condition  or  readily  fermentable  ;  (2)  by  adopting  such 
hygienic  and  tonic  measures  as  would  invigorate  the  bodily  pow¬ 
ers  and  especially  bring  the  gastric  juice  up  to  its  normal  stand¬ 
ard  of  quality  and  quantity,  and  increase  the  muscular  power  of 


Oct.  25,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


469 


tbe  stomach ;  and  (3)  by  local  antiseptic  treatment,  including 
the  administration  of  drugs  that  retarded  fermentation,  and  es¬ 
pecially  by  irrigation  of  the  stomach  with  weak  disinfectant  so¬ 
lutions  or  simply  recently  boiled  water. 

Help  and  Hindrance  to  Medical  Progress. — Dr.  John  II 
Hollister,  ot  Chicago,  read  a  paper  on  this  subject.  He  said 
the  possibility  of  progress  was  conditioned  upon  the  present 
imperfection  of  attainment ;  results  were  dependent  upon  our 
abilities,  upon  our  methods,  and  upon  the  obstacles  to  be  over¬ 
come.  The  profession  must  command  a  much  higher  average 
ot  native  talent;  that  talent  must  receive  a  much  higher  grade 
of  culture;  and  the  present  methods  of  research  on  the  part  of 
the  profession  must  be  greatly  modified  and  improved. 

{To  be  continued.) 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  SURGERY. 

Meeting  of  October  13 ,  1890. 

Dr.  B.  F.  Curtis  in  the  Chair. 

Fractures  of  the  Fibula.— Dr.  A.  J.  McCosn  showed  a  pa¬ 
tient.  aged  fortyr-six  years,  who,  on  May  22,  1889,  had  been  in¬ 
jured  while  in  the  act  of  lifting  a  horse’s  foot.  The  animal  had 
rolled  over  against  the  inside  of  his  thigh  at  the  same  time  that 
his  leg  slipped  under  the  horse  into  a  position  of  extreme  ad¬ 
duction,  when  he  felt  a  pain  and  u  something  gave  way”  on  the 
outer  side  of  his  knee,  and  he  found  himself  unable  to  get  up. 
On  examination,  the  injury  was  found  to  consist  of  a  breaking 
oft  of  the  upper  end  of  the  fibula,  a  fragment  about  three  quar¬ 
ters  of  an  inch  in  length  being  drawn  upward  for  an  inch  by 
the  contracting  force  of  the  outer  hamstring.  There  was  con¬ 
siderable  swelling  about  the  outer  side  of  the  joint,  but  no  lux¬ 
ation  could  be  produced.  The  limb  was  flexed  in  a  double-in¬ 
clined  plane  about  thirty  degrees  and  the  thigh  slightly  bent  on 
the  pelvis.  A  strip  of  adhesive  plaster  steadied  and  pulled  down 
the  upper  fragment.  In  this  position  the  distance  was  about 
halt'  an  inch.  At  the  end  of  three  weeks  a  plaster-of- Paris 
splint  was  applied,  the  leg  being  semi-flexed.  The  patient  went 
about  on  crutches,  and  at  the  end  of  the  sixth  week  the  splint 
was  removed.  After  three  months  tbe  patient  walked  without 
a  limp  and  his  injured  limb  was  practically  as  good  as  ever. 

A  second  patient  was  shown,  aged  thirty-one  years,  who 
had  several  years  before  sustained,  on  two  occasions,  a  fracture 
of  the  left  femur,  and  in  consequence  had  had  partial  ankylosis 
of  the  knee  joint.  On  August  26th,  while  descending  some 
stairs,  he  slipped,  and  made  a  violent  and  sudden  effort  to  re¬ 
cover  himself.  In  doing  so  he  heard  and  felt  something  snap 
on  the  outer  side  of  his  left  knee.  He  fell  and  was  unable  to 
get  up.  Fracture  of  the  upper  end  of  the  fibula  was  found.  The 
upper  fragment  consisted  of  the  styloid  process,  which  was 
drawn  slightly  upward  by  the  biceps  tendon.  The  leg  was  flexed 
on  the  thigh  and  a  right-angled  splint  applied,  a  pad  pressing 

the  upper  fragment  into  place.  The  patient  now  bad  bony 

union. 

Dr.  C.  A.  Powers  said  that  of  the  record  of  four  hundred 
and  forty-eight  cases  of  fracture  of  the  leg  in  the  service  of  Dr 
W-  r-  Boll,  at  tbe  Chambers  Street  and  Bellevue  Hospitals,  there 
had  been  only  one  case  of  fracture  of  the  fibula  immediately  be¬ 
low  its  head.  No  nerve  lesion  or  paralysis  had  supervened,  and 
perfect  bony  union  had  taken  place  in  about  eight  weeks,  with 
uo  limp  and  no  deformity. 

Extensive  Bullet  Wound  of  the  Knee  without  Injury 
to  the  Bones.— The  next  case  was  that  of  a  police  officer.  On 
the  evening  of  August  21st  he  accidentally  shot  himself  through 


the  knee  joint.  The  bullet  entered  the  upper  part  of  the  joint, 
which  it  ti  a  versed  for  nearly  its  whole  extent,  lodging  just  be¬ 
neath  the  skin.  In  its  passage  through  the  joint  not  the  slight¬ 
est  damage  was  done  to  any  of  the  bony  structures.  Blood  and 
synovial  fluid  had  oozed  from  the  joint,  and  a  few  fragments  of 
clothing  were  picked  out.  The  joint  was  irrigated  with  boro- 
salicvlic  solution  and  a  small  drainage-tube  inserted,  the  upper 
part  of  the  wound  being  packed  with  iodoform  gauze.  The  knee 
was  kept  immobilized  until  September  23d.  On  September  26th, 
thirty-five  days  from  the  accident,  the  patient  had  begun  to  walk. 
It  was  now  seven  weeks  and  he  walked  without  a  limp.  The 
leg  could  be  flexed  to  a  right  angle  and  was  daily  improving. 
I  here  wras  no  doubt  that  in  another  month  the  patient  would 
have  a  perfect  limb. 

Two  Cases  of  Hip-joint  Disease  treated  by  Immobiliza¬ 
tion.— Dr.  A.  M.  Phelps  showed  two  patients,  one  cured  and 
tbe  other  under  treatment  by  means  of  his  immobilization 
splints.  [A  report  of  these  cases  to  be  published.] 

II is  argument  was  that,  if  a  case  were  treated  in  time  and 
upon  proper  surgical  principles,  no  deformity  ought  to  result. 
It  had  been  urged  again  and  again,  as  an  argument  against  fixa¬ 
tion  of  the  hip  joint,  that  ankylosis  was  sure,  or  very  likely,  to 
ensue.  The  patient,  a  little  girl,  whom  he  now  presented  cured, 
had  been  put  under  treatment  and  her  limb  had  been  immobil¬ 
ized  for  sixteen  months.  It  would  be  seen  that  she  could  now 
walk  well,  there  was  scarcely  any  shortening,  and  the  joint  was 
freely  movable. 

The  Chairman  said  that  the  cases  presented  were  speaking 
witnesses  of  the  freedom  from  danger  and  excellent  results  that 
were  attainable  by  the  method. 

Trendelenburg’s  Operating  Chair.— Dr.  Willy  Meyer  de¬ 
scribed  and  showed  a  new  operating  table  that  he  had  brought 
Irom  abroad.  The  table  was  designed  by  Professor  Trendelen¬ 
burg,  chief  of  the  surgical  clinic  at  the  University  of  Bonn, 
Germany,  for  the  purpose  of  facilitating  operations  in  the  post¬ 
ure  bearing  his  name.  The  only  difficulty  that  had  been  con¬ 
nected  with  this  position,  which  became  especially  evident  in 
operations  occurring  in  private  practice,  was  the  providing  of 
a  proper  and  steady  support  for  the  patient  without  the  help  of 
an  additional  nurse.  Trendelenburg’s  new  table  overcame  this 
insufficiency  in  a  simple  and  effective  manner,  and  offered  be¬ 
sides  many  new  and  important  advantages.  The  table  consisted 
of  four  parts,  which  could  be  put  together  easily  find  taken 
apart  just  as  simply.  They  were  small  enough  to  be  sent  by  an 
expiess  wagon  to  the  patient’s  home.  The  four  parts  were:  1 
The  pedestal.  2.  The  seat,  which  had  the  shape  of  a  carriage 
seat.  3.  The  rest  for  the  back.  4.  The  rest  for  the  head.  Two 
movable  shoulder  hollows  were  attached  to  the  back-rest.  If 
everything  was  in  place,  the  table  could  be  adapted  to  Trende¬ 
lenburg’s  posture  by  pressing  down  the  handle  at  the  top  of  tbe 
back-rest.  The  back-rest  and  seat  were  connected  by  hinges. 
The  table  could  be  lowered  to  2|  feet  from  the  ground  and 
raised  to  5  feet  by  means  of  a  rack  and  pinion,  and  also  swung 
around  a  vertical  axis.  If  one  was  operating  with  the  help  of 
light  from  the  side,  a  full  daylight  view  could  always  be  got  of 
the  true  pelvis  and  its  contents  without  moving  the  whole  table. 
There  was  a  trap-door  in  the  seat  of  the  chair,  by  which  means, 
the  whole  perinseura,  rectum,  urethra,  bladder,  or  vagina  could 
be  brought  into  view  and  fully  exposed  while  the  patient  re¬ 
mained  entirely  undisturbed  in  the  recumbent  posture.  The 
patient  was  put  on  the  table,  as  in  an  ordinary  office  chair.. 

1  he  feet  were  secured  by  straps,  and  the  shoulders  caught  by 
the  hollows  mentioned  above.  The  table  was  now  fastened, 
the  patient  upon  it,  at  any  height  or  angle  of  inclination.  The 
table  could  also  be  utilized  for  office  use  by  using  a  narrower  seat 
and  divergent  foot-holders.  There  was  no  doubt  that  Trendelen- 


470 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


burg’s  posture  had  been  made  much  more  useful  by  his  new- 
table,  and  would  conseqoently  be  still  more  generally  adopted. 
The  chair  could  be  obtained  or  ordered  from  Mr.  F.  A.  Esth- 
baum,  Bonn,  Germany.  The  price  without  duty  was  about 
$90;  with  substitute  seat.  $125. 

Lessons  taught  by  Three  Fatal  Abdominal  Operations. 
— Dr.  J.  B.  Roberts,  of  Philadelphia,  read  a  paper  with  this 
title.  The  operations  were :  1.  An  attempt  at  nephrectomy,  by 
the  abdominal  route,  for  tubercular  and  calculous  nephritis. 
The  autopsy  in  this  case  had  shown  quite  clearly  that  lumbar 
nephrotomy  would  have  led  to  a  definite  diagnosis,  and  pos¬ 
sibly,  perhaps  probably,  would  have  been  followed  by  cure  after 
a  prolonged  course  of  treatment.  2.  Cholecystotomy.  Gall¬ 
stones  were  not  found,  and  the  cause  of  jaundice  was  not  dis¬ 
covered.  The  post-mortem  examination  revealed  a  foetid  ab¬ 
scess  between  the  gall-bladder  and  adherent  coils  of  intestine, 
and  indicated  that  the  jaundice  was  due  to  pressure  on  the  com¬ 
mon  bile  duct  by  this  abscess  and  other  inflammatory  products. 
3.  An  operation  for  radical  cure  of  a  large  umbilical  hernia,  in 
which  death  had  followed.  The  clinical  history  of  the  first  case 
was  as  follows:  The  patient,  a  woman  aged  forty -two  years, 
had  previously  suffered  with  what  was  said  to  have  been  pneu¬ 
monia,  from  which  time  she  had  never  been  in  good  health. 
About  nine  months  previous  to  the  writer’s  seeing  her  she  had 
been  seized  suddenly  with  severe  pain  in  the  right  side,  which 
extended  down  into  the  right  leg.  This  was  followed  by  an 
illness  which  coufined  her  to  bed  for  fourteen  weeks.  During 
this  time  the  urine  was  scanty  and  cloudy,  and  produced  a  burn¬ 
ing  sensation  when  being  voided.  Her  health  had  progressively 
failed,  and  she  had  lost  nearly  fifty  pounds  in  weight  in  the  two 
years  folio  wing  the  pneumonic  trouble.  Before  she  came  under 
the  writer’s  notice  a  tumor  was  discovered  in  the  right  hypochon¬ 
driac  region.  Examination  had  shown  the  patient  to  be  ex¬ 
tremely  emaciated,  very  feeble,  and  with  a  hard,  globular  mass, 
of  about  the  size  of  a  foetal  head  at  term,  situated  in  the  right 
hypochondrium.  Counter-pressure  on  the  loin  caused  the  tu¬ 
mor  to  project  much  more  prominently  against  the  anterior 
wall.  The  urine  contained  large  quantities  of  pus.  The  diag¬ 
nosis  was  of  a  growth  of  renal  origin,  which,  in  all  probability, 
would  be  found  to  be  a  disorganized  and  suppurating  kidney, 
perhaps  containing  calculi.  After  consultation,  an  abdominal 
incision  was  decided  upon,  with  the  expectation  of  removing 
the  tumor  radically.  An  incision  was  made  over  the  convexity 
of  the  tumor  corresponding  with  the  right  semilunar  line.  The 
omentum,  which  was  spread  over  and  adherent  to  the  mass, 
was  torn  through  with  the  fingers.  The  presenting  part  of  the 
growth  consisted  of  a  sac  filled  with  a  whitish  fluid.  This  was 
recognized  as  a  puriform  collection  in  the  kidney,  and  was 
then  removed  as  well  as  possible,  the  contents  being  too  thick 
to  flow  readily.  About  half  of  the  tumor  was  separated  from 
its  surroundings,  but  it  soon  became  apparent  that  it  would 
be  impossible  to  enucleate  it  completely,  because  of  the 
firm  adhesions  to  the  viscera  and  the  posterior  abdominal 
wall.  It  was  determined  that  the  only  safe  course  was  to 
abandon  the  operation  of  nephrectomy  and  to  stitch  the  peri- 
tonseum,  at  the  edges  of  the  abdominal  incision,  to  the  sur¬ 
face  of  the  disorganized  kidney.  A  portion  of  the  tumor  would 
thus  be  exposed,  so  that  after  its  adhesion  to  the  parietal  peri¬ 
tonaeum  it  would  be  possible  to  split  open  the  diseased  kidney 
and  scrape  away  the  disorganized  tissue.  The  shock  of  such 
serious  and  prolonged  manipulations,  added  to  the  patient’s 
previously  bad  condition,  had  caused  death  within  twenty-four 
hours.  Removal  of  the  kidney  even  after  death  was  exceed¬ 
ingly  difficult,  because  of  its  strong  adhesion  to  the  liver,  dia¬ 
phragm,  intestines,  and  spinal  column.  When  the  specimen  was 
cut  open,  a  multitude  of  sacs  was  disclosed,  with  diffluent  or 


cheesy  pus  for  their  contents.  Within  the  kidney,  calculous 
sand  was  discovered,  and  in  one  place  a  calculus  as  large  as  the 
tip  of  the  finger  was  found.  A  large  lumbar  incision  would 
undoubtedly  have  been  better,  for  then  the  disorganized  kidney 
could  have  been  laid  open  and  the  pus  and  calculi  removed  by 
curetting,  without  involving  the  peritoneal  cavity. 

The  second  case  was  that  of  a  woman,  aged  forty-two,  who 
had  suffered  for  sixteen  years  with  periodical  pains  in  the  right 
hypochondrium.  Nine  months  before  coming  under  the  notice 
of  the  writer  her  condition  increased  in  severity,  and  a  lump 
was  noticed  in  the  right  side  of  the  abdomen.  The  case  was 
looked  upon  as  being  one  of  biliary  calculi  which  could  be 
treated  by  medicinal  remedies.  After  a  month’s  treatment  an 
operation  was  decided  upon,  and  the  abdomen  was  opened  over 
the  gall-bladder,  which  was  found  greatly  distended  with  liquid 
bile  and  bound  by  adhesions  to  the  intestines.  After  evacua¬ 
tion  of  the  bile,  an  incision  was  made  into  the  gall-bladder  and 
search  made  for  calculi,  but  none  could  be  found.  The  patient 
was  in  a  fair  condition  after  the  operation,  but  died  within 
twenty-four  hours.  The  autopsy  revealed  a  pu9-pocket  between 
the  bladder  and  the  transverse  colon.  The  delay  in  attempting 
exploration  was  unfortunate.  It  was  also  possible  that  death 
might  have  been  avoided  even  at  the  time  of  operation  if  force 
had  been  used  and  the  gall-bladder  separated  from  the  adherent 
colon ;  this  would,  at  any  rate,  have  disclosed  the  pus,  which 
was  the  chief  cause  of  the  serious  symptoms. 

The  third  fatal  abdominal  section  of  the  series  was  in  a 
woman,  aged  forty-six,  who  was  subjected  to  an  operation  for 
the  radical  cure  of  an  enormous  umbilical  hernia  which,  it  was 
stated,  had  existed  for  four  years.  An  incision  only  large 
enough  to  admit  the  finger  into  the  sac  was  first  made,  with  the 
hope  that  reduction  of  the  mass  might  be  accomplished  by 
tearing  up  the  adhesions  and  enlarging  the  umbilical  opening. 
Adhesions,  however,  were  so  generally  present  that  this  was 
impossible.  A  large  incision,  therefore,  was  made  so  as  to  un¬ 
cover  the  protruding  intestine  thoroughly.  During  the  making 
of  the  incision  some  foetid  fluid  escaped.  The  intestines  were 
congested.  Thick  masses  of  inflammatory  lymph  were  stripped 
from  the  sac  wall  and  a  good  deal  of  congested  and  inflamed 
omentum  cut  away.  In  tearing  through  the  adhesions  between 
the  various  coils  of  bowel  the  two  outer  intestinal  coats  were 
torn  at  one  place  for  about  an  inch,  leaving  nothing  but  mucous 
membrane  remaining.  The  rent  was  at  once  sutured  with  cat¬ 
gut.  The  adhesions  at  the  lower  border  of  the  ring  were  finally 
separated,  but  at  the  upper  margin  of  the  opening  they  were 
too  firm  to  permit  of  separation  of  the  protruding  omentum  from 
the  abdominal  wall.  The  ring  was  enlarged  by  incision,  and 
reduction  of  the  intestines  accomplished,  although  a  part  of  the 
colon  aud  the  stumps  of  the  excised  portions  of  omentum  were 
left  adherent  to  the  upper  border  of  the  ring.  A  drain  was 
not  put  into  the  peritoneal  9ac,  but  one  was  left  in  the  umbilical 
opening.  The  patient’s  temperature  after  being  put  to  bed  was 
101'2° ;  pulse,  104.  The  next  day  the  abdomen  became  some¬ 
what  tympanitic,  and  the  boweD  were  thoroughly  moved  with 
saline  purgatives.  Her  condition  becoming  serious  about  forty 
hours  after  the  operation,  the  abdomen  was  opened  and  thor¬ 
oughly  irrigated  and  drainage-tubes  were  inserted.  Death  had 
occurred  in  a  few  hours.  It  was  evident  from  the  autopsy  that 
death  had  resulted  from  acute  septic  peritonitis,  due  to  the  in¬ 
troduction  into  the  abdominal  cavity  of  coils  of  intestine  in  a 
state  of  septic  inflammation. 

Dr.  J.  D.  Bryant  thought  the  reader  of  the  paper  had  set 
an  excellent  example  in  recording  his  results  so  frankly.  If  all 
the  unfortunate  issues  were  so  told,  more  would  be  learned  than 
from  the  flowery  recitation  of  successes.  As  to  the  kidney  case, 
he  thought  it  was  a  pretty  well  established  fact  that  the  re- 


Oct.  25,  1890. J 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


471 


moval  of  this  organ  through  the  loin,  if  permissible  at  all,  was 
better  than  through  the  anterior  abdominal  wall.  Some  be¬ 
lieved  that  the  surgical  handling  of  the  abdominal  cavitv,  under 
proper  precautions,  offered  no  more  danger  than  manipulation 
of  other  regions  of  the  body.  The  speaker  did  not  believe  it 
proper  to  open  this  cavity  when  the  object  could  be  effected 
without  doing  so.  The  rate  of  mortality  after  removal  of  the 
kidney  was  about  ten  per  cent,  in  favor  of  the  lumbar  incision. 
As  to  drainage  of  the  abdominal  cavity  for  the  various  re¬ 
quirements  met  with  in  the  surgery  of  the  region,  he  made  it 
a  rule  to  employ  drainage  when  there  was  evidence  to  warrant 
the  belief  that  inflammatory  action  would  ensue  at  the  site  of 
the  operation  or  in  the  tissues  contiguous  to  it.  If  there  had 
been  any  exposure  by  the  stripping  off  of  the  serous  coat  which 
could  not  be  covered  by  drawing  them  together,  he  employed 
drainage  by  means  of  the  tube  or  an  iodoform  tampon.  The 
question  of  introducing  into  the  abdominal  cavity  quantities  of 
water  or  other  fluid  for  the  purposes  of  its  better  toilet  had  been 
a  point  of  serious  consideration.  He  should  hesitate  very  much, 
where  there  was  a  local  disease,  or  where  an  operation  had  been 
performed  for  disease  which  had  not  extended  beyond  the  reach 
of  the  surgeon,  to  wash  out  the  abdominal  cavity,  fearing  that 
other  parts  might  become  infected.  He  should  prefer  to  rely 
on  local  washing  or  the  careful  use  of  the  sponge,  followed  by 
the  introduction  of  a  drainage-tube.  As  to  the  hernia  case,  he 
did  not  see  how  any  other  termination  could  have  been  expected, 
and  thought  that  all  had  been  done  surgically  that  was  pos¬ 
sible. 

Dr.  G.  M.  Edebohls  thought  that  Dr.  Roberts  had  been  quiet 
justified  in  opening  the  abdominal  cavity.  This  in  itself  was  not 
an  improper  measure  for  purposes  of  exploration.  In  case  the 
growth  sought  for  could  not  be  removed  by  the  abdominal  route, 
or  st> me  other  organ  was  found  to  be  diseased,  as  in  the  case  of 
a  kidney,  the  cavity  might  be  closed  and  the  operation  finished 
by  means  of  a  lumbar  incision. 

Dr.  W.  W.  Van  Arsdale  referred  to  a  method  which  was 
an  exploratory  incision,  but  one  in  which  the  abdominal  cavity 
was  not  opened.  All  the  tissues  were  divided  down  to  the  peri¬ 
tonaeum,  which  was  not  disturbed.  Most  of  the  tumors  usually 
sought  for  by  opening  the  cavity  could  be  diagnosticated  readily 
without  running  this  risk. 

Dr.  T.  II.  Manley  thought  the  fatal  results  that  so  often  fol¬ 
lowed  these  abdominal  sections,  from  wbat  was  presumably  sep¬ 
tic  invasion,  could  hardly  be  accounted  for  always  in  this  way. 

In  many  of  the  cases  there  was  scarcely  sufficient  interval  for 
the  development  of  general  septic  peritonitis.  He  thought  that 
the  element  of  shock  was  very  often  a  potent  factor  in  the  fatal 
issue. 


venous  blood.  The  most  common  cause  of  asphyxia  and  resulting 
haemorrhage  is  prolonged  and  difficult  labor.  It  may  also  occur  during 
paroxysms  of  whooping-cough,  violent  attacks  of  vomiting,  or  convul¬ 
sions.  The  bleeding  is  usually  bilateral,  and  most  commonly  involves 
the  parietal  region.  The  clot  separates  the  pia  mater  from  the  surface 
of  the  convolutions,  tearing  the  vessels  which  pass  from  the  pia  to  the 
gray  matter.  The  result  is  interference  with  the  nutrition  of  the  nerve- 
centers  and  more  or  less  degeneration.  In  a  majority  of  cases  there 
are  no  symptoms  of  a  surface  lesion  at  first.  An  extensive  haemor¬ 
rhage  may  be  present  without  paresis  or  even  convulsions.  This  is  no 
doubt,  due  to  the  undeveloped  state  of  the  cortical  centers  at  birth. 
Symptoms  appear  as  the  child  develops. 

3.  Syphilitic  arteritis  and  softening.  Disease  of  the  brain  in  con¬ 
nection  with  hereditary  syphilis  is  not  common  in  young  infants.  When 
it  does  occur,  it  usually  takes  the  form  of  an  arteritis. 

4.  Acute  cerebral  paralysis.  Much  controversy  has  taken  place  with 
regard  to  the  cause  of  this  condition.  It  usually  takes  the  form  of 
hemiplegia,  and  may  be  due  to  tubercular  meningitis,  meningeal  haemor¬ 
rhage,  or  embolism  of  the  middle  cerebral  artery.  The  paralysis  ap¬ 
pears  suddenly,  convulsions  or  an  acute  febrile  disease  being  present  at 
the  onset.  The  cause  of  the  primary  illness  is  often  uncertain,  and  the 
relation  of  the  convulsions  to  the  paralysis,  in  most  instances,  can  not 
be  determined.  This  is  also  true  of  the  hyperpyrexia  which  is  fre¬ 
quently  present.  It  has  been  suggested  by  Striimpell  that  a  polio¬ 
encephalitis  takes  place  analogous  to  anterior  poliomyelitis.  This  is 
suggestive,  but  is  as  yet  only  a  theory. 

5.  Acute  spinal  paralysis  (atrophic  paralysis,  anterior  poliomyelitis). 
Here  the  lesions  are  found  chiefly  in  the  anterior  horns  of  the  spinal 
cord,  and  are  regarded  by  the  author  as  inflammatory  in  character. 

6.  Peripheral  paralyses.  These  play  an  unimportant  part  in  the  pa¬ 
ralyses  of  early  life.  The  group  includes  diphtheritic  paralysis  and 
the  various  paralyses  resulting  from  injury  to  the  nerves. 

The  Spinal  Cord  in  Infantile  Paralysis.— Angel  Money  ( Provincial 
Medical  Journal ,  Jan.  1,  1890)  reports  a  case  of  great  interest.  The 
patient  was  a  girl  two  years  of  age.  Two  months  before,  paralysis  had 
been  noticed  following  a  brief  illness  marked  by  fever  and  vomiting, 
but  no  convulsions.  This  paralysis  involved  both  lower  extremities, 
which  were  wasted,  flabby,  and  relaxed,  but  not  rigid.  The  knee-jerk 
was  lost  on  both  sides,  the  abdominal  and  gluteal  reflexes  were  absent, 
but  the  epigastric  was  easily  obtained.  The  wasting  was  symmetrical. 
None  of  the  paralyzed  muscles  acted  to  the  strongest  faradaic  current, 
but  all  responded  to  the  constant  current  of  thirty  cells.  Six  weeks 
after  admission  to  the  hospital  the  child  died  of  pneumonia. 

At  the  autopsy  the  diagnosis  of  pneumonia  was  confirmed.  The 
parenchymatous  organs  were  in  a  state  of  cloudy  swelling.  The  brain 
and  eyes  were  normal. 

The  spinal  cord,  on  removal  from  its  canal,  presented  no  signs  of 
disease,  but,  on  making  transverse  sections,  certain  alterations  were 
discovered  in  the  lumbar  region.  In  the  middle  of  the  lumbar  enlarge¬ 
ment  a  red  area  was  seen  to  occupy  each  anterior  cornu;  that  on  the 
right  side  being  the  more  extensive.  Each  anterior  cornu  had  at  its 
periphera  a  translucent  border,  which  Dr.  Turner  has  described.  These 


Reports  on  tjre  progress  of  gtcbicinc. 

DISEASES  OF  CHILDREN". 

By  FLOYD  M.  CRANDALL,  M.  D. 

Points  in  the  Pathology  of  the  Paralyses  occurring  during  the 

First  Two  Years  of  Life.— Henry  Ashby  (. British  Medical  Journal ,  Feb. 
k  1890)  divides  the  paralyses  of  infants  into  six  classes: 

1.  Intra-uterine  lesions  (meningo-encephalitis).  Grave  lesions  may 
>ccur  in  the  foetus,  and  it  may  continue  to  live  and  be  born  at  term, 
rhe  results  of  meningeal  inflammation  appear  in  the  brains  of  idiotic 
hildren,  which  show  atrophy,  sclerosis,  or  chronic  hydrocephalus. 

2.  Meningeal  hiemorrhage.  This  occurs  under  a  variety  of  circum- 
tances  during  early  life,  but  the  invariable  immediate  cause  is  as- 
>  yxia,  the  delicate  vessels  being  readily  ruptured  when  distended  with 


changes  existed  in  varying  degrees  throughout  the  lumbar  enlarge¬ 
ment,  A  microscopical  section  from  the  part  where  the  disease  was 
most  marked  showed  (1)  great  distention  and  thrombosis  of  vessels,  es¬ 
pecially  in  the  anterior  cornu  ;  (2)  infiltration  of  the  cornua,  with 
abundant  leucocytes ;  (3)  absence  of  large  multipolar  or  other  nerve 
cells.  The  disease  was  not  confined  to  the  anterior  horns,  but  spread 
in  every  direction,  though  the  focus  of  mischief  was  certainly  in  the 
anterior  horn.  The  lesion  was  most  marked  farthest  from  the  center 
of  circulation.  The  author  believes  that  the  morbid  signs  were  those 
of  acute  inflammation. 

As  to  mtiology,  it  is  probable  that  a  study  of  the  circulation  of  the 
spinal  cord  may  furnish  an  explanation.  There  is  evidence  for  the  be¬ 
lief  that  the  gray  matter  is  not  as  well  supplied  with  blood  as  the  white. 
In  proof  of  this  are  the  researches  of  Young  and  Ross,  Adamkiewicz,  and 
Moxon.  The  spinal  cord  is  not  well  supplied  with  pabulum  ;  the  lower 
part  is  not  as  well  supplied  as  the  upper,  while  the  gray  matter  and 
nerve  nuclei  have  a  most  precarious  supply.  By  invoking  Cohnheim’s 
theory  of  inflammation,  the  matter  is  easily  explained.  Upon  any  dam- 


472 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Joitb., 


age  to  the  walls  of  the  blood-vessels,  the  phenomena  of  inflammation 
follow.  Such  injury  may  result  from  an  abnormal  condition  of  the 
blood  or  blood-pressure,  and  a  direct  result  of  this  is  damage  to  the 
vital  protoplasm  forming  the  vascular  walls.  If  damage  to  the  walls  be 
sufficient,  actual  haemorrhages  occur,  as  found  by  Clifford  Allbutt.  The 
essential  feature  of  this  view  is  the  unimportant  part  played  by  the 
nerve-cells  in  originating  the  disease.  They  are  simply  damaged  by 
disorder  of  the  blood-vessels,  and  are  the  victims  of  the  vascular  dis¬ 
ease. 

The  Nature  and  Treatment  of  Rickets. — Dr.  Kassowitz  ( Wiener 
med.  Wochenschrift,  Nos.  28  to  88,  1889)  contends  strongly  against  the 
opinion  that  rickets  is  due  to  a  diminution  of  lime  salts  in  the  food  or 
to  their  insufficient  absorption  due  to  weakened  digestion.  He  believes 
the  essential  cause  to  be  an  inflammatory  condition  of  the  bony  tissues 
and  not  a  lack  of  calcareous  material.  After  Wagner  had  demonstrated 
the  specific  action  of  phosphorus  upon  the  bones  of  animals  during  the 
period  of  growth,  the  author  conceived  the  idea  of  availing  himself  of 
the  drug  in  the  treatment  of  rickets.  The  favorable  results  first  pub¬ 
lished  in  1884  have  since  been  confirmed  by  numerous  observers.  He 
usually  administers  the  phosphorus  in  cod-liver  oil,  giving  a  half 
milligramme  a  day.  This  oil  of  phosphorus  is,  as  a  rule,  well  tolerated 
and  may  be  continued  during  the'  warm  season.  When  not  well  taken, 
the  phosphorus  may  be  exhibited  in  an  emulsion  of  lipanine,  mucilage, 
and  syrup. 

A  Case  of  Myxcedematous  Idiocy. — Bourneville  (Arch,  de  neurol., 
March,  1890)  reports  another  well-marked  case  of  this  disease.  Noth¬ 
ing  unusual  was  observed  until  the  child  was  three  years  of  age,  when 
development  ceased  and  he  began  to  grow  fat.  He  first  came  under 
observation  at  the  age  of  twenty-five.  He  was  three  feet  in  height ;  the 
anterior  fontanelle  was  still  open ;  the  eyes  were  scarcely  visible,  due  to 
swelling  of  the  lids  ;  the  lips  were  thick  and  prominent ;  the  cheeks  fat 
and  puffy.  The  thyreoid  was  absent ;  the  neck  was  short  and  thick, 
and  on  each  side  there  was  a  lipomatous  mass,  while  similar  masses 
existed  on  the  sides  of  the  trunk  and  in  the  axillae.  The  abdomen  was 
prominent  and  there  was  an  umbilical  hernia.  The  hands  and  feet 
were  short  and  fat ;  the  skin  was  waxy-white,  and  in  places  trans¬ 
lucent.  The  speech  was  slow,  the  voice  harsh,  the  vocabulary  limited, 
and  intelligence  poorly  developed. 

The  Pathology  and  Treatment  of  Tubercular  Adenitis  in  Children. 
— Dr.  Wohlgemuth  (Arch,  fur  Kinderh.,  v  and  vi,  1890)  considers 
this  subject  in  a  lengthy  paper  based  on  127  cases.  Of  these,  46  pa¬ 
tients  were  treated  without  operation,  of  which  24  per  cent,  completely 
recovered  ;  36  underwent  a  slight  operation,  and  63-9  per  cent,  recov¬ 
ered  ;  in  the  remaining  45  the  glands  were  completely  removed,  and 
70'5  per  cent,  recovered. 

The  following  conclusions  are  drawn  :  1.  In  tuberculosis,  during  the 
first  ten  years  of  life  the  most  frequent  seat  of  disease  is  the  glands, 
those  of  the  neck  being  most  commonly  involved.  2.  Adults  are  also 
attacked  in  like  manner.  3.  The  prognosis  varies  according  to  circum¬ 
stances  more  in  children  than  in  adults.  4.  The  greater  the  diffusion 
of  involvement,  the  less  favorable  the  prognosis.  5.  Removal  is  less 
dangerous  than  has  usually  been  alleged,  but  radical  removal  does  not 
positively  insure  against  recurrence,  either  local  or  general. 

Two  Cases  of  Congenital  Malformation  of  the  Heart. — Dr.  Ludwig 
Klepstein  (Arch,  fur  Kinderh.,  v  and  vi,  1890)  discusses  abnormities 
of  the  heart,  and  reports  two  cases.  He  considers  aetiology  under  two 
heads:  1.  Simple  lack  of  development.  2.  Inflammatory  action.  En¬ 
docarditis  or  myocarditis,  occurring  during  the  process  of  development, 
checks  further  growth ;  occurring  after  complete  development,  destruc¬ 
tion  of  existing  parts  is  the  usual  result.  Anomalies  of  the  larger  ves¬ 
sels  may  occur  as  follows  :  1.  No  division,  the  vessels  forming  one  large 
tube.  2.  Abnormal  relative  positions.  3.  Unnatural  size.  4.  Combi¬ 
nation  of  the  last  two — the  most  common  anomaly. 

In  the  author’s  first  case  the  heart  lay  in  a  peculiar  cavity,  and  was 
twisted  upon  itself  like  a  root.  The  right  ventricle  was  contracted, 
the  walls  of  the  left  were  much  thickened,  and  there  was  no  septum 
between  the  two.  The  foramen  ovale  was  open.  The  pulmonary  artery 
was  large.  It  was  an  utterly  useless  organ. 

In  the  second  case  the  heart  was  large,  the  right  ventricle  was  dis¬ 
tended,  the  foramen  ovale  open.  The  left  ventricle  contained  neither 


mitral  nor  aortic  opening,  nor  vestige  of  the  aortic  valves.  The  aorta 
existed,  but  was  small,  while  the  pulmonary  artery  was  abnormally  large. 
The  thymus  was  of  unusual  size. 

Lithotrity  in  Children. — Southam  (Med.  Chronicle ,  June,  1890)  be¬ 
lieves  that  lithotrity  is  applicable  in  most  cases  in  children  when  the 
stone  does  not  exceed  three  quarters  of  an  inch  in  its  greatest  diame¬ 
ter.  In  his  experience,  larger  stones  than  this  are  rare,  and,  in  a  large 
.proportion  of  cases,  are  capable  of  being  crushed.  The  larger  the  stone 
and  the  younger  the  patient,  the  greater  is  the  reason  for  performing 
suprapubic  lithotomy  in  preference  to  the  lateral  operation. 

Disease  of  the  Heart  as  it  occurs  in  children  possesses  many  pecul¬ 
iar  features,  which  are  discussed  by  Dr.  Mitchell  Bruce  (Brit.  Med. 
Jour.,  April  26,  1890)  in  an  article  of  unusual  interest.  The  various 
periods  of  this  eventful  disease  may  be  considered  under  three  heads : 

1.  Acute  inflammation.  Among  the  numerous  causes,  rheumatism 
is  by  far  the  most  common,  but  is  frequently  “latent”  and  very  diffi¬ 
cult  of  detection.  Far  behind  rheumatism  are  chorea,  scarlet  fever, 
diphtheria,  measles,  and  tonsillitis.  Even  pericarditis  is  frequently  of 
rheumatic  origin,  and  the  sooner  this  is  recognized  the  better  it  will  be 
for  all  concerned.  Four  tests  may  be  employed  to  determine  whether 
pericarditis  be  rheumatic  or  not:  (1)  The  presence  of  an  endocardial 
murmur  ;  (2)  the  effect  of  antirrheumatic  treatment ;  (3)  the  discovery, 
after  minute  examination,  of  tenderness  of  the  joints  ;  (4)  the  family 
history. 

The  symptoms  of  cardiac  disease  in  children  are  mild  and  often 
very  obscure;  the  physical  signs  are  relatively  distinct,  but  are  marked 
by  numerous  peculiarities.  The  heart  lies  higher,  the  apex-beat  being 
usually  in  the  fourth  space  and  more  to  the  left  than  in  the  adult.  The 
impulse,  as  a  whole,  is  often  widely  visible  and  palpable.  The  sounds 
have  a  puerile  character  and  are  frequently  divided,  both  periods  of 
silence  being  marked.  Reduplication  is  more  frequent  than  in  the 
adult.  Prominence  of  the  prmcordia  is  especially  striking,  friction 
fi’emitus  is  distinct,  and  friction  sounds  are  relatively  loud.  The  area 
in  the  back  over  which  systolic  murmurs  are  conducted  is  frequently 
very  extensive. 

The  immediate  prognosis  should  be  guarded.  It  is  true  that  un¬ 
complicated  inflammation  of  the  heart  rarely  proves  directly  fatal  in 
young  subjects,  but  its  complications  are  frequently  the  cause  of  death. 
Rheumatic  pleuro-pneumonia,  associated  with  endocarditis  and  pericar 
ditis,  is  a  condition  full  of  peril  to  life.  The  ultimate  result  depends 
largely  upon  the  hygienic  surroundings  and  social  condition  of  the  pa¬ 
tient.  It  is,  as  a  rule,  better  in  the  child  than  in  the  adult.  It  is  un¬ 
wise  to  give  a  too  unfavorable  prognosis,  for  in  a  certain  number  of 
cases  the  signs  of  valvular  disease  ultimately  disappear. 

Much  may  be  done  to  prevent  endocardial  inflammation  by  imme¬ 
diately  and  vigorously  combating  every  rheumatic  process  and  insuring 
proper  care.  Salicine  and  quinine  sometimes  succeed  where  salicylates 
fail.  Entire  freedom  from  excitement,  absolute  rest  in  bed,  and  proper 
nursing  must  be  continued  week  after  week.  Food  should  be  given  in 
small  quantities  and  at  short  intervals,  and  must  be  rigidly  fluid.  The 
disease  runs  an  irregular  course,  sometimes  continuing  for  weeks. 
Such  cases  must  be  managed  rather  than  “  treated.”  Lack  of  firm¬ 
ness,  patience,  and  consistency  in  management  must  too  often  account 
for  the  severity  of  some  cases  of  chronic  valvular  disease. 

2.  The  establishment  and  maintenance  of  compensation.  There 
can  be  no  doubt  that  compensation  occurs  with  exceptional  complete¬ 
ness  and  rapidity  in  the  child.  The  first  cause  of  interference  with 
compensation  is  impoverished  blood-supply,  which  may  result  from 
anaemia,  starvation,  dyspepsia,  or  disturbed  action  of  the  liver.  The 
second  set  of  causes  rises  in  connection  with  muscular  exertion.  A 
weakened  valve  is  sometimes  strained  by  a  child  at  play,  but  this  is 
rare  compared  with  the  damage  which  often  occurs  to  the  heart  of 
hard-working  men.  Nervous  influences,  which  are  so  fruitful  of  evil  in 
the  adult,  are  much  less  active  in  the  child.  Yet  a  child  suffering  from 
cardiac  disease  should  be  guarded  against  nervous  shocks,  worry,  and 
anxiety.  The  chief  source  of  worry  in  most  cases  is  the  lessons  and 
school.  We  must  be  on  the  outlook  for  symptoms  of  mental  strain — 
headaches,  night-talking,  sleep-walking,  or  irritability  of  temper.  At 
the  same  time  we  must  see  that  muscular  exercise  is  neither  abused 
nor  neglected.  We  should  speak  definitely  as  to  games.  Quiet  cricket 


Oct.  25,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


473 


may  be  allowed,  but  match  games,  with  their  excitement,  and  violent 
games,  like  foot-ball,  must  be  totally  forbidden.  Cycling  would  seem 
to  be  a  safe  form  of  exercise,  but  actual  experience  proves  it  to  be 
dangerous,  from  a  tendency  to  over-ride. 

The  subject  of  chronic  valvular  disease  must  be  specially  protected 
from  rheumatism.  The  most  trifling  symptom  of  its  approach  must 
not  be  disregarded.  The  most  trying  period  is  from  the  tenth  year  to 
puberty.  The  heart  is  then  especially  susceptible,  and  in  most  cases 
requires  constant  attention.  Periodical  examinations  should  be  made, 
however  free  from  symptoms  the  child  may  be.  As  to  medicinal  treat¬ 
ment,  the  routine  employment  of  such  drugs  as  digitalis  and  its  allies 
is  frequently  unnecessary  and  often  positively  harmful. 

3.  Heart  failure.  Symptoms  appear  only  when  compensation  begins 
to  fail.  In  several  important  respects  they  are  peculiar  to  the  child. 
Pain  is  less  prominent  than  in  the  adult,  but  dysffnuea  is  a  constant  and 
striking  feature.  Cardiac  dropsy  and  albuminuria  are  infrequent.  Epis- 
taxis  is  not  uncommon.  Failure  of  compensation  never  arises  without 
a  cause.  No  attack  of  palpitation  or  dyspnoea  should  be  allowed  to  pass 
without  search  for  the  cause,  for  upon  that  the  prognosis  will  largely 
depend.  If  it  be  injudicious  treatment,  nervous  strain,  or  muscular  ex¬ 
ertion,  a  period  of  rest  and  judicious  treatment  will  restore  the  heart. 
The  danger  is  much  greater  if  rheumatism  or  other  intercurrent  disease 
is  at  work.  On  the  whole,  the  prognosis  of  cardiac  failure  in  the  child 
is  better  than  in  the  adult.  When  the  more  unusual  symptoms,  as 
dropsy  and  albuminuria,  occur,  the  prognosis  is  especially  bad,  being 
worse  than  when  those  symptoms  appear  in  the  adult.  Dyspnoea,  pal¬ 
pitation,  and  failure  of  the  pulse  demand  instant  and  active  attention. 
Of  the  various  new  remedies  and  cardiac  stimulants  there  are  a  number 
of  much  value,  but,  on  the  whole,  digitalis,  if  rationally  employed,  is  still 
the  best.  As  prompt  stimulants,  ether,  ammonia,  and  alcohol  are  fa¬ 
miliar  to  all,  but  strychnine  used  hypodermically  has  in  some  instances 
an  effect  little  short  of  marvelous  in  restoring  the  action  of  the  ven¬ 
tricles.  A  one-per-cent,  solution  of  the  hydrochloride  should  be  em¬ 
ployed. 

Mitral  Stenosis  in  Children.— Dr.  Sansom,  in  the  Lancet  of  Dec.  28, 
1889,  reports  forty  cases  of  mitral  stenosis  with  nineteen  autopsies,  all 
in  children  under  twelve  years  of  age.  In  the  less  marked  cases  a  ring 
of  granulations  was  found  on  the  mitral  aperture  on  its  auricular  aspect. 
They  are  in  some  cases  friable  and  fibrin-covered,  in  others  fibrous  and 
firmly  fixed.  The  subjacent  structures  were  more  or  less  thickened. 
In  the  more  prouounced  forms  the  mitral  curtains  were  fused  to  form 
a  funnel.  The  button-hole  opening,  so  common  in  adults,  occurred  in 
children  in  the  proportion  of  but  1  to  8  as  compared  with  the  funnel- 
shaped  opening.  The  left  ventricle  was  usually  of  normal  size ;  the 
right  chambers  were  almost  invariably  dilated.  Mitral  stenosis  was  in 
no  case  congenital.  It  was  extremely  rare  under  five  years,  and  was  in¬ 
variably  the  result  of  endocarditis.  As  to  aetiology,  rheumatism  was 
the  most  common  factor.  In  the  more  severe  forms  of  rheumatism  mi¬ 
tral  insufficiency  was  far  more  common  than  stenosis,  while  in  the 
milder  forms  the  proportion  of  the  latter  greatly  increased.  The  author 
believes  that  stenosis  is  the  result  of  a  limited  and  slow  endocarditis, 
while  insufficiency  is  due  to  retraction  of  the  valves,  the  result  of  more 
intense  inflammation. 

Strophanthus  in  Cardiac  Disease  in  Children.  —  Dr.  Moncorvo 
L' Union  medicate,  Jan.  9,  1890)  has  employed  strophanthus  extensively 
n  children  from  fifteen  months  to  fifteen  years.  He  has  seen  no  intol- 
irance  manifested  to  the  drug  even  in  the  youngest  cases.  It  strength¬ 
ens  the  muscular  force  of  the  heart  and  frequently  regulates  the  rhythm 
without  prejudice  to  arterial  tension.  He  reports  eight  cases  of  mitral 
liseasewith  irregular  rhythm  and  the  symptoms  common  to  cardiac  dis¬ 
ease  in  young  children  :  palpitation,  dyspnoea,  insomnia,  and  precordial 
eppression.  The  symptoms  were  invariably  relieved,  sometimes  imme- 
liately,  and  ultimately  disappeared  more  or  less  completely.  In  some 
uses  of  an  asthmatic  type  the  irregular  heart’s  action  was  improved 
'ithout  relief  to  the  dyspnoea.  In  other  cases  the  dyspnoea  was  made 
o  disappear.  In  three  cases  of  nephritis  with  lesions  of  the  heart, 
edema  disappeared  under  the  use  of  the  drug,  and  the  action  of  the 
leart  was  improved.  In  broncho-pneumonia  and  other  pulmonary  dis- 
ases  complicated  by  dyspnoea  and  weakness  of  the  heart,  strophanthus 
■endered  excellent  service. 


In  most  instances  the  good  effects  persisted  after  the  administration 
was  suspended.  The  temperature  was  not  reduced  nor  was  any  effect 
noted  on  the  nervous  system. 

Lipanine  as  a  Substitute  for  Cod-liver  Oil. — Galatti  (Arch.  f.  Kin- 
derhk.,  xi,  Fas.  1)  reports  twenty-seven  cases  of  tuberculosis  and  rickets 
treated  by  this  preparation  with  very  favorable  results.  It  was  well 
tolerated  and  taken  without  difficulty.  Although  the  appetite  improved 
in  all  cases  and  there  was  a  surprising  increase  in  weight,  the  progress 
of  the  disease  in  tuberculous  cases  was  unchecked.  The  dose  is  a  des¬ 
sertspoonful,  pure  or  combined  with  syrup. 

[Lipanine  is  an  artificial  compound  of  oil  and  a  fatty  acid.  Mering 
uses  a  mixture  of  100  parts  of  oleic  acid  with  6  of  olive-oil.] 

The  Causes  of  Laryngismus  in  Infants. — Mantle  (Brit.  Med.  Jour., 
Feb.  8,  1890)  describes  a  form  of  laryngismus  characterized  less  by 
stridulous  breathing  than  by  a  distinct  catch  in  the  breath,  bringing 
respiration  temporarily  to  a  standstill.  The  infant  is  observed  to 
awake  suddenly  from  sleep  and  struggle  for  breath.  He  seems  to  be 
suffocating,  but  eventually  recovers  the  breath.  Sometimes  there  is 
a  crowing  inspiration,  but  frequently  disturbance  of  the  natural  rhythm 
of  respiration  is  the  only  symptom  noticed.  At  first  spasm  is  confined 
to  the  laryngeal  muscles ;  but  if  the  disease  continues,  other  muscles  are 
at  length  involved.  Carpo-pedal  contractions  soon  appear,  and  these 
may  be  succeeded  by  general  eclampsia.  In  the  words  of  Dr.  Cheadle, 
“  Laryngismus,  tetany,  and  general  convulsions  are  the  positive,  com¬ 
parative,  and  superlative  of  the  convulsive  state  in  children.” 

Among  the  causes  of  this  disorder,  rickets  is  by  far  the  most  com¬ 
mon.  The  best  explanation  for  this  would  seem  to  be  that  the  weak¬ 
ened  and  deformed  chest  wall  of  the  rickety  child  interferes  with  the 
proper  aeration  of  the  blood.  Increased  venosity  without  doubt  tends 
to  irritation  of  the  respiratory  centers.  Another  cause  described  by 
Goodhart  is  excessive  recurving  of  the  epiglottis  in  its  vertical  axis,  as 
if  it  had  been  bent  in  half  down  the  middle,  and  that  thus  the  ary- 
epiglottic  folds  are  brought  into  apposition,  and  a  mere  chink  is 
left  between  them.  In  cases  of  this  character  the  symptoms  gradu¬ 
ally  disappear,  but  are  little  relieved  by  treatment.  Another  cause 
is  found  in  enlarged  bronchial  glands,  but  this  accounts  for  but  few 
cases.  Enlargement  of  the  thymus  gland  accounts  for  a  still  smaller 
number. 

There  is  still  another  cause  which  has  not  before  been  recognized, 
except  indirectly  by  Ringer.  This  is  elongation  of  the  uvula  with 
thickening  and  congestion  of  the  palatal  folds.  The  history  of  an  ex¬ 
tremely  interesting  case  is  given  in  detail.  A  child,  eight  weeks  old, 
suffered  successively  from  laryngismus,  carpo-pedal  contractions,  and 
general  convulsions.  Removal  of  the  uvula,  which  was  much  elongated 
and  congested,  resulted  at  once  in  complete  and  permanent  cure. 

Congenital  Laryngeal  Stridor. — Dr.  Suckling  (Lancet,  March  15, 
1890)  reports  the  case  of  an  infant,  one  week  old,  suffering  from  laryn¬ 
geal  stridor.  It  had  existed  since  birth  and  was  persistent,  though 
worse  at  times,  especially  during  sleep.  There  was  no  evidence  of 
syphilis.  The  stridor  was  attributed  to  some  congenital  abnormity  in 
the  larynx,  possibly  a  recurved  epiglottis.  Such  cases  are  unaffected 
by  treatment,  and  the  stridor  gradually  disappears. 

Diphtheria  and  Croup. — It  is  believed  quite  generally  in  Germany 
that  there  is  a  simple  idiopathic  or  inflammatory  croup,  less  frequent 
than  diphtheritic  croup,  but  often  so  grave  as  to  require  tracheotomy. 
Goldschmidt  (Ctrlbl.f.  klin.  Med.,  No.  48,  1889)  is  inclined  to  doubt 
the  existence  of  simple  idiopathic  croup.  Though  such  a  disease  may 
occur,  it  is  in  most  cases  a  manifestation  of  diphtheria.  This  is  proved 
by  the  contagious  character  it  often  presents,  by  subsequent  paralysis, 
and  by  the  small  membranous  spots  so  frequently  found  upon  autopsy. 
In  these  cases  the  results  of  tracheotomy  are  especially  good,  as  they 
are  rarely  complicated. 

Recent  Investigations  in  Diphtheria. — The  Canada  Medical  Record 
(May,  1890)  reports  the  investigations  of  several  government  inspectors 
into  the  origin  of  certain  outbreaks  of  diphtheria.  The  most  interesting 
points  are  presented  in  parts  of  the  report  which  deal  with  the  influence  of 
factories  in  disseminating  the  disease  and  the  possibility  of  conveyance 
of  the  infection  by  clothing.  Evidence  is  undoubted  that  factory  women 
employed  during  the  week  in  a  town  where  diphtheria  was  prevailing 
communicated  the  disease  extensively  in  villages  where  they  spent  Sun- 


474 


NEW  INVENTIONS. 


[N.  Y.  Med  Jobr., 


day.  Instances  are  given  of  the  families  of  clergymen  and  doctors  in 
rural  parts  owing  their  attacks  to  the  head  of  the  family  bringing  the 
infection  home  in  the  clothes.  It  was  also  carried  by  coats  and  straw 
plaits  sent  out  from  infected  houses.  The  potent  influence  of  schools 
in  disseminating  and  furthering  the  disease  is  proved  beyond  a  doubt. 

A  Case  of  Chorea  of  unusual  severity  is  reported  by  Dr.  Henry  Ash¬ 
by  in  the  Medical  Chronicle  for  May,  1890.  The  patient  was  a  girl, 
nine  years  of  age.  Choreic  movements  began  early  in  June.  On  the 
19th  the  power  of  speech  was  lost,  a  condition  which  lasted  eighty-one 
days.  At  about  the  same  time  control  over  the  limbs  was  lost  and 
marked  paralysis  soon  developed.  Several  joints  also  became  tender 
and  the  choreic  movements  were  greatly  increased.  Early  in  July  a 
mitral  regurgitant  murmur  developed,  the  rheumatic  pains  were  con¬ 
stant,  and  subcutaneous  nodules  began  to  appear.  At  one  time  at  least 
two  hundred  were  present,  being  situated  on  the  scalp,  borders  of  the 
scapula,  along  the  ribs,  and  in  the  tendons  of  the  hands  and  feet.  On 
the  12th  of  July  a  friction  sound  was  heard  over  the  heart,  followed  by 
a  large  effusion  into  the  pericardium.  This  disappeared,  to  be  followed 
by  another  attack  in  August.  In  August,  emaciation  and  exhaustion 
were  extreme  and  the  paralysis  marked.  Gradual  improvement  then 
began  to  be  noted,  which  continued  till  January.  Heart  failure  then 
set  in,  accompanied  by  anaemia,  dyspnoea,  and  oedema,  and  the  patient 
died  February  19th.  The  case  illustrates  in  a  remarkable  manner  the 
close  association  between  chorea  and  the  rheumatic  state.  The  loss  of 
speech  was  doubtless  due  to  a  loss  of  control  over  the  muscles  of  the 
tongue  and  lips. 

The  Transmission  of  Aphthous  Disease  to  Infants. — Weissenberg 
{Allgem.  med.  Ccniral-Zeit.,  No.  1, 1890)  reports  a  case  of  aphthous  stoma¬ 
titis  in  which  the  cause  could  be  clearly  traced  to  tainted  milk.  It  is 
probable  that  an  epidemic  of  this  disease  in  Berlin  was  due  to  diseased 
animals.  It  was  not  simple  stomatitis  marked  by  a  shallow  round 
ulcer,  but  true  vesicles  occurred,  which  dried  and  disappeared  without 
leaving  a  cicatrix.  Contagion  may  result  from  direct  contact,  or  through 
the  milk  of  infected  animals.  The  disease  was  produced  even  when 
one  part  of  the  infected  milk  was  mixed  with  eight  parts  of  sound 
milk.  Sibberty  isolated  a  micrococcus  from  the  milk  of  the  diseased 
cows,  but  reached  no  positive  conclusion. 

Insomnia  in  Infants. — Dr.  Jules  Simon  {Revue  mens,  des  mal.  de  Ven- 
fance ,  March,  1890)  considers  insomnia  a  symptom  of  much  importance 
iD  infants.  In  many  diseases  it  is  a  symptom  of  minor  importance  and 
of  no  special  interest.  In  others  it  is  one  of  the  chief  manifestations 
of  the  disease.  The  influence  of  dentition  has  been  greatly  exagger¬ 
ated.  Unless  congestion  of  the  gums  or  surrounding  parts  is  present, 
it  causes  but  little  disturbance  of  the  sleep. 

Dyspepsia  and  indigestion  are  the  most  common  and  universal  cause 
of  disturbed  sleep,  even  without  the  definite  symptoms  of  vomiting, 
diarrhoea,  or  marked  constipation.  A  discussion  of  the  treatment  would 
involve  a  review  of  the  whole  subject  of  dietetics. 

Causes  referable  to  the  nervous  system  probably  occur  next  in  fre¬ 
quency.  All  young  infants  may,  even  in  the  first  year,  present  evi¬ 
dences  of  acute  cerebral  congestion.  Extremes  of  either  cold  or  heat 
may  produce  the  same  result.  A  child  who  has  been  exposed  to  a 
strong  wind  during  its  daily  airing,  or  one  who  has  had  insufficient  pro¬ 
tection  from  the  sun,  may  pass  a  restless  and  uncomfortable  night. 
This  condition  must  be  distinguished  from  the  insomnia  of  men¬ 
ingitis,  which,  in  some  cases,  is  for  many  days  the  only  sign. 

In  older  children,  headache  due  to  overtaxing  of  the  brain 
is  not  uncommon.  Anaemia  and  rapid  growth,  in  conjunction  with 
over-study,  is  a  fruitful  cause  of  insomnia.  In  children  of  rheu¬ 
matic  parents  this  tendency  is  especially  marked.  Among  nervous  causes 
in  these  older  children,  hysteria,  chorea,  and  epilepsy  are  the  most  com¬ 
mon.  The  young  hysterical  subject  is  always  liable  to  insomnia,  with 
or  without  headache.  Some  attribute  all  headaches  of  this  period  to 
hysteria,  but  the  author  believes  that  the  distinction  should  be  care¬ 
fully  made  between  such  headaches  and  those  due  simply  to  rapid 
growth  and  over-study. 

The  insomnia  of  epilepsy  is  peculiar  to  itself,  and  is  sometimes  the 
only  symptom  for  a  considerable  period.  The  child  suddenly  wakes 
from  profound  sleep,  sits  up,  and  begins  to  cry,  but  soon  lies  back,  as 
if  exhausted,  and  falls  into  a  deep  sleep.  These  attacks  are  alwavs 


accompanied  by  incontinence  of  urine.  Insomnia  complicating  chorea 
is  an  exceedingly  grave  symptom. 

Earache  is  always  accompanied  by  insomnia*  and  usually  by  con¬ 
tinuous  crying.  Hernia  is  a  cause  of  pain  and  sleeplessness  that  is  fre¬ 
quently  overlooked.  Intermittent  fever  is  in  some  cases  marked  by 
wakefulness  at  a  definitely  recurring  period.  Insomnia  and  headache 
are  prominent  and  early  symptoms  of  albuminuria.  Disturbed  sleep  is 
frequent  in  children  of  six  or  seven  years  of  the  rheumatic  diathesis, 
and  is  accompanied  by  profuse  sweating  and  severe  headache. 


Heto  Intentions,  etc. 


A  RETINOSCOPE  AND  STRABISMOMETER  COMBINED. 

By  John  Herbert  Claiborne,  M.  D. 

The  instrument  represented  by  the  following  cut  consists  of  a  plane 
mirror  an  inch  and  three  quarters  in  diameter,  perforated  centrally  bv 
an  aperture  for  the  eye.  As  a 
handle  to  the  mirror  a  strabis- 
mometer  has  been  employed.  The 
handle  is  attached  by  a  joint  which 
snaps  and  holds  fast  when  ex¬ 
tended.  Its  length  is  such  that 
when  flexed  over  the  mirror  it  ex¬ 
actly  spans  it  and,  being  slightly 
arched  in  the  center,  protects  the 
glass  from  fracture.  As  may  be 
seen,  the  handle  at  its  broad  ex¬ 
tremity  is  crescentic  in  shape,  and 
is  marked  off  in  lines.  The  width 
of  the  scale  is  an  inch  and  two 
eighths,  so  that  a  deviation  of 
five  eighths  of  an  inch  in  the  vis¬ 
ual  axis  may  be  measured. 

The  instrument  is  handy  and 
may  be  carried  with  comfort  and 
safety  in  the  waistcoat  pocket. 

It  is  of  value  in  the  diagnosis  at  a  distance  of  errors  of  refraction  and 


in  the  estimation  of  the  amount  of  strabismus. 
Schmidt  &  Berlin,  16  East  Forty-second  Street. 


It  is  made  by  Messrs. 


A  NEW  ADJUSTER  FOR  APPROXIMATING  AND  INVERTING 
THE  EDGES  OF  WOUNDS,  ESPECIALLY  IN  OPER¬ 
ATIONS  ON  THE  CERVIX  UTERI. 

By  Sinclair  Tousey,  A.  M.,  M.  D., 

HOUSE  SURGEON  TO  THE  ROOSEVELT  HOSPITAL. 

The  instrument  that  I  have  devised  (that  has  been  in  successful  use 
in  the  Gynaecological  Division  of  this  hospital)  is  seven  inches  long  (of 
just  twice  the  size  of  the  illustration),  and  is  in  effect  a  miniature  pitch¬ 


fork.-  The  points  are  as  sharp  as  those  of  an  ordinary  tenaculum,  and 
the  notch  between  them  is  a  little  less  than  an  eighth  of  an  inch  in 
breadth  and  depth. 

Puncturing  the  edge  of  the  wound,  it  can  be  accurately  adjusted 
and  inverted  as  required  while  the  sutures  are  tightened.  In  most  op¬ 
erations  upon  the  cervix,  especially  in  Schroeder’s  and  Emmet’s  opera¬ 
tions,  the  adjustment  is  much  more  readily  accomplished  than  by  the 
ordinary  tenaculum. 

Mr.  Clarence  Ford  has  carried  out  my  idea  in  the  construction  cf  an 
instrument  of  a  single  piece  of  polished  steel,  which  can  be  readily  kept 
aseptic. 


Oct.  25,  1890. J 


MISCELLANY. 


475 


Stis-ttllang. 


The  Evils  of  Early  Marriage  in  India  are  thus  spoken  of  edi¬ 
torially  in  the  September  number  of  the  Indian  Medical  Gazette ,  of  Cal¬ 
cutta  : 

The  case  of  fatal  rupture  of  the  vagina  in  a  child-wife  consequent 
on  sexual  intercourse  with  a  mature  husband  which  we  reported  in  our 
last  issue  has  attracted  attention  to  a  subject  of  very  great  social  im- 
oortance — namely,  the  nubile  age  of  females  in  this  country.  The  ap¬ 
pearance  of  menstruation  is  held  by  the  great  majority  of  natives  of 
India  to  be  evidence  and  proof  of  marriageability,  but  among  the  Hindu 
community  it  is  considered  disgraceful  that  a  girl  should  remain  unmar- 
ied  until  this  function  is  established.  The  consequence  is  that  girls 
ire  married  at  the  age  of  nine  or  ten  years,  but  it  is  understood  or  pro- 
■essed  that  the  consummation  of  the  marriage  is  delayed  until  after  the 
irst  menstrual  period.  There  is,  however,  too  much  reason  to  believe 
hat  the  earlier  ceremony  is  very  frequently,  perhaps  commonly,  taken 
o  warrant  resort  to  sexual  intercourse  before  the  menstrual  flux  has 
•ccurred.  This  came  out  clearly  at  the  recent  trial,  and  was  indeed 
idvanced  in  extenuation  of  the  prisoner’s  “  rash  and  negligent  act  ”  by 
iis  counsel,  and  from  evidence  which  we  have  gathered  since  the  trial 
t  may  be  accepted  as  true  that  pre-menstrual  copulation  is  largely 
iracticed  under  the  cover  of  marriage  in  this  country. 

From  this  practice  it  results  that  girls  become  mothers  at  the  earli- 
st  possible  period  of  their  lives.  A  native  medical  witness  testified  that 
n  about  20  per  cent,  of  marriages,  children  were  borne  by  wives  of  from 
welve  to  thirteen  years  of  age.  The  state  of  matters  thus  revealed 
mplies  consequences  of  a  very  hurtful  nature  to  the  victims  of  the 
ractice  of  immature  sexual  congress,  to  the  welfare  of  the  race,  and 
o  the  tone  and  well-being  of  society  in  general.  As  regards  the  unfor- 
anate  children,  apart  from  the  demoralization  entailed  by  premature 
exual  intercourse  and  the  evils  consequent  on  the  assumption  of  the 
unctions  of  womanhood  in  childhood,  there  is  abundant  evidence  to 
how  that  pain,  damage,  and  death  result  from  premature  copulation, 
ases  of  death  caused  by  the  first  act  of  sexual  intercourse  are  by  no 
leans  rare.  They  are  naturally  concealed,  but  ever  and  anon  they 
ame  to  light.  Dr.  Chevers  mentions  some  fourteen  cases  of  this  sort 
i  the  last  edition  of  his  Hand-book  of  Medical  Jurisprudence  for  India, 
ad  Dr.  Harvey  found  five  in  the  medico-legal  returns  submitted  by  the 
ivil  Surgeons  of  the  Bengal  Presidency  during  the  years  1870-72. 
ut  very  serious  injuries  may  be  inflicted  by  a  mature  male  in  inter¬ 
lude  with  an  immature  female  short  of  being  fatal — lacerations  of 
ie  external  genitals  and  severe  tearing  of  the  vaginal  canal.  These 
•e  inevitable  under  the  circumstances  in  every  case  in  which  meehani- 
il  measures  have  not  been  previously  resorted  to  for  dilating  the  sex- 
il  passage.  There  is  reason  to  believe  that  such  measures  are  not  in- 
equently  used,  and  it  is  difficult  to  decide  which  is  the  greatest  evil 
id  disgrace— the  injury  caused  by  the  natural  method,  or  the  degrada- 
an  due  to  the  artificial.  But  more  physical  injury  and  mortality  are 
•obably  due  to  premature  maternity  than  to  premature  copulation, 
tie  function  of  parturition  demands  a  higher  degree  of  maturity  of 
e  skeleton  and  soft  parts  than  the  function  of  copulation.  Dif- 
ult  and  delayed  labor,  laceration  and  sloughing  of  the  passages, 
■ath  of  the  child,  exhaustion,  fever,  abscesses,  contractions,  and 
tulae  are  the  principal  consequences  of  premature  maternity,  and 
I  of  these  are  more  common  than  is  generally  known.  Then  early 
aternity  causes  premature  aging,  and  accordingly  the  women  of 
is  country  lose  the  bloom  of  youth  and  vigor  of  adult  life  long 
fore  they  ought  or  would  if  they  were  allowed  to  mature  before 
coming  wives  and  mothers.  Menstruation  is  not  a  sign  of  ma- 
rity.  It  is  in  the  great  majority  of  cases  a  sign  of  puberty — of 
ulation  and  impregnability.  It  is  not  even  an  infallible  sign  of  that, 
■me  female  children  menstruate  long  before  they  begin  to  ovulate, 
lers  menstruate  once  casually  and  the  regular  establishment  of  the 
action  is  delayed  for  many  months ;  in  others  ovulation  commences 
ig  before  menstruation  appears.  Recent  researches  tend  to  show 
it  menstruation  and  ovulation  are  by  no  means  so  closely  related  as 
e\  were  supposed  to  be,  and  menstruation  is  not  therefore  the  cer¬ 


tain  and  infallible  sign  of  marriageability  it  is  supposed  to  be  in  India. 
But  maturity  physical,  mental,  and  moral — is  not  attained  in  women 
f°r  many  years  after  menstruation  has  appeared,  and  it  is  true  bevond 
question  or  doubt  that  maternity  as  a  function  and  duty  should  be 
undertaken  by  mature  women  and  not  by  immature  girls.  As  regards 
the  race,  there  can  be  equally  little  doubt  that  the  marriage  of  chil- 
dien,  often  with  aged  males,  tends  to  the  physical  deterioration  of  the 
human  stock,  and  physical  deterioration  implies  effeminacy,  mental  im¬ 
perfection,  and  moral  debility.  The  effect  of  premature  covering  and 
bearing  is  veiv  well  understood  in  stock-breeding,  and  the  more  robust 
races  of  the  world  contract  and  consummate  marriage  after  and  not 
before  maturity  in  every  sense  of  the  term  has  been  reached  by  both 
man  and  woman.  The  social  evils  caused  by  infant  marriage  are  a 
theme  rather  for  the  moralist  than  the  physician,  but  they  are  very  evi¬ 
dent,  more  especially  in  connection  with  rape  and  prostitution.  Social 
customs  find  in  vice  and  crime  hideous  exaggerations,  and  the  legalized 
love  of  child-wives  in  marriage  is  apt  to  be  represented  by  lust  for 
female  children  outside  of  marriage. 

The  medico-legal  returns  submitted  to  the  Inspector-General  of 
Hospitals  by  the  Civil  Surgeons  in  the  Bengal  Presidencv  for  the  year 
1868  and  1869  formed  the  subject  of  a  report  prepared  by  Dr.  K.  Mc¬ 
Leod,  and  those  for  the  years  1870-’71  and  1872  by  Dr.  R.  Harvey. 
Dr.  McLeod’s  report  includes  forty-eight  cases  of  rape.  In  two  the  age 
is  put  down  as  five  years,  in  seventeen  between  six  and  ten,  in  ten  be¬ 
tween  eleven  and  fifteen,  in  seven  between  sixteen  and  twenty,  in  three 
above  twenty,  and  in  nine  the  age  was  not  stated— that  is  to  say,  about 
half  of  the  victims  were  under  ten  and  about  three  fourths  of  them 
under  fifteen.  Most  of  these  children  had  been  badly  hurt,  some  had 
venereal  disease,  and  in  some  “the  parts  gave  evidence  of  habitual  or 
repeated  intercourse.” 

Dr.  Harvey’s  report  includes  372  cases,  of  which  206  were  consid¬ 
ered  certain  and  167  doubtful.  Of  the  205,  one  was  two  years  old; 
one,  two  and  a  half;  one,  three;  three,  four;  five,  five;  nine,  six ; 
nine,  seven ;  eighteen,  eight;  twenty-one,  nine;  twenty-six,  ten ;  nine¬ 
teen,  eleven;  twenty,  twelve;  thirty,  between  twelve  and  fifteen  ;  and 
nineteen  above  fifteen.  That  is  to  say,  of  those  whose  ages  are  given, 
61  per  cent,  were  under  ten,  and  eighty-nine  under  fifteen.  Five  of 
these  cases  were  fatal,  and  in  twenty-five  instances,  besides  external 
injuries,  laceration  of  the  vagina  was  found.  The  perinasum  was  torn 
in  fourteen  cases. 

Among  the  “  doubtful  ”  cases,  “  in  sixty  instances  children  from  nine 
to  thirteen  years  of  age  were  reported  as  ‘  accustomed  to  intercourse.’  ” 

Statistics  of  this  kind  are  fortunately  peculiar  to  India,  but  they  tell 
a  ghastly  tale.  We  have  no  facts  in  our  possession  regarding  infant 
prostitution,  but  very  cursory  observation  in  Calcutta  suffices  to  indi¬ 
cate  that  females  are  trained  and  prepared  fora  life  of  vice  from  a 
very  tender  age.  It  is  time  that  native  society  bestirred  itself  in  this 
matter.  The  evil  is  one  which  saps  national  vigor  and  national  morality. 
Reform  must  come  from  conviction  and  effort  as  in  every  other  case 
but  meantime  the  strong  arm  of  the  law  should  be  put  forth  for  the  pro¬ 
tection  of  female  children  from  the  degradation  and  hurt  entailed  by  pre¬ 
mature  sexual  intercourse.  This  can  easily  be  done  by  raising  the  age 
of  punishable  intercourse  which  is  now  fixed  at  the  absurd  limit  of  ten 
years.  Menstruation  very  seldom  appears  in  native  girls  before  the 
completed  age  of  twelve  years,  and  if  the  “  age  of  consent  ”  were  raised 
to  that  limit,  it  would  not  interfere  with  the  prejudices  and  customs 
which  insist  on  marriage  before  menstruation.  This  would  be  a  step 
in  the  right  direction  ;  but  we  would  impress  strongly  and  earnestly  on 
the  native  community  that  maturity  and  not  puberty  is,  on  physiological 
as  well  as  social  grounds,  the  true  time  and  condition  of  marriage. 

The  Southern  Surgical  and  Gynaecological  Association  will  meet  in 
Atlanta,  Ga.,  on  Tuesday,  Wednesday,  and  Thursday,  November  11th, 
12th,  and  13th,  under  the  presidency  of  Dr.  George  J.  Engelmann,  of 
St.  Louis.  Besides  the  president’s  annual  address,  the  preliminary  pro¬ 
gramme  mentions  the  following:  How  shall  we  treat  our  Cases  of  Pel¬ 
vic  Inflammation  ?  by  Dr.  R.  B.  Maury,  of  Memphis,  Tenn. ;  The  Gen¬ 
eral  and  Local  Treatment  of  Gangrenous  Diseases  and  Wounds,  by  Dr. 
Bedford  Brown,  of  Alexandria,  Va. ;  A  Further  Study  of  the  Direct 
and  Reflex  Effects  of  Lacerations  of  the  Female  Perimeum,  by  Dr.  J. 


476 


MISCELLANY. 


[N.  Y.  Med.  Joob. 


H.  Blanks,  of  Nashville,  Tenn. ;  Abdominal  and  Pelvic  Surgery  in 
America,  by  Dr.  Joseph  Price,  of  Philadelphia ;  Intraligamentous  Ova¬ 
rian  Cystoma,  by  Dr.  Cornelius  Kollock,  of  Cheraw,  S.  C.  ;  The  Anato¬ 
my  and  Pathology  of  the  Ilio-caecal  Region,  by  Dr.  Richard  Douglas,  of 
Nashville,  Tenn. ;  Wet  Antiseptic  Dressings  in  Hand  Injuries,  by  Dr. 
W.  Perrin  Nicolson,  of  Atlanta,  Ga. ;  The  Best  Route  to  the  Bladder  in 
the  Male  for  Disease  or  for  Foreign  Bodies,  by  Dr.  Hunter  McGuire,  of 
Richmond,  Ya. ;  Suprapubic  Cystotomy  in  a  Case  of  Enlarged  Prostate, 
by  Dr.  W.  H.  H.  Cobb,  of  Goldsboro,  N.  C. ;  The  Indications  for  Chole- 
cystotomy,  by  Dr.  A.  M.  Owen,  of  Evansville,  Ind. ;  Uterine  Moles  and 
their  Treatment,  by  Dr.  J.  T.  Wilson,  of  Sherman,  Texas  ;  Strictures  of 
the  Male  Urethra,  by  Dr.  W.  F.  Westmoreland,  of  Atlanta,  Ga. ;  The 
Treatment  of  Urethral  Strictures  by  Electricity,  by  Dr.  W.  Frank  Glenn, 
of  Nashville,  Tenn. ;  The  Surgical  Treatment  of  Empyema,  by  Dr.  J. 
A.  Goggans,  of  Alexander  City,  Ala.  ;  Cases  in  Abdominal  Surgery,  by 
Dr.  I.  S.  Stone,  of  Lincoln,  Ya.  ;  Rectal  Medication  in  Pelvic  Troubles, 
by  Dr.  W.  Hampton  Caldwell,  of  Lexington,  Ivy. ;  Conservative  Surgery 
in  Injuries  of  the  Foot,  by  Dr.  J.  T.  Wilson,  of  Sherman,  Texas ;  The 
Management  of  the  Infantile  Prepuce,  by  Dr.  George  B.  Johnston,  of 
Richmond,  Va. ;  The  Ultimate  Results  of  Trachelorrhaphy,  by  Dr.  Vir¬ 
gil  0.  Hardon,  of  Atlanta,  Ga. ;  Further  Observations  on  the  Dangers 
of  Operative  Delay  in  Prostatic  Troubles,  with  Personal  Experience,  by 
Dr.  R.  D.  Webb,  of  Birmingham,  Ala. ;  The  Clinical  History  of  the 
Epicystic  Surgical  Fistula,  with  Cases,  by  Dr.  J.  D.  S.  Davis,  of  Bir¬ 
mingham,  Ala. ;  Foreign  Bodies  in  the  Air-passages,  with  Report  of 
Cases,  by  Dr.  John  E.  Pendleton,  of  Hartford,  Ky.  ;  Cholecystotomy, 
by  Dr.  W.  E.  B.  Davis,  of  Birmingham,  Ala, ;  Two  Cases  of  Laparoto¬ 
my  for  Intestinal  Obstruction,  by  Dr.  J.  T.  Jelks,  of  Hot  Springs, 
Ark. ;  Is  Gonorrhoea  Ever  a  Cause  of  Pelvic  Inflammations  ?  by  Dr.  J. 
R.  Buist,  of  Nashville,  Tenn. ;  and  papers,  the  titles  of  which  are  not 
determined,  by  Dr.  W.  0.  Roberts,  of  Louisville ;  Dr.  L.  S.  McMurtry, 
of  Louisville ;  Dr.  W.  D.  Haggard,  of  Nashville,  Tenn.  ;  and  Dr.  Hunter 
P.  Cooper,  of  Atlanta,  Ga. 


The  Fairchild  Digestive  Preparations  are  said  to  have  formed  a 
part  of  the  outtit  of  Stanley’s  Emin  expedition,  and  articles  of  food 
predigested  with  Fairchild’s  extractum  pancreatis  to  have  been  used 
exclusively  by  Mr.  Stanley  during  his  recent  illness. 


The  New  York  Pasteur  Institute. — Dr.  Paul  Gibier,  director  of  the 
institute,  informs  us  of  the  results  of  the  preventive  inoculations 
against  hydrophobia  performed  at  this  institute  since  its  opening  (Feb¬ 
ruary  18,  1890). 

To  date,  610  persons  bitten  by  dogs  or  cats  came  to  be  treated. 
These  patients  may  be  divided  into  two  categories  : 

1.  For  480  of  these  persons  it  was  demonstrated  that  the  animals 
which  attacked  them  were  not  mad.  Consequently  the  patients  were 
sent  back  after  having  had  their  wounds  attended  to  during  the  proper 
length  of  time,  when  it  was  necessary.  Four  hundred  patients  of  this 
series  were  advised  or  treated  gratis. 

2.  In  130  cases  the  antihydrophobic  treatment  was  applied,  hydro¬ 
phobia  having  been  demonstrated  by  veterinary  examination  of  the  ani¬ 
mals  which  had  inflicted  the  bites  or  by  inoculation  in  the  laboratory, 
and  in  many  cases  by  the  death  of  some  other  persons  or  animals  bit¬ 
ten  by  the  same  dogs.  All  these  persons  are  to-day  enjoying  good 
health.  In  80  cases  the  patients  received  the  treatment  free  of  charge. 

The  persons  treated  were  : 

64  from  New  York.  3  from  Pennsvlvania.  1  from  Ohio. 


12 

12 

8 

9 

3 

3 


“  New  Jersey.  2 
“  Massachusetts.  2 
“  Connecticut.  2 
“  Illinois.  1 

“  Missouri.  1 

“  N’th  Carolina.  1 


New  Hampshire.  1 
Georgia.  1 

Texas.  1 

Maryland.  1 

Maine.  1 

Kentucky.  1 


Arizona. 

Iowa. 
Nebraska. 
Arkansas. 
Louisiana. 
Ontario  (Can.). 


Intra-uterine  Death  and  Placental  Disease. — “  Dr.  Prinzing,  of 
Munich,  has  examined  a  series  of  placent*  under  the  microscope,  with 
a  view  of  obtaining  fresh  knowledge  as  to  the  pathology  of  placental 
disease.  He  minutely  investigated  six  specimens ;  four  belonged  to 
dead  and  macerated  foetuses  born  at  term  or  prematurely.  The  histo¬ 
logical  changes  resembled  those  which  have  been  observed  in  the  ves¬ 


sels  of  the  brain  in  syphilis.  Endoarteritis  was  marked,  and  the  vas¬ 
cular  disease  involved  plugging,  induration  of  surrounding  connective 
tissue,  and  calcareous  degeneration.  The  fifth  placenta  was  from  a 
premature  birth ;  the  child  was  dead  and  macerated.  A  large  white 
infarct  lay  in  its  substance,  the  result,  in  Dr.  Prinzing’s  opinion,  of  co¬ 
agulation  from  anaemia.  Unlike  Ackermann,  he  attaches  less  impor¬ 
tance  to  periarteritis  in  this  form  of  placental  disease.  In  a  sixth  case, 
where  the  foetus  was  delivered  at  the  fourth  month  and  was  not 
macerated,  intraplacental  haemorrhage  was  evident  even  to  the  naked 
eye.  In  the  last  two  cases  there  was  no  evidence  of  syphilis.  In  all 
six  the  diseased  condition  of  the  placenta  sufficiently  accounted  for 
death.  The  above  researches  are  of  scientific  interest ;  diagnosis  before 
birth  or  abortion  is  impossible.” — British  Medical  Journal. 


ANSWERS  TO  CORRESPONDENTS. 

No.  33 j. — We  are  not  aware  of  any  book  that  gives  them  all. 

No.  335. — Our  impression  is  that  more  cases  occur  in  Austria  than 
in  any  other  country.  See  an  article  by  W.  G.  Lumley,  in  the  Journal 
of  the  Statistical  Society  of  London,  vol.  xxv,  1862,  page  219. 

No.  336. — We  know  of  none. 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed :  ( 1 )  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notifed 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  ( 2 )  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
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THE  NEW  YORK  MEDICAL  JOURNAL,  November  1  1890. 


Origin  a  l  Com  m  umcaii  o  n  s . 


RETENTION-  OF  URINE 
FROM  PROSTATIO  OBSTRUCTION  IN  ELDERLY  MEN  : 

ITS  NATURE,  DIAGNOSIS,  AND  MANAGEMENT* 

By  JOHN  W.  s.  GOULEY,  M.  D., 

SURGEON  TO  BELLEVUE  HOSPITAL. 

While  urethro-vesical  obstruction  occurs  in  voung  and 
middle-aged  men  from  bladder  and  prostate  stones,  from 
acute  prostatitis,  from  contracture  of  the  vesical  neck  due 
to  the  extension  of  chronic  urethritis,  or  from  malignant 
disease  of  the  prostate,  it  should  not  be  confounded  with 
the  gradual  and  slow  process  of  prostatic  obstruction  which 
rarely  begins  to  impede  urination  before  the  age  of  fifty- 
five  and  is  as  rarely  known  to  begin  after  the  age  of  sev¬ 
enty. 

To  the  question,  What  is  it  that  causes  this  impediment 
to  urination  in  elderly  men  ?  a  common  hut  incomplete  an¬ 
swer  is  enlargement  of  the  prostate.  This  answer  is  incom¬ 
plete  because  of  its  failure  to  specify  the  kind  of  enlarge¬ 
ment,  for  it  is  known  that  elongation  and  also  uniform  gen¬ 
eral  enlargement  of  the  prostate  do  not  obstruct  the  ure¬ 
thro-vesical  orifice  or  impede  urination.  Very  large  pros¬ 
tates  have  been  discovered  after  death  in  elderly  men  who 
had  never  suffered  the  least  inconvenience  in  urinating  and 
whose  bladders  were  in  a  normal  condition.  On  the  other 
hand,  small  prostates — i.  e.,  of  even  less  bulk  than  natural, 
with  only  moderate  increase  of  the  lower  isthmus,  suffi¬ 
ciently  obstruct  the  urethro-vesical  orifice  to  give  rise  to 
stagnation  of  urine,  cystitis,  and  even  to  complete  retention 
of  urine. 

It  is  then  only  when  the  prostate  is  unequally  enlarged 
that  it  interferes  with  urination,  and  to  this  even  there  are 
exceptions,  for  multiple  tumors  at  its  base  sometimes  cause 
true  incontinence  of  urine,  as  do  other  forms  of  prostatic 
enlargement  which  prevent  the  closure  of  the  urethro-vesi¬ 
cal  orifice  and  allow  the  urine  to  flow  constantly  from  the 
bladder  as  fast  as  it  trickles  out  of  the  ureters.  In  this 
connection,  enlargement  of  the  prostate,  conveying  as  it 
does  only  a  general  notion  that  the  organ  is  in  an  abnormal 
state,  needs  to  be  specified,  and  it  can  ordinarily  in  some 
measure  be  specified  after  due  observation  of  its  immediate 
effects;  for  instance,  an  elderly  man  from  whom  normal 
urine  is  constantly  dribbling  and  who  suffers  no  other  in¬ 
convenience  presumably  has  true  incontinence  of  urine  due 
to  some  form  of  enlargement  of  the  prostate  which  keeps 
open  the  urethro-vesical  orifice,  while  another  elderly  man 
from  whom  foetid  purulent  urine  is  constantly  dribbling 
presumably  has  chronic  retention  of  urine  due  to  urethral 
or  to  urethro-vesical  obstruction  from  some  one  of  the 
forms  of  prostatic  enlargement  specified  below,  urethral 
stricture  or  the  impaction  of  a  calculus  in  the  urethra  hav¬ 
ing  been  excluded. 

Of  the  several  forms  of  unequal  enlargement  of  the 

*  Read  before  the  New  York  State  Medical  Association,  October, 

1890. 


pi  ostate  which  obstruct  the  urethro-vesical  orifice  the  fol¬ 
lowing  only  need  now  be  named  :  (1)  General  enlargement 
with  excessive  development  of  the  posterior  third  of  the 
lower  isthmus,  called  supra-montanal  portion  by  Mercier 
and  third  lobe  by  Home;  (2)  enlargement  of  the  posterior 
third  of  the  lower  isthmus  without  apparent  increase  in  the 
rest  of  the  prostate,  sometimes  called  centric  enlargement; 
(3)  enlargement  of  one  lobe  which  encroaches  upon  the 
opposite  lobe  and  obstructs  the  prostatic  urethra;  (4)  un¬ 
equal  enlargement  of  both  lobes,  rendering  the  prostatic 
urethra  tortuous  and  obstructing  it;  (5)  multiple  intra-ure- 
thral  tumors;  (6)  intra-vesical  enlargement  of  one  lobe. 
Such  are  the  principal  forms  of  prostatic  enlargement  that 
[  impede  urination. 

These  alterations  of  structure  differ  somewhat  in  their 
component  elements.  The  majority  of  cases  are  diffuse 
leiomyomata,  with  a  very  small  quantity  of  fibrous  tissue 
accompanying  the  blood-vessels,  and  ectasia  of  the  prostatic 
crypts,  the  sympexia  of  the  crypts  often  dying  and  becom¬ 
ing  coated  with  phosphate  of  calcium,  and  consequently  in¬ 
creasing  considerably  in  volume.  They  are  those  prostates 
which  are  softer  than  normal  and  which  attain  the  greatest 
size.  In  some  cases  there  are  multiple  circumscribed  leio- 
myomata.  Other  cases  are  of  diffuse  and  circumscribed 
inomata.  They  are  the  small,  hard  prostates  which  some¬ 
times  contain  retention  epithelial  cysts.  Adenomata  are 
not  so  frequently  found  as  arc  the  myomata  and  inomata, 
and  are  circumscribed. 

The  first  effect  of  urethral  or  of  urethro-vesical  obstruc¬ 
tion  is  stagnation  of  urine  in  the  bladder.  The  stagnant 
urine,  even  a  few  drachms,  soon  decomposes,  and,  acting  as 
an  irritant  foreign  body,  gives  rise  to  cystitis.  The  in¬ 
flamed  bladder  then  makes  vigorous  but  vain  efforts  to  ex¬ 
pel  this  offending  urine,  in  consequence  of  which  its  mus¬ 
cular  coat  increases  in  thickness.  In  certain  cases  the  larger 
part  of  the  stagnant  urine  is  expelled,  but  the  small  quan¬ 
tity  which  remains  is  sufficient  to  induce  such  frequent 
spasmodic  contractions  of  the  bladder  that  the  capacity  of 
this  organ  gradually  decreases  until  it  is  reduced  to  only 
two  or  three  ounces.  In  other  cases  the  bladder  is  dilated 
and  capable  of  containing  a  quart,  or  even  several  quarts,  of 
stale  urine.  In  either  class  of  cases,  unless  artificial  relief 
be  promptly  obtained,  the  consequences  are  of  the  gravest 
order.  The  urine,  thus  dammed  up,  leads  to  dilatation  of 
the  ureters,  ureteritis,  pyelitis,  nephritis,  and  death. 

It  may  be  asked,  Is  it  possible  to  make  a  reasonably  ac¬ 
curate  diagnosis  of  these  several  kinds  of  prostatic  obstruc¬ 
tion  ?  Y  es,  at  least  in  four  of  the  six  just  enumerated,  and 
it  is  of  no  little  practical  consequence  that  they  be  differ¬ 
enced,  for  some  of  them  require  modifications  in  their  sur¬ 
gical  management. 

The  early  manifestations  pf  prostatic  enlargement  do 
not  always  cause  anxiety  and  are  often  overlooked.  The 
patient,  having  perhaps  only  vague  notions  of  bis  condition, 
generally  misinterprets  the  gradually  increasing  frequency 
of  the  calls  to  urination,  does  not  perceive  that  his  urine  is' 
slimy,  pays  little  attention  to  the  slight  sensation  of  scald¬ 
ing  during  urination,  is  not  aware  of  the  significance  of  the 


478 


GOULEY:  RETENTION  OF  URINE. 


[N.  Y.  Med.  Jour., 


changes  in  the  mode  of  propulsion  of  the  urine,  notably  the 
vertical  direction  of  the  jet,  fails  to  notice  the  diminished 
size  of  the  stream  whose  sudden  cessation  induces  him  to 
think  that  the  act  of  urination  is  accomplished,  when,  to 
his  surprise,  more  urine  is  expelled  drop  by  drop,  to  be 
succeeded  byTthe  former  perpendicular  stream  and  again  by 
the  drops,  and  does  not  solicit  the  advice  of  his  physician 
until  all  these  symptoms  are  greatly  intensified  or  until  he 
is  already  distressed  by  complete  retention  of  urine. 

Of  the  several  steps  in  the  diagnosis  of  abnormal  urina¬ 
tion  and  retention  of  urine  due  to  prostatic  enlargement, 
chiefly  the  following  are  employed  : 

The  history  of  the  patient’s  prior  ailments,  of  his  actual 
infirmity,  and  of  his  habits  of  life,  having  been  obtained,  an 
inspection  of  his  general  condition  is  made.  His  mode  of 
urinating,  if  he  can  urinate,  is  noted,  and  his  urine  is  duly 
examined.  Then  follows  physical  exploration. 

The  first  step. in  this  exploration  is  palpation,  then  per¬ 
cussion  of  the  hypogastric  region.  If  there  is  no  tumefac¬ 
tion,  if  percussion  is  clear,  it  will  be  inferred  that  the  blad¬ 
der  is  empty  or  nearly  so;  and  if  at  the  same  time  it  is  no¬ 
ticed  that  normal  urine  is  constantly  flowing,  it  will  be  fair 
to  infer  that  there  is  incontinence  rather  than  retention  of 
urine,  although  the  involuntary  flow  of  urine  indicates  often- 
er  its  retention  than  its  incontinence  ;  but  if  there  is  a 
rounded,  tense,  and  painful  tumor,  dull  or  flat  under  per¬ 
cussion,  and  with  this  a  constant  desire  to  urinate,  the  in¬ 
ference  will  be  that  there  is  acute  retention  of  urine.  If, 
ihowever,  there  happens  to  be  a  diffuse,  slack  swelling  with 
{fluctuation,  also  flatness  under  percussion,  a  dull  instead  of 
-an  acute  pain,  and  no  urgent  desire  to  urinate,  but  slobber¬ 
ing  of  urine,  the  existence  of  chronic  retention  of  urine  will 
be  inferred. 

It  is  proper  to  state  that,  while  percussion  possesses 
some  value  in  the  diagnosis  of  retention  of  urine,  it  is  not 
to  be  absolutely  dependeduipon.  For  example,  flatness  on 
percussion  does  not  necessarily  indicate  the  presence  of 
urine  in  the  bladder,  for,  in  the  hypogastric  region,  flatness 
.may  be  owing  to  a  solid  tumor  in  front  of  the  bladder.  Cir¬ 
cumscribed  flatness  and  fluctuation  may  indicate  a  pelvic 
.abscess  as  well  as  stagnation  of  urine  in  the  bladder,  with 
more  or  less  distention.  Resonance  on  percussion  does  not 
indicate  absence  of  retention  of  urine,  for  such  resonance 
unay  be  owing  to  the  presence  of  knuckles  of  small  intestine 
between  a  distended  bladder  and  the  anterior  abdominal 
parietes. 

The  second  step  in  physical  exploration  consists  in  mak¬ 
ing  a  digital  examination  of  the  prostate  through  the  rec¬ 
tum,  by  which  some  idea  may  be  formed  of  the  .size  and 
consistence  of  the  organ.  As  a  general  rule,  hard  prostates 
are  little  if  at  all  enlarged,  while  soft  prostates  are  large 
and  sometimes  attain  enormous  dimensions.  By  this  same 
digital  examination,  the  form’as  well  as  the  size  of  the  pros¬ 
tate  is  estimated.  It  may  be  simply  elongated  ;  one  of  its 
lateral  lobes  may  be  larger  than  the  other ;  it  may  be  uni¬ 
formly  enlarged  ;  it  may  be  nodulated,  and  this  suggests 
the  existence  of  multiple  tumors ;  or  it  may  not  be  larger 
than  natural,  but  its  apex  may  be  rounded  instead  of  being 
insensibly  lost  in  the  membranous  region  of  the  urethra. 


These  are  the  principal  circumstances  to  be  noted  from  a 
rectal  exploration. 

The  third  step  in  physical  exploration  consists  in  ascer¬ 
taining  the  particular  kind  of  prostatic  enlargement  which 
affects  urination.  The  exploration  is  made  by  introducing 
certain  metallic  instruments  through  the  urethra  into  the 
bladder.  This  method  was  suggested  and  practiced  by 
Mercier  many  years  ago,  and  is  as  follows:  A  rectangular, 
short-beaked  metallic  sound  (Fig.  1)  or  catheter  is  slowly 


Fig.  1.— Mercier’s  rectangular  sound. 

introduced  until  it  reaches  the  prostatic  region  of  the 
urethra.  If  then  the  handle  turns  to  the  right  of  the  pa¬ 
tient,  it  is  because  the  point  of  the  instrument  has  been  de¬ 
flected  by  an  intra-urethral  projection  of  the  left  lobe  of  the 
prostate,  and  vice  versa.  If  first  to  the  right  and  then  to 
the  left  half  an  inch  or  thereabouts  farther  back,  it  is  be¬ 
cause  the  point  of  the  instrument  is  deflected  first  by  a  pro¬ 
jection  of  the  left  and  then  by  a  projection  of  the  right  lobe 
of  the  prostate,  showing  unequal  enlargement  of  both  lobes. 
If  the  sound  meets  no  impediment  until  it  has  nearly 
reached  the  bladder,  and  then  its  blunt  heel  encounters  an 
obstacle,  it  is  because  there  is  enlargement  of  the  posterior 
third  of  the  lower  isthmus  (supramontanal  portion,  third 
lobe).  By  moderately  depressing  its  handle  and  gently 
pushing  the  sound  onward,  it  enters  the  bladder.  Its  beak 
is  then  reversed,  and  turned  to  the  right  and  to  the  left  in 
order  to  form  some  idea  of  the  general  character  of  the  ob¬ 
stacle,  if  there  be  intravesical  projection. 

But  for  greater  precision  the  cysto-pylometer  (Figs.  2 
and  3)  may  be  used.  By  means  of  this  simple  instrument 
the  thickness  of  the  obstacle  can  be  accurately  measured, 
and  it  can  be  ascertained  if  this  consist  of  a  crescentic  val¬ 
vule,  of  a  “  bar,”  or  of  a  sessile  or  a  pedunculated  tumor. 

Fig.  2  represents  the  first  cysto-pylometer  devised  by 
the  author.  It  is  so  constructed  that  the  vesical  extremity 
of  the  male  blade  can  easily  override  any  urethro-vesical 
barrier  without  giving  pain  to  the  patient.  This  construc¬ 
tion  of  the  jaw  of  the  male  blade  rendering  the  prehensile 
part  a  trifle  too  short,  a  new  pylometer  (Fig.  3)  with  the 
male  prehensile  part  one  third  longer  was  lately  contrived 
with  the  view  of  remedying  the  defect  of  the  first  instru¬ 
ment,  but  in  this  new  pylometer  the  inclination  of  the  jaw 
is  so  abrupt  that  it  is  necessary  to  observe  the  greatest  care 
in  opening  the  jaw  of  the  instrument  to  carryT  the  male 
part  over  a  urethro-vesical  barrier. 

The  several  forms  of  prostatic  enlargement  already  in¬ 
dicated  give  rise  to  acute  and  to  chronic  retention  of  urine. 

By  acute  retention  of  urine  is  meant  a  sudden  hindrance 
to  the  expulsion  of  urine  from  the  bladder.  It  is  char¬ 
acterized  by  great  pain  in,  and  an  almost  intolerable  sense 
of  distention  of,  the  bladder;  by  a  scalding  sensation  in  the 
urethra;  and  by  a  constant  desire  to  urinate  which  seems 
incessantly  on  the  point  of  without  being  gratified. 

Acute  retention  of  urine  occurs  as  well  among  elderly 


Nov.  1,  1890.  J 


GOULEY:  RETENTION  OF  URINE. 


men  with  incontinence  as  among  those  who  have  no  hin 
drance  to  normal  urination,  or  only  a  very  slight  impedi 
ment  i.  e .,  the  beginning  of  prostatic  obstruction. 


Fig.  2.  The  author’s  first  Fig.  3. — The  author’s  second 

cy  sto-pylometer .  cysto-pylometer. 

The  mechanism  of  acute  retention  of  urine  is  as  follows : 
After  exposure  to  cold,  venereal  excess,  or  a  debauch,  the 
pelvic  vessels  sometimes  become  so  gorged  with  blood  that 
the  prostate  swells,  principally  in  the  direction  of  the 
urethra  and  urethro-vesical  orifice,  to  the  extent  of  occlud¬ 
ing  the  passage.  This  sudden  engorgement  is  soon  followed 
by  exudations  which  do  not  always  entire!}’  disappear. 
Resolution  is  occasionally  very  slow,  and  even  fails;  the 
swollen  prostate  is  then  little,  if  at  all,  diminished,  and 
acute  retention  may  thus  pass  into  chronic  retention  of 
urine. 

Acute  retention  of  urine  is  ordinarily  preceded  by  dys- 
ury  tor  an  hour  or  two.  Urination  is  unduly  frequent, 
irregular,  scanty,  and  accompanied  with  scalding  pain  in 
the  whole  urethra  until  strangury  occurs;  then  urine  mixed 
with  mucus  and  blood  escapes  only  in  drops  at  each  spas¬ 
modic  contraction  of  the  bladder.  Finallv,  a  few  hours 
after  the  exposure  or  debauch,  comes  ischury.  The  patient 
is  now  unable  to  discharge  a  single  drop  of  urine  and  is 
tormented  with  violent  straining,  which  favors  the  escape 
of  faecal  matter  and  even  causes  prolapse  of  the  rectum. 
1  he  passage  being  entirely  occluded,  the  urine  accumulates 
from  hour  to  hour  until  the  bladder  is  greatly  overdis- 
tended  and  loses  its  power  of  contracting,  generally  for  a 
time  only,  sometimes  indefinitely.  At  the  expiration  of 


479 

-  the  first  day  the  suffering  is  still  very  great,  the  patient  be¬ 
comes  more  restless,  feverish,  and  thirsty  ;  his  face  is  con¬ 
gested  from  the  constant  straining,  his  skin  is  dry,  and  his 
intestines  are  distended  with  gas.  On  the  second  day  the 
pain  extends  to  the  lumbar  regions,  and  the  dryness  of  the 
skin  is  succeeded  by  profuse  perspiration  having  a  urinous 
odor.  The  urine  then  begins  to  dribble,  and  this  is  delu¬ 
sive  to  the  patient  and  to  his  family,  who  imagine  that 
spontaneous  relief  has  come,  when  in  truth  the  urine  is  still 
accumulating  in  the  bladder,  a  little  only  slobbering  out 
from  overflow.  The  consequence  of  this  misinterpretation 
of  a  symptom  is  failure  to  invoke  medical  aid  until  it  is 
deemed  proper  to  repress  what  is  wrongly  believed  to  be  a 
superabundant  flow  of  urine.  Meanwhile  the  patient  lapses 
into  a  muttering  delirium,  his  utterances  being  obscured 
partly  by  the  extreme  dryness  of  his  tongue  and  mouth. 
The  secretion  of  urine  is  now  lessened  (oligury),  and  may 
soon  be  abolished  (anury),  although  the  bladder  is  dis 
tended  to  the  extent  of  four  or  five  pints.  In  some  cases 
the  physician  is  not  summoned  until  many  nauseous,  use¬ 
less,  and  often  hurtful  nostrums  and  diuretics  have  been 
administered. 

Tn  the  management  of  acute  retention  of  urine  to  tem¬ 
porize  or  to  rely  solely  upon  the  use  of  medicaments  in  any 
case  is  to  place  the  life  of  the  patient  in  great  jeopardy. 
Having  informed  himself  of  the  circumstances  connected 
with  the  case  and  having  made  a  preliminary  examination, 
he  physician  selects  the  form  of  catheter  best  suited  and 
orthwith  introduces  it,  allowing  the  urine  to  flow  very 
slowly,  and  every  few  seconds  stopping  up  the  distal  end 
of  the  catheter.  If  called  during  the  first  twenty -four 
hours,  he  may  empty  the  bladder  at  one  sitting  of  three 
quarters  of  an  hour,  but  if  on  the  second  day,  he  should 
draw  off  slowly  only  about  one  third  of  the  contents  of  the 
.(ladder,  and  after  this  once  every  two  or  three  hours  he 
should  introduce  the  catheter  and  allow  more  urine  to  flow, 
until  in  a  day  or  two  he  finally  empties  the  bladder,  or  he 
may  leave  in  the  catheter  with  its  distal  end  closed  and 
direct  that  six  ounces  be  drawn  off  every  two  hours.  The 
reason  for  these  precautions  is  that  the  too  precipitate 
evacuation  of  an  overdistended  bladder  is  sometimes  fol¬ 
lowed  by  distressing  and  dangerous  effects,  such  as  profuse 
haemorrhage  from  its  mucous  membrane  and  consequent 
general  cystitis,  polyury,  etc. 

The  after-treatment  should  accord  with  the  particular 
necessities  of  the  case.  The  use  of  the  catheter  should  not 
be  abandoned  until  the  patient  is  able  to  empty  sponta¬ 
neously  his  bladder,  which  should  not  again  on  any  account 
be  allowed  to  become  overdistended.  If  the  swelling  of 
the  prostate  does  not  diminish,  the  use  of  the  catheter 
should  be  continued  indefinitely.  In  the  mean  time  the 
urine  should  be  kept  bland  bv  the  internal  administration 
of  diluents,  and  the  bladder  should  be  irrigated  once  daily 
with  a  warm  boric-acid  solution,  three  grains  to  the  ounce, 
with  the  addition  of  one  fourth  of  peroxide-of-hydrogen 
solution. 

By  chronic  retention  of  urine  is  meant  a  gradual  and 
slow  hindrance  to  the  expulsion  of  urine  from  the  bladder. 
Its  characters  are  not  generally  perceived  by  the  patient 


480 


GOULET:  RETENTION  OF  URINE. 


[N.  Y.  Med.  Jour., 


and  are  not  always  manifest  to  the  physician,  partly  because 
this  retention  of  urine  does  not  become  complete  for  many 
weeks  or  months,  or  even  may  never  become  complete. 
When  incomplete  it  is  at  first  characterized  by  much  irrita¬ 
bility  of  the  bladder,  which  is  constantly  wrestling  against 
the  obstruction  to  force  out  the  urine ;  but  this  subsides  in 
the  course  of  a  few  months,  when  the  sensibility  and  con¬ 
tractility  of  the  bladder  are  somewhat  impaired,  as  evinced 
by  less  painful,  less  urgent,  and  less  frequent  urination,  and 
by  the  stream  being  small,  feeble,  frequently  interrupted, 
and  replaced  by  a  succession  of  drops.  When  the  reten¬ 
tion  is  complete  it  is  characterized  by  inability  on  the  part 
of  the  patient  to  expel  a  single  drop  of  urine. 

As  already  stated,  chronic  retention  of  urine  is  the  out¬ 
come  of  gradual,  progressive,  but  ordinarily  incomplete 
closure  of  the  urethra  or  urethro-vesical  orifice  by  unequal 
enlargement  of  the  prostate  which  obstructs  the  canal. 
From  being  incomplete,  this  retention  of  urine  becomes 
complete  when  the  enlarged  prostate  further  swells  to  the 
extent  of  closing  the  passage.  It  again  becomes  incom¬ 
plete  when  from  overdistention  of  the  bladder  the  urethro- 
vesical  orifice  opens  sufficiently  to  allow  the  urine  to  over¬ 
flow  and  slobber  out. 

The  differential  diagnosis  of  acute  and  chronic  reten¬ 
tion  of  urine  having  been  set  forth  in  a  paper  read  before 
the  Medical  Society  of  the  County  of  Kings  and  published 
in  its  proceedings  in  January,  1882,  will  not  now  be  dis¬ 
cussed. 

Grave  errors  are  occasionally  made  in  certain  cases  of 
extreme  distention  of  the  bladder  from  neglect  to  use  the 
catheter  as  a  means  of  diagnosis,  for  in  elderly  men  the 
urine  sometimes  accumulates  so  slowly  and  gradually  that 
the  vesical  distention  causes  little  or  no  pain,  or  the  slight 
pain  is  attributed  to  something  else,  and  increases,  in  the 
course  of  weeks  or  months,  to  such  an  extent  as  to  mislead 
the  unwary.  Such  cases  have  been  confounded  with  as¬ 
cites,  with  abdominal  tumors  connected  with  the  omentum, 
intestines,  liver,  or  kidneys,  with  hydatids,  with  hydrone¬ 
phrosis,  and  even  with  faecal  impaction.  In  one  instance  a 
trocar  was  plunged  into  the  abdomen,  two  inches  below  the 
umbilicus,  the  physician  believing  the  case  to  be  one  of 
hydatid  cysts,  and  seven  pints  of  fluid  drawn,  which  proved 
to  be  urine. 

To  the  question,  What  is  the  most  suitable  catheter  in 
cases  of  retention  of  urine  from  prostatic  obstruction  ?  the 
reply  is  that  one  catheter  can  not  answer  in  all  cases.  The 
catheter  should,  as  far  as  possible,  be  adapted  to  a  particu¬ 
lar  kind  of  obstruction.  Therefore  the  physician  should 
be  supplied  with  several  very  different  catheters,  and,  after 
due  exploration,  as  before  indicated,  be  able  to  select  one 
which  is  adapted  to  the  particular  deformity  found  in  the 
prostatic  region. 

For  exploration  the  metallic  instruments  already  de¬ 
scribed  should  be  used,  but  after  this,  and  for  evacuative 
catheterism,  metallic  catheters  should  be  avoided,  for  it  is 
by  their  use  that  false  passages  are  so  commonly  made. 
The  most  dangerous  among  these  is  the  so-called  prostatic 
catheter  of  great  curve  and  extra  length.  The  main  diffi¬ 
culties  in  catheterism,  as  a  general  rule,  are  not  due  to  in¬ 


creased  length  of  the  prostatic  urethra,  but  to  its  several 
deviations;  and  a  rigid  catheter  of  great  curve,  even  when 
used  with  caution,  ordinarily  fails  to  pass,  besides  being 
very  apt  to  tear  the  urethra. 

The  catheters  which  are  indispensable  in  the  physician’s 
armamentarium,  all  but  one — i.  e.,  the  soft,  vulcanized  India- 
rubber  “  velvet-eyed  ”  catheter — consist  of  a  tubular  fabric 
of  silk,  coated  with  a  pliable  material,  with  a  single  eye 
close  to  the  vesical  extremity ;  the  form  of  this  extremity 
being  in  accordance  with  the  particular  use  to  which  each 
instrument  is  designed.  The  most  useful  are  the  five  forms 
indicated  below. 

The  catheter  (Fig.  6)  woven  upon  a  curved  stylet  is  well 
adapted  to  cases  of  moderate  supramontanal  (centric)  en¬ 
largement,  or  of  urethro-vesical  bars.  When  greater  curva¬ 
ture  is  needed,  as  in  a  case  of  very  large  tumor  of  the  supra¬ 
montanal  region,  or  when  a  false  route  impedes  catheterism, 
a  stylet  may  be  inserted,  and  the  catheter  introduced  after 
the  method  of  William  Hey.  This  efficiently  replaces  the 
so-called  prostatic  catheter.  All  the  pliable  catheters  are 
from  twelve  to  fourteen  inches  in  length. 

The  olivary  catheter  (Fig.  7)  is  also  woven  upon  a  curved 
stylet  ;  but  the  straight  olivary  catheter,  very  pliable  for  an 
inch  from  the  point  to  the  eye,  is  useful  in  cases  of  ex¬ 
tremely  tortuous  urethrae  from  unequal  enlargement  of  both 
prostatic  lobes. 

The  elbowed  catheter  of  Mercier  (Fig.  4)  is  particu¬ 
larly  well  adapted  to  cases  of  intra-uretliral  tumors,  of  uni- 


Fig.  4.  Fig.  5.  Fig.  6.  Fig.  7.  Fig.  8. 


lateral  enlargement,  or  of  unequal  enlargement  of  both 
lobes  of  the  prostate,  but  is  also  successfully  used  in  cases 
of  urethro-vesical  barriers. 


Nov.  1,  1890.] 


QOULEY:  RETENTION  OF  URINE. 


The  crulched  catheter  (Fig.  8),  more  angular  than  the 
elbowed,  answers  well  in  cases  of  great  enlargement  of  the 
supramontanal  region,  the  heel  instead  of  the  point  of  the 
instrument  coming  in  contact  with  and  gliding  over  the  ob¬ 
stacle. 

The  double-elbowed  catheter  of  Mercier  (Fig.  5)  is 
adapted  to  cases  of  enlargement  of  the  superior  isthmus, 
together  with  supramontanal  increase,  causing  great  depres¬ 
sion  of  the  floor  of  the  prostatic  sinus. 

Respecting  the  size  of  the  catheters,  the  question, 
Should  they  be  small  or  large?  is  very  commonly  asked. 
The  answer  is  that  they  should  be  neither  large  nor  small, 
but  adapted  to  the  particular  urethra  to  be  catheterized.  A 
•catheter  of  full  size  for  a  urethra  under  the  average  is  too 
small  for  a  urethra  of  extraordinary  large  caliber.  A  No. 
14  (English)  is  small  for  the  latter,  and  entirely  too  large 
for  the  former,  to  which  a  No.  7  (English)  is  likely  to  be 
much  more  suitable.  These,  however,  are  extreme  cases. 
The  most  convenient  size  to  the  physician  and  to  the  patient, 
one  that  strikes  a  fair  average,  is  No.  9  (English).  It  is 
rare  to  find  urethrae  that  will  not  admit  a  No.  9,  particu¬ 
larly  in  cases  of  stagnation  of  urine  from  prostatic  obstruc¬ 
tion,  stricture  being  excluded.  Many  patients  who  are 
obliged  to  catheterize  themselves  labor  under  the  delusion 
that  small  catheters  are  safest  and  give  least  pain.  To  the  use 
of  small  catheters  may  be  ascribed  the  majority  of  prostatic 
false  routes  and  the  frequent  attacks  of  urethritis  and  orchi¬ 
tis  from  which  auto-catheterists  suffer.  The  best  sized  and 
safest  catheter  for  each  individual  is  the  catheter  that  mod¬ 
erately  fills  and  therefore  does  not  stretch  the  urethra. 
■Such  an  instrument  gives  less  pain  than  the  too  large  or  the 
too  small  catheter. 

The  India-rubber  “  velvet-eyed  ”  catheter  is  ordinarily 
the  safest  for  general  use  by  the  inexperienced  and  for  auto- 
catheterism,  but  its  long-continued  use  upon  or  by  the  same 
patient  is  not  advisable.  The  security  felt  by  the  patient 
is  often  a  source  of  danger,  for  he  is  soon  heedless  of  the 
precautions  advised  by  the  physician  and  suffers  much  in 
consequence.  How  much  more  frequently  the  physician  is 
called  upon  to  remove  from  the  bladder  fragments  of  or 
entire  India-rubber  catheters  than  of  other  firmer  instru¬ 
ments!  But,  aside  from  these  accidents,  the  urethra  is 
often  greatly  irritated  by  the  rubber  catheter,  not  on  ac¬ 
count  of  this  material  itself,  but  of  the  carelessness,  bold¬ 
ness,  and  undue  frequency  of  its  use,  which  come  of  its 
easy  introduction.  Painstaking,  prudent,  and  intelligent 
patients  soon  acquire  sufficient  skill  in  the  use  of  any  of 
the  several  pliable  catheters  and  learn  to  keep  them  in  good 
order. 

An  important  advantage  of  the  India-rubber  catheter  is 
that  it  can  be  kept  in  an  aseptic  condition  without  injury 
to  its  structure.  Very  lately  Yergne,  a  Paris  manufacturer, 
has  announced  that  he  has  succeeded  in  making  pliable 
catheters  which  are  susceptible  of  being  rendered  aseptic 
without  injury. 

It  frequently  happens  that  the  physician  is  called  upon 
to  relieve  patients  from  retention  of  urine  when  ordinary 
catheterism  is  impossible  by  reason  of  false  passages  in  the 
prostatic  region.  In  such  cases  the  common  practice  has 


481 

been  to  make  a  suprapubic  puncture  with  an  ordinary  tro¬ 
car  and  insert  a  catheter  or  a  silver  tube,  to  be  opened  as 
often  as  necessary  for  urination.  Twenty  years  ago  capil¬ 
lary  puncture  with  aspiration  was  introduced  to  the  profes¬ 
sion  by  Dieulafoy,  and  this  novelty  soon  became  the  fash¬ 
ion.  Many  successful  cases  were  reported,  and  capillary 
puncture  with  pneumatic  aspiration  was  to  be  the  operation 
in  retention  of  urine.  Although  at  first  no  reference  was 
made  to  accidents,  in  a  few  years  the  vogue  of  the  process 
was  on  the  wane;  now  it  is  employed  with  more  discrimi¬ 
nation,  and  only  to  relieve  extreme  distention  once  or  twice, 
and  not  ten,  twenty,  or  thirty  consecutive  times  in  the  same 
case.  Capillary  puncture  with  pneumatic  aspiration  is  an 
excellent  resource  in  medicine  and  surgery  ;  it  can  not  be 
too  highly  praised,  but  its  abuse  should  be  loudly  decried. 

No  kind  of  puncture  of  the  bladder  ever  can  remove  a 
false  route,  and  capillary  puncture  is  not  so  safe  a  process 
as  was  at  first  believed.  The  consequences  of  the  escape 
of  a  few  drops  of  urine  in  the  pra3vesical  connective  tissue 
have  been  so  disastrous  in  a  number  of  cases  as  to  deter 
cautious  physicians  from  employing  this  method  of  relief 
except  under  circumstances  of  the  greatest  urgency;  but 
there  is  an  equally  forcible  objection  to  its  general  employ¬ 
ment — to  wit,  a  simple,  safe,  and  efficient  procedure  has 
existed  for  the  past  forty  years.  Why  it  has  not  been  more 
frequently  employed  is  not  apparent,  but  it  is  nevertheless 
valuable.  In  the  year  1850  Dr.  Mercier  published  in  the 
Union  medicate  an  account  of  his  invaginated  catheter  for 
use  in  cases  of  prostatic  false  routes.  Descriptions  and  draw¬ 
ings  of  the  instrument  have  appeared  in  different  books  and 
periodicals,  but  little  heed  seems  to  have  been  otherwise 
taken  of  this  precious  device.  It  may  be  fairly  stated  that 
in  ninety-five  per  cent,  of  cases  of  prostatic  false  routes  the 
invaginated  catheter  can  be  successfully  applied.  The  in¬ 
strument  (Fig.  9)  as  now  made  consists  of  two  catheters — 


Fig.  9. — Mercier’s  invaginated  catheter. 


one  metallic,  the  other  non-metallic.  The  first  or  female 
part  is  a  thin-walled  No.  10  (English)  silver  catheter  eleven 
inches  long,  very  slightly  curved,  and  having  in  its  concav¬ 
ity,  about  half  an  inch  from  the  point,  an  oval  eye  five 
eighths  of  an  inch  in  length  and  three  sixteenths  in  breadth. 
From  the  vesical  extremity  of  the  eye  is  an  inclined  plane, 
which  is  lost  in  the  floor  of  the  opening  at  the  distance  of 
a  quarter  of  an  inch,  serving  to  tilt  up  the  point  of  the  male 
part.  This  male  part  is  a  flexible  but  firm  “gum  ”  catheter 
(No.  7  English)  eighteen  inches  long,  fitting  loosely  in  the 
lumen  of  the  female  part,  and  having  a  single  eye  an  eighth 
of  an  inch  from  its  point.  The  way  to  use  the  invaginated 


/ 


482 


LANG  MAID:  HOARSENESS  AND  LOSS  OF  VOICE. 


[N.  Y.  Med.  Jour., 


catheter  is  to  introduce  the  male  into  the  female  part  as 
far  as  the  eye  of  the  latter,  then  to  pass  the  instrument  as 
far  as  the  obstacle  and  engage  the  point  of  the  metallic 
part  in  the  false  route,  and  finally  project  the  male  part, 
which  will  override  the  false  route  thus  blocked  and  enter 
the  bladder.  If  no  urine  should  flow,  it  would  be  owing  to 
closure  of  the  eye  of  the  male  part  by  a  blood-clot,  which 
might  be  forced  out  by  the  injection  of  a  little  water  through 
the  male  catheter.  The  female  part  can  then  be  withdrawn 
and  the  male  left  in  as  long  as  may  be  required;  this  is  the 
reason  for  the  increased  length  of  the  male  part. 

In  twenty  cases  the  author  has  resorted  to  divulsion  of 
the  prostatic  false  route  during  catheterism  with  the  in  vagi  - 
nated  catheter.  This  process,  though  comparatively  easy,  is 
not  advisable  except  in  the  most  experienced  hands.  While 
the  immediate  result  has  generally  been  good,  it  has  not  been 
lasting,  for  he  has  not  known  spontaneous  urination 
to  continue  more  than  two  years  in  any  case  after  this 
operation. 

The  management  of  ordinary  cases  of  chronic  re¬ 
tention  of  urine  from  prostatic  obstruction,  without 
false  routes,  may  be  summarized  as  follows:  Cathe¬ 
terism  having  been  successful,  only  a  part  of  the  stag¬ 
nant  urine  should  be  drawn  off,  and  the  bladder  not 
completely  emptied  for  a  day  or  two,  and  sometimes  not 
for  a  week,  but  the  quantity  of  retained  urine  should 
be  lessened  every  day.  Then  the  bladder  should  be 
daily  washed.  In  many  cases  it  is  not  wise  to  begin 
at  once  with  irrigations,  or  to  use  them  too  frequent¬ 
ly.  Bladders  that  have  long  contained  purulent, 
slimy  urine  do  not  bear  the  contact  of  limpid  fluids  of  low 
specific  gravity  well  at  first.  It  is  therefore  necessary  to 
increase  the  density  of  the  water  used  for  vesical  irrigation 
in  such,  and,  indeed,  in  the  great  majority  of  cases.  A 
good  formula  for  vesical  irrigation  is  the  following,  after 
dilution  of  one  in  twenty  : 

B  Hydrarg.  chloridi  corrosivi.  . .  gr.  v  ; 

Ammonii  chloridi .  gr.  xx  ; 

Spir.  gaultheriae .  fl  f  ss. ; 

Acidi  borici .  |  j  ; 

Glycerini .  fl  §  viij.  M. 

To  half  a  fluidounce  of  this  solution  are  added  seven 
fluidounces  of  warm  water  (110°  F.)  and  two  fluidounces 
and  a  half  of  peroxide-of-hydrogen  solution. 

These  ten  ounces  of  fluid  are  sufficient  for  four  wash¬ 
ings  ot  two  ounces  and  a  half  at  each  sitting.  Only  in  very 
exceptional  cases  should  the  bladder  be  irrigated  more  than 
once  a  day.  After  the  bladder  has  been  completely  emp¬ 
tied,  evacuating  catheterism  should  be  employed  every  five 
or  six  hours,  except  in  cases  of  contracture  with  diminished 
capacity,  when  the  catheter  may  be  needed  every  two  hours. 
In  these  cases  it  is  necessary  to  resort  to  gradual  hydraulic 
dilatation,  a  very  delicate  operation,  which  is  successful 
when  there  has  not  been  too  long  continued  cystitis  with 
connective-tissue  sclerosis. 

The  general  treatment  in  cases  of  stagnation  of  urine 
should  be  conducted  in  accordance  with  sound  hygienic 
principles  and  little  else.  Opium,  belladonna,  or  hyoscya- 
mus  should  be  used  only  to  relieve  extreme  pain  and  spasm. 


The  urine  should  be  kept  bland  by  the  use  of  diluent  bev¬ 
erages  and  the  rectum  completely  emptied  every  day,  for, 
next  to  stagnant  urine  in  the  bladder,  the  accumulation  of 
faeces  in  the  rectum  is  tbe  greatest  source  of  discomfort.  A 
little  generous  wine  at  dinner,  and  a  drink  of  brandy  or 
whisky  and  water  at  bed-time,  may  be  allowed  without  fear 
of  causing  local  irritation  ;  it  is  only  in  excess  that  alcohol 
is  hurtful  in  these  as  in  all  circumstances. 

The  question  of  prostatotomy  and  prostatectomy,  inter¬ 
nal  and  external,  will  not  now  be  discussed,  but  a  few  words 
will  be  said  of  circumstances  under  which  a  portion  of  the 
prostate  may  be  excised  during  suprapubic  cystotomy  for 
a  tumor  or  stone.  When  epicystotomy  has  become  neces¬ 
sary  for  the  extraction  of  a  stone  or  the  ablation  of  a  mor¬ 
bid  growth,  it  may  be  proper  to  excise  a  portion  of  the  pros¬ 
tate  or  a  pedunculated  prostatic  tumor  projecting  in  the 


bladder  and  interfering  with  urination.  Pedunculated  tu¬ 
mors  can  be  excised  by  means  of  scissors  with  rectangular 
blades ;  but  if  a  bar  or  median  outgrowth  is  to  be  cut,  the 
rectangular  intravesical,  suprapubic  prostatectome  (Fig. 
10),  constructed  on  the  principle  of  the  hawk-bill  scissors 
of  Dr.  Skene,  will  be  found  to  answer  the  purpose  of  excis¬ 
ing  as  considerable  a  portion  of  the  prostatic  obstruction  as 
may  be  desired,  leaving  a  V-shaped  chink  for  the  escape  of 
urine. 

The  removal  of  a  urethro-vesical  tumor  of  the  prostate 
during  suprapubic  lithotomy  was  done  about  half  a  cent¬ 
ury  ago  by  Amussat. 


HOARSENESS  AND  LOSS  OF  YOICE 
CAUSED  BY  WRONG  YOCAL  METHOD.* 
By  S.  W.  LANGMAID,  M.  D., 

BOSTON. 

Such  a  case  as  the  following  often  presents  itself  in  my 
own  practice,  as  I  suppose  it  does  in  the  practice  of  all  who 
see  many  singers’  throats. 

A  young  person,  generally  a  female,  complains  of  hoarse¬ 
ness,  of  difficulty  in  producing  such  tones  as  still  remain  to 
the  singing  voice,  of  a  constant  tired  feeling  in  the  region 
of  the  larynx,  and  of  aching  or  pain  there  after  singing. 

The  history  is  generally  as  follows :  The  patient  is  a 


*  Read  before  the  American  Laryngological  Association  at  its 


twelfth  annual  congress. 


Nov.  1,  1890.] 


LA  N  CM  AID :  H OA RSENESS  AND  LOSS  OF  VOICE. 


student  of  vocal  music.  Before  commencing  the  study  of 
vocalization  she  sang  freely,  thoughtless  of  her  manner  of 
do.ng  so,  with  no  sense  of  fatigue,  hut,  on  the  contrary, 
with  a  feeling  of  physical  enjoyment;  in  fact,  as  a  child  of 

musical  aptitude  and  a  naturally  good  singing  voice  always 
sings. 

\ery  soon  after  beginning  to  receive  instruction  she 
began  to  experience  some  of  the  above-mentioned  symp¬ 
toms,  and  the  highest  notes  of  the  voice  were  produced 
with  increasing  effort.  After  a  time  these  high  notes  were 
lost,  and  at  last  the  speaking  as  well  as  the  singing  voice 
became  hoarse.  To  such  a  recital  is  added  the  remark 
that  before  taking  singing  lessons  there  had  never  been  any 
throat  affection  or  hoarseness. 

The  examination  of  the  throat  reveals  perhaps  a  mod¬ 
erate  naso  pharyngitis  and  a  catarrhal  laryngitis,  and,  upon 
attempted  vocalization,  one  or  both  vocal  bands  are  seen  to 
be  paretic.  The  closure  of  the  cartilaginous  and  ligament¬ 
ous  glottis  is  imperfect  and  there  is  defective  tension. 

Now  to  the  patient  as  well  as  to  the  physician  such  a 
history  and  such  appearances  reveal  nothing  more  than  a 
catarrhal  affection  of  the  mucous  membrane,  and  conse¬ 
quent  paresis  of  the  laryngeal  muscles,  caused  by  hostile 
climate.  Especially  would  this  be  likely  if  the  patient  had 
formerly  resided  in  an  inland  region  and  was  pursuing  her 
studies  in  a  seaboard  or  lake  city.  Of  course,  under  any 
circumstances,  the  first  command  given  by  the  physician 
would  be  entire  rest  of  the  singing  voice  and  as  much  as 
might  be  possible  of  the  speaking  voice  also. 

The  ordinary  treatment  for  the  catarrhal  condition 
would  be  instituted,  and,  should  the  paresis  not  disappear, 
faradization  and  strychnine  would  probably  assist  the  ac¬ 
tion  of  the  vocal  bands  and  help  to  restore  the  quality  and 
capability  of  the  voice. 

Such  a  result  will  naturally  lead  to  mutual  congratula¬ 
tions.  But  should  the  cure  prove  to  be  short-lived,  and  the 
same  treatment  be  required  almost  as  soon  as  the  lessons 
or  practice  are  resumed,  the  physician  and  patient  may 
well  ask  if  a  disease  which  yields  so  readily  to  rest  and 
almost  routine  treatment  in  an  otherwise  healthy  young 

person,  has  not  some  causative  factor  besides  atmospheric 
conditions. 

The  natural  inference  would  be  that  singing  had  some¬ 
thing  to  do  with  it.  Now  singing,  properly  performed, 
never  injured  a  healthy  throat.  I  believe,  on  the  contrary, 
that  declamatory  exercises  and  singing  are  not  only  restora¬ 
tive  to  throats  which  have  congestive  tendencies,  but  are 
also  most  efficient  in  preventing  catarrhal  inflammations. 

If  this  is  true,  and  I  think  no  one  will  dispute  it,  the  de¬ 
cision  will  not  be  that  singing  must  be  abandoned,  but 

inquiry  must  be  made  with  regard  to  the  manner  of  using 
the  voice. 

Let  it  not  be  said  that  this  is  not  within  the  province  of 
the  medical  adviser.  Granted  that  the  laryngologist  is  not 
expected  to  teach  vocalization,  it  is,  nevertheless,  the  fact 

that  the  anatomy  and  physiology  of  the  vocal  organs  are 

his  daily  study. 

Most  of  us  are  fully  competent  to  detect  a  wrong  physio¬ 
logical  procedure  by  inference,  if  not  by  the  result  which 


483 


special  training  or  a  musically  appreciative  ear  instantly 
stamps  as  vocally  wrong— that  is,  physiologically  wrong. 
To  abandon  the  practice  of  singing  may  entail  in  our  pa¬ 
tients  great  individual  deprivation,  as  well  as  loss  to  a  com¬ 
munity,  small  or  large,  as  the  case  may  be. 

The  medical  adviser  in  the  case  described  above  will 
not  be  able  to  prevent  the  return  of  the  morbid  conditions 
except  by  determining  the  fact  that  wrong  use  of  the  voice 
is  probably  the  cause  of  its  deterioration. 

And  now  it  may  be  properly  asked  of  me  to  show  how 
the  voice  has  been  improperly  trained  or  used. 

First  of  all,  let  me  say  that  the  defects  in  vocal  produc¬ 
tion  are  many,  and  the  various  wrong  ways  of  singing  are 
almost  numberless.  The  peculiar  morbid  conditions  of  the 
throat  which  I  have  described  are  most  frequently  caused 
by  the  instruction  which  is  given  by  some  teachers,  and  not 
infrequently  inculcated  by  treatises  on  singing,  that  the 
tongue  should  be  forced  to  lie  flat  in  the  mouth  during 
vocalization. 

If  I  should  assert  that  this  was  wrong,  I  should  simply 
answer  one  dogmatic  assertion  by  another.  Therefore  we 
must  examine  the  mechanism  of  the  natural  emission  of 
tone,  and  contrast  this  with  what  we  have  found  will  pro¬ 
duce  the  diseased  condition  which  we  have  described. 

A  different  position  of  the  laryngeal  parts  is  demanded 
foi  each  note  of  the  scale.  In  a  previous  paper  T  have  said 
that  the  muscular  arrangements  of  the  larynx  are  capable 
of  adjusting  the  position  of  the  larynx  for  every  note  of 
the  scale  independently  of  the  action  of  the  breath.  In 
order  that  these  adjustments  may  take  place  rapidly,  there 

must  be  no  hindering,  opposing  action  of  antagonistic  mus¬ 
cles. 

The  theory  which  induces  the  teacher  to  insist  upon  the 
depression  of  the  tongue  is  that  the  cavities  of  the  mouth 
and  pharynx  are  thereby  enlarged,  and  the  corollary  is  that 
the  larger  these  cavities  are  the  larger  the  tone  is.  Not 
only  is  this  deduction  erroneous,  but,  if  true,  the  method 

employed  would  be  the  least  suited  to  gain  the  desired  re¬ 
sult. 

The  attempt  to  depress  the  tongue  necessarily  causes 
tension  of  the  posterior  and  especially  of  the  anterior  pil¬ 
lars  of  the  pharynx,  and  the  isthmus  faucium  is  thereby  nar¬ 
rowed.  Whatever  may  be  the  explanation,  the  fact  remains 
that  such  instruction  is  given  by  many  teachers,  and  the  ef¬ 
fects  are  as  pictured  above. 

Forced  flattening  of  the  tongue  prevents  the  necessary 
free  movement  of  that  organ  as  well  as  of  the  jaw  and  the 
velum  palati.  The  epiglottis  is  bent  backward  and  the  lar¬ 
ynx  is  driven  down  and  held  in  a  constrained  position. 

We  know  that  constant  alteration  in  the  shape  of  the 
mouth  takes  place  during  singing,  because  its  shape  varies 
for  every  different  vowel  sound. 

We  all  witness,  many  times  each  day,  that  the  base  of 
the  tongue  changes  its  position  or  form  with  each  different 
vowel  sound  which  the  patient  is  asked  to  produce  during 
the  ordinary  laryngoscopic  examination. 

lo  insist  that  the  root  of  the  tongue  should  remain  flat 
in  singing  the  vowels  e  and  i  (Italian)  is  demanding  that 
opposing,  hindering  muscular  efforts  shall  be  put  into  ac- 


484 


[N.  Y.  Med.  Jock., 


LANGMAID:  HOARSENESS  AND  LOSS  OF  VOICE. 


tion  ;  moreover,  the  natural,  frank  emission  of  these  vowels 
is  impossible.  To  hold  the  tongue  flat  for  such  vowels  as 
are  naturally  produced  with  a  lower  position  of  the  tongue 
and  larynx,  a  and  u  (Italian)  is  to  prevent  the  free  action 
of  the  muscular  adjustments  which  are  necessary  for  every 
successive  note  of  the  scale. 

So  far  I  have  spoken  only  of  the  effects  of  this  evil 
instruction  upon  the  pharynx  and  the  laryngeal  movement 
en  masse.  The  constrained  and  unnatural  positions  into 
which  the  pharyngeal  muscles  are  forced  will  largely  ac¬ 
count  for  the  catarrhal  processes,  hut  the  greatest  injury  is 
produced  within  the  larynx  itself. 

I  have  said  that  a  different  adjustment  of  the  laryngeal 
parts  is  demanded  for  each  note  of  the  scale.  That  a  vari¬ 
ation  in  the  action  of  intrinsic  muscles  is  necessary  is  proved 
by  the  changed  appearance  of  the  glottis  with  every  group 
of  notes  which  constitute  the  so-called  registers.  At  a  cer¬ 
tain  note  of  the  scale,  differing  with  the  character  of  the 
voice — soprano,  contralto,  tenor,  etc. — a  well-marked  change 
in  the  shape  of  the  glottis  is  perceived  by  the  mirror.*  The 
cartilaginous  glottis  is  closed  and  the  vibration  is  confined 
to  the  ligamentous  portion.  Again,  the  shape  of  the  liga¬ 
mentous  glottis  changes  as  the  scale  is  sung  upward.  Now, 
all  these  changes  in  the  shape  of  the  glottis  are  produced 
by  changing  muscular  action. 

If  we  consider  how  rapidly  these  changes  occur  we  must 
admit  that  no  restraining  force,  by  opposing  muscular  ac¬ 
tion,  can  be  permitted.  Add  to  this  the  variation  in  the 
longitudinal  tension  of  the  bands  and  we  need  say  nothing 
further  with  regard  to  the  freedom  of  action  which  is  de¬ 
manded  for  all  laryngeal  movements. 

The  fatigue  of  the  intrinsic  laryngeal  muscles  which 
results  in  a  real  paresis  arises  from  the  unnaturally  forced 
endeavor  of  these  muscles,  together  with  their  assisting  ex¬ 
trinsic  ones,  to  form  the  glottis  into  the  proper  shape  for 
the  production  of  the  different  tones  of  the  scale ;  for,  if 
the  position  of  the  larynx  is  not  the  natural  one  for  the  pro¬ 
duction  of  any  note,  the  glottis-shaping  muscles  can  not 
perform  their  function  unassisted,  and  the  help  of  the  in¬ 
creased  wind-blast  is  called  for. 

The  contest  can  not  be  carried  on  forever,  and  sooner 
or  later  the  tired  muscles  are  incapable  of  the  required  con¬ 
tracting  force,  and  tension,  as  well  as  adducting  power,  is 
lost.  The  cartilaginous  and  the  ligamentous  glottis  of  one 
or  both  sides  remain  inactive,  and  congestion  of  the  relaxed 
hands  and  an  open  glottis  result.  I  might  stop  at  this 
point,  but  I  can  not  refrain  from  the  brief  citation  of  a  few 
cases  which  seem  to  illustrate  my  argument. 

In  two  cases  I  have  seen  extravasation  of  blood  under 
the  mucous  membrane  of  the  vocal  band — a  condition  which 
I  venture  to  call  the  spirit-level  form  of  haemorrhage,  for 
the  globule  of  blood  during  phonation  changes  its  position 
as  the  drop  of  air  in  the  level  does  at  any  departure  from 
the  horizontal.  I  first  saw  this  extravasation  in  the  vocal 
band  of  a  young  lady  who  was  being  taught  to  force  the 
tongue  flat  while  singing.  I  saw  the  same  condition  in  the 


*  Although  this  change  is  not  so  exact  as  would  appear  from  the 
foregoing  statement,  it  is  sufficiently  so  for  the  argument. 


vocal  band  of  a  favorite  actor,  whose  wonderful  character 
acting  has  astonished  and  delighted  the  public  for  a  few 
years  past.  The  role  in  which  he  has  been  so  successful 
demands  a  double  impersonation — the  constant  uso  of  a 
peculiar  low  voice,  quickly  alternating  with  a  quite  differ¬ 
ent  higher  voice  of  contrasted  timbre.  The  extraordinary 
low'  voice  is  evidently  produced  by  forcing  down  the  larynx, 
while  the  result  is  great  vocal  fatigue  and,  certainly  on  one 
occasion,  has  been  haemorrhage  into  the  substance  of  the 
vocal  band. 

Case  of  a  Young  Tenor. — A  few  months  ago  a  young  tenor 
desired  my  advice  for  exactly  the  conditions  which  have  been 
described  in  the  beginning  of  this  paper.  It  so  happened  that 
for  two  or  three  years  I  had  listened  to  his  singing  and  had  had 
abundant  opportunity  to  know  that  his  voice  was  a  true  tenor 
of  large  compass  and  of  pleasing  quality,  but  for  some  months 
past  I  had  noticed  that  it  had  lost  much  of  its  brilliancy  and 
purity,  and  that  the  upper  tones  were  sung  as  if  with  unusual 
effort.  Upon  inquiry,  I  found  that  he  had  been  studying  with 
a  teacher  who  had  insisted  that  all  the  different  vowel  sounds 
should  be  sung  with  flat  tongue  and  low  larynx.  Abstinence 
from  singing  and  the  complete  abandonment  of  the  vicious  in¬ 
struction,  together  with  the  usual  treatment  for  the  catarrhal 
inflammation,  quickly  restored  the  natural  quality  and  compass 
of  the  voice. 

What  has  been  so  far  said  is  the  result  of  my  own  ob¬ 
servation  and  belief.  It  is  agreeable  to  find  corroboration 
in  the  writings  of  teachers  and  physicians.  With  your  in¬ 
dulgence  I  will  make  but  two  quotations  which  seem  too 
apposite  to  be  omitted. 

Patton  says :  *  “  But  the  aim  of  all  vocal  practice  con¬ 
sists  in  establishing  perfectly  normal  relations  between  the 
motor  power  and  the  cords.  Now,  this  result  is  only  to  be 
reached  by  the  absence  of  all  undue  efforts;  and,  whereas 
certain  vocal  theorists,  who  rely  wholly  for  success  on  va¬ 
rious  muscular  movements,  may  occasionally  produce  some 
local  benefit,  yet  in  general  they  impart  to  the  pupil  an 
idea  that  singing  is  laborious  work,  and  the  latter  seldom 
reaches,  judging  from  experience  and  various  instances,  the 
ease  of  tone-emission  which  is  a  charm  both  tor  the  singer 
and  the  listener.  Therefore,  would  it  not  seem  far  better, 
as  a  general  rule,  that  the  vocal  scholar  were  told  to  think 
as  little  as  possible  about  his  tongue,  for  instance,  excepting 
to  let  it  alone  and  at  rest,  relying  for  vocal  effect  exclusive¬ 
ly  on  the  correct  breath  action  ?  .  .  .  Let  the  vocal  student 
learn  to  open  his  mouth  with  the  utmost  ease.  Let  him 
learn  to  drop  the  lower  jaw  in  uttering  a  tone  with  the 
same  absolutely  unconscious  ease,  even  as  the  eyelids  drop 
apart,  and  let  him  in  this  natural  way  develop  any  other 
set  of  muscles  called  in  play  for  vocal  purposes  in  the  most 
gentle  manner,  ever  remembering  how  quietly  Nature  per¬ 
forms  all  her  normal  functions.  I  desire  to  impress  it  on 
the  minds  of  vocal  scholars  that  any  abnormal  and  straiued 
muscular  gymnastics  for  vocal  purposes — as,  for  instance, 
the  pulling  up  and  down  of  the  larynx  as  a  whole,  apart 
from  its  natural  movements,  as  in  swallowing,  etc. — must  be 
pernicious,  because  all  such  movements  are  unnatural  in 
singing.  The  muscles  involving  the  production  of  the 

*  The  Art  of  Voice  Production ,  New  York,  1882,  pp.  84  el  seq. 


Nov.  1,  1800.J  SMITH:  OBSERVATION S_  ON  THE  VARIABILITY  OF  DISEASE  GERMS. 


voice  are  instinctively  set  to  work,  and  their  wonderful  ad¬ 
justment  far  surpasses  all  human  conception  and  ingenuity.” 

Sir  Morell  Mackenzie*  writes: 

“If  the  master  persists  in  making  the  pupil  sing  in  a 
way  that  is  felt  to  be  a  severe  strain,  if  every  lesson  is  fol¬ 
lowed  by  distressing  fatigue  of  the  laryngeal  muscles,  pain 
in  the  throat,  or  huskiness  of  the  voice,  then  I  say,  what¬ 
ever  be  the  authority  of  your  instructor,  do  not  listen  to 
him,  but  rather  heed  the  warning  that  is  given  you  by  your 
overtaxed  organs.” 

I  am  aware  that  the  picture  I  have  drawn  exhibits  fa¬ 
tigue  of  the  vocal  organs  and  is  to  be  treated  as  such,  but 
it  is  not  fatigue  caused  by  the  legitimate  or  necessary  use 
of  the  voice,  which  may  occur  to  the  best  singers  from  the 
exigencies  of  the  exercise  of  their  profession.  It  is  a  fa¬ 
tigue  which  occurs  from  wrong  vocal  training,  and  has 
ruined  many  a  good  voice. 

The  pupil  is  ignorant  and  trusting,  and  the  teacher  con¬ 
scientiously  inculcates  a  method  which,  so  far  as  I  know, 
always  produces  injury.  The  physician  must  heal  and  re- 
stoie  the  injured  organ,  and,  if  possible,  prevent  recurrence 
of  the  diseased  condition.  It  seems  to  me  that  he  should 
warn  the  pupil  that  unnatural,  unphysiological  processes 
will  render  his  treatment  abortive. 


485 


OBSERVATIONS  ON 

TEE  VARIABILITY  OF  DISEASE  GERMS,  f 


By  THEOBALD  SMITH,  Ph.  B.,  M.  D., 


OF  THE  BUREAU  OF  ANIMAL  INDUSTRY,  DEPARTMENT  OF  AGRICULTURE 
WASHINGTON,  D.  C.  ;  LECTURER  ON  BACTERIOLOGY  IN  THE 
COLUMBIAN  UNIVERSITY  MEDICAL  SCHOOL. 


The  problems  relating  to  this  subject  may,  for  conven¬ 
ience,  be  grouped  under  three  heads  : 

1.  The  variation  of  a  given  species  at  will  in  the  labora¬ 
tory  by  subjecting  it  to  special  conditions. 

2.  The  observed  variation  of  a  given  species  in  nature. 

3.  The  relation  to  one  another  of  bacteria  which  can 
not  be  distinguished  by  our  present  tests,  but  which  pro¬ 
duce  disease  in  different  species  of  animals. 

Under  the  first  head  I  might  cite,  by  way  of  illustration, 
the  investigations  of  Pasteur  on  vaccination  of  anthrax  and 
rouget,  those  of  Chauveau  on  anthrax,  etc. 

Under  the  second  head  I  might  cite  a  number  of  ob¬ 
servations  now  on  record.  Thus  recent  investigations  of 
Bneger  and  Frankel  have  shown  that  diphtheria  bacilli 
from  different  sources  are  liable  to  vary  in  virulence  as  well 
as  in  intensity  of  growth  on  culture  media.  I  have  ob¬ 
served  marked  variation  in  the  virulence  of  swine-plague 
bacteria  from  different  epizootics.  In  cultures  of  glanders 
bacilli  I  have  noticed  considerable  variation  in  the  inten¬ 
sity  of  growth  and  production  of  pigment.  Among  sapro¬ 
phytes  this  tendency  to  vary  is  still  more  pronounced. 

The  problems  arising  under  the  third  head  are  very 
puzzung,  and  their  provisional  interpretation  has  a  deter- 


*  Hygiene  of  the  Vocal  Organs ,  p.  10o. 

f  Read  in  the  Biological  Section  of  the  American  Association  for 
the  Advancement  of  Science,  August,  1890. 


mining  influence  upon  our  conception  of  the  origin  and  dis¬ 
tribution  of  certain  infectious  diseases.  We  know,  for  ex¬ 
ample,  bacteria,  such  as  the  bacilli  of  mouse  septicemia  and 
rouget,  which,  as  regards  appearance  and  pathogenic  prop¬ 
erties,  are  certainly  very  closely  related.  One  is  the  cause 
of  a  disease  of  swine  in  Europe,  the  other  is  occasionally 
present  in  putrefactive  substances  and  is  fatal  to  mice  and 
pigeons.  A  still  better  illustration  is  furnished  by  a  large 
group  of  diseases  among  animals,  including  some  cattle  dis¬ 
eases  (  Wildseuche  of  Bollinger),  fowl  cholera  and  swine 
plague,  which  are  caused  by  bacteria  very  closely  related- 
in  fact,  scarcely,  if  at  all,  distinguishable  from  one  another. 
Can  the  germ  of  one  ot  these  diseases  produce  epizootics  of 
another  at  any  given  moment  and  under  certain  conditions, 
or  are  the  barriers  which  separate  these  germs  insurmount¬ 
able  ?  If  we  admit  the  former-if,  for  instance,  we  grant  that 
fowl  cholera  can  give  rise  to  swine  plague  under  certain 
conditions— we  evidently  regard  the  germs  of  these  diseases 
simply  as  varieties  of  one  species.  If  we  regard  the  dis¬ 
eases  as  wholly  distinct  and  not  convertible  one  into  the 

other,  we  must  consider  the  respective  germs  as  distinct 
species. 

Without  delaying  to  discuss  these  problems  or  express 
any  opinions  which  I  may  hold  temporarily  concerning  them, 

I  pass  on  to  the  subject  of  this  communication. 

Several  years  ago  I  presented  a  brief  paper  to  this  Sec¬ 
tion  in  which  I  described  a  variety  of  the  hog-cholera  germ, 
which  presented  the  minor  peculiarity  of  forming  speedily 
a  membrane  on  the  surface  of  liquid  culture  media,  a  feat¬ 
ure  not  possessed  by  the  hog-cholera  germ  found  by  me  in 
1885.  This  fact,  although  of  apparently  slight  significance 
to-day,  was  of  more  importance  at  that  time,  since  our  con¬ 
ception  of  disease  germs,  formulated  by  Koch  and  his 
school,  endowed  germs  with  little  if  any  capacity  to  appear 
under  varying  characters.  Since  that  time,  as  I  have 
pointed  out  before,  slight  variability  among  disease  germs 
has  been  detected  by  many  observers. 

Early  in  1889  an  epizootic  came  under  my  observation 
from  which  I  obtained  a  bacillus  departing  still  more  from 
the  original  type.  It  is  beyond  the  scope  of  this  paper  to 
give  in  detail  the  biological,  morphological,  and  pathogenic 
characters  of  the  hog-cholera  bacillus.  I  must  refer  you  to 
the  published  reports  of  the  Bureau  of  Animal  Industry, 
especially  those  of  1885  and  ]  886,  for  this  matter.  1  shall 
simply  refer  to  those  points  necessary  to  bring  into  relief 
the  differences  between  the  two  germs  to  be  compared.  I 
shall  designate  the  original  germ  of  1885,  since  found  in  a 
large  number  of  epizootics  in  different  parts  of  (he  country, 
as  bacillus  a,  that  of  1889  as  bacillus  (3.  I  should  add  that 
neither  of  the  germs  has  anything  in  common  with  the 
swine-plague  germ,  which,  in  truth,  belongs  to  a  wholly  dif¬ 
ferent  group  of  bacteria. 

If  I  were  asked  to  state  in  a  general  way  the  difference 
between  bacillus  a  and  bacillus  A,  I  should  say  that  the 
bacillus  p  was  in  every  way  nearer  the  saprophytic  stage 
than  a.  This  is  readily  apparent  from  the  following  con¬ 
On  gelatin  plates,  (3  grows  more  rapidly,  its  deep  as 
well  as  surface  colonies  attain  much  larger  dimensions  than 


486 


SMITH:  OBSERVATIONS  ON  THE  VARIABILITY  OF  DISEASE  GERMS.  [N.  Y.  Med.  Jour., 


those  of  a,  the  surface  colonies  frequently  reaching  a  di¬ 
ameter  of  four  to  five  millimetres,  while  those  of  a  usually 
show  little,  if  any,  tendency  to  spread  out.  In  alkaline 
bouillon  with  peptone,  a  barely  clouds  the  liquid,  while  (3 
produces  a  high  degree  of  turbidity.  In  other  culture 
media  there  are  no  differences  perceptible.  Bacillus  /3  in 
cultures  appears  slightly  larger  than  a ;  in  the  tissues  of  ani¬ 
mals,  however,  the  difference  in  size  is  not  appreciable. 

Bacillus  (3  has  much  less  pathogenic  power  than  a.  Pigs 
are  readily  infected  with  a  fatal  disease  when  fed  with  bou¬ 
illon  cultures  of  a.  When  fed  with  cultures  of  j 3  they  be¬ 
come  very  sick,  but  recover  within  a  week.  Only  one  suc¬ 
cumbed  to  feeding,  and  in  this  case  the  bacilli  had  pene¬ 
trated  the  body  only  as  far  as  the  mesenteric  glands. 

When  we  come  to  smaller  experimental  animals,  the  rab¬ 
bit  is  perhaps  the  best  to  illustrate  the  differences  between 
a  and  j 8. 

When  inoculated  subcutaneously  with  bacillus  a  (as  lit¬ 
tle  as  one  millionth  of  a  c.  c.  of  a  bouillon  culture  has  been 
sufficient  to  produce  a  fatal  disease),  the  rabbit  dies  within 
from  seven  to  ten  days.  The  temperature  rises  4°  to  5°  F. 
from  three  to  four  days  before  death.  At  the  autopsy  the 
spleen  is  found  very  large,  due  to  blood  engorgement;  in  the 
liver  are  small  foci  of  yellowish  necrotic  tissue.  The  kidneys 
have  undergone  parenchymatous  inflammation.  The  urine 
contains  albumin  and  casts.  The  heart  muscle  is  far  ad¬ 
vanced  in  fatty  degeneration.  Beyer’s  plaques  in  the  small 
intestines  are  frequently  reddened.  There  are  usually  haem¬ 
orrhagic  patches  in  the  duodenum  at  the  pylorus.  The  ba¬ 
cilli  are  present  in  all  the  organs  and  in  the  blood. 

When  I  came  to  test  bacillus  (3  on  rabbits  I  was  aston¬ 
ished  to  find  that  they  remained  alive  even  after  the  injec¬ 
tion  of  a  quarter  of  a  c.  c.  of  bouillon  culture.  It  had  not 
happened  to  me  since  the  discovery  of  the  germ,  with  the 
probable  exception  to  be  mentioned  farther  on,  to  find  rab¬ 
bits  survive  inoculation.  I  soon  found,  however,  that  the 
injection  of  a  minimum  dose  into  an  ear-vein  (xo  t0  To~o  c*  c*) 
gave  rise  to  a  fatal  disease  which  differed  in  the  following 
particulars  from  the  disease  as  described  above  :  It  lasted 
nearly  a  week  longer.  The  spleen  was  not  enlarged  ;  the 
necrotic  foci  were  not  found  in  the  liver ;  there  was  no 
haemorrhage  in  the  duodenum,  but,  on  the  other  hand,  a 
striking  disease  of  the  intestines  was  present.  The  Peyer’s 
patches  of  the  small  intestines  were  very  much  thickened 
and  appeared  as  aggregations  of  whitish  dots.  The  mucous 
surface  over  these  patches  was  not  infrequently  covered  by 
a  slough.  In  the  appendix  vermiformis,  pait  or  all  of  the 
solitary  follicles  were  enlarged,  whitish,  nodular,  occasion¬ 
ally  ulcerated.  The  Peyer’s  patches  at  the  ileo-csecal  valve 
— one  in  the  ileum,  the  other  in  the  caecum — were,  as  a  rule, 
much  thickened  and  covered  by  sloughs.  In  several  cases 
the  mucosa  of  the  caecum  was  covered  with  ulcers,  probably 
due  to  bacilli  discharged  from  the  ulcerating  Peyer’s  patches 
and  localized  here.  The  bacilli  were  readily  demonstrated 
in  the  form  of  clumps  in  the  infiltrated  Peyer’s  patches  and 
in  all  the  internal  organs.  The  disease  might  be  denomi¬ 
nated  typlioid  fever  of  rabbits. 

The  question  will  be  asked,  Was  this  really  hog  cholera 
and  not  some  other  disease  like  it?  In  swine  the  disease 


from  which  the  bacillus  (3  was  obtained  was  identical  with 
hog  cholera  as  usually  observed,  with  the  exception  that  it 
lasted  somewhat  longer,  and  seemed  to  affect  the  digestive 
tract  much  more  severely  than  the  hog  cholera  of  former 
outbreaks  did. 

The  following  results  of  experiments  which  can  only  be 
summarized  here  show  that  we  really  have  a  less  virulent 
form  of  hog  cholera  before  us  : 

1.  When  through  attenuation  by  heat,  according  to 
Pasteur,  bacillus  a  was  so  modified  as  to  produce  a  pro¬ 
longed  disease  in  rabbits,  the  same  post-mortem  lesions  were 
obtained  as  those  produced  by  (3. 

2.  When  the  disease  produced  by  a  was  prolonged  by 
making  the  rabbit  less  susceptible  (by  vaccination  with  /3), 
the  intestinal  lesions  were  likewise  present. 

3.  A  series  of  investigations  have  shown  that  rabbits 
protected  by  two  inoculations  of  bacillus  f3  have  resisted  in¬ 
oculation  of  bacillus  a. 

These  results  indicate  not  only  that  the  disease  produced 
by  a  is  convertible  into  the  disease  produced  by  (3,  but  that 
/ 3  may  be  used  in  rabbits  as  a  vaccine  for  a  when  the  dose 
is  chosen  sufficiently  small.  In  short,  the  disease  produced 
by  [3  is  simply  a  more  chronic  type  of  hog  cholera  in  rab¬ 
bits  than  that  caused  by  a. 

I  might  proceed  to  draw  a  great  many  inferences  and 
lessons  from  this  clear  case  of  variability  of  a  most  interest¬ 
ing  pathogenic  organism,  but  a  few  of  the  most  important 
must  suffice.  In  the  first  place,  the  tendency  to  vary  en¬ 
hances  the  difficulties  surrounding  the  differentiation  of  bac¬ 
teria,  especially  when  the  test  of  animal  inoculation  upon 
which  so  much  reliance  has  been  placed  should  not  prove  a 
final  test. 

As  an  illustration  of  this  difficulty  I  may  cite  a  personal 
experience  of  mv  own.  Several  years  ago  I  was  directed 
by  Dr.  Salmon  to  make  an  investigation  of  an  epizootic  of 
swine  disease  in  one  of  the  Eastern  States.  From  two  cases 
I  isolated  a  bacillus  which,  though  resembling  the  hog-chol¬ 
era  germ,  was  not  quite  like  it,  and  it  did  not  prove  fatal  to 
rabbits  on  subcutaneous  inoculation.  I  was  unable  to  come 
to  any  conclusion  as  to  the  nature  of  the  germ  at  the  time. 
When  more  than  a  year  later  I  became  acquainted  with  ba¬ 
cillus  (3,  I  again  carefully  looked  over  the  notes  of  this  in¬ 
vestigation,  and,  although  the  cultures  had  in  the  mean  time 
been  discarded,  I  felt  confident  that  1  had  at  that  time  the 
bacillus  (3  in  my  hands.  This  tendency  to  vary  also  en¬ 
hances  the  difficulties  arising  between  observers  in  different 
parts  of  the  country.  One  may  find  one  variety,  another  a 
second,  and  when  to  this  difficulty  are  added  insufficient 
preparation  for  such  work,  hasty  conclusions,  faulty  and 
incomplete  descriptions  of  experiments  as  actually  per¬ 
formed,  of  facts  as  actually  observed,  mutual  distrust  is  the 
result. 

When  we  come  to  such  germs  as  the  typhoid-fever  ba¬ 
cillus,  for  which  tests  upon  animals  have  thus  far  proved 
useless,  because  the  bacilli  seem  to  have  little  or  no  effect 
on  them,  the  difficulty  of  pronouncing  a  given  bacillus  the 
genuine  typhoid  bacillus  or  not  in  the  face  of  possible  vari¬ 
ation  becomes  very  great,  especially  when  we  consider  that 
such  investigations  have  a  very  great  influence  upon  the 


Nov.  1,  1890.J 


WESTBROOK:  A  CASE  OF  DOUBLE  EMPYEMA. 


487 


administration  of  public  health.  The  remedy  in  such  cases 
consists  in  a  thorough,  exhaustive  knowledge  of  all  the 
biological  phenomena  of  any  given  germ. 

The  experiments  with  bacillus  (3  on  rabbits,  which  have 
shown  that  a  veritable  typhoid  fever  may  be  induced  in 
rabbits,  illustrate  once  again  the  care  which  must  be  exer¬ 
cised  in  the  interpretation  of  the  results  of  animal  inocula¬ 
tion.  In  the  early  days  of  bacteriology  an  observer  might 
have  readily  come  to  the  conclusion  that  this  bacillus  (3 
could  produce  typhoid  fever  in  man  because  it  caused  ul¬ 
ceration  of  Beyer’s  patches  in  the  rabbit.  And  indeed  a 
prominent  observer  in  this  country  did  make  such  a  diag¬ 
nosis  a  few  years  ago,  when  inoculation  of  some  germ  into 
cats  revealed  some  lesion  of  these  patches. 

The  discovery  of  bacillus  (3  has  furnished  the  means  of 
grouping  the  hog-cholera  bacilli  (at  least  provisionally)  with 
a  very  common  saprophyte  living  in  the  intestinal  tract  of 
animals,  the  Bacillus  coli  communis  of  Escherich.  If  gela¬ 
tin  plate  cultures  are  made  of  the  contents  of  the  intes¬ 
tines,  especially  the  rectum,  of  slaughtered  healthy  cattle 
and  swine,  colonies  of  this  bacillus  will  largely  predomi¬ 
nate — in  fact,  superficial  observers  might  consider  the  faeces 
as  a  pure  culture  of  this  bacillus.  This  is  not  true,  how¬ 
ever,  as  there  are  many  forms  present  which  fail  to  multi¬ 
ply  in  gelatin.  This  bacillus  may  thus  be  considered  a 
regular  inhabitant  of  the  intestinal  tract.  The  bacillus  (3 
stands  between  a  and  the  Bacillus  coli ,  forming,  as  it  were, 
a  connecting  link.  The  most  obvious  differences  between 
the  hog-cholera  bacilli  a  and  (3  and  the  Bacillus  coli ,  bar¬ 
ring  a  slight  difference  in  the  form  of  the  colonies  on  gela¬ 
tin,  are  the  feeble  pathogenic  power  of  the  latter  and  its 
power  to  cause  coagulation  of  milk  by  splitting  up  the  milk 
sugar.  The  Bacillus  coli  sometimes  penetrates  into  the  in¬ 
ternal  organs  in  swine  diseases,  where  I  have  several  times 
detected  it  during  the  past  three  op  four  years.  The  dan¬ 
gers  of  confounding  it  with  the  true  hog-cholera  germ  are, 
therefore,  not  insignificant.  In  grouping  these  forms  to¬ 
gether  I  am  far  from  implying  that  the  Bacillus  coli  can  be 
converted  into  the  hog-cholera  bacillus,  and  thus  be  an  ever¬ 
present  source  of  hog-cholera  germs.  The  change  of  sapro¬ 
phytic  into  parasitic  or  disease  germs  probably  goes  on  as 
slowly  as  changes  in  higher  organisms,  and  has  nothing 
sensational  about  it.  The  theoretical  advantages  of  thus 
grouping  organisms  together  will  be  admitted  by  all  biolo¬ 
gists.  But  there  are  certain  practical  advantages  most 
easily  discerned  by  the  active  worker.  We  are  put  on  our 
guard  not  to  confound  organisms  which  may  be  mistaken 
tor  one  another,  but  which  are  really  quite  unlike.  On  the 
other  hand,  the  facts  which  have  been  presented  to  you 
show  that  the  danger  of  keeping  apart  organisms  which  in 
reality  belong  together  is  almost  as  great  as  that  of  failing 
to  distinguish  between  them.  In  any  case,  as  I  have  sug¬ 
gested  before,  a  thorough  knowledge  of  all  the  biological 
phenomena  of  groups  of  organisms,  some  of  which  may  be 
pathogenic,  some  not,  and  a  true  sense  of  the  relative  value 
of  different  properties  which  are  variable  will,  I  think,  gen¬ 
erally  guard  us  from  falling  into  extreme  errors.  Finally, 
in  bacteriology,  as  in  the  older  departments  of  research,  it 
is  the  care  we  bestow  upon  apparently  trifling,  unattrac¬ 


tive,  and  very  troublesome  minutiae  which  determines  the 
result. 

In  the  prosecution  of  this  work  I  received  valuable  aid 
from  my  assistant,  Dr.  V.  A.  Moore,  as  well  as  from  the 
veterinarian  of  the  Experiment  Station  of  the  Bureau,  Dr. 
F.  L.  Kilborne. 


A  CASE  OF  DOUBLE  EMPYEMA. 

DOUBLE  PLEUROTOMT ;  RECOVERY. 

By  GEORGE  R.  WESTBROOK,  M.  D., 

BROOKLYN. 

In  the  Transactions  of  the  American  Pcediatric  Society , 
1889,  Dr.  Francis  Huber,  of  New  York,  reports  the  his¬ 
tory  and  treatment  of  two  cases  of  double  empyema  that 
came  under  his  observation,  in  both  of  which  the  patients 
recovered  ;  and  gives  a  list  of  several  others,  which  are 
about  all  the  cases  that  have  been  reported,  so  far  as  I  have 
been  able  to  find. 

As  these  cases  are  seldom  seen,  and,  as  recovery  is 
probably  not  the  usual  termination,  the  following  case, 
coming  under  my  care  last  spring,  is  of  interest : 

February  15,  1890 ,  wras  called  to  see  F.  M.  P.,  female,  aged 
four  years;  was  told  that  the  day  before  she  had  walked  across 
the  river  on  the  Brooklyn  Bridge,  about  a  mile  and  a  quarter. 
During  the  night  she  was  ill  with  symptoms  of  croup  ;  the 
family  had  used  some  domestic  remedies,  which  had  partially 
relieved  her.  I  found  her  with  a  croupy  cough,  slight  dyspnoea, 
and  slight  rise  in  temperature;  prescribed  one  tenth  of  a  grain 
of  calomel  every  hour  ;  saw  her  again  in  the  evening,  when  the 
croupy  symptoms  had  disappeared;  the  cough  was  then  loose 
and  the  temperature  normal,  and  she  was  feeling  quite  com¬ 
fortable. 

Next  morning  found  her  with  a  dry  cough,  temperature 
101°,  pulse  120,  respirations  40,  and  complaining  of  pain  in  her 
right  side.  On  examination,  found  dullness  on  percussion  and 
bronchial  breathing  over  lower  lobe  of  right  lung.  Diagnos¬ 
ticated  pneumonia. 

20th. — Coughs  a  great  deal;  cough  is  loose,  but  she  does  not 
expectorate.  Temperature  100°,  pulse  120,  and  respirations  48. 

22d. — Her  condition  is  about  the  same.  To-day  Dr.  F.  H. 
Stuart  saw  her  in  consultation  and  confirmed  the  diagnosis  of 
pneumonia. 

March  1st. — During  the  past  week  she  has  had  severe  pain 
in  the  abdomen,  bowels  loose,  passing  undigested  food,  and  oc¬ 
casionally  complaining  of  nausea.  Her  pulse  has  ranged  from 
120  to  180,  temperature  100°  to  101°,  and  respirations  from  50 
to  60.  Fed  her  with  peptonized  milk,  beef  juice,  and  brandy. 
Her  cough  still  continues  loose,  though  there  is  occasionally  a 
day  when  it  seems  tight. 

5th. — During  the  past  few  days  the  area  of  dullness  has  in¬ 
creased;  to-day  made  an  exploratory  puncture  with  a  hypo¬ 
dermic  syringe  and  found  pus. 

6th. — Assisted  by  Dr.  B.  F.  Westbrook,  after  giving  her 
chloroform,  an  incision  was  made  between  the  seventh  and 
eighth  ribs  a  little  posterior  to  the  axillary  line,  when  about  a 
pint  of  pus  drained  away  ;  a  soft-rubber  drainage-tube  was  in¬ 
serted  and  the  wound  dressed  with  marine  lint  and  absorbent 
cotton.  The  quantity  of  pus  discharged  for  several  days  was 
sufficient  to  saturate  the  dressings.  The  wound  was  dressed 
daily.  Notwithstanding  the  free  drainage,  her  condition  did  not 
improve,  her  temperature  keeping  between  100°  and  102°,  pulse 
120  to  130,  and  respirations  from  50  to  60.  Her  stomach  troub- 


488 


FERGUSON:  THE  TREATMENT 

led  her  more  now  than  at  any  time  during  her  illness,  and  she 
had  constant  pain  and  frequent  vomiting. 

12th.— As  pus  was  found  last  evening  by  means  of  a  hypo¬ 
dermic  syringe  in  the  left  pleural  cavity,  it  was  aspirated  to¬ 
day  and  four  ounces  removed. 

18th. — Since  the  aspiration  on  March  12th  her  condition 
has  not  changed;  temperature  fluctuating  between  100°  and 
102°,  pulse  120  to  130,  and  respirations  50  to  60.  To-day  the 
left  pleural  cavity  was  again  aspirated,  but  only  about  two 
ounces  of  very  thick  pus  were  obtained,  when  the  needle  became 
plugged;  it  was  removed  and  inserted  in  a  new  place,  but  with 
a  negative  result.  During  the  past  week  the  right  pleural  cav¬ 
ity  has  been  washed  out  daily  with  a  warm  l-to-5,000  bichloride 
solution ;  suppuration  was  very  free  and  very  offensive  in 
odor. 

21th. — To-day  the  left  pleural  cavity  was  again  aspirated 
and  six  ounces  of  pus  were  taken  away. 

Her  condition  does  not  seem  so  good ;  she  is  weaker,  and  it 
is  with  difficulty  she  can  be  induced  to  take  any  nourishment; 
her  pulse  and  temperature  have  kept  about  the  same,  but  her 
respirations  are  accelerated,  running  from  60  to  70.  Before 
the  aspiration  to-day  had  intended  to  do  a  pleurotomy,  but  her 
father  would  not  consent. 

April  12th. — For  four  or  five  days  after  the  last  aspiration 
her  condition  improved;  her  pulse  and  temperature  became 
lower  and  her  respirations  less  frequent ;  her  appetite  improved, 
and  she  had  very  little  trouble  with  her  stomach  and  bowels, 
but  during  the  past  week  the  unfavorable  symptoms  have  re¬ 
turned  ;  to-day  she  was  aspirated  for  the  fourth  time  and  ten 
ounces  of  pus  were  removed. 

19th. — She  has  not  improved  since  the  last  aspiration,  her 
pulse,  temperature,  and  respirations  still  keeping  very  high. 
To-day  she  was  aspirated  for  the  fifth  time,  but  only  two  ounces 
of  pus  were  obtained. 

May  6th. — As  there  has  been  no  improvement,  and  as  the 
left  pleural  cavity  is  evidently  filling  up,  her  father  consented 
to  have  an  operation  done.  So  to-day,  assisted  by  Dr.  B.  F. 
Westbrook,  after  giving  her  chloroform,  an  incision  was  made 
into  the  left  pleural  cavity  and  about  eight  ounces  of  thin,  dark- 
colored,  and  foul-smelling  pus  were  evacuated.  A  soft-rubber 
drainage-tube  was  inserted  and  a  dressing  of  marine  lint  and 
absorbent  cotton  applied.  There  was  considerable  shock  fol¬ 
lowing  the  operation;  she  was  put  on  an  ounce  of  champagne 
every  hour,  which  was  retained  after  the  second  dose;  after 
five  or  six  hours  the  interval  was  increased  to  two  hours.  The 
next  day  she  commenced  to  take  a  little  peptonized  milk. 

The  left  pleuraDcavity  was  washed  out  daily  with  a  l-to- 
5,000  bichloride  solution  for  four  days,  when  her  temperature 
came  down  to- normal  and  remained  there.  From  this  time 
there  was  a  steady  improvement,  though  her  pulse  and  respira¬ 
tions  did  not  come  down  to  normal  for  three  or  four  weeks. 

The  tube  was  removed  from  the  right  side  on  June  8th, 
three  months  after  the  operation,  and  the  sinus  had  closed  ten 
days  later. 

On  J une  22d  the  tube  was  removed  from  the  left  side,  seven 
weeks  after  the  pleurotomy,  and  the  sinus  was  closed  in  a  week. 

At  this  writing,  three  months  after  the  second  tube  was  re¬ 
moved,  the  child  seems  well.  The  percussion-note  and  aus¬ 
cultatory  sounds  are  normal ;  her  appetite  is  good  and  she  has 
gained  in  weight. 

Indubitably  the  second  pleurotomy  in  this  case  should 
have  been  done  at  least  a  month  earlier,  but  it  was  impos¬ 
sible  to  get  the  consent  of  her  family. 

How  many  times  it  is  advisable  to  aspirate  a  pleural 
cavity  containing  pus  before  making  an  incision  I  can  not 


OF  INTERNAL  HAEMORRHAGES.  [N.  Y.  Mkd.  Jorn., 

say.  There  is  nothing  very  formidable  about  the  opera¬ 
tion,  and  certainly  in  this  case  there  was  no  benefit  derived 
from  aspiration. 


THE  TREATMENT  OF  INTERNAL  HAEMORRHAGES. 

Bv  JOHN  FERGUSON,  M.  A.,  M.  D., 

L.  R.  C.  P.,  L.  F.  P.  8., 

DEMONSTRATOR  OF  ANATOMY,  MEDICAL  DEPARTMENT, 

UNIVERSITY  OF  TORONTO,  AND  LECTURER  ON  NERVOUS  DISEASES  IN 
THE  SUMMER  SESSION. 

There  are  few  more  trying  positions  which  the  prac¬ 
titioner  of  medicine  can  find  himself  suddenly  forced  to  oc¬ 
cupy  than  that  of  facing  a  severe  internal  haemorrhage — 
cerebral,  pulmonary,  gastric,  intestinal,  or  uterine.  At  the 
lonely  hour  of  midnight  and  far  away  from  consultation  he 
maybe  called  upon  to  act;  and  it  is  well  to  have  one’s  mind 
already  made  up  as  to  the  course  that  should  be  pursued  in 
the  various  forms  of  haemorrhages,  for  “  to  be  forewarned  is 
to  be  forearmed.”  It  is  with  the  view  of  summing  up  our 
knowledge  on  this  subject,  and  with  the  hope  of  adding  a 
few  new  points,  that  this  contribution  is  offered  to  the  medi¬ 
cal  profession. 

In  the  first  place,  it  is  very  apparent  that  the  amount  of 
blood  that  will  flow  through  a  rent  in  the  wall  of  any  vessel 
must  be  greatly  influenced  by  the  total  amount  of  blood  in 
the  system  and  the  amount  of  pressure  upon  the  vessel 
from  within.  This  being  the  case,  the  first  step  to  take 
in  dealing  with  a  haemorrhage  is  to  cut  off  the  supply  of 
liquids.  In  this  way  the  amount  of  blood  is  kept  down, 
while  it  becomes  thicker  in  quality  and  better  fitted  for  the 
forming  of  a  good,  firm  clot  in  the  torn  or  ruptured  vessel. 
Another  step  in  the  same  direction  is  to  reduce  the  volume 
of  blood  by  actively  eliminating  water  from  the  system. 
The  hypodermic  injection  of  pilocarpine  rapidly  unloads 
the  body  of  water  and  inspissates  the  blood  left  behind, 
lessening  thereby  the  freeness  of  the  flow.  This  would  not, 
however,  be  suitable  in  cases  of  pulmonary  bleeding.  Other 
diaphoretics  might  be  selected,  according  to  the  judgment 
of  the  physician,  or  the  nature  of  the  case  and  the  condition 
of  the  patient. 

Another  group  of  remedies  is  of  much  value  in  dealing 
with  such  cases.  Those  purgatives  that  produce  copious 
watery  stools,  and  at  the  same  time  are  not  irritating  or  de¬ 
pressing,  must  be  placed  high  on  the  list  of  things  we  may 
use  for  the  relief  of  the  sufferer  intrusted  to  our  charge.  Of 
these  purgatives  there  is  none  so  good  as  Epsom  salts — the 
sulphate  of  magnesium.  When  given  in  saturated  solu¬ 
tion,  without  water,  in  free  doses,  and  oft  repeated,  very 
free  watery  evacuations  are  produced,  the  amount  of  fluid 
in  the  vascular  system  is  speedily  lessened,  and  the  haemor¬ 
rhage  to  this  extent  controlled.  By  maintaining  this  action 
for  some  time,  the  ruptured  vessel  has  time  to  heal,  because 
the  pressure  is  largely  taken  off  it,  and  it  is  put  into  the 
condition  of  rest.  In  addition  to  this,  however,  the  blood 
is  thickened.  In  some  cases  of  cholera — sporadic  or  epi¬ 
demic — where  the  rice-water  stools  have  been  very  abun¬ 
dant,  the  blood  becomes  so  reduced  in  volume  and  so  in¬ 
spissated  as  not  to  flow  from  a  wound  made  in  a  large  vein. 
In  the  event  of  the  haemorrhage  being  due  to  the  ulceration 
of  typhoid  fever,  this  plan  could  not  be  had  recourse  to, 


Nov.  1,  1890. J 


PRITCHARD:  A  CASE  OF  TRAUMATIC  NEURITIS. 


489 


although  I  have  used  it  with  advantage  in  the  bleeding  of 
gastric  ulcer.  In  the  haemorrhage,  often  so  free,  from  soft 
and  rapidly  growing  uterine  fibroids,  it  is  specially  useful, 
if  continued  long  enough — say  for  months. 

Some  persons  have  a  strong  tendency  to  bleed,  and  any 
haemorrhage  is  hard  to  stay.  The  mucous  membranes  of 
the  nose,  stomach,  bowels,  or  bronchial  tubes  ooze  away,  and 
though  the  flow  may  not  be  very  rapid  at  any  one  time,  the 
total  amount  lost  is  very  considerable.  I  once  saw  a  girl 
of  thirteen  brought  almost  to  death’s  door  by  such  a  haem¬ 
orrhage  from  the  mucous  membrane  of  her  lip.  In  purpura 
we  know  how  readily  patients  suffer  from  subcutaneous  ex¬ 
travasations.  For  this  form  of  slow,  continuous  oozing  the 
following  formula  maybe  found  highly  serviceable:  Mix 
one  ounce  each  of  absolute  alcohol  and  oil  of  turpentine  in  a 
glass  or  Wedgwood  mortar.  To  this  add  very  slowly,  stir¬ 
ring  all  the  while,  one  ounce  of  sulphuric  acid.  When  all 
chemical  action  is  over,  the  mixture  may  be  bottled.  Of 
this,  ten  or  fifteen  minims  may  be  ordered  every  two,  three, 
or  four  hours  as  needed.  I  have  found  these  “black  drops” 
of  very  great  value  in  some  exceedingly  troublesome  cases. 

In  the  event  of  a  very  severe  post-partum  hamiorrhage 
the  medical  attendant  may  try  ergotine  hypodermically,  or 
hot  vaginal  or  rectal  injections  ;  but  these  may  fail.  It  is 
a  belief,  not  yet  quite  dead,  that  the  uterine  sinuses  are 
closed  by  clots.  This  is  quite  erroneous.  The  uterine  ves¬ 
sels  and  sinuses  are  interlaced  by  muscular  fibers,  and  it  is 
the  contraction  of  these  that  arrests  the  htemorrhage.  This 
muscular  tissue,  as  it  were,  ligates  the  vessels  that  would 
bleed  ;  and  so  long  as  the  contraction  is  good  there  is  no 
danger.  Now,  for  the  maintenance  of  this  tonic  action  of 
the  muscular  tissue  in  the  uterus  I  have  found  the  applica¬ 
tion  of  heat  to  the  lumbar  portion  of  the  spine  very  useful. 
It  stimulates  this  portion  of  the  nervous  system  by  bringing- 
more  blood  to  it.  There  is  a  greater  influx  of  nerve  energy 
to  the  uterus  and  contraction  is  brought  about.  It  is  true 
that  the  uterus  seems  to  be  very  independent  of  the  spinal 
cord,  and  labor  may  take  place  in  a  paraplegic.  This  does 
not,  however,  invalidate  the  fact  that  heat — applied  to  the 
spine  by  a  large  sponge  dipped  into  hot  water — does  much 
good  in  the  way  of  rousing  the  uterus  to  action.  But  when 
all  things  fail,  as  fail  they  will  at  times;  when  ergotine, 
acetate  of  lead  in  large  doses,  hot  injections,  and  heat  to 
the  spine  disappoint  us,  we  have  one  last  resort :  Tampon 
the  uterus  and  vagina  thoroughly  with  iodoform  gauze,  or, 
if  this  is  not  at  hand,  some  cloths  to  which  glycerin  is 
added.  This  plan  I  am  quite  sure  will  not  fail.  The  bleed¬ 
ing  is  soon  arrested,  the  uterus  begins  to  contract,  tone  in 
its  walls  is  secured,  and  one  can  feel  at  ease  that  the  patient 
is  out  of  all  immediate  danger. 

As  a  means  of  arresting  hajmorrhages  and  gaining  time 
for  other  remedies,  I  would  suggest  the  following  plan,  one 
great  feature  of  which  is  that  it  is  always  available  and  does 
good.  It  is  applicable  to  cases  of  capital  operations  on  the 
body,  such  as  the  removal  of  large  and  vascular  tumors  from 
the  neck,  the  female  breast,  etc.  The  plan  is  simply  to  tie 
bands  around  the  legs  and  arms  close  up  to  the  body.  This 
arrests  the  return  of  blood  to  the  body,  while  the  flow  of 
blood  into  the  limbs  still  goes  on.  By  this  means  a  very 


large  amount  of  the  blood  in  the  body  is  rapidly  collected 
into  the  four  extremities  and  the  pressure  taken  off  the  cen¬ 
tral  vessels.  One  day,  when  in  my  last  year  as  a  student,  in 
1879,  I  was  walking  along  the  streets,  when  I  came  upon 
an  excited  little  crowd  of  people.  I  saw  that  one  of  the  num¬ 
ber,  a  young  man  of  about  thirty  years,  was  bleeding  freely 
from  his  lungs.  I  had  nothing  with  me,  but  had  just  been 
thinking  about  venesection  and  the  swollen  condition  of 
the  veins  in  the  arm.  I  seized  the  present  opportunity,  tore 
up  a  handkerchief,  and  tied  the  strips  very  firmly  around 
the  four  extremities.  The  results  were  very  gratifying. 
Ever  since  I  have  made  extensive  use  of  these  bands,  and 
now  feel  a  good  deal  of  confidence  in  recommending  them 
to  others. 

I  have  already  mentioned  the  usefulness  of  the  hot 
sponge  to  the  lumbar  region  in  post-partum  haemorrhage. 
Now,  in  other  cases  of  internal  lnemorrhage — as  from  the 
mucous  membranes  of  the  stomach,  nose,  and  bowels — the 
spinal  ice  bag  is  no  mean  therapeutic  agent.  It  induces 
anaemia  of  the  spinal  cord  and  a  marked  dilatation  of  the 
surface  blood-vessels.  The  internal  strain  is  reduced,  and 
consequently  the  haemorrhage  lessens. 


A  CASE  OF  TRAUMATIC  NEURITIS 

ILLUSTRATING  THE 

MEDICO-LEGAL  VALUE  OF  ELECTRICITY  IN  DIAGNOSIS. 

By  WILLIAM  BROADDUS  PRITCHARD,  M.  D., 

LECTURER  ON  MENTAL  AND  NERVOUS  DISEASES,  NEW  YORK  POLYCLINIC. 

The  statement  was  recently  made  in  the  presence  of 
the  writer  that  the  number  of  civil  suits  for  damages  for 
injury  received  through  accident  or  carelessness  averaged, 
in  the  courts  of  the  cities  of  New  York  and  Brooklvn 
alone,  as  many  as  five  hundred  weekly.  The  additional 
statement  was  made  that  at  least  one  third  of  these  cases 
were  fraudulent,  the  trivial  character  of  the  injury  received, 
or  some  other  factor,  entitling  the  plaintiff  to  neither  dam¬ 
ages  nor  commiseration.  The  important  point  in  such 
cases  is  the  difficulty  in  discriminating  between  the  honest 
suitor  and  the  malingerer.  With  a  skilled  expert  this  is 
ordinarily  not  a  troublesome  task.  It  should  be  remem¬ 
bered,  however,  that,  in  the  majority  of  instances,  these 
suits  are  for  small  amounts,  and  the  insignificance  of  the 
sum  at  stake  does  not  justify  the  employment  of  an  expen¬ 
sive  specialist.  The  only  medical  testimony  introduced  in 
such  cases  is  that  of  the  attendant  physician,  who  is  usu¬ 
ally  a  general  practitioner,  and,  by  reason  of  that  fact,  not 
competent  to  express  an  expert  opinion.  In  many  instances 
the  injury  is  of  such  a  gross  and  palpable  character  that 
the  simple  appearance  of  the  plaintiff  in  court  is  all  that  is 
necessary  to  convince  both  judge  and  jury  of  the  justice  of 
his  claim.  Such  cases  rarely  come  to  trial,  however,  for 
the  defendant  recognizes  the  strength  of  the  suitor’s  posi¬ 
tion  and  his  own  consequent  weakness,  and  the  case  is  set¬ 
tled  out  of  court.  Very  serious  injury  may  have  occurred, 
however,  and  of  a  permanent  character,  of  which  there  may 
be  no  evidence  superficially,  or  even  upon  fairly  close  ex¬ 
amination,  except  the  sensations  of  the  patient.  The  pa- 


490 


PRITCHARD:  A  CASE  OF  TRAUMATIC  NEURITIS. 


[N.  Y.  Mbd.  Joub., 


tient’s  statements,  when  he  is  also  plaintiff  and  a  money 
issue  is  at  stake,  are  notoriously  unreliable.  The  most 
striking  and  conspicuous  illustration  of  the  difficulties  en¬ 
countered  in  adjusting  such  cases  upon  a  basis  of  merit  is 
to  be  met  with  in  the  numerous  suits  in  which  the  plaintiff’s 
injury  is  that  of  so-called  spinal  concussion.  The  medico¬ 
legal  literature  of  the  subject  alone  represents  an  expendi¬ 
ture  of  money  which  would  afford  a  generous  income  for 
life  to  every  honest  victim  of  this  injury.  There  is  an¬ 
other  class  of  cases  which  bids  fair  to  rival  the  now  famous 
“railway  spine’’  in  the  obscurity  which  often  surrounds  a 
correct  diagnosis  and  a  consequent  correct  estimate  of  the 
amount  of  damage  incurred.  For  this  new  class  of  cases 
we  are  indebted  to  the  investigations  of  the  neurologists, 
who  have  added  to  the  nosology  of  medicine  a  compara¬ 
tively  new  and  distinct  entity  in  disease  in  neuritis,  or  in¬ 
flammation  of  a  nerve.  While  it  is  true  that  nerve  inflam¬ 
mation,  from  injury  or  other  cause,  has  been  for  many 
years  recognized  pathologically  and,  to  a  certain  extent, 
symptomatically,  it  is  only  within  the  recent  past  that  the 
symptomatology  and  clinical  diagnosis  have  been  accu¬ 
rately  understood,  or  the  disease  classified  as  a  distinct 
affection  in  text-books  upon  medicine.  Even  to-day,  full  as 
is  our  knowledge  of  the  subject,  cases  are  not  infrequently 
encountered  in  which  the  absence  of  objective  symptoms 
renders  a  diagnosis  a  matter  of  much  obscurity  and  doubt. 
Such  a  case  recently  occurred  in  the  practice  of  the  writer, 
and  is  taken  as  the  occasion  for  this  paper.  The  history  is 
as  follows : 

On  November  6,  1889,  I  was  called  to  see  B.,  aged  fifty- 
nine,  a  janitor  by  occupation.  I  found  him  suffering  from  an 
injury  to  the  right  shoulder,  said  to  have  been  received  two 
days  previously,  caused  by  a  fall  through  an  open  coal  hole  in 
the  sidewalk.  Upon  removing  the  bandages  and  dressings,  which 
had  been  applied  at  the  hospital  immediately  after  the  receipt 
of  the  injury,  I  found  his  shoulder  very  much  swollen  and  dis¬ 
colored  from  bruises  involving  the  outer  aspect  of  the  shoulder 
and  upper  arm,  the  region  occupied  principally  by  the  deltoid 
group  of  muscles.  Careful  examination  showed  no  evidence  of 
fracture  or  dislocation,  though  there  was  considerable  interfer¬ 
ence  with  motion  from  soreness  and  swelling,  especially  in  ab¬ 
duction.  The  swelling  was  sufficient  to  produce  a  difference 
of  an  inch  and  an  eighth  in  the  circumference  of  the  two 
shoulders,  as  shown  by  measurement.  The  patient  freely  an¬ 
nounced  his  intention  of  bringing  suit  for  damages,  and  insisted 
upon  a  careful  and  accurate  examination  of  his  condition,  which, 
however,  revealed  nothing  beyond  the  symptoms  detailed  above. 
The  swelling  and  inflammation  gradually  disappeared  under 
treatment,  and  the  interference  with  motion  became  less.  On 
December  23,  1889,  nearly  eight  weeks  after  the  injury  was  re¬ 
ceived,  the  patient  called  at  my  office  complaining  of  continued 
pain  and  a  loss  of  power  in  the  arm  affected.  I  had  not  seen 
him  for  nearly  two  weeks  previously.  The  pain,  he  stated,  was 
confined  to  the  outer  aspect  of  the  shoulder.  Upon  examina¬ 
tion,  I  found  no  special  painful  spot,  but  tenderness  on  pressure 
and  pain  on  motion  in  areas  supplied  by  the  supra-acromial 
branch  of  the  cervical  plexus  and  the  circumflex  nervee.  The 
swelling  had  disappeared  entirely,  and  motion  in  every  direc¬ 
tion  was  normal,  except  that  elevation  of  the  arm  at  the  shoulder 
was  done  quite  slowly  on  account  of  the  pain  produced  in  the 
attempt,  there  existed  a  state  of  cutaneous  liyperaasthesia  and 
a  subjective  sensation  of  numbness  in  the  part  affected.  Meas¬ 


urement  of  the  two  arms  showed  no  special  wasting  or  atrophy. 
The  right-hand  grasp  was  slightly  diminished.  Pain,  tactile 
and  muscular  sense  were  normal  in  the  forearm  and  hand.  A 
mild  current  from  the  secondary  coil  of  a  faradaic  battery  gave 
a  painful,  irritable  response.  To  the  galvanic  current  the  re¬ 
sponse  was  at  that  time  normal.  Although  neuritis  was  sus¬ 
pected,  a  diagnosis  could  not  at  that  time  be  made  which  would 
conform  to  the  requirements  of  a  medico-legal  standard.  The 
patient’s  condition  remained  practically  unchanged  up  to  May, 
1890,  the  pain  and  weakness  varying  in  intensity  and  degree, 
the  periods  of  temporary  amelioration  corresponding  to  treat¬ 
ment  by  electricity,  which  was  kept  up,  though  with  great 
irregularity  and  at  infrequent  intervals.  Examination  on  May 
2d  showed  slight  atrophy,  which,  however,  might  have  been 
(apparently)  due  to  non  use.  Pain  was  still  complained  of,  and 
the  loss  of  power  had  increased,  as  shown  by  the  patient’s 
greater  helplessness  and  the  dynamometer,  neither  test,  how¬ 
ever,  being  absolutely  reliable.  The  bypersesthesia  had  disap¬ 
peared,  though  the  subjective  sensation  of  numbness  still  re¬ 
mained.  I  failed  to  demonstrate  absolute  loss  or  very  marked 
diminution  of  either  tactile  or  pain  sense  in  the  upper  arm  and 
shoulder.  Muscular  sense,  on  account  of  the  difficulty  of  testing 
it  in  this  locality,  I  did  not  investigate.  So  far  ray  diagnosis  of 
traumatic  neuritis,  while  more  plausible,  was  not  established, 
but,  upon  testing  the  circumflex  nerve  by  the  galvanic  current, 
all  doubt  was  at  once  dispelled,  the  reaction  showing  a  reversal 
of  the  normal  polar  formula  of  Erb — an  indication  of  degenera¬ 
tion. 

A  brief  resume  of  the  history  and  circumstances  of  the 
case  will  bring  out  the  more  clearly  the  points  which  it  is 
intended  to  illustrate.  A  man  received  an  injury  under  cir¬ 
cumstances  which  gave  him  good  grounds  for  a  suit  for 
damages.  Carelessness  on  the  part  of  the  defendant  could 
be  easily  established  and  was  practically  not  denied.  The 
extent  and  permanency  of  the  injury  received,  by  which  the 
amount  sued  for  was  to  be  regulated,  was  the  only  point  at 
issue.  It  can  readily  be  seen  that  here  was  a  strong  motive 
for  exaggeration,  in  both  particulars,  in  a  man  whose  social 
sphere  and  surroundings  were  such  as  to  almost  preclude 
the  possibility  of  any  extraordinary  sense  of  moral  or  eth¬ 
ical  responsibility.  There  was  little  tangible  evidence  of 
serious  injury  for  a  long  time.  The  arm,  after  the  swelling 
disappeared,  looked  like  its  fellow,  and  the  symptoms  of  pain 
and  loss  of  power  might  have  been  readily  assumed.  Such, 
at  any  rate,  was  the  plea  of  the  defense,  and  upon  it  they 
expected  to  either  defeat  the  plaintiff  outright,  or  so  far  to 
reduce  the  amount  of  damages  awarded  as  practically  to  win 
in  any  event.  On  the  other  hand,  the  plaintiff’s  case  was  a 
just  one ;  he  had  been  seriously  and  more  or  less  perma¬ 
nently  injured  (for  the  prognosis  is  not  extraordinarily 
good  in  such  cases  and  never  certain),  but  how  was  he  to 
prove  it?  His  personal  statement,  that  of  the  interested 
party,  was  almost  the  only  evidence  to  support  his  claim. 
The  physician  might  have  testified  as  to  a  probable  diag¬ 
nosis,  but,  until  after  the  demonstration  by  the  galvanic 
current  of  a  degeneration  in  the  nerve,  his  evidence  would 
have  been  problematical  and  necessarily  uncertain  in  its 
effect.  This  demonstration,  however,  altered  the  whole 
aspect  of  the  case.  Becoming  satisfied  of  its  correctness, 
the  attorneys  tor  the  defense,  foreseeing  defeat,  would  not 
allow  the  case  to  come  to  trial,  but  paid  over  at  once  almost 
the  lull  amount  claimed  as  damages. 


Nov.  1,  1890. J 


CORRESPONDED  CE. 


491 


My  object  in  reporting  this  case  is  to  illustrate  the  value 


of  electricity  as  a  means  of  diagnosis,  already  firmly  estab¬ 
lished,  in  diseases  of  the  nervous  system.  In  this  particu¬ 
lar  instance  it  transformed  a  prospective  failure  into  an  ab¬ 
solute  success,  it  proved  an  invaluable  aid  to  the  adminis¬ 
tration  of  justice,  and  it  lifted  the  black  shadow  of  suspicion 
from  an  honest  man. 

355  West  Fifty-eighth  Street. 


C0msj}0nbmce. 


LETTER  FROM  LONDON. 

Post-graduate  Instruction  in  London. —  The  University  of  Lon¬ 
don  Scheme. — The  Commencement  of  the  Winter  Session. — 
The  Clinical  Society. — A  New  Dictionary  of  Practical  Medi¬ 
cine. 

London,  October  11 ,  1890. 

The  third  session  of  the  London  post-graduate  course  is 
about  to  begin,  and  the  present  time  may  therefore  seem  not 
inopportune  to  review  its  working  and  success  so  far.  It  was 
framed  originally  with  the  intention  of  affording  to  practitioners 
in  our  own  country  or  to  those  from  foreign  parts  an  opportunity 
of  brushing  up  their  knowledge  and  becoming  familiarized  with 
modern  methods  of  diagnosis  and  treatment,  and  for  this  pur¬ 
pose  our  leading  special  hospitals  united  to  give  a  combined 
programme  of  clinical  lectures  and  demonstrations.  Five  hos¬ 
pitals  originally  took  part  in  it,  representing  diseases  of  the 
chest,  of  the  nervous  system,  of  the  eye,  of  the  skin,  and  of 
children ;  and  subsequently  arrangements  were  made  whereby 
the  patients  at  one  asylum  for  the  insane  and  one  poor-law  in¬ 
firmary  were  made  available  for  the  purposes  of  the  class.  The 
hospitals  that  joined  in  the  scheme  were  the  best  known  in 
their  respective  branches.  The  lectures  and  demonstrations 
were  so  arranged  as  not  to  clash  with  each  other,  and  yet  so 
that  the  members  of  the  class  should  have  their  time  fairly  well 
occupied,  and  the  fee  for  the  course  was  ridiculously  small. 
Moreover,  it  was  permitted  to  any  one  to  join  for  only  certain 
portions  of  the  course  if  he  wished  to  do  so  and  pay  a  propor¬ 
tionate  part  of  the  fee.  Notwithstanding  all  the  advantages 
which  the  scheme  appeared  to  offer,  the  number  of  entries  was 
absurdly  small,  and  the  second  course  did  not  meet  with  more 
success  than  the  first  in  point  of  numbers,  and,  if  this  third 
course  does  not  attract  students  in  greater  numbers,  the  scheme 
will  almost  inevitably  die  a  natural  death.  The  lecturers  and 
teachers  engaged  in  it  are  almost  without  exception  men  who 
hold  appointments  at  the  general  hospitals,  with  plenty  of 
teaching  to  do  at  their  own  schools,  and  it  can  not  be  expected 
that  they  will  continue  to  take  part  in  this  post-graduate  teach¬ 
ing  unless  there  is  much  better  evidence  than  has  hitherto  been 
supplied  that  their  efforts  are  appreciated.  It  is  my  firm  belief 
that  the  great  majority  of  English,  Scottish,  Canadian,  and 
American  practitioners,  who  every  year  spend  a  lot  of  time  and 
money  in  Paris,  Berlin,  or  Vienna,  would  do  far  better  if  they 
spent  the  time  in  studying  at  the  special  hospitals  of  London. 

In  my  last  letter,  I  believe,  I  referred  to  the  University  of 
London  scheme  as  on  the  point  of  being  satisfactorily  arranged. 

I  was  a  little  too  premature  in  doing  so,  for  at  the  last  minute 
the  senate  of  that  body  found  themselves  quite  unable  to  rec¬ 
oncile  the  conflicting  views  pressed  upon  them  from  all  sides, 
and  gave  up  the  task  in  despair.  Such  a  contingency  had  been 
foreseen,  but  it  is  one  thing  to  be  able  to  foresee  what  may 


happen  and  quite  another  to  be  able  to  prevent  it.  What  will 
probably  happen  now  is  that  the  commissioners  who  were  for¬ 
merly  appointed  to  consider  this  subject,  and  by  whose  advice 
the  existing  university  was  requested  to  undertake  the  settle¬ 
ment  of  the  questions,  will  be  called  upon  to  resume  their  labors, 
and  that  they  will  frame  a  scheme  which  the  Government  will 
endeavor  to  carry  into  effect,  whether  the  existing  bodies  like  it 
or  no.  In  their  former  report  the  commissioners  were  divided 
as  to  whether  a  new  university  should  be  founded  or  not.  It  is 
tolerably  certain  that  a  new  university  is  inevitable  now,  a  fact 
which  I  think  the  great  majority  of  those  who  have  followed 
the  question  have  long  since  realized. 

Another  winter  session  has  begun,  with  its  usual  comple¬ 
ment  of  introductory  addresses  and  old  students’  dinners,  and 
the  chief  topic  at  present  is  as  to  the  relative  number  of  entries 
at  the  different  schools.  I  suppose  they  will  be  published  next 
week.  At  present  I  have  no  very  reliable  information  to  give 
on  the  subject,  but  I  should  not  be  surprised  if  this  year  and 
next  the  entries  were  unusually  good,  for  in  1892  the  new  regu¬ 
lation  will  come  into  force  requiring  a  five-year  curriculum  in¬ 
stead  of  four,  and  that  will  presumably  mean  an  increase  of 
fees — a  fact  to  which  parents  and  guardians  will  be  fully  alive. 

The  Clinical  Society  is  the  first  to  get  under  way  this  year. 
It  held  its  first  meeting  yesterday  evening.  It  is  also  the  first 
in  the  field  with  its  annual  volume  of  Transactions ,  which  was 
distributed  to  the  members  a  few  days  ago.  The  volume  is 
quite  up  to  the  average  of  its  predecessors,  the  majority  of  the 
papers,  as  usual,  being  surgical.  Perhaps  the  first  is  as  valua¬ 
ble  as  any.  It  is  by  Mr.  Mayo  Robson,  and  refers  to  a  series  of 
fourteen  cases  of  cholecystotomy. 

The  only  book  that  has  come  out  lately  of  any  importance 
is  a  Dictionary  of  Practical  Medicine ,  published  by  Messrs. 
Churchill  and  edited  by  Dr.  Kingston  Fowler.  It  is  of  con¬ 
venient  size,  and,  those  who  like  having  their  subjects  condensed 
for  them  ought  to  be  pleased  with  it,  for  the  writers  include  all 
the  best  men  of  the  rising  generation  of  physicians.  The  arti¬ 
cles  are  short  and  to  the  point,  and,  for  the  most  part  at  any 
rate,  do  not  waste  the  reader’s  time  with  long  dissertations 
upon  theoretical  points.  The  book  has  come  out  none  too  soon, 
for  Quain’s  Dictionary  is  undergoing  revision,  and  will  be  a 
formidable  antagonist  for  its  younger  rival. 

Two  well-known  names  have  been  added  to  our  death  roll 
during  the  last  few  weeks.  Handheld  Jones  has  passed  away 
in  the  fullness  of  years  after  a  long  afid  active  career  as  a  clini¬ 
cian  and  pathologist.  A  stupendous  worker,  he  never  became 
widely  known,  but  at  his  own  hospital  (St.  Mary’s)  he  was 
greatly  respected.  Dr.  Matthews  Duncan,  on  the  other  hand, 
was  of  world-wide  renown,  and  as  a  clinical  teacher  and  lect¬ 
urer  had  few  if  any  superiors,  certainly  none  in  his  own  line. 
He  will  long  be  missed  at  St.  Bartholomew’s  Hospital,  where 
his  lectures  were  immensely  appreciated. 


The  Mortality  of  Widowers  from  Phthisis. — “  In  a  paper  on  Tuber¬ 
culosis  in  Belgium  MM.  Destree  and  Gallmaerts  come  to  the  conclusion 
as  the  result  of  their  investigations  that,  in  comparing  the  mortality 
from  phthisis  of  bachelors,  married  men,  and  widowers,  the  last  are 
very  much  more  subject  to  this  disease  than  either  of  the  other  classes. 
The  same  statement  holds  good  for  all  ages,  and  it  is,  they  say,  also 
true  that  widows  are  more  liable  than  single  women  to  die  of  phthisis. 
The  authors  do  not  think  this  is  to  be  explained  except  by  direct  con¬ 
tagion  of  wife  to  husband  or  husband  to  wife.  They  can  not  think  ir¬ 
regularities  and  excesses  indulged  in  by  widowers  can  be  answerable 
for  it,  for  advanced  age  does  not  seem  to  make  any  difference.  They 
would  ascribe  it  to  infection  occurring  during  married  life,  the  disease 
claiming  its  second  victim  some  time  after  the  death  of  the  first.” — 
Lancet. 


492 


LEADING  ARTICLES. 


[N.  Y.  Mkd.  Jock., 


the 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  oj  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  NOVEMBER  1,  1890. 


ACUTE  PLEURISY  AND  ACUTE  RHEUMATISM. 

In  1883  Aufrecht  drew  attention  to  the  decided  results  he 
had  obtained  in  the  treatment  of  acute  pleurisy  with  the  sali¬ 
cylates.  Recent  writers,  notably  Tetz  (in  the  Therapeutische 
MonaUhefte ,  No.  7,  1890),  have  confirmed  his  observations. 
We  must  allow  that  the  title  of  a  remedy  to  cure  acute  pleurisy 
must  be  very  well  substantiated.  Acute  pleurisies  have  a  way 
of  stopping  short  without  treatment,  of  beginning  with  a  fierce 
pain  which  suddenly  abates,  and  of  suddenly  going  on  into  the 
stage  of  extensive  effusion  with  very  little  warning  pain  at  all. 
Nevertheless,  the  successful  results  of  the  administration  of  sali¬ 
cylates  in  acute  pleurisy,  as  recorded  by  these  writers,  are  suf¬ 
ficient  to  raise  in  our  minds  the  question  as  to  whether  acute 
rheumatism  and  acute  pleurisy  are  not  the  same  disease.  Long 
ago  Mr.  Hilton,  in  his  admirable  lectures  on  Rest  and  Pain, 
pointed  out  the  resemblance  between  the  pleura  and  pericardi¬ 
um  and  the  joints.  The  pleural  cavity  represents  a  huge  joint 
constantly  in  motion.  It  has  the  two  surfaces  covered  by  se¬ 
rous  membrane  and  gliding  smoothly  upon  each  other  by  the  aid 
of  a  lubricating  fluid.  And  Mr.  Hilton  went  on  to  apply  his 
law  of  associated  muscular  action,  nerve  supply,  and  function 
to  the  pleura,  showing  how,  when  inflammation  took  place,  the 
nerves  of  the  pleura  that  were  directly  in  communication  with 
those  supplying  the  intercostal  muscles  called  for  cessation  of 
movement,  and  how  the  pain  felt  in  the  skin  over  the  inflamed 
area  was  the  agent  by  which  this  needed  rest  was  obtained. 
Practically  the  same  thing  occurs  in  the  joint  that  is  inflamed 
and  painful  from  acute  rheumatism.  Probably  the  resemblance 
between  inflammation  of  a  serous  membrane  and  that  of  a  joint 
would  be  more  striking  were  the  conditions  exactly  similar. 
But  in  the  case  of  the  serous  membrane  complete  rest  of  the 
opposed  surfaces  can  not  be  obtained.  The  lungs  can  not  cease 
taking  in  air,  and  the  heart  can  not  stop  beating.  Probably 
this  accounts  for  the  more  fibrinous  and  adhesive  character  of 
the  effusion,  a  further  effort  of  Nature  to  secure  rest.  In  the 
case  of  the  joint  immediate  rest  is  secured,  and  the  effusion  is 
not  adhesive  in  ordinary  cases. 

The  clinical  features  of  acute  rheumatism  point  to  a  com¬ 
mon  origin  with  pleurisy,  if  not  to  a  practical  identity.  Many 
cases  of  acute  articular  rheumatism  are  complicated  wfith  effu¬ 
sion  into  the  serous  membranes.  We  say  complicated,  but  we 
mean  really  that  the  pleural  joint  or  the  pericardial  joint  has 
been  attacked  as  well  as  the  wrist  joint  or  the  elbow  joint. 
And  pleural  effusions  are  of  much  more  frequent  occurrence  in 
the  course  of  rheumatism  than  is  commonly  supposed.  In  the 
ordinary  run  of  cases  of  acute  rheumatism  the  joints  are  so  very 
painful  that  an  examination  of  the  bases  of  the  lungs  is  not 


quite  practicable,  and,  moreover,  there  are  many  practitioners 
who  do  not  injure  themselves  writh  overzeal  in  the  clinical  ex¬ 
amination  of  patients,  particularly  after  a  good  working  diag¬ 
nosis  has  once  been  made  out.  We  are  satisfied  that,  if  pleural 
effusions  in  rheumatism  were  more  frequently  looked  for,  they 
would  be  oftener  found,  and  those  who  found  them  would  be 
more  disposed  to  regard  rheumatism  as  a  general  attack  on  all 
the  joints,  including  the  serous  membranes. 

The  general  tendency  to  look  with  suspicion  upon  “ex¬ 
posure  to  cold  ”  as  a  cause  for  so  many  diseases,  to  regard 
chilliness  as  an  effect  consequent  upon  the  poisoning  of  the 
system  by  some  external  agent,  rather  than  as  a  cause  of  dis¬ 
ease,  makes  us  skeptical  as  to  whether  such  a  thing  as plevrith 
afrigore  exists.  Is  it  not  more  rational  to  regard  it  as  being 
due  to  some  inherent  tendency  in  the  individual  to  inflamma¬ 
tions  of  an  arthritic  form,  and  to  infer  that,  when  pleurisy  oc¬ 
curs  alone,  it  simply  means  that  only  one  joint  is  affected,  or 
perhaps  that  the  main  attack  has  been  upon  one  joint,  the 
others  escaping  lightly  ?  The  frequent  occurrence  of  pleurisy 
without  effusion  into  other  joint  cavities  might  arise  from  the 
fact  that  into  the  pleura  a  quantity  of  fluid  may  be  effused 
rapidly,  while  when  the  joints  are  the  main  point  of  attack  but 
little  can  make  its  way  into  them.  To  borrow  an  old  expres¬ 
sion,  the  materies  morbi  readily  leaves  the  blood  to  fill  up  the 
pleural  cavity,  but,  attempting  to  pour  itself  into  a  joint,  it 
meets  with  resistance  and  seeks  an  outlet  elsewhere.  The 
effect  of  the  salicylates,  so  well  marked  in  rheumatism,  ought 
to  be  equally  good  in  this  disease,  and  we  trust  that  many  ob¬ 
servations  will  be  made  in  this  interesting  subject. 


FAULTY  METHODS  OF  SINGING. 

Physicians  have  from  time  to  time  called  attention  to  the 
injurious  effects  of  faulty  methods  in  the  use  of  the  singing 
voice.  We  do  not  recall,  however,  so  pointed  and  convincing 
an  argument  against  the  practice  of  forcing  the  tongue  to  lie 
flat  on  the  floor  of  the  mouth  while  singing  as  is  contained  in 
Dr.  Langmaid’s  article,  published  in  this  issue  of  the  Journal. 
That  the  author  speaks  with  the  authority  of  one  well  versed 
in  vocal  physiology,  and  having  had  abundant  opportunities  for 
observing  the  actual  relationship  of  cause  and  effect  between 
certain  styles  of  vocal  exertion  and  the  physical  impairments 
that  he  attributes  to  them,  everybody  conversant  with  what 
has  been  going  on  in  laryngology  in  this  country  for  a  number 
of  years  past  is  fully  aware  ;  but  it  seems  from  his  article  that, 
in  addition,  he  speaks  with  no  little  knowledge  of  the  real  re¬ 
quirements  of  the  art  of  singing.  Even  were  all  this  not  the 
case,  however,  the  presumption  in  this  matter  would  be  alto¬ 
gether  in  favor  of  his  contention,  for  attempts  to  trammel  an 
organ  in  the  performance  of  any  of  its  functions  seldom  if  ever 
accomplish  anything  that  can  be  called  advantageous,  all  things 
considered,  and  almost  as  rarely  anything  desirable  considered 
by  itself.  Forced  depression  of  the  tongue  in  singing  probably 
increases  the  reverberation  that  takes  place  within  the  cavity 
of  the  mouth  and  swells  the  volume  of  sound,  but  mere  quan- 


Nov.  1,  1890.] 


MINOR  PA  RAO  RAP  MS. 


tity  of  clang  is  a  small  factor  in  vocal  music,  and,  if  it  were 
the  chief  factor,  it  might  perhaps  be  obtained  by  devices  that, 
however  grotesque  they  might  seem,  would  not  interfere  with 
the  play  of  any  of  the  parts  concerned  in  phonation  and  articu¬ 
lation. 

We  do  not  know  how  general  the  practice  of  forcing  the 
tongue  down  is  among  singers,  or  what  proportion  of  those 
who  resort  to  it  escape  the  serious  disability  that  was  observet 
in  Dr.  Langmaid’s  cases  ;  but  it  is  evident  that  there  is  a  goo< 
deal  of  defective  enunciation  among  public  singers,  and  it  seems 
reasonable  to  suppose  that  it  may  be  due  in  great  measure  to 
the  practice  in  question.  The  tongue  is  not  absolutely  essen¬ 
tial  to  intelligible  articulation,  as  is  shown  in  persons  who  have 
had  the  misfortune  to  have  the  member  excised ;  but  its  im¬ 
portance  to  that  function  is  unquestionable.  Vocal  music  is 
defective  so  long  as  the  words  are  not  distinctly  uttered,  no 
matter  what  the  excellence  of  phonation  may  be.  Probably 
the  best  results  as  regards  both  elements  are  to  be  attained, 
other  things  being  equal,  only  when  the  composer  is  his  own 
librettist,  for  it  is  well  known  that  certain  notes  are  easier  of 
production  with  some  vowel  sounds  than  with  others.  If  the 
proper  conformity  of  words  to  notes  were  always  maintained, 
perhaps  such  devices  as  restraining  the  tongue  in  singing  might 
be  resorted  to  with  an  approach  to  impunity,  for  possibly  it  is 
the  tax  they  impose  on  articulation  rather  than  on  phonation 
that  proves  injurious.  Until  it  is  shown,  however,  that  this  is 
the  case,  vocalists  will  show  their  prudence  by  avoiding  them. 


MINOR  PARAGRAPHS. 

THE  SLEEPING  SICKNESS  OF  AFRICA. 

At  the  Harley  House,  London,  there  is  a  young  man,  a  native 
of  the  Congo  River  valley,  who  has  journeyed  to  England  for 
the  purposes  of  an  autopsy.  He  believes  himself  to  be  in  the 
incipient  stage  of  the  mysterious  and  incurable  disease  known 
as  the  sleeping  sickness,  and  he  has  left  his  wife  and  children 
to  place  himself  and  his  body,  after  death,  at  the  disposal  of  the 
medical  men,  in  order  that  they  may  so  study  his  case  as  to  as¬ 
certain  the  cause,  morbid  changes,  and  means  of  relief  of  this 
comparatively  unknown  malady.  The  young  man’s  name  is 
Mandombi,  and  he  is  a  member  of  the  missionary  church  at  the 
Banza  Manteka  station,  where  not  fewer  than  sixty  of  his  fel¬ 
low-converts  have  been  carried  off  by  the  sleeping  sickness. 
His  own  sister  is  dying  by  it;  she  becomes  almost  maniacal  at 
the  full  of  the  moon.  His  brother,  by  marriage,  died  by  it  at 
about  the  time  of  his  departure,  which  was  a  spontaneous  action 
on  his  part,  in  order  that  by  dying  in  a  foreign  land  he  might 
perchance  benefit  his  yet  unafflicted  countrymen.  Mandombi 
is  yet  well  and  able  to  work,  but  he  is  smitten  with  the  trouble, 
as  is  shown  to  others  by  some  little  impairment  of  his  mental 
alertness.  The  disease  is  not  believed  to  be  contagious,  although 
several  members  of  the  same  family  may  die  by  it.  So  far  as 
the  observation  of  the  missionaries  goes,  no  case  has  been  saved 
from  a  fatal  termination  by  treatment.  The  duration  may  ex¬ 
tend  for  three  years,  or  it  may  be  only  two  or  three  weeks.  As 
the  disease  progresses  the  patient  is  said  to  sleep  his  life  away, 
although  in  severe  cases  maniacal  symptoms  develop.  Great 
emaciation  marks  the  chronic  cases.  “Nelavan”  is  a  term 
used  by  D6clat  and  some  other  French  writers  as  descriptive  of 
the  sleep  disease  of  Africa  at  some  points  to  the  north  of  the 


493 

Congo,  but  on  the  west  coa>t.  where  it  appears  to  be  endemic, 
D6clat  thinks  he  has  found  some  points  of  resemblance  between 
nelavan  and  the  chicken-cholera.  Mr.  Stanley  makes  no  refer¬ 
ence  in  his  last  volumes  to  the  occurrence  of  the  disease  among 
his  carriers,  not  a  few  of  whom  were  probably  taken  from  the 
lower  Congo  districts,  where  the  disease  is  most  frequent. 


THE  SEXUAL  PERVERSION  OF  HAIR-CUTTING. 

Dr.  A.  Motet,  the  well-known  alienist,  has  reported  to  the 
Societe  de  medecine  legale ,  as  recorded  in  Le  Progres  medical , 
a  case  of  unusual  sexual  perversion.  A  young  man  was  ar¬ 
rested  for  attempting  to  cut  off  a  young  woman’s  hair.  The 
police  were  led  to  make  a  search  of  the  rooms  occupied  by  the 
accused,  and  there  found  a  considerable  quantity  of  hair,  the 
motive  for  the  cutting  off  of  which  had  been  sexual  and  not 
mercenary  in  origin.  It  was  subsequent  to  an  attack  of  herpes 
intercostalis  in  1886  that  his  erratic  behavior  began;  he  then 
for  the  first  time  began  to  have  the  imperative  propensity  to 
cut  off  women’s  hair.  So  soon  as  the  shears  would  touch  the 
hair  he  had  an  erection,  and  the  cutting  off  was  followed  by  an 
ejaculation.  It  was  found  that  his  parents,  on  both  sides,  had 
transmitted  to  him  a  marked  neurotic  tendency,  but  this  had 
not  prevented  his  acquiring  his  trade  and  becoming  a  skillful 
and  intelligent  artisan.  He  was  adjudged  insane  and  confined 
for  a  time  in  an  asylum.  He  recovered  under  treatment  and 
was  set  free  from  his  peculiar  perversion.  He  was  enabled 
afterward  to  resume  work  at  his  trade. 


ANAESTHESIA  BY  HYPNOTISM. 

According  to  the  British,  Medical  Journal ,  Dr.  Schmelz,  of 
Nice,  recently  removed  a  sarcomatous  breast  from  a  girl,  aged 
twenty  years,  during  anaesthesia  produced  by  hypnotism.  The 
entire  breast,  with  the  aponeurosis  of  the  pectoralis  major  mus¬ 
cle,  was  removed  by  the  usual  oval  incision,  drainage-tubes 
were  inserted,  and  the  wound  was  closed  with  thirty-two 
metallic  sutures.  The  operation  lasted  an  hour,  the  patient 
remaining  in  a  state  of  anaesthesia  during  the  entire  period, 
though  she  encouraged  the  operator  by  her  words,  laughed, 
and  was  quite  gay.  The  only  symptom  noticeable  during  the 
operation  was  great  pallor  of  the  countenance,  but  there  was 
no  dilatation  of  the  pupil  or  weakening  of  the  pulse.  She  had'"’' 
no  pain  after  the  operation,  and  the  wound  healed  on  the  fif¬ 
teenth  day. 


A  SLUR  ON  THE  POLYCLINIC  CORRECTED. 

The  statement  having  been  made  in  one  of  the  New  York 
newspapers  that  a  young  Alabama  clergyman  had  “  died  from 
die  effect  of  an  operation  performed  in  the  New  York  Poly¬ 
clinic  eight  months  since  and  pronounced  at  the  time  ‘highly 
successful,”’  the  father  of  the  deceased,  also  a  clergyman,  has 
lad  the  manliness  to  write  to  the  editor  of  the  newspaper  as¬ 
suring  him  that  the  operation  was  indeed  completely  success¬ 
ful,  and  that  his  son’s.death  could  in  no  way  be  attributed  to  it. 


THE  SOUTHERN  SURGICAL  AND  GYNAECOLOGICAL  ASSO¬ 
CIATION. 

Tiie  meeting  to  be  held  shortly  in  Atlanta  will  undoubtedly 
ie  one  of  great  interest  and  profit  to  the  members  of  the  asso¬ 
ciation.  This  is  to  be  inferred  from  the  programme,  which  we 
lave  already  published,  as  well  as  from  the  character  of  the 
last  meetings.  The  association  must  be  set  down  as  one  of 
exceptional  vigor.  It  includes  most  of  the  leading  surgeons 
and  gynaecologists  of  the  South,  and  is  evidently  well  managed. 


494 


MINOR  PARAGRAPHS.— ITEMS. 


[N.  Y.  Med.  Jock., 


THE  PUBLIC  SCHOOLS  OF  NEW  YORK. 

Much  has  been  said  from  time  to  time  about  the  bad  sani¬ 
tary  state  of  some  of  the  public-school  buildings  of  New  YTork, 
but  little  impression  seems  to  have  been  made  on  those  who 
are  charged  with  their  supervision.  Last  Monday  evening, 
however,  the  committee  on  hygiene  of  the  Medical  Society  of 
the  County  of  New  York  made  a  report  setting  forth  the  defects 
of  certain  of  the  buildings  most  pointedly,  and  this  report, 
having  been  summarized  in  some  of  the  newspapers,  seems 
likely  to  prove  more  effective. 


DEATH  FROM  FOOTBALL  INJURIES. 

A  fatal  casualty  is  reported  by  the  Lancet  resulting  from  a 
football  match.  A  young  man  came  into  collision  with  another 
player  and  was  injured  in  the  groin  on  Saturday,  September 
20th.  On  Monday  he  was  dead,  although  meanwhile  an  opera¬ 
tion  had  been  attempted  for  his  relief. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  October  28,  1890: 


DISEASES. 

Week  ending  Oct.  21- 

Week  ending  Oct.  28. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  fever . 

44 

9 

37 

7 

Scarlet  fever . 

25 

1 

42 

1 

Cerebro-spinal  meningitis . 

0 

0 

0 

0 

Measles . 

52 

5 

82 

6 

Diphtheria . 

57 

17 

67 

21 

Small-pox . 

1 

0 

0 

0 

Varicella . 

2 

0 

1 

0 

The  Johns  Hopkins  University. — It  is  announced  that  a  committee 
of  ladies  who  had  resolved  to  raise  the  sum  of  $100,000  for  founding 
a  medical  college  to  which  women  would  be  admitted  has  succeeded  in 
its  object,  and  that  the  trustees  of  the  Johns  Hopkins  University  have 
accepted  the  fund  in  accordance  with  the  following  terms,  stated  in  a 
communication  to  them  from  Mrs.  Davis: 

“  The  committees  formed  for  the  purpose  of  raising  a  fund  to  pro¬ 
cure  the  most  advanced  medical  education  for  women  can  now  place  at 
your  disposal  the  sum  of  $100,000  for  the  use  of  our  medical  school,  if 
you  will  by  resolution  agree  that  women  whose  previous  training  has 
been  equivalent  to  your  preliminary  medical  course  shall  be  admitted 
to  the  school,  when  it  shall  open,  upon  the  same  terms  which  may  be 
prescribed  for  men.  There  is  little  doubt  that  a  sufficient  number  of 
women  ought  to  be  educated  and  trained  in  such  manner  as  to  be  fully 
able  to  care  for  sick  women  who  may  wish  or  ought  to  be  treated  by 
women.  We  have  devoted  ourselves  to  the  furtherance  of  this  object. 
We  have  reason  to  hope  that  a  university  which  proposes  to  found  a 
medical  school  intended  to  teach  advanced  methods  in  the  treatment  of 
those  diseases  which  afflict  mankind  will  not  refuse  to  women  the  op¬ 
portunity  of  learning  such  methods.  There  is  now  a  general  interest 
in  our  movement.  In  order  that  this  interest  may  be  sustained,  we  ask 
you  to  consider  our  offer  at  the  earliest  possible  moment.” 

The  Medical  Society  of  the  County  of  New  York.— At  the  annual 
meeting,  held  on  Monday  evening,  the  27th  inst.,  officers  for  the  ensu¬ 
ing  year  were  elected  as  follows :  President,  Dr.  Orlando  B.  Douglas ; 
vice-president,  Dr.  Arthur  M.  Jacobus  ;  secretary,  Dr.  Charles  H.  Avery ; 
assistant  secretary,  Dr.  William  E.  Bullard ;  treasurer,  Dr.  John  S. 
Warren;  and  censors,  Dr.  George  E.  Abbott,  Dr.  S.  O.  Yan  der  Poel, 
Dr.  Alexander  S.  Hunter,  Dr.  William  M.  McLaury,  and  Dr.  Richard 
Van  Santvoord. 

The  Mount  Sinai  Hospital  Alumni  Association.— At  a  meeting  held 
at  the  hospital  on  Tuesday  evening,  the  28th  inst.,  Dr.  Abraham  Jacobi 


read  a  paper  on  Some  Points  in  the  Pathology  and  Therapeutics  of  the 
Genito-urinary  Organs,  and  Dr.  Charles  H.  May  read  one  on  The  Early 
Eye  Symptoms  of  Chronic  Alcoholism. 

Changes  of  Address. — Dr.  Augustin  M.  Fernandez,  to  No.  209  West 
Tenth  Street ;  Dr.  Maurice  L.  Healey,  to  No.  220  East  Thirty-sixth 
Street;  Dr.  Elizabeth  Johnson,  to  No.  68  West  Thirty-eighth  Street; 
Dr.  M.  R.  Richards,  to  No.  77  East  One  Hundred  and  Sixteenth  Street; 
Dr.  Edward  F.  Schwedler,  to  No.  43  East  Fifty-ninth  Street ;  Dr.  Wins¬ 
low  W.  Skinner,  to  the  Adirondack  Cottage  Sanitarium,  Saranac  Lake, 
N.  Y. ;  Dr.  J.  E.  Welliver,  from  Rushville,  Ind.,  to  the  northeast  corner 
of  Second  and  Ludlow  Streets,  Dayton,  O. 

The  Death  of  Dr.  George  T.  Foster,  of  Pittsfield,  Mass.,  occurred  on 
October  22d,  of  gastro-enteritis.  He  was  born  in  Lyndon,  Vt.,  in  1810, 
and  graduated  from  the  Albany  Medical  College  in  the  class  of  1847. 
He  began  practice  in  Windsor,  Mass.  He  remained  there  but  a  short 
time,  when  he  removed  to  Chatham,  N.  Y.,  where  he  practiced  for  a 
number  of  years.  Finally  his  health  failed  and  he  again  removed  to 
Pittsfield,  where  he  afterward  resided.  For  over  twenty  years  his 
health  did  not  permit  him  to  engage  in  active  practice,  but  he  was  well 
and  favorably  known  in  the  vici.ity  as  a  consultant.  He  is  survived 
by  his  son,  Dr.  M.  L.  Foster,  of  New  York. 

The  Death  of  Dr.  Justus  E.  Gregory,  of  Brooklyn,  occurred  suddenly 
on  October  26th,  while  he  was  absent  from  his  home.  He  was  a  great 
sufferer  from  neuralgia,  and  occasionally  obtained  from  chloroform  in¬ 
halation  a  sufficient  relief  to  enable  him  to  complete  his  round  of  visits. 
On  Sunday  last  he  had  recourse  to  this  treatment  while  resting  in  an 
apothecary’s  shop  not  far  from  his  office,  but  death  ensued  suddenly. 
He  was  an  expert,  in  the  minds  of  his  professional  neighbors,  in  the 
administration  of  anaesthetics.  He  was  a  native  of  Troy,  and  an 
alumnus  of  the  Albany  Medical  College. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army ,  from  October  19  to  October  25,  1890 : 

Glennan,  J.  D.,  First  Lieutenant  and  Assistant  Surgeon,  is  granted 
leave  of  absence  for  one  month,  to  take  effect  about  the  31st  in¬ 
stant.  Par.  1,  S.  O.  146,  Department  of  the  Missouri,  October  23, 
1890. 

Jarvis,  N.  S.,  Assistant  Surgeon,  is  granted  leave  of  absence  for  one 
month  on  surgeon’s  certificate  of  disability.  S.  O.  107,  Department 
of  Arizona,  October  14,  1890. 

Pilcher,  James  E.,  Captain  and  Assistant  Surgeon,  is  granted  leave  of 
absence  for  four  months,  by  direction  of  the  Secretary  of  War. 
Par.  12,  S.  0.  244,  A.  G.  O.,  October  18,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  October  25,  1890 : 

Cordeiro,  F.  J.  B.,  Passed  Assistant  Surgeon.  Detached  from  U.  S, 
Steamer  Nipsic  and  granted  three  months’  leave  of  absence. 
Hkffenger,  A.  C.,  Passed  Assistant  Surgeon.  Placed  on  the  Retired 
List,  October  20,  1890. 

Society  Meetings  for  the  Coming  Week : 

Monday,  November  3d:  New  York  Academy  of  Sciences  (Section  in 
Biology) ;  German  Medical  Society  of  the  City  of  New  York  ;  Mor- 
risania  Medical  Society  (private) ;  Brooklyn  Anatomical  and  Sur¬ 
gical  Society  (private) ;  Utica,  N.  Y.,  Medical  Library  Association ; 
Boston  Society  for  Medical  Observation  ;  St.  Albans,  Vt.,  Medical 
Association  ;  Providence,  R.  I.,  Medical  Association ;  Hartford,  Conn., 
City  Medical  Association ;  Chicago  Medical  Society. 

Tuesday,  November  1/th:  New  York  Obstetrical  Society  (private);  New 
York  Neurological  Society;  Elmira  Academy  of  Medicine;  Buffalo 
Medical  and  Surgical  Association ;  Ogdensburgh  Medical  Associa¬ 
tion  ;  Hampden,  Mass.,  District  Medical  Society  (Springfield) ;  Hud¬ 
son,  N.  J.,  County  Medical  Society  (Jersey  City);  Androscoggin,  Me., 
County  Medical  Association  ;  Baltimore  Academy  of  Medicine. 
Wednesday,  November  5th:  Society  of  the  Alumni  of  Bellevue  Hospi¬ 
tal  ;  Harlem  Medical  Association  of  the  City  of  New  York  ;  Medical 
Microscopical  Society  of  Brooklyn  ;  Medical  Society  of  the  County  of 


Nov.  1,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


495 


Richmond  (Stapleton),  N.  Y. ;  Penobscot,  Me.,  County  Medical  So¬ 
ciety  (Bangor) ;  Bridgeport,  Conn.,  Medical  Association. 

Thursday,  November  6th:  New  York  Academy  of  Medicine;  Metro¬ 
politan  Medical  Society  (private) ;  Society  of  Physicians  of  the  Vil¬ 
lage  of  Canandaigua;  Medical  Society  of  the  County  of  Orleans  (an¬ 
nual — Albion),  N.  Y. ;  Boston  Medico-psychological  Association  ; 
Obstetrical  Society  of  Philadelphia;  United  States  Naval  Medical 
Society  (Washington). 

Friday,  November  7th:  Practitioners’  Society  of  New  York  (private); 
Baltimore  Clinical  Society. 

Saturday,  November  8th:  Obstetrical  Society  of  Boston  (private). 


fjrjomfrtnp  of  Soritties. 

MISSISSIPPI  VALLEY  MEDICAL  ASSOCIATION. 

Sixteenth  Annual  Meeting ,  held  in  Louisville , 

October  8 ,  9,  and  10 ,  1890. 

The  President,  Dr.  J.  M.  Mathews,  of  Louisville,  in  the  Chair. 

( Concluded  from  page  lf.69.) 

Coffee. — Dr.  I.  N.  Love,  of  St.  Louis,  in  a  paper  on  this  sub¬ 
ject,  said  that  his  experience  for  five  or  six  years  past  had  been 
strongly  in  favor  of  taking  a  cup  of  strong,  black  coffee,  with¬ 
out  cream  or  sugar,  between  two  glasses  of  hot  water,  before 
rising  every  morning— at  least  an  hour  before  breakfast.  The 
various  secretions  were  stimulated,  the  nervous  force  was  aroused, 
an  hour  later  a  hearty  meal  was  enjoyed,  and  the  day’s  labor 
was  begun  favorably,  no  matter  how  the  duties  of  the  day  and 
night  preceding  might  have  drawn  upon  the  system.  Another 
cup  at  four  in  the  afternoon  was  sufficient  to  sustain  the  ener¬ 
gies  for  many  hours.  In  this  way  the  full  effect  was  secured. 
If,  along  with  this,  the  proper  diet  was  taken  at  the  proper 
times — and  the  ideal  diet  for  those  who  make  large  drafts  upon 
their  nervous  systems  and  expected  to  have  them  honored  was 
hot  milk — and  at  least  eight  hours  of  sleep  were  taken  out  of 
every  twenty-four,  one’s  capacity  for  work  would  be  almost  un¬ 
limited. 

Mechanical  Obstruction  in  Diseases  of  the  Uterus.— Dr. 

George  Hulbert,  of  St.  Louis,  read  a  paper  on  this  subject. 
He  submitted  the  following  conclusions  :  1.  That  in  the  natural 
order  of  things  we  find  the  uterus  in  form  and  structure  en¬ 
dowed  with  a  power  and  capacity  for  the  performance  of  the 
function  of  menstruation  far  in  excess  of  any  legitimate  demand, 
to  the  exteot  that  with  a  quarter-inch  diameter  of  the  canal  the 
excess  equals  7724  8  times  the  demand,  and  with  a  one  thirty- 
second-inch  diameter  the  excess  equals  120  7  times  the  require¬ 
ment.  2.  That  in  the  pathological  conditions  considered  essen¬ 
tial  for  mechanical  obstruction  we  find  that  the  conservation  of 
force  is  capable  of  regulating,  and  does  so  regulate,  conditions 
that  the  capacity  is  not  abolished,  but  persistent  in  an  eminent 
degree,  so  that  in  the  presence  of  the  normal  physiological  ener¬ 
gy  the  function  is  accomplished,  save  in  one  emeigency,  that  of 
total  annihilation  of  the  normal  state — namely,  atresia.  3. 
That  the  phenomena  considered  as  attendant  and  dependent 
upon  mechanical  obstruction  are  not  due  to  the  forcible  expul¬ 
sion  of  retained  fluids  through  the  uterine  canal,  but  are  resi¬ 
dent  and  produced  within  the  tissues ,  and  are  dependent  upon 
disturbed  rhythm  of  physiological  forces ,  evolved  through  ab¬ 
normal  innervation,  muscular  action,  and  circulation.  4.  That 
the  demand  upon  the  uterus  for  the  passage  of  blood-clots, 
membranes,  mucousplugs,  uterine  sounds,  sponge  tents,  uterine 
dilators,  etc.,  in  order  that  the  diagnosis  of  mechanical  obstruc¬ 
tion  may  be  made,  is  not  only  vicious  in  the  extreme,  but  irra¬ 


tional,  illogical,  and  unscientific.  5.  That  the  correct  and  ra¬ 
tional  interpretation  of  the  testimony  offered  by  symptomatolo¬ 
gy,  pathology,  and  therapeutics  removes  mechanical  obstruction 
from  the  domain  of  gynaecology  as  a  demonstable  fact,  save  in 
atresia  uteri. 

Professor  Flint’s  Doctrine  of  the  Self-limitation  of  Phthi¬ 
sis  was  the  subject  of  a  paper  by  Dr.  William  Porter,  of  St. 
Louis,  in  which  he  said  that  some  time  before  his  death  Pro¬ 
fessor  Flint  had  promulgated  the  doctrine  of  the  self-limitation 
of  phthisis,  and  presented  it  with  all  his  well-known  power  and 
great  ability  to  the  profession.  This  very  interesting  proposi¬ 
tion  had  been  at  the  time  the  subject  of  free  debate  in  various 
medical  societies.  Recent  years  had  been  full  of  the  wonderful 
results  of  the  study  of  pulmonary  disease  and  bacteriological 
research,  and  the  possibility  of  a  positive  diagnosis  had  over¬ 
shadowed  the  equally  interesting  question  of  prognosis.  After 
having  carefully  examined  the  facts  cited  in  support  of  the 
proposition,  Dr.  Porter  had  no  hesitation  in  asserting  that  he 
found  no  sulficient  evidence  co  warrant  us  in  accepting  the  state¬ 
ment  that  phthisis  was  self-limiting,  or  that  the  element  of  self¬ 
limitation  had  a  decided  influence  upon  the  result  in  any  given 
case.  He  did  not  mean  that  all  patients  with  phthisis  neces¬ 
sarily  died  from  this  disease,  but  he  did  mean  that  where  phthi¬ 
sis  was  firmly  established  there  was  nothing  in  the  nature  of 

the  disease  itself  that  indicated  in  any  stage  a  fixed  boundary _ 

a  line  of  demarkation,  as  it  were— but  rather  that  all  its  tend¬ 
encies  were  progressive  and  downward. 

Cough;  its  Relation  to  Intra-nasal  Disease.— Dr.  A.  B. 
Iiirasher,  of  Cincinnati,  read  a  paper  on  this  subject.  The 
cough  due  to  nasal  disease  might  sometimes  be  recognized  by 
its  metallic  ring  and  the  ab.-ence  of  expectoration.  It  could,  as 
a  rule,  be  provoked  at  will  by  touching  the  irritable  spot  in  the 
nose  with  a  probe.  Dr.  Thrasher  recited  three  cases  illustrative 
of  nasal  cough. 

The  Medical  Student  was  the  title  of  a  public  address  by 
Dr.  John  A.  Wyeth,  of  New  York.  The  hall  was  literally 
packed  with  people,  and  many  members  of  the  association  who 
had  come  to  hear  the  lecture  were  turned  away,  the  students 
of  the  Louisviile  University  having  taken  possession  of  nearly 
all  the  seats,  thus  literally  freezing  the  members  out.  The  ad¬ 
dress  was  listened  to  very  attentively,  and  Dr.  Wyeth  received 
applause  several  times  during  its  delivery. 

He  said  the  first  or  preliminary  stage  of  a  medical  student’s 
life  was  his  preparatory  or  academic  life;  the  second,  his  medi¬ 
cal-college  life;  the  third,  his  post-graduate  or  practical  life, 
and  it  lasted  from  the  day  he  left  his  alma  mater  until  useful¬ 
ness  ceased.  In  the  acquirement  of  a  practical  training  three 
ways  were  open,  and  in  order  of  preference  they  were;  1. 
Service  as  an  interne,  preferably  for  a  term  of  two  years,  in  a 
general  hospital.  2.  Service  in  some  post-graduate  institution 
where  all  departments  of  practical  medicine  were  taught  by 
teachers  specially  trained  in  their  respective  branches.  3.  Serv¬ 
ice  as  an  assistant  to  one  or  more  well-qualified  practitioners  in 
general  medicine. 

Gunshot  Wound  of  the  Intestine.— Dr.  M.  T.  Scott,  of 
Lexington,  Ky.,  reported  a  case.  (To  be  published.) 

The  Cranial  Development  of  Criminals.— Dr.  G.  Frank 
Lydston,  of  Chicago,  exhibited  the  skulls  of  a  number  of  the 
in>>st  notorious  criminals  of  the  world,  and  made  some  remarks 
with  reference  to  their  peculiarities,  shape,  size,  etc. 

Cases  of  Penetrating  Stab  Wounds  of  the  Abdomen; 
Laparotomy;  Results. —  Dr.  H.  C.  Dalton,  of  St.  Louis,  read 
a  paper  thus  entitled,  in  which  he  reported  six  cases  of  lapa¬ 
rotomy  in  which  there  was  visceral  injury.  One  of  them  had 
ended  in  death  and  five  in  recovery.  He  laid  particular  stress 
on  the  necessity  of  following  the  wounds  to  the  bottom  and 


496 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


making  ocular  inspection  of  the  same  rather  than  trusting  to 
the  introduction  of  the  finger.  He  deprecated  depending  im¬ 
plicitly  on  Senn’s  hydrogen-gas  test,  on  account  of  its  fallibility. 

Wiring  the  Separated  Symphysis  Pubis,  supplemented 
by  a  Novel  Pelvic  Clamp,  was  the  title  of  a  paper  by  Dr.  W.  P. 
King,  of  Kansas  City.  He  reported  a  case  of  separation  of  the 
svmphysis  pubis,  with  fracture  of  the  interposed  fibro  cartilage 
and  fracture  of  the  descending  ramus  of  the  pubes  with  deep 
lacerations  of  the  surrounding  soft  parts,  and  spoke  particularly 
of  the  methods  resorted  to  in  order  to  support  the  pelvis  and 
re-enforce  the  stitches  after  the  pubic  bones  had  been  wired  to¬ 
gether.  The  case  suggested  the  following  points:  1.  The  op¬ 
eration  of  wiring  so  completely  coaptated  the  parts  that  it 
would  seem  that  scarcely  any  other  method  of  dealing  with  this 
condition  could  be  equal  to  it.  2.  The  manner  of  applying  the 
plaster-of-Paris  support  in  the  first  place,  with  the  use  of  the 
water-bag  to  make  an  arch  under  which  to  dress  the  wounded 
parts,  was  new  and  original  so  far  as  the  author  knew,  and  it 
was  a  method  that  might  be  adopted  and  easily  practiced  by 
any  one  who  knew  how  to  use  plaster  of  Paris.  3.  The  steel 
hip  clamp  as  a  permanent  support  was  also  new,  so  far  as  he 
knew,  and  was  a  means  that  might  be  adopted  with  benefit  in 
any  case  of  fracture  of  the  pelvis  in  which  immobilization  of 
the  fractured  part  would  contribute  to  the  comfort  of  the  pa¬ 
tient  and  to  the  union  of  the  fracture. 

Inguinal  Colotomy. — Dr.  Arou  Dixon,  of  Henderson,  Ky., 
in  a  paper  on  this  subject,  said  that  colotomy  had  during  the 
past  decade  met  with  much  attention  from  the  surgical  world. 
As  a  measure  intended  to  ward  off  imminent  death,  it  was  called 
for  in  all  cases  of  obstruction  in  the  colon,  from  whatever  cause 
arising.  For  imperforate  anus  the  operation  held  a  special  po¬ 
sition.  It  was  intended  to  prevent  impending  death,  but  it 
might  or  might  not  be  a  cure  for  the  disease.  In  many  cases  it 
was  the  first  step  in  the  process  of  cure.  In  every  infant  born 
with  an  imperforate  anus  an  operation  of  a  local  nature  was 
first  attempted;  if  this  failed,  colotomy  by  some  method  was 
performed  to  ward  off  death.  Later  on  an  attempt  might  be 
made  to  get  the  bowel  to  discharge  through  the  anus.  In  a 
few  words,  it  might  be  said  that  the  indications  to  operate  in 
any  given  case  depended,  in  the  first  place,  on  the  chance  that 
the  patient  had  of  getting  well  without  an  operation;  and,  in 
the  second  place,  on  the  degree  of  probability  of  success  fol¬ 
lowing  the  operation.  To  cases  of  acute  obstruction  in  the  sig¬ 
moid  flexure  or  elsewhere  there  was  practically  but  one  termi¬ 
nation — death.  No  case  of  volvulus,  whether  of  the  large  or 
small  intestine,  had  as  yet  been  known  to  recover  under  treat¬ 
ment  purely  medicinal.  Here,  then,  the  indication  was  clear 
enough,  as  clear  as  the  indication  to  tie  a  bleeding  carotid — an 
operation.  Dr.  Dixon  reported  an  interesting  case,  after  which 
he  dwelt  upon  the  comparative  merits  of  the  two  operations, 
inguinal  and  lumbar  colotomy. 

Hypnotism  in  its  Relation  to  Surgery.— Dr.  Emory 
Lamphear,  of  Kansas  City,  read  a  paper  on  this  subject  and 
reported  cases.  He  reported  a  case  of  double  talipes  in  which 
the  subject  had  chronic  Bright’s  disease,  which  contra-indicated 
the  use  of  ether,  and  at  the  same  time  had  an  organic  heart 
trouble,  which  prevented  the  safe  use  of  chloroform.  The 
patient  wanted  to  be  operated  upon,  and  the  author  hesitated 
to  give  the  ordinary  anaesthetic,  and  so  hypnotized  him.  This 
was  the  first  stance,  and,  contrary  to  the  generally  accepted 
idea  that  at  the  first  trial  a  sufficient  degree  of  anaesthesia  could 
not  be  produced  to  admit  of  an  operation,  he  performed  the 
operation  for  talipes,  and  the  patient  lay  upon  the  table  as  fixed 
and  immovable  as  a  piece  of  marble  during  the  whole  proced¬ 
ure.  Another  case  (reported  by  permis.-ion  of  Dr.  Shaw,  of 
St.  Louis)  was  that  of  a  patient  suffering  from  Jacksonian  epi¬ 


lepsy  due  to  brain  tumor.  He  was  hypnotized  and  trephined, 
and  made  no  manifestation  of  pain. 

Certainty  in  the  Diagnosis  of  Tuberculosis.— Dr.  Theo¬ 
dore  Potter,  of  Indianapolis,  presented  a  paper  in  which  he 
mentioned  features  of  the  disease  that  called  in  a  peculiar  way 
for  early  treatment.  But  this  must  depend  upon  early  diag¬ 
nosis.  In  spite  of  constant  progress  from  the  time  of  Laennec 
to  that  of  Fiint,  there  had  been  no  one  sLn  and  no  combina¬ 
tion  of  signs  that  was  absolute.  There  was  always  some  un¬ 
certainty,  especially  in  the  early  or  unusual  cases.  But  now, 
with  the  new  light  of  the  present  added  to  the  knowledge  of 
the  past,  we  were  able  to  make  the  diagnosis  in  the  great  ma¬ 
jority  of  cases  not  only  early,  but  with  absolute  certainty. 

The  Hypodermic  Use  of  Arsenic. — Dr.  Harold  N.  Moyer, 
of  Chicago,  contributed  a  paper  on  this  subject.  He  said  the 
hypodermic  use  of  Fowler’s  solution  had  been  recommended 
by  various  writers,  among  others  Hammond,  who  stated  that 
the  dose  that  could  be  administered  in  this  way  was  much  greater 
than  could  safely  be  administered  by  the  mouth,  he  having 
given  as  high  as  fifty  drops  of  Fowler’s  solution  as  an  initial 
dose.  Again,  he  had  often  carried  the  amount  given  by  the 
mouth  to  the  utmost  bounds  of  prudence,  till  the  eyes  were 
puffed  and  vomiting  was  almost  incessant,  and  then  had  con¬ 
tinued  the  use  of  arsenic  in  larger  doses  by  hypodermic  injec¬ 
tion,  with  the  result  of  the  cessation  of  all  gastric  symptoms 
and  the  cure  of  the  disorder.  In  a  case  of  chorea  in  a  girl,  the 
patient  had  been  placed  immediately  upon  the  hypodermic  use 
of  arsenic,  beginning  with  three  minims  of  the  five-per-cent, 
solution  and  increasing  every  second  day  until  three  weeks  after 
beginning  treatment  she  was  receiving  thirteen  minims  of  the 
solution  at  each  injection,  with  an  amount  of  arsenic  equiva¬ 
lent  to  about  thirty-six  minims  of  Fowler’s  solution.  At  the 
ninth  injection  she  was  discharged  cured.  In  the  case  of  a 
woman  who  presented  herself  at  the  clinic  in  Rush  Medical 
College  with  an  enormous  lymphadenoma  of  the  side  of  the 
neck,  after  a  few  deep  injections  into  the  glandular  mass  it  began 
to  diminish  rapidly.  When  it  had  lessened  one  half,  the  patient 
ceased  attending,  and  the  further  results  could  not  be  noted. 
Dr.  Moyer’s  observation  was  in  accord  with  that  of  numerous 
writers  who  had  reported  equally  good  results  from  the  use  of 
Fowler’s  solution  in  various  forms  of  glandular  enlargement 
passing  under  the  terms  lymphoma,  lymphadenoma,  and  Hodg¬ 
kin’s  disease.  The  action  of  arsenic  given  under  the  skin,  if  it 
had  any  virtue,  must  certainly  be  greater  than  when  it  was 
taken  hy  the  stomach.  Thrown  into  the  cellular  tissue  in  the 
form  of  a  feeble  alkaline  and  readily  soluble  salt,  it  was  at  once 
absorbed  by  the  blood  and  carried  to  all  the  tissues. 

Perineal  Cystotomy  versus  Suprapubic  Cystotomy.— Dr. 
H.  O.  Walker,  of  Detroit,  rehd  a  paper  on  this  subject.  (To 
be  published.) 

Two  Cases  of  Tubal  Pregnancy  were  reported  by  Dr.  Ed¬ 
win  Walker,  of  Evansville,  Ind.  He  thought  that  laparotomy 
was  the  safest  procedure  to  adopt. 

The  Treatment  of  Organic  Stricture  of  the  Male  Urethra. 
— Dr.  Seaton  Norman,  of  Evansville,  Ind.,  contributed  a  paper 
thus  entitled,  in  which  he  said  that  in  the  practice  of  urethral 
surgery  the  operator  could  not  be  too  emphatically  impressed 
with  the  fact  of  the  exquisite  tenderness  and  sensitiveness  of 
the  urethra,  and  the  employment  of  the  slightest  amount  of 
force  in  the  introduction  of  an  instrument  should  be  regarded 
as  a  relic  of  barbaric  surgery.  When  commencing  the  treat¬ 
ment  by  gradual  dilatation  in  sensitive  patients,  he  always  pro¬ 
duced  local  anaesthesia  by  the  injection  of  twenty  to  thirty 
minims  of  a  four-per  ceDt.  solution  of  hydrochloride  of  cocaine. 
Relative  to  internal  urethrotomy,  he  believed  that  when  it  was 
properly  and  thoroughly  executed,  and  special  care  was  exer- 


Nov.  1,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


497 


cised  to  maintain  the  patency  of  the  canal  until  the  wound  was 
entirely  healed,  recontraction  was  of  rare  occurrence.  Au¬ 
thority  was  divided  in  regard  to  the  performance  of  internal 
urethrotomy  in  the  bulbous  and  membranous  urethra.  Judging 
from  the  results  obtained  by  Harrison,  the  combination  of  ex¬ 
ternal  and  internal  urethrotomy  offered  encouragement  for  the 
permanent  cure  of  stricture.  Dr.  Norman  had  performed  ex¬ 
ternal  urethrotomy  without  a  guide  only  three  times,  and  his  re¬ 
sults  as  regarded  the  non-recurrence  of  contraction  had  been  en¬ 
tirely  satisfactory.  Of  the  various  scales  that  had  been  proposed 
for  urethral  instruments,  only  the  French,  in  his  opinion,  was 
worthy  of  consideration.  To  have  urethrotomes  graduated  in 
millimetres — and  all  with  which  the  author  was  familiar  were  so 
manufactured — and  the  sounds  corresponding  to  the  English  or 
any  other  scale,  was  a  manifest  absurdity. 

The  Application  of  Antiseptic  Methods  in  Midwifery- 
Practice. — Dr.  L.  S.  McMurtry,  of  Louisville,  Ky.,  made  some 
impromptu  remarks  on  this  subject.  He  said  many  medical 
practitioners  could  remember  the  time  when  they  had  heard 
that  the  wards  of  certain  hospitals  were  closed  and  undergoing 
renovation  because  puerperal  fever  had  become  epidemic  in 
such  institutions.  The  hospital  to-day  was  the  safest  place  in 
which  a  woman  could  be  confined.  A  few  years  ago,  led  by 
Fordyce  Barker,  we  had  been  taught  that  puerperal  fever  was 
an  entity,  a  distinct  fever,  dependent  upon  a  separate  materies 
morbi,  just  as  malarial  fever  was  an  entity.  To-day  we  knew 
that  puerperal  fever  so  called  was  a  septic  peritonitis,  just  as 
when  a  woman  became  infected  after  abdominal  section  or 
after  wounds  of  the  peritonaeum  from  any  cause,  or  from  infec¬ 
tion  of  the  endometrium  and,  through  the  Falloppian  tubes,  of 
the  peritonaeum.  A  woman  after  labor  was  a  wounded  woman. 
She  had  undergone  certain  physiological  processes;  she  had  re¬ 
ceived  certain  injuries  in  the  process  of  labor  which  opened  the 
lymphatic  channels  by  which  she  might  have  become  infected 
from  without..  There  was  no  such  thing  as  a  woman  having  a 
peritonitis  unless  she  was  infected  from  without.  To  prevent 
this  infection,  the  vagina  must  be  sterilized,  the  bed  surgically 
clean,  the  examining  finger  clean,  the  nurse  clean,  and  the  at¬ 
mosphere  as  approximately  aseptic  as  it  was  possible  to  make 
it,  etc. 

Officers  for  the  ensuing  year  were  elected  as  follows: 
President,  Dr.  0.  H.  Hughes,  of  St.  Louis;  vice-presidents,  Dr. 
John  H.  Hollister,  of  Chicago,  and  Dr.  S.  S.  Thorn,  of  Toledo; 
secretary.  Dr.  E.  S.  McKee,  of  Cincinnati.  It  was  voted  to  hold 
the  next  meeting  in  St.  Louis,  beginning  on  the  third  Wednes¬ 
day  in  October,  1891. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  PAEDIATRICS. 

Meeting  of  October  10,  1890. 

Dr.  L.  Emmett  Holt  in  the  Chair. 

Stricture  of  the  Rectum  following  an  Operation  for  Im¬ 
perforate  Anus. — Dr.  H.  D.  Chapin  presented  an  infant,  thir¬ 
teen  months  of  age,  which  he  stated  had  been  discovered  at  birth 
to  have  imperforate  anus.  It  had  been  operated  upon  by  simple 
incision  at  once.  Since  that  time  the  child  had  suffered  from 
chronic  constipation,  and  when  brought  to  the  hospital  was  in 
bad  condition,  having  had  no  passage  from  its  bowels  for  sev¬ 
eral  days.  A  very  tight  stricture  was  found  to  exist  just  within 
the  anus.  An  enema  was  given  of  ox-gall  and  glycerin,  and  a 
free  evacuation  resulted.  This  treatment  was  repeated  daily. 
Examination  revealed  a  large  concretion  of  faecal  material  just 
above  the  stricture, 
child  had  had  diarrhoea. 


inches  into  the  bowel,  and  a  partially  successful  attempt  made 
to  break  up  the  hard  mass.  He  had  brought  the  case  before 
the  Section  with  a  view  to  gleaning  what  had  better  be  done. 
His  own  feeling  would  be  to  put  in  something  and  divulse  the 
stricture. 

Dr.  C.  B.  Kelsey  called  attention  to  the  fact  that  the  child 
had  already  been  operated  upon  unsuccessfully.  If  this  were 
done  again,  the  condition  of  things  would  probably  not  be 
changed.  It  was  very  easy  to  put  in  a  blunt-pointed  bistoury, 
divide  the  septum,  separating  the  anus  from  the  cavity  of  the 
rectum,  and  thereby  give  immediate  relief;  but  this  would  not 
be  permanent.  Mere  incision  and  subsequent  dilatation  would 
be  futile.  A  more  radical  operation  was  called  for. 

That  which  offered  the  most  promising  results  was  a  com¬ 
plete  circular  resection  of  the  thickened  tissues  and  the  draw¬ 
ing  down  of  the  gut  from  above  and  joining  it  to  the  skin  be¬ 
low.  It  the  stricture  was  too  high  to  admit  of  the  drawing 
down  of  healthy  rectum  to  the  healthy  skin,  then  it  was  usual 
to  excise  a  portion  of  the  coccyx.  He  would  advise  an  early 
operation.  It  would  have  been  better  to  have  it  done  imme¬ 
diately  after  birth.  If  the  operation  did  not  succeed,  there  was 
still  left  an  inguinal  colotomy.  The  time  had  gone  by  when  a 
child  was  to  be  relegated  to  the  grave  rather  than  make  for  it  an 
artificial  anus.  If  the  necessary  care  was  taken  to  insure  regu¬ 
larity  of  the  bowels,  the  condition  was  by  no  means  an  insup¬ 
portable  one.  He  believed  that  inguinal  colotomy  was  the  best 
operation  at  birth  in  a  very  large  number  of  cases. 

Congenital  Hydrocephalus  without  Enlargement  of  the 
Head.— The  Chairman  presented  a  brain  removed  from  a  child, 
who  had  died  at  the  age  of  three  weeks,  in  which  a  very  marked 
degree  of  hydrocephalus  existed,  the  head,  however,  being  of 
normal  size.  The  lateral  ventricles  were  much  dilated  and  con¬ 
tained  six  ounces  of  fluid.  The  brain  outside  was  a  mere  shell. 
Spina  bifida  also  existed.  Death  was  caused  by  suppuration  in 
the  spina-bifida  sac,  which  had  extended  upward  along  the 
whole  cerebro-spinal  axis.  No  operation  had  been  performed. 

This  was  the  second  case  this  year  in  which  an  autopsy  had 
revealed  this  condition  without  enlargement.  There  was  no 
history  of  blood  disease  in  the  case  just  reported,  and  the  child 
had  died  of  acute  empyema. 

A  Study  of  One  Hundred  Cases  of  Pneumonia  in  Chil¬ 
dren.— Dr.  W.  L.  Stowell  read  a  paper  with  this  title. 

Dr.  Francis  Delakield  said  that  it  seemed  necessary  to  have 
a  well-defined  idea  of  the  kind  of  pneumonia  under  considera¬ 
tion — whether  it  was  a  broncho-pneumonia  or  croupous  pneu¬ 
monia.  He  thought  the  difference  well  marked,  not  because 
there  was  bronchitis  in  the  one  and  not  in  the  other,  because,  as 
a  matter  of  fact,  bronchitis,  to  a  greater  or  less  extent,  was  pres¬ 
ent  in  all  forms  of  pneumonia;  not  because  of  the  consolida¬ 
tion  of  a  portion  of  a  lobe  in  the  one  and  of  an  entire  lobe  in 
another,  for  consolidation  of  the  whole  of  one  or  more  lobes 
was  common  enough.  The  real  difficulty  seemed  to  lie  in  the 
character  of  the  inflammatory  processes.  Croupous  pneumonia 
appeared  to  be  au  exudative  inflammation  in  which  the  blood¬ 
vessels  alone  were  concerned,  the  affected  portion  of  the  lung 
becoming  infiltrated  with  serum,  fibrin,  and  pus.  These  inflam” 
matory  products  were,  if  the  case  was  of  moderate  severity,  ab¬ 
sorbed,  and  after  a  time  the  site  of  the  inflammation  became 
practically  in  the  same  condition  as  before  the  attack.  Broncho- 
meumonia  was,  however,  quite  different.  It  was  an  inflamma¬ 
tion  with  the  formation  of  new  connective  tissue  in  the  walls 
of  the  bronchi  and  air  vesicles  surrounding  the  inflamed  parts. 
The  inflammatory  processes  were  likely  to  last  a  long  time,  it 
was  much  more  difficult  for  the  tissues  to  return  to  their  normal 


During  the  last  twenty-four  hours  the 
A  catheter  had  been  passed  some  ten 


state,  and  there  was  great  probability  of  a  subacute  or  chroni 
inflammatory  condition  being  left.  Broncho-pneumonia  was  th 


498 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


characteristic  variety  in  young  children,  though  the  croupous 
form  did  occur.  In  adults  the  opposite  was  the  rule,  while  in  the 
intermediate  ages  a  greater  variety  was  met  with.  As  to  whether 
alcohol  was  likely  to  further  or  to  hinder  recovery,  he  had,  he 
said,  a  very  strong  objection  to  giving  alcohol  to  children  under 
five  years  of  age.  For  adults  he  was  in  the  habit  of  ordering 
it,  when  indicated,  in  very  large  quantities.  He  had  never  seen 
a  child  with  pneumonia  take  alcohol  without,  in  his  opinion, 
being  the  worse  for  it.  The  question  of  the  advisability  of 
antipyretics  in  pneumonia  must  be  subdivided — on  the  one 
hand,  whether  they  should  be  given  to  secure  greater  comfort 
to  the  children  or  with  a  view  to  lessen  their  chances  of  dying. 
He  did  not  believe  they  had  much  effect  on  the  mortality, 
unless  given  in  unreasonably  large  quantities.  They  might  be 
used  in  small  doses  for  the  purpose  of  promoting  comfort,  and 
he  thought  that  children  bore  the  disease  better  by  reason  of 
their  use.  He  looked  upon  an  abortive  case  as  an  acute  inflam¬ 
matory  process  running  a  short  course.  He  had  never  been  able 
to  believe  that  these  short  cases  were  short  as  the  result  of 
treatment. 

Dr.  J.  E.  Winters  thought  croupous  pneumonia  compara¬ 
tively  frequent  in  children.  He  thought  the  majority  of  physi¬ 
cians  would  admit  that  they  saw  very  little  broncho-pneumonia 
in  private  practice.  It  was  likely  to  occur  in  certain  epidemics 
of  pertussis  and  of  measles.  When  one  saw  cases  of  circum¬ 
scribed  consolidation  of  the  lung  in  infants,  running  a  rapid 
course  and  terminating  in  recovery,  these  might  be  put  down  as 
being  cases  of  croupous  or  lobar  pneumonia.  His  views  on  the 
subjectof  alcohol  in  cronpouspneumonia  were  the  sameas those 
of  Dr.  Delafield.  As  to  antipyretics,  it  was  not  often  that  the 
temperature  in  lobar  pneumonia  needed  any  interference.  If  an 
attempt  was  made  to  reduce  the  temperature  in  broncho-pneu¬ 
monia,  more  harm  than  good  would  be  done.  As  to  aborting 
the  attacks,  he  had  seen  a  great  many  of  these  cases  in  which 
it  was  stated  that  the  attack  had  been  aborted.  It  was  a  ques¬ 
tion  whether  these  were  cases  of  pneumonia  at  all.  Certainly 
it  was  possible  to  find  cases  of  an  inflammatory  process  with 
some  exudation  which  would  terminate  in  from  forty-two  to 
seventy-two  hours,  hut  such  were  rare.  A  child  with  some  dis¬ 
turbance  in  the  alimentary  canal,  with  a  cold  added  thereto, 
would  soon  get  up  a  high  temperature  and  exhibit  many  of  the 
signs  indicative  of  pneumonia.  After  the  use  of  medicines  act¬ 
ing  upon  the  intestines  and  skin,  the  symptoms  disappeared  and 
nobody  could  say  whether  pneumonia  had  existed  or  not. 

Dr.  J.  L.  Smith  said  he  thought  it  convenient  to  recognize 
three  forms  of  pneumonia  in  children :  (1)  catarrhal  or  bron¬ 
chial,  (2)  croupous,  and  (3)  hypostatic.  He  thought  that  the 
first-named  might  be  aborted.  He  was  surprised  to  hear  Dr. 
Delafield’s  views  on  alcohol.  He  thought  its  medicinal  value 
unquestionable.  Of  course,  like  any  other  medicine,  it  would 
be  harmful  in  over-doses. 


AMERICAN  GYNAECOLOGICAL  SOCIETY. 

Fifteenth  Annual  Meeting ,  held  in  Buffalo ,  September  16,  17, 

and  18,  1890. 

The  President,  Dr.  John  P.  Reynolds,  of  Boston,  in  the  Chair. 

( Continued  from  page  J/-41.) 

The  Question  of  Amperage  in  the  Treatment  of  Fibroid 
Tumors  by  Electricity  was  the  title  of  a  paper  by  Dr.  W.  C. 
Ford,  of  Utica,  N.  Y.  Myomatous  growths,  he  said,  were 
easily  managed  by  galvanism.  They  were  of  comparatively 
low  resistance,  a  very  large  and  hard  one  offering  but  300 
ohms.  The  question  had  been  asked,  What  happened  when 
the  current  passed  through  a  fibroid  mass?  Simply  the  sepa¬ 


ration  of  the  fluids  in  this  mass  and  their  re-formation  into  dif¬ 
ferent  chemical  combinations,  that  interfered  with  the  intra¬ 
uterine  existence  of  the  growth.  This  was  merely  a  process  of 
electrolysis.  The  current  necessary  to  produce  this  electrolysis 
was  not  one  of  tension,  but  of  volume  or  quantity,  and  this  de¬ 
pended  entirely  on  the  cell  used.  The  small  bichromate-of- 
potassimn  battery  with  a  single  plate  of  zinc  and  carbon,  so 
much  in  use,  unless  a  very  large  number  of  cells  was  employed, 
did  not  give  sufficient  volume,  and  had  not  sufficient  amperage 
to  effect  the  necessary  electrolysis,  but  by  using  a  larger  cell, 
having  a  zinc  plate  between  two  good-sized  carbon  plates,  say 
seven  by  two,  we  got  a  greater  surface  exposed  for  chemical 
action,  and  hence  a  greater  volume  or  amperage  of  current, 
which  afforded  sufficient  electrolytic  action  to  decompose  the 
fluids  of  the  fibroid  tumor  and  arrest  its  growth;  but  with 
high  tension  and  low  amperage,  as  in  the  small-cell  battery, 
this  result  could  not  be  accomplished  without  employing  a 
great  number  of  cells.  The  latter  had  an  electro-chemical  ac¬ 
tion  or  cauterizing  action,  while  the  former  produced  simple 
electrolysis. 

The  author  used  the  negative  or  active  electrode  in  the 
uterus,  and  the  positive  electrode  externally  over  the  abdominal 
wall.  His  uterine  electrode  consisted  of  a  pure  platinum  needle 
with  a  blunt  end,  like  Apostoli’s  needle.  He  had  also  used  the 
gas-carbon  electrode.  For  an  abdominal  electrode,  a  plate  of 
copper  covered  with  punk  was  substituted  for  Apostoli’s  clay 
electrode.  The  plates  were  of  all  sizes.  The  fluids  of  the 
tumor  decomposed  at  the  internal,  negative,  electrode  and 
bubble  up  and  run  out  over  the  electrode  in  sufficient  quantity 
to  be  caught  in  a  spoon  speculum,  after  a  few  minutes’  applica¬ 
tion,  if  the  current  had  the  proper  amperage.  The  author  had 
accomplished  this  with  a  battery  of  fifteen  of  the  large  bichro- 
mate-of  potassium  cells  referred  to.  The  fluid  of  the  tumor 
had  an  intense  chlorine  smell  and  was  strongly  alkaline.  The 
current  was  well  distributed  by  the  abdominal  electrode,  and 
there  was  no  risk  of  blistering  the  abdomen,  as  there  was  abso¬ 
lutely  no  cauterization  produced.  The  author  was  convinced 
that  the  cure  of  these  fibroids  by  electricity  could  be  brought 
about  in  no  other  way  than  by  having  a  sufficient  volume  of 
electricity  carried  by  the  electrode  to  produce  perfect  electrol¬ 
ysis. 

Dr.  Tremaine,  of  Buffalo,  had  not  been  able  to  obviate  in- 
tra-uterine  cauterization  even  with  a  very  mild  current,  and 
after  an  experience  of  sixteen  cases  he  was  rather  disappointed 
with  the  electrical  treatment.  He  believed  the  actual  value  of 
Apostoli’s  treatment  of  fibroids  was  still  sub  judice,  and  raised 
the  question  as  to  what  became  of  the  abdominal  walls  and  other 
thin  tissues;  if  the  electrolytic  action,  which  passed  through 
them  to  get  at  the  tumor,  was  sufficient  to  completely  decom¬ 
pose  and  dissipate  the  tumor,  why  these  tissues  were  not  also 
decomposed. 

Dr.  Skene  believed  there  was  a  certain  amount  of  electroly¬ 
sis  going  on  in  the  abdominal  walls  and  in  the  tissue  interven¬ 
ing  between  them  and  the  fibroid  tumor,  but  that  they  re¬ 
mained  intact  while  the  tumor  was  dissipated,  for  the  reason 
that  it  was  of  lower  vitality  and  could  not  resist  the  decom¬ 
posing  action  of  the  current.  Even  if  the  normal  tissues  did 
sustain  a  certain  electrolytic  action,  their  great  vitality  enabled 
them  to  soon  regain  their  original  condition,  while  the  fibroid 
did  not.  He  did  not  believe  that  cauterization  was  ever  neces¬ 
sary  to  stop  the  growth  of  the  tumor,  and  that  in  avoiding  it 
all  the  dangers  of  electrolysis  would  be  obviated.  He  would 
never  carry  electrolysis  to  the  point  of  cauterization.  He  be¬ 
lieved  that  electrolysis  with  the  positive  pole  in  the  cavity  of 
the  uterus  produced  stenosis,  and  that  it  could  be  avoided  by 
the  use  of  the  negative  pole.  Very  few  cases  could  ever  be 


Nov.  1,  1890.]  PROCEEDINGS 

said  to  be  cured  in  tlie  sense  that  the  tumor  entirely  disap¬ 
peared  ;  but  if  we  limited  the  word  cure  to  mean  an  arrest  of 
the  growth,  in  that  sense  many  had  been  cured.  In  many 
cases  the  tumor  had  been  very  much  diminished  in  size  and  the 
symptoms  had  been  cured,  which  might  be  called  “sympto 
matic  cure.”  He  thought  that  Apostoli  meant  to  be  honest, 
but,  like  all  other  enthusiasts,  he  was  inclined  to  overestimate 
his  work,  but  in  the  main  he  was  correct. 

Dr.  H.  P.  0.  Wilson,  of  Baltimore,  believed  that  for  violent 
bleeding  myomata  the  carbon  uterine  electrode  was  the  proper 
one,  and  he  much  preferred  it  to  the  platinum  electrode;  that 
electricity  was  not  applicable  to  intra-uterine  pedunculated  myo¬ 
mata,  or  subperitoneal  pedunculated  myomata,  or  soft  cedema- 
tous  myomata;  but  that  the  intramural  form  could  be  cured 
in  the  sense  referred  to  by  Dr.  Skene.  He  believed  that  much 
of  the  dissatisfaction  with  the  use  of  the  electrical  treatment 
was  due  to  the  fact  that  operators  were  too  sanguine  and  used 
electricity  for  all  kinds  of  tumors  when  it  should  only  be  used 
in  selected  cases. 

Dr.  H.  Mynter,  of  Buffalo,  called  attention  to  Dr.  Ford’s 
statement  in  regard  to  the  difference  between  electrolytic  action 
and  electro-chemical  action,  the  former  being  produced  by  a 
moderate  number  of  cells  with  a  large  surface  and  low  intensity, 
while  the  latter  was  caused  by  the  application  of  a  battery  of 
very  small  cells  having  a  very  high  tension,  and  thought  that  per¬ 
haps  the  diversity  of  opinion  in  regard  to  electricity  was  due  to 
the  fact  that  many  who  administered  it  did  not  have  the  proper 
battery.  He  was  also  convinced  that  the  electro-chemical  action 
frequently  caused  sloughing. 

Dr.  George  Keith,  of  Edinburgh,  emphasized  the  impor¬ 
tance  of  first  making  a  correct  diagnosis  and  then  proceeding  to 
treatment. 

Dr.  Rosebrttgh,  of  Hamilton,  Ontario,  asked  whether  in  the 
cases  alleged  to  be  cured  there  had  been  any  other  form  of 
medication,  such  as  with  ergot  employed  conjointly  with  elec¬ 
tricity. 

Dr.  Wilson  had  used  no  medication  except  enough  to  regu¬ 
late  the  bowels  and  nervous  system  with  bromide  of  potassium, 
etc.  He  considered  ergot  absolutely  worthless  in  fibroids. 

Dr.  Ford  had  never  found  that  the  soft  oedematous  fibroids 
would  not  yield  to  electricity,  but  in  the  very  hard  ones  he  had 
found  it  necessary  to  cauterize  in  order  to  make  any  impression 
on  them. 

Dr.  Gehrung,  of  St.  Louis,  believed  that  better  results 
would  be  obtained  by  puncture,  where  it  was  admissible,  than 
by  treating  the  tumor  through  the  walls  of  the  uterus,  and  that 
the  large  exudation  tumors  filling  the  pelvic  cavity  and  firmly 
adherent  to  all  the  pelvic  organs — where  any  operation  was  im¬ 
possible— could  be  treated  successfully  by  puncture  and  elec¬ 
trolysis.  He  used  the  trocar-electrode  and  double  cannula, 
with  two  tubes  attached,  through  which,  by  the  use  of  the  as¬ 
pirator,  he  could  wash  out  the  cavities  of  the  tumor  if  it  was  a 
cystic  one. 

Dr.  Skene  thought  that  ergot  was  only  useful  in  submucous 
uterine  tumors  with  a  tendency  to  become  pedunculated,  or  those 
that  were  undergoing  a  natural  process  of  elimination — cases 
which  did  not  call  for  electrolysis.  In  cases  of  bleeding  fibroids 
he  would  remove  a  portion  of  the  hypertrophied  mucous  mem¬ 
brane  of  the  uterus  to  control  haemorrhage ;  then  apply  iodine 
to  the  mucous  membrane,  which  acted  as  a  disinfectant ;  and 
then  electricity.  In  cases  where  the  haemorrhage  was  not  severe 
he  would  use  ordinary  disinfectants,  but  in  obstinate  cases  he  be¬ 
lieved  that  Hydrastis  canadensis  was  valuable  and  that  it  had  a 
beneficial  effect  on  the  mucous  membrane  of  the  uterus.  He 
frequently  used  it  in  connection  with  curetting,  iodine,  and 
electricity. 


OF  SOCIETIES. 


Vaginal  Fixation  of  the  Stump  in  Abdominal  Hysterec¬ 
tomy-  Hr.  Henry  I.  Byford,  of  Chicago,  presented  a  paper 
as  a  supplement  to  one  written  by  him  a  year  before,  in  which 
a  certain  operative  procedure  was  recommended.  Extended 
experience  had  shown  the  advisability  of  making  some  changes 
in  the  details  of  the  operation,  particularly  in  the  fixation  of 
the  stump.  The  characteristic  steps  of  the  operation  as  now 
perfoimed  were  as  follows:  Ligate  the  broad  ligaments;  sep¬ 
arate  the  bladder  from  the  cervix ;  put  on  a  temporary  elastic 
ligatui e  below  the  tumor;  transfix  and  cut  off  the  mass  above; 
ligate  the  stump  in  several  parts  with  silk;  remove  the 
elastic  ligature;  perforate  the  anterior  vaginal  wall  in  front 
of  the  cervix ;  turn  the  stump  forward  into  the  vagina, 
and  clamp  it  firmly  there;  sew  the  peritoneal  edge,  that 
was  separated  along  with  the  bladder  from  the  anterior 
surface  of  the  uterus,  to  the  posterior  surface  of  the  stump, 
so  as  to  close  off  the  peritoneal  cavity  from  the  vagina:  close 
the  ventral  incision,  with  or  without  toilet  and  drainage,  as  in 
other  cases.  A  small  piece  of  iodoform  gauze  stuffed  from  be¬ 
low  into  the  rent  in  the  anterior  vaginal  wall,  and  left  for 
twenty-foui  to  thirty-six  hours,  might  be  useful  in  preventing 
any  possible  accumulation  of  discharge  at  that  point.  The 
time  occupied  in  separating  the  bladder  and  the  anterior  vagi¬ 
nal  wall  from  the  cervix  and  putting  on  the  clamp-forceps 
should  not  be  greater  than  for  adjustment  of  the  stump  in  ven¬ 
tral  fixation.  Ihe  other  steps  were  practically  the  same. 
Bladder  wounds  could  be  treated  extraperitoneally,  without 
displacement  of  the  viscus. 

Dr.  Byford  reported  eight  cases,  one  of  which  bad  resulted 
fatally,  but  this  result  could  not  be  attributed  to  the  operation. 
In  the  others,  the  shortened  upper  end  of  the  stump  had 
worked  its  way  back  into  the  connective  tissue  behind  the 
bladder,  so  that  in  a  few  weeks  the  os  and  cervical  canal  were 
normal  as  to  position  and  mobility. 

Vaginal  Fixation  of  the  Stump  after  Myomectomy. — 
Dr.  Howard  Kelly,  of  Baltimore,  would  divide  fibroids  into 
four  classes:  1.  Those  that  were  pedunculated  and  intra-uterine, 
which  could  be  removed  from  the  cervix.  2.  Those  that  could 
be  removed  through  the  abdominal  wall  by  myomectomy  with¬ 
out  removing  any  substantial  portion  of  the  uterus.  3.  Those 
with  a  distinct  pedicle,  which  could  be  removed  by  supra-vagi- 
nal  hysterectomy ;  also  those  in  which  a  pedicle  could  be 
formed,  but  where  it  was  necessary  to  cut  under  the  tubes  and 
ovaries  and  through  the  broad  ligament  to  get  at  it.  4.  Atypi¬ 
cal  cases,  where  the  tumor  was  spread  out  laterally  in  the  broad 
ligament,  almost  filling  the  pelvis,  where  it  was  impossible  to 
make  a  pedicle,  and  the  patient  usually  died  from  haemorrhage 
and  shock.  These  latter  cases  could  not  be  treated  by  section, 
which  was  limited  to  cases  with  a  distinct  pedicle  ;  and  there 
was  no  well-defined  method  of  treatment  for  them.  In  treat¬ 
ing  these  fibroids,  one  must  consider  first  that  there  was  a  very 
large,  fleshy  pedicle,  the  ligating  of  which  controlled  the  hiem- 
orrhage  at  the  time  of  operation,  but  that  it  might  bleed  profusely 
after  it  had  been  dropped  back  into  the  abdominal  cavity, and  thus 
prove  a  source  of  contamination.  He  compared  Hegar’s  meth¬ 
od  of  treatment — the  extraperitoneal— and  its  modification  by 
Zweifel ;  Schroeder’s — the  intraperitoneal ;  his  own — a  modi¬ 
fication  of  the  two  ;  and  Dr.  Byford’s.  The  first  had  had  such 
a  death-rate  that  it  had  been  abandoned,  but  subsequently  ren¬ 
dered  legitimate  by  Zweifel,  who  performed  it  with  more  care. 
Hegar’s  method  of  allowing  the  stump  to  slough  oft’  he  consid¬ 
ered  as  unsurgical  a  procedure  as  to  tie  a  string  around  the  fin¬ 
ger  and  allow  it  to  slough  off.  It  was  also  very  difficult  where 
the  stump  was  short.  To  overcome  this  difficulty,  he  had  adopt¬ 
ed  the  plan  of  suturing  the  stump  with  buried  and  superficial 
sutures  and  suspending  it  in  the  lower  angle  of  the  abdominal 


500 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mien.  Jour., 


incision.  A  square  pad  of  iodoform  gauze  was  placed  over  the 
externa]  end  of  the  stump,  through  a  hole  in  the  middle  of 
which  the  sutures,  left  with  long  ends,  were  drawn  and  could 
be  grasped  with  the  forceps  at  any  time  in  case  of  accident,  thus 
giving  complete  control  of  the  stump.  This  had  stood  the  test 
of  nine  cases  with  but  one  death,  which  had  been  due  to  vascu¬ 
lar  lesions.  Dr.  Byford’s  method  was  good  for  the  smaller  tu¬ 
mors,  but  it  would  be  very  difficult  to  deal  with  a  broad  pedicle 
by  it.  It  had  the  advantage  of  avoiding  the  risk  of  hernia  which 
followed  from  suspension  of  the  tumor  in  the  angle  of  the  ab¬ 
dominal  wound,  and  also  afforded  excellent  drainage. 

Dr.  William  M.  Polk,  of  New  York,  referred  to  the  fourth 
class  of  tumors  mentioned  by  Dr.  Kelly,  which  he  treated  by  a 
plan  that  was  a  modification  of  the  one  suggested  by  Dr.  Miner, 
of  Buffalo,  in  the  treatment  of  non-pedunculated  ovarian  tumors 
— a  process  of  complete  enucleation.  He  would  ligate  the  uter¬ 
ine  artery,  and  in  some  cases  where  there  was  a  good  deal  of 
haemorrhage  from  the  posterior  wall  he  thought  it  advisable  to 
cut  down  and  ligate  the  utero-sacral  ligament  on  either  side,  in 
order  to  control  the  haemorrhage.  He  burned  a  hole  with  the 
cautery  through  the  cervical  canal,  burning  the  tissues  well 
around  the  hole,  after  which  the  cavity  was  packed  with  a  long 
strip  of  iodoform  gauze,  which  was  brought  out  of  the  opening, 
and  the  abdominal  incision  was  closed  in  the  ordinary  manner 
adopted  in  the  treatment  of  ovarian  tumors  that  were  enucle¬ 
ated  in  a  like  manner,  thus  affording  complete  disinfection  of 
the  cervix. 

Dr.  E.  0.  Dudley,  of  Chicago,  had  performed  Bvford's  op¬ 
eration  in  two  cases  with  perfect  success,  with  a  simple  modi¬ 
fication  in  the  packing  of  iodoform  gauze. 

Dr.  A.  J.  C.  Skene,  of  Brooklyn,  thought  that  Byford’s 
method  was  only  adapted  to  cases  where  the  stump  was  small. 
He  believed  that  complete  removal  of  the  cervix  might  be  sub¬ 
stituted  for  Byford’s  operation,  also  in  dilatation  of  the  cervix 
and  complete  inversion  of  the  same.  Before  adopting  Byford’s 
method  the  relative  value  of  these  other  two  methods  should 
be  ascertained. 

Dr.  Dudley  had  tried  inversion  of  the  stump,  and  found  it 
exceedingly  difficult  and  almost  impossible  to  accomplish,  no 
matter  how  much  dilatation  was  used.  He  had  also  attempted 
the  removal  of  the  entire  stump  by  applying  the  lock  forceps 
through  the  vagina  to  secure  haemostasis,  but  believed  it  a  very 
difficult  and  not  very  practicable  operation.  Dr.  Byford’s  meth¬ 
od  should  be  adopted  in  all  cases  of  large  fibromata  which  com¬ 
pletely  filled  the  uterus  and  spread  out  into  the  broad  ligament, 
especially  if  the  size  of  the  cervix  was  reduced  by  the  cautery, 
as  spoken  of  by  Dr.  Polk.  The  vagina  was  quite  capacious  and 
would  hold  a  pretty  large  stump. 

Dr.  Joseph  Taber  Johnson,  of  Washington,  had  successfully 
performed  five  operations  by  the  Bantock  method.  He  thought 
it  was  better  to  have  a  long  convalescence  caused  by  the  slough¬ 
ing  off  of  the  stump  in  this  operation  than  to  try  some  other 
operation  and  have  no  recovery  at  all.  He  believed  the  method 
referred  to  by  Dr.  Skene  of  the  complete  removal  of  the  infected 
stump,  providing  proper  drainage,  would  be  the  ideal  method. 

Dr.  Polk  agreed  with  Dr.  Dudley  that  the  operation  for  the 
complete  removal  of  the  uterus  and  cervix  by  applying  clamps 
through  the  vagina  to  control  haemorrhage  was  a  very  difficult 
and  unsatisfactory  operation,  and  was  inferior  to  the  complete 
removal  of  the  uterus  by  the  use  of  the  ligature,  notwithstand¬ 
ing  the  fact  that  in  some  cases  where  the  cervix  was  deep  that 
operation  was  prolonged  by  a  good  deal  of  bleeding.  Dr.  By¬ 
ford’s  method  had  the  advantage  of  simplifying  and  shortening 
the  operation.  Another  method  suggested  about  the  same 
time,  or  since  Dr.  Byford’s,  that  accomplished  about  the  same 
end,  was  that  in  which,  after  the  stump  was  cut  off  and  the 


bladder  dissected  away,  instead  of  making  an  opening  into  the 
vagina,  with  one  blade  of  the  scissors  in  the  cervix  and  the 
other  outside,  the  cervix  could  be  cut  down  into  the  vagina  and 
the  mass  turned  inside  out,  on  the  same  principle  as  in  the 
Porro  operation. 

Dr.  Kelly  believed  there  was  still  another  class  of  cases  in 
which  haemorrhage  could  not  be  controlled  by  the  methods  de¬ 
scribed  by  Dr.  Polk  and  others,  and  for  those  cases  he  had 
devised  a  corrugated  uterine  sound  by  which  he  could  discover 
tl i e  relative  position  of  the  uterine  arteries  when  they  were 
displaced,  and  in  that  way  control  the  haemorrhage.  These 
tumors,  no  matter  how  large,  seldom  reached  to  the  ovarian 
arteries  and  veins  at  their  points  of  emergence  from  the  ab¬ 
dominal  aorta,  and  he  would  in  cases  of  excessive  haemorrhage 
tie  these  arteries  and  veins  in  the  abdominal  cavity,  and  in  des¬ 
perate  cases,  where  it  was  impossible  to  get  the  tumor  out,  he 
would  adopt  the  heroic  treatment  of  temporarily  compressing 
the  abdominal  aorta;  and  he  was  convinced  that  there  was  a 
certain  class  of  cases  that  could  not  be  treated  in  any  other 
way.  In  his  own  operation,  if  there  was  any  oozing  after  the 
stump  was  sutured,  he  ligated  the  uterine  arteries,  and  had 
always  succeeded  in  checking  any  haemorrhage  that  might  have 
occurred.  Bantock’s  operation  was  fitted  only  for  cases  of 
pedunculated  fibroids,  and,  if  it  was  applied  strictly  to  such 
cases,  the  mortality  should  be  nil. 

Dr.  J.  0.  Temple,  of  Toronto,  agreed  with  Dr.  Skene  that 
removal  of  the  entire  mass  was  the  most  rational  procedure. 
He  did  not  believe  in  the  inversion  of  the  mass  through  the 
dilated  cervix,  as  he  had  found  it  a  most  difficult  method.  Dr. 
Byford’s  plan  was  a  good  one  in  selected  cases  where  it  was  not 
desired  to  remove  the  whole  of  the  tumor. 

Injuries  to  the  Ureters  during  Labor  was  the  title  of  a 
paper  by  Dr.  A.  J.  C.  Skene,  of  Brooklyn.  The  writer  stated 
that  he  had  attended  many  cases  in  both  hospital  and  private 
practice  that  differed  from  the  puerperal  diseases  recorded  in 
obstetrical  literature.  He  had  been  led  to  believe  that  the 
symptoms  he  had  observed  were  due  to  injury  to  the  ureters. 
The  patients  had  usually  been  primiparae  or  had  had  many  chil¬ 
dren  ;  the  labor  had  been  tedious,  instrumental,  or  manual,  and 
the  progress  after  delivery  satisfactory  or  fairly  so.  The  lochial 
discharge  and  the  secretion  of  milk  had  been  normal,  and  the 
bowels  and  the  kidneys  apparently  normal.  In  some  cases 
there  was  retention  of  urine  or  frequent  and  painfui  urination. 
Pelvic  pain  and  tenderness  in  the  lower  part  of  the  abdomen 
were  present,  but  were  not  always  severe  at  first.  These  symp¬ 
toms  became  more  acute  after  a  time,  the  pain  and  tenderness 
increased  rather  abruptly,  and  a  chill  might  occur  at  this  time. 
Distention  of  the  bowels  took  place,  and  the  temperature  and 
the  pulse-rate  increased.  Pressure  showed  increased  tender¬ 
ness,  and  bimanual  manipulation  of  the  kidney  on  the  affected 
side  usually  produced  a  sense  of  distress  rather  than  of  acute 
pain.  An  increase  in  the- severity  of  the  symptoms  supervened 
in  from  three  to  five  days,  and  soon  thereafter  a  quantity  of 
pus,  and  sometimes  blood,  appeared  in  the  urine.  The  patient 
was  generally  relieved  to  some  extent  when  the  discharge  of 
pus  began;  the  pain  was  less  and  the  temperature  and  pulse- 
rate  were  reduced  a  little.  In  connection  with  pus  and  blood, 
renal  casts  might  be  found.  The  pus  continued  to  be  dis¬ 
charged,  but  in  diminished  quantity,  for  a  week  or  more.  The 
bleeding  generally  subsided  in  a  day  or  so,  and  most  of  the 
patients  recovered.  In  some  other  cases  acute  disease  of  the 
kidneys  appeared  about  the  time  that  pus  began  to  be  dis¬ 
charged  from  the  bladder;  uraemia  followed,  and  sometimes 
uraemic  coma.  Such  cases  usually  terminated  fatally,  although 
recovery  might  take  place.  In  most  instances  there  was  not  a 
pre-existing  renal  disease. 


Nov.  1,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


501 


The  diagnosis  of  injury  to  the  ureter  must  be  made  by  the 
exclusion  of  the  more  common  puerperal  affections — such  as 
peritonitis,  cellulitis,  general  septicaemia,  cellular  abscess,  am 
cystitis.  If  there  was  a  metro-cellulitis  following  injury  to  the 
cervix  uteri,  the  ureters  became  affected  secondarily,  and  the 
symptoms  developed  in  reverse  order. 

The  following  was  a  convenient  classification  of  diseases 
and  injuries  of  the  ureters:  1.  Injuries  of  the  ureters  during 
labor.  2.  Obstructions  to  the  ureters  secondary  to  pelvic  in¬ 
flammations.  3.  Obstructions  due  to  neoplasms  and  uterine 
displacements.  The  second  and  third  were  taken  from  Engel- 
mann. 

Injuries  to  the  ureters  might  be  avoided  in  great  measure. 
Care  to  dilate  before  rupture  of  the  membranes,  the  proper  use 
of  the  forceps,  and  having  the  patient  in  the  best  possible  phys¬ 
ical  condition,  were  essential  as  prophylactics. 

The  treatment  was  in  great-  measure  expectant.  The  sur¬ 
gical  treatment  of  these  affections  was  not  in  a  highly  devel¬ 
oped  state. 

Incontinence  of  Urine  due  to  Malposition  of  the  Ureter 

was  the  title  of  a  paper  by  Dr.  F.  H.  Davenport,  of  Boston. 
This  was  a  report  of  a  case  in  which  a  woman  of  twenty-nine 
years  had  suffered  all  her  life  from  incontinence  of  urine.  A 
careful  examination  showed  that  one  ureter,  instead  of  opening 
as  usual  into  the  bladder,  was  continued  along  in  the  septum 
between  the  bladder  and  the  vagina,  and  emptied  by  a  special 
opening  near  the  meatus.  An  operation  to  establish  a  proper 
opening  into  the  bladder  was  clearly  the  only  hope  of  relief. 
This  was  performed,  but  a  subsequent  retraction  of  the  vesical 
end  of  the  ureter  had  made  a  second  operation  necessary.  The 
latter  had  been  successful. 

Dr.  W.  W.  Jagg-ard,  of  Chicago,  thought  that  injuries  to 
the  ureters  were  quite  common  during  pregnancy,  and  that 
those  existing  before  pregnancy  might  become  intensified,  but 
that  they  were  not  common  during  labor,  as  at  that  time  the 
bladder  was  drawn  up  into  the  abdominal  cavity  and  the  ure¬ 
ters  were  out  of  the  way  of  the  pressure  from  the  head  of  the 
child;  that  they  were  rarely  injured  by  the  dilatation  of  the 
cervix  or  the  application  of  the  forceps  before  the  engagement 
of  the  head.  In  1878  a  German  observer  had  called  attention 
to  compression  or  dilatation  of  the  ureters  as  a  cause  of  eclamp¬ 
sia,  and  Morgagni  had  noticed  the  same  thing.  The  speaker  had 
seen  one  case  where  compression  was  believed  to  be  the  prin¬ 
cipal  cause  of  eclampsia.  Recent  anatomical  investigations 
with  frozen  sections  of  women  who  had  died  early  and  late  in 
the  puerperium,  particularly  in  cases  of  difficult  labor,  had  dem¬ 
onstrated  that  the  bladder  was  then  an  abdominal  and  not  a 
pelvic  organ.  Among  the  causes  specially  operative  in  produc¬ 
ing  injury  of  the  ureters  during  pregnancy  he  mentioned:  1. 
Increased  abdominal  tension.  2.  The  presence  of  small  ureteral 
calculi.  He  had  seen  two  cases  in  which  calculi  were  probably 
the  cause  of  a  dilated  ureter.  He  believed  that  palpation  of  the 
ureters  during  the  puerperium  was  extremely  hazardous,  pro¬ 
ductive  of  no  good,  and  entirely  a  work  of  supererogation. 

Dr.  A.  W.  Johnstone,  of  Danville,  Ky.,  related  a  fatal  case 
of  injury  to  the  ureter  after  laparotomy  for  multilocular  ovarian 
cyst,  where  furious  mania  was  developed  forty-eight  hours  after 
the  operation.  The  tumor  pressed  on  the  ureter  just  where  it 
passed  over  the  pelvic  brim,  and  from  that  point  up  to  the  kid¬ 
ney  it  was  so  enlarged  that  it  would  admit  the  finger;  there 
was  purulent  inflammation  of  the  ureter  and  hilum  of  the  kid¬ 
ney,  and  the  kidney  itself  was  seriously  disorganized.  The 
lower  portion  of  the  ureter  was  normal.  He  believed  that  many 
of  the  cases  of  mania  after  laparotomy  were  due  to  some  such 
condition  as  this.  Tuberculosis  was  a  very  frequent  disease  of 
the  ureters,  and  had  been  noticed  in  a  young  girl  who  was  sup¬ 


posed  to  be  dying  of  phthisis,  who  presented  no  compjication  of 
the  lung  whatever,  but  had  all  the  symptoms  of  tuberculosis. 
The  post-mortem  revealed  the  bladder,  the  ureters,  the  hilum  of 
the  kidney,  and  the  kidney  itself  studded  with  miliary  tubercles. 
The  ureters  were  a  frequent  source  of  trouble,  and  should  not 
be  overlooked  in  gynaecological  work. 

Dr.  Henry  T.  Byford,  of  Chicago,  thought  that  in  many 
cases  of  pelvic  disease  death  was  due  to  ureteral  trouble,  such 
as  uraemic  convulsions,  etc.,  although  they  were  generally  at¬ 
tributed  to  the  earlier  disease  which  caused  the  ureteral  trou¬ 
ble.  Oatheterism  of  the  ureter  was  difficult  aud  required  a 
practiced  hand,  but  it  was  unreasonable  to  doubt  that  it  could 
be  done. 

Is  the  Mortality  after  Gynaecological  Operations  affected 
by  Climatic  Influences?— Dr.  Henry  C.  Coe,  of  New  York, 
read  a  paper  on  this  subject.  The  conclusions  that  he  had 
drawn,  after  a  most  careful  analysis  of  his  own  cases  and  ex¬ 
tended  inquiry  in  regard  to  the  cases  of  others,  were  against  the 
belief  that  season  had  any  influence  in  the  way  of  affecting  the 
mortality  rate  after  gynecological  operations. 

Cephalsematoma. — In  a  paper  on  this  subject  Dr.  Howard 
A.  Kelly,  of  Baltimore,  stated  that  this  disease  occurred  once 
in  every  two  hundred  and  fifty  obstetric  cases,  but  that  it  was 
rarely  recognized  by  the  general  practitioner.  Cephalematoma 
was  a  well-defined  lesion,  running  a  brief,  definite  course,  tend¬ 
ing,  as  a  rule,  toward  resolution,  but  capable  of  seriously  affect¬ 
ing  the  health,  or  even  implicating  the  life,  of  the  child. 

A  cephalaematoma  was  usually  resolved  by  absorption,  and 
it  was  wise  to  wait  for  two  or  three  weeks.  If  absorption  did 
not  take  place,  extirpation  was  indicated. 

Dr.  Jaggard  believed  that  external  cephalsematoma  occurred 
in  many  labors  and  healed  spontaneously,  attracting  little  or  no 
attention.  The  internal  variety,  where  the  tumor  was  between 
the  inner  layer  of  the  periosteum  and  the  bone,  sometimes 
caused  strabismus  and  death  ;  it  was  not  difficult  to  diagnosti¬ 
cate,  but  usually  difficult  to  cure.  He  was  of  the  opinion  that 
injury  was  always  the  cause  of  these  tumors,  and  that  it  oc¬ 
curred  during  labor  by  reason  of  the  stretching  of  the  perios¬ 
teum  downward  and  rupture  of  its  blood-vessels,  or  by  reason 
of  the  bringing  together  of  the  bones  of  the  foetal  head  by  the 
application  of  the  forceps.  It  was  essentially  traumatic,  and 
occurred  in  a  slight  degree  in  many  labors,  but  reached  a  per¬ 
ceptible  size  in  about  the  proportion  stated  by  Dr.  Kelly.  It 
was  nearly  as  frequent  in  the  after-coming-head  and  transverse 
presentations  as  when  the  vertex  presented. 

Dr.  Fredericks,  of  Buffalo,  reported  three  cases  of  cephalae- 
matoma. 

Dr.  Kelly  was  convinced  that  these  tumors  were  not  the 
result  of  traumatism  from  severe  labors  or  instrumental  deliv¬ 
eries,  being  most  frequently  observed  after  simple  and  easy 
abors.  They  had  been  detected  on  the  head  of  the  child  before 
firth,  on  the  head  of  a  five  or  six  months’  foetus,  and  in  one 
case  on  the  head  of  a  child  born  by  Caesarean  section;  all  of 
which  would  lead  him  to  believe  that  there  must  be  some  pre¬ 
disposing  cause  that  was  not  as  yet  understood. 

Drainage  after  Laparotomy.— Dr.  Thomas  A.  Ashby,  of 
Baltimore,  read  a  paper  thus  entitled,  in  which  he  advocated 
using  drainage  for  the  purpose  of  disposing  of  the  products  of 
intrapelvic  operations,  etc.  He  maintained  that  when  drainage 
was  employed  there  was  a  lower  temperature,  less  tympanites, 
and  less  gastric  disturbance.  The  abdomen  should  be  washed 
out  every  few  hours. 

Dr.  A.  Palmer  Dudley,  of  New  York,  in  a  series  of  seventy- 
nine  cases  of  abdominal  section,  including  eight  hysterectomies, 
one  Caesarean  section,  two  cases  of  extra- uterine  pregnancy, 
and  five  cases  of  pyosalpinx,  had  used  the  drainage-tube  in  but 


502 


BOOK  NOTICES. 


[N.  Y.  Med.  Jour.' 


two  case%  (of  fibroids),  and  both  patients  bad  died  on  the  eighth 
day — the  first  from  a  circumscribed  abscess  of  the  omentum 
without  general  peritonitis,  and  the  second  from  intestinal  ob¬ 
struction  caused  by  adhesion  of  the  intestines  around  the  tube. 
Sixty-nine  of  these  abdominal  sections  had  been  made  without 
the  use  of  a  drainage-tube  and  without  a  death,  although  in 
many  of  them  there  had  been  a  large  quantity  of  fluid.  The 
drainage-tube  should  be  used  only  under  two  conditions:  1. 
Where  there  was  general  peritonitis  and  haemorrhage  was  sus¬ 
pected.  2.  Where  the  peritonaeum  was  congested  from  a  recent 
peritonitis  and  bled  if  irritated  with  a  sponge.  Under  all  other 
conditions  the  proper  toilette  of  the  peritoneal  cavity  before 
closing  the  abdomen  would  accomplish  more  than  any  drainage- 
tube.  The  drainage-tube  was  dangerous  in  the  hands  of  those 
whothoughtthey  could  accomplish  with  it  what  they  should  have 
done  before  closing  the  cavity.  The  dangers  of  the  drainage- 
tube  were:  1.  Intestinal  adhesions  from  the  exudation  of  lymph 
around  the  tube.  2.  Faecal  fistula.  3.  Occasionally,  hernia. 
Where  there  was  sufficiently  grave  septic  inflammation  in  the 
pelvic  cavity  to  endanger  life,  the  tube  was  useless,  as  it  very 
soon  became  walled  in  by  a  rapidly  forming  lymph  cavity  and 
cut  off  from  the  pus  that  was  collecting1  around  it.  The  suc¬ 
cess  of  the  laparotomists  was  due  to  great  care  in  the  toilette 
of  the  peritonaeum.  He  had  great  faith  in  washing  out  the  ab¬ 
dominal  cavity  with  a  stream  of  hot  water.  The  greater  drain¬ 
age-tube — the  intestinal  tract— he  took  advantage  of  by  the 
administration  of  saline  cathartics  just  before  an  operation,  and 
the  vermicular  action  of  the  intestines  still  went  on  after  the 
operation  and  afforded  ample  drainage,  especially  in  cases  of 
intestinal  fistula.  This,  together  with  the  use  of  hot  water  and 
careful  closure  of  the  peritoneal  cavity,  was  safer  and  better 
than  any  form  of  drainage-tube. 

Dr.  E.  0.  Dudley,  of  Chicago,  referred  to  the  inadequacy  of 
the  ordinary  glass  drainage-tube  for  extensive  drainage  on  ac¬ 
count  of  its  being  surrounded  in  a  few  hours  by  the  agglutinat¬ 
ed  surfaces  of  the  peritonaeum,  and  believed  that  the  system  of 
drainage  devised  by  Michaelis,  which  consisted  in  packing  the 
part  to  be  drained  with  iodoform  gauze,  was  a  good  one,  and 
that  the  mistake  most  frequently  made  was  in  removing  the 
gauze  too  soon,  causing  the  adhesions  around  the  gauze  to  break, 
with  subsequent  infection  of  the  peritoneal  cavity,  lie  would  use 
this  system  of  drainage  in  all  bad  cases  where  there  was  a  large 
surface  to  be  drained ;  but,  where  there  was  doubt  as  to  the  ne¬ 
cessity  of  drainage,  the  trial  of  the  glass  tube  would  serve  to 
indicate  or  contra  indicate  the  necessity  of  more  extensive  drain¬ 
age  by  the  application  of  Michaelis’s  dressing. 

Dr.  H.  P.  C.  Wilson,  of  Baltimore,  agreed  with  Dr.  Dudley 
that  the  glass  drainage-tube  was  utterly  inadequate  to  drain 
large  surfaces,  and  that  the  Michaelis  drainage  was  an  excellent 
one.  He  referred  to  the  frequency  with  which  some  of  the 
European  operators,  Bantoek  and  others,  used  the  drainage- 
tube,  the  latter  saying  that  he  always  felt  safer  when  he  had  in 
a  drainage-tube. 

Dr.  M.  D.  Mann,  of  Buffalo,  thought  the  drainage-tube  was 
used  too  much.  He  had  almost  abandoned  it,  and  if  he  did  use 
it  he  always  felt  uneasy  while  it  was  in  ;  unless  it  was  watched 
with  the  greatest  care,  very  great  harm  might  result  from  it; 
he  never  used  it  where  it  was  possible  to  do  without  it.  He 
would  reverse  the  rule,  “  When  you  are  in  doubt,  drain,”  and 
say,  “  When  you  are  in  doubt,  wait;  ”  don’t  close  the  abdomen 
too  quickly  unless  there  is  great  shock  ;  put  in  a  sponge  and  use 
hot-water  irrigation,  and  very  frequently  the  haemorrhage  will 
stop,  and  the  abdomen  may  be  closed  without  the  necessity  of 
drainage.  He  agreed  with  Dr.  A.  P.  Dudley  that  drainage  by 
the  intestines  was  an  excellent  plan.  He  starved  his  patients 
for  forty-eight  hours,  giving  them  only  a  little  water  to  moisten 


their  lips,  and,  by  thus  depriving  the  system  of  fluids,  a  gre9t 
call  was  made  on  the  lymphatics,  which  would  take  up  the 
effused  serum  from  the  abdomen  much  more  safely  than  any 
tube. 


§00  k  JJottcts. 


Beitrdge  zur  Aug enheilkunde.  Yon  Professor  R.  Deutschmann, 
in  Hamburg.  1.  Heft,  mit  10  Abbildungen  in  Text.  Ham¬ 
burg  und  Leipzig:  Leopold  Voss,  1890.  Pp.  80. 

This  little  brochure  is  the  first  part  of  a  series  of  observa¬ 
tions  on  certain  rare  forms  of  disease  of  the  eyes  which  have 
been  met  with  in  the  experience  of  the  author.  The  first  article 
is  a  somewhat  lengthy  one  upon  the  value  of  antiseptic  proced¬ 
ures  in  the  treatment  of  injuries  of  the  eye.  The  second  article 
consists  of  remarks  upon  the  pathology  of  the  optic  nerve,  with 
special  reference  to  the  entrance  of  the  optic  nerve  into  the  eye¬ 
ball.  The  third  gives  an  account  of  an  interesting  case  of 
homonymous  hemianopsia  following  injury  to  the  skull.  The 
fourth  gives  an  account  of  a  very  rare  case  of  amaurosis  due  to 
self-infection  from  carcinoma  of  the  stomach.  The  fifth  is  an 
interesting  recital  of  the  microscopic  appearances  of  a  rare  form 
of  detachment  of  the  retina.  The  brochure  ends  with  a  discus¬ 
sion  on  some  rare  forms  of  ocular  tumors,  with  microscopical 
examinations.  Some  of  the  articles  are  illustrated,  and  all  may 
be  read  with  profit.  The  little  book  is  an  interesting  contribu¬ 
tion  to  ophthalmological  literature. 


Hysteropexie  abdominale  anterieure  et  operations  sus-pubiennes 
dans  lesrdtrodeviations  de  I’utdrus.  Par  Maroel  Battdouin. 
Avec  vingt-deux  figures  dans  le  texte.  Paris:  Lecrosnier  et 
Babe,  1890.  Pp.  x-414.  [Publications  du  Progrh  medical.] 
Hysteropexia  is  the  term  proposed  by  Treiat  for  the  oper¬ 
ation  performed  by  Kceberie,  in  1869,  of  gastrotomy  with  per¬ 
manent  fixation  of  the  uterus  to  the  abdominal  wall.  Of  the 
various  operations,  the  author  prefers  that  proposed  by  Dr.  T. 
Gaillard  Thomas.  Hysteropexia  is  held  to  be  indicated  in  all 
cases  of  adherent  or  severe  retroversions  or  retroflexions,  in 
some  cases  of  inversion  and  of  prolapsus,  and  in  grave  retrover¬ 
sion  of  the  gravid  uterus.  The  danger  of  the  operation  is  slight, 
unless  there  are  numerous  and  resistant  adhesions.  The  book 
is  well  written,  and  contains  excellent  tables  of  the  reported 
cases  of  this  operation  and  an  extensive  bibliography. 

Ruptures  des  tendons  svs-  et  sous-rotuliens.  Traitement  par  la 
suture.  Par  Herve,  Docteur  en  medecine  de  la  Faculty  de 
Paris.  Paris:  Henri  Jouve,  1890.  Pp.  5  to  88. 

The  author  finds  that  Ruysch,  in  1720,  first  reported  a  case 
of  rupture  of  the  quadriceps  tendon,  and  concludes,  from  a 
study  of  the  published  cases,  that  ruptures  of  that  tendon  above 
or  below  the  patella  are  susceptible  of  successful  surgical  inter¬ 
ference.  Suture  is  equally  indicated  in  recent  and  in  old  cases, 
and  especially  where  there  is  considerable  separation  of  the 
torn  extremities.  The  operation  of  suturing,  performed  anti- 
septically,  is  not  dangerous  and  permits  of  a  more  rapid  and 
certain  recovery  of  usefulness  of  the  limb  thau  immobilization 
does.  The  monograph  is  a  valuable  contribution  to  the  litera¬ 
ture  of  the  subject. 

Chronic  Urethritis  and  Other  Affections  of  the  Genito-urinary 
Organs.  Three  Lectures  delivered  at  the  Royal  College  of 
Surgeons,  in  June,  1889.  By  Matthew  Berkeley  Hill, 


Nov.  1,  1890.] 


BOOK  NOTICES. 


503 


*  *  -  i  -•  **•  w  itu  vuiureu  i  iaies  rrom 

Drawings  by  Frank  Collins,  M.  R.  0.  S.,  L.  E.  C.  P.  Lon¬ 
don  :  II.  K.  Lewis,  1890.  Pp.  viii-47. 

The  author  of  this  little  work  has  collected  together  some  of 
the  principal  methods  of  treating  chronic  urethral  discharges 
now  in  vogue.  He  is  a  close  follower  of  Grunfeld  in  the  use  of 
the  urethroscope,  and  agrees  with  Otis  concerning  urethral 
caliber.  The  book  contains  some  excellent  lithographs  of  the 
uretkroscopic  field  and  a  chapter  of  interest  on  tuberculosis  of 
the  prostate,  but  the  attempt  is  made  to  cover  entirely  too  much 
ground  in  so  limited  a  space. 


The  Intestinal  Diseases  of  Infancy  and  Childhood.  Physiology, 
Hygiene,  Pathology,  and  Therapeutics.  By  A.  Jacobi,  M.  D., 
etc.  Yols.  I  and  II.  Second  Edition.  Detroit:  GeorgeS. 
Davis,  1890.  [The  Physician’s  Leisure  Library.] 

The  first  of  these  little  volumes  is  devoted  largely  to  the 
subject  of  infant  feeding,  and  is  an  exposition  of  the  author’s 
well-known  views  upon  that  subject.  Thefact  that  the  hygiene 
of  infants  concerns  the  digestive  organs  mainly  gives  abundant 
reason  for  assigning  to  that  subject  so  large  a  share  of  a  work 
on  intestinal  diseases.  The  section  on  dentition  is  a  judicious 
review  of  that  much-discussed  subject,  and  is  especially  good. 
On  the  whole,  the  book  is  eminently  practical  and  a  thoroughly 
good  one  for  the  general  practitioner,  for  whom  it  is  designed. 


Protoplasm  and  Life.  Two  Biological  Essays.  By  Charles 
F.  Cox,  M.  A.  New  York':  N.  D.  C.  Hodges,  1890.  Pp 
3  to  67. 

TnESE  essays  on  the  cell  doctrine  and  the  theory  of  spon¬ 
taneous  generation  are  very  carefully  written,  including  in  their 
scope  a  general  survey  of  the  more  recent  utterances  on  these 
subjects.  The  author  concludes  that  the  general  theory  of  evo¬ 
lution  is  still  in  the  stage  of  hypothesis,  and  that  the  “  missing 
link  ”  is  in  the  gap  between  inorganic  and  organic  substances. 


A  Natural  Method  of  Physical  Training ,  making  Muscle  and 
reducing  Flesh  without  Dieting  or  Apparatus.  By  Edwin 
Cheokley.  Third  Edition.  Fully  illustrated  from  Photo¬ 
graphs  taken  especially  for  this  Treatise.  Brooklyn:  Will¬ 
iam  C.  Bryant  &  Co.,  1890.  Pp.  4-7  to  152. 

The  author  seeks  to  popularize  a  plan  of  muscle-training 
independent  of  apparatus.  But  will  uot  the  “something  or 
other  always  interfering  with  that  half  hour  at  the  machine” 
defer  in  like  manner  the  application  of  Mr.  Checkley’s  system  ? 
However,  this  would  have  nothing  to  do  with  the  efficacy  of 
the  method  proposed;  that  would,  if  regularly  followed,  un¬ 
doubtedly  increase  muscular  tone.  Physicians  are  notoriously 
sedentary  as  a  class,  and,  while  they  mayr  not  always  agree  w'ith 
Mr.  Checkley  in  his  theories,  they  will  undoubtedly  commend 
the  general  scope  of  his  work. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

A  Manual  of  Modern  Surgery :  an  Exposition  of  the  Accepted  Doc- 
rines  and  Approved  Operative  Procedures  of  the  Present  Time.  For 
he  Use  of  Students  and  Practitioners.  By  John  B.  Roberts,  A.  M., 
4.  D.,  Professor  of  Surgery  in  the  Woman’s  Medical  College  of  Penn- 
ylvania,  etc.  With  Five  Hundred  and  One  Illustrations.  Philadel- 
>hia  :  Lea  Brothers  &  Co.,  1890.  Pp.  xvi-33  to  800.  [Price,  $4.50.] 
Epilepsy  ;  its  Pathology  and  Treatment.  Being  an  Essay  to  which 
>  as  awarded  a  Prize  of  Four  Thousand  Francs  by  the  Academie  Royale 
e  Medecine  de  Belgique,  December  31,  1889.  By  Hobart  Amory  Hare, 

I.  D.,  Clinical  Professor  of  Diseases  of  Children  and  Demonstrator  of 
’herapeutics  in  the  University  of  Pennsylvania,  etc.  Philadelphia  :  F. 
u  Davis,  1890.  Pp.  228. 


A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  By  J.  Lewis 
Smith,  M.  D.,  Clinical  Professor  of  Diseases  of  Children,  Bellevue  Hos¬ 
pital  Medical  College,  etc.  Seventh  Edition,  thoroughly  revised.  With 
Fifty-one  Illustrations.  Philadelphia:  Lea  Brothers  &  Co.,  1890.  Pp. 
xiv-33  to  900.  [Price,  $4.50.] 

Ointments  and  Oleates  especially  in  Diseases  of  the  Skin.  By  John 
V.  Shoemaker,  A.  M.,  M.  D.,  Professor  of  Materia  Medica,  Pharmacolo¬ 
gy,  Therapeutics,  and  Clinical  Medicine,  and  Clinical  Professor  of  Dis¬ 
eases  of  the  Skin  in  the  Medico-chirurgical  College  of  Philadelphia, 
etc.  Second  Edition,  revised  and  enlarged.  Philadelphia :  F  A  Davis' 
1890.  Pp.  ix-298. 

The  Medical  Student’s  Manual  of  Chemistry.  By  R.  A.  Witthaus 
A.  M.,  M.  D.,  Professor  of  Chemistry  and  Physics  in  the  University  of 
the  City  of  New  York,  etc.  Third  Edition.  New  York :  William  Wood 
&  Co.,  1890.  Pp.  xii-528. 

Bacteriological  Technology  for  Physicians.  With  Seventy-two  Fig¬ 
ures  in  the  Text.  By  Dr.  C.  J.  Salomonsen.  Authorized  Translation 
from  the  Second  Revised  Danish  Edition.  By  William  Trelease.  New 
York  :  William  Wood  &  Co.,  1890.  Pp.  162. 

Transactions  of  the  American  Surgical  Association.  Volume  the 
Eighth.  Edited  by  J.  Ewing  Mears,  M.  D.,  Recorder  of  the  Associa¬ 
tion. 

A  Digest  of  Current  Orders  and  Decisions,  with  Extracts  from 
Army  Regulations,  relating  to  the  Medical  Corps  of  the  U.  S.  Army, 
Compiled  under  Direction  of  the  Surgeon-General  by  Charles  R.  Green- 
leaf,  Major  and  Surgeon,  U.  S.  A.  Pp.  125. 

The  Treatment  of  Syphilis  of  the  Nervous  System.  (Read  before 
the  International  Medical  Congress  at  Berlin,  August,  1890.)  By  Julius 
Althaus,  M.  D.,  M.  R.  C.  P.  Lond.,  Senior  Physician  to  the  Hospital  for 
Epilepsy  and  Paralysis,  Regent’s  Park.  London  :  Longmans  Green  & 
Co.,  1890.  Pp.  35. 

Diagnosis  and  Operative  Treatment  of  Gunshot  Wounds  of  the 
Stomach  and  Intestines.  By  N.  Senn,  M.  D.,  Ph.  D.,  of  Milwaukee, 
Wis.  (Read  by  invitation  in  the  Surgical  Section  of  the  Tenth  Inter¬ 
national  Medical  Congress,  August  8,  1890.)  [Reprinted  from  the 
Journal  of  the  American  Medical  Association.] 

Transactions  of  the  Michigan  State  Medical  Society.  Twenty-fifth 
Annual  Meeting,  held  in  Grand  Rapids,  June  19  and  20,  1890. 

Transactions  of  the  Medical  Society  of  the  State  of  Pennsylvania, 
at  its  Fortieth  Annual  Session,  held  at  Pittsburgh,  1889-’90.  Volume 
XXI.  Published  by  the  Society. 

Transactions  of  the  Texas  State  Medical  Association.  Twenty-second 
Annual  Session,  held  at  Fort  Worth,  Texas,  April  22,  23  24  and  25 
1890. 

Index-Catalogue  of  the  Library  of  the  Surgeon-General’s  Office, 
United  States  Army.  Authors  and  Subjects.  Vol.  XI.  Phmdronus— 
Regent.  Pp.  1102. 

Acute  Myelitis  preceded  by  Acute  Optic  Neuritis.  By  J.  T.  Esk¬ 
ridge,  M.  D.,  Denver,  Col.  -  [Reprinted  from  the  Journal  of  Nervous 
and  Mental  Disease.] 

Comparison  between  Perineal  and  Suprapubic  Cystotomy,  with  Re¬ 
port  of  Cases.  By  A.  Vander  Veer,  M.  D.,  Albany.  [Reprinted  from 
the  Albany  Medical  Annals.] 

The  New  Treatment  of  Peritonitis.  By  Emory  Lamphear,  M.  D. 

Kansas  City,  Mo.  (Read  before  the  Grand  River  District  Medical  So¬ 
ciety.) 

Electricity  vs.  the  Knife  in  the  Treatment  of  Pelvic  Disease.  By 
W.  B.  Sprague,  M.  D.,  Detroit.  [Reprinted  from  the  Proceedings  of  the 
Michigan  State  Medical  Society.] 

Description  of  a  Series  of  Tests  for  the  Detection  and  Determina¬ 
tion  of  Subnormal  Color-Perception  (Color-Blindness),  designed  for 
Use  in  Railway  Service.  By  Charles  A.  Oliver,  M.  D„  of  Philadelphia. 

[Reprinted  from  the  Transactions  of  the  American  Ophthalmoloaical 
Society.] 

Medical  Education.  The  Address  in  Medicine,  Yale  University 
1890.  By  Francis  Delafield,  M.  D.,  LL.  D.,  New  York.  [Reprinted 
from  the  New  Englander  and  Yale  Review. ] 

Report  of  Carlos  F.  MacDonald,  M.  D.,  on  the  Execution  by  Electri¬ 
city  of  William  Kemmler,  alias  John  Hart.  Presented  to  the  Governor 
September  20,  1890. 


504 


MISCELLANY. 


[N.  Y.  Med.  Jouk. 


Medical  Communications  of  the  Massachusetts  Medical  Society. 
Vol.  XY,  No.  1,  1890. 

Eighth  Annual  Report  of  the  Provincial  Board  of  Health  of  On¬ 
tario,  being  for  the  Year  1889. 

A.  New  Method  of  Suture  in  Perineorrhaphy.  By  George  M.  Ede- 
bohls,  M.  D.  [Reprinted  from  the  American  Journal  of  Obstetrics  and 
Diseases  of  Women  and  Children .] 

Heredity-Criminality,  etc.,  vs.  Education.  By  Sophie  McClelland, 
of  New  York.  [Reprinted  from  the  Medico-legal  Journal .] 

Proceedings  of  the  National  Conferences  of  State  Boards  of  Health 
at  the  Seventh  Annual  Meeting,  held  at  Nashville,  Tenn.,  May  19  and 
20,  1890. 


JUtsrellattg. 


Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  October  24tli : 


CITIES. 

Week  ending — 

Estimated  popu¬ 
lation* 

Total  deaths  from 
all  causes. 

DEATHS 

FROM — 

x 

O) 

o 

5 

h 

4> 

► 

* 

JD 

X 

© 

r 

a 

'5 

'C 

x 

> 

X 

V 

*5 

> 

lx 

0 

> 

it 

to 

3 

<■© 

o. 

>- 

H 

8 

>• 

<22 

o 

*C 

it 

a 

W 

t- 

0! 

> 

<2 

<u 

g 

m 

c: 

"Z 

<v 

£ 

J3 

a. 

Q 

1 

2 

tt) 

•1-°' 
o  IF 
8 

£ 

New  York,  N.  Y . 

Oct.  18. 

1,646,098 

618 

14 

4 

15 

7 

6 

Chicago,  Ill . 

Oct.  1R 

1,100,000 

348 

99 

4 

15 

1 

3 

Philadelphia,  Pa . 

Oct.  11. 

1,0647277 

322 

10 

3 

14 

4 

Brooklyn,  N.  Y . 

Oct.  18. 

880,225 

342 

5 

7 

15 

10 

Baltimore,  Md . 

Oci.  18. 

500,343 

166 

10 

7 

4 

St.  Louis,  Mo  . 

Oct.  11. 

460,000 

144 

St.  Louis,  Mo . 

Oct.  18. 

460,000 

8 

o 

Boston,  Mass . 

Oct.  18. 

446,507 

177 

8 

4 

1 

Washington,  D.  C _ 

Oct.  14. 

250,000 

108 

7 

2 

i 

Milwaukee,  Wis . 

Oct.  8. 

220,000 

67 

6 

1 

New  Orleans,  La . 

Oct.  11. 

216,000 

124 

1 

4 

2 

Richmond,  Ya . 

Oct.  11. 

100,000 

54 

5 

Toledo,  Ohio . 

Oct.  17. 

82^652 

22 

2 

1 

i 

Nashville,  Tenn . 

Oct.  18. 

76,309 

26 

2 

Fall  River,  Mass . 

Oct,  18. 

75,000 

29 

1 

1 

Manchester,  N.  H _ 

Oct.  18. 

44.000 

Galveston,  Texas .... 

Oct.  3. 

40.000 

14 

1 

Binghamton,  N.  Y. .  . 

Oct.  18. 

35,000 

11 

1 

Portland,  Me . 

Oct.  18. 

33,810 

12 

Yonkers,  N.  Y . 

Oct.  3. 

31,969 

11 

Auburn,  N.  Y . 

Oct.  11. 

25,887 

22 

1 

Newton,  Mass . 

Oct.  18. 

24,375 

6 

1 

Newport,  R.  I . 

20,000 

San  Diego,  Cal . 

Oct.  11. 

16,000 

2 

Pensacola,  Fla . 

Oct.  11. 

15,000 

2 

Bromidia  in  the  Treatment  of  Tetanus. — In  the  Journal  of  the 
American  Medical  Association  for  July  19th  there  is  an  account,  by  Dr. 
Robert  Reyburn  and  Dr.  A.  W.  Tancil,  of  Washington,  of  a  case  of 
traumatic  tetanus,  ending  in  recovery,  in  which  bromidia  was  employed. 
The  clinical  history  was  furnished  by  Dr.  Tancil,  and  Dr.  Reyburn  added 
the  following  remarks  : 

The  case  is  a  typical  example  of  the  more  chronic  variety  of  trau¬ 
matic  tetanus,  and  is  interesting  because  it  illustrates  very  well  what  I 
believe  to  be  the  correct  method  of  treatment  of  such  cases.  The  reflex 
action  of  the  great  nervous  centers,  and  more  especially  the  spinal  cord, 
is  so  immensely  exaggerated  in  tetanus  that  the  slightest  noise,  the  ex¬ 
posing  the  patient  to  a  current  of  cold  air,  or  even  a  slight  movement 
of  the  patient,  may  develop  a  fatal  spasm  either  of  the  muscles  of 
respiration,  or  some  other  of  the  group  of  muscles  which  control 
functions  necessary  to  life.  Unfortunately,  I  have  had  so  much  of 
an  experience  in  this  disease  from  the  year  1862  to  the  present  time 
as  to  have  seen  every  variety  of  treatment  tried,  including  all  the 
narcotics  and  nerve  sedatives  of  the  Pharmacopoeia,  also  the  con¬ 
tinued  use  of  chloroform  and  ether  by  inhalation.  Anaesthetics,  how¬ 
ever,  while  they  for  a  time  do  seem  to  modify  and  control  the  spas¬ 
modic  contractions  of  the  muscles,  have  in  my  experience  never 
effected  a  cure.  The  only  treatment  that  I  have  found  to  be  rea¬ 
sonably  successful  is  with  morphine  given  in  large  doses  and  in  com¬ 
bination  with  bromide  of  potassium,  but  in  order  to  do  any  good 


with  the  remedy  it  must  be  given  in  double  or  triple  the  ordinary  doses 
and  continuously  ;  in  other  words,  you  must  keep  the  patient  in  a  con¬ 
dition  of  semi-narcotism  all  the  time  for  days  or  weeks  if  necessary. 
In  the  treatment  of  this  case  it  was  found  absolutely  necessary  to  dis¬ 
regard  the  ordinary  rules  of  dosage  and  to  give  with  a  liberal  hand  the 
bromidia  in  quantities  sufficiently  large  to  keep  the  muscles  relaxed. 
Several  times  during  the  early  stages  of  the  treatment  of  the  case  the 
attempt  was  made  to  diminish  the  doses  of  the  powerful  agents  used, 
but  the  aggravation  of  the  trismus  and  the  painful  and  powerful  con¬ 
tractions  of  the  muscles  of  the  abdomen  and  extremities  compelled  a 
return  to  the  larger  doses.  Patients  suffering  from  traumatic  tetanus, 
as  a  rule,  in  the  cases  I  have  seen,  die  from  violent  contractions  of  the 
respiratory  muscles,  which  stop  respiration,  and,  of  course,  they  die 
very  suddenly  and  unexpectedly.  Another  most  important  point  in 
the  management  of  these  cases  is  to  insist  upon  the  most  absolute  rest 
and  quiet.  The  patient  is  to  be  placed  in  the  darkest  and  most  secluded 
corner  of  the  house,  away  from  noise  and  secure  from  the  well-meant 
but  often  fatal  kindness  of  visitors  and  friends.  Many  a  case  has 
been  doing  well  when  the  excitement  of  a  strange  face  or  a  visit  from 
a  friend  may  bring  on  a  spasm  which  may  instantly  prove  fatal. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  ahvays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (2)  when  a  manuscript  is  sent  to  this  jour¬ 
nal ,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (. 2 )  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal ,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not ,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particidar  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor ,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NE \Vr  YORK  MEDICAL  JOURNAL,  November  8,  1890. 


futures  ani>  ftfcbrtsses. 


AN  ADDRESS  ON 
THE  PRESENT  POSITION  OF 
ANTISEPTIC  SURGERY* 

By  HENRY  O.  MARCY,  A.  M.,  M.  D.,  LL.  D., 

BOSTON. 

The  treatment  ot  operative  wounds  has  from  time  im¬ 
memorial  been  considered  a  subject  of  vital  importance  in 
the  healing  art.  In  evidence  that  there  is  nothing  new 
under  the  sun,  it  is  now  alleged  that  recent  researches  dem 
onstrate  that  the  early  Greeks  were  familiar  with,  and  for 
quite  a  period  at  least  taught  and  practiced,  what  we  con¬ 
sider  fundamental  in  modern  aseptic  wound  treatment. 

Upon  the  one  hand  the  philosophic  observer  holds  ever 
prominent  in  consideration  the,  so  to  speak,  x  factorage 
of  individual  type,  the  vital  resistant  power.  This  is  sub¬ 
ject  not  alone  to  modification  in  the  individual— as,  for  ex¬ 
ample,  by  age,  physical  vigor,  surroundings — but  is  also 
represented  by  family  type,  as  heredity,  which  is  easily 
broadened  out  in  general  consideration  to  climatic  influ 
ence,  race,  etc. 

On  the  other  hand,  we  have  actively  discussed  the  va¬ 
rious  changes  which  are  observed  to  go  on  in  wounds  under 
different  conditions  seemingly  with  little  profit  until  within 
the  present  generation.  There  still  remain  many  interest¬ 
ing  minor  questions  of  great  interest  and  importance  for 
consideration,  and  which  our  present  knowledge  still  affords 
an  inadequate  means  for  definite  solution.  The  ever-pres¬ 
ent  material  for  infection  and  the  reason  of  its  non-develop¬ 
ment  in  a  vei)  considerable  class  of  wounds  has  been  ac¬ 
cepted  by  many  as  sufficient  evidence  for  discarding  the 
conclusions  arrived  at  by  the  earlier  advocates  of  antiseptic 
surgery.  To  many  superficial  observers  it  seemed  to  be 
sufficiently  proved  that  the  entire  system  was  untrustworthy 
and  impracticable.  Scientific  data  were  certainly  wantino* 
to  answer  clearly  the  queries  which  arose,  although  in  gen 
eral  the  reply  was  made  that  the  vital  resistant  power  of 
the  individual  was  sufficient  to  prevent  the  growth  and  de¬ 
velopment  of  the  bacterial  infection.  Why,  when  the  seed 
was  vitalized  and  implanted  in  a  culture  medium  ample  to 
serve  as  food  and  retained  at  an  equable  temperature,  did  it 
not  develop?  Our  laboratory  experiments  threw  no  light 
upon  the  question,  for  here,  under  the  conditions  given,  re 
production  was  a  constant  factor.  In  wounds  that  were 
maintained  at  rest  with  careful  coaptation  of  the  parts  to 
prevent  the  accumulation  of  fluids,  where  the  tissues  them¬ 
selves  remained  comparatively  uninjured,  it  was  observed 
Jiat  a  rapid  proliferation  of  cell  character  ensued,  which 
went  on  undisturbed  to  the  complete  restoration  of  the 
larts.  This  in  many  instances  entirely  failed,  when  the 
iiirrounding  tissues  were  in  a  measure  devitalized  and  a 
floody  or  serous  exudation  had  taken  place. 

In  the  first  instance  Nature  did  not  furnish  the  condi- 


*  Read  at  the  meeting  of  the  Boston  Gynecological  Society,  October 

',  1890. 


tions  for  the  development  of  the  ferments  accidentally  in¬ 
troduced  into  the  wound,  while  in  the  second  the  develop¬ 
ing  medium  was  ample. 

The  query  arose  as  to  what  became  of  the  vitalized  or¬ 
ganism  which  failed  to  develop,  as  well  as  the  reason  of  the 
failure.  The  observations  of  Metschnikoff  upon  the  power 
of  the  leucocytes  to  surround  and  destroy,  so  to  speak,  to 
digest  the  bacteria  under  favorable  circumstances,  are  now 
generally  known.  These  observations  are  of  interest  as  a 
possible  explanation  of  this  hitherto  unknown  quantity  in 
the  problem,  the  so-called  vital  resisting  power  of  the  tissues 
which  may  vary  greatly  in  individuals.  Sir  Joseph  Lister 
very  properly  emphasized  this  fact  in  his  address  before  the 
late  International  Medical  Congress  held  in  Berlin.  Al¬ 
though  such  an  important  communication,  given  by  such  a 
master,  to  the  medical  profession,  under  the  auspices  of  the 
great  congress,  will  early  be  familiar  to  all,  I  have  reason 
for  briefly  referring  to  it  at  this  time.  After  giving  Metsch¬ 
nikoff  s  experiments,  which  demonstrate  that  the  spores  of 
anthrax  failed  to  germinate  in  the  tissues  of  the  green  frog, 
because  of  the  action  of  the  leucocytes,  Sir  Joseph  Lister 
refers  to  certain  of  his  own  studies  which  seemed  earlier  to 
teach  “  that  a  blood-clot  within  the  body  may  exert  a  power¬ 
ful  antibacteric  agency.”  How  this  took  place  had  remained 
hitherto  a  mystery.  It  is  certainly  demonstrated  that  in 
wounds  of  the  first  class  referred  to,  while  the  fluid  exuda¬ 
tion  is  minimized  and  the  leucocytes  are  abundant,  septic 
conditions  much  more  rarely  supervene,  and  the  important 
observations  of  Metschnikoff,  so  far  as  they  go,  offer  a 
plausible  solution  of  a  hitherto  unknown  resultant  condi¬ 
tion.  It  is  quite  too  early  to  draw  general  deductions  from 
our  present  premises  and  declare  that  in  this  the  entire  so¬ 
lution  is  found,  but  there  is  every  reason  to  believe  that 
this  is  an  important  discovery  of  a  power  which  the  organ¬ 
ism  brings  to  rescue  it  under  favorable  circumstances  from 
impending  danger.  The  practical  deduction  of  the  lesson 
is  that  we  seek  to  place  the  wound  in  such  a  condition  that 
the  phagocytes  of  Metschnikoff  may  be  made  the  active 
allies  of  the  surgeon.  All  this  helps  also  in  a  measure  to 
explain  the  successes  which  surgeons  have  obtained  by 
means  which  seemed  directly  opposite  in  their  methods  of 
wound  treatment. 

Let  us  interrogate  a  little  more  closely  Nature’s  pro¬ 
cesses,  which,  in  a  general  way,  are  well  known  to  us  all, 
and  ascertain,  if  we  may,  the  manner  of  repair  which  en¬ 
sues  in  the  minor  subcutaneous  injuries  of  every-day  life. 
Here  a  small  blood-clot,  located  in  almost  any  part  of  the 
body,  undergoes  with  considerable  rapidity  the  changes 
which  lead  indirectly  to  its  disappearance,  and  results  in  a 
complete  restoration  of  the  parts  to  their  normal  condition. 
We  find  tbe  borders  of  the  blood-clot  about  the  separated  tis- 
suesinvaded  by  leucocytes,  which  appropriate  for  their  own 
further  development  the  material  of  the  exudate  ;  little  by 
little,  minute  capillary  vessels  are  formed  in  the  line  of  these 
invading  cells,  and  the  process  of  clot-disappearance  and 
gianulation-tissue  development  go  on  pari  passu  until  the 
clot  has  disappeared  and  new  connective  tissue  restores  tbe 
part  to  its  former  condition.  A  small  blood-clot  in  the  line 


MARCY:  THE  PRESENT  POSITION  OF  ANTISEPTIC  SURGERY.  [N.  Y.  Med.  Jock., 


5u6 


of  a  clean-cut  wound,  when  aseptic,  does  not  materially  in¬ 
terfere  with  the  process  of  repair,  and  is  appropriated,  as 
in  the  first  instance,  by  the  leucocytes  or  germinating  tissue 
cells.  In  an  open  aseptic  wound,  the  granulation  tissue 
which  closes  it  germinates  in  a  similar  manner,  and  the 
surface,  which  has  the  appearance  of  a  clot,  readily  bleeds 
upon  injury,  owing  to  the  lesion  of  the  newly  formed  capil¬ 
laries. 

A  somewhat  similar  series  of  observations  of  equal  in¬ 
terest  and  importance  are  seen  to  ensue  about  the  ligature 
of  an  artery  in  continuity  when  the  surrounding  parts  are 
maintained  in  an  aseptic  or  healthy  condition.  Here  repair 
takes  place  by  the  host  of  little  workers  leading  up  their 
forces  in  different  directions.  The  blood-clots  in  the  ex¬ 
tremity  of  the  occluded  vessel  undergo  changes  not  un¬ 
like  those  already  referred  to  in  other  locations,  while  the 
leucocytes  speedily  surround  and  shut  in  the  material  used 
as  a  ligature,  forming  a  capsule.  At  an  early  period  this 
may  be  lifted  away  from  the  thread,  more  or  less  distinctly 
as  a  layer,  and  little  or  no  change  has  taken  place  in  the 
constricting  material,  although  this  may  differ  very  widely 
in  character. 

Even  when  applied  to  the  vessels  of  very  young  animals, 
after  a  considerable  period,  the  silk  ligature  is  compara¬ 
tively  unchanged.  Often  at  the  end  of  three  or  four  weeks 
it  may  be  found  intact,  although  firmly  shut  in  by  a  sheath 
of  new  connective-tissue  cells. 

When  the  tissues  are  held  at  rest,  the  same  general  con¬ 
dition  may  be  observed  if  silk  worm  gut  or  silver  wire  has 
been  used.  After  a  period  of  some  weeks  the  silk  ligature 
smav  have  completely  disappeared,  and  the  changes  which 
;bave  led  up  to  this  are  traced  in  an  invasion  of  leucocytes 
^between  the  strauds  and  fibers  of  the  silk,  slowly  separating 
them  and  causing  their  disintegration.  If  these  conditions 
are  interfered  with  in  a  mechanical  way,  this  process  seems 
to  be  held  in  abeyance. 

The  cell  changes  which  should  go  on  in  the  develop¬ 
ment  of  connective  tissue  fail,  and  then  the  little  army  of 
workmen  invade  the  surrounding  tissues,  and  the  processes, 
'eavlier  called  proliferating,  ensue,  and  the  constricting  ma¬ 
terial  is  thrown  off  as  a  foreign  body.  When  an  aseptic 
animal  ligature  has  been  used,  catgut  or  tendon,  and  the 
parts  about  maintained  in  a  healthy  state,  the  ligature  ma¬ 
terial  becomes  invaded  by  leucocytes,  which  utilize  it  for 
their  own  development,  causing  it,  little  by  little,  to  disap¬ 
pear.  So  marked ‘is  this  process  that  an  aseptic  animal 
suture,  introduced  into  various  parts  of  a  healthy  young 
animal,  may  for  a  considerable  period  be  traced  by  a  line  of 
newly  developed  connective  tissue,  although  not  a  single 
vestige  of  the  original  material  remains.  These  processes, 
which  I  have  described  at  some  length,  have  for  a  longtime 
been  recognized  in  a  general  way  and  accepted,  and  yet  we 
are  all  familiar,  almost  equally  so,  with  the  reverse  of  the 
picture,  where  any  considerable  colony  of  micrococci  de¬ 
velop  in  the  line  of  a  wound. 

Here  this  process  may  be  completely  local;  that  is  to 
say,  the  leucocytes  surround  and  shut  in  the  invading  army 
with  a  wall  of  living  granulation  cells  until,  little  by  little, 
it  is  forced  to  surrender,  and  a  localized  abscess  is  the  sum 


total  of  damage.  The  most  of  us,  however,  who  were  sur¬ 

geons  of  an  earlier  day  recall  the  too  common  and,  I  am 
sorry  to  admit,  even  at  present,  not  rare  experiences  in  the 
every-day  work  of  many — the  foul  suppurating  wounds  and 
general  systemic  poisoning.  In  such  wounds  the  feeble 
barriers  of  leucocytes,  thrown  up  against  an  invading  army, 
fail  to  protect  the  organization,  and  the  much-dreaded 
“  blood  poisoning  ”  supervenes. 

If  it  may  be  accepted,  in  a  general  way,  that  the  above 
descriptions  are  correct,  let  us  use  them  as  basic  and  funda¬ 
mental,  from  which  to  draw  further  conclusions.  If  we  find 
in  the  so  called  phagocytes  of  Metschnikoff  the  familiar  leu¬ 
cocytes  above  mentioned,  we  certainly  have,  in  a  very  con¬ 
siderable  measure,  an  explanation  of  the  vital  resisting  power 
of  the  individual  organism.  If,  under  favorable  circum¬ 
stances,  these  cannibalistic  little  workmen  not  alone  sur¬ 
round,  but  actually  eat  up  their  enemies,  we  have  the  best 
of  reasons  for  understanding  why  the  comparatively  few 
germs  in  the  atmosphere  of  a  healthy  locality  are  far  less 
dangerous  to  wounds  than  was  earlier  supposed.  Again, 

o 

too,  we  see  that  in  the  so-called  surgically  clean  wound— that 
is,  a  wound  where  great  care  is  taken  to  exclude  foreign 
material,  where  blood-clots  are  removed,  and  the  compara¬ 
tively  uninjured  clean-cut  surfaces  are  closely  approximated 
— the  reparative  processes  go  on  steadily,  and  rapid  recovery 
supervenes,  although  in  a  strict  scientific  sense  the  wound 
is  not  aseptic. 

In  wounds  where  the  surrounding  tissue  is  devitalized 
these  favorable  conditions  are  not  maintained,  and  here  the 
germination  of  bacteria  goes  on  much  as  seen  in  laboratory 
culture  experiments. 

I  am  constrained  to  believe  that  very  few  scientific  ob¬ 
servers  or  practical  surgeons  can  be  found  who  will  not  ad¬ 
mit  that  the  bacterial  infection  is  one  of  the  chief  factors  in 
the  problem.  This  seems  so  clearly  demonstrated  from  oft- 
repeated  and  critical  observation  that  it  may  be  accepted  as 
a  fundamental  scientific  truth.  The  greatly  varying  condi¬ 
tions  of  the  infecting  material,  as  well  as  that  of  the  gen¬ 
eral  organism,  make  possible  the  extremely  confusing  fac¬ 
torage,  often  kaleidoscopic  in  its  changing  forms,  of  the 
problem. 

It  is  quite  twenty  years  ago  since  a  good  fortune  en¬ 
abled  me  to  profit  from  Lister’s  personal  instructions, 
and  I  have  watched  with  a  never-failing  interest  the  various 
phases  of  the  discussion  of  the  subject  of  wound  treatment 
until  the  present.  Mr.  Lawson  Tait,  of  Birmingham,  dur¬ 
ing  all  these  vears  has  been  the  most  heterodox  of  unbe¬ 
lievers.  This  noted  surgeon,  most  intense  in  his  personal 
convictions,  has  abundantly  demonstrated  by  his  practical 
experience  that  wounds  treated  in  utter  disregard  of  what 
he  calls  Lister’s  theories  do  exceptionally  well.  He  is 
a  rapid  and  dexterous  operator,  observes  most  carefully  the 
conditions  and  surroundings  of  bis  patients  and  the  most 
scrupulous  cleanliness  of  the  operative  field,  and  maintains 
a  clean,  dry  wound  of  the  tissues  with  the  minimum  of  in¬ 
jury.  He  laughs  to  scorn  the  idea  of  bacterial  infection  in 
such  wounds,  since  he  maintains  that  these  conditions  ren¬ 
der  bacterial  development  impossible.  This  sturdy  knight 
sees  only  the  obverse  side  of  Sir  Joseph’s  golden  shield,  and 


Nov.  8,  1890. J 


MARGY:  THE  PRESENT  POSITION  OF  ANTISEPTIC  SURGERY. 


507 


with  vigorous  home  thrust,  in  a  recent  address,*  declares 
the  whole  basis  of  antiseptic  surgery  “  an  absolute  and  lu¬ 
dicrous  logical  error.”  To  show  that  Mr.  Tait  is  really,  not¬ 
withstanding  his  loud  outcry  to  the  contrary,  in  acceptance 
ot  what  [  consider  the  very  basis  of  aseptic  surgery,  I  quote 
the  following  from  the  above  address :  “  The  ordinary  ba¬ 
cilli  of  decomposition  will  not  attack,  at  least  will  not  pro¬ 
duce,  these  ordinary  phenomena  in  living  tissue,  but  they 
do  so  in  dead  tissue.  Inclose  some  dead  tissue  with  the 
necessary  germs  in  living  tissue,  and  you  get  a  disturbance 
very  fairly  proportionate  to  the  dose  given.  If  the  dose  is 
small,  or  the  tissue  not  very  favorable  for  decomposition, 
the  constitutional  disturbance  is  slight.  Thus  a  piece  of 
dead  beef  as  large  as  a  walnut  introduced  into  the  calf  of 
a  man’s  leg  would  speedily  excite  a  tremendous  disturb¬ 
ance,  but  a  piece  the  size  of  a  millet-seed  would  probably 
give  no  trouble.  An  ivory  peg  thrust  into  a  bone  rarely 
gives  trouble,  and  leaden  bullets  lie  quietly  even  in  the 
brain  for  years,  because,  though  such  tissue  is  dead,  it 
is  not  prone  to  decomposition.  Under  the  term  tissue  I 
include,  of  course,  blood-clot  and  serum.  Such  tissues, 
when  effused  subcutaneously,  may  be  either  maintained  in  a 
really  living  condition,  or  they  may  become  dead  ;  on  this 
most  important  question  we  really  have  no  knowledge,  but 
we  know  the  fact.  Whether  living  or  dead,  if  protected 
from  the  access  of  germs,  they  do  not  decompose.  The 
familiar  example  of  a  broad  ligament  haematocele  proves 
this  up  to  the  hilt.  Leave  it  alone,  and  the  chances  are 
fifty  to  one  that  it  will  slowly  disappear  without  giving- 
trouble.  Open  it  or  tap  it — that  is,  admit  the  ordinary 
germs  of  decomposition — and  you  will  secure  abundant  sup¬ 
puration  without  fail.  This  is  exactly  the  same  thing  as 
Lister’s  famous  clot  experiment,  which  Nature  herself  has 
been  showing  us  in  black  eyes  and  other  contusions  for 
centuries.  ...  If  Sir  Joseph  Lister  would  witness  the 
facts  of  the  case,  as  they  are  in  my  practice  daily,  he  will 
see  that  I  care  not  a  straw  for  injuring  the  peritonaeum  ; 
that  in  the  great  bulk  of  my  operations  it  is  already  so 
damaged  that  further  injury  is,  and  must  be,  a  matter  of 
utter  indifference,  and  the  only  fact  iu  his  whole  statement 
concerning  me  which  is  correct  is  that  I  wash  away  clots 
(pus,  serum,  and  a  great  deal  more)  to  avoid  the  risk  of 
sepsis  in  the  residuum.  This  is  precisely  what  I  have  been 
teaching  for  the  last  twelve  years.  Lister's  view  was : 
‘Keep  out  the  germ  matter  and  you  may  leave  blood-clots 
(and  other  matters)  to  take  care  of  themselves.’  My  view 
was  and  is  :  ‘  Get  out  all  decomposable  matter,  and  you  can 
let  the  germs  in  freely.’  Lister  has  now  come  round  to  my 
view,  so  where  is  Listerism  now?  As  I  said  a  few  months 
ago  at  the  debate  at  the  Medical  Society  of  London,  ‘it  is 
as  dead  as  Julius  Caesar,  after  a  short  life  of  twenty  years.’ 

.  .  .  There  are  two  factors  in  the  trouble,  and  it  can  be 
shown  conclusively  that  one,  the  germs,  are  wholly  incon¬ 
siderable  without  pabulum  on  which  to  feed,  while  the 
other,  the  pabulum,  is  sure  to  breed  trouble,  because  it  is 
practically  and  mechanically  impossible  to  keep  the  germs 
out;  they  exist  already  in  the  blood  and  elsewhere,  and  are 


*  British  Medical  Journal ,  September  27,  1890,  p.  728. 


ever  present,  according  to  the  best  authorities.  Finally 
Sir  Joseph  Lister  claims  the  drainage  of  the  peritonaeum 
as  an  antiseptic  measure.  It  is  not  many  months  since  we 
were  vigorously  told  by  an  eminent  authority  on  abdomi¬ 
nal  surgery  that  if  the  Listerian  precautions  were  properly 
carried  out,  drainage  was  wholly  unnecessary,  indeed  per 
nicious.  When  Kceberle  first  taught  me  drainage  in  1878, 
he  told  me  its  use  was  to  prevent  the  collection  and  reten¬ 
tion  of  material  capable  of  decomposition.  In  Chassaig- 
nac’s  writings  may  be  found  the  most  minute  and  detailed 
directions  for  the  same  purpose,  and  the  most  perfect  rea¬ 
soning  on  the  subject.  There  is  hardly  a  possible  point  in 
which  Chassaignac  does  not  meet  the  whole  requirements, 
save  in  abdominal  surgery,  which  was,  of  course,  not  then 
invented.  It  is  a  matter  of  ever-increasing  wonder  to  me 
how  Chassaignac’s  logical  common  sense  and  practical  pro¬ 
posals  have  been  neglected,  while  antisepsis  has  driven  the 
surgical  world  wild  with  a  wholly  misdirected  enthusiasm.” 

Returning  to  the  address  of  Sir  Joseph  Lister,  referred 
to  above,  after  discussing  the  various  methods  of  wound 
infection,  he  says:*  “In  general  surgery  the  direct  appli¬ 
cation  of  strong  antiseptic  solutions  is  not  attended  with  the 
same  disadvantages  as  in  operations  in  the  peritoneal  cavity. 
My  practice  for  some  time  past  has  been  to  wash  the  wound, 
after  securing  the  bleeding  points,  with  a  pretty  strong  solu¬ 
tion  of  corrosive  sublimate  (1  to  500),  and  irrigate  with  a 
weaker  solution  (1  to  4,000)  during  the  stitching,  and  l  have 
had  no  reason  to  complain  of  the  results.  And  yet  I  must 
confess  that  I  have  for  a  long  time  doubted  whether  either 
the  washing  or  the  irrigation  was  really  necessary.  .  .  . 
Since  we  abandoned  the  spray  three  years  ago,  we  have 
been  careful  to  compensate  for  its  absence,  not  only  by  anti¬ 
septic  washings  and  irrigation,  but  by  surrounding  the  seat 
of  operation  with  wide-spread  towels  wrung  out  of  an  anti¬ 
septic  solution.  For  the  spray,  though  useless  for  the  ob¬ 
ject  for  which  it  was  originally  designed,  had  its  value  as  a 
diffuse  and  perpetual  irrigator,  maintaining  purity  of  the 
surgeon’s  hands  and  their  vicinity  as  an  unconscious  care¬ 
taker.  But  if,  besides  the  spray,  we  give  up  all  washing 
and  irrigation  of  the  wound,  our  vigilance  must  be  re¬ 
doubled.  Yet  I  believe  that,  with  assistants  duly  impressed 
with  the  importance  of  their  duties,  the  task  would  prove 
by  no  means  difficult.  I  have  not  yet  ventured  to  make 
the  experiment  on  any  large  scale,  thougn  I  have  long  had 
it  in  contemplation.  It  is  a  serious  thing  to  experiment 
upon  the  lives  of  our  fellow-men,  but  I  believe  the  time  has 
now  arrived  when  it  may  be  tried.  And  if  it  should  suc¬ 
ceed,  then  perhaps  may  be  fulfilled  my  early  dream.  Judg¬ 
ing  from  the  analogy  of  subcutaneous  injuries,  I  hoped  that 
a  wound  made  under  antiseptic  precautions  might  be  forth¬ 
with  closed  completely,  with  the  line  of  union  perhaps 
sealed  hermetically  with  some  antiseptic  varnish,  and  bitter 
was  my  disappointment  at  finding  that  the  carbolic  acid 
used  as  our  antiseptic  agent  induced  by  its  irritation  such 
a  copious  effusion  of  bloody  serum  as  to  necessitate  an  open¬ 
ing  for  its  exit ;  hence  came  the  drainage  of  wounds.  But 
if  we  can  discard  the  application  of  an  antiseptic  to  the  cut 


*  British  Medical  Journal ,  August  16,  1890,  p.  378. 


DEL  AVAN:  MALIGNANT  DISEASE  OF  THE  LARYNX. 


[N.  Y.  Med.  Jottb., 


508 

surfaces,  using  sponges  wrung  out  of  a  liquid  that  is  aseptic 
but  unirritating,  such  as  the  1  to-10,000  solution  of  corro¬ 
sive  sublimate,  we  may  fairly  hope  that  the  original  ideal 
may  be  more  or  less  nearly  attained.  We  have  already 
made  of  late  considerable  approaches  toward  it.  Our 
wounds  being  no  longer  subjected  to  the  constant  irrigation 
of  the  spray,  and  carbolic  acid  having  given  place  to  the 
less  irritating  though  more  efficient  solutions  of  corrosive 
sublimate,  serous  discharge  is  much  less  than  formerly  and 
less  drainage  required.  In  many  small  wounds  where  we 
used  to  find  drainage  imperative  we  omit  it  altogether,  and 
in  those  of  larger  extent  we  have  greatly  reduced  it.  Thus, 
after  removing  the  mamma  and  clearing  out  the  axilla,  I 
now  use  one  short  tube  of  very  moderate  caliber,  where  I 
used  to  employ  four  of  various  dimensions.  But  it  would 
be  a  grand  thing  if  we  could  dispense  with  drainage  alto¬ 
gether,  without  applying  the  very  firm  elastic  compression 
adopted  by  some  surgeons,  which,  besides  involving  the 
risk  of  sloughing  of  parts  of  low  vital  power,  with  the 
chance  that  it  may,  after  all,  fail  in  its  object,  proves  often 
extremely  irksome  to  the  patient.” 

I  am  fully  aware  that  even  quotations  so  freely  made 
render  but  imperfectly  the  ideas  of  these  prominent  teach¬ 
ers,  although  the  general  thought  and  spirit  of  each  is 
fairly  represented.  It  has  recently  been  my  privilege  to 
see  something  of  Dr.  Bantock’s  work,  who  in  the  main  is 
an  advocate  of  the  general  thought  which  permeates  Mr. 
Tait’s  teaching.  There  can  be  no  question  but  that  he  ex¬ 
ercises  the  greatest  care  in  his  technique  as  an  aseptic 
operator,  although  he  emphasizes  his  disavowal  in  the  belief 
in  or  use  of  antiseptics  of  any  kind. 

The  unbiased  student  must  observe  in  the  recent  prog¬ 
ress  in  wound  treatment  a  fundamental  truth  based  upon 
the  repeated  observations  of  abundant  facts.  This  consists 
of  three  factors:  First,  the  condition  of  the  patient,  the  so- 
called  vital  resistant  power;  second,  the  bacterial  infection, 
the  seeding  of  the  field  ;  third,  the  condition  of  the  soil,  the 
pabulum  necessary  for  the  growth  of  the  direful  harvest. 
Upon  this  tripod  at  present  rests  the  scientific  basis  of  wound 
treatment.  There  are  many  workers  equally  earnest,  equally 
thoughtful.  It  is  better  they  should  make  their  observations 
as  independent  original  investigators.  Much  profit  comes 
from  the  resutsof  such  heroic  workers  as  Mr.  Tait,  Dr.  Ban- 
tock,  and  many  others  we  could  mention.  The  recent  teach¬ 
ings  of  those  who  advocate  the  so-called  dry  treatment  of 
wounds  convey  another  side  view  of  the  great  fundamental 
truth  of  much  value.  Here  primary  union  is  prompt  and 
there  is  little  effusion  which  seems  to  require  drainage.  It 
will  be  noted  that  Sir  Joseph  Lister  looks  forward  to  the 
possible  abandonment  of  drainage,  which  he  has  during 
the  last  three  years  greatly  lessened.  On  the  contrary,  Mr. 
Tait,  as  may  be  inferred  from  the  quotations,  elevates  drain¬ 
age  to  a  most  important  factor  of  wound  treatment,  and  at 
the  late  International  Medical  Congress  both  lie  and  Dr. 
Bantock  predicted  a  greatly  extended  use  of  the  drainage- 
tube.  They  disregard  the  bacterial  infection,  but  insist 
upon  the  withdrawal  of  all  material  which  could  aid  in  its 
possible  development. 

The  ideal  of  wound  treatment  is  surely  to  restore  the 


condition  of  the  parts  to  as  nearly  their  primal  state  as  is 
possible.  If  this  can  be  assuredly  aseptic,  then  there  is  no 
bacterium  to  remove;  if  surgically  clean,  with  accurate  co¬ 
aptation  of  the  sundered  parts,  then  there  is  no  material 
which  needs  removal,  nothing  to  drain.  If,  as  we  have 
seen,  the  leucocytes  go  promptly  to  work  under  such  favor¬ 
able  conditions,  the  first  series  of  the  repair  processes  takes 
place,  which  ends  in  a  prompt  and  speedy  restoration.  This 
should  be  effected  under  a  dressing  which  will  permit  of 
the  introduction  of  no  foreign  factorage.  To  this  end 
Lister  has  unweariedly  labored  for  nearly  a  quarter  of  a 
century.  The  various  antiseptic  dressings  now  so  generally 
employed  have  a  value  in  wounds  necessarily  drained, 
which  must  be  considered  open  to  a  possible  infection,  but 
in  a  wound  that  is  closed  without  drainage  they  are  unne¬ 
cessary,  expensive,  and  cumbersome.  Lister’s  ideal  pro¬ 
tective  varnish  is  found  in  the  closure  of  the  wound  with 
iodoform  collodion. 

My  last  five  years  of  experience  in  the  treatment  of 
hundreds  of  aseptic  wounds  of  every  variety,  closed  in  lay¬ 
ers  with  buried  tendon  sutures  and  treated  in  no  other  way 
than  by  a  protective  layer  of  collodion,  is  cited  in  ample 
proof.  Even  in  the  major  amputations  such  wounds  go  on 
to  a  speedy  repair  without  pain  or  oedema  of  the  surround¬ 
ing  parts.  Call  the  various  methods  adopted  to  secure  the 
end  obtained  by  whatever  name  you  will,  the  great  funda* 
mental  principles  of  antiseptic  surgery  as  enunciated  by  Sir 
Joseph  Lister  many  years  ago  rest  upon  a  sure  foundation, 
and  the  results  in  modern  wound  treatment  are  the  marvel 
of  our  age. 


#rtgmal  Commummttons. 


ON  THE  EARLY  DIAGNOSIS  OF 
MALIGNANT  DISEASE  OF  THE  LAKYNX.* 
By  D.  BRYSON  DELAY  AN,  M.  D., 

PROFESSOR  OF  LARYNGOLOGY  IN  THE  NEW  YORK  POLYCLINIC. 

The  early  diagnosis  of  malignant  disease,  in  general  by 
no  means  easy,  is  nouffiere  more  difficult  than  in  the  mucous 
membrane  and  on  the  glandular  structures  in  the  neighbor¬ 
hood  of  the  throat.  From  a  simple  inspection  of  the  sur¬ 
face  of  the  suspected  region  so  little  may  be  learned  that  it 
has  become  the  accepted  custom  to  withhold  judgment  in 
doubtful  cases  until  a  diagnosis  can  be  established  by  the 
aid  of  the  microscope,  or,  on  the  contrary,  excluded  through 
the  testimony  of  the  lungs,  or  upon  the  results  of  constitu¬ 
tional  treatment.  Thus  it  would  be  supposed  that  if  a 
thickening  or  ulceration  of  the  larynx  were  associated  with 
pulmonary  lesions  indicative  of  phthisis,  the  disease  of  the 
larynx  would  probably  be  tuberculous ;  that  a  localized 
tumefaction  and  congestion  of  the  pharynx  or  larynx  which 
seemed  to  yield  to  the  internal  administration  of  the  iodide 
of  potassium  would  probably  be  syphilitic;  and,  finally, 

*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


Nov.  8,  1890.] 


DEL  AVAN:  MALIGNANT  DISEASE  OF  TEE  LARYNX. 


509 


that  a  similar  lesion,  associated  with  well-marked  evidences 


of  specific  disease,  could  hardly  be  other  than  a  manifesta¬ 
tion  of  that  dyscrasia.  Accordingly,  we  are  taught  that 
cancer,  syphilis,  tuberculosis,  and  lupus  all  present  charac¬ 
teristics  wrhich  distinguish  them  to  the  eye,  and  that,  be¬ 
sides  the  visual  evidence  offered,  the  diagnosis  can  be  still 
further  sustained  by  the  corroborative  evidence  mentioned 
above. 

Unfortunately,  however,  none 'of  these  assumptions  are 
able  to  stand  the  test  of  experience.  Not  only  are  the  ob¬ 
jective  appearances  present  in  a  given  case  of  swelling  or 
ulceration  puzzling,  or  perhaps  contradictory,  but  even  the 
history  of  the  case  and  the  subjective  symptoms  are  some¬ 
times  obscure  and  misleading.  As  an  example  of  this,  a 
large  number  of  the  cases  in  which  the  microscope  has  re¬ 
vealed  tubercular  disease  of  the  tongue  have  been  operated 
upon  under  the  supposition  that  the  disease  was  malignant, 
and  the  diagnosis  only  established  upon  a  microscopical  ex¬ 
amination  of  that  organ  after  its  removal.  On  the  other 
hand,  obscure  cases,  in  which  the  characteristic  appearances 
of  tubercular  ulceration  have  been  present,  have  been 
promptly  healed  by  the  iodide  of  potassium.  Exceptional 
cases  of  the  nature  alluded  to  are  not  rare.  For  the  pur¬ 
pose  of  arranging  them  more  accurately  and  of  explaining 
them  more  fully,  the  following  classification  is  offered  : 

I.  Cancer  of  the  larynx  may  be  uncomplicated,  but  the 
diagnosis  obscured  by  the  absence  of  the  usual  signs  and 
symptoms.  On  the  other  hand,  conditions  other  than  can¬ 
cer  may  be  mistaken  for  that  disease. 

II.  Cancer  of  the  larynx  may  be  associated  with  or  mis¬ 
taken  for  tubercular  disease.  Conversely,  tubercular  dis¬ 
ease  may  closely  resemble  cancer. 

III.  Cancer  may  be  associated  with  or  simulate  specific 
disease.  On  the  other  hand,  syphilis  may  readily  be  mis¬ 
taken  for  cancer. 

Difficulty  of  diagnosis  in  laryngeal  cancer,  therefore, 
may  present  itself  in  two  general  classes  of  cases — namely, 
those  in  which  the  disease  exists  by  itself  and  uncompli¬ 
cated  with  other  conditions;  and,  secondly,  those  in  which 
the  recognition  of  its  presence  is  made  difficult  by  the  ex¬ 
istence  of  some  complicating  factor. 

These  conditions  have  all  occurred  in  the  writer’s  exper 
rience — some  rarely,  others  with  considerable  frequency — 
and  it  has  seemed  that  no  better  way  of  describing  them 
could  be  chosen  than  that  of  presenting  a  few  of  the  more 
instructive  cases  bearing  upon  the  less  common  varieties. 

Of  the  uncomplicated  cases  seen  by  the  writer  in  which 
the  diagnosis  was  obscure,  the  following,  observed  a  num¬ 
ber  of  years  ago  in  the  dead-house  of  the  New  York  Hos¬ 
pital,  is  the  most  interesting  and  unusual,  and  well  illus¬ 
trates  the  difficulty  of  diagnosis  sometimes  met  with  : 

Case  I. — Male,  aged  fifty-four,  married,  Italian.  Denied 
specific  disease.  Badly  nourished.  Principal  symptoms,  laryn¬ 
geal  cough,  aphonia,  and  occasional  dyspnoea.  Laryngoscopic 
examination  made  by  the  writer  revealed  apparent  paralysis  of 
the  right  side  of  the  larynx  with  moderate  thickening  of  the 
false  vocal  cord,  the  surface  of  the  mucous  membrane  of  which 
was  distinctly  smooth.  There  was  slight  loss  of  motion  of  the 
left  side  of  the  larynx,  abduction  not  being  completvly  accom¬ 


plished  and  marked  spasmodic  action  being  sometimes  observed. 
Tracheotomy  was  recommended,  but  the  patient  died  in  an  at¬ 
tack  of  dyspDoea  while  it  was  being  performed.  The  autopsy 
revealed  a  subglottic  enlargement  of  the  right  side  of  the  larynx, 
the  surface  of  which  was  nodular,  which  on  microscopic  ex¬ 
amination  proved  to  be  epitheliomatous,  and  which  was  com¬ 
pletely  overhung  by  the  right  vocal  band  and  concealed  by  it, 
so  that  its  demonstration  by  the  laryngoscope  was  impossible. 
There  was  no  ankylosis  of  the  aryteenoid  articulations. 

A  more  striking  case  than  the  preceding  is — 

Case  II. — Mrs.  G.,  married,  aged  thirty- five.  The  husband 
of  this  woman,  aged  forty,  developed  an  ulcerative  condition 
of  the  larynx,  which  presented  all  of  the  characteristic  appear¬ 
ances  of  epithelioma,  both  to  the  eye  and  under  the  microscope, 
and  which  followed  the  usual  course  of  that  disease,  and  finally 
destroyed  the  patient’s  life.  During  the  progress  of  the  disease 
in  the  husband  the  wife  also  became  affected  with  what  appeared 
to  be  precisely  the  same  condition.  Her  symptoms,  subjective 
and  objective,  were  so  similar  to  those  present  in  the  case  of 
the  husband  and  so  thoroughly  characteristic  of  epithelioma, 
that  it  was  impossible  to  offer  a  prognosis  more  favorable  in 
the  case  of  the  one  than  in  that  of  the  other.  With  both  it 
became  necessary  to  perform  tracheotomy.  The  effect  in  each 
case  was,  as  usual,  temporarily  to  retard  the  progress  of  the 
disease.  Subsequently  the  man  died.  The  woman,  in  whom 
the  disease  was  limited  to  the  right  side  of  the  larynx,  mean¬ 
while  fell  into  the  hands  of  the  late  Dr.  Elsberg,  who,  oper¬ 
ating  upon  her  at  repeated  sittings  through  the  tracheal  open¬ 
ing,  finally  succeeded  in  removing  the  offending  tissue.  The 
patient  recovered,  and  up  to  eight  years  afterward  was  often 
seen  by  the  writer,  in  excellent  general  condition  and  with  a 
larynx  in  which  there  existed  not  a  sign  of  active  disease, 
although  the  right  vocal  band  was  gone,  the  right  side  of 
the  larynx  immovably  fixed,  and  the  riina  glottidis  so  narrow 
that  the  use  of  the  tracheal  cannula  was  still  required.  The 
question  of  the  precise  nature  of  the  above  case  remains  unset¬ 
tled,  as  I  am  unable  to  learn  that  any  microscopical  examination 
of  it  was  ever  made.  Examined  side  by  side  with  the  husband 
during  the  active  stage,  it  was  impossible  to  believe  that  the  dis¬ 
ease  in  the  wife’s  case  was  not  malignant,  while  the  fact  of  its 
non-recurrence  is  strong  proof  of  the  improbability  of  its  having 
been  epithelioma. 

The  deceptive  character  of  growths  of  the  larynx  of 
the  papillomatous  class  has  become  almost  proverbial.  Not 
only  is  the  eye  at  fault  in  judging  of  many  of  them,  but 
even  the  microscope  may  sometimes  lead  us  into  error. 
This  latter  accident  can  hardly  be  misunderstood  by  any  ex¬ 
perienced  pathologist,  for  it  is  not  uncommon,  in  examining 
the  whole  thickness  of  a  tumor,  to  find  that  the  elements 
near  the  surface  differ  materially  from  those  of  the  deeper 
portions  of  the  growth.  It  would  be  supposed  that  the  ex¬ 
ternal  appearance  of  an  ordinary  papilloma  would  be  suffi¬ 
ciently  characteristic.  That  this  is  not  always  the  fact  is 
shown  by  the  following: 

Case  III. — A  man,  aged  sixty,  upon  one  side  of  whose  larynx 
appeared  three  small  papillomatous  gi’owths.  Thyreotomy  was 
performed  and  the  interior  of  the  larynx  presented  to  view. 
Thus  exposed  to  the  light  and  under  the  most  careful  inspec¬ 
tion,  it  still  was  impossible  to  detect  any  positive  appearance  of 
malignant  disease.  The  growths  having  been  removed,  micro¬ 
scopic  examination  easily  established  the  diagnosis  of  epitheli¬ 
oma.  The  disease  recurred  shortly  after  this,  and  a  highly  sue- 


510 


DELAY  AN:  MALIGNANT  DISEASE  OF  THE  LARYNX. 


[N.  Y.  Med.  Jour., 


cessful  extirpation  of  the  larynx,  performed  by  Professor  Will¬ 
iam  T.  Bull,  prolonged  the  patient’s  life  for  nearly  two  years. 

It  appears  not  uncommonly  that  epithelioma  of  the  lar¬ 
ynx  is  complicated  with  pulmonary  phthisis.  Indeed,  a  re¬ 
cent  writer  has  called  attention  to  the  possibility  of  the  de¬ 
pendence  of  the  malignant  disease  upon  the  other.  It  is 
easy  to  understand  that  with  the  existence  of  the  pulmo¬ 
nary  lesion  a  thickening  of  the  mucous  membrane  of  the  lar¬ 
ynx  not  sufficiently  well  marked  to  excite  the  suspicion  that 
it  was  malignant,  might  easily  be  mistaken  for  tubercular 
laryngitis,  as  is  well  illustrated  in  the  history  of — 

Case  IV. — John  B.,  Ireland,  aged  fifty,  married,  porter.  The 
patient  applied  for  treatment  at  the  College  of  Physicians  and 
Surgeons,  New  Tork,  October  15,  1882.  Had  always  enjoyed 
excellent  health;  was  not  aware  of  any  heredity;  had  been 
strictly  temperate  in  the  use  of  alcoholics,  and  regular  in  his 
habits  ;  was  a  moderate  smoker  ;  gave  no  evidence  whatever  of 
syphilis.  During  the  month  of  August,  1882,  while  employed 
as  gate-keeper  on  the  elevated  railroad,  first  noticed  a  slight 
hoarseness  of  voice.  This  increased  slowly,  and  soon  began  to 
be  attended  with  a  mild  laryngeal  cough.  Soon  afterward  be¬ 
gan  to  lose  strength,  appetite,  and  flesh. 

When  first  examined,  two  months  after  the  beginning  of 
these  symptoms,  the  patient  appeared  to  be  a  fairly  well-nour¬ 
ished  man,  of  medium  height  and  build,  light  complexion,  and 
good  intelligence. 

Laryngoscopic  examination,  made  with  some  difficulty  by 
reason  of  a  marked  hyperesthesia  of  the  pharynx,  revealed  a 
condition  which  differed  little  from  an  ordinary  chronic  laryn¬ 
gitis.  Both  vocal  bands  were  congested  and  thickened,  the  con¬ 
gestion  extending  throughout  the  whole -interior  of  the  larynx, 
but  being  most  pronounced  upon  the  left  false  cord,  which  was 
also  slightly  enlarged  and  prominent. 

Examination  of  the  chest  showed  physical  signs  of  phthisis, 
first  stage,  at  apices  of  both  lungs. 

By  the  middle  of  December  following,  the  above-mentioned 
enlargement  of  the  left  false  cord  had  progressed  decidedly,  and 
its  surface,  from  being  smooth  and  natural,  began  to  be  nodu¬ 
lated  and  uneven.  This  continued  to  such  an  extent  that  the 
presence  of  a  new  growth  in  the  larynx,  long  before  recognized 
and  for  some  weeks  suspected  to  be  of  a  malignant  type,  could 
no  longer  be  doubted.  From  this  time  it  developed  with  in¬ 
creasing  rapidity,  following  the  usual  course  of  epithelioma, 
which  it  was  proved  by  the  microscope  to  be,  and  finally  ending 
with  the  patient’s  death.  The  autopsy  showed  advanced  phthi¬ 
sis  in  both  lungs. 

Syphilis  may  readily  be  mistaken  for  malignant  disease, 
even  in  cases  where  the  appearances  are  in  the  main  pa¬ 
thognomonic.  This  accident  is  of  such  frequent  occurrence 
that  the  importance  of  a  tentative  course  of  specific  treat¬ 
ment  can  not  be  too  strongly  insisted  upon.  On  the  other 
hand,  malignant  disease  has  occasionally  been  mistaken  for 
syphilis,  an  error  by  no  means  difficult  to  make  in  view  of 
the  apparently  beneficial  influence  of  the  iodide  of  potassium 
early  in  the  course  of  its  administration  upon  the  former  con¬ 
dition.  Indeed,  it  is  a  matter  of  somewhat  common  oc¬ 
currence  for  the  first  effects  of  the  iodide  to  be  markedly 
salutary.  Y\  ithin  a  short  time,  as  a  rule,  the  deceptive  char¬ 
acter  of  this  improvement  becomes  evident,  and,  in  spite  of 
the  drug,  the  disease  makes  steady  progress.  Where  the  evi¬ 
dences  of  syphilis  are  actually  present  and  the  use  of  the 


iodide  is  followed  temporarily  by  good  results,  the  difficul¬ 
ties  in  the  way  of  an  early  diagnosis  of  cancer  are  particu¬ 
larly  great,  as  illustrated  in  the  following: 

s 

Case  Y. — J.  W.  B.,  aged  fifty-six,  consulted  me  for  neuralgic 
pain  in  the  right  lateral  wall  of  the  pharynx,  from  which  he 
had  lately  been  troubled.  He  stated  that  many  years  ago  he 
had  contracted  syphilis  and  had  suffered  severely  from  ulcera¬ 
tion  of  the  throat.  Had  been  somewhat  intemperate  and  had 
been  an  immoderate  smoker.  Examination  of  the  pharynx 
revealed  partial  destruction  of  the  soft  palate  and  numerous 
old  cicatricial  bands  upon  it  and  the  posterior  pharyngeal  wall, 
which  were  characteristic  of  former  specific  ulceration.  There 
was  slight  redness  of  the  tonsil,  which  extended  deeply  into  the 
pharynx,  but  absolutely  no  apparent  indication  of  thickening 
or  tumefaction.  Under  large  doses  of  the  iodide  of  potassium 
there  was  a  slight  but  transient  improvement.  The  pain,  how¬ 
ever,  soon  returned,  and,  although  markedly  improved  by  the 
local  application  of  astringents  and  particularly  of  nitrate  of 
silver,  never  entirely  disappeared.  A  change  in  the  character 
of  the  pain  began  to  take  place,  and  it  became  of  a  more  dis¬ 
tinctly  lancinating  character.  Suspecting  the  possibility  that 
the  case  was  malignant,  the  patient  was  seen  in  consultation  by 
one  of  the  best  diagnosticians  living,  who  promptly  and  posi¬ 
tively  pronounced  it  specific. 

The  redness  meanwhile  spread  below  the  tonsil  and  across 
the  base  of  the  tongue,  and  a  gradual  thickening  of  the  mucous 
membrane,  imperceptible  at  first  but  growing  more  and  more 
distinct,  began  to  take  place.  The  diagnosis  of  probable  epi¬ 
thelioma  was  .made,  but  it  was  a  long  while  before  the  appear¬ 
ances  were  such  that  it  could  be  confirmed.  Later  one  of  the 
cervical  glands  became  involved  and  ulceration  of  the  mucous 
membrane  adjacent  to  and  outside  of  the  larynx  took  place. 
The  disease  progressed,  and  death  in  the  usual  manner  resulted. 
The  points  of  special  interest  in  this  case  are  (1)  the  impossi¬ 
bility  of  early  diagnosis;  (2)  the  fact  that  the  disease  was  dif¬ 
fused  and  that  a  widespread  infiltration  had  existed  from  the 
outset;  (3)  that,  in  consequence,  at  no  time  in  its  history  could 
an  operation  have  been  performed  with  any  reasonable  pros¬ 
pect  of  relief. 

From  the  histories  quoted  above  and  in  the  light  of 
general  clinical  experience,  it  appears  that  numerous  varia¬ 
tions  in  the  typical  course  of  malignant  disease  of  the  lar¬ 
ynx  are  observed.  Even  the  most  marked  and  constant 
of  them  are  sometimes  wanting  during  the  earlier  stages 
of  the  difficulty  and  do  not  develop  until  the  latter  ha? 
made  considerable  progress.  Even  the  common  symptoms 
— aphonia,  cough,  dysphagia — may  at  first  be  wanting, 
while  the  appearance  of  the  growth  and  the  general  history 
of  the  case  are  often  misleading  throughout  the  earlier  stages 
and  do  not  reveal  the  true  character  of  the  disease  until  the 
case  has  become  helpless.  Again,  pain  of  lancinating  char¬ 
acter.  almost  invariably  present,  will  sometimes  not  appear 
early  in  the  history  of  laryngeal  epithelioma,  particularly, 
according  to  Mr.  Lennox  Browne,  where  the  growth  is 
intralaryngeal  and  unilateral. 

Swelling  of  the  cervical  glands  is  often  absent  in  the 
earlier  stages  and  may  be  of  such  late  occurrence  as  to  be 
useless  as  an  early  diagnostic  sign,  while  secretion  and 
well-defined  deformity  may  be  entirely  absent  for  a  consid¬ 
erable  length  of  time. 

In  view  of  these  things,  it  remains  to  us  to  study  the 
value  of  means  not  fully  recognized  and  accepted,  to  test 


Nov.  8,  1890.] 


PHELPS:  SOME  NEW  LATERAL-TRACTION  HIP  SPLINTS. 


the  worth  of  whatever  new  suggestions  may  be  made  in  this 

direction,  and  to  seek  to  discover  efficient  methods  hitherto 

untried. 

Of  the  first-mentioned  class  of  methods,  thyreotomv  is 
the  one  most  likely  to  challenge  attention.  By  means  of 
this  operation  the  larynx  may  he  opened  and  its  interior 
fully  exposed  to  view.  Even  under  conditions  thus  favora¬ 
ble  for  the  careful  and  accurate  examination  of  the  tumor 
it  is  not  always  possible  to  establish  the  diagnosis,  as  was 
seen  in  Case  IV,  unless  through  the  removal  of  the  growth 
and  its  examination  under  the  microscope,  a  somewhat 
severe  procedure. 

The  objections  to  thyreotomy,  therefore,  are  (l)  the  mag¬ 
nitude  of  the  operation,  and  (2)  the  possibility  of  finding^ 
benign  growth  after  all.  Three  other  and  less  radical  atds 
to  diagnosis  have  lately  been  advanced.  The  first  two  are 

based  upon  the  pathological  appearances  ;  the  third  is  me¬ 
chanical. 

1.  Thickening  of  the  mucous  membrane,  with  marked 
loss  of  motion  in  the  neighborhood  of  such  thickening,  im¬ 
plies  an  infiltration  of  the  muscles  which,  it  is  said,  is^ gen¬ 
erally  due  to  malignant  disease.  An  apparent  paralysis  of 
one  side  of  the  larynx,  associated  with  thickening  upon  the 
same  side,  should  always  call  for  extreme  caution  in  the 
matter  of  prognosis. 


511 


early  period,  the  point  aimed  at  by  this  article  is  to  dem¬ 
onstrate  that  they  may  be  postponed  until  the  disease  has 
passed  the  stage  in  which  it  may  be  regarded  as  possibly 

remediable,  and  thus  offer  no  real  aid  in  the  saving  of  the 
patient’s  life. 

The  presence  of  muscular  infiltration ;  the  occurrence  of 
a  reddened  areola  around  the  base  of  the  tumor,  if  indeed 
the  disease  present  itself  in  the  form  of  a  tumor  havino-  a 
base;  the  appearances  developed  by  the  use  of  transmitted 
lght— all  of  these,  although  uncertain  reliances,  do  add  in 
some  measure  to  our  scanty  resources,  and,  together  with 
the  general  history  of  the  case,  the  ordinarily  recognized 
symptoms,  objective,  subjective,  microscopical,  and  thera¬ 
peutical,  and,  finally,  with  the  training  of  the  judgment 
which  comes  to  the  experienced  observer  from  the  study  of 
many  examples,  enable  us  in  most  instances  to  determine 
tolerably  early  the  true  character  of  the  disease.  Neverthe- 
ess,  since  the  only  hope  of  saving  the  life  of  the  patient 
may  depend  upon  the  earliest  possible  performance  of  an 
operation,  it  is  evident  that  with  the  above-mentioned  diag¬ 
nostic  resources  we  are  still,  in  spite  of  recent  allegations, 
ar  behind  in  the  knowledge  necessary  to  the  successful 
radical  treatment  of  malignant  laryngeal  disease. 


2.  As  the  result  of  numerous  investigations  made  dur¬ 
ing  the  last  two  years,  it  is  held  by  many  that  of  new 
growths  of  the  larynx,  those  that  are  papillomatous  in  form 
and  the  bases  of  which  are  not  surrounded  by  a  zone  of 
inflammation  are  probably  benign,  while  those  which  are 
encircled  by  a  ring  of  reddened,  infiltrated  membrane  are 
almost  certain  to  be  malignant.  The  truth  of  this  assertion 
has  been  verified  in  several  instances  by  the  writer,  although, 
on  the  other  hand,  he  has  found  that  it  is  not  constant  and, 
therefore,  that  it  can  not  be  depended  upon. 

3.  Translumination  of  the  larynx,  first  suggested  by 
Voltohm,  has  been  studied  of  late  by  several  observers. 
While,  by  the  use  of  the  electric  light  applied  to  the  ex¬ 
terior  of  the  larynx,  the  writer  has  found  it  possible  to  gain 
tolerably  satisfactory  results  in  causing  the  light  to  pene¬ 
trate  the  walls  of  the  larynx,  it  would  hardly" be  possible 
by  this  method  to  recognize  the  presence  of  an  abnormal 
thickening  which  was  not  already  sufficiently  well  devel¬ 
oped  to  be  visible  to  the  eye  by  the  ordinary  intralaryn- 
geal  demonstration.  As  a  means  of  recognizing  the  pres¬ 
ence  of  a  new  growth  of  recent  origin  and  of  small  extent, 
this  method  is  at  present  of  doubtful  value.  For  the  pur¬ 
pose,  however,  of  demonstrating  the  relative  density  of  an 
enlargement  of  appreciable  size,  translumination  of  the 
larynx  is  a  method  of  considerable  importance;  and  even 
in  cases  of  the  class  first  mentioned  it  may  occasionally  be 
found  useful.  At  least  it  should  not  be  entirely  con¬ 
demned,  since  it  is  yet  in  its  infancy,  both  as  regards  the 
apparatus  used  and  as  to  the  skill  of  those  employing  it, 
and  it  may  in  the  future  be  so  perfected  as  to  become  of 
practical  importance. 

Thus,  in  conclusion,  it  will  be  seen  that  while,  in  cases 
of  laryngeal  cancer,  all  of  the  classical  symptoms  will  ulti¬ 
mately  appear,  and  that,  as  a  rule,  they  are  present  from  an 


SOME  NEW  LATERAL-TRACTION  HIP  SPLINTS.* 
By  A.  M.  PHELPS,  M.  D., 

NEW  YORK. 

In  presenting  these  splints  to  this  Section  it  is  neces¬ 
sary  for  me  to  state  briefly  the  object  of  the  splints  and 
the  principle  which  is  desired  to  be  carried  out.  They  are 
designed,  first,  so  far  as  possible,  to  absolutely  immobilize 
the  joint ;  secondly,  to  relieve  intra-articular  'pressure. 

I  am  convinced  that  these  two  are  the  first  principles 
to  be  followed  in  the  treatment  of  joint  disease.  Fixation 
and  rest  allow  the  processes  of  repair  to  take  place,  unin¬ 
terrupted  by  the  trauma  of  motion.  Traction  relieves  intra- 
articular  pressure  and  controls  muscular  spasm. 

Those  gentlemen  who  advocate  the  constant  moving  of 
joints  during  inflammation  argue  that  ankylosis  will  cer¬ 
tainly  follow  unless  motionfis  kept  up.  Thomas,  of  Liver¬ 
pool,  says  that  ankylosis  is  more  certain  to  follow  if  motion 
is  allowed,  and  that  an  inflamed  joint  is  not  so  likely  to 
become  ankylosed  if  absolutely  immobilized  ;  that  the  an¬ 
kylosis  which  follows  is  produced  by  the  severity  of  the 
inflammation  and  not  by  immobilization. 

Many  also  teach  that  healthy  joints  will  become  anky¬ 
losed  if  immobilized  for  any  considerable  period.  In  an¬ 
swer  to  them  I  will  say  that  I  have  immobilized  inflamed 
hip  joints  from  ten  months  to  a  year  and  a  half  without 
producing  ankylosis;  that  I  have  also  immobilized  healthy 
joints  in  animals  from  six  weeks  to  four  months  without 
producing  that  result.  (See  Transactions  of  the  Loomis 
Laboratory  for  1889.) 

It  seems  to  me  that  those  who  have  carefully  observed 


*  A  paper  read  before  the  Tenth  International  Congress  Berlin 
1890. 


PHELPS:  SOME  NEW  LATERAL-TRACTION  HIP  SPLINTS. 


[N.  Y.  Mbd.  Jour., 


512 

tubercular  inflammation  of  this  joint  or  its  appendages  will 
have  been  convinced  that  the  spasmodic  action  of  the  mus¬ 
cles  is  a  very  serious  element  in  producing  the  destructive 
changes  which  so  frequently  and  so  generally  follow  in 
joints  not  treated. 

Where  abnormal  intra-articular  pressure  is  present  there 
is  danger  of  destruction  of  the  head  of  the  bone  even  in  a 
healthy  joint,  as  was  illustrated  by  one  of  the  specimens 
here  referred  to.  The  hind  leg  of  the  dog  was  fixed  over 
his  back  with  plaster  of  Paris  in  a  cramped  position.  At 
the  end  of  six  weeks  he  was  killed  and  the  hip  joint  exam¬ 
ined.  The  head  of  the  bone  and  acetabulum  were  red  and 
congested,  and  the  cartilage  was  commencing  to  degen¬ 
erate.  The  knee  joint,  in  which  no  intra-articular  pressure 
was  made,  was  found  normal. 

To  the  gentlemen  who  argue  that  motion  should  be 
permitted  in  an  inflamed  joint,  I  will  say  that  they  seem  to 
forget  that  one  of  the  laws  of  surgery  is  that  where  a  part 
is  inflamed  it  should  be  put  at  rest,  whether  it  is  muscle  or 
joint  or  any  other  part  of  the  body  that  can  be  immobi¬ 
lized.  By  constantly  moving  the  joint,  the  delicate  new 
tissue  which  Nature  is  trying  to  produce  is  broken  up, 
which  may  lead  to  destruction  of  the  joint  either  by  ne¬ 
crosis  or  cicatricial  contraction  of  the  capsule. 

I  fully  agree  with  Sayre,  Taylor,  Barwell,  Marsh,  and 
others  that  spasm  of  the  muscle  should  be  overcome  by  ex¬ 
tension.  I  also  fully  agree  with  Thomas,  of  Liverpool,  that 
every  joint  should  be  fixed  and  absolutely  immobilized 
until  all  inflammatory  action  has  subsided  and  a  cure  is 
effected.  But  I  do  not  believe  that  immobilization  of  the 
joint  can  be  accomplished  without  extension  ;  neither  do  I 
ao-ree  with  the  first-named  gentleman  that  extension  immob¬ 
ilizes  a  joint  sufficiently  to  attain  the  best  results  possible, 
but  that  a  combination  of  the  principles  of  fixation  and  ex¬ 
tension  should  be  the  law.  Hence  the  long  traction  splint , 
which  admits  of  motion ,  does  not  immobilize,  and  the  patient 
produces  injury  of  the  joint  every  time  he  steps  upon  it,  as  is 
evidenced ,  in  the  vast  majority  of  cases,  by  the  almost  con¬ 
stant  increase  of  the  deformity  after  the  splint  is  adjusted. 
Neither  does  a  Thomas  splint  produce  extension  or  relieve 
intra-articular  pressure ;  hence  there  must  be  abnormal  in¬ 
tra-articular  pressure  when  spasm  or  contraction  of  muscles 
is  present,  which  must  produce  congestion  of  the  head  of 
the  bone.  And  then,  if  extension  is  to  be  applied,  it  should 
be  in  the  direction  opposite  to  the  line  of  traction  made  by 
the  muscles.  In  other  words,  to  apply  extension  to  a  hip 
joint,  we  should  not  only  make  traction  in  the  line  of  de¬ 
formity,  but  also  in  a  line  at  right  angles  to  that  deformity. 
To  relieve  perfectly  intra-articular  pressure,  extension  must 
be  made  in  a  line  corresponding  to  the  axis  of  the  neck, 
and  not  with  the  axis  of  the  shaft,  for  the  following  reasons: 
The  adductors  and  abductors  pass  diagonally  across  the 
body  from  the  pelvis  to  the  femur.  These,  with  other  mus¬ 
cles,  are  the  ones  affected  by  spasm.  When  they  contract, 
the  head  of  the  bone  is  firmly  drawn  into  the  acetabulum, 
the  force  operating  on  a  line  corresponding  to  the  axis  of 
the  neck.  The  flexors  act  on  a  line  corresponding  to  the 
axis  of  the  shaft  of  the  bone. 

Busch,  I  believe,  was  first  to  call  the  attention  of  the 


profession  to  this  fact.  In  1873  Albert,  of  Vienna,  again 
emphasized  it,  and  quoted  from  an  article  published  years 
before  by  Busch.  He  says,  quoting  from  Busch,  that  “  this 
is  a  second  clear  indication  that  distraction  has  a  beneficial 
effect.  But  this  purpose  has  not  been  reached  by  the  usual 
method  of  traction.  Busch  has  demonstrated  in  a  manner 
apparent  to  everybody  that  traction  ought  to  be  made  in 
the  axis  of  the  trochanter”  (or  neck).  He  further  adds 
that  Dumreicher  says  that  “  if  you  want  to  control  the 
pressure  it  is  necessary  to  make  traction  in  two  lines;  the 
muscles  which  pass  from  the  pelvis  to  the  femur  act  in  two 
directions.  The  one  draws  the  femur  toward  the  median 
line”  (adductors  and  abductors)  “and  the  other  flexes  it.” 
( Medizinische  Jahrbucher,  Strieker’s,  page  454,  1873.) 

When  I  published  my  article  setting  forth  these  prin¬ 
ciples  last  year  I  was  not  aware  of  the  fact  that  these  dis¬ 
tinguished  gentlemen  had  already  arrived  at  and  had  pub¬ 
lished  the  same  conclusions.  For  years  I  had  applied  the 
principle  of  double  extension  and  had  taught  it  to  the  va¬ 
rious  medical  classes  in  the  universities  where  I  had  had 
the  honor  of  teaching.  That  the  principle  is  correct  I  have 
no  doubt,  provided  it  is  admitted  that  traction  is  necessary 
in  the  treatment  of  hip-joint  inflammation.-.  And  I  am  as 
firmly  convinced  of  the  necessity  of  traction  .when  mus¬ 
cular  spasm  and  contraction  exist  as  I  am  of  the  only  sci¬ 
entific  method  of  applying  it — viz.,  in  a  line  parallel  to  the 
axis  of  the  neck  of  the  femur. 

Then,  believing  that  immobilization  and  extension  in 
proper  lines  are  the  law,  I  have  constructed  the  following 
splints : 


Fig.  1.  •  Fig.  2. 

To  fix  the  hip  joint,  a  splint  must  extend  from  the  foot 
to  the  axilla.  (See  Figs.  1  and  2.) 


Nov.  8,  1890.] 


PHELPS:  SOME  NEW  LATERAL-TRACTION  HIP  SPLINTS. 


Fur.  2  represents  the  perineal  crutch,  with  the  abduction 
bar  (1),  adjustable  by  means  of  the  key  (6),  for  the  pur¬ 
pose  of  making  lateral  extension.  The  steel  bar  (2)  is  ad 
justed  to  the  steel  ring  (3),  which  makes  a  firm  crutch,  the 

pressure  coming  on  the  tuber¬ 
osity  of  the  ischium.  Adhe¬ 
sive  straps,  extending  to  near 
the  body  from  the  ankle,  fur¬ 
nish  means  of  extension  by 
tightly  buckling  them  to  the 
straps  (7,  7),  the  ring  (3) 
furnishing  counter-extension. 
The  rod  (5),  ending  in  the  up¬ 
per  ring,  prevents  fiexion  and 
extension  of  the  legs.  The 
splint  is  intended  to  prevent 
every  motion  at  the  hip  joint, 
and  at  the  same  time  apply 
extension  in  a  line  with  the 
neck  of  the  femur.  Fig.  1 
shows  the  crutch  and  splint 
adjusted,  the  patient  using 
crutches,  and  standing  upon 
a  high  shoe  upon  the  well  leg. 

This  splint  I  found  a  little 
too  expensive  for  dispensary 
work.  I  then  constructed  the 


513 


Fig.  3. 


splint  (Fig.  3),  which  simply  does  away  with  the  extension 
joint  and  key.  This  was  also  too  expensive  for  hospital 
work,  but  both  splints  did  the  work  perfectly. 

After  a  time,  for  my  poor  patients  in  the  hospitals  and 
dispensaries,  1  succeeded  in  perfecting  a  cheap  splint,  which 
applies  the  principle  of  fixation  and  traction  in  the  line  of 
the  neck. 


Fig.  4. 


Fig.  5. 


A  glance  at  the  cut  will  convey  the  idea.  Fig.  4  is  the 
single  and  Fig.  5  the  double  splint  for  double  hip  disease. 


The  splint  is  a  bar  of  steel,  extending  from  the  foot  to  the 
axilla,  accurately  bent  to  fit  the  body.  A  tracing  made  on 
paper  by  laying  the  child  on  it  will  assist  in  shaping  the 
bar.  A  pelvic  belt,  a-thoracic  belt,  and  a  steel  perineal  ring 
complete  the  fixation  part  of  the  splint.  The  straps  in 
the  toot-piece  buckles  to  adhesive  straps  attached  to  the 
leg,  which  make  longitudinal  traction.  The  strap  lashes 
the  leg  to  the  splint,  making  lateral  traction  precisely  as 
the  abduction  bar  acts  in  Figs.  1  and  2. 

An  ordinary  blacksmith  can  construct  this  splint. 

Before  either  these  or  any  other  splint  is  adjusted, 
however,  the  patient  should  be  treated  in  bed  until  deformi¬ 
ty  is  overcome  and  the  active  stage  of  the  disease  some¬ 
what  modified. 

To  conclude,  ray  observations  lead  me  to  believe  that 
the  most  serious  element  of  destruction  in  hip-joint  disease 
is  the  trauma  and  pressure  produced  by  the  spasm  of  the 
muscle  ;  that  fixation  of  the  joint  without  extension  is  an 
impossibility;  that  the  successful  treatment  of  the  joint 
must  depend  upon  its  absolute  immobilization,  which  can 
only  be  produced  by  proper  extension  and  fixation  ;  that 
the  constitutional  treatment  of  hip-joint  disease  amounts 
to  but  little,  independent  of  mechanical  treatment ;  that 
mechanics  is  everything  ;  that  extension  in  a  line  with 
the  axis  of  the  shaft  and  deformity  alone ,  in  hip-joint  dis¬ 
ease,  is  entirely  wrong ;  that  extension  should  be  made  in 
a  line  parallel  to  the  axis  of  the  neck—  in  other  words,  two 
lines  of  extension  otherwise  the  idea  of  extension  is’  not 
perfectly  carried  out;  that  ankylosis  of  the  joint  is  not 
produced  by  immobilization,  but  by  the  severity  and  char¬ 
acter  of  the  inflammation  ;  that  the  long  traction  hip-splints 
m  general  use  neither  properly  extend  nor  immobilize 
the  joint;  that  the  intra-articular  pressure  results  in  the 
destruction  of  the  joint  or  ankylosis  in  a  large  percentage 
of  cases  is  proved  by  statistics;  that  the  results  in  hip-joint 
disease  should  be  as  good  as  those  of  knee-joint  disease,  and 
will  be,  provided  perfect  immobilization  can  be  carried  out ; 
that  patients  should  never  be  allowed  to  step  upon  any  porta¬ 
tive  apparatus ;  that  a  high  shoe  on  the  well  leg  and  crutches 
should  be  insisted  upon  until  the  patient  is  cured ;  finally, 
that  the  angular  deformity  seen  in  cured  cases  should  not  oc¬ 
cur,  and  such  cases  are  a  standing  rebuke  to  the  splint  and 
methods  employed.  In  other  words ,  no  patient  with  hip-joint 
disease  need  ever  recover  with  angular  deformity.  In  excep¬ 
tional  neglected  cases  of  dislocation  a  slight  amount  of  de¬ 
formity  had  better  be  left  than  resort  to  osteotomy. 

40  West  Thirty-fourth  Street. 


Against  Counter  Prescribing.  —  “  Some  of  the  physicians  of  St. 
Joseph,  Mo.,  have  inaugurated  a  war  on  counter  prescribing,  which 
they  claim  has  become  so  flagrant  as  to  necessitate  some  action  on  their 
part.  It  is  said  that  evidence  has  been  secured,  for  presentation  to  the 
grand  .jury  in  November,  implicating  a  number  of  druggists  and  drug 
clerks.  It  is  reported  that  the  testimony  in  one  instance  is  that  of  a 
young  man  who  suffered  from  syphilitic  disease,  and  made  a  contract 
with  a  druggist’s  clerk,  who  agreed  to  cure  him  in  four  months  in  con¬ 
sideration  of  the  sum  of  $6  per  month.  The  patient  is  still  under 
treatment..  The  law  iD  the  case  is  not  exactly  clear,  but  the  physicians 
interested  in  the  movement  believe  that  a  conviction  will  be  secured  for 
the  violation  of  the  medical  practice  law.”— Druggist's  Circular  and 
Chemical  Gazette. 


514 


DUNNING:  PELVIC  ABSCESS. 


[N.  Y.  Med.  Jmuk., 


PELVIC  ABSCESS. 

REPORT  OF  FIVE  CASES,  WITH  COM  MEETS. 

By  L.  II.  DUNNING,  M.  D., 

INDIANAPOLIS. 

The  following  history  of  cases  contains  some  points  of 
interest  which,  the  writer  thinks,  justifies  their  publica¬ 
tion  : 

Case  I.— Mrs.  II.,  white,  German,  aged  thirty-two  years, 
mother  of  three  children,  was  admitted  to  the  City  Hospital  in 
February,  1890.  She  was  said  to  be  suffering  of  inflammation 
of  the  bowels.  This  was  her  third  attack,  and  in  it  she  had 
been  very  sick.  She  was,  however,  better  on  admission. 

I  saw  her  a  few  days  after  admission.  She  had  so  far  recov¬ 
ered  as  to  be  able  to  sit  up  a  few  minutes  at  a  time.  She  com¬ 
plained  of  great  pain  through  the  abdomen  and  pelvis,  and  had 
a  temperature  ranging  fron  99°  to  101°.  Upon  examination, 
found  marked  tympanites,  yet  could  map  out  a  cystic  tumor 
with  lax  walls  and  rapid  wave  of  fluctuation.  The  uterus  was 
fixed,  vagina  hot,  and  tissues  very  tender.  Diagnosis — ovarian 
tumor  and  purulent  peritonitis  due  to  rupture  of  cyst  walls. 
Two  days  later,  after  careful  preparation  of  the  patient,  an  ab¬ 
dominal  section  was  made.  A  medium-sized  ovarian  tumor  on 
right  side  was  found  with  universal  adhesions.  It  was  tapped, 
but  not  removed.  A  small  tumor  of  the  left  ovary  was  re¬ 
moved.  While  lifting  up  this  tumor  the  walls  of  an  abscess 
were  ruptured,  and  probably  four  ounces  of  pus  poured  out 
into  the  pelvic  cavity.  Upon  examination  of  the  abscess  cavity, 
it  was  found  to  extend  well  down  into  the  pelvis  behind  the 
uterus.  In  consequence  of  the  alarming  condition  of  our  pa¬ 
tient,  we  were  obliged  to  hasten  through  the  operation.  The 
abdominal  and  pelvic  cavities  were  flushed  with  warm  sterilized 
water,  the  cystic  walls  stitched  to  the  incisioD,  a  drainage-tube 
inserted  into  the  cyst  cavity  and  another  one  left  in  the  ab¬ 
dominal  incision  and  reaching  down  into  the  pelvis,  and  finally 
the  incision  was  closed  with  deep  and  superficial  sutures. 
The  patient  survived  the  operation  thirty-six  hours.  A  post¬ 
mortem  examination  was  made,  and  evidences  of  both  old  and 
recent  peritonitis  were  found,  also  numerous  small  abscesses  in 
different  locations  in  the  abdominal  cavity. 

Case  II.— L.  D.,  colored,  aged  thirty-two  years,  was  under 
my  treatment  during  the  months  of  January,  February,  and 
March  of  the  present  year  for  fibroid  tumor  of  the  uterus. 
Apostoli’s  method  was  employed.  The  tumor  was  interstitial 
and  very  hard.  It  was  developed  more  on  the  right  side  than 
on  the  left,  and  lay  well  down  in  the  pelvis.  The  upper  border 
was  on  a  level  with  the  umbilicus.  The  menses  had  been  sup¬ 
pressed  five  months,  aud  the  patient  had  frequent  seizures  of 
hystero-epilepsy.  She  had  one  of  these  paroxysms  one  day 
while  upon  the  chair  taking  electricity,  and  furnished  a  fine 
clinical  study  for  a  number  of  students  who  were  present  wit¬ 
nessing  the  electrical  application.  In  consequence  of  the  sup¬ 
pressed  menstruation,  the  negative  pole  was  attached  to  the 
intra-uterine  electrode.  There  were  in  all  eleven  seances.  We 
began  with  thirty  milliamp^res,  and  gradually  worked  up  to  one 
hundred  and  fifty  milliamperes.  The  time  in  employing  the 
stronger  currents  was  five  minutes,  and  the  weaker  ones  seven 
to  ten  minutes.  Before  and  after  each  application  the  most 
strict  antiseptic  precautions  were  observed.  In  her  visit  to  the 
office  on  April  12th  the  patient  stated  she  had  had  a  large  dis¬ 
charge  of  matter  from  the  rectum  at  stool  each  day  for  ten 
days.  A  digital  examination  per  vaginam  was  made.  The  tu¬ 
mor  was  fixed,  the  tissues  around  the  uterus  hard,  hot,  and  very 
tender.  There  was  one  spot  in  the  vagina  at  the  right  of  the 
uterus  that  felt  slightly  boggy,  and  here  an  indistinct  sense  of 


fluctuation  could  be  elicited  by  combined  examination.  Noth¬ 
ing  further  could  be  learned  by  digital  examination  per  rectum. 
On  introducing  the  speculum  into  the  rectum,  quite  a  quantity 
of  yellow,  bad-smelling  pus  ran  out  and  formed  a  small  pool 
upon  the  chair.  We  concluded  that  the  electricity  had  induced 
suppuration  in  the  tumor,  that  the  pelvic  tissues  had  become 
inflamed,  and  finally  participated  in  the  suppurative  process. 

The  opening  of  the  abscess  into  the  rectum  was  not  found. 

Dr.  Cook  subsequently  examined  the  patient  and  confirmed 
our  diagnosis,  but  failed  to  find  the  opening.  The  treatment 
consisted  of  tonic,  nutritious  diet,  and  copious  injections  of  hot 
water  into  the  rectum  three  times  a  day.  When  six  weeks  had 
elapsed,  the  discharge  of  pus  had  ceased,  the  tumor  was  dimin¬ 
ished  to  less  than  half  its  former  size,  and  the  evidence  of  cellu¬ 
litis  nearly  disappeared.  At  present  the  patient  is  feeling  well, 
is  menstruating  regularly,  and  has  had  no  convulsive  seizures 
since  April. 

Case  III.— Mrs.  B.,  a  domestic,  colored,  aged  twenty-eight 
years,  was  admitted  to  the  City  Hospital  on  January  2,  1890. 
She  gave  the  following  history :  She  had  been  confined  three 
years  previously,  and  had  had  gonorrhoea  a  year  later.  During 
the  last  two  years  menstruation  had  been  painful  and  scanty. 
At  the  time  of  admission,  menstruation  was  exceedingly  pain¬ 
ful,  there  was  a  mere  show,  and  she  had  epileptic  seizures  at 
each  epoch.  There  was  marked  pain  in  the  pelvic  region,  and 
considerable  tenderness  upon  pressure.  The  temperature  ranged 
from  99°  to  100°  F.  The  patient  walked  with  considerable  diffi¬ 
culty  and  always  with  the  trunk  bent  forward. 

Upon  examination,  laceration  of  the  cervix  and  cervical 
endometritis  were  found.  The  right  ovary  was  found  in  the 
cul-de-sac,  and  an  obloDg  mass  above  it  extending  toward  the 
uterus.  Both  were  exquisitely  tender  to  the  touch.  The  left 
ovary  could  not  be  felt,  but  a  sausage-like  mass  was  mapped 
out  upon  this  side  upon  a  level  with  the  body  of  the  uterus. 
This  was  thought  to  be  a  pyosalpinx,  and  a  like  condition  be¬ 
lieved  to  be  present  upon  the  right  side.  An  operation  for  their 
removal  was  advised  and  accepted.  Ihe  patient  was  carefully 
prepared,  and  on  January  12th  a  laparotomy  was  done  in  the 
usual  manner.  The  tubes  and  ovaries  were  found  adherent,  but 
were  lifted  up  and  removed.  Both  tubes  were  distended  by  pus. 
The  left  one  ruptured  in  handling,  so  tense  and  thin  were  its 
walls.  The  thinnest  portion  of  the  tube  lay  against  and  was 
adherent  to  the  layer  of  the  broad  ligament  near  the  upper  bor¬ 
der.  The  patient  made  an  uninterrupted  recovery,  having, 
however,  several  epileptic  seizures  during  the  three  weeks  im¬ 
mediately  following  the  operation.  She  was  discharged  from 
the  hospital  in  six  weeks  in  a  very  goo'd  condition  of  general 
health.  I  saw  her  three  months  later,  when  she  stated  that  she 
had  had  no  convulsions  since  she  left  the  hospital,  and  that  she 
was  able  to  attend  to  her  work  as  a  domestic. 

Case  IV. — Miss  A.  B.,  aged  twenty-six,  was  admitted  to  the 
hospital  August  19,  1890.  A  few  days  previously  she  had  ex¬ 
pelled  a  two-months-and-a-half  embryo  with  membranes  intact. 
Eight  days  later  a  second  embryo  was  expelled  inclosed  in  the 
membranes.  For  two  or  three  days  all  seemed  to  go  well  with 
the  patient,  except  that  she  had  a  slight  abnormal  temperature. 
On  August  29th,  three  days  after  the  expulsion  of  the  last  em¬ 
bryo,  the  temperature  rose  to  UffvS0  F.,  and  the  pulse  was  135  per 
minute.  The  uterus  was  mopped  out  and  irrigated.  Irrigations 
were  frequently  used.  Quinine,  whisky,  and  antipyretics  were 
given.  Under  this  treatment  the  patient’s  general  condition  im¬ 
proved  somewhat.  The  temperature  ranged  from  101°  to  103°  F. 
till  September  1st.  Upon  that  day  she  came  under  my  obser¬ 
vation  and  treatment.  A  physical  examination  revealed  the 
following  facts — viz. :  there  was  slight  tympanites  with  consid¬ 
erable  tenderness  upon  pressure  in  the  vaginal  regions,  more 


Nov.  8,  1890.J 


DUNNING:  PELVIC  ABSCESS. 


51 5 


marked  upon  the  right  side.  There  were  secondary  syphilitic 
sores  upon  the  labia.  The  vagina  was  hot  and  the  tissues  were 
very  much  swollen  upon  the  right  side,  where  there  was  also 
bulging  of  the  anterior  and  lateral  walls.  The  most  prominent 
point  of  bulging  was  on  a  level  with  the  cervix  and  to  the  right. 
Here  fluctuation  was  detected.  With  the  assistance  of  Dr.  Oli¬ 
ver  and  Dr.  Wright,  aspiration  was  done.  A  large-sized  trocar 
needle  was  carried  into  the  tissues  at  the  point  of  fluctuation 
an  inch  and  a  half.  A  small  amount  of  bloody  serum  was  with¬ 
drawn,  and  two  or  three  drops  of  pus  followed  the  withdrawal 
of  the  trocar.  A  hot  bichloride  douche  was  given  and  the  pa¬ 
tient  put  to  bed.  The  next  morning  the  temperature  had  fallen 
to  99-4°  and  there  was  a  slight  discharge  of  pus  into  the  vagina 
The  following  day  a  digital  examination  was  made  and  a  large 
opening  found  at  the  point  of  puncture  admitting  the  tip  of  the 
finger.  Through  this  opening  pus  was  discharging  freely.  From 
this  date,  September  3d,  the  patient  rapidly  improved,  and  on 
September  25th  was  walking  about  the  wards.  There  is  still 
slight  discharge  of  pus  and  some  thickening  and  tenderness  of 
the  pelvic  tissues  upon  the  right  side.  After  the  opening  of  the 
abscess  the  treatment  was  limited  to  tonics  and  stimulants  and 
vaginal  irrigations  of  bichloride  solution  (1  to  3,000). 

Case  Y. — Mrs.  P.,  aged  forty  seven  years,  a  small,  delicate, 
refined  lady,  has  been  an  invalid  three  or  four  years.  About 
two  years  ago  Dr.  Harvey  informed  her  that  she  had  a  uterine 
fibroid.  Menstruation  is  too  frequent,  is  excessive  and  painful. 
There  is  a  profuse  discharge  in  the  interval  between  the  men¬ 
strual  periods.  Tnis  discharge  is  sometimes  pus  and  sometimes 
muco-pus. 

Upon  physical  examination,  the  uterus  was  found  much  en 
larged,  and  an  interstitial  fibroid  in  the  right  side  of  the  body 
of  the  organ.  Extending  to  the  left  and  posterior  to  the  uterus 
was  an  oblong  mass  I  estimated  to  be  two  inches  long  and  an 
inch  thick.  This  mass  was  soft  and  boggy  and  the  uterine  end 
began  near  the  left  corner.  This  I  pronounced  a  pyosalpinx. 
Laparotomy  was  advised,  but  the  patient  positively  refused  to 
submit  to  any  operative  procedure.  She  had  heard  of  the  bene¬ 
fit  of  electricity  in  cases  of  fibroid  tumors,  and  wanted  it  tried 
in  her  case.  I  explained  to  her  that  the  presence  of  pus  in  the 
pelvis  was  considered  a  contra-indication  to  the  use  of  electricity, 
but  that  some  operators  had  beneficial  results  in  treating  pyosal¬ 
pinx  with  electricity,  and  signified  my  willingness  to  use  electric 
ity  in  moderate  doses,  but  would  make  no  promises  as  to  result 
She  accepted  these  conditions,  and  on  February  1st  the  first  appli¬ 
cation  was  made,  a  current  of  twenty-five  milliamperes’  strength 
being  employed  five  minutes,  using  Martin’s  abdominal  electrode 
and  Apostoli’s  intra-uterine  electrode,  the  latter  being  connect 
ed  with  the  negative  pole  of  the  battery.  From  this  time  to 
April  15th  the  patient  had  twelve  applications  of  the  current, 
the  positive  pole  being  attached  to  the  intra-uterine  electrode 
every  time  after  the  first.  From  twenty-five  to  fifty  milliam- 
p£res  were  used  at  first;  once  the  strength  of  the  current  was 
sixty-five  milliamperes,  and  once,  on  account  of  the  milliampere- 
meter  failing  to  register,  about  one  hundred  and  twenty-five 
milliamperes  were  employed.  This  latter  application  caused  con¬ 
siderable  pain  and  produced  cauterization  of  the  tissues  of  the 
cervical  and  uterine  canal.  The  pain  lasted  but  a  few  hours,  and 
then  the  patient  was  for  several  days  easier  than  she  had  been 
for  a  long  time.  Following  this  strong  application,  weak  ones 
were  used  until  the  superficial  slough  separated  and  the  surface 
healed;  then  1  tried  a  stronger  current  (sixty-five  milliamperes), 
but  it  induced  so  much  pain  and  soreness  that  it  was  never  re¬ 
peated,  but  weaker  ones  were  employed.  On  April  15th  the 
patient  moved  away  from  the  city,  and  I  lost  sight  of  the  case 
until  September  8th.  The  electricity  had  the  effect  of  dimin¬ 
ishing  the  amount  of  flow  at  menstruation,  and  at  first  caused  a 


marked  diminution  in  the  size  of  the  tumor.  The  purulent  dis¬ 
charge  continued  about  the  same  as  when  first  seen. 

On  September  8th  Mrs.  P.  came  to  the  city  to  consult  me. 
She  stated  that  she  had  not  menstruated  for  ten  weeks,  that  her 
general  health  had  improved  somewhat,  but  that  she  still  suf¬ 
fered  considerable  pain,  and  that  the  discharge  of  pus  was  quite 
profuse.  By  combined  examination  the  uterus  was  found 
slightly  movable.  The  abdominal  walls  were  so  lax  and  the 
vagina  so  large  that  the  uterus  could  easily  be  grasped  by  the 
hands.  It  was  larger  than  normal  and  the  right  side  thicker, 
but  one  not  knowing  the  previous  history  would  hardly  have 
suspected  the  presence  of  a  myofibroma.  A  soft,  boggy,  oblong 
mass  extended  from  the  left  horn  of  the  uterus  outward  and 
slightly  downward  and  backward.  Thin  creamy  pus  was  seen 
oozing  from  the  os.  It  was  mopped  away,  and  in  a  few  minutes 
more  made  its  appearance.  The  cervix  and  os  looked  healthy, 
except  slightly  macerated.  The  pus  undoubtedly  proceeded 
from  the  left  tube.  Here  was  a  condition  of  affairs  entirely 
new  to  me — a  fibroid  tumor  undergoing  absorption,  atrophic 
metamorphosis  of  the  uterus  occurring,  while  a  pyosalpinx  was 
freely  discharging  into  the  uterine  cavity. 

Since  the  patient’s  condition  was  slowly  improving,  I  con¬ 
cluded  to  keep  hands  off  for  a  time,  but  explained  the  situation 
to  the  patient,  and  also  the  advisability  of  consulting  a  physician 
at  once  should  the  discharge  cease  suddenly,  pain  increase,  and 
illness  develop.  I  shall  watch  the  further  developments  j^i  this 
case  with  great  interest. 

Extended  comment  on  these  cases  is  unnecessary. 

In  Case  I  the  pelvic  abscess  was  coincident  with  ab¬ 
scesses  in  other  parts  of  the  pelvic  and  abdominal  cavity 
and  dependent  upon  the  same  cause — viz.,  peritonitis.  There 
was  no  involvement  of  the  tubes  or  ovaries  in  the  suppura¬ 
tive  process. 

Cases  IT  and  Y  are  interesting-  on  account  of  their  bear¬ 
ing  upon  the  much-discussed  question  of  the  effects  of  elec¬ 
tricity  in  diseases  of  the  ovaries,  tubes,  and  uterus.  The  sup¬ 
puration  in  Case  JI  was  not,  I  think,  due  to  septic  infection. 

The  current  had  a  caustic  effect  upon  the  endometrium, 
hut  the  canal  was  always  patulous,  and  every  precaution  we 
were  acquainted  with  was  used  to  prevent  infection.  The 
treatments  were  given  at  my  office,  but  the  patient  took  a 
ong  rest,  rode  home,  and  went  to  bed,  remaining  there  the 
remainder  of  the  day.  The  suppuration  must  have  taken 
place  slowly,  for  the  patient  was  around  the  house  continu¬ 
ally  and  insisted  that  she  was  gradually  improving.  Men¬ 
struation  occurred  once  before  the  rupture  of  the  abscess 
and  was  nearly  normal.  The  suppuration  must  have  been 
due  to  the  interpolar  action  of  the  current. 

Case  Y  tends  to  show  that  a  pyosalpinx  does  not  al¬ 
ways  contra-indicate  the  use  of  electricity.  How  great  an 
effect  the  current  had  in  effecting  a  diminution  of  the 
fibroid  tumor  I  am  unable  to  say.  The  apparent  effect  was 
to  considerably  lessen  the  size  of  the  morbid  growth.  There 
was  a  profuse  discharge  of  serum  after  each  application  of 
the  current,  so  that  it  may  have  acted  simply  in  the  way  of 
setting  up  a  drainage  of  the  tumor.  I  have  observed  in 
treating  fibroid  tumors  by  the  Apostoli  method  that  the  de¬ 
crease  in  the  size  of  the  tumor  was  greater  when  there  was 
a  copious  serous  discharge  following  each  application.  The 
amount  of  liquid  draining  away  from  one  of  these  tumors 
when  removed  by  hysterectomy  is  something  surprising  to 


one  witnessing  it  for  the  first  time. 


516 


SCOTT:  FRACTURE  OF  THE  PATELLA. 


[N.  Y.  Med.  Joor., 


Iu  the  application  of  the  electrical  currents  of  high  in¬ 
tensity,  if  the  negative  pole  be  attached  to  the  intra-uterine 
electrode,  the  transudation  of  serous  liquid  from  the  tumor 
into  the  uterine  cavity  will  begin  at  once  and  continue  for 
two  or  three  days,  and  there  will  be  usually  at  the  begin¬ 
ning  of  the  treatment  a  decrease  in  the  size  of  the  tumor  in 
some  degree  corresponding  to  the  amount  of  fluid  tran¬ 
suded.  This  I  believe  to  be  the  explanation  of  the  fact 
that  in  nearly  all  cases  in  which  this  method  is  adopted  the 
tumor  will  at  first  decrease  in  size,  but,  soon  or  late,  a  point 
is  reached  where  the  size  of  the  tumor  is  unaffected  by  the 
passage  of  the  current.  It  will  explain,  too,  another  fact: 
that  in  many  instances  very  soon  after  the  application  of 
electricity  is  discontinued  the  tumor  grows  rapidly  to  its 
former  dimensions.  We  can  not  find  here,  however,  an  ex¬ 
planation  of  all  the  interpolar  changes  induced  when  the 
electrical  current  is  passed  through  tissues,  for  Case  II 
shows  us  one  instance  in  which  suppuration  was  induced. 
Sometimes  the  growth  of  the  tumor  is  permanently  checked, 
and  occasionally  it  is  caused  to  disappear  entirely.  In  our 
case,  probably  the  changes  incident  to  the  menopause  led 
to  the  gradual  disappearance  of  the  tumor. 

Case  III  presents  one  point  worthy  of  comment.  The 
left  tlhe  was  closed  at  both  ends  and  distended  to  the  point 
of  bursting  the  thinnest  point;  the  one  ruptured  in  hand¬ 
ling  lay  against  and  was  adherent  to  the  posterior  layer  of 
the  broad  ligament.  In  a  brief  time  it  would  have  ruptured 
and  infectious  inflammation  of  the  broad  ligament  followed ; 
then  ulceration  through  the  posterior  layer  of  the  broad 
ligament  would  have  occurred.  Soon  would  have  followed 
the  pouring  of  pus  into  the  space  between  the  folds  of  the 
ligament  and  a  violent  inflammation  of  all  the  tissues  of 
that  structure,  and  finally  the  formation  of  a  large  abscess 
rupturing  into  the  vagina,  rectum,  or  pelvic  cavity. 

Here  is  certainly  indicated  one  of  the  ways  in  which 
pyosalpinx  may  lead  to  the  formation  of  large  abscesses 
and  to  general  infection  of  the  pelvic  and  abdominal 
cavities. 

- / 

A  CASE  OF 

COMPOUND  COMMINUTED  FRACTURE  OF  THE 
PATELLA  INTO  THE  KNEE  JOINT.* 

By  M.  T.  SOOTT,  M.  D., 

LEXINGTON,  KT. 

On  December  28,  1889,  I  was  summoned  four  miles  into  the 
country  to  see  VV.  0.  P.,  aged  thirty-seven,  who  gave  the  fol¬ 
lowing  history : 

Two  hours  previous  he  was  sitting  on  the  front  of  a  two- 
horse  wagon,  with  legs  flexed  at  right  angles  on  the  thighs. 
While  in  this  position  he  struck  the  off  horse  of  the  team  with 
a  whip;  the  animal  jumped  forward,  snapped  the  trace  chain, 
and  at  the  same  time  kicked  viciously.  The  horse  had  on  the 
previous  day  been  rough  shod,  the  calks  on  the  hind  shoes  being 
very  long  and  wedge-shaped.  The  calk  struck  the  patient  a 
quarter  of  an  inch  below  the  center  of  the  right  patella,  causing 
a  transverse  wound  half  an  inch  wide. 

The  use  of  an  aseptic  probe  revealed  a  puncture  of  the  pa¬ 


*  Read  before  the  Mississippi  Valley  Medical  Association  at  its  six¬ 
teenth  annual  meeting. 


tella  with  comminution,  together  with  a  transverse  fissure. 
Grasping  the  upper  half  with  the  fingers  of  one  hand  and  the 
lower  segment  with  the  fingers  of  the  other  hand,  a  distinct  but 
slight  crepitation  with  motion  was  detected.  There  was,  how¬ 
ever,  no  material  separation,  as  the  periosteum  was  but  slightly 
lacerated.  The  point  of  the  heel  of  the  shoe  had  penetrated  the 
knee  joint,  as  was  shown  by  the  passage  of  an  aseptic  probe 
three  inches  down  in  a  vertical  direction.  Pressure  over  the 
lateral  and  posterior  aspects  of  the  joint  forced  out  a  consider¬ 
able  amount  of  bloody  synovial  fluid  and  air  bubbles,  the  pres¬ 
ence  of  air  in  the  joint  being  due  to  the  patient’s  attempts  to 
walk  and  his  endeavors  to  estimate  the  amount  of  injury  im¬ 
mediately  after  its  infliction. 

Realizing  t^at  I  had  to  deal  with  a  compound,  comminuted 
fracture  of  the  patella,  complicated  by  an  open  wound  of  the 
knee  joint,  I  proceeded  to  treat  the  case  on  aseptic  principles. 
The  surrounding  tissues  were  thoroughly  cleansed.  The  ex¬ 
ternal  wound  was  enlarged  half  an  inch.  Small  detached  frag¬ 
ments  of  patella  were  removed  with  aseptic  instruments.  The 
joint  was  copiously  flushed  with  bichloride  solution,  1  to  3,000, 
until  the  fluid  came  away  clear.  No  drainage  was  used.  The 
external  wound  was  closed  with  catgut  and  dressed  with  iodo¬ 
form  and  bichloride  gauze.  A  long,  straight  posterior  splint 
was  applied  from  the  gluteal  fold  to  the  foot. 

Twenty-four  hours  after  the  operation  the  pulse  was  86  and 
the  temperature  99°.  The  recovery  was  rapid  and  uneventful. 
At  no  time  did  the  pulse  run  higher  than  92  or  the  temperature 
rise  above  99‘5°.  The  wound  healed  kindly  by  the  first  inten¬ 
tion  without  any  suppuration  whatever.  A  slight  effusion  into 
the  joint  was  noticed  at  the  first  dressing,  which  was  on  the 
eighth  day.  This  rapidly  subsided  and  gave  rise  to  no  trouble. 
On  the  twenty-fourth  day  the  splint  was  discarded  and  passive 
motion  commenced.  Seven  weeks  after  the  injury  the  patient 
reported  at  my  office,  walking  with  a  cane.  Extension  was  per¬ 
fect  and  active  flexion  existed  to  a  right  angle.  An  adherent 
scar  across  the  patella  and  a  depression  barely  perceptible  were 
the  only  sequelae  of  the  previous  injury.  Since  then  I  have 
examined  the  joint  and  find  all  motions  normal.  No  lameness. 

In  closing  the  report  of  this,  which  to  me  has  been  an 
interesting  case,  I  would  say  that  the  patient  was  far  from 
being  a  stout  man  and  one  in  whom  we  should  hope  to  see 
a  vigorous  display  of  that  beautiful  power  which  our  fore¬ 
fathers  were  pleased  to  style  the  vis  medicatrix  natures. 
He  was  a  sufferer  from  chronic  diarrhoea  with  prolapsus 
recti.  An  inability  to  empty  his  bladder  occasioned  a  con¬ 
stant  dribbling  of  urine,  which  necessitated  the  use  of  a 
urinal.  Chronic  cystitis,  the  cause  of  which  he  refused  to 
have  investigated,  occasioned  ammoniacal  urine,  alkaline 
and  foul  smelling,  which  did  not  aid  us  in  our  endeavors  to 
secure  cleanliness  and  an  aseptic  condition. 

The  Eyes  of  Eye  Surgeons. — “At  the  dinner  of  the  Ophthalmo- 
logical  Section  of  the  International  Medical  Congress  at  Berlin,  Professor 
Hermann  Cohn,  of  Breslau,  showed  a  collection  of  autographs  of  the 
oculists  who  had  taken  part  in  the  annual  meetings  at  Heidelberg  for 
twenty  years,  which  was  made  specially  interesting  by  the  fact  that 
opposite  each  name  the  signatory’s  visual  power  with  the  right  and  left 
eye  respectively  was  indicated.  Among  other  celebrities  who  figured 
in  this  list  were  Arlt,  Horner,  the  elder  Critchett,  Schweigger,  and 
Knapp.  Among  44  oculists  tested,  visual  acuity  was  normal  in  32, 
over  the  normal  in  10,  and  under  it  in  2.  Twenty-eight,  or  61  per  cent., 
were  short-sighted ;  the  concave  glasses  required  varied  between  Nos. 
5  and  24,  the  average  being  20,  so  that  the  myopia  of  the  distinguished 
ophthalmologists  in  question  was,  as  a  rule,  moderate  in  degree.” — Brit¬ 
ish  Medical  Journal. 


leading  articles. 


Nov.  8,  1890. J 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co. _ Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  NOVEMBER  8,  1890. 


PASTEURISM  BEFORE  THE  ACADEMY. 

It  was  really  Pasteur’s  system  of  preventive  inoculation 
that  was  under  discussion  at  the  New  York  Academy  of  Medi¬ 
cine  on  the  evening  of  October  16th,  although  various  aspects 
of  the  subject  of  rabies  were  made  the  theme  of  remarks,  even 
the  question  of  the  existence  of  that  disease.  The  few  who 
have  always  maintained  that  there  was  no  ground  for  regard¬ 
ing  rabies  as  a  disease  sui  generis  seem  to  have  been  re-enforced 
to  a  certain  extent  b^  the  carpers  who  assert  that  no  such 
number  of  cases  as  recent  reports  have  enumerated  can  possi¬ 
bly  have  occurred.  The  two  classes  together  have  been  able 
to  keep  up  enough  opposition  to  the  beneficent  practice  of 
antirabietic  inoculation  to  breed  some  distrust  of  it  among  the 
public,  and  even  to  influence  professional  opinion  against  it  in 
a  measure,  as  is  exemplified  by  the  fact  that  many  well-known 
medical  journals  have  shown  an  inclination  to  discredit  it. 
But  what  is  there  for  the  cavilers  to  stand  on?  To  say  that 
there  is  no  such  disease  as  rabies  argues,  to  our  mind,  the  pos¬ 
session  of  a  child-like  simplicity  worthy  of  the  votaries  of 
“Christian  science,”  or  of  those  wiseacres  who  are  fond  of 
repeating,  whenever  dread  of  any  epidemic  disease  is  ex¬ 
pressed,  the  vulgar  dictum  that  a  person  is  safe  enough  from 
pestilence  if  he  is  not  afraid  of  it,  ignoring  the  mortality 
caused  by  it  among  infants,  who  of  course  have  no  dread  of 
disease.  Little  more  worthy  of  consideration  is  the  criticism 
that  the  number  of  cases  of  rabies  reported  since  Pasteurism 
came  into  vogue  is  ridiculously  out  of  proportion  to  the  num¬ 
bers  reported  in  previous  times.  From  no  point  of  view  could 
this  objection  be  held  to  be  cogent,  for  it  does  not  touch  the 
real  question,  but  at  most  could  only  operate  to  discredit  the 
reporters’  accuracy.  Perhaps  rabies  has  been  unusually  preva¬ 
lent  in  France  during  the  past  few  years,  but,  if  it  has  not,  the 
great  popular  interest  in  it  that  has  been  brought  about  by  the 
adoption  of  Pasteur’s  system  may  well  have  given  rise  to  in¬ 
creased  diligence  in  discovering  and  reporting  the  cases.  We 
can  not  admit  that  the  cases  reported  are  so  numerous  as  to 
preclude  their  being  accounted  for  in  this  way.  But,  allowing 
that  the  figures  are  exaggerated,  the  admission  proves  only 
either  that  Pasteurism  has  not  saved  quite  so  many  lives  as  the 
reports  show,  or  else  that  the  figures  have  been  falsified  pur¬ 
posely  or  ignorantly,  and  therefore  that  their  promulgators  are 
open  to  the  verdict  falsus  in  uno ,  falsus  in  omne.  This  last  is 
probably  what  is  sought  to  be  implied,  but  the  implication  may 
well  be  disregarded  by  Pasteur  and  his  associates.  The  results 
of  their  inoculations  are  in  no  wise  influenced  by  the  degree  of 
their  accuracy  or  honesty  in  collecting  statistics.  The  plain 
fact  remains  that  hundreds  of  persons  bitten  by  animals  un- 


517 

questionably  rabid  have  escaped  the  disease.  It  will  not  do  to 
say  that  only  a  certain  percentage  of  such  persons  are  infected, 
for  nothing  like  that  percentage  of  infection  has  obtained 
among  the  exposed  persons  on  whom  Pasteurism  has  been 
tried. 

Ibis  expresses  what  we  have  maintained  ever  since  the 
practice  was  begun,  but  its  opponents  have  been  persistent  and 
talkative,  and  we  confess  to  much  gratification  at  the  general 
drift  of  what  was  said  at  the  Academy’s  meeting.  In  particu¬ 
lar,  it  strikes  us  that  Dr.  Dana’s  paper  on  The  Reality  of  Rabies 
shows  such  a  spirit  of  fairness  and  such  close  reasoning  as  must 
go  far  to  silence  the  last  sputter  of  incredulity,  or  as  would,  at 
least,  if  men  were  influenced  more  by  reason  and  less  by  preju¬ 
dice  or  an  innate  propensity  to  oppose  whatever  is  new.  Un¬ 
fortunately,  doctrines  that  tend  to  overturn  established  dogmas 
and  practices  always  have  to  contend  against  very  much  the 
same  kind  and  degree  of  opposition,  but  they  invariably  be¬ 
come  established  on  a  basis  all  the  more  solid,  and  it  is  there¬ 
fore  not  a  matter  for  unmitigated  regret  that  Pasteurism  has 
had  to  encounter  the  same  obstacles. 


THE  NEW  YORK  STATE  MEDICAL  ASSOCIATION. 

It  is  now  seven  years  since  this  organization  was  started. 
It  owed  its  origin  to  an  irreconcilable  disagreement  between 
its  founders  and  their  fellow-members  of  the  Medical  Society 
of  the  State  of  New  York— a  disagreement  having  reference 
solely  to  ethical  declarations.  The  division  was  a  matter  of  re¬ 
gret  at  the  time,  and  certainly  it  entailed  upon  the  physicians 
of  the  State  a  weakening  of  their  influence  in  a  corporate  ca¬ 
pacity.  In  no  other  way,  however,  has  it  proved  injurious;  as 
regards  scientific  work,  it  has  been  in  a  high  degree  beneficial. 
Both  societies  have  constantly  issued  programmes  overflowing 
with  titles  of  important  contributions  by  men  high  in  the  es¬ 
teem  of  their  fellows.  There  is  no  enmity  between  them,  but 
only  a  wholesome  emulation.  The  State  is  large  and  populous, 
and  perhaps  it  is  best  that  it  should  have  two  medical  societies, 
for  meetings  much  larger  than  each  of  them  now  holds  would 
probably  prove  unwieldy.  This  would  breed  apathy,  and  stag¬ 
nation  would  be  in  danger  of  following. 

The  new  association  has  unquestionably  been  well  managed. 
We  have  always  held  that  it  had  a  great  advantage  in  tHe  fact 
that  it  held  all  its  meetings  in  New  York.  This  advantage  is 
now  supplemented  by  its  acquirement  of  permanent  quarters 
for  its  library  and  for  other  purposes.  There  is  something 
tangible  about  an  organization  occupying  a  building  of  its  own. 
Perhaps  another  advantage  is  to  be  found  in  its  district 
branches,  holding  meetings  at  various  times  during  the  year 
and  having  a  closer  connection  with  the  association  than  the 
county  societies  have  with  the  old  organization.  Moreover, 
the  pride  of  the  members  must  have  been  stimulated  by  the 
handsome  and  well-edited  annual  volumes  of  transactions  pub¬ 
lished  by  the  association.  It  will  be  seen  that  there  is  no 
dearth  of  conceivable  reasons  for  the  prosperity  and  creditable 
career  of  the  association,  the  existence  of  which,  whatever  the 


518 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Jour.’ 


real  reasons  may  have  been,  is  beyond  question.  The  meetings 
are  of  benefit  not  alone  to  the  members,  but  in  a  very  high  de¬ 
gree  to  the  profession  at  large  in  the  city,  many  of  whom  either 
attend  them  or  read  the  published  reports;  and  this  benefit  can 
hardly  fail  to  be  decidedly  enhanced  by  the  establishment  of  a 
permanent  home  for  the  association. 


MINOR  PARAGRAPHS. 

THE  SPECIFIC  PATHOLOGY  OF  CANCER. 

A  recent  number  of  the  Proceedings  of  the  Royal  Society 
contains  an  article  by  Dr.  0.  A.  Ballance  and  Dr.  S.  G.  Shat- 
tock  on  experimental  investigations  into  the  pathology  of  can¬ 
cer.  Their  object  was  to  find  out  if  any  special  micro-organ¬ 
isms  could  be  cultivated  from  malignant  tumors,  as  had  been 
done  from  tubercle  and  the  pathological  formations  of  certain 
other  infective  diseases.  The  experiments  were  made  with 
three  lipomata,  one  myxoma,  three  sarcomata,  and  about  thirty 
carcinomata.  I  he  results  obtained,  both  in  the  cultivation  and 
in  the  transplantation,  were  entirely  nil.  Notwithstanding 
such  results,  the  authors  did  not  think  the  evidence  from  anal¬ 
ogy  that  cancer  was  probably  micro-parasitic  in  origin  was  en¬ 
tirely  overthrown,  but  that  it  was  possible  that  the  micro¬ 
organism  of  cancer  did  not  belong  to  the  Protophyta ,  but  to 
the  Protozoa ,  in  which  case  the  difficulty  of  artificial  culture 
would  be  easily  explained;  and  the  enormous  rapidity  of  cell 
growth  in  cancer  might  be  thought  of  as  being  induced  by  a 
cancerous  rejuvenescence  setting  in  as  a  consequence  of  the 
conjugation  of  the  “parasite”  with  the  cell  of  the  normal  tis¬ 
sue.  The  authors  had  conducted  some  of  their  experiments 
wTith  human  blood-serum,  but  no  growth  had  occurred  under 
sterile  conditions,  either  when  the  serum  had  been  simply  in¬ 
oculated  or  when  a  piece  of  living  cancer  tissue  had  been  placed 
in  or  upon  it. 


MICROSCOPICAL  STUDIES  OF  THE  BRAIN. 

Dr.  0.  E.  Breevor,  in  the  Proceedings  of  the  Royal  Society, 
gives  the  results  of  some  investigations  on  the  course  of  the 
fibers  of  the  cingulum,  of  the  posterior  parts  of  the  corpus  cal¬ 
losum,  and  of  the  fornix  in  the  marmoset  monkey.  The  hori¬ 
zontal  part  of  the  cingulum  was  found  to  consist,  not  of  fibers 
extending  throughout  its  whole  length,  but  of  internuncial  fibers 
coursing  between  the  gyrus  fornicatus  and  the  centrum  ovale; 
the  anterior  part  connecting  the  olfactory  nerve  with  the  frontal 
region,  the  posterior  part  containing  internuncial  fibers  between 
the  hippocampi  and  the  inferior  surface  of  the  temporo-sphe- 
noidal  lobe.  Broca’s  conclusion,  that  the  cingulum  was  con¬ 
nected  with  the  hippocampal  lobule  and  its  contained  nucleus, 
was  not  confirmed  in  the  present  investigation.  The  superficial 
fibers  of  the  gyrus  fornicatus  were  found  to  be  a  separate  tract, 
and  not  part  of  the  cingulum.  N o  connection  between  the  fibers 
of  the  posterior  parts  of  the  corpus  callosum  and  those  of  the 
internal  capsule,  as  described  by  Hamilton,  could  be  found. 
I  he  median  part  was  traced  horizontally  backward  into  the 
septum  between  the  body  and  the  splenium  of  the  corpus  callo¬ 
sum,  but  was  not  found  to  join  the  cingulum,  as  had  been  de¬ 
scribed  by  Meynert. 


BONE-GRAFTING  FROM  THE  DOG. 

On  the  15th  of  October,  at  the  Post-graduate  Medical  School 
and  Hospital,  Dr.  A.  M.  Phelps  performed  at  his  clinic  the  op¬ 
eration  of  transplanting  a  large  section  of  the  fore  leg  of  a  dog 
into  the  tibia  of  a  patient  suffering  from  an  ununited  fracture 


with  bad  deformity.  The  patient  had  been  operated  on  twice, 
and  all  means  employed  had  failed.  A  medium-sized  dog  was 
selected  and  carefully  prepared  for  the  operation.  The  dog’s 
elbow  was  excised,  and  its  leg  amputated  so  as  to  leave  a  piece 
of  bone  long  enough  to  till  in  the  space  between  the  denuded 
ends  of  the  patient’s  tibia.  The  dog  was  then  lashed  to  the  pa¬ 
tient’s  leg  with  a  plaster-of-Paris  bandage,  and  the  bone  graft 
securely  wired  into  the  patient’s  tibia.  It  was  expected  that  by 
this  procedure  the  dog’s  brachial  artery  would  keep  up  the  nu¬ 
trition  of  the  transplanted  part  and  furnish  the  material  for  new 
bone,  which  the  patient  seemed  incapable  of  producing.  Dr. 
Phelps  will  soon  furnish  the  details  of  the  operation  for  publi¬ 
cation  in  the  Journal. 


THE  NEW  VOLUME  OF  THE  INDEX-CATALOGUE. 

Tiie  eleventh  volume  of  the  Index- Catalogue  of  the  Library 
of  the  Surgeon- General's  Office ,  United  States  Army,  has  just 
been  issued.  It  contains  the  fourth  addition  to  the  alphabeti¬ 
cal  list  of  abbreviations  of  titles  of  medical  periodicals,  and 
carries  the  vocabulary  from  Phaedronus’  to  Regent.  The  work, 
it  will  be  seen,  is  nearing  its  end.  When  its  publication  was 
begun  the  fear  was  entertained,  not  unnaturally,  that  one  man’s 
lifetime  would  hardly  sutfice  for  its  completion,  but  such  a 
foreboding  may  now  be  regarded  as  practically  dispelled ;  Dr. 
Billings  is  still  in  the  prime  of  life  and  will  yet  be  at  the  height 
of  his  powers  when  he  gives  us  the  concluding  volume.  If  the 
medical  profession  needed  any  reminder  of  the  immense  service 
he  has  performed  tor  its  literature,  each  of  the  volumes  as  it 
appears  would  serve  the  purpose  amply. 


PRECAUTIONS  AGAINST  LUNATICS. 

It  is  to  be  hoped  that  the  late  Dr.  Lloyd  did  not  die  in  vain. 
The  Grand  Jury  of  Kings  County  has  censured  the  State  Com¬ 
mission  in  Lunacy  for  countenancing  the  practice  in  asylums  of 
registering  patients  as  “discharged  ”  when  they  have  escaped. 
It  has  also  censured  the  officials  of  the  Kings  County  Insane 
Asylum  for  the  laxity  displayed  in  the  case  of  the  lunatic  who 
killed  Dr.  Lloyd,  and  recommended  the  employment  of  a  police 
force  in  the  asylum. 


AN  ISLAND  FOR  INEBRIATES. 

At  the  Berlin  Congress  Dr.  Karl  Kahlbaum  stated  that  one 
very  serious  error  had  often  been  made  in  the  treatment  of 
inebriety,  namely,  that  the  patient  was  not  kept  long  enough 
under  observation  to  make  sure  of  his  real  cure.  Improvement 
was  too  often  mistaken  for  and  reported  as  cure.  He  proposed 
that  the  Government  should  set  apart  an  island  for  dipsoma¬ 
niacs  solely. 


SIGNOR  SUCCI. 

Tnis  gentleman,  who  has  entertained  the  residents  of  sev¬ 
eral  European  cities — or  at  least  secured  a  portion  of  their 
attention — by  prolonged  abstinence  from  food,  is  now  in  New7 
lork,  and  is  advertised  to  fast  for  forty-five  days.  Just  what 
there  is  about  such  a  performance  to  attract  spectators  we  shall 
not  undertake  to  say,  but  we  do  not  doubt  that  there  is  some¬ 
thing. 


THE  NEW  YORK  ACADEMY  OF  MEDICINE. 

The  programme  for  the  meeting  on  Thursday  evening  of 
this  week  consisted  of  reports  of  so-called  “  delegates  ”  to  the 
1  enth  Internationa]  Medical  Congress — eleven  in  number.  It 


Nov.  8,  1890.] 


MIN  OB  PARAGRAPHS.— ITEMS. 


519 


is  well  known  that  these  congresses  are  not  made  up  of  dele¬ 
gates.  It  was  therefore  a  work  of  supererogation  for  the  Acade¬ 
my  to  appoint  them,  and  to  devote  a  meeting  to  their  “  reports  ” 
seems  to  us  to  argue  such  a  lack  of  legitimate  material  as  ought 
not  to  be  encountered  at  this  time  of  the  year. 


THE  BALTIMORE  MEDICAL  AND  SURGICAL  RECORD. 

This  is  the  title  of  a  new  monthly  journal,  owned  and  edited 
by  Dr.  T.  H.  Graham.  The  first  number,  for  October,  contains 
forty-two  pages  of  reading  matter,  and  is  embellished  with  an 
excellent  portrait  of  a  well-known  physician  of  Baltimore,  Dr. 
H.  P.  0.  Wilson.  The  number  includes  articles  by  Dr.  E.  S. 
McKee,  of  Cincinnati,  and  Dr.  Frank  West,  Dr.  W.  J.  Jones, 
Dr.  William  B.  Canfield,  and  Dr.  George  II.  Roh6,  of  Baltimore. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York.— We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  November  3,  1890: 


DISEASES. 

Week  ending  Oct.  28. 

Week  ending  Nov.  3. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Tvphoid  fever . 

37 

7 

25 

6 

Scarlet  fever . 

42 

1 

39 

1 

Cerebro-spinal  meningitis. .  .  . 

0 

0 

2 

1 

Measles . 

82 

6 

97 

6 

Diphtheria . 

67 

21 

54 

17 

Varicella . 

1 

0 

5 

0 

A  Death  during  Etherization  occurred  at  the  Brooklyn  City  Hospi¬ 
tal  on  October  29th.  The  patient,  who  was  about  to  undergo  an  opera¬ 
tion  for  necrosis  of  one  of  the  bones  of  the  foot,  had  been  sick  for  a 
long  time,  but  a  careful  cardiac  examination  before  the  operation  was 
decided  upon  showed  no  contra-indication  to  etherization.  About  four 
drachms  only  of  the  ether  had  been  administered  when  respiration  sud¬ 
denly  ceased,  and  a  few  seconds  later  the  heart’s  action  became  imper¬ 
ceptible.  Approved  means  of  resuscitation  were  diligently  employed 
by  the  house  staff  for  two  hours,  but  without  avail. 

The  Medical  Colleges  of  Baltimore.— The  Baltimore  Medical  and 

Surgical  Record  announces  that  the  new  building  of  the  College  of 
Physicians  and  Surgeons  will  be  ready  for  the  coming  term,  and  that 
the  class  is  a  large  one.  The  same  journal  states  that  a  story  has  been 
added  to  the  building  of  the  Baltimore  Medical  College,  with  fully 
equipped  laboratories  and  a  well-arranged  dissecting  room. 

The  Death  of  Dr.  Gustave  Monod,  of  Paris,  formerly  a  professor  of 
the  Faculty  of  Medicine,  is  announced  as  having  taken  place  on  the  21st 
of  October.  He  was  eighty-six  years  old. 

The  New  York  Academy  of  Medicine. — At  the  next  meeting  of  the 
Section  in  Paediatrics,  on  Thursday  evening,  the  13th  inst..  Dr.  Walter 
Mendelson  will  read  A  Jvote  on  How  to  obtain  the  Best  Practical  Re¬ 
sults  with  a  Milk-sterilizer,  and  Dr.  J.  Lewis  Smith  a  paper  on  Peritoni¬ 
tis  in  Infancy  and  Childhood. 

I)r.  C.  Eugene  Riggs,  of  St.  Paul,  Minn.,  a  commissioner  in  lunacy 
of  that  State,  was  given  a  reception  last  Saturday  evening  at  the  house 
of  Dr.  Landon  Carter  Gray,  of  New  York. 

The  American  Academy  of  Medicine  will  hold  its  annual  meeting  in 
Philadelphia  on  Wednesday  and  Thursday,  December  3d  and  4th. 

The  Harlem  Medical  Association. — The  programme  for  the  second 
regular  meeting,  on  Wednesday  evening,  the  5th  inst.,  included  the 
presentation  of  patients  by  Dr.  J.  G.  Truax  and  Dr.  E.  Fridenberg,  the 
presentation  of  a  ruptured  ectopic  gestation  sac  by  Dr.  T.  H.  Manley, 
and  the  reading  of  a  paper  on  Ectopic  Gestation  by  Dr.  F.  H.  Daniels. 

Changes  of  Address— Dr.  Alexander  Duane,  to  No.  11  East  Thir¬ 
tieth  Street;  Dr.  Max  Einhorn,  to  No.  120  East  Sixty-fourth  Street; 
Dr.  V  illiam  J.  Morton,  to  No.  19  East  Twenty-eighth  Street. 


The  Death  of  Professor  von  Nussbaum,  of  the  University  of  Munich, 
occurred  on  the  31st  of  October.  The  deceased  was  sixty-one  vearsold. 
He  is  reported  to  have  been  ill  for  the  past  year  as  the  result  of  an  at¬ 
tack  of  influenza. 

Army  Intelligence. —  Official  Inst  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army ,  from  October  26  to  November  1 ,  1890: 

Cowrey,  Stevens  G.,  Surgeon,  is  granted  leave  of  absence  for  one 
month,  with  permission  to  apply  for  an  extension  of  fifteen  days,  to 
take  effect  upon  the  arrival  of  Acting  Assistant  Surgeon  A.  P. 
Frick  at  Fort  Marey.  Par.  2,  S.  0.  112,  Department  of  Arizona, 
Los  Angeles,  Cal.,  October  24,  1890. 

By  direction  of  the  Secretary  of  W ar,  the  following  changes  in  the 
stations  of  officers  of  the  medical  department  are  ordered  : 
Woodruff,  Charles  E.,  First  Lieutenant  and  Assistant  Surgeon,  is  re¬ 
lieved  from  duty  at  Fort  Gibson,  California,  and  will  report  in  per¬ 
son  to  the  commanding  officer,  Fort  Missoula,  Montana,  for  duty  at 
that  post,  relieving  De  Witt,  Calvin,  Major  and  Surgeon.  Major 
De  Witt,  upon  being  so  relieved,  will  report  in  person  to  the  com¬ 
manding  officer,  Fort  Hancock,  Texas,  for  duty  at  that  post.  Par. 
6,  S.  0.  249,  A.  G.  0.,  Washington,  D.  C.,  October  24,  1890. 

Ewing,  Charles  B.,  Captain  and  Assistant  Surgeon.  By  direction  of 
the  Secretary  of  War  the  leave  of  absence  granted  in  S.  0.  131,  Sep¬ 
tember  22,  1890,  Department  of  the  Missouri,  is  extended  fourteen 
days.  S.  0.  250,  A.  G.  0.,  October  25,  1890. 

Edie,  Guy  L.,  Captain  and  Assistant  Surgeon,  is  granted  leave  of  ab¬ 
sence  for  one  month,  on  surgeon’s  certificate  of  disability,  Fort 
Douglas,  Utah.  S.  0.  80,  Headquarters  Department  of  the  Platte, 
Omaha,  Nebraska,  October  27,  1890. 

Wales,  Philip  G.,  First  Lieutenant  and  Assistant  Surgeon,  is  relieved 
from  station  and  further  duty  at  Fort  Huachuca,  Arizona  Territory, 
and  assigned  to  duty  at  San  Carlos,  Arizona  Territory,  where  he  is 
now  temporarily  serving.  Par.  13,  S.  0.  254,  A.  G.  0.,  October  30, 
1890. 

So  much  of  Paragraph  2,  S.  0.  208,  A.  G.  0.,  September  5,  1890,  as  di¬ 
rects  Jarvis,  Nathan  S.,  First  Lieutenant  and  Assistant  Surgeon, 
to  report  for  duty  at  San  Carlos,  Arizona  Territory,  is  revoked.  On 
the  expiration  of  his  present  sick  leave  of  absence,  Lieutenant  Jarvis 
will  report  in  person  to  the  commanding  officer,  Fort  Bayard,  New 
Mexico,  for  duty  at  that  station.  Par.  1 3,  S.  0.  254,  A.  G.  0.,  Oc¬ 
tober  30,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 

of  the  United  States  Navy  for  the  week  ending  November  J,  1890 : 

Stephenson,  F.  B.,  Surgeon.  Detached  from  the  Receiving-ship  Wa¬ 
bash  and  to  wait  orders. 

Martin,  H.  M.,  Surgeon.  Ordered  to  the  Receiving-ship  Wabash. 

Stone,  Lewis  H.,  Assistant  Surgeon.  Ordered  to  the  U.  S.  Steamer 
Pinta. 

Arnold,  William  F.,  Assistant  Surgeon.  Detached  from  the  U.  S. 
Steamer  Pinta  and  granted  two  months’  leave. 

Owens,  Thomas,  Surgeon.  Detached  from  the  Coast  Survey  Steamer 
Blake  and  to  wait  orders. 

Blackwood,  N.  J.,  Assistant  Surgeon.  Ordered  to  the  Receiving-ship 
Vermont. 

Bogert,  E.  S.,  Assistant  Surgeon.  Detached  from  the  U.  S.  Receiving- 
ship  Vermont  and  ordered  to  the  Coast  Survey  Steamer  Blake. 

Moore,  A.  M.,  Surgeon.  Detached  from  the  U.  S.  Steamer  Kearsarge 
and  ordered  to  the  Naval  Hospital,  Mare  Island,  Cal. 

Marine-Hospital  Service.—  Official  List  of  Changes  of  Stations  and 

Duties  of  Medical  Officers  of  the  United  States  Marine- Hospital  Service 

from  October  6,  1890 ,  to  October  25,  1890  : 

Hutton,  W.  H.  H.,  Surgeon.  Detailed  as  chairman,  Board  of  Examin¬ 
ers,  revoked;  ordered  to  Washington,  D.  C.,  for  temporary  duty. 
October  14,  1890. 

Wyman,  Walter,  Surgeon.  To  inspect  quarantine  stations.  October 
14,  1890. 

Long,  W.  H.,  Surgeon.  Detailed  as  chairman,  Board  of  Examiners. 
October  14,  1890. 


520 


ITEMS.— LETTERS  TO  THE  EDITOR. 


( N.  Y.  Mkl>.  Joor., 


Sawtelle,  H.  W.,  Surgeon.  Granted  leave  of  absence  for  five  days. 
October  13,  1890. 

Gassaway,  J.  M.,  Surgeon.  Granted  leave  of  absence  for  thirty  days. 
October  11,  1890. 

Irwin,  Fairfax,  Surgeon.  Detailed  as  recorder,  Board  of  Examiners. 
October  14,  1890. 

Ames,  R.  P.  M.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  thirty  days.  October  14,  1890. 

White,  J.  H.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  thirty  days.  October  24,  1890. 

Pettus,  Y\ .  J.,  Passed  Assistant  Surgeon.  To  proceed  to  Vineyard 
Haven,  Mass.,  for  temporary  duty.  October  9,  1890. 

Perry,  T.  B.,  Assistant  Surgeon.  Ordered  to  examination  for  promo¬ 
tion.  October  9,  1890. 

Kinyoun,  J.  J.,  Assistant  Surgeon.  Ordered  to  examination  for  pro¬ 
motion.  October  10,  1890. 

Condict,  A.  W.,  Assistant  Surgeon.  To  proceed  to  Baltimore,  Md.,  for 
temporary  duty.  October  18,  1890. 

Resignation. 

Ames,  R.  P.  M.,  Passed  Assistant  Surgeon.  Resignation  accepted  by 
the  President,  to  take  effect  November  15,  1890.  October  14,  1890. 

Society  Meetings  for  the  Coming  Week  : 

Monday,  November  10th:  New  York  Academy  of  Medicine  (Section  in 
Surgery);  New  York  Ophthalmological  Society  (private);  New  York 
Medico-historical  Society  (private) ;  Lenox  Medical  and  Surgical  So¬ 
ciety  (private) ;  New  York  Academy  of  Sciences  (Section  in  Chemis¬ 
try  and  Technology);  Boston  Society  for  Medical  Improvement; 
Gynaecological  Society  of  Boston ;  Burlington,  Vt ,  Medical  and  Sur¬ 
gical  Club  (annual);  Norwalk,  Conn.,  Medical  Society  (private) ;  Bal¬ 
timore  Medical  Association. 

Tuesday,  November  11th:  New  York  Medical  Union  (private);  Medical 
Society  of  the  County  of  Rensselaer,  N.  Y. ;  Norfolk,  Mass.,  District 
Medical  Society  (Hyde  Park) ;  Newark,  N.  J.,  and  Trenton  (private), 
N.  J.,  Medical  Associations;  Camden,  N.  J.,  County  Medical  Socie¬ 
ty  (semi-annual — Camden) ;  Baltimore  Gynaecological  and  Obstet¬ 
rical  Society ;  Southern  Surgical  and  Gynaecological  Association 
(first  day — Atlanta,  Ga.). 

Wednesday,  November  12th:  New  York  Surgical  Society;  New  York 
Pathological  Society;  American  Microscopical  Society  of  the  City 
of  New  York  ;  Medical  Society  of  the  County  of  Albany;  Pittsfield, 
Mass.,  Medical  Association  (private);  Worcester,  Mass.,  District 
Medical  Society  (Worcester) ;  Philadelphia  County  Medical  Society; 
Southern  Surgical  and  Gynaecological  Association  (second  day). 

Thursday,  November  18th:  New  York  Academy  of  Medicine  (Section 
in  Paedriatics) ;  Society  of  Medical  Jurisprudence  and  State  Medi¬ 
cine;  New  York  Physicians’  Mutual  Aid  Association  (annual); 
Brooklyn  Pathological  Society ;  Medical  Society  of  the  County  of 
Cayuga;  South  Boston,  Mass.,  Medical  Club  (private — annualj  ; 
Pathological  Society  of  Philadelphia ;  Southern  Surgical  and  Gynae¬ 
cological  Association  (third  day). 

Friday,  November  llfh:  Yorkville  Medical  Association  (private);  Ger¬ 
man  Medical  Society  of  Brooklyn ;  Medical  Society  of  the  Town  of 
Saugerties. 

Saturday,  November  15th  :  Clinical  Society  of  the  New  York  Post¬ 
graduate  Medical  School  and  Hospital. 


letters  to  %  (Sbttor, 


THE  SLUR  ON  THE  POLYCLINIC. 

267  Madison  Avenue,  October  31,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir  :  I  am  sure  every  member  of  the  staff  of  teachers  at  the 
Polyclinic  will  appreciate  the  publicity  you  have,  in  your  issue 


of  last  week,  given  to  the  “correction  of  a  slur  ”  on  this  insti¬ 
tution. 

The  New  York  Times  on  October  11th,  as  a  part  of  the 
obituary  notice  of  a  most  excellent  man,  a  minister  of  the  gos¬ 
pel,  respected  and  loved  by  all  who  knew  him,  so  far  forgot  the 
dignity  and  sense  of  propriety  which  usually  characterize  this 
paper  as. to  include  the  gratuitous  falsehood  that  death  was 
“  trom  the  effect  of  an  amputation  of  the  hip  performed  in  the 
New  York  Polyclinic  and  pronounced  at  the  time  to  be  ‘highly 
successful.'  ” 

I  at  once  wrote  the  editor  asking  from  what  source  he  had 
obtained  this  information.  He  replied  that  the  notice  “  was 
written  in  this  office  upon  information  which  I  am  disposed  to 
believe  is  thoroughly  reliable.”  To  my  further  inquiry,  asking 
that  if  I  would  prove  his  information  to  be  absolutely  false,  he 
would  publish  a  correction  as  prominently  as  was  published  the 
misstatement,  I  received  no  reply. 

A  day  or  two  later  appeared  the  manly  letter  from  the  dead 
man’s  father,  printed  under  the  title  of  An  Impression  Cor¬ 
rected.  This  letter  gave  not  only  the  testimony  of  the  father, 
but  of  three  well-known  practitioners  in  Alabama,  who  had 
seen  the  patient  .just  before  his  death,  that  the  fatal  termination 
was  in  no  way  due  to  the  operation  performed  eight  months 
before.  Dr.  J.  T.  Searcy,  of  Tuscaloosa,  one  of  the  most  promi¬ 
nent  physicians  of  Alabama,  in  answer  to  my  inquiry  as  to  the 
cause  of  death,  writes  :  “  The  operation  was  a  perfect  success. 
The  stump  was  in  a  perfectly  healthy  condition  at  the  time  of 
his  death.  There  was  no  return  of  the  sarcoma  in  the  field  of 
operation  or  anywhere  else  in  his  body.  He  died  of  miliary 
tuberculosis.  His  consumption  was  very  rapid  toward  the  last.” 

This  case  attracted  considerable  attention,  as  it  was  the  first 
one  in  which  my  bloodless  method  was  employed. 

John  A.  Wyeth,  M.  D. 


THE  TREATMENT  OF  ABORTION. 

Seaton,  III.,  October  Ilf.,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  Dr.  T.  Gaillard  Thomas,  in  a  clinical  lecture  recently, 
published  in  the  Annals  of  Oynwcology  and  Pcediatry ,  and 
quoted  in  Ihe  Therapeutic  Analyst ,  said  :  “  When  called  upon 
to  attend  a  case  of  abortion,  there  is  one  of  two  things  that  you 
will  have  to  decide  upon  at  once — whether  you  can  prevent  the 
abortion,  and  if  you  can  not  do  this,  how  to  conduct  it  judi¬ 
ciously  to  a  termination.  .  .  . 

“  We  will  assume  in  this  case  that  the  abortion  can  not  be 
prevented.  Under  such  circumstances  it  is  no  more  right  to 
stop  its  pains  than  it  is  right  to  stop  the  pains  of  labor  at  full 
term.  .  .  . 

“We  have  in  abortion  haemorrhage  usually  going  on  all  the 
time.  I  want  to  give  you  a  remedy  for  this  haemorrhage,  when 
it  becomes  severe — a  method  by  which  it  can  be  controlled  at 
once. 

“This  one  remedy  is  the  tampon.  This  is  the  one  great 
remedy  for  this  condition.  One  great  danger  in  abortion  is 
haemorrhage,  and  the  indication  is  to  stop  that  haemorrhage. 
This  is  the  one  and  only  indication  to  be  fulfilled  in  the  begin¬ 
ning,  and  when  you  have  done  this  thoroughly  you  have  done 
your  whole  duty  to  your  patient.” 

He  then  gives  a  very  thorough  and  effective  method  of  tam¬ 
poning,  and  proceeds : 

“After  some  hours,  from  twelve  to  twenty-four,  take  out 
the  tampon,  being  guided  in  this  by  the  pain  of  the  patient,  and 
you  will  then,  in  the  majority  of  cases,  have  brought  the  abor¬ 
tion  to  a  successful  termination.” 

This  is  no  doubt  classical  and  efficient,  and  sufficiently  dog- 


Nov.  8,  1890.] 


LETTERS  TO  THE  EDITOR.— PROCEEDINGS  OF  SOCIETIES. 


521 


matical.  I  would  not  criticise  it  as  one  method  ot'  treating 
abortion  ;  but  it  is  not  the  only  method,  nor,  to  my  mind,  is  it 
the  best  way.  I  will  report  my  method. 

A\  hen  called  to  a  case  of  unpreventable  abortion,  after 
proper  purification  I  proceed  at  once  to  rid  the  vagina  of  clots. 
I  next  make  a  digital  examination  of  the  os  uteri,  and  if,  as  is 
frequently  the  case,  I  find  the  products  of  couception  presenting 
at  the  external  os,  I  bring  them  away  with  the  finger. 

If  they  are  not  presenting  at  the  external  os,  or,  if  present¬ 
ing,  only  a  part  comes  away,  I  thrust  my  forefinger  through  the 
cervical  canal  into  the  cavity  of  the  womb.  I  next  bring  the 
womb  forward  if  necessary  with  the  finger  in  it,  and  with  the 
other  hand  steady  the  uterus  and  make  pressure  downward. 
I  then  proceed  to  disengage  the  placenta.  Having  done  so,  I 
bring  away,  with  the  finger,  all  the  products  of  conception,  and 
rid  the  vagina  of  any  remaining  clots,  and  the  case  is  terminated. 

In  order  to  reach  the  fundus  with  the  finger  it  is  often  ne¬ 
cessary  to  push  the  hand  entirely  inside  the  vagina.  This  I 
have  never  had  any  great  difficulty  in  doing.  After  the  hand 
has  passed  into  the  pelvic  cavity,  there  is  no  special  complaint 
of  discomfort. 

I  now  give  half  a  teaspoonful  of  Squibb’s  fluid  extract  of 
ergot,  and  direct  it  to  be  given  in  twenty-drop  doses  every  four 
hours,  or  more  frequently  if  necessary  to  control  haemorrhage, 
for  twenty-four  or  forty-eight  hours. 

I  next  impress  upon  the  patient’s  mind  the  importance  of 
keeping  quiet  in  bed  for  a  week  or  ten  days,  direct  her  to  keep 
her  person  and  bed  scrupulously  clean,  to  keep  her  bowels  open 
with  mild  laxatives,  to  sit  on  the  chamber  when  passing  urine, 
and  to  take  her  accustomed  food. 

In  conclusion,  what  may  be  said  of  this  method? 

1.  It  is  sufficiently  simple. 

2.  It  is  not  very  difficult. 

3.  I  have  found  no  great  difficulty  in  passing  the  finger  into 
the  uterus  at  the  fifth  or  sixth  week  of  pregnancy. 

4.  It  is  the  best  method  of  arresting  the  haemorrhage ;  it 
ceases  or  becomes  practically  harmless  as  soon  as  the  finger  has 
passed  the  cervix,  especially  if  the  finger  fits  the  cervical  canal 
tightly. 

5.  It  saves  the  woman  the  hours  of  exquisite  suffering  of 
the  uterine  contractions  and  the  blood-pressure  of  the  tampon. 

6.  It  terminates  the  case  in  about  the  time  it  would  take  to 
make  ready  the  tampon. 

7.  In  a  fair  experience  of  over  twenty-two  years  I  have  not 

met  with  a  case  in  which  it  failed,  or  a  case  in  which  there 
were  after-complications.  Thomas  A.  Elder,  M.  D. 


DK.  GIBIER’S  THEORY  OF  TEMPERAMENTS. 

Ill  Warwick  Street,  Brooklyn,  October  22,  1890. 

To  the  Editor  of  the  New  Fork  Medical  Journal : 

Sir:  On  reading  the  article  of  Dr.  Paul  Gibier,  on  A  New 
Theory  about  Temperaments,  in  the  Journal  for  October  18, 
1890,  it  occurred  to  my  mind  that  the  well-known  therapeutico- 
chemical  fact — namely,  that  acids  check  acid  secretions  and  in¬ 
crease  alkaline  secretions,  also  the  reverse — played  an  impor¬ 
tant  r61e  here. 

1.  As  it  is  in  the  alkaline  subjects  that  tuberculosis  is  com¬ 
mon,  not  in  the  acid  subjects. 

2.  It  requires  alkalinity  to  favor  the  growth  of  the  tubercle 
bacillus  ;  acids  even  diluted  to  thousandths  will  destroy  it. 

3.  Children  of  tubercular  parents  are  oftentimes  healthy 
through  life  and  show  no  disposition  to  develop  tuberculosis, 
but  the  children  of  these  again  are  tubercular  without  cause, 
except  the  diathesis. 

4.  Hashot  the  temperament,  if  taken  according  to  the  theory 


of  Gibier,  something  to  do  with  the  development  of  tuberculosis 
in  alternate  generations?  Say,  first,  alkaline  parents  have  acid 
children  and  the  reverse  in  a  tubercular  generation,  whereas  an 
acid  and  an  alkaline  parent  have  neutral  children. 

5.  Could  not  tuberculosis  lie  dormant  in  persons,  and  when 
the  opportunity  of  acid  or  equal  temperaments  or  acid  tubercu¬ 
lar  parents  arrives,  produce  alkaline  or  tubercular  children  ? 

The  same  may  bo  said  of  other  diseases. 

Will  some  one  with  a  wider  range  of  experience  than  myself 
give  this  further  investigation  if  ho  thinks  it  worth  while,  for 
the  benefit  of  medical  men  and  sanitarians  as  well  as  the  tuber¬ 
cular  race  or  generation  ?  C.  A.  von  Urff,  M.  D. 


|)rocecbtngs  of  Societies. 


NEW  YORK  STATE  MEDICAL  ASSOCIATION. 

Seventh  Annual  Meeting ,  held  at  the  Mott  Memorial  Ilall ,  New 
York,  October  22,  23,  and  21+,  1890. 

The  President,  Dr.  John  G.  Orton,  of  Binghamton,  in  the 

Chair. 

The  Chairman  of  the  Committee  of  Arrangements,  Dr.  J.  G. 
Truax,  in  his  report  formally  welcomed  the  association  to  its 
occupation  of  a  new  home  and  library  at  the  Mott  Memorial 
Hall,  recently  acquired  for  permanent  use. 

The  Report  of  the  Secretary  contained  pointed  reference 
to  the  New  York  State  Medical  Examination  Bill,  which  had 
recently  become  law.  He  stated  that  every  pressure,  by  argu¬ 
ment  and  remonstrance,  had  been  brought  to  bear  upon  the 
Governor  to  withhold  his  signature,  upon  the  ground  that  the 
bill  had  not  been  duly  considered  in  the  Senate  and  that  its 
clauses  were  unjust  and  one-sided.  The  tenor  of  the  reply  to 
this  appeal  was  that  the  Governor  must  assume  the  bill  to  have 
been  duly  considered  in  committee,  and  that  if  exception  was 
taken  to  it  another  bill  in  modification  could  be  sent  up  next 
year. 

The  President’s  Address. — The  President  congratulated 
i:he  association  on  having  at  last  acquired  a  home  for  its  mem¬ 
bers  and  its  library.  He  then  considered  at  some  length  the 
question  of  educational  preparation  for  the  profession.  He  said 
that  while  upholding  the  principle  that  medical  colleges  should 
demand  proof  of  adequate  preliminary  education  from  would-be 
medical  students,  he  was  not  prepared  to  go  so  far  as  to  say 
that  the  possession  of  academic  degrees  should  be  demanded  as 
a  sine  qua  non  of  qualification  for  entering  upon  a  medical 
course.  He  did  not  believe  that  the  colleges  of  this  country 
were  below  par.  There  was  every  evidence  that  they  were 
steadily  raising  the  standard  of  excellence  in  the  educational 
oabulum.  They  were  really  better  adapted  to  the  require¬ 
ments  than  those  of  the' old  country.  The  unfortunate  phase 
of  the  situation  was  that  the  colleges  had  not  shut  their 
doors  against  inadequately  prepared  students.  The  speaker 
then  paid  unqualified  tribute  to  the  value  of  medical  journals, 
which  he  said  had  assumed  a  proportion  and  weight  of  charac¬ 
ter  unequaled  in  any  other  branch  of  science  or  art.  To¬ 
day  a  subscription  to  a  reliable  medical  journal  was  an  in¬ 
vestment  which  would  repay  with  interest  many  times  com¬ 
pounded.  He  advocated  the  establishment  of  local  boards  of 
sanitation,  the  business  of  which  should  be  to  formulate  prin¬ 
ciples  of  sanitary  science  for  the  people,  for  publication  in  the 
secular  press,  which  would  enable  them  to  intelligently  guard 
against  preventable  disease. 


522 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jouk., 


Prognostics  in  Medicine.— Dr.  John  Ceonyn,  of  Erie 
County,  read  a  paper  on  this  subject.  In  the  course  of  an  ex¬ 
tended  review  of  points  for  prognosis  he  touched  upon  the  ques¬ 
tion  of  treatment.  He  thought  that  prognosis  in  cases  of  apo¬ 
plexy  could  now  hardly  be  as  favorable  as  when  bloodletting 
was  more  in  vogue.  Pneumonia  was  not  as  low  in  the  mortal¬ 
ity  tables  as  the  vaunted  progress  in  medical  science  would 
seem  to  warrant. 

New  Method  of  Treatment  for  Retro-displacements 
of  the  Uterus  with  Adhesions. — Dr.  A.  P.  Dudley,  of  New 
\  ork  County,  described  his  present  method  of  surgical  treat¬ 
ment  for  certain  forms  of  the  above  condition.  After  a  review 
of  the  various  methods  for  correcting  this  lesion  recently  in 
vogue,  he  narrated  the  details  of  his  operative  procedure  in  a 
case  of  diseased  ovaries  and  tubes.  He  opened  the  abdomen, 
broke  up  the  adhesions  (about  the  uterus,  and  then  taking  the 
left  ovary  and  tube,  he  drew  them  up  through  the  abdominal 
incision  and  saw  that  the  fimbriated  extremity  was  open.  He 
then  took  a  piece  of  No.  27  silver  wire,  slightly  pointed  at  one 
end,  which  he  gently  passed  through  the  entire  length  of  the 
tube,  demonstrating  it  as  pervious.  The  ovary,  which  contained 
several  cysts,  was  then  tapped  with  a  spear  pointed  needle  by 
passing  the  needle  directly  through  the  organ  and  squeezing 
the  water  out.  The  sacs  were  then  allowed  to  fill  with  fresh 
blood.  The  tube  and  ovary  were  dropped  back  and  the  right 
side  was  treated  in  the  same  manner.  An  assistant  then  placed 
two  fingers  in  the  vagina  and  lifted  the  uterus  as  high  as  possi¬ 
ble  in  the  pelvis.  The  operator  was  thus  enabled  to  bring  the 
uterus  close  up  to  the  abdominal  incision.  With  a  pair  of  deli¬ 
cate  scissors  he  then  denuded  the  peritonaeum  from  the  anterior 
wall  of  the  uterus,  the  surface  thus  freshened  being  ot  an  oval 
shape.  Care  was  taken  nut  to  go  too  near  the  bladder.  Then 
each  round  ligament  was  brought  up  and  a  portion  of  the  peri¬ 
toneal  covering  upon  the  inner  side  denuded  to  correspond  with 
'that  upon  the  uterus.  With  a  continuous  suture  of  catgut  he 
then  sewed  these  denuded  surfaces  together.  The  sutures  were 
passed  deep  enough  to  secure  against  their  cutting  out  before 
union  took  place.  The  uterus  was  then  dropped  back,  and  the 
traction  upon  the  round  ligaments  immediately  drew  the  organ 
into  a  position  of  anteversion,  the  sutured  surfaces  lying  in  ap¬ 
position  to  the  posterior  surface  of  the  bladder.  He  did  not  in¬ 
troduce  a  pessary,  preferring  to  allow  the  work  to  rest  upon  its 
merits.  The  advantages  of  this  operation  were  threefold:  1. 
It  shortened  the  round  ligaments,  without  sacrificing  any  part 
of  them,  sufficiently  to  hold  the  uterus  in  a  position  anterior  to 
the  perpendicular  line  of  the  body.  2.  Denuding  and  firmly 
fastening  the  round  ligament  to  the  anterior  surface  of  the 
uterus  thickened  and  gave  extra  support  to  the  latter.  3.  The 
uterus  was  maintained  in  a  normal  portion  without  fastening 
any  of  it  to  the  anterior  abdominal  wall,  a  position  which  he 
thought  Nature  never  intended  it  to  occupy. 

This  operation  the  speaker  maintained  presented  the  follow¬ 
ing  advantages  over  hysterorrhaphy  or  Alexander’s  operation :  1. 
It  corrected  the  displacements  by  utilizing  the  natural  supports 
of  the  uterus  without  sacrificing  any  of  them.  2.  The  proper 
diaphragmatic  action  of  the  pelvic  floor  was  not  interfered  with. 
3.  The  bladder  was  not  imprisoned  and  its  proper  action  was 
undisturbed.  4.  There  was  no  chance  for  intestinal  adhesion 
about  the  line  of  suture,  for  the  latter  lay  in  apposition  to  the 
posterior  surface  of  the  bladder,  and  adhesion  taking  place  at 
this  point  simply  elongated  the  utero-vesical  junction.  5.  In 
case  of  impregnation,  the  uterus  was  free  to  rise  in  the  abdomi¬ 
nal  cavity  naturally.  6.  The  use  of  the  catgut  suture  did  away 
with  the  danger  of  the  formation  of  sinuses  by  the  ligature. 
One  of  his  objects  in  performing  this  operation  had  been  to 
save  the  ovaries,  for  he  had  come  to  believe  that  more  was  taken 


out  than  should  be.  He  had  operated  in  the  manner  described 
four  times,  and  he  thought  this  was  enough  to  demonstrate  that 
it  was  possible  to  attack  the  cysts  in  the  ovaries  and  still  not 
have  any  trouble  in  the  tubes  and  ovaries  after  the  laparotomy. 

Discussion  on  Intracranial  Lesions. — This  subject  was  con¬ 
sidered  by  various  speakers  under  the  following  subdivisions: 

The  present  means  of  localizing  intracranial  lesions. 

The  nature  of  the  chief  intracranial  lesions  (haemorrhage, 
abscesses,  tumors),  and  how  can  they  be  discriminated. 

The  indications  and  contra-indications  of  operative  interfer¬ 
ence  in  cases  of  intracranial  lesions. 

The  best  modes  of  operating  in  cases  of ‘intracranial  lesions. 

The  immediate  and  also  the  remote  results  of  operative 
treatment  in  cases  of  intracranial  lesions. 

Dr.  W.  W.  Keen,  of  Pennsylvania,  prefaced  his  remarks  by 
the  exhibition  and  description  of  a  new  Rolandic-tissure  meter, 
with  radiating  arm  and  index  built  after  the  manner  of  the 
cvrtometer,  and  the  design  of  Horsley,  of  England.  The  indi¬ 
cations  for  operative  treatment  in  brain  lesions,  he  said,  should 
be  based  on  careful  observation  of  the  peculiar  physical  char¬ 
acteristics,  the  mechanical  depressions,  and  functional  disturb¬ 
ances. 

In  the  course  of  an  elaborate  survey  of  the  whole  clinical 
aspect  of  the  subject  from  an  operator’s  point  of  view  the 
speaker  emphasized  his  opinion  that  if  a  lesion  could  be  located 
and  distinguished  from  other  conditions  which  might  produce 
more  or  less  similar  phenomena,  and  if  the  general  clinical  in¬ 
dications  were  such  as  pointed  to  the  neee-sity  for  operative  treat¬ 
ment,  then  it  was  the  duty  of  the  competent  surgeon  to  open 
the  head.  The  head  had  been  too  long  regarded  as  something 
apart  and  different  from  other  portions  of  the  body,  and  he 
would  urge  that  it  should  be  made  to  fall  into  line  with  other 
cavities,  subject,  as  it  was,  to  the  same  diseases  and  injuries. 
The  methods  of  treatment  might  require  modification  in  detail, 
but  should  be  the  same  in  principle. 

Dr.  J.  J.  Putnam,  of  Boston,  drew  attention  to  the  relative 
value  of  certain  so-called  localizing  signs  of  cerebral  tumors, 
especially  such  tumors  as  lay  a  little  outside  the  familiar  areas 
of  the  central,  temporal,  and  occipital  zones,  and  only  imping¬ 
ing  upon  them,  so  that  the  symptoms  to  which  they  gave  rise 
would  be  liable  to  occur  rather  late  in  the  progress  of  the  case. 
There  were  cases  which,  obviously  for  more  reasons  than  one, 
were  relatively  unsuited  for  surgical  treatment.  It  was  gen¬ 
erally  admitted  as  a  clinical  principle  that  the  monoplegias  and 
localized  paralyses  were  more  valuable  as  localizing  signs  than 
the  monospasm  or  localized  convulsions.  Those  functions  of 
the  brain  which  were  relatively  of  a  highly  specialized  and  com¬ 
plex  character  were  more  likely  to  suffer  disturbance  than  the 
less  highly  specialized  and  complex  or  more  fundamental  func¬ 
tions.  There  must  be  few  tumor  operations  in  which  the  con¬ 
volutions  near  the  growth  were  not  found  more  or  less  dis¬ 
placed,  and  often  they  were  broadened  to  twice  their  natural 
size  or  flattened  to  the  thickness  of  cardboard.  There  were 
cases,  however,  where  this  error  was  of  importance — those, 
namely,  where  convolutions  were  excited  by  pressure  trans¬ 
mitted  from  a  considerable  distance,  or  by  oedema  and  anaemia. 
This  had  occurred  in  a  case  of  the  author’s.  Unilateral  neu¬ 
ritis  had  been  held  as  being  significant  in  indicating  the  press¬ 
ure  of  a  tumor  of  the  opposite  side  cf  the  brain.  But  the  re¬ 
verse  of  this  condition  was  true  in  the  author’s  case  of  tumor 
of  the  middle  frontal  convolution,  so  that  this  sign  was  really 
of  vetry  little  value.  No  one  interested  in  cerebral  localization 
could  have  failed  to  notice  the  experiences  of  Schaeffer  and 
Mank  in  showing  that  infinite  movements  of  the  eyes  and  the 
eyelids  were  represented  in  the  posterior  limb  of  the  angular 
gyrus  and  in  the  occipital  lobes,  the  connecting  tracts  reaching 


Nov.  8,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


5*3 


the  oculo-motor  nuclei  not  indirectly  through  the  Eolandic  area, 
but  by  direct  paths. 

Dr.  J.  B.  Koberts,  of  Philadelphia,  thought  that,  though 
many  lives  had  undoubtedly  been  saved  by  judicious  surgery 
about  the  head  after  fractures,  still  the  impulse  given  to  rush  into 
operations  in  this  region  had  done  a  great  deal  of  harm.  lie  was 
glad  that  the  pendulum  was  swinging  the  other  way.  Trau¬ 
matic  cases  offered  the  best  prospect  of  good  results,  and  proba¬ 
bly  many  patients  died  who  could  have  been  saved  by  timely 
operative  interference. 

Dr.  0.  K.  Mills,  of  Philadelphia,  said  the  causes  of  failure 
in  the  present  method  of  localizing  intracranial  lesions  were 
due  to  a  variety  of  circumstances,  and  might  conveniently  be 
arranged  into  several  classes.  First,  by  giving  too  much  weight 
to  certain  classes  of  symptoms,  which  were  regarded  as  deter¬ 
minative  of  the  site  of  the  lesion,  as,  for  example,  the  so-called 
signal  or  initial  symptoms;  second,  by  considering  only  symp¬ 
toms  of  late  invasion,  as  in  the  case  of  lesions  growing  from 
latent  to  active  areas  ;  third,  by  giving  relatively  too  much  im¬ 
portance  to  motor  localizing  symptoms  ;  fourth,  by  overlooking 
multiple  or  diffused  lesions;  fifth,  by  operating  for  incurable 
cases  of  arrested  development.  The  so-called  signal  or  initial 
symptom,  while  of  great  value,  had  proved  sometimes  a  mis¬ 
leading  light.  The  motor  signal  symptom  had  been  made  use 
of  in  a  large  number  of  cases  to  guide  the  surgeon,  sometimes 
successfully,  but,  the  author  was  almost  inclined  to  say,  almost 
as  often  not  so.  It  must  be  remembered  that  in  every  case  of 
unilateral  or  monospasm,  whether  reflex,  dural,  nephritic, 
toxic,  or  hysterical,  the  spasm  really  or  apparently  began  with 
an  initial  symptom  in  the  limb  or  face.  This  might  indicate 
that  the  beginning  of  the  cerebral  discharge  occurred  in  the 
area  of  the  cortex,  which  was  the  seat  of  the  representation  of 
the  movement,  but  it  would  be  unwise  to  operate  with  such 
indications.  Occasionally  conjugate  deviation  of  the  eyes  and 
head  had  been  used  as  a  guide  to  operative  procedure.  This 
was  one  of  the  errors  into  which  a  thoughtless  or  badly  in¬ 
formed  neurologist  might  sometimes  be  led.  In  making  a  diag¬ 
nosis  as  to  the  existence  of  haemorrhage,  we  must  depend  more 
largely  upon  general  symptoms.  What  was  true  of  tumor  in 
this  respect  was  still  more  strikingly  true  of  abscess.  A  num¬ 
ber  of  mistakes  bad  been  made  in  cases  of  trephining  for  tumor 
or  abscess  by  the  operator  being  guided  too  much  by  motor 
symptoms,  which  were  really  the  result  of  the  diffusion  of  the 
lesion  to  the  motor  areas.  In  the  analysis  of  the  symptoms 
with  a  view  of  deciding  as  to  operation,  too  much  stress  was 
sometimes  placed  upon  motor  symptoms,  particularly  on  more 
or  less  circumscribed  spasmodic  manifestations.  In  not  a  few 
cases  of  cerebral  abscess,  sensory  or  special  symptoms  might 
decide  in  favor  of  operating,  and  at  the  same  time  might  not 
pioperly  guide  to  the  seat  of  operation.  All  active  localized 
symptoms  of  the  brain,  the  result  of  mastoid  or  aural  disease, 
unless  it  was  word-deafness  and  left-sided  affections,  were  the 
result  of  the  extension  of  the  purulent  process.  Several  mis¬ 
takes  had  been  made  in  cases  in  which  large  lesions,  either  in 
the  frontal  or  temporal  lobe,  had  caused  prominent  motor 
symptoms  by  pressure  either  upon  the  motor  tracts  in  the  cap¬ 
sule  oi  upon  the  cortical  areas  of  these  tracts.  In  one  case  of 
this  kind  the  symptoms  all  pointed  to  brachial  crural  monople¬ 
gia,  due  to  tumor  and  intercurrent  haemorrhage.  The  autopsy 
showed  a  tumor,  with  large  haemorrhage  in  the  right  temporal 
lobe,  and  strictly  confined  to  this  lobe,  but  evidently  causing 
great  pressure.  Several  recorded  failures  had  been  the  result 
of  overlooking  the  pressure  of  multiple  or  diffused  lesions. 
Operating  in  cases  of  tubercular  disease  of  the  brain  vessels  or 
membranes  had  also  been  another  source  of  error  and  cause  of 
failure.  It  was  an  error,  at  least  in  the  majority  of  cases,  to  I 


operate  guided  by  certain  localizing  phenomena  of  the  spastic 
and  paralytic,  congenital  and  early  infantile  affections. 

A  careful  review  of  the  surgical  operations  guided  by  lo¬ 
calization  rule,  in  whole  or  part,  showed  that  probably  the 
greatest  success  during  the  last  few  years  had  been  trephining 
for  endocranial  haemorrhage.  Occasional  failure  had  resulted 
in  traumatic  cases,  and  for  several  reasons.  In  the  first  place, 
the  fact  was  not  fully  considered  that,  in  many  cases  of  depressed 
or  non- depressed  fractures,  haemorrhages  took  place  not  only  at 
oi  in  direct  connection  with  the  place  of  injury,  but  also  at 
various  positions  more  or  less  remote. 

Dr,  J.  D.  Bryant,  of  New  York  County,  in  considering  the 
question  as  to  the  present  means  of  localizing  intracranial  le¬ 
sions,  limited  the  term  lesion  to  abscess,  haemorrhage,  depressed 
bone,  and  tumors  of  intracranial  origin.  The  present  means 
of  localizing  these  lesions  could  be  classified  for  convenience’ 
sake  as  topographical,  physiological,  and  instrumental.  The 
topogi  aphical  related  to  the  connection  existing  between  cer¬ 
tain  established  landmarks  and  lines  of  the  cranium  that  were 
found  to  bear  a  decided  relationship  to  superficial  parts  of  the 
encephalon,  many  of  which  parts  had  had  definite  functions  as¬ 
signed  to  them  already.  The  physiological  means  related  to  the 
establishment  of  the  site  of  a  pathological  process  by  studying 
the  derivation  of  the  function  of  a  part  from  the  normal,  as  the 
result  of  a  local  disease  or  injury.  The  instrumental  means 
weie  largely  subsidiary  and  their  application  was  often  more  of 
an  experimental  than  of  a  practical  character.  The  speaker 
then  further  dealt  with  the  question  by  the  recitation  of  cases 
having  direct  bearing  on  the  subject.  Among  the  most  impor¬ 
tant  deductions  were :  1.  That  a  small  and  presumptively  cir¬ 
cumscribed  injury  of  the  brain  substance  at  the  upper  end  of 
;he  fissure  of  Rolando  might  incite  an  advancing  cerebral  disin¬ 
tegration  sufficient  to  involve  the  motor  centers  associated  with 
this  fissure  without  causing  notable  constitutional  symptoms. 
2.  That  aspiration  of  the  brain  as  a  means  of  diagnosticating 
the  existence  or  the  situation  of  an  abscess  was  of  uncertain 
utility,  even  when  a  fair-sized  needle  was  used,  and  that  the 
employment  of  the  ordinary  hypodermic  appliances  for  this 
purpose  was  entirely  unreliable  and  misleading.  3.  That  ex¬ 
tensive  fissure  could  begin  at  some  distance  from  the  violence 
causing  i$,  and  that  its  existence  might  remain  unrecognized 
without  an  extended  exploration.  4.  That  extensive  and  fatal 
vascular  complications  might  be  caused  at  a  considerable  dis¬ 
tance  from  the  seat  of  an  apparently  innocent  injury  of  the 
scalp  or  skull.  5.  That  where  paralysis,  involving  the  motor 
areas  of  the  brain,  followed  an  apparently  trivial  injury  of  the 
head,  an  operation  at  the  seat  of  the  areas  was  indicated  for  the 
purpose  of  exploration  alone.  6.  That  the  removal  of  a  com¬ 
pressed  brain  clot  was  not  necessarily  followed  by  improvement 
of  the  symptoms  of  compression,  and  that  if  the  brain  did  not 
soon  resume  the  normal  relation  with  the  skull,  death  would 
ensue  as  the  result.  In  another  of  the  cases  cited  the  patient 
had,  immediately  after  being  hit  over  the  head  with  a  bottle, 
lost  the  power  of  speaking  his  own  name,  but  had  been  able  to 
write  it  and  the  name  of  his  assailant  on  paper.  When  admit¬ 
ted  to  the  hospital  he  could  not  recall  his  own  name  or  those  of 
many  common  things.  An  examination  of  the  injury  had  dis¬ 
closed  a  small  circumscribed  compound  depressed  fracture  of 
the  skull,  located  near  the  lower  end  of  the  fissure  of  Rolando. 

On  the  following  day  the  depression  was  elevated  and  the  apha- 
sic  symptoms  had  all  disappeared.  The  case  had  impressed  the 
fact  that  a  circumscribed  compression,  due  to  traumatic  influ¬ 
ence,  might  limit  its  effects  to  one  motor  center  onlv. 

Dr.  T.  H.  Manley,  of  New  York  County,  said  it  was  neces¬ 
sary  to  divide  intracranial  lesions  into  two  classes— viz.,  those 
of  an  extrinsic  and  those  of  an  intrinsic  origin ;  those  arising 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mki<.  Jour., 


524 

from  violence  or  mechanical  influences,  and  those  resulting 
from  pathological  changes  within  the  skull.  He  confined  his 
observations  to  lesions  of  a  traumatic  character,  although  what 
was  said  concerning  the  changes  which  lay  in  the  way  when 
those  were  treated  by  active  surgical  intervention  would  prac¬ 
tically  apply  with  slight  modification  to  intracranial  formations 
of  a  constitutional  origin.  Cephalic  lesions  attributable  to 
trauma  were  commonly  of  a  compound  nature,  being  associated 
with  contusion,  laceration  or  puncture  of  the  scalp  with  the 
underlying  textures,  with  fracture  or  depression  of  the  osseous 
plates  of  the  skull,  and  hence  we  might  with  propriety  desig¬ 
nate  them  cranio-cepbalic  lesions.  Conditions  following  cranial 
injuries  in  which  the  patients  survived  had  reference  to  (1) 
shock,  (2)  laceration  of  brain  substance,  (3)  haemorrhage,  (4) 
inflammation,  (5)  purulent  formation,  (6)  localized  ulceration, 
breaking  down  or  softening.  The  utility  or  justifiability  of  op¬ 
erative  interference  depended  on  a  multiplicity  of  circum¬ 
stances,  which  demanded  a  most  careful  consideration.  It  was 
true  that  operations  were  frequently  done  on  patients  while  in 
a  state  of  shock  and  coma  ;  it  was  also  true  that  diagnosis  could 
not  be  made  at  such  a  time.  In  a  general  way,  it  might  be 
said  that  fractured  or  depressed  bone  of  the  skull  could,  when 
necessary,  be  expeditiously  dealt  with  by  the  trephine.  It  was 
well  known  that  we  might  have  a  laceration  or  injury  to  the 
brain  without  evident  injury  to  the  skull;  and,  on  the  other 
hand,  the  brain  might  be  injured  without  symptoms  occurring 
of  sufficient  gravity  to  make  trephining  admissible.  The  author 
did  not  believe  in  the  reimplanting  of  bone  in  the  skull,  and 
did  not  think  that  osseous  union  took  place,  thereby  leaving 
the  brain  susceptible  of  hernia  cerebri.  It  was  needless  to  say 
that  the  dura  mater  was  always  exposed  to  laceration  when  the 
large  trephine  was  employed.  Haemorrhage  was  a  symptom 
considered  by  many  as  one  of  the  most  dangerous  to  occur  in 
trauma  of  the  brain,  but  the  author  did  not  see  why  it  should 
be  so.  He  thought  that  in  many  cases,  if  it  were  let  alone,  ab¬ 
sorption  would  take  place,  and  at  any  rate  the  trephine  in 
most  cases  increased  the  danger.  Since  the  advent  of  antisep¬ 
tics,  combined  with  cleanliness,  the  danger  of  inflammation 
arising  as  a  sequela  of  the  trephine  was  eliminated,  though  not 
wholly  banished.  While  with  these  means  the  trouble  might 
be  avoided,  still  mechanical  irritation  or  constitutional  predis¬ 
position  often  favored  inflammatory  processes.  But  meningitis 
was  at  times  absolutely  unavoidable  after  trephining.  The 
author  thought  that  in  traumatic  meningitis  trephining  for 
the  purpose  of  draining  and  irrigating  was  not  only  useless  but 
almost  criminal.  Iu  the  cases  in  which  the  operation  had  been 
done  for  this  purpose  there  was  no  doubt  that  life  had  been 
shortened.  He  had  never  seen  abscess  follow  the  use  of  the 
trephine.  When  the  use  of  the  trepan  was  attended  with  or 
followed  by  much  laceration  of  brain  substance,  or  by  the  di¬ 
vision  or  occlusion  of  the  vascular  supply,  that  part  which  was 
exposed  thereby  gradually  disintegrated  and  was  absorbed  ;  in¬ 
sanity  might  result  or  recovery  ensue.  Anaesthetics  increased 
the  vascularity  of  the  brain,  so  that  it  stood  to  reason  that  a 
brain  after  trauma  should  be  kept  as  quiet  as  possible,  and 
would  not  be  benefited  by  this  anaesthesia.  Manipulation  at 
such  a  time  was  also  bad.  The  author  thought  that  in  many 
cases  of  trephining  for  trauma  where  death  had  occurred  the 
anaesthetic  had  been  an  important  element  in  the  cause.  For 
trephining  to  be  stripped  of  elements  of  danger,  it  required  an 
exact  anatomical  knowledge  and  a  careful  discriminating  judg¬ 
ment. 

Hypnotism. — Dr.  Ernest  Schmid,  in  his  remarks  upon  this 
subject,  said  nobody  hesitated  to  admit  the  influence  of  the  body 
upon  the  brain.  Eminent  alienists  maintained  that  no  diseased 
state  of  the  mind  ever  existed  without  a  pathological  condition 


of  some  portion  of  the  brain.  Why  should  we  then  hesitate  to 
admit  the  influence  of  the  mind  upon  the  body?  The  author 
held  that  every  unconscious  imitation  was  a  transfer  of  a  brain 
movement  communicated  to  another  brain  in  such  a  manner 
that  the  brain  which  repeated  this  movement  of  the  first  brain 
adopted  it  as  one  of  its  own  originating,  and  not  a  repetition. 
On  this  rested  the  great  problem  of  hypnotism.  That  the  view 
of  the  contagiousness  of  brain  movements  of  physical,  intellect¬ 
ual,  and  moral  diseases  was  not  a  singular  one,  and  was  demon¬ 
strable  among  other  things  by  the  fact  that  not  a  few  alienists 
had  formed  the  belief  that  mental  aberration  might  be  com¬ 
municated  to  a  sound  mind  by  example  and  daily  intercourse 
with  the  insane.  There  did  exist  within  us  a  secret  force  which 
constantly  conformed  our  thoughts  to  our  actions  and  our  entire 
inner  being  to  our  external  habits.  The  speaker  was  convinced 
that  the  true  essence  of  hypnotism  possessed  kindred  elements 
to  those  thoughts.  It  was  the  imparting  of  a  brain  movement 
to  others  or  the  creating  a  new  one  in  another  which  became  as 
the  other  self-originated  thought.  That  the  hypnotic  state  could 
be  produced  was  an  established  fact.  Like  all  other  therapeutic 
measures,  it  had  its  circumscribed  sphere,  but  its  usefulness  was 
destined  to  become  very  great. 

Retention  of  Urine  from  Prostatic  Obstruction  in  Eld¬ 
erly  Men:  its  Nature,  Diagnosis,  and  Management.— This 
was  the  title  of  a  paper  by  Dr.  J.  W.  S.  Goulet,  of  New  York 
County.  (See  page  477.) 

Dr.  J.  A.  Wyeth,  of  New  York  County,  said  that  in  cases 
of  persistent  cystitis  it  was  his  practice  to  perform  suprapubic 
section;  he  thought  this  the  best  method  for  dealing  with  this 
very  obstinate  disease.  This  operation  in  his  hands  had  given 
better  results  than  when  treated  by  the  urethra.  Not  only  was 
immediate  relief  obtained,  but  a  better  command  of  the  bladder 
was  possible.  He  had  only  been  doing  this  operation  the  last 
two  years,  but  in  that  time  about  thirty  cases  had  been  so  treat¬ 
ed,  five  of  which  were  tumors  of  the  prostate,  good  results  be¬ 
ing  obtained  in  all.  He  thought  that  for  prostatic  tumors  the 
high  operation  was  by  far  the  best.  It  was  his  method  in  re¬ 
moving  such  to  use  the  clamp  forceps,  and,  with  the  fingers  at 
the  prostate,  gradually  to  twist  them  off,  using  the  actual  cau¬ 
tery  to  the  stump.  Relief  had  always  been  prompt,  and  in  only 
one  casedid  the  bladder  fail  to  resume  its  function.  The  speaker 
had  found  that  the  oil  of  gaultheria  was  the  best  remedy  to  pre¬ 
vent  the  decomposition  of  urine.  He  gave  it  by  the  mouth,  four 
or  five  drops,  three  or  four  times  daily.  When  this  drug  was 
given,  the  urine  would  not  decompose.  The  Trendelenburg  drain¬ 
age-tube  was  the  one  used,  and  six  to  eight  weeks  was  the  long¬ 
est  it  had  ever  been  necessary  to  leave  it  in  situ. 

Dr.  Goulet  was  in  full  accord  with  the  speaker  as  to  doiDg 
suprapubic  cystotomy  for  the  removal  of  prostatic  tumors,  but 
he  would  not  do  the  operation  for  this  alone,  but  rather  inci¬ 
dentally.  He  believed  that  in  the  majority  of  cases  the  bladder 
could  best  be  reached  through  the  urethra,  and  as  fordoing  the 
operation  for  the  purpose  of  cleansing  and  drainage,  it  should 
not  be  thought  of.  In  cases  of  contracted  bladder  from  pros¬ 
tatic  obstruction,  it  was  the  speaker’s  practice  to  use  hydraulic 
pressure  to  dilate,  frequently  increasing  the  capacity  of  the  blad¬ 
der  from  half  an  ounce  to  four  ounces.  He  did  not  think  it 
necessary  to  give  anything  by  the  mouth  for  the  purpose  of  pre¬ 
venting  decomposition  of  urine,  when  we  had  the  means  of  ap¬ 
plying  it  directly  in  the  bladder. 

The  Address  on  Surgery— The  Ligature  of  Arteries.— 
Dr.  Stephen  Smith,  of  New  York,  said  that  his  paper  had  been 
prepared  with  a  view  of  noticing  some  of  the  contributions  of 
American  surgeons  to  the  improvement  and  development  in  the 
ligature  of  arteries.  The  general  surgical  history  of  this  work 
for  the  cure  of  aneurysm  might  be  divided  into  three  epochs. 


Nov.  8,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


The  first  came  down  to  1785,  and  was  known  as  the  old 
method;  the  second,  or  intermediate  period,  was  known  as  the 
new  method;  while  that  of  the  third,  or  present  period,  was 
called  the  antiseptic  period.  The  principle  upon  which  the  old 
method  was  based  was  the  obliteration  of  the  aneurysmal  tumor 
by  freely  opening  the  sac  and  promoting  suppuration.  The 
feature  of  the  operation  which  had  excited  most  interest  among 
surgeons,  and  which  had  led  to  improvements,  was  the  method 
o  ariesting  hasmorrhage.  At  first  the  open  artery  was  plugged 
after  the  sac  was  incised,  pledgets  of  cotton  being  sometimes 
employed.  Subsequently  the  open  artery  was  ligated  at  the 
bottom  of  the  sac,  and  then  the  sac  was  closed  and  allowed  to 
suppurate.  Then  the  ligation  was  done  outside,  but  close  to, 
the  tumor,  with  the  subsequent  incision  of  the  sac.  Again' 
ligatures  were  applied  one  above  and  the  other  below  the  tu¬ 
mor.  Whatever  the  variation  in  detail,  the  operation  had  al¬ 
ways  terminated  by  the  opening  of  the  sac.  The  speaker  then 
went  on  to  trace  the  steady  advance  of  operative  work  in  this 
direction.  Of  the  work  of  Hunter,  he  said  that  a  review  of  the 
surgical  literature  of  that  period  made  it  very  evident  that 
Hunter’s  operation  was  only  one  step,  and  not  a  very  long  one, 
in  the  treatment  of  aneurysm  by  operative  methods.  It  had 
proved  that  the  condition  might  be  cured  by  the  simple  ligature 
o  the  artery  on  its  proximal  side,  without  incision  of  the  sac 
and  incurring  the  danger  of  subsequent  suppuration.  The  sug¬ 
gestion  of  Brasdor— that  the  ligature  should  be  applied  on  the 
distal  side  of  the  tumor— was  important,  as  it  had  enabled  the 
operator  to  successfully  treat  a  class  of  cases  in  which  it  was 
impossible  to  ligate  the  main  trunk  on  the  cardiac  side.  Mott 
had  heartily  approved  of  the  operation,  and  the  success  that  had 
since  attended  it  evidenced  that  surgeon’s  practical  sagacity. 
After  going  very  thoroughly  over  the  whole  ground  inelaborate 
historical  survey  and  paying  graceful  tribute  to  the  work  of 
Post,  Mott,  Rodgers,  and  others  identified  with  progress  in  this 
direction,  the  author  stated  that  the  part  borne  by  American 
surgeons  in  the  history  of  the  ligature  of  arteries  was  most 
avorabl^.  They  had  not  only  been  pioneers  in  enlarging  the 

hnnn/lnitirt.-,  •  r*  i  i  n 


525 


|T  "  - - j  in  emailing  me 

boundaries  of  this  field  of  practice,  but  they  had  cultivated  it 
with  a  degree  of  success  unrivaled  even  by  British  surgeons. 
Statistics  demonstrated  that  during  the  first  three  quarters  of 
the  present  century,  of  sixteen  operations  upon  the  innominata, 
six  were  done  in  this  country.  Of  these  operations,  an  Ameri¬ 
can  surgeon  had  performed  the  first.  Of  thirteen  ligations  of 
the  subclavian  in  the  first  part  of  its  surgical  course,  Americans 
had  performed  five.  An  American  surgeon  had  alone  ligated 
the  subclavian  within  the  scaleni.  It  was,  however,  on  the  31st 
of  December,  1868,  that  an  event  had  occurred  which  was  des¬ 
tined  to  be  the  final  consummation  of  all  improvement  in  the 
ligature  of  arteries.  This  was  the  occasion  of  the  application 
of  ligatures  to  the  carotid  of  a  calf  by  Mr.  Joseph  Lister.  The 
ligatures  were  of  two  different  kinds,  and  were  applied  at  in¬ 
tervals  of  about  an  inch  and  a  half.  The  cardiac  ligature  was 
composed  of  three  strips  of  peritonaeum  from  the  small  intes¬ 
tine  of  an  ox,  firmly  twisted  ;  the  distal  end  was  made  of  fine 
catgut.  Both  had  been  treated  with  a  saturated  solution  of 
carbolic  acid.  The  ligatures  were  cut  short,  one  end  being  left 
longer  than  the  other.  The  wound  was  completely  closed,  and 
it  had  promptly  healed.  Thirty  days  after  the  operation  the 
parts  were  examined  post  mortem.  There  was  an  entire  ab¬ 
sence  of  inflammatory  thickening  in  the  vicinity  of  the  vessel. 
The  knots  of  the  distal  ligature  had  disappeared,  and  the  only 
indication  of  the  end  which  had  been  left  long  was  a  black 
speck  here  and  there  upon  a  delicate  cellular  tissue  in  connec¬ 
tion  with  the  vessel.  The  cardiac  ligature  was  continuous  in 
structure  with  the  arterial  wall ;  the  short  end  had  disappeared, 
but  the  knot  was  represented  by  a  soft,  smooth  lump,  in  the 


center  of  which  and  lying  close  to  the  artery  was  a  small  re¬ 
sidual  portion  of  the  original  knot,  quite  distinct  from  the  liv¬ 
ing  tissue  around  it.  Between  the  proximal  ligature  and  the 
heart  the  formation  of  a  coagulum  had  been  entirely  prevented 
by  a  large  vessel  taking  origin  immediately  above  the  part 
which  had  thus  borne  the  brunt  of  the  cardiac  impulse  for  a  full 
month.  Clots  had  been  formed  on  the  distal  side  of  the  ligature 
A  more  minute  examination  showed  that  the  material  which 
had  been  formed  at  the  expense  of  the  ligature  was  a  beautiful 
example  of  fibro-plastic  structure.  At  the  situation  of  the  distal 
ligature  the  structure  of  the  vessel  had  seemed  to  be  entirelv 
unaffected.  The  middle  coat  was  neither  thicker  nor  thinner 
than  the  neighboring  parts.  The  vessel,  so  far  from  showing 
any  signs  of  giving  way,  had  appeared  to  have  gained  additional 
strength ;  the  encircling  ring  of  new  tissue,  incorporated  with 
the  arterial  walls,  must  have  had  a  corroborative  effect  Mr 
Lister  in  commenting  upon  this  result,  had  made  the  assertion 
that  the  application  of  a  ligature  of  animal  tissue  antisepticallv 
upon  an  artery,  whether  tightly  or  gently,  virtually  surrounded 
it  with  a  ring  of  living  tissue,  and  strengthened  the  vessel 
where  it  constricted  it.  A  more  complete  revolution  in  prac¬ 
tice  could  hardly  be  imagined.  Mr.  Lister’s  further  assertion 
that  the  surgeon  might  now  tie  an  arterial  trunk  in  its  conti¬ 
nuity  close  to  a  deep  branch,  secure  against  secondary  hemor¬ 
rhage  and  deep-seated  suppuration,  had  been  amply  verified 
A  casein  point  in  the  author’s  experience  was  that  of  a  man' 
aged  forty,  who  had  suffered  from  cancer  of  the  tongue  tonsil’ 
and  pharynx,  and  had  come  under  observation  at  a  stage  of  the 
disease  to  avoid  the  repetition  of  the  haemorrhages  which  had 
already  occurred  and  of  which  the  patient  stood  in  great  dread 
The  speaker  had  ligated  with  carbolized  catgut  between  the  di 
visions  of  the  common  carotid  and  the  superior  thyreoid  branch 
of  the  external  carotid.  The  ligature  was  drawn  tightly  but 
not  so  firmly  as  to  divide  the  coats  of  the  vessel.  The  man 
dying  soon  after  from  inanition  and  exhaustion  due  to  his  dis 
ease  it  was  found  post  mortem  that  the  operation  had  accom¬ 
plished  all  that  was  expected  of  it.  The  common  carotid  was 
perfectly  free  and  without  change.  At  the  bifurcation  and 
along  the  extent  of  the  internal  carotid  the  caliber  of  the  ves 
sels  was  normal  and  there  was  no  inflammatory  product.  At 
about  a  quarter  of  an  inch  from  the  origin  of  the  external  ca¬ 
rotid  the  caliber  of  that  vessel  suddenly  diminished,  and  an 
eighth  of  an  inch  higher  it  was  completely  closed.  There  was 
no  evidence  that  clot  had  ever  existed.  Externally  there  was 
a  bulbous  enlargement  at  the  seat  of  the  ligature.  The  arterv 
seemed  to  be  encircled  by  a  ring  of  newly  formed  tissue  as 
hard  and  dense  as  a  cicatrix.  The  result  of  the  ligature  as  a 
who  e,  was  (1)  the  closure  of  the  artery  immediately  by  pressure 
(2)  the  closure  of  the  artery  permanently  by  the  union  of  the 
opposing  surfaces  of  the  living  membranes,  and  (3)  the  strength 
emng  of  the  artery  at  the  point  of  ligation  tenfold  by  the  for 
mation  of  an  immense  ligature  of  fibrous  tissue.  Standing  upon 
the  present  delectable  heights,  said  the  speaker,  how  vain 
seemed  the  struggle  of  the  fathers  in  this  branch  of  surgery! 
Operations  which  they  had  performed  only  after  days*  and 
nights  of  wearisome  study  and  anxiety  might  now  be  turned 

°Vem[°  tmlh0Spital  8tudent  for  hi9  technical  improvement 
The  Therapeutics  of  Exophthalmic  Goitre.— Dr  E  D 
Ferguson,  of  Rensselaer  County,  read  a  paper  with  this  title! 
Exophthalmic  goitre,  he  said,  was  not  a  common  disease,  and 
yet  it  was  not  so  rare  as  to  render  it  a  curiosity.  Though  the 
disease  was  one  with  sufficiently  well  defined  characteristics  to 
allow  of  its  ready  recognition,  still  errors  of  diagnosis  might 
and  doubtless  did  occur.  The  fact  was  that  enlargement  of  the 
thyreoid  body  was  not  peculiar  to  the  disease,  and  that  a  frequent 
pulse  was  attendant  on  a  multitude  of  morbid  conditions,  and 


526 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


occasional  prominence  of  the  eyes  might  be  added  from  causes 
not  the  same  as  the  condition  determining  the  development  of 
exophthalmic  goitre.  The  conclusion  that  the  condition  was 
not  at  any  rate  a  pathological  unit  had  been  strengthened,  in 
the  judgment  of  the  writer,  by  the  results  of  the  use  of  digi¬ 
talis,  for  in  every  instance  in  which  he  had  felt  confident  of  the 
diagnosis  that  drug  had  not  only  failed  to  afford  relief,  but  was 
apparently  productive  of  injury.  The  writer  then  gave  in  de¬ 
tail  the  histories  of  several  cases  of  exophthalmic  goitre  treated 
with  strophanthus.  The  administration  of  this  had  afforded 
prompt  relief,  the  patients  being  able  to  return  to  their  ordinary 
occupation.  In  no  instance  had  either  the  exophthalmia  or 
the  goitre  been  entirely  removed,  and  so  far  as  the  latter  was 
concerned,  the  author  would  not  expect  its  removal,  for  when 
the  enlargement  had  existed  for  some  time  it  became  of  so 
dense  or  fibrous  a  consistence  as  to  preclude  the  idea  of  its  com¬ 
plete  removal.  There  was,  however,  a  notable  degree  of  im¬ 
provement  both  in  the  exophthalmia  and  in  the  thyreoid  body, 
but  it  was  impossible  to  express  in  mathematical  terms  the 
changes  in  these  features  of  the  disease  so  well  as  could  be 
done  in  the  rate  of  the  pulse.  Not  only  were  the  rate  and 
rhythm  of  the  contractions  favorably  influenced,  but  in  these 
cases  there  undoubtedly  existed  a  dilatation  of  the  left  ventricle 
which  improved  so  as  to  leave  no  physical  or  symptomatic  evi¬ 
dence  of  cardiac  lesion.  Recent  pathological  considerations 
tended  to  place  exophthalmic  goitre  in  the  category  of  the 
neuroses,  and  the  locus  of  its  origin  in  the  floor  of  the  fourth 
ventricle.  Still,  the  evidence  was  not  such  as  to  give  any  clew 
concerning  its  aetiology  or  treatment,  aside  from  clinical  ob¬ 
servations,  and  consequently  there  was  no  explanation  to  offer 
as  to  the  method  by  which  strophanthus  afforded  relief,  aside 
from  the  idea  that  first  suggested  its  use,  and  that  was  to  re¬ 
lieve  an  apparently  overtaxed  heart  through  the  lessening  of 
the  resistance  in  the  systemic  circulation  which  was  alleged  to 
be  its  action.  Aside  from  any  theoretical  consideration  as  to 
the  way  in  which  the  agent  acted,  the  fact  remained  that  bene¬ 
fit  was  apparently  the  direct  result  of  the  use  of  strophanthus — 
a  benefit  so  notable  as  to  almost  justify  the  announcement  of  a 
cure  in  some  of  the  cases.  The  only  preparation  used  by  the 
writer  was  the  tincture,  given  by  the  mouth,  three  times  daily 
at  each  meal,  the  initial  dose  being  from  eight  to  ten  drops, 
which  was  increased,  if  necessary  to  reduce  the  frequency  of 
the  pulse,  to  fifteen  or  twenty,  or  even  twenty  five  drops. 
Whether  its  apparent  utility  would  bear  the  test  of  time  and 
larger  experience  was  still  problematical.  At  present  it  seemed 
to  be  our  most  valuable  therapeutic  resource  in  exophthalmic 
goitre. 

Dr.  Cronyn  was  glad  that  the  speaker  had  given  digitalis 
its  proper  place  in  the  treatment  of  the  disease. 

Dr.  A.  L.  Carroll,  of  New  York  County,  said  that  he  had 
been  impressed  with  the  difference  which  existed  in  the  prepa¬ 
rations  of  the  drug  strophanthus  now  in  the  market.  He 
thought  he  had  been  the  first  to  employ  it  here  after  the  pub¬ 
lication  of  the  first  paper  on  the  subject.  His  case  was  one  of 
dilatation  following  valvular  lesion.  Its  action  had  been  prac¬ 
tically  nil.  He  had  then  directed  that  another  preparation 
should  be  procured.  This  had  produced  marked  physiological 
action  after  a  few  doses. 

Obstetrics. — This  subject  was  made  the  basis  of  special  and 
general  discussion,  the  following  questions  being  propounded: 

(1)  How  may  the  present  prophylactic  measures  in  obstet¬ 
rics  be  more  extended  and  applied  ? 

(2)  Is  the  present  technique  in  the  management  of  labor 
and  convalescence  in  accordance  with  sound  physiology? 

(3)  To  what  extent  have  the  surgical  means  of  treatment  of 
labor  complications  been  successful,  or  should  these  complica¬ 


tions  and  the  process  of  repair  have  been  more  generally  left  to 
Nature? 

(4)  What  influence  would  a  more  advanced  obstetric  sci. 
ence  have  on  the  biological  and  social  condition  of  the  race? 

Dr.  S.  B.  W.  McLeod,  of  New  York  County,  presented  the 
first  paper  on  this  subject.  He  said  that  as  a  science  obstetrics 
was  conservative,  but  was  pre-eminently  progressive  as  an  art. 
Antiseptics,  meddlesome  midwifery,  and  prophylaxis  were  then 
fully  dealt  with.  The  support  of  the  perinseum  was  the  sub¬ 
ject  of  much  consideration.  The  dorsal  and  the  lateral  postures 
of  the  patient  in  labor  and  the  use  of  bandages  had  their  advo¬ 
cates,  and  these  not  a  few.  It  was  worthy  of  special  attention 
that,  while  there  were  about  one  hundred  and  thirty  medicines 
now  before  the  profession,  those  that  were  designated  “  new 
remedies,”  a  few  of  these,  perhaps  eight,  were  of  use  in  obstet¬ 
rics.  Ergot  as  an  oxytocic  still  remained  without  a  successful 
rival.  The  tears  in  ruptured  uteri  were  sewed  under  antiseptic 
details,  and  these  lesions  always  offered  prospects  of  recovery. 

Dr.  W.  MoCollom,  of  Kings  County,  thought  that  between 
extremes  there  was  always  a  golden  mean.  Savage  and  untu¬ 
tored  natives  did  not  become  extinct  by  reason  of  puerperal  fe¬ 
ver,  nor  did  all  the  civilized  women  die  because  of  the  amount 
of  bichloride  that  was  thrown  into  the  gaping  veins  of  the  re¬ 
cently  emptied  uterus.  In  answer  to  the  question  propounded, 
he  should  say  that  all  medical  students  should  be  instructed  that 
if,  when  in  practice,  they  were  called  to  a  case  of  obstetrics,  they 
should  first  take  a  Russian  bath,  have  the  hair  cut  and  sham¬ 
pooed,  and  buy  a  new  suit  of  clothes.  On  entering  the  lying-in 
chamber,  the  physician  should,  if  he  had  touched  the  door-knob, 
plunge  his  hands  into  a  strong  solution  of  carbolic  acid  or  bi¬ 
chloride.  Then  he  should  have  a  steam  atomizer  at  work  cast¬ 
ing  a  spray  that  would  act  like  a  Gatling  gun  on  any  bacilli  that 
might  have  come  in  out  of  curiosity  or  with  fiendish  intent.  The 
bacteria  must  then  be  dug  from  the  finger-nails  and  thrown  into 
the  fire.  Then,  after  again  washing  the  hands  and  face  in  bi¬ 
chloride,  the  chemically  pure  accoucheur  might  make  an  ex¬ 
amination  when  the  patient  told  him  that  the  child  was  com¬ 
ing.  The  patient  should  have  a  constant  stream  of  bichloride 
thrown  on  the  genitals,  or  have  the  nates  immersed  in  a  tub  fit¬ 
ted  to  the  bed,  full  of  the  same  material.  If  the  child,  when 
born,  should  swallow  some  of  the  fluid,  it  would  at  once  kill 
any  bacilli  of  which  it  had  inadvertently  partaken  in  utero.  No 
competent  practitioner  would  allow  the  child  to  drown,  of  course. 
If  the  case  should  be  one  of  breech  presentation,  a  cork  should 
be  adjusted  within  the  sphincter  ani  to  prevent  the meconial  cocci 
from  getting  out  too  soon.  The  douching  or  hip-bath  should 
be  continued  till  the  placenta  was  expelled.  Then  a  bichloride 
pad  should  be  placed  over  the  genitals  and  they  should  be  her¬ 
metically  sealed,  not  to  be  opened  except  under  like  antiseptic 
precautions.  They  might  think  him  frivolous,  but  he  had  heard 
as  ridiculous  teaching  from  high  authority.  As  a  matter  of 
serious  fact,  he  would  have  everything  as  clean  as  possible. 
The  speaker  made  this  the  sine  qua  non  of  all  procedures 
throughout  the  whole  parturient  period,  whether  complicated 
or  not. 

Dr.  G.  T.  Harrison,  of  New  York  County,  said  that  the 
most  important  work  of  the  obstetrician  was  to  see  that  he  did 
not  infect  his  patient.  Vaginal  examination  should  be  made 
only  in  the  interest  of  the  mother  and  child.  The  most  ex¬ 
treme  limitations,  and  even  entire  omission  of  internal  exami¬ 
nation,  might  be  very  well  compensated  for  and  replaced  by  ex¬ 
ternal  methods.  Of  the  paramount  importance  of  the  thorough 
disinfection  of  the  hands,  and  of  all  instruments,  vessels,  and 
clothing  likely  to  be  brought  into  contact  with  the  parturient 
woman,  so-called  subjective  antisepsis,  we  were  all  agreed.  Of 
the  necessity  for  an  objective  antisepsis,  so  far  as  thorough 


Nov.  8,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


cleansing  and  disinfection  were  concerned,  there  could  be  no 
question.  A  streptococci  invasion  through  so-called  self-in¬ 
fection  by  the  natural  genital  secretions  was  impossible,  and 
the  healthy  parturient  woman  might  be  regarded  as  aseptic. 
Virulent  infective  germs  always  came  from  without.  Antisep¬ 
tic  vaginal  douches  should  not  be  given,  therefore,  before  or 
during  the  birth  in  a  normal  condition  of  the  pregnant  or  par¬ 
turient  woman.  These  were  also  contra-indicated  under  the 
same  conditions  immediately  after  the  birth  and  during  the 
puerperal  state,  as  they  were  not  only  useless  but  positively  in¬ 
jurious.  It  must  be  borne  in  mind  that  the  course  of  birth  was 
mechanically  retarded  by  the  loss  of  the  vaginal  mucus,  as  one 
of  its  physiological  functions  was  to  diminish  friction  and  facili¬ 
tate  the  passage  of  the  child’s  head  through  the  canal  invested 
by  it.  The  detachment  and  expulsion  of  the  placenta  from  the 
uterine  body  into  the  lower  uterine  segment  occurred  spontane¬ 
ously,  and,  according  to  physiological  law,  required  for  its  com¬ 
pletion  from  five  to  fifteen  minutes.  The  author  would  not  in¬ 
terfere  with  the  placenta  unless  there  was  some  obstacle  in  the 
way  of  its  complete  expulsion,  and  would  not  adopt  external 
manipulation.  The  natural  forces  were  fully  adequate  to  the 
detachment  of  the  placenta,  and  there  was  no  necessity  of  any 
kind  of  active  interference  on  the  part  of  the  obstetrician  to 
assist  the  physiological  act.  In  regard  to  haemorrhage,  Orede’s 
method  and  Schroeder’s  modification  were  not  objectionable 
when  properly  employed  with  reference  to  retained  portions  of 
decidua  and  chorion.  Too  much  emphasis  could  not  be  laid  upon 
the  importance  of  an  ocular  inspection  of  the  external  genitalia 
immediately  after  the  expulsion  of  the  placenta  in  order  to  ascer¬ 
tain  the  existence  of  any  wounds  about  the  vaginal  outlet.  Dur¬ 
ing  the  puerperal  state  two  predisposing  factors  came  into  play 
which  rendered  it  comparatively  easy  for  dislocating  forces  to 
unfold  their  efficacy.  All  the  pelvic  organs  were  in  a  condi¬ 
tion  of  relaxation  and  the  uterus  was  enlarged  and  swollen ;  if, 
therefore,  the  patient  lay  persistently  ou  her  back  and  the 
bladder  was  allowed  to  become  distended,  and  if  the  rectum,  in 
addition,  was  left  permanently  filled,  it  must  follow  as  a  neces- 
saiy  consequence  that  the  fundus  uteri  was  forced  backward 
on  the  one  hand  and  the  cervix  was  anteposed  on  the  other 
hand,  involution  was  hindered,  and  retro-utero-fiexio  was  the 
result. 

Dr.  T.  J.  McGilliotjddy,  of  New  York  County,  thought  that 
the  skillful  use  of  the  forceps  undoubtedly  decreased  infantile 
mortality,  but  its  bungling  manipulation  increased  it.  It  was 
said  that  the  forceps  was  applied  much  more  frequently  in 
private  than  in  hospital  practice.  This  was  to  be  deplored,  be¬ 
cause  in  many  cases  the  child  often  lived  only  a  week  or  two, 
and  generally  died  from  some  cerebro-spinal  lesion.  Episeoto- 
my  was  an  operation  which  seldom  did  what  was  expected 
of  it. 

Dr.  W.  H.  Robb,  of  Montgomery  County,  thought  that  we 
might  look  forward  to  the  time  not  far  distant  when  the  ad¬ 
vance  in  obstetrical  science  would  furnish  the  instruments  and 
therapeutic  resources  by  which  the  most  deformed  women  could 
be  safely  delivered  of  a  living  child.  Obstacles  to  the  safe  de¬ 
livery  of  the  mother  resulting  from  deformity  of  the  child 
would  be  surmounted  in  a  similar  way.  All  injuries  to  the 
mother  resulting  from  labor  would  be  immediately  repaired 
and  any  injury  to  the  child  would  be  promptly  treated.  With 
these  accidents  successfully  met  or  prevented  we  should  find  at 
our  command  resources  for  the  prevention  of  puerperal  dis¬ 
eases.  New  remedies  would  be  discovered,  new  methods  would 
be  tried  until  a  more  advanced  obstetrical  science  furnished 
means  by  which  the  diseases  and  accidents  incident  to  gestation 
would  be  relieved,  the  changes  resulting  from  difficult  labor 
overcome,  and  complications  of  the  puerperal  state  entirely  ^ 


527 

prevented,  "lhe  race  would  be  benefited  by  the  preservation 
of  many  valuable  lives.  A  goodly  number  of  mature  and 
healthy  women  would  be  saved.  Women  who  now  suffered 
for  years  as  the  result  of  injury  or  disease  due  more  or  less  to 
the  complications  of  the  lying-in  state,  women  who  from  pro¬ 
tracted  suffering  were  rendered  almost  demoniacal,  would  be 
preserved  to  adorn  their  natural  sphere  as  ministering  angels. 

Dr.  A.  P.  Dudley,  speaking  to  the  point  as  to  whether 
the  complications  and  processes  of  repair  should  be  more  gen¬ 
erally  left  to  Nature,  spoke  very  emphatically  upon  the  subject 
of  the  Caesarean  section.  It  was  a  measure,  he  contended,  now 
very  nearly  perfect  in  technical  detail.  If  properly  done,  he  be¬ 
lieved  it  would  in  time  become  more  successful  than  craniotomy 
done  when  a  woman  was  thoroughly  exhausted  by  her  own  ef¬ 
forts  to  expel  the  child  naturally  or  by  the  efforts  of  the  phy¬ 
sician  to  do  so  with  the  forceps.  One  of  the  chief  conditions 
of  success  in  this  operation  was  that  it  should  be  begun  early, 
before  the  patient  became  too  exhausted.  He  had  never  given 
a  vaginal  douche  before  the  birth  of  the  child,  and  had  never 
had  a  case  of  sepsis.  He  would  suggest  that  the  existence  of  a 
condition  of  pyosalpinx  was  likely  to  prove  a  very  fertile  source 
of  infection  at  the  time  of  delivery.  In  such  event  the  uterus 
might  have  been  washed  out  and  every  antiseptic  precaution 
have  been  taken ;  there  might  exist  no  injury  to  the  cervix  or 
perinseum,  and  still  puerperal  fever  would  develop  and  the  pa¬ 
tient  die.  The  same  result  might  ensue  from  any  diseased  con¬ 
dition  about  the  bladder.  He  thought  he  had  seen  such  cases 
in  hospital  practice.  As  a  matter  of  fact,  it  was  seldom  that  sep¬ 
sis  occur  1  ed,  except  as  the  result  of  gross  neglect.  It  was  his 
rule  never  to  consider  a  case  of  labor  ended  till  he  had  exam¬ 
ined  the  uterus.  It  was  very  easy  to  pass  a  speculum.  He  was 
in  the  habit  of  delivering  the  woman  on  her  side.  In  this  post¬ 
ure  he  had  the  perinseum  well  in  view  and  under  control.  He 
could  sew  up  a  tear  and  the  patient  never  know  it.  A  few  drops 
of  cocaine  were  all  that  was  necessary.  He  then  introduced  a 
needle  at  the  top  ot  the  rent  and  repaired  the  injury  with  an 
over-and-over  catgut  suture.  His  answer  to  the  second  question 
propounded  would  be  “  No.” 

Dr.  0.  0.  Frederick,  of  Erie  County,  said  he  thought  that 
the  point  of  primary  importance  to  the  race  to  come  was  the 
question  of  the  present  preservation  of  the  healt  h  of  the  species. 
Reviewing  the  accidents  during  labor,  he  said  the  predisposing 
causes  of  injuries  of  the  ureters  at  that  time  were  found  in  alow 
position  of  the  bladder  and  ureters,  and  an  impaired  nutrition 
of  these  organs  during  gestation,  due  to  oedema  and  pressure. 
When  the  membranes  ruptured  before  dilatation  was  completed, 
the  cervix  and  the  bladder  were  carried  down  into  the  pelvis 
before  the  advancing  head,  thus  exposing  the  ureters  to  danger 
of  injury.  The  use  of  forceps  in  such  cases  was  a  frequent  cause 
of  injury.  To  prevent  injury  of  this  kind,  complete  dilatation 
should  be  secured,  if  possible,  before  the  membranes  ruptured. 

If  they  did  rupture  early  and  the  cervix  was  tense,  support 
9hould  be  given  to  the  bladder  and  anterior  vaginal  wall,  and 
retraction  of  the  cervix  over  the  vertex  secured  as  early  as  pos¬ 
sible.  The  discussion  between  the  advocates  of  the  expectant 
method  of  placental  delivery  and  the  followers  of  Cred6  still 
continued,  especially  in  Europe. 

Dr.  A.  L.  Carroll  read  an  elaborately  prepared  statistical 
paper  bearing  upon -the  subject  of  the  discussion.  (To  be  pub¬ 
lished.) 

The  Medicine  of  the  Classics.— The  Hon.  C.  II.  Truax,  of 
New  York,  delivered  an  address  on  this  subject.  He  took  for 
his  remarks  the  humorous  side  of  the  picture  and  brought  out, 
as  the  result  of  a  great  deal  of  very  scholarly  research,  the  fact 
that  even  as  far  back  as  iEsculapius  the  physicians  of  that 
period  were  given  to  playing  upon  the  credulity  of  their  pa- 


528 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jock., 


tients  and  were  as  unscrupulous  in  the  matter  of  fees  when  op¬ 
portunity  offered  as  their  possibly  equally  necessitous  brethren 
of  to-day. 

The  Physician  as  a  Witness. — Dr.  Martin  Cay  ana,  of 
Madison  County,  in  a  telling  paper  on  this  subject,  urged  upon 
the  profession  to  take  more  pains  to  qualify  for  the  work  of  ex¬ 
pert  testimony  before  going  into  the  witness  box.  Then  it  was 
■well  to  adhere  to  the  one  or  two  authorities  which  had  been 
studied  and  to  disclaim  any  familiarity  with  others.  While  the 
main  anatomical  features  likely  to  come  up  should  be  looked  up, 
the  witness  need  never  hesitate  to  admit  having  forgotten  such 
portions  of  the  matter  as  he  could  not  readily  recall.  lie  could 
then  take  the  opportunity  to  remind  the  court  that  even  the 
lawyers  were  obliged  to  consult  their  authorities.  It  was  well  to 
secure  the  favor  of  the  entire  court  by  manifesting  a  spirit  of 
fairness  to  both  parties  in  the  action.  Technicalities  should  be 
avoided  and  the  purport  of  every  question  by  the  cross-examina¬ 
tion  well  weighed  before  answering.  People  with  no  business 
in  the  autopsy  room  should  be  kept  out  of  it.  If  the  fire-shovel 
or  wood-saw  was  used  in  making  the  dissection,  it  was  well  not 
to  let  any  non-professional  eyes  witness  the  fact,  lest  it  should 
lay  the  operator  open  to  unpleasant  remarks. 

Some  Observations  on  Bone  and  Skin  Grafting  was  the 
subject  of  a  paper  by  Dr.  B.  M.  Ricketts,  of  Cincinnati,  Ohio. 
Grafting  or  dermapenthesis  in  the  vegetable  kingdom  had  been 
developed  to  such  an  extent  that  there  was  hardly  any  limit  as 
to  what  could  be  done  in  the  way  of  repair  and  production, 
beauty  and  financial  gain  being  the  greatest  de>iderata.  While 
the  results  of  grafting  animal  tissue  were  less  gratifying  than 
those  of  vegetable  tissue,  much  had  been  done  to  convince  us 
that  the  limit  was  far  beyond  anything  yet  attained.  Of  the 
many  questions  that  arose  relative  to  the  subject  of  bone  and 
skin  grafting,  there  were  three  most  prominent,  namely:  1. 
Where  and  how  should  skin  be  grafted  upon  raw  surfaces 
caused  by  injury,  or  by  the  removal  of  malignant  or  non  malig¬ 
nant  growths?  2.  How  and  where  might  bones  be  restored? 
3.  Should  fragments  of  normal  bone  be  permanently  removed 
except  in  case  of  amputation?  The  author  limited  the  first 
question  to  the  cases  where  the  edges  of  the  resulting  wound 
could  not  be  immediately  coapted,  coaptation  being  given  pref¬ 
erence  under  all  circumstances.  In  the  second  class  of  cases 
he  included  the  restoration  of  the  bones  of  the  hands,  feet,  arms, 
or  legs  that  had  been  removed  by  trauma  or  surgical  interfer¬ 
ence  without  amputation.  Bone  grafting  or  osteopenthesis, 
while  not  so  far  advanced,  was  capable  of  the  same  successes  as 
skin  grafting.  Enough  had  already  been  done  to  show  that  its 
confines  were  not  narrow  by  any  means.  As  to  the  third  ques¬ 
tion — that  of  bone  fragments  in  either  compound  or  compound 
comminuted  fractures — where  a  bone  was  crushed  or  broken 
into  two  or  more  pieces,  the  greatest  care  should  be  taken  to 
replace  the  fragments  and  to  offer  every  opportunity  for  their 
union,  that  the  strength  and  original  shape  of  the  bone  might 
be  preserved.  That  this  might  be  more  certain,  all  clots  and 
foreign  matter  should  be  cleared  away  and  shreds  of  tissue  re¬ 
moved  from  between  the  fragments,  which  should  be  imme¬ 
diately  restored  to  their  proper  places.  In  some  cases,  as  in 
the  long  bones,  the  fragments  might  be  firmly  brought  together 
with  silver  wire,  which  could  afterward  be  removed.  The  au¬ 
thor  looked  upon  exploratory  incisions  in  cases  where  the  con¬ 
ditions  of  the  bone  could  not  be  determined  as  justifiable  and 
as  being  the  only  means  of  knowing  the  exact  condition,  clean 
surgery  being  the  safeguard.  A  number  of  specimens  of  bone 
wiring  in  the  dog  were  then  exhibited. 

Abdomino-pelvic  Serous  Cysts  and  Cystic  Formations.— 
This  was  the  subject  of  a  paper  by  Dr.  T.  II.  Manley,  read  by 
title.  The  author  described  a  serous  cyst  as  a  structure  of  a  low 


grade  of  development  not  under  ordinary  circumstances  pro¬ 
ducing  mixed  elements,  and,  when  unencumbered  by  patho¬ 
logical  changes,  maintaining  its  original  histological  character. 
The  anatomical  essentials  were  an  investing  envelope,  composed 
of  cellular  elements,  with  more  or  less  numerous  nucleated 
strands  of  fibrous  tissue,  and  becoming  eliminated  only  by  age 
or  inflammatory  changes.  Internally  the  lining  was  of  endothe¬ 
lial  cells,  having  the  power  of  both  increasing  and  diminishing 
the  quantity  of  the  encapsulated  liquid.  The  liquid  contents, 
although  designated  serous,  possessed  no  property  in  common 
with  the  serum  of  the  blood  except  in  physical  character. 
These  cysts,  he  was  convinced,  had  for  their  origin  an  undis¬ 
covered  microbe,  which  gained  entry  by  way  of  the  aerial  or 
alimentary  passages,  and,  when  finding  suitable  soil  or  the  sys¬ 
tem  in  a  receptive  state,  they  rapidly  developed.  In  considering 
the  aetiology  of  these  formations,  the  writer  pointed  out  that 
age  and  sex  were  important  factors,  females  being  the  greatest 
sufferers.  The  formations  might  be  regarded  as  evidences  of  a 
degenerative  process,  and,  inasmuch  as  serous  cysts  were  sel¬ 
dom  seen  except  in  the  reproductive  and  urinary  organs,  they 
might  be  regarded  as  in  some  manner,  as  yet  inexplicable,  con¬ 
nected  with  the  functional  derangements  in  this  region.  After 
an  exhaustive  review  of  the  morbid  anatomy  and  symptoms, 
the  writer,  in  dealing  with  the  subject  of  treatment,  said  it 
would  not  do  to  be  deluded  by  the  reports  from  palatial  hospi¬ 
tals,  as  such  statistics  could  hardly  be  regarded  as  reliable  cri¬ 
teria  for  the  isolated  rural  practitioner.  Not  that  such  state¬ 
ments  were  wanting  in  truth  or  were  varnished,  but  because 
there  was  but  little  comparison  in  the  facilities  for  operating. 
In  many  hospitals  the  cases  were  selected  with  great  care. 
The  advice  given  by  the  elder  generation  of  surgeons  and  prac¬ 
titioners  was  sound.  They  recommended  marriage  as  a  physio¬ 
logical  relief  when  the  cysts  were  of  recent  growth  in  the  pelvis 
of  the  female.  It  was  argued  that,  when  fecundation  followed 
copulation,  the  immediate  active  vascularity  in  the  formerly 
languid,  congested  capillaries  soon  aroused  the  latent  vitality  in 
the  reproductive  organs,  and  that  superfluous  adventitious  pro¬ 
ductions,  recent  in  growth  and  moderate  in  size,  underwent  de¬ 
generative  changes  and  disappeared.  He  had  never  seen  any 
benefit  from  massage  or  electricity.  When  cystic  disease  threat¬ 
ened  to  compromise  health  and  became  the  source  of  pain  or 
discomfort,  internal  remedies  would  make  no  impression,  and 
active  interference  was  in  many  cases  all  that  was  left.  Stu¬ 
pendous  progress  had  been  made,  it  was  true,  but  it  must  be 
remembered  that  all  operations  involving  the  abdomen  were 
fraught  with  more  or  less  danger,  and  all  entailed  mutilation; 
hence  conservatism  should  be  the  word. 

Functional  Disorders  of  the  Nervous  System  of  Women. 
— This  was  the  title  of  a  paper  by  Dr.  F.  J.  MoGillicuddy. 
Under  this  heading  he  classified  a  number  of  diseases  which, 
although  not  entirely  restricted  to  women,  were  found  much 
more  frequently  in  the  female  than  in  the  male  sex.  The  hys- 
teroneuroses  were  gastric,  glandular,  cardiac,  brachial,  pharyn¬ 
geal,  spinal,  cerebral,  ophthalmic,  and  dermatic — hystero-epi- 
lepsy,  hysterocatalepsy,  trance,  lethargy,  narcdepsy,  ecstasy, 
hysteric  hypnotism,  somnambulism,  migraine,  and  recurrent 
orgasm.  A  knowledge  of  the  different  hysteroneu roses  was 
extremely  important,  otherwise  the  wrong  organs  would  get 
the  medication.  In  the  menstrual  hysteroneuroses  there  was 
undoubtedly  local  congestion  dependent  on  reflex  irritation. 
The  globulus  hystericus  was  most  assuredly  in  many  instances 
a  local  congestion,  which  could  be  determined  by  placing  the 
finger,  during  its  existence,  on  the  front  of  the  throat,  when  it 
would  be  found  to  be  very  tender  to  the  slightest  pressure. 
Hystero-epilepsy  was  only  hysteria  in  the  highest  degree,  and 
not  hysteria  complicated  with  other  neuroses. 


Nov.  8,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


529 


The  Management  of  the  Placenta  in  Abortion.— Dr. 
Darwin  Colvin,  of  \Y  ayne  County,  in  a  paper  on  the  correct 
method  ot  dealing  with  the  placenta  in  the  second  stage  in  cases 
of  abortion,  said  he  made  it  a  rule  never  to  leave  the  parturient 
chamber  until  the  placenta  was  in  his  hands.  He  should  con¬ 
sider  that  in  the  event  of  any  trouble  arising  out  of  neglect  to 
do  this  a  physician  would  be  guilty  of  malpractice. 

Dr.  McLeod  said  that  in  a  very  extensive  obstetric  practice 
he  had  never  had  a  death  occur  from  sepsis  due  to  retained 
secundines. 

Dr.  i  ergdson  said  that  if  that  was  really  the  case,  the  last 
speaker  was  very  much  more  lucky  than  most  of  his  hearers. 

The  meeting  closed  with  the  introduction  of  the  newly 
elected  president,  Dr.  Stephen  Smith,  of  New  York. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Meeting  of  October  16 ,  1890. 

The  President,  Dr.  Alfred  L.  Loomis,  in  the  Chair. 

Hydrophobia;  its  Clinical  Aspect.— Dr.  L.  C.  Gray  read 
a  paper  with  this  title.  At  the  very  threshold  of  the  subject, 
he  said,  we  were  confronted  by  the  question  as  to  whether  there 
was  such  a  thing  as  rabies  or  hydrophobia.  There  had  been 
much  and  bitter  discussion  upon  this  point  during  the  last  few 
years.  Those  who  would  answer  this  question  in  the  affirma¬ 
tive  alleged  as  proof  the  fixed  belief  of  ages,  and  the  many 
epizootics  of  which  we  had  historical  record.  The  disease  had 
never  been  very  prevalent  in  this  country,  although  local  epi¬ 
zootics  of  it  had  been  reported  from  time  to  time.  It  would 
also  appear  to  be  conclusively  proved  that  many  people  had  died 
after  being  bitten  by  rabid  animals.  But  there  had  sprung  up 
in  America  in  the  last  few  years  a  small  number  of  very  decided 
opponents  of  these  statements.  The  extreme  variability  in  the 
period  of  incubation  in  hydrophobia  lent  credence  to  the  belief, 
that  was  firmly  held  by  many  competent  observers,  that  death 
could  occur  from  fear,  with  symptoms  closely  resembling  those 
of  the  true  disease.  Although  a  recent  writer  had  characterized 
such  a  belief  as  childish,  it  was  nevertheless  a  matter  of  clinical 
observation  that  great  psychical  shock  could  produce  mental 
disease  and  death.  The  author  related  several  cases  which  had 
come  under  his  own  notice  that  bore  out  this  statement.  In 
the  city  of  New  Y  ork  during  a  period  of  thirty-five  years,  from 
1855  up  to  the  present  time,  there  had  been  but  seventy-six 
deaths  from  hydrophobia.  The  author  believed,  from  a  review 
of  the  subject,  that  he  was  justified  in  the  following  conclusions: 
That  frequent  mistakes  were  made  in  the  diagnosis  of  rabies 
and  hydrophobia;  that  the  so-called  dumb  rabies  was  a  symp¬ 
tom  of  simple  purulent  meningitis  and  meningo  encephalitis; 
and  that  very  few  cases  of  either  rabies  or  hydrophobia  had 
been  observed  in  New  York  city  or  in  the  country  at  large. 
Admitting  all  this,  however,  the  question  still  remained  as  to 
whether  there  was  a  true  rabies  or  a  true  hydrophobia.  The 
author  believed  that  there  was  a  disease  running  a  fatal  epi¬ 
zootic  course  in  the  dog  and  also  other  lower  animals,  and  capa¬ 
ble  of  being  communicated  to  the  human  being  and  causing 
death,  although  the  evidence  of  this  would  rest  mainly  upon  the 
pathological  and  experimental  considerations  which  would  be 
presented  by  Dr.  Dana  and  Dr.  Biggs. 

The  Reality  of  Rabies  was  the  title  of  a  paper  by  Dr.  0.  L. 
Dana.  He  said  that  in  order  to  prove  that  a  certain  disease  was 
autonomous,  distinct,  and  special,  we  must  establish  the  fact  that 
its  aetiology  and  its  clinical  history  were  essentially  uniform,  or 
that  the  anatomical  changes  found  after  death  were  the  same, 
or  that  inoculations  of  animals  with  the  secretions  or  tissues  of 


the  victim  of  the  disease  reproduced  the  disease.  The  proof  of 
the  unity  of  a  disease  was,  therefore,  (1)  aetiological,  (2)  clinical, 
(3)  anatomical,  aud  (4)  experimental.  The  unity  of  some  dis¬ 
eases  could  be  established  by  only  one  or  two  of  the  four  meth¬ 
ods,  not  by  all.  In  the  case  of  rabies,  a  comparatively  rare  and 
obscure  disorder  occurring  in  the  lower  animals,  so  that  only 
objective  symptoms  could  be  studied,  it  was  important  that  all 
the  proofs  should  be  brought  into  use.  The  aetiological  and 
clinical  proof  of  the  existence  of  the  disease  rabies  was  based 
upon  the  fact  that  different  observers  in  every  part  of  the  world, 
from  time  immemorial  until  the  present  time,  had  all  united  in 
describing  a  disease  in  the  dog  having  essentially  the  same 
origin,  clinical  symptoms,  course,  and  termination.  It  was  an 
established  fact  that  the  clinical  symptoms  of  rabies  were  not 
absolutely  sufficient  for  a  diagnosis.  Of  the  anatomical  proof 
there  was  no  constant  change  to  be  found  in  this  disease.  The 
nervous  centers,  which  were  the  parts  chiefly  involved,  were 
congested  and  occasionally  showed  haemorrhagic  and  softened 
spots,  and  later  in  the  disease,  if  it  was  prolonged,  evidences 
of  increased  vascular  activity  occurred — exudation  of  leucocytes 
into  the  circumvascular  spaces — and  one  might  find  the  begin¬ 
nings  of  a  multiple  focal  myelo-encephalitis  or  of  focal  necrosis. 
The  symptoms  of  rabies  it  was  evident  were  caused  not  by  any 
organic  change  in  the  nervous  tissues,  but  by  a  profoundly  dis¬ 
tinct  poison,  the  product  undoubtedly  of  microbic  activity.  This 
poison  acted  first  upon  the  nerve  cells  and  fibers,  and  only  later 
did  it  affect  the  vascular  apparatus.  It  had  been  by  a  continu¬ 
ation  of  aetiological,  semeiological,  and  anatomical  evidence  that 
in  the  past  the  autonomy  of  rabies  had  been  established.  In 
recent  years,  chiefly  through  the  labors  of  Pasteur,  the  experi¬ 
mental  proof  had  been  added,  and  this,  in  the  opinion  of  most, 
if  properly  carried  out,  was  an  absolutely  positive  one.  Pasteur 
found  that  the  virulence  of  the  rabietic  poison  was  confined 
chiefly  and  most  uniformly  to  the  brain  and  spinal  cord.  He 
found  that  rabbits  inoculated  subdurally  with  this  virulent  nerv¬ 
ous  tissue,  after  a  certain  incubation  developed  a  paralytic  dis¬ 
ease  having  a  uniform  course  and  termination,  with  no  marked 
anatomical  change  discoverable  after  death.  He  found  that  this 
disease  was  true  rabies,  because  when  dogs  were  inoculated  with 
the  rabbit’s  virus  they  were  attacked,  after  a  period  of  incuba¬ 
tion,  with  the  symptoms  of  canine  rabies.  In  the  light  of  such 
scientific  work  as  Pastenr  had  done,  the  author  did  not  see  how 
one  could  deny  that  the  specific  character  of  rabies  was  experi¬ 
mentally  proved.  But,  beyond  this  fact,  other  experimenters 
had  abundantly  confirmed  Pasteur’s  results.  Was  hydrophobia 
a  specific  inoculable  disease  identical  with  rabies  in  the  lower 
animals?  1  he  author  had  spent  a  good  deal  of  time  upon  this 
joint,  because  its  establishment  was  the  key  to  the  whole  ques¬ 
tion  of  the  reality  of  rabies  in  man,  and  to  all  the  practical 
points  regarding  its  prevention.  The  proof  that  a  specific  in¬ 
oculable  disease  known  as  rabies  or  hydrophobia  affected  man 
was  furnished  by  the  four  criteria  previously  mentioned,  viz. : 

(1)  the  aetiological,  (2)  the  clinical,  (3)  the  anatomical,  and  (4) 
the  experimental.  In  the  attempt  to  discredit  Pasteur  or  dis¬ 
prove  the  existence  of  human  rabies,  a  great  deal  bad  been 
made  of  pseudo-hydrophobia  or  lyssophobia,  and  of  its  alarm¬ 
ing  frequency  and  extraordinary  dangers.  Asa  matter  of  fact, 
there  were  no  authentic  clinical  records  of  a  single  case  in 
which  fear  of  hydrophobia  had  caused  a  disease  measurably  simi¬ 
lar  to  rabies.  And  there  was  no  genuine  case  of  death  from 
this  particularly  hypothetical  phantasm.  There  had  been  per¬ 
haps  fatal  cases  of  tetanus  following  the  bites  of  dogs,  and  there 
had  possibly  been  fatal  cases  of  acute  mania,  generated  in  those 
predisposed  by  fright.  These  extremely  doubtful  instances 
would  explain  the  fatal  cases  of  so  called  pseudo-hydrophobia. 
Closely  connected  with  the  subject  of  the  specific  character  of 


530 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mki>.  Jocr., 


rabies  in  man  and  the  lower  animals  came  the  question  of  the 
production  of  immunity  from  its  horrible  and  fatal  effects.  The 
establishment  of  the  specific  inoculable  character  of  a  disease 
gave  presumption  in  favor  of  the  power  of  securing  immunity 
from  it,  for  to  the  great  majority  of  specific  diseases  the  animal 
body  either  naturally  possessed  or  might  acquire  immunity. 
This  was  true  of  all,  or  nearly  all,  infectious  diseases  from 
syphilis  to  small  pox.  The  question  now  finally  came,  Could 
the  immunity  to  rabies,  which  it  was  known  could  be  conferred 
upon  dogs,  be  conferred  upon  man.  This  could  only  be  settled 
by  statistics.  From  1886  to  1889  Pasteur  had  treated  1,336 
persons  who  had  been  bitten  by  animals  proved  to  have  been 
rabid,  either  by  experimental  tests  or  by  the  fact  that  other  ani¬ 
mals  bitten  at  the  same  time  had  suffered  with  the  disease.  Of 
these  1,336,  only  13  had  died.  Collected  proofs  of  the  propor¬ 
tion  of  deaths  among  persons  bitten  by  rabid  dogs,  giving  a  rea¬ 
sonable  and  low  estimate  of  the  average,  showed  it  to  be  fifteen 
per  cent.  There  was,  in  the  author’s  opinion,  no  experimental 
method,  no  pathological  fact,  and  no  prophylactic  measure  more 
firmly  established  than  that  antirabietic  inoculations  could  be 
successfully  applied  to  man.  In  demonstrating  this,  Pasteur  had 
done  more  than  simply  save  a  few  from  a  horrible  death.  He 
had  established  the  principle  of  the  possibility  of  protective  in¬ 
oculations  in  other  specific  infectious  diseases.  He  had  opened 
up  an  immense  field  for  future  productive  labor — the  prevention 
or  regulation  of  scarlet  fever,  typhoid,  typhus,  and  even  phthi¬ 
sis  was  made  to  appear  possible,  and  a  revolution  in  medical 
practice  of  extraordinary  importance  could  be  foreseen. 

The  most  important  fact  in  the  recent  history  of  rabies  was 
that  all  of  Pasteur’s  statements  concerning  the  procedure  of 
rabies  vaccination  and  its  efficacy  in  experiments  on  animals  had 
been  in  all  essential  particulars  unreservedly  corroborated  by 
nearly  all  authors  of  the  last  two  years.  That  there  was  yet 
much  to  learn  about  rabies  was  pretty  (dearly  shown  by  the  vast 
difference  in  the  methods  that  were  used  with  approximately  the 
same  results.  In  Pasteur’s  simple  method,  three  or  four  c.  c.  of 
active  virus,  the  strongest  five  days  old,  was  used  in  the  entire 
treatment.  In  virulence,  probably  the  whole  amount  employed 
was  not  equivalent  to  more  than  one  c.  c.  of  the  fresh  medulla,  and 
was  used  only  after  tolerance  had  been  established  by  the  use  of  a 
series  of  spinal  cords  possessing  a  gradually  increasing  virulence, 
commencing  with  one  having  no  appreciable  activity.  In  the 
intensive  method  the  virus  employed  exceeded  this  by  ten  times 
in  both  virulence  and  amount.  In  Ferran’s  method,  without 
any  preliminary  inoculations  with  weak  virus,  the  fresh,  most 
virulent  virus  was  immediately  used,  not  one  c.  c.,  but  four  c.  c. 
daily,  and  this  inoculation  repeated  on  five  successive  days.  Ac¬ 
cording  to  Ferran,  the  more  the  virulence  and  the  greater  the 
quantity  of  virus  introduced,  the  greater  the  immunity,  and  this 
immunity  was  immediately  acquired  apparently,  for  he  com¬ 
menced  with  inoculations  of  virus  far  exceeding  in  virulence  and 
amount  that  which  could  have  been  introduced  by  any  possibility 
through  the  bite  of  a  rabid  dog.  On  the  other  hand,  another 
experimenter  produced  immunity  by  the  frequent  injection  of 
almost  infinitesimal  quantities  of  virus.  From  the  purely  experi¬ 
mental  side  of  the  question,  it  seemed  to  the  author  that  the 
evidence  was  very  strong  of  the  protective  influence  of  Pasteur’s 
inoculations  in  both  animals  and  man.  In  fact,  it  appeared 
that  an  unprejudiced  observer  must  either  assume  that  there 
was  no  such  disease  as  rabies,  that  Pasteur  and  others  were  not 
dealing  with  rabies,  or  candidly  admit  that  the  inoculations  did 
give  relative  immunity.  As  to  Pasteur’s  statistics  and  the  rela¬ 
tive  mortality  after  the  inoculations,  the  author  confessed  tothe 
greatest  incredulity.  First,  because  he  could  find  no  evidence 
to  justify  the  assumption  that  there  were  anything  like  as  many 
cases  of  rabies  in  France  or  anywhere  else  as  one  would  be  led 


to  believe  was  the  case  from  the  number  of  patients  inoculated 
in  Paris  and  in  other  antirabietic  institutions.  Second,  it  seemed 
to  him,  from  personal  experience  in  sending  patients  to  the  Pas¬ 
teur  institute,  that  little  care  was  used  to  determine  whether  the 
persons  had  been  bitten  by  rabid  dogs,  and  no  attempt  was  made 
to  follow  the  history  of  the  cases  afterward.  Pasteur’s  first 
assumption  was  that  the  virus  of  rabies  was  present  in  a  con¬ 
centrated  form  in  the  central  nervous  system,  and  e-pecially  the 
medulla  oblongata  and  the  spinal  cord.  This  obseivation  had 
been  confirmed  by  several  investigators,  the  author  included^ 
The  second  was  that  rabies  might  be  produced  with  the  greatest 
certainty  by  the  subdural  inoculation  of  other  animals  with 
portions  of  the  brain  and  spinal  cord  of  animals  dead  of  rabies. 
Again,  that  the  virulence  of  the  virus  could  be  increased  and 
the  period  of  incubation  shortened  by  the  successive  subdural 
inoculations  of  rabbits.  The  fourth  contention  was  that  the  rabi- 
etic  virus  present  in  the  brain  and  spinal  cord  might  be  attenu¬ 
ated  in  a  constant  and  progressive  degree  by  drying  the  cord  at  a 
fixed  temperature,  and  that  the  virulence  was  entirely  destroyed 
after  about  fourteen  days.  Up  to  this  point  there  could  be  no 
question  about  the  complete  acceptation  of  the  conclusions  of 
Pasteur.  The  author  was  unable  to  understand  why  the  ques¬ 
tion  of  the  apparent  increase  in  the  number  of  cases  of  hydro¬ 
phobia  had  been  so  generally  left  out  of  consideration  in  the 
various  reviews  as  to  the  value  of  the  results  obtained  in  the 
inoculation  of  human  beings.  In  1883  it  was  reported  that  183 
animals  suffered  from  rabies  in  France;  in  1888  this  number 
had  increased  to  863.  Statistics,  to  be  sure,  were  not  worth 
much  ;  but  when  the  records  of  all  countries,  as  well  as  the  con¬ 
sensus  of  medical  opinion  everywhere,  showed  that  rabies  had 
been  an  exceedingly  rare  disease,  it  was  curious  to  know  how 
one  could  accept  without  questioning  the  statement  that  three 
hundred  or  four  hundred  lives  were  saved  annually  in  France, 
as  many  more  in  Russia,  and  a  proportionate  number  in  other 
countries  where  there  were  antirabietic  institutes.  In  conclu¬ 
sion,  it  might  be  said  that,  experimentally  in  animals,  Pasteur’s 
method  conferred  relative  immunity  to  rabies,  and  probably 
might  also  do  so  in  the  human  being,  but  that  the  statistics  of 
results  derived  from  inoculation  of  human  beings  must  be  ac¬ 
cepted  with  reserve. 

Dr.  H.  0.  Ernst,  of  Boston,  who  has  done  considerable  ex¬ 
perimental  work  in  this  field  of  inquiry,  said  that  he  regarded 
the  results  accomplished  by  Pasteur  as  among  the  greatest 
achievements  of  modern  medicine.  The  speaker  had  been  en¬ 
tirely  converted  to  a  thorough  acceptance  of  the  theory  after 
conducting  a  series  of  inoculation  experiments.  If  there  was 
one  thing  certain  in  medicine,  it  was  the  unerring  precision  in 
the  results  obtained  by  the  inoculation  with  these  cord  emul¬ 
sions  under  the  dura  mater  of  the  healthy  rabbit.  There  was 
nothing  like  it  in  the  whole  range  of  scientific  experimenta¬ 
tion.  As  to  the  existence  of  a  constant  lesion  pathognomonic 
of  rabies,  he  did  not  know  that  this  could  at  present  be  defined 
with  scientific  accuracy,  but  careful  observation  had  demon¬ 
strated  the  very  uniform  presence  of  infiltration  of  the  mi¬ 
nute  vessel  walls  in  the  medulla  oblongata  with  white  cells, 
engorgement  of  the  veins,  and  occasionally  circumvascular 
haemorrhages.  What  appeared  like  small  miliary  abscesses 
were  also  present.  The  condition  had  been  aptly  covered  by 
the  term  miliary  bulbar  inflammation.  The  speaker  then  gave 
the  clinical  histories  of  three  cases  of  true  rabies  in  man  which 
had  come  under  his  own  personal  observation,  and  which,  taken 
with  the  fact  that  a  large  number  of  dogs  were  affected  at  or 
about  the  same  period,  pointed  to  the  recent  existence  of  an 
epidemic  of  rabies  in  Boston.  One  of  the  cases  cited  in  detail 
was  of  special  interest,  because  the  patient  between  the  parox¬ 
ysms  was  able  to  describe  his  condition.  He  had  been  specially 


Nov.  8,  1890.] 


MISGELLA  A'  H 

 v 


questioned  as  to  whether  tliere  existed  any  repugnance  to  water, 
and  had  positively  stated  that  there  was  not,  but  that  any  men¬ 
tal  process  connected  with  the  act  of  deglutition  caused  an  un¬ 
controllable  spasm  of  the  muscles  of  the  throat.  This  patient 
had  also  described  himself  as  perfectly  conscious  of  his  acts  dur¬ 
ing  the  violent  paroxysms,  but  as  being  utterly  unable  to  control 
himself.  Even  while  he  was  thus  quietly  describing  his  sensa¬ 
tions  the  fit  would  come  on,  and  the  next  moment  he  would  be  on 
the  floor  struggling  with  four  or  five  men.  Then,  as  to  the  value  of 
the  preventive  method,  the  speaker  instanced  the  case  of  a  boy 
who  was  bitten  in  August  by  a  dog  which  within  fifteen  minutes 
had  also  bitten  several  dogs.  Of  these,  two  had  died  of  rabies, 
and  the  father  of  the  boy,  becoming  alarmed,  had  consulted  the 
speaker.  Inoculation  was  advised  and  submitted  to  twice  a  day. 
No  bad  symptom  had  resulted.  Before  the  boy’s  return  home 
a  third  dog  had  succumbed  to  unquestionable  rabies.  Whether 
there  was  anything  in  Pasteur’s  contentions  or  not,  one  thing  was 
certain  :  he  had  got  hold  of  a  specific  virus  which  could  be  trans¬ 
ferred  from  one  animal  to  another  indefinitely,  always  produc¬ 
ing  a  sequence  of  practically  identical  symptoms.  The  experi¬ 
ments  made  by  Dr.  Spitzka  had  not  been  carried  far  enough. 
They  had  produced  something  similar  to  the  appearance  of  ra¬ 
bies  in  the  rabbits,  but  had  offered  no  sort  of  ground  for  com¬ 
parison  with  Pasteur’s  experiments.  While  hardly  wishing  to 
stand  up  as  a  champion  of  the  Pasteur  method,  if  the  statistics 
of  the  institute  were  not  reliable,  he  was  still  bound  to  believe 
in  the  honesty  in  purpose  of  Pasteur  and  his  assistants.  It  was 
a  significant  fact  that,  after  the  careful  elimination  of  all  cases 
in  which  an  element  of  uncertainty  existed,  the  mortality  rate 
for  those  treated  by  inoculation  under  the  method  was  only 
ninety-eight  one-hundredths  of  one  per  cent.  He  expressed 
surprise  at  the  statement  that  there  could  be  no  such  condition 
as  pseudo-hydrophobia  or  lyssophobia. 

Dr.  R.  W.  Birdsall  said  he  had  seen  a  number  of  cases  of 
pseudo-rabies  resulting  from  fright  after  a  bite  or  scratch  of  a 
dog.  These  cases  had  not  resulted  in  death,  though  he  was  not 
prepared  to  go  so  far  as  to  say  that  death  from  fright  was  not 
possible.  The  nervous  shock  sustained  might  set  up  a  series  of 
changes,  such  as  motor  paresis,  oedema  of  the  brain,  and  coma, 
resulting  in  death.  He  did  not  believe  we  were  yet  in  a  position 
to  be  able  to  refer  the  phenomena  of  true  rabies  to  the  exist¬ 
ence  of  one  kind  of  specific  germ.  The  effects  might  be  due  to 
the  presence  of  distinct  varieties. 

Dr.  H.  P.  Loomis  had  only  considered  the  subject  from  a 
pathological  standpoint.  The  findings  tallied  very  much  with 
those  described  by  Dr.  Ernst.  Sections  of  the  lower  portion  of 
the  medulla  oblongata  had  shown  congestion  of  the  capillary 
vessels  and  giant-cell  infiltration  of  the  adventitia,  but  no  capil¬ 
lary  hfemorrhages  or  thrombi. 

Dr.  Byron,  who  had  made  extensive  experiments  at  both  the 
Carnegie  and  the  Loomis  laboratories,  had  arrived  at  the  con¬ 
clusions  that  (1)  inoculations  of  the  specific  virus  of  rabies  under 
the  skin  were  completely  useless ;  (2)  the  results  desired  could 
never  be  produced  by  any  process  except  subdural  inoculation, 
and  even  then  the  effect  was  not  inevitable.  The  question  was 
a  serious  one,  and  the  subject  still  open  to  further  experimental 
research  before  any  definite  scientific  conclusions  could  be 
formulated. 

Dr.  E.  C.  Spitzka  said  he  had  made  no  experiments  on  rab¬ 
bits  as  intimated  by  Dr.  Ernst,  who  had  evidently  not  followed 
the  points  of  the  speaker’s  work.  In  the  experiments  made  by 
him  on  dogs  he  had  made  no  statement  that  these  animals  had 
represented  true  cases  of  hydrophobia,  but,  by  the  introduction 
of  various  irritating  substances  into  the  brains  of  these  dogs,  he 
had  produced  conditions  of  bogus  hydrophobia.  He  was  now 
associated  with  the  conduct  of  a  series  of  elaborate  experi- 


531 

ments  on  rabies  the  results  of  which  could  not  as  yet  be  for¬ 
mulated. 

I)r.  Gray  thought  the  discussion  had  proved  (1)  that  there 
existed  undoubtedly  in  the  lower  animals  a  disease  known  as 
rabies,  possibly  made  up  of  several  diseases,  due  to  different 
micro-organisms;  (2)  that  this  disease  was  more  frequent  in  the 
lower  animals  than  a  similar  disease  in  man  known  as  hydro¬ 
phobia  ;  (3)  that,  while  this  so-called  rabies  in  animals  occurred 
very  often  in  this  country,  it  occurred  less  frequently  in  the 
human  being;  (4)  that  very  few  medical  men  had  seen  genuine 
cases  of  hydrophobia ;  (5)  that  cases  of  pseudo-hydrophobia 
were  by  no  means  uncommon,  and  that  death  could  result  from 
the  condition  ;  and  (6)  that  there  still  existed  considerable  di¬ 
versity  of  opinion  as  to  the  value  of  Pasteur’s  method,  which 
would  furnish  material  for  discussion  and  incite  to  further 
experiment. 


S#isf  ell  anu. 


Peroxide  of  Hydrogen  and  Ozone.— The  following  paper,  published 
in  the  Medical  fieivs  for  October  25th,  was  read  by  Dr.  Paul  Gibier 
before  the  International  Medical  Congress  at  Berlin : 

Since  the  discovery  of  peroxide  of  hydrogen  by  Thenard,  in  1818 
the  therapeutical  applications  of  this  oxygenated  compound  seem  to 
have  been  neglected  both  by  the  medical  and  the  surgical  professions  • 
and  it  is  only  in  the  last  twenty  years  that  a  few  bacteriologists  have 
demonstrated  the  germicidal  potency  of  this  chemical. 

Among  the  most  elaborate  reports  on  the  use  of  this  compound 
may  be  mentioned  those  of  Paul  Bert  and  Regnard,  Baldy,  Pean,  and 
Larrive. 

Dr.  Miguel  places  peroxide  of  hydrogen  at  the  head  of  a  long  list  of 
antiseptics,  and  close  to  the  silver  salts. 

Dr.  Bouchet  has  demonstrated  the  antiseptic  action  of  peroxide  of 
hydrogen  when  applied  to  diphtheritic  exudations. 

Professor  Nocart,  of  Alfort,  attenuates  the  virulence  of  the  symp¬ 
tomatic  microbe  of  carbuncle  before  he  destroys  it  by  using  the  same 
antiseptic. 

Dr.  E.  R.  Squibb*  of  Brooklyn,  has  also  reported  the  satisfactory 
results  which  he  obtained  with  peroxide  of  hydrogen  in  the  treatment 
of  infectious  diseases. 

Although  the  above-mentioned  scientists  have  demonstrated  by 
their  experiments  that  peroxide  of  hydrogen  is  one  of  the  most  power¬ 
ful  destroyers  of  pathogenic  microbes,  its  use  in  therapeutics  has  not 
been  as  extensive  as  it  deserves  to  be. 

In  my  opinion,  the  reason  for  its  not  being  in  universal  use  is  the 
difficulty  of  procuring  it  free  from  hurtful  impurities.  Another  objec¬ 
tion  is  the  unstableness  of  the  compound,  which  gives  off  nascent  oxy¬ 
gen  when  brought  in  contact  with  organic  substances.f 

Besides  the  foregoing  objections,  surgical  instruments  decompose 
the  peroxide;  hence,  if  an  operation  is  to  be  performed,  the  surgeon 
uses  some  other  antiseptic  during  the  procedure,  and  is  apt  to  continue 
the  application  of  the  same  antiseptic  in  the  subsequent  dressings. 

Nevertheless,  the  satisfactory  results  which  I  have  obtained  at  the 
Pasteur  Institute  of  New  York  with  peroxide  of  hydrogen  in  the  treat¬ 
ment  of  wounds  resulting  from  deep  bites  and  those  which  I  have  ob¬ 
served  at  the  French  clinic  of  New  York  in  the  treatment  of  phage¬ 
denic  chancres,  varicose  ulcers,  parasitic  diseases  of  the  skin,  and  also 
in  the  treatment  of  other  affections  caused  by  germs,  justify  me  in 

adding  my  statement  as  to  the  value  of  the  dru" 

•  • 

But  it  is  not  from  a  clinical  Standpoint  that  I  now  direct  attention 
to  the  antiseptic  value  of  peroxide  of  hydrogen.  What  I  now  wish  is 

*  Gaillard’s  Medical  Journal,  March,  1889. 

f  The  peroxide  of  hydrogen  that  I  use  is  manufactured  by  Mr. 
Charles  Marchand,  of  New  York.  This  preparation  is  remarkable  for 
its  uniformity  in  strength,  purity,  and  stability. 


532 


MISCELLANY. 


[N.  Y.  Mkd.  Joch. 


merely  to  give  a  full  report  of  the  experiments  which  I  have  made  on 
the  effects  of  peroxide  of  hydrogen  upon  cultures  of  the  following  spe¬ 
cies  of  pathogenic  microbes :  Bacillus  anthracis ,  Bacillus  pyocyaneus, 
the  bacilli  of  typhoid  fever,  of  Asiatic  cholera,  and  of  yellow  fever, 
Streptococcus  pyogenes,  Microbacillus  prodigiosus,  Bacillus  megatherium , 
and  the  bacillus  of  osteomyelitis. 

The  peroxide  of  hydrogen  which  I  used  was  a  3'2-per-cent,  solution, 
yielding  fifteen  times  its  volume  of  oxygen;  but  this  strength  was  re¬ 
duced  to  about  1'5  per  cent.,  corresponding  to  about  eight  volumes  of 
oxygen,  by  adding  the  fresh  culture  containing  the  microbe  upon  which 
I  was  experimenting.  I  have  also  experimented  upon  old  cultures 
loaded  with  a  large  number  of  the  spores  of  the  Bacillus  anthracis.  In 
all  cases  my  experiments  were  made  with  a  few  cubic  centimetres  of 
culture  in  sterilized  test-tubes,  in  order  to  obtain  accurate  results. 

The  destructive  action  of  peroxide  of  hydrogen,  even  diluted  in  the 
above  proportions,  is  almost  instantaneous.  After  a  contact  of  a  few 
minutes,  I  have  tried  to  cultivate  the  microbes  which  were  submitted 
to  the  peroxide,  but  unsuccessfully,  owing  to  the  fact  that  the  germs 
had  been  completely  destroyed. 

My  next  experiments  were  made  on  the  hydrophobic  virus  in  the 
following  manner : 

I  mixed  with  sterilized  water  a  small  quantity  of  the  medulla  taken 
from  a  rabbit  that  had  died  of  hydrophobia,  and  to  this  mixture  added 
a  small  quantity  of  peroxide  of  hydrogen.  Abundant  effervescence 
took  place,  and,  as  soon  as  it  ceased,  having  previously  trephined  a  rab¬ 
bit,  I  injected  a  large  dose  of  the  mixture  under  the  dura  mater.  Slight 
effervescence  immediately  took  place  and  lasted  a  few  moments,  but 
the  animal  was  not  more  disturbed  than  when  an  injection  of  the  ordi¬ 
nary  virus  is  given.  This  rabbit  is  still  alive,  two  months  after  the  in¬ 
oculation. 

A  second  rabbit  was  inoculated  with  the  same  hydrophobic  virus 
which  had  not  been  submitted  to  the  action  of  the  peroxide,  and  this 
animal  died  at  the  expiration  of  the  eleventh  day  with  the  symptoms  of 
hydrophobia. 

I  am  now  experimenting  in  the  same  manner  upon  the  Bacillus  tu¬ 
berculosis,  and,  if  I  am  not  disappointed  in  my  expectation,  I  will  be  able 
to  impart  to  the  profession  some  interesting  results. 

It  is  worthy  of  notice  that  water  charged,  under  pressure,  with  fif¬ 
teen  times  its  volume  of  pure  oxygen  has  not  the  antiseptic  properties 
of  peroxide  of  hydrogen.  This  is  due  to  the  fact  that  when  the  perox¬ 
ide  is  decomposed  nascent  oxygen  separates  in  that  most  active  and  po¬ 
tent  of  its  conditions  next  to  the  condition,  or  allotropic  form,  known 
as  ozone.  Therefore  it  is  not  illogical  to  conclude  that  ozone  is  the 
active  element  of  peroxide  of  hydrogen. 

Although  peroxide  of  hydrogen  decomposes  rapidly  in  the  presence 
of  organic  substances,  I  have  observed  that  its  decomposition  is  checked 
to  some  extent  by  the  addition  of  a  sufficient  quantity  of  glycerin;  such 
a  mixture,  however,  can  not  be  kept  for  a  long  time,  owing  to  the  slow 
but  constant  formation  of  secondary  products  having  irritating  prop¬ 
erties. 

Before  concluding,  I  wish  to  call  attention  to  a  new  oxygenated 
compound,  or  rather  ozonized  compound,  which  has  been  recently  dis¬ 
covered  and  called  “  glycozone  ”  by  Mr.  Marchand. 

This  glycozone  results  from  the  reaction  which  takes  place  when 
glycerin  is  exposed  to  the  action  of  ozone  under  pressure — one  volume 
of  glycerin  with  fifteen  volumes  of  ozone  produces  glycozone. 

By  submitting  the  Bacillus  anthracis,  pyocyaneus,  prodigiosus,  and 
megatherium  to  the  action  of  glycozone,  they  were  almost  immediately 
destroyed. 

I  have  observed  that  the  action  of  glycozone  upon  the  typhoid-fever 
bacillus,  and  some  other  germs,  is  much  slower  than  the  influence  of 
peroxide  of  hydrogen. 

In  the  dressing  of  wounds,  ulcers,  etc.,  the  antiseptic  influence  of 
glycozone  is  rather  slow  if  compared  with  that  of  peroxide  of  hydrogen, 
with  which  it  may,  however,  be  mixed  at  the  time  of  using. 

It  has  been  demonstrated  in  Pasteur’s  laboratory  that  glycerin  has 
no  appreciable  antiseptic  influence  upon  the  virus  of  hydrophobia ; 
therefore  I  mixed  the  virus  of  hydrophobia  with  glycerin,  and  at  the 
expiration  of  several  weeks  all  the  animals  which  I  inoculated  with  this 
mixture  died  with  the  symptoms  of  hydrophobia. 


On  the  contrary,  when  glycerin  has  been  combined  with  ozone  to 
form  glycozone,  the  compound  destroys  the  hydrophobic  virus  almost 
instantaneously. 

Two  months  ago  a  rabbit  was  inoculated  with  the  hydrophobic  virus 
which  had  been  submitted  to  the  action  of  this  new  compound,  and  the 
animal  is  still  alive. 

I  believe  that  the  practitioner  will  meet  with  very  satisfactory  re¬ 
sults  with  the  use  of  peroxide  of  hydrogen,  for  the  following  reasons : 

1.  This  chemical  seems  to  have  no  injurious  effect  upon  animal 
cells. 

2.  It  has  a  very  energetic  destructive  action  upon  vegetable  cells — 
microbes. 

3.  It  has  no  toxic  properties ;  five  cubic  centimetres  injected  be¬ 
neath  the  skin  of  a  guinea-pig  do  not  produce  any  serious  result,  and  it 
is  also  harmless  when  given  by  the  mouth. 

As  an  immediate  conclusion  resulting  from  my  experiments,  my 
opinion  is,  that  peroxide  of  hydrogen  should  be  used  in  the  treatment 
of  diseases  caused  by  germs,  if  the  microbian  element  is  dii’ectly  acces¬ 
sible  ;  and  that  it  is  particularly  useful  in  the  treatment  of  infectious 
diseases  of  the  throat  and  mouth. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti¬ 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (i)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  ( 3 )  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases ,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal ,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  A  ll  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  lime. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor ,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


S^WYORKJIEDICAL  JOURNAL,  November  ifi  1890. 


^ccturfs  a  n  ft  ^bbrcsses. 


AN  ADDRESS  INTRODUCTORY  TO 

THE  REPORTS  ON  THE  PROCEEDINGS  OF  SECTIONS  IN  THE 

TENTH  INTERNATIONAL  MEDICAL  CONGRESS, 

DELIVERED  BEFORE  THE  NEW  YORK  ACADEMY  OF  MEDICINE 

November  6,  1890. 

By  A.  JACOBI,  M.  D. 

Mr.  President:  On  August  4,  1890,  during  the  first 
and  largest  general  meeting  of  the  Tenth  International 
Medical  Congress,  there  were  three  universal  and  sponta¬ 
neous  outbursts  of  applause.  The  first  and  most  sympa¬ 
thetic  greeted  the  name  of  James  Paget,  and  never  was 
there  an  ovation  more  deserved.  The  second  rang  through 
the  immense  building  when  it  was  announced  that  the  gov¬ 
ernment  of  the  French  Republic  had  sent  thirty-four  official 
delegates,  and  that  nearly  one  hundred  and  fifty  more 
Frenchmen  had  joined  the.  congress.  They  had  overcome 
political  enmity  and  jealousy,  disregarded  a  rather  slight¬ 
ing  reference  to  their  “  national  insanity  ”  of  twenty  years 
ago,  and  come  with  open  hearts  and  friendly  feelings,  a 
large  number  of  them  men  of  fame  and  high  rank.  The 
third  greeted  the  announcement  of  the  fact  that  on  the 
first  day  of  the  gathering  more  than  six  hundred  Ameri¬ 
cans  were  inscribed  on  the  rolls.  This  recognition  afforded 
to  our  name  must  have  flattered  the  national  pride  of  every 
one  of  us  who  were  present. 

This  hearty  welcome  was  more  than  I  had  mustered  the 
courage  to  expect,  for,  indeed,  Americans  visiting  Europe 
on  such  occasions  as  this  labor  under  certain  difficulties 
Europeans  do  not  quite  understand  our  country,  its  politi¬ 
cal  and  social  configuration,  or  its  scientific  attainments. 

If  that  is  so  even  in  Great  Britain,  both  race  and  language 
being  identical  and  mutual  intercourse  more  frequent,  how 
much  less  can  we  expect  to  be  known  on  the  continent. 
Besides,  it  is  not  always  the  best  political,  social,  and  sci¬ 
entific  class  of  our  fellow-citizens  who  travel  extensively, 
and,  though  it  is  not  the  crowd  of  the  profanum  vulgus 
that  ought  to  tell  in  the  estimation  of  the  best  spirit  of 
their  country,  it  does  so  tell.  Now,  the  majority  of  medi¬ 
cal  Americans  they  know  in  Europe,  and  particularly  in 
Germany,  belong  to  one  of  two  classes— either  they"  are 
bona  fide  students  whom,  being  mere  foreigners,  they  con¬ 
sent  to  matriculate  even  without  the  preliminary  education 
rigoiously  insisted  upon  with  their  oAvn  young  country¬ 
men,  or  they  are  our  young  doctors  who  pass  a  few  months 
or  a  year  in  European  laboratories  and  clinics  for  the  sake 
of  special  studies.  It  is  these  that  are  also  the  occasional 
participants  in  their  national  associations,  where,  nobody 
else  being  present,  they  are  naturally  considered  the  repre¬ 
sentatives  of  American  medicine.  Our  best  men  travel  but 
little  and  talk  less.  Indeed,  some  of  those  who  were  most 
fit  to  represent  us  in  the  congress  kept  in  the  rear,  modest 
and  retiring.  Besides,  the  great  opportunity  America 
might  have  had  to  present  to  the  view  of  the  world  what¬ 
ever  there  is  great  and  progressive  in  American  medicine 


appears  lost,  for  in  the  very  number  of  the  German  Medi¬ 
cal  Weekly  which  was  published  in  the  week  of  the  con¬ 
gress  you  could,  in  the  history  of  previous  congresses,, 
read  the  statement  that  the  Washington  congress  was  un¬ 
fortunately  a  failure,  for  which  all  of  us,  being  Americans,, 
are  held  responsible.  Moreover,  though  English  is  read 
by  a  great  many  of  the  best  men  in  Europe,  the  knowledge- 
of  our  language  is  not  so  general  as  to  insure  a  wide  ac¬ 
quaintance  with  our  literature  through  anything  but  the 
uncertain  channels  of  extracts  or  translations.  Nor  are 
even  these  well  selected.  We  are  all  aware  that  our  medi- 
ca  journals  are  of  as  unequal  rank  as  our  schools,  and  not 
infrequently  will  you  find  a  journal  which  is  deservedly 
unknown  among  us,  but  is  quoted  in  Europe  under  the  im¬ 
pression  that  it  is  a  fair  representative  of  American  medi¬ 
cal  literature.  Nor  is  the  treatment  Europeans  receive  at 
our  hands  always  very  courteous  or  considerate.  The  edi¬ 
torial  remarks  of  a  great  New  York  weekly  were  quoted  as 
unkind,  inasmuch  as  the  efforts  to  make  the  congress  in¬ 
ternational  and  Berlin  a  neutral  ground  for  the  whole 
world  did  not  appear  to  be  appreciated  with  us.  It  must 
be  admitted,  though,  that  they  did  not  deem  that  Western 
journal  worthy  of  serious  consideration  which  spoke  of  the 
lenth  International  Medical  Congress  as  a  congress  of 
snobs,  and  advised  every  one  of  the  forty  thousand  practi¬ 
tioners  of  the  Mississippi  Valley,  “every  one  superior  to 
the  leaders  of  the  congress,”  to  stay  at  home. 

Public  opinion  is  often  made  or  unmade  by  trivialities 
sometimes  indeed  by  personalities  of  an  inferior  nature.  It 
was  a  source  of  complaint  in  Berlin  that  an  American  who 
had  been  honored  with  the  request  to  represent  our  coun¬ 
try  by  delivering  one  of  the  great  addresses  had  neglected 
to  see  to  it  that  his  refusal  reached  the  Committee  of  Or¬ 
ganization  in  anything  like  due  time.  The  proverbial  court¬ 
esy  of  Americans  was  found  wanting,  and  that  at  a  time  of 
feverish  excitement  and  overwork.  Such  occasions  are  the 
very  opportunities  for  those  formerly  Europeans  who  try 
to  rise  in  their  own  estimation  and  that  of  their  former 
countrymen  by  detraction  of  us,  for  there  are  those  who 
do  not  immediately  succeed,  when  they,  our  guests  and 
future  fellow-citizens,  arrive  among  us,  in  impressing  us 
with  their  superiority,  or  in  being  appreciated  by  us  as 
they  are  by  themselves,  or  in  obtaining  at  once  a  lucrative 
practice  and  professional  positions  and  honors.  It  is  they 
who  pay  for  the  hospitality  proffered  by  our  country  with 
shoulder-shrugging  insinuations  and  pitying  remarks  upon 
our  crudeness  and  inferiority,  our  “mob  rule,”  our  “civil¬ 
ized  barbarism,”  instead  of  aiding  in  the  realization  of  the 

national  and  cosmopolitan  aims  of  the  medical  profession 
and  science. 

Nothing  is  so  small  as  not  to  have  some  effect.  Unfor¬ 
tunately,  there  is  still  so  much  national  jealousy  everywhere 
that  faults  and  shortcomings  in  your  neighbor  beyond  the 
boundary  line  are  easily  believed  in,  and  slanderers  and 
libelers  are  always  busy.  When  I  arrived  in  Germany  a 
newspaper  article  was  shown  me  which  was  concocted  by 
a  sectarian  practitioner,  formerly  in  New  York,  who  de¬ 
tailed  the  inferiority  of  American  medicine,  schools,  and 


534 


JACOBI:  INTRODUCTORY  ADDRESS. 


[N.  Y.  Med.  Jock., 


practice  to  the  horrified  sanctity  of  the  German  public;  and 
in  the  very  week  preceding  the  congress  hundreds  or  per¬ 
haps  thousands  of  pamphlets  were  distributed  in  Berlin  for 
the  avowed  purpose  of  insulting  us  and  making  us  uncom¬ 
fortable.  The  pseudonymous  author,  who  appears  to  have 
lived,  or  to  live,  in  Chicago,  says,  among  a  great  many  other 
things,  the  following : 

“  In  reference  to  the  transatlantic  gentlemen,  nothing 
is  more  out  of  place  than  indulgence.  American  toler¬ 
ance,  so  frequently  extolled,  exists  for  Americans  only. 
When  about  to  travel  they  leave  it  at  home.  It  is  almost 
always  the  result  of  ignorance,  indifference,  and  bad  con¬ 
science.  As  the  average  American  never  cares  for  the  his¬ 
tory  of  a  science,  the  majority  of  the  transatlantic  members 
of  the  International  Congress  are  totally  unacquainted  with 
European  institutions,  labors,  and  scientific  methods  and 
their  aims.  Nevertheless,  every-  one  of  these  gentlemen 
carries  a  paper  in  his  pocket,  easily  compiled,  wherewith  to 
resuscitate  the  obsolete  science  of  Europe.”  In  the  same 
sheet  the  man  asserts  that  forty-two  per  cent,  of  all  the 
doctors  in  Chicago  are  professed  abortionists,  and  a  great 
many  followers  of  “  Christian  science.” 

Some  of  the  great  Germans  with  whose  names  everyone 
pf  us  is  perfectly  familiar  denied  being  in  any  way  influ¬ 
enced  by  such  rubbish  ;  but  then  again  it  was  through  them 
that  I  had  to  learn  of  a  New  York  specialist,  a  fellow  of 
this  Academy,  who  was  reported  to  have  availed  himself 
of  his  personal  intimacy  with  the  officers  of  the  Associated 
Press  for  the  purpose  of  having  his  congress  paper  served  at 
the  breakfast  tables  of  a  million  of  American  households  on 
the  day  of  its  delivery.  That  was  a  week  before  the  opening. 

Still,  though  they  are  human  on  the  other  side  of  the 
Atlantic,  as  we  are  on  this,  the  facilities  of  communication 
have  become  such  as  to  assure  those  wishing  to  see  and 
know  the  truth  that  the  time  when  American  medicine  was 
merely  receptive  and  imitative  has  long  passed  by,  and  that 
we  have  entered  the  arena  as  co-operating  peers.  They 
were  anxious  to  have  us  and  secure  a  large  American  at¬ 
tendance.  In  order  to  accomplish  that  end,  the  general 
committee  appointed  an  American  committee  which  was  to 
enlist  universal  sympathy  in  our  country.  No  time  was  to 
be  lost,  and  the  first  ten  medical  men  who  expressed  their 
willingness  to  serve  were  appointed.  The  territorial  jeal¬ 
ousy,  one  of  the  most  marked  of  American  littlenesses,  which 
was  expressed  in  some  journals,  obliged  me  to  explain  pub¬ 
licly,  in  the  May  meeting  of  the  Association  of  American 
Physicians,  why  that  committee  consisted  of  Stewart,  Fitz, 
Lusk,  Draper,  Hun,  Pepper,  Busey,  Osier,  and  Peyre  Por- 
cher.  Will  the  Western  gentlemen  who  found  fault  with 
the  committee,  and  heaped  vituperation  on  the  mode  of  it§ 
composition,  tell  us  that  the  names  selected  did  not  deserve 
the  honor  conferred  upon  them,  or  that  there  are  better  ones 
among  us  ?  Does  American  medicine  begin  at  the  Alle- 
ghanies  or  the  Sierra  ?  Or  will  you,  gentlemen  of  Ohio, 
Mississippi,  or  Nevada,  tell  us  which  of  the  forty-four  stars 
of  the  glorious  flag  is  the  one  you  claim  as  yours  ?  Yours 
are  the  forty-four  ;  so  they  are  ours.  Are  your  minds  not 
big  enough,  your  hearts  not  large  enough,  to  embrace  the 
love  of  and  the  pride  in  the  whole  flag  of  America  ? 


A  further  proof  of  anxiety  to  secure  the  co-operation 
and  good-will  of  the  Americans  was  given  by  the  Berlin 
committee  in  this,  that  they  iusisted  upon  one  of  the  public 
addresses  in  the  general  meetings  being  delivered  by  an 
American.  Weir  Mitchell  having  declined  in  time  and 
courteously,  and  Osier  not  being  within  reach,  I  was  tele¬ 
graphically  directed  to  select  an  orator.  The  choice  of 
Horatio  C.  Wood  was  heartily  approved  of  in  Berlin  and 
elsewhere.  Again,  a  few  have  asked  why  could  not  a  New 
Yorker  have  been  honored  with  that  commission?  That 
question  is  answered  by  some  other  queries  :  Do  you  know 
of  a  better  man  ?  Is  America  bounded  by  the  East  and 
North  Rivers  ?  And,  lastly,  has  New  York  forgotten  that 
she  can  afford  to  be  courteous  and  generous  ? 

More.  A  few  brief  weeks  before  the  meeting  of  the 
congress  the  American  orthopaedists  expressed  the  desire 
that  there  should  be  a  separate  Section  of  Orthopaedics. 
When  I,  then  already  in  Europe,  was  notified  of  that  re¬ 
quest  by  the  chairman  of  the  Orthopaedic  Section  of  this 
Academy,  and  expressed  my  fear  lest  it  might  be  too  late 
to  make  arrangements  for  that  change,  I  was  by  returning 
mail  informed  by  the  Secretary-General  that  the  request  had 
at  once  been  granted  by  the  Committee  of  Organization,  on 
the  ground  that  my  countrymen  must  know  best  what  suited 
them  and  their  scientific  labors. 

The  organization  of  the  congress  was  not  completed 
without  the  election  of  an  American  vice-president,  John 
S.  Billings,  and  an  American,  Mr.  Allen  Starr,  as  one  of  the 
two  English-speaking  secretaries,  and  a  large  number  of 
American  vice-presidents  of  sections.  And,  lastly,  when 
on  the  third  day  of  the  congress,  and  in  the  second  general 
meeting,  the  hour  grew  late  and  the  audience  melted  under 
the  hot  sun,  Dr.  Wood’s  address  was,  out  of  consideration 
for  the  Americans,  postponed  to  be  the  first  topic  of  the 
third  meeting,  though  the  hour  and  arrangements  and 
printed  preparations  had  to  be  changed  accordingly. 

All  this  was  meant,  and  was  believed  to  suffice,  to  make 
every  American  feel  at  home.  If  it  did  not  succeed,  it 
ought  to  have  accomplished  that  end.  But  I  have  been 
told  that  disappointments  have  been  keenly  felt  and  com¬ 
plaints  been  uttered. 

When  an  English  paper  was  read,  many  have  been  re¬ 
ported  to  leave  the  room.  Many  essays  were  not  read  at 
all,  some  were  not  allowed  the  time  required  by  the  authors, 
some  men  would  read  beyond  the  legal  limits.  Such  com¬ 
ments  are  natural,  but  so  also  are  their  causes.  The  un¬ 
precedented  number  of  papers  offered  at  a  late  date,  and 
too  courteously  accepted,  and  some  acoustic  disadvantages 
of  many  of  the  audience  halls,  are  among  the  causes  of  dis¬ 
appointments  which  are  unavoidable  in  everything  human. 
The  experience  of  the  past  can  furnish  remedies  in  the 
future.  However,  when  one  man  complains  that  he  was 
not  one  among  the  five  per  cent,  of  members  who  could  be 
admitted  to  the  court  reception  in  Potsdam,  another  that 
he  had  to  pay  for  his  share  of  the  section  dinners  on  the 
evening  of  Wednesday  the  sixth,  proclaiming  that  matters 
were  different  in  Washington,  where  no  foreigner  paid  any¬ 
thing,  it  proves  one  of  two  things — either  that  there  were 
those  who  went  more  for  the  incidental  appurtenances  of 


Nov.  15,  1890.  J 


JACOBI:  INTRODUCTORY  ADDRESS. 


the  congress  than  for  the  congress,  or  that  our  national 
tailing,  which  is  a  highly  developed  emotional  hyperjes- 
thesia,  was  rather  demonstrative.  I  can  assure  those  who 
are  rinding  fault  with  the  scantiness  of  their  enjoyments 
that  I  know  of  some  at  least  who  neither  shared  in  the  en¬ 
tertainment  in  the  City  Hall,  for  which  Berlin  paid  eighty 
thousand  marks,  nor  danced  at  any  of  the  five  balls,  nor  im¬ 
bibed  the  music  and  songs  in  eleven  languages,  and  other 
beverages,  at  Kroll’s,  and — did  not  feel  the  worse  for  it  the 
following  mornings.  If  I  have  any  fault  to  find,  it  is  with 
the  overflow  of  entertainments,  the  excess  of  generosity,  the 
multiplicity  of  luncheons,  dinners,  and  receptions,  the  waste 
of  money  in  the  vast  number  of  public  and  private  social 
gatherings. 

It  there  ever  were  hosts  spending  unstintingly,  aye, 
squandering  money  in  the  service  of  unlimited  hospitality, 
they  were  the  profession  as  a  whole,  and  the  single  medical 
men  of  Berlin. 

In  connection  with  this  fact,  let  me  make  a  remark 
which  is  dictated  by  no  caviling  spirit,  for  I  have  too  many 
reasons  to  appreciate  the  universal  kindness  and  untiring 
hospitality  of  the  great  and  gentlemanly  members  of  the 
Berlin  profession,  who  were  bent  on  nothing  but  rendering 
the  sojourn  of  the  foreign  guests  comfortable  and  pleasant,  I 
must  here  mention  the  names  of  Virchow,  Bergmann,  Wald- 
eyer,  Gerhardt,  Henoch,  and  Leyden  and  his  accomplished 
wife,  the  Chairman  of  the  Ladies’  Committee,  and  could 
name  a  host  of  others.  Many  of  us  found  it  impossible  to 
respond  at  the  same  time  to  the  requirements  of  actual  con¬ 
gressional  duties  and  the  urgent  demands  of  hospitable 
courtesy.  In  this  also  there  are  discomfort  and  loss  for  the 
individual  member.  But  the  matter  has  a  very  much  more 
important  aspect.  An  excess  of  social  entertainments  and 
the  accomplishment  of  the  end  for  which  the  International 
Congress  is  convened  are  incompatible  at  a  certain  point. 
Too  many  feasts  interfere  with  legitimate  work.  The  expec¬ 
tation  of  a  good  time  may— if  I  can  not  say  it  does — invite 
the  attendance  of  many,  of  hundreds,  perhaps  of  thousands, 
who  would  not  go  for  the  sake  of  work.  On  the  other  hand, 
those  who  have  gone  for  the  latter  are  liable  to  feel  sorely 
disconcerted.  Thus  it  has  happened— at  least  this  disap¬ 
pointment  can  be  held  in  part  responsible — that  the  national 
associations  have  suffered  from  the  persistent  absence  of 
those  who  do  not  wish  to  lose  great  opportunities;  and 
that  all  over  America,  Great  Britain,  France,  Germany,  and 
other  countries,  there  have  been  formed  by  dissatisfied  men 
who  place  scientific  work  over  any  distractions,  be  they 
ever  so  pleasant,  special  societies,  the  objects  of  all  of  which 
ought  to  have  been  accomplished  in  the  sections  of  the  gen¬ 
eral  bodies.  It  would  be  a  sad  development  if  the  same 
tendency  were  to  grow  up  in  international  congresses. 

At  this  very  moment  there  are  already  in  existence  an 
international  ophtbalmological  and  an  international  oto- 
logical  congress.  It  would  be  the  fault  of  the  man¬ 
agement  of  international  medical  congresses  if  other 
specialties  or  doctrines  should  follow  the  example  for 
no  other  reason  than  the  predominance  of  the  social  over 
the  scientific  element.  If  the  latter  ceases  to  rule,  the 
great  men  of  science  will  stay  away,  and  the  holiday- 


535 

seekeis  and  a  few  ambitious  office-holders  will  remain. 
Docet  experientia. 

It  is  only  a  wealthy  city  and  rich  professional  men  who 
can  entertain  as  Berlin  did.  For  such  hospitality  as  was 
display  ed  there  you  require  large  and  generous  hearts,  ample 
and  well-filled  purses.  There  are  but  few  communities  like 
hers.  If  the  habit  of  prodigality  becomes  persistent,  we 
shall  be  leceived  in  future  with  misgivings  on  the  part  of 
our  hosts,  who  must  fear  lest  their  efforts  fall  short  both  of 
the  results  of  predecessors  and  of  the  expectations  of  the 
guests.  Let  these  two  calamities  occur — viz.,  the  absence 
of  the  best  men  of  all  nations  and,  on  the  part  of  cities  and 
mou,  hesitation  to  request  our  coming — what  will  become 
of  the  international  congresses  ? 

And  where  is  the  prevention  of  the  danger  alluded  to? 
Ileie.  Let  the  social  entertainments  be  reduced  to  a  mini¬ 
mum.  Then  any  city  with  ample  hotel  accommodations  will 
be  able  to  receive  us,  though  we  be  thousands.  Then  those 
bent  upon  pleasure  only  will  seek  it  elsewhere.  Then  the 
numbers  will  no  longer  be  unwieldy’  and  shapeless.  Then 
the  men  looking  for  work  and  for  the  men  who  work  will 
be  eager  to  come  and  see  and  be  seen,  to  teach  and  be 
taught. 

The  unprecedented  success  of  the  American  Congress 
of  I  hysicians  and  Surgeons,  the  first  meeting  of  which  was 
held  in  Washington  in  September,  1888,  tells  its  own  tale 
and  exhibits  the  proof  of  what  I  have  said.  In  my  mind 
there  is  no  doubt  that  its  second  meeting,  in  September, 
1891,  will  be  equally  successful ;  its  three  days  will  be  dedi¬ 
cated  to  work,  and  the  official  social  entertainment  limited 
to  a  plain  subscription  banquet.  In  that  way  neither  the 
lawful  work  of  the  congress  nor  private  intercourse  and 
hospitality  are  interfered  with. 

It  may  appear  invidious  to  muster  the  co-operative  serv¬ 
ices  rendered  by  the  members  of  the  different  nations  rep¬ 
resented  in  the  various  sections  of  the  congress.  Still,  as 
we  generally  have  a  good  opinion  of  ourselves,  we  are  not 
afraid  of  looking  back  at  our  own  contributions  to  the  scien¬ 
tific  material  that  was  furnished.  When  we  do  so,  we  have 
to  admit,  however,  that  but  a  small  percentage  of  our  seven 
hundred  participated  in  the  general  work.  It  is  true  there 
was  one  who  got  himself  delivered  of  quintuplets;  fortu¬ 
nately,  he  had  no  equals,  and  he  was  not,  as  a  medical  jour¬ 
nal  reported,  “  taken  in  earnest.”  Still,  there  were  a  num¬ 
ber  of  papers,  not  compiled,  but  original.  The  Orthopaedic 
Section  was  American  to  a  great  extent.  The  Neurological 
had  a  very  fair  representation  from  our  country.  The 
Gynaecological  and  Paediatric  sections  were  not  without 
American  contributions.  The  Surgical  was  supplied  with 
papers  which  were  highly  appreciated,  mostly  from  the 
West.  Indeed,  there  were  but  few  sections  in  which  no 
American  took  part,  though  there  were  some  in  which  no 
active  work  at  all  was  furnished  by  us.  The  most  redeeming 
feature  wTas  the  meeting  of  the  combined  Laryngological 
and  Paediatric  Sections,  in  which  the  ingenious,  painstak¬ 
ing,  and  successful  efforts  of  O’Dwver  were  heartily  ap¬ 
plauded. 

After  all,  however,  the  labor  performed  in  the  sessions 
may  be  the  principal,  but  is  certainly  not  the  only,  object 


536 


VON  DON  HOFF:  THE  MANAGEMENT  OF  FRACTURED  LIMBS.  [N.  Y.  Med.  Jodr., 


in  view.  An  English  journal  has  said  that  “  congresses  are 
not  instruments  of  research,”  and,  still,  the  transactions  of 
all  are  replete  with  it.  It  is  true  a  congress  is  not  so  much 
meant  for  new  discoveries  as  for  the  broad  dissemination 
of  facts,  hints,  and  ideas.  A  man  —  not  being  ubiquitous 
— may  not  take  away  with  him  many  things  new,  but  what 
he  carries  home  is  a  new  stimulus  and  encouragement. 

In  the  congress  you  saw  a  great  many  men  whom  you 
thought  you  knew,  but,  since  you  listened  to  them  and 
watched  them  while  you  listened  and  took  their  measure, 
know  better  now.  You  saw  and  heard  the  living  objects 
■of  your  admiration,  the  molders  of  professional  thought 
in  all  countries  ;  discoverers,  teachers,  laboratory-workers, 
practitioners;  those  who,  after  hard  work,  create  books  by 
•spontaneous  generation  out  of  their  brains,  and  those  who 
•compile  them  out  of  their  pigeon-holes;  the  eagles,  the 
bees,  and  the  moles — also  the  parrots  and  that  class  of  en¬ 
vious  cuckoos  that  “  transfer  other  birds’  eggs  into  their 
own  nests.”  You  found  there  was  room  in  our  great  army 
for  many  men  and  many  classes  of  men.  You  gathered 
encouragement  from  learning  that  even  truly  great  men 
were  still  men  and  human,  and  that  some  degree  of  great¬ 
ness  was  within  the  grasp  of  any  man  in  town  or  village 
who  would  work  for  it  intelligently,  bravely,  and  honora¬ 
bly.  All  this  is  what  a  congress  will  teach  those  who  con¬ 
sent  to  learn. 

There  is  another  lesson  that  is  taught  by  a  congress: 
The  separation  into  twenty  sections  proves  the  endless  and 
diversified  branching  of  the  grand  old  tree  of  medical  sci¬ 
ence.  Their  working  under  the  same  roof,  however,  and 
under  the  sajne  administration,  their  occasional  combina¬ 
tion  for  a  common  purpose,  their  gathering  in  general 
meetings,  and  their  listening  to  the  same  addresses,  with 
the  same  interest  and  profit — all  this,  in  spite  of  the  fact 
that  some  of  the  twenty  appear  to  be  threatened  with  the 
danger  of  degenerating  into  mere  handicraft,  proclaim 
louder  than  steeple  bells  that  medical  science  is  “  one  and 
indivisible,  now  and  forever.” 

The  congress  conveyed  to  me,  like  its  predecessors  in 
•Copenhagen  and  London,  a  great  lesson  and  furnished  an 
■elevating  spectacle.  Imagine,  those  of  you  who  have  not 
been  present,  thousands  of  medical  men  from  all  parts  of 
the  world  and  speaking  a  dozen  different  languages,  not  per¬ 
haps  eudowed  with  the  same  erudition  or  mental  or  moral 
power,  but  moved  by  the  same  instincts  and  interests  and 
assembling  at  the  same  call  and  for  the  same  special  purpose. 
The  great  and  the  lowly,  the  old  and  young,  meet  as  breth¬ 
ren  on  the  same  platform,  if  not  of  equality,  still  of  frater¬ 
nity  and  solidarity.  National  jealousy  and  prejudice  are 
shelved  for  at  least  a  week,  and  the  lesson  is  taught  that 
brethren  may  live  together  peaceably  under  the  same  roof, 
an  example  to  the  nations  of  the  future.  The  man  and  the 
man  of  science  are  appreciated  and  loved,  though  political 
adversaries.  Applause  takes  the  place  of  hisses.  The  con¬ 
test  is  no  longer  against  each  other  but  with  each  other, 
side  by  side,  arm  in  arm,  with  the  same  weapons  of  the 
brain  and  soul  against  the  common  enemy  of  science  and 
mankind — viz.,  physical  deterioration  and  social  misery. 
Thus  the  cosmopolitan  spirit  of  coming  centuries  is  fore¬ 


shadowed  and  initiated  by  the  co-operation  of  the  men  ar¬ 
rayed  in  the  army  of  the  noblest  of  all  sciences  and  profes¬ 
sions.  Therefore  may  no  man  who  can  prove  an  example 
to  his  peers  in  this  or  any  other  country,  no  man  who  can 
teach,  none  who  can  learn,  none  who  can  worthily  represent 
his  country  in  any  capacity  and  do  honor  to  America  among 
foreigners — may  no  man,  except  for  valid  reasons,  ever  shirk 
his  duty  to  attend  an  International  Medical  Congress. 


#rt0tnal  Communications. 


THE  MANAGEMENT  OF  FRACTURED  LIMBS.* 
By  EDWARD  YON  DONHOFF,  M.  S.,  M.  D. 

When  the  proper  method  of  avoiding  the  unsightly  and 
mischievous  consequences  of  bad  management  of  fractures 
in  the  continuity  of  limbs  seems  to  be  shrouded  in  impene¬ 
trable  mystery  (?),  the  solution  is  often  enough  to  be 
found,  if  rightly  sought  for,  in  the  ignorance  of  certain 
radical  principles,  and  growing  out  of  this  an  element  of 
harmful  fearfulness  on  the  part  of  the  medical  attendant. 
To  mv  mind,  a  more  rational  answer  than  this  can  not,  in  a 
majority  of  instances  demanding  it,  be  found  to  account 
for  the  wooden  and  unsymmetric  appearance,  if  not  perma¬ 
nently  compromised  usefulness,  of  many  limbs  issuing  after 
treatment  (?)  for  fracture  from  the  hands  of  the  surgeon. 
The  more  deplorable  is  this  state  of  things  since  one  may 
speak  in  this  connection  with  greater  propriety  than  in 
most  others  of  definite  rules  of  management,  these  being 
based  upon  notably  constant  reparative  phenomena,  so 
uniformly  attendant  upon  injuries  of  this  class  and  in  such 
thoroughly  accredited  guise  that,  barring  unessential  con¬ 
tretemps t,  each  variety  of  the  two  grand  divisions  of  fract¬ 
ures  of  limbs — that  involving  the  shaft  only  and  that  affect¬ 
ing  the  joint — may  be  successfully  treated  by  the  thence 
deducible  formulae.  When  it  is  borne  in  mind  that  books 
on  general  surgery,  and  even  those  specially  devoted  to 
fractures,  fail  to  definitely  indicate  the  proper  length  of  time 
during  which  it  is  necessary  to  maintain  uninterruptedly  a 
fixed  apparatus  upon  a  fractured  limb,  and  added  to  this 
other  neglects  of  detail,  and  the  tendency  on  the  part  of 
many  practitioners  to  follow  literally  and  tremblingly  what 
of  inexplicit  rules  (?)  they  may  find  laid  down  in  such 
works;  and,  further,  the  infrequent  and  wavering  use  made 
by  many  of  the  most  palpable  fruits  of  induction — any 
adverse  feeling  as  to  the  seasonableness  of  the  following 
remarks  will,  it  is  hoped,  be  mollified. 

Ordinarily,  the  broad  proposition  that  when  a  patient 
who  has  sustained  a  fracture  of  a  limb  or  a  joint  leaves  the 
care  of  the  surgeon,  the  functional  capacity  and  symmetry 
of  the  erstwhile  injured  part  should  be  very  nearly  if  not 
quite  perfectly  re-established,  is  thoroughly  logical  if  the 
proper  methods  of  management  have  been  observed,  and 

*  Read  before  the  New  York  County  Medical  Association,  October 
20,  1890. 


Nov.  15,  1890.] _ VQN  DONHOFF:  THE  MANAGEMENT  OF  FRACTURED  LIMBS. 

provided  there  were  no  constitutional  influences  to  militate 


against  the  repair.  This  is  especially  true  of  simple  fract¬ 
ures  resulting  from  indirect  violence,  and  only  exceptionally 
untrue  of  compound  fractures— i.  e.,  when  the  modifying 
element  is  of  the  most  serious  nature  permitting  qf  the  con¬ 
duct  of  the  case  as  one  of  fracture.  So  that  in  our  day,  to 
quote  a  great  Nestor  of  surgical  philosophy,  “a  simple 
fracture,  or  one  convertible  in  time  to  this  form,  should 
rather  he  considered  a  serious  inconvenience  than  a  fear¬ 
fully  hazardous  malady  to  the  unfortunate.”  Even  age 
is  a  comparatively  insignificant  factor  of  prognosis,  for¬ 
midable  (?)  only  in  that  it  bears  upon  the  likelihood  of  ac¬ 
quired  diathetic  influences  which  may  become  active  as 
local  interruptions.  In  this  connection  it  is  a  remarkable 
fact  that  fractures  occurring  in  the  bodies  of  pronouncedly 
strumous  young  individuals  in  whom  analogues  of  histo¬ 
logical  senile  changes  are  frequent  are  not  discernibly  in¬ 
fluenced  by  the  existing  diathesis  except  in  much  debili¬ 
tated  subjects,  or  such  as  have  already  existing  active  bone 
disease.  Active  syphilis,  congenital  or  acquired,  is  much 
more  apt  to  exert  an  adverse  influence  in  either  young  or 
older  persons.  Upon  the  whole,  there  seems  to  be  less 
danger  of  total  or  partial  failure  of  treatment,  so  far  as 
union  of  fragments  and  symmetry  of  limb  and  function  are 
concerned,  from  diathetic  influences  or  acutely  developed 
local  causes  or  temporary  diseased  conditions  of  the  body  at 
large  than  from  faulty  mechanics  or  dilatory  manipulation. 
The  largest  proportion  of  rational  failures  are  in  epiphyseal 
fractures,  necessitating  special  consideration  of  muscular  at¬ 
tachments  in  the  mechanism  of  apparatus  to  be  adapted  to 
the  injury.  This  variety  embraces,  of  course,  fractures  of 
the  femoral  and  humeral  head  and  glenoid  cavity  and  the 
olecranon  and  coronoid  processes.  It  is  perhaps  as  excusa¬ 
ble  to  fail  in  satisfactorily  dismissing  a  case  of  this  sort 
after  ordinary  treatment  as  it  is  inexcusable  to  abandon  a 
case  of  simple  fracture  of  the  forearm  or  leg  healed  (?)  with 
a  remaining  iucurvature  or  excurvature,  or,  what  is  rarer, 
however,  a  pseudarthrosis.  It  is  equally  unpardonable  to 
dismiss  a  case  in  which,  through  faulty  management  alone, 
there  remains  what  ought  never  to  have  been  permitted  to 
develop — a  fibrous  ankylosis  of  joints,  whether  involved  in 
the  fracture  or  not.  Such  conditions  often  enough  are  the 
source  ot  seriously  modified  or  quite  abridged  usefulness  of 
a  whole  limb  and  the  utter  helplessness  of  the  sutferer. 

It  is  just  here  that  an  absence  of  that  knowledge  of  de¬ 
tail,  so  rarely  vouchsafed  the  student  of  text-books  and 
auditors  at  didactic  lectures,  is  most  poignantly  felt  and  too 
tardily  admitted  to  be  the  basis  of  the  success  of  acknowl¬ 
edged  superior  skill.  A  half-dozen  or  so  of  ankylosed  el¬ 
bows,  wrists,  hands,  etc.,  in  one’s  surgical  repertoire  should, 
it  seems,  be  a  sufficiently  effective  means  of  suggesting  the 
propriety  of  a  change  in  the  erstwhile  practiced  methods. 
And  yet  there  are  those  within  the  sound  of  my  voice  who 
have  a  much  longer  score  to  their  credit  (?).  This  is,  of 
course,  not  the  only  field  of  surgery  in  which  such  evidences 
of  unfitness  exhibit  themselves,  as  witness  the  salutary  revolu¬ 
tion  effected  in  operative  surgery  generally  by  the  inducted, 
methodical  attention  to  detail  of  its  most  modern  and  most 
brilliantly  successful  school.  Such  revolution  could  only 


537 

have  been  possible  in  the  face  of  such  acknowledgedly 
criminal  negligence  as  it  has  swept  out  of  existence.  It  is 
said  of  Lister  that,  during  the  time  when  the  antisep¬ 
tic  (?)  spray  was  by  him  considered  a  sine  qua  non  of  suc¬ 
cess,  he  dismissed  an  otherwise  competent  assistant  for 
having,  during  a  very  short  interval — an  operation  by  Sir 
Joseph  being  under  way — permitted  the  spray  to  cease. 
Whatever  the  justice  of  this  incident,  surely  the  offense 
was  not  so  reprehensible  as  a  neglect  on  the  part  of  the 
surgeon  to  use  the  proper  precaution  against  the  establish¬ 
ment,  quite  unnecessarily,  of  a  stiff  joint,  or  a  crooked  limb, 
or  a  much  shortened  one  ;  and  yet  English  surgery  is  re¬ 
markably,  though  not  exceptionally,  free  from  distinct  rules 
of  prophylactic  practice  in  this  regard.  From  a  text-book 
as  much  sought  and  consulted  as  Erichsen’s,  it  is  impossi¬ 
ble  to  learn  when  a  fracture  dressing  is  to  be  finally  re¬ 
moved,  or  when  passive  motion  of  a  fractured  elbow  may 
be  safely  begun,  etc.  Indeed,  no  text-book  is  known  to 
me  in  which  this  information  is  distinctly  and  aetiologically 
imparted,  and  only  in  comparatively  recent  times  have  oc¬ 
casional  articles  appeared  in  medical  journals  looking  to 
the  establishment  of  the  “treatment  of  fractures”  upon  a 
physiological  and  scientific  basis. 

When  the  surgeon  of  a  decade  since  is  confronted  with 
his  then  faulty  technique,  such  as  a  failure  to  securely 
arrest  haemorrhage  from  the  smallest  bleeding  point,  or  his 
failure  to  adapt  the  closure  of  a  wound  to  the  known  re¬ 
quisites  underlying  the  physiological  union  of  cut  surfaces, 
or  inattention  to  the  imperative  details  of  drainage,  and 
last,  but  not  least,  failure  to  secure  all  the  hygienic  and 
other  physiological  addenda  of  wholesome  physical  com¬ 
fort  to  the  patient  he  wished  to  safely  tide  over  a  surgical 
danger,  he  stands  confessed  an  erstwhile  unthinking  votary 
of  dogmas  which,  while  they  embodied  the  spirit,  failed  to 
impress  the  literal  necessity  of  attention  to  the  smallest 
details  of  truths  underlying,  as  chiefest  corner-stones,  the 
grandeur  of  modern  surgical  achievement. 

There  is  no  less  a  need  of  attention  to  detail,  in  order 
to  secure  proper  results  in  the  management  of  fractures, 
than  there  is  of  assuring  similar  desiderata  in  other  fields 
of  practice,  and  these  are  by  no  means  easier,  but  rather 
more  difficult  of  establishment  here  than  elsewhere.  Be¬ 
sides  being  of  the  first  importance  from  a  medico-legal 
point  of  view,  the  perfect  success  in  the  treatment  of  fract¬ 
ured  limbs  is  essentially  tributary  to  utilitarian  philanthro¬ 
py.  The  treatment  of  a  fracture  should  begin  with  a  cor¬ 
rect  understanding  of  the  mechanical  history  and  topog¬ 
raphy  of  the  injury.  In  order  to  secure  this,  it  is,  in  my 
opinion,  necessary,  in  the  majority  of  cases,  as  a  matter  of 
both  safety  and  accuracy  of  adjustment — the  most  essen¬ 
tial  initial  step  to  success — to  anaesthetize  the  patient,  at 
least  in  every  instance  where  muscular  resistance  to  effect¬ 
ive  manipulation  is  expected,  or  a  doubt  as  to  the  exact 
line  of  fracture  exists.  I  should  positively  make  no  conclu¬ 
sive  (?)  examination  in  any  case  of  fracture  of  the  shoulder, 
elbow,  wrist,  hip,  knee,  or  ankle  joint  without  the  exhibi¬ 
tion  of  an  anaesthetic,  unless,  indeed,  it  were  possible  (?)  to 
secure  through  the  will-power  of  the  individual  or  by  ap¬ 
paratus — these  resources  to  be  substituted  only  under  cir- 


538 


VON  JDONHOFF:  THE  MANAGEMENT  OF  FRACTURED  LIMBS.  |N.  Y.  Med.  Jour., 


cumstances  contra-indicating  the  use  of  anaesthetics — such 
a  passivity  of  muscles  as  to  assure  a  satisfactory  explora¬ 
tion.  The  examination  should  note  the  amount  of  enlarge¬ 
ment  growing  out  of  infiltration  of  the  surrounding  soft 
parts  with  serum  or  blood,  also  the  probable  amount  of  fluid 
— probably  blood — lying  in  immediate  contact  with  the 
fracture,  and  the  degree  of  displacement  of  fragments  and 
the  direction  of  it. 

We  will  assume  the  study  of  a  simple  comminuted 
fracture  of  the  elbow.  The  diagnosis  being  complete, 
the  limb  should  now  be  scrupulously  cleansed.  Begin 
the  first  dressing  of  a  fracture  by  fixing  the  replaced  frag¬ 
ments — i.  e.,  the  site  of  the  fracture  first — with  a  plaster- 
of-Paris  roller,  adjusted  over  suitably  arranged  batting  or 
other  cushioning  of  available  material,  in  only  sufficient 
quantity  to  prevent  painful  or  undue  pressure.  This  roller 
is  permitted  to  harden  somewhat  before  the  succeeding 
ones  are  applied,  as  its  evident  purpose  is  to  secure  the 
fragments  in  the  position  given  them  by  the  operator  in 
such  a  manner  as  to  prevent  their  slipping  during  the  sub¬ 
sequent  manipulation.  The  limb  is  now  swathed  as  usual 
and  the  plaster  bandage  adjusted,  beginning  at  the  distal 
extremity  over  the  first  applied  roller  and  including  the 
shoulder  in  a  spica.  In  fractures  of  the  elbow  I  have  for 
a  long  time  preferred  a  pose  of  about  110°,  because  of  the 
muscular  equilibrium  thus  attained  and  the  greater  useful¬ 
ness  of  the  limb  in  this  position  to  a  laborer  should  (?)  the 
joint  become  ankylosed. 

If  great  restlessness  is  expected  at  this  time,  the  an¬ 
esthesia  may  be  prolonged  for  a  few  moments,  which  will 
suffice  for  the  hardening  of  the  plaster,  especially  if  it  is 
rubbed  with  powdered  alum.  When  the  patient  is  thor- 
oughly  conscious  and  the  surgeon  convinced  of  his  complete 
comfort,  the  first  dressing  may  be  regarded  as  properly  ad¬ 
justed  ;  as  soon  after  this  time — ordinarily  from  two  to 
three  days — as  the  more  or  less  complete  recedenee  of  the 
swelling  is  indicated  by  the  general  sense  of  comfort,  and 
the  evidences  elicited  by  careful  percussion  of  the  plaster 
casing,  this  should  be  carefully  divided  into  two  equal  halves 
longitudinally,  and  the  upper  half  carefully  lifted  off  with¬ 
out  in  the  least  disturbing  the  limb.  The  exposed  cotton 
is  then  smoothly  teased  away,  observing  the  middle  line  in 
the  process,  and  so  the  arm  is  bared  quite  perfectly  for 
all  purposes  of  inspection. 

If  the  swelling  has,  as  is  most  likely,  receded  and  the 
shapeliness  of  the  limb  is  suggestive  of  good  apposition  of 
the  fragments,  the  removed  half  of  the  dressing  should  be, 
after  trimming  down,  reapplied  and  fastened  in  position 
with  a  cheese-cloth  roller  snugly  applied,  and  the  patient 
allowed  to  rest  undisturbedly  during  the  ensuing  two  or 
three  days.  At  the  end  of  this  time  the  patient  should  be 
again  anaesthetized  and  the  dressing  carefully  removed  alto¬ 
gether.  Passive  motion  should  be  slightly  effected  at  the 
elbow.  The  shoulder  and  wrist  joints,  as  also  the  fingers, 
should  be  thoroughly  moved.  The  limb  is  then  lightly 
swathed  in  batting,  including  the  wrist  but  not  the  shoulder 
joint,  which  is  held  in  position  by  a  few  turns  of  ordinary 
sewing  thread.  The  whole  is  then  covered  with  two  leather 
splints  previously  cut  and  shaped,  by  measurement. 


Birch-tanned  saddle-skirting,  which  I  prefer,  is  made 
quite  soft  by  dipping  it  quickly  into  very  hot  water  (160° 
to  170°),  and  so  becomes  as  adjustable  as  papier-mache. 
The  splints  are  quickly  and  accurately  molded  to  the  limb, 
and  held  in  position  with  turns  of  sewing  thread,  to  be  di¬ 
rectly  followed  by  a  cheese-cloth  roller.  In  a  few  hours 
this  case  will  be  found  to  be  quite  bone-like  in  hardness, 
and  having,  of  course,  the  exact  shape  of  the  limb.  On  the 
day  following,  the  upper  half  is  lifted  off  and  slight  passive 
motion  made  at  the  elbow  and  wrist.  Everything  progress¬ 
ing  favorably,  the  slight  remaining  swelling  of  the  limb  will 
decrease  visibly  day  by  day,  and  the  edges  of  the  leather 
may  be  trimmed  accordingly  to  preserve  a  close  fit.  Each 
disturbance  of  the  dressing  must  be  followed  by  its  careful 
readjustment.  On  the  eighth  or  tenth  day  I  remove  the 
whole  casing  and  fix  its  two  halves  together,  at  their  pos¬ 
terior  border,  with  a  series  of  points  of  waxed-end  sutures; 
their  anterior  edges  are  provided  with  shoe-lace  hooks. 
Thus  a  perfect  and  reliable  boot  is  secured.  The  case  or 
boot  is  then  replaced  and  laced  in  position,  after  the  proper 
passive  motion  has  been  practiced.  During  the  succeeding 
four  to  five  days  the  bandage  is  regularly  removed  by  the 
surgeon  and  readjusted  after  passive  motion,  which  by  this 
time  will  be  possible  to  an  extent  very  nearly  simulating 
the  normal  area.  Now  the  patient  may  be  instructed  to 
leave  oft' the  boot  during  the  day-time  and  readjust  it  only 
when  about  to  retire  for  the  night,  so  that  he  may  be  pro¬ 
tected  against  injury  from  involuntary  motion  during  sleep. 
After  arising  and  bathing  the  limb  with  tepid  water  and 
subjecting  it  to  gentle  friction  with  a  towel,  the  patient 
should  be  required  to  make  voluntary  motion  to  the  limit 
of  his  comfort  in  imitation  of  all  the  normal  motions  of  the 
limb;  during  the  day  he  should  carry  a  small  round  ob¬ 
ject  in  the  hand  of  the  injured  limb  and  manipulate  it  for  a 
time  ;  he  should  also  be  required  to  occasionally  make  com¬ 
plete  pronation  and  supination.  At  the  end  of  the  fourth 
week  the  individual  whose  injury  has  been  treated  as  above 
described  can  be  safely  dismissed  from  attendance.*  He  will 
have  been  sufficiently  educated  by  this  time  in  the  manage¬ 
ment  of  his  condition,  and  will,  at  the  time  of  his  dismissal, 
be  finally  instructed  to  keep  up  the  nightly  adjustment  of  the 
apparatus  during  the  following  two  weeks.  Bathing,  mas¬ 
sage,  motion,  etc.,  are  to  be  likewise  systematically  prac¬ 
ticed. 

The  foregoing  is  a  typical  case  exemplifying  my  practice 
during  the  past  fifteen  or  sixteen  years,  during  which  time  I 
have  seen  no  failures  in  the  treatment  of  similar  or  other 
kinds  of  fracture  managed  in  this  fashion.  I  have  during 
that  period  induced  many  surgeons  to  practice  the  method, 
and  have  only  heard  words  of  commendation.  Some  years 
since,  a  considerable  number  of  cases  (one  hundred  and 
sixty-five)  of  fracture,  very  varied  in  character  and  taken 
from  the  practice  of  colleagues  who  kindly  contributed  their 
experience  with  this  method,  were  collated  and  tabulated 

*  In  fractures  of  the  lower  extremities  the  patient  should  not  be 
permitted  to  bear  his  weight  continuously  on  the  injured  limb  until  the 
close  of  the  fifth  week,  lest  he  incur  the  danger  of  refracturing  it  or 
producing  a  curvature  at  the  point  of  fracture  because  of  the  still  rela¬ 
tively  soft  condition  of  the  callus. 


Nov.  15,  1890. J 


by  myself  and  reported  to  the  State  Medical  Society  of 
entucky.  This  statistical  table  embraced  many  cases  of 
complicated  and  comminuted  fractures  at  the  elbow,  and 
also  a  number  of  intracapsular  fractures  at  the  hip.  In  no 
instance  did  an  adverse  or  at  all  questionable  result  obtain, 
though  many  cases  were  of  the  gravest  and  most  difficult 
nature.  Many  were  instances  of  surgical  fracture  by  the 
Macewen  operation. 

A.  number  of  intracapsular  fractures  (hip)  were  also 
contained  in  the  list.  The  average  duration  of  active  treat¬ 
ment  and  attendance  by  the  surgeon,  in  all  the  cases  thus 
recorded,  was  twenty-eight  days. 

In  no  case  was  there  remaining  any  deformity,  atrophy, 
or  vestige  of  fibrous  ankylosis,  or  marked  abridgment  of 
voluntary  motor  capacity— surely  a  very  encouraging  sum¬ 
From  an  analysis  of  the  supposititious  case  preceding 
we  may  formulate  rules  of  practice  which  are  applicable  to 
the  management  of  every  form  of  simple  fracture  of  the 
long  bones  and  joints  of  the  upper  and  lower  extremities, 
and  are  based  upon  such  unvarying  (?)  attendant  physio¬ 
logical  reparative  phenomena  that  they  are  quite  self-evi¬ 
dent  as  well  as  safe  guides.  In  the  management  of  com¬ 
minuted  simple  and  compound  fractures  the  added  diffi¬ 
culties  ot  the  situation  are  occasionally  such  as  demand  nice 
discriminative  mechanical  tact  during  the  arrangement  of 
the  fragments  at  the  time  of  the  first  dressing  ;  and  for  the 
rest,  a  thorough  appreciation  of  phenomena  attendant  upon 
the  repair  of  bone  injuries  complicated  with  contused  or 
similar  lacerations  of  adjacent  soft  parts,  the  significance  of 
which  varies  in  degree  of  importance  as  an  element  of  prog¬ 
nosis  as  well  as  a  never-to-be-overlooked  guide  in  the  very 
first  steps  to  be  taken,  dependent  upon  well-understood 
probabilities  in  this  connection. 


TAYLOR :  LA  TER  A  L  OURVA  TURK  OF  THE  SPINE. 


539 


time  at  which  the  “pin”  and  “  ensheathing  ”  callus  and 
periosteum  have  been  reformed  and  the  new  structures  are 
sufficiently  firm  to  support  the  “part”  thoroughly  against 
all  prospectively  reasonable  chances  of  displacement ;  but  of 
course  not  against  great  violence,  or,  in  the  case  of  the  lower 
extremity,  against  the  uninterrupted  effect  of  the  superim¬ 
posed  weight  of  the  body,  as  in  walking,  etc.  But  I  have 
frequently  exhibited  patients  to  medical  societies,  after  a 
Macewen  operation  done  for  the  correction  of  deformity  of  the 
thigh  or  leg,  able  to  stand  without  artificial  support  as  early 
as  the  twelfth  day.  These  tests  were  quite  sufficient  to  demon¬ 
strate  the  feasibility  of  my  proposition,  and  I  can  not  there¬ 
fore  too  strongly  emphasize  my  belief  that  it  is  unnecessary 
and  baneful-promoting,  as  it  does,  atrophic  changes  and 
retarding  the  reacquisition  in  numerous  directions  of  inter¬ 
rupted  functions  even  in  many  cases  of  the  simplest  form— 
to  maintain  fixation  by  artificial  means  after  a  natural  and 

safe  provision  against  displacement  of  the  fragments  is  as¬ 
sured. 

It  is  of  the  first  importance  to  effect  an  accurate  and  ex¬ 
act  adjustment  of  fragments,  as  well  in  fracture  of  bone  as 
in  divisions  through  the  soft  parts,  as  certainly  the  most 
valuable  desideratum  underlying  the  prompt  union  of  divid¬ 
ed  structure.  .  This  is  more  or  less  constantly  possible  to 
expert  and  painstaking  hands,  and  is  always  (?)  followed  by 
the  best,  strongest,  and  most  rapid  cementing  of  the  breach. 

It  is  only  fair  to  add,  for  the  benefit  of  those  who  would 
witness  for  themselves  the  results  described  in  the  preced 
mg  paragraphs  and  than  which  /  have  seen  few  others  dur¬ 
ing  the  past  fifteen  or  sixteen  years,  that  it  will  not  be  per¬ 
missible  in  the  premises  to  overlook  or  slight  the  least  detail 
in  the  management  of  their  future  cases. 


As  to  the  time  of  beginning  passive  motion  of  a  fract¬ 
ured  joint  and  those  necessarily  included  in  the  first  fixa¬ 
tion  apparatus,  it  is  only  requisite  to  remember  how  readi¬ 
ly  stiffness  and,  a  little  later  on,  ankylotic  appearances  de¬ 
velop  in  temporarily  confined  joints,  to  appreciate  the 
necessity  of  taking  advantage  of  the  earliest  moment  of 
safety  to  interfere  and  interrupt  fibrous  formations  between 
the  articular  surfaces  ;  such  interferences  need,  fortunately, 
to  be  very  slight  indeed,  and' neglect  now  will  afterward 
constitute  an  almost,  if  not  quite,  complete  nullification  of 
our  best  (?)  efforts  in  other  respects.  No  phase  of  a  clini¬ 
cal  fracture  history  is  of  graver  significance  than  this  mat¬ 
ter  of  possible  fibrous  ankylosis.  It  is  this,  too,  which 
evolves  those  phenomenal  appearances  of  atrophic  and  pa¬ 
retic  developments,  especially  often  associated  in  the  late 
history  of  the  so-called  graver  forms  of  fracture,  which  are 
wont  to  excite  our  commiseration  when,  alas  !  it  is  too  late 
to  aid  the  victim.  Experience,  based  upon  an  observation 
of  a  great  number  and  variety  of  cases,  including  many 
comminuted  and  compound  and  otherwise  complicated  fract¬ 
ures  of  the  extremities,  has  satisfied  me  perfectly  that  it  is 
safe  and  best,  ordinarily,  to  leave  off  “  fixation  apparatus” 
except  as  a  protection  against  untoward  involuntary  acts 
or  such  as  might  occur  during  sleep— at  the  earliest  practica- 
Jle  moment  i.  e.,  about  the  fourteenth  or  fifteenth  day,  a 


THE  TREATMENT  OF 

LATERAL  CURVATURE  OF  THE  SPINE* 

By  HENRY  LING  TAYLOR,  M.  D., 

NEW  YORK. 

In  spite  of  untold  labor  devoted  to  the  subject  of  lateral 
curvature  by  able  men,  we  still  seem  to  lack,  for  the  ordi¬ 
nary  forms  of  this  affection,  a  scientifically  observed  and 
well-digested  clinical  history,  a  satisfactory  theory  of  pa¬ 
thogeny,  and  a  thoroughly  rational  treatment. 

There  are,  no  doubt,  diversity,  multiplicity,  and  com- 
p  exity  of  causation  in  these  cases,  but  the  theories  so  far 
advanced  either  fail  to  explain  or  conflict  with  observed 
tacts,  such  as  the  following : 

1.  Most  delicate  children  with  weak  spinal  muscles, 
leading  a  sedentary,  precocious,  and  intense  life,  and  habitu* 

ally  assuming  faulty  attitudes,  do  not  develop  lateral  curva¬ 
ture. 

2.  Some  vigorous  children,  leading  an  active,  out-door 
life,  and  whose  spinal  muscles  seem  as  strong  as  or  stronger 
than  the  average,  do  develop  lateral  curvature. 

3.  Right-handed  people  sometimes  develop  scoliosis 
with  the  dorsal  convexity  to  the  left. 


*  Read  at  the  meeting  of  the  American  Orthopedic 
Philadelphia,  September  17,  1890. 


Association, 


540 


TAYLOR:  LATERAL  CURVATURE  OF  TEE  SPINE. 


[N.  Y.  Med.  Jottk., 


4.  Most  children  with  considerable  differences  in  the 
length  of  the  lower  extremities  and  consequent  pelvic  ob¬ 
liquity  do  not  develop  a  rotary  lateral  curvature. 

5.  A  patient  with  shortness  of  the  right  leg  (without 
joint  or  muscle  trouble)  and  with  the  pelvis  sloping  to  the 
right  may  develop  a  curve,  with  the  convexity  to  the  left, 
in  the  lumbar  region. 

6.  Lateral  curvature  with  extreme  rotation 
may  develop  with  the  spine  in  the  horizontal 
position.  (See  specimen  of  mammalian  spine 
in  the  Museum  of  the  College  of  Physicians 
and  Surgeons,  New  York.) 

What  is  the  reason  that,  out  of  a  hundred 
pale,  flabby,  undertrained  and  overstrained 
children  who  assume  faulty  attitudes,  and 
some  of  whom  have  flat  feet  or  crural  asym¬ 
metry,  only  a  few  develop  scoliosis  ? 

In  estimating  the  effects  ot  treatment  it  is 
necessary  to  know  that  many  cases  of  lateral 
curvature  are  self-limited,  or  at  least  do  not 
progress  very  far  even  without  treatment.  I 
am  constantly  discovering  mild  or  moderate 
forms  of  scoliosis  in  adults  in  the  course  of 
examination  for  other  troubles,  and  some  of  them  have 
never  suspected  the  existence  of  the  spinal  affection.  On 
the  other  hand,  it  is  even  more  important  to  know  that 
very  many  cases  do  grow  worse  unless  carefully  managed, 
and  some  have  a  strong  tendency  to  go  on  to  extreme  de¬ 
formity.  even  under  persistent  treatment. 

When  beginning  cases  are  brought  for  an  opinion,  cer¬ 
tain  data— such  as  the  height,  chest  expansion,  and  Roth’s 
horizontal  dorsal  contour — should  be  noted, 
and  the  patients  should  be  examined  once  in 
a  few  months  to  see  if  the  deformity  in¬ 
creases.  In  the  mean  time  explicit  directions 
are  given  for  the  regulation  of  the  mental, 
physical,  and  social  life.  It  seems  clear  that 
regular  habits,  moderate  exercise,  stated  com¬ 
plete  rests  in  the  daytime,  plenty  of  fresh  air, 
and  an  open-air  life,  with  the  avoidance  of 
physical,  mental,  and  emotional  forcing  and 
strain,  are  a  vast  help  to  these  patients,  and  I 
believe  that  the  rational  employment  of  these 
rational  means  docs  arrest  the  progress  of  the 
curvature  in  many  cases. 

I  have  observed  several  instances  of  city 
school-children  with  moderate  osseous  curves, 
but  who  had  never  worn  braces,  who  im¬ 
proved  notably  during  a  three  months’  so¬ 
journ  in  the  country,  with  a  natural  open-air 
life.  On  the  other  hand,  I  have  seen  severe 
curvatures  develop  in  sturdy  children  brought  up  in  the 
country  under  apparently  just  as  favorable  conditions.  At¬ 
tention  to  these  points,  however,  is  always  imperative  and 
often  sufficient  in  the  earlier  and  milder  cases. 

The  backache  and  spinal  tenderness  so  sedulously  sought 
by  the  inexpert  are  not  properly  symptoms  of  lateral  curva¬ 
ture.  They  may  be  symptoms  of  a  system  below  par,  or 
of  nervous  or  spinal  weakness,  and  are  often  accompanied 


by  headaches  and  other  local  and  general  symptoms.  A 
few  of  these  patients  have  lateral  curvature  in  addition,  and 
a  moderate  proportion  of  scoliotics  have  headache  and  back¬ 
ache  as  an  expression  of  their  general  condition  of  health. 
The  rib  pains  and  other  pains  of  some  of  the  extreme  cases 
belong  to  a  different  category.  These  patients  with  backache 
— usually  anaemic  and  with  impaired  digestion,  nutrition,  and 


elimination,  and  a  faulty  nervous  and  blood  distribution — 
are  much  benefited  by  systematic  attention  to  mode  of  life, 
general  and  special  exercise,  rest,  diet,  bathing,  and  mental 
and  moral  hygiene,  and,  if  they  at  the  same  time  happen  to 
be  suffering  from  scoliosis,  these  indications  are  all  the  more 
clear  and  urgent.  While  lateral  curvature  is  not  caused  by 
general  lack  of  vigor,  it  is  much  more  apt  to  develop  in 
such  constitutions  when  the  other  necessary  factors  are 


present;  when  it  is  developed,  it  acts  as  a  constant  drag 
and  strain  upon  the  economy  through  imperfect  equili¬ 
brium,  overworked  muscles,  and  crowded  viscera,  according 
to  the  grade  of  the  affection.  By  careful  attention  to  the 
measures  mentioned,  for  which  it  is  necessary  to  give  spe¬ 
cific  directions  and  to  secure  the  co-operation  of  the  patient 
and  her  family,  and  the  use  of  special  exercises,  we  ar? 
nearly  always  able  to  improve  the  general  health  and  vigor 


Fig.  2. 


Nov.  15,  1890.] 


TAYLOR:  LATERAL  CURVATURE  OF  TEE  SPINE. 


_ _ _ _  _  541 

of  our  patients  give  tone  to  the  muscles,  relieve  backache' I  longest  diagonal  of  the  chest,  At  the  same  time  the  concave 

tzt; and  often  improve  of  1,10  ^ is — * 

»  v  .  ,  excursion  of  the  coi responding  arm  (Fio-  4]* 

As  chest  power  and  capacity  are  threatened  or  already  V  8  '* 

encroached  upon,  we  give  special  attention  to  respiratory 
exercises,  by  which  means  we  also  favor  oxygenation  of  the 
blood  and  improvement  of  nutrition  and  circulation,  but 
are  careful  to  avoid  overtaxing  a  system  in  many  instances 
already  delicate  and  tired.  To  fulfill  these  indications  we 
have  found  nothing  so  useful  as  certain  specific  exercises, 
mainly  passive,  adapted  by  Dr.  C.  Fayette  Taylor  from  the' 
system  of  Ling.  The  apparatus  called  the  respirator  (Figs. 

1  and  2),  elsewhere  described,*  actuated  by  steam-power, 
and  giving  sixteen  deep  respiratory  movements  a  minute,  is 
prescribed  for  nearly  all  our  scoliotic  cases  requiring  special 
treatment. 

By  means  of  another  power  apparatus  we  give  alternate 
right  and  left  lateral  flexion,  forty-six  times  a  minute,  of 
the  trunk  through  the  loins,  the  patient  lying  on  the  back. 

This  increases  lumbar  flexibility,  strengthens  the  muscles 
about  the  waist,  and  acts  on  the  abdominal  viscera. 

Another  useful  exercise  is  taken  while  the  patient  lies 
on  a  couch  made  of  two  halves  hinged  in  the  middle,  and 
so  contrived  that  the  body  may  be  flexed  and  extended  at 
the  waist  against  a  balancing  weight,  the  upper  and  lower 
half  being  fixed  at  choice  (Fig.  3).f  This  and  the  preced- 


e 


cv 


v1 


?!  X;; 

Fig.  3. 

ng  are  excellent  exercises  for  improving  abdominal  circula¬ 
tion  and  increasing  peristalsis,  and  the  latter  strengthens 
the  back  and  abdominal  muscles. 

To  attack  the  deformity  directly,  we  use  lateral  suspen¬ 
sion  from  the  hands  in  an  apparatus  consisting  of  a  vertical, 
adjustable  upright,  hinged  near  the  middle  and  carrying  a 
reversible  pad  for  pressure  upon  the  convexity  of  the  main 
curve,  and  a  hand-piece  for  grasping.  When  the  upper 
part  of  the  apparatus  is  drawn  over  to  the  side,  the  patient 
is  lifted  from  the  floor,  and  the  weight  of  the  body  forces 
the  pad  against  the  projecting  ribs  in  the  direction  of  the 


The  Therapeutic  \  alue  of  Systematic  Passive  Respiratory  Move¬ 
ments.  Medical  Record ,  May  4,  1889. 

f  From  Spinal  Irritation,  by  Dr.  C.  Fayette  Taylor  p  23  W 

Wood,  1870. 


Fig.  4. 

In  addition  to  these  movements,  I  have  lately  given  to 
some  of  my  patients  certain  active  free  exercises  similar  to 
those  recommended  by  Roth. 

We  shall  be  in  a  better  position  to  judge  of  the  value 
of  prescribed  exercise  in  the  treatment  of  scoliosis  when 
we  have  more  exact  information  in  relation  to  the  special 
physiology  of  muscular  movements,  and  particularly  of  as¬ 
sociated  and  co-ordinated  movements.  We  know  well  that 
the  contraction  of  any  given  muscle  or  group  involves  the 
contraction  of  many  other  muscles ;  in  fact,  determines  a 
change  greater  or  less  in  nearly  every  muscle  and  tissue  of 
the  body ;  but  we  need  to  know  how  simple  and  combined 
movements  affect  carriage,  attitude,  and  the  normal  and  ab¬ 
normal  positions  of  the  spinal  column,  and  how  these  effects 
can  be  varied  to  produce  specific  results. 

Whatever  factors  may  be  present  in  addition,  we  cer¬ 
tainly  have  to  do  with  a  problem  in  balancing.  The  spinal 
column  sustains  the  weight  of  the  trunk,  but  the  muscles 
balance  the  column.  The  varying  tonicity  of  the  trunk 
muscles,  responsive  to  changes  in  position  and  strain,  keep 
the  unstable  column  delicately  poised,  but  slight  causes  may 
destroy  this  harmonious  action,  especially  in  the  period 
of  muscular  instability  and  spinal  flexibility  common  in 
adolescence  (and  more  marked  in  girls  than  in  boys),  and 
throw  continued  strain  on  feeble  parts;  and  further  pro- 

*  Described  and  figured  on  page  98  in  Theory  and  Practice  of  the 
Movement  Cure ,  by  Dr.  C.  Fayette  Taylor,  1860. 


542 


TAYLOR:  LATERAL  CURVATURE  OF  THE  SPINE. 


[N.  Y.  Mbd.  Jour., 


gressive  changes  will  take  place  in  the  lines  of  least  resist¬ 
ance. 

It  should  be  remembered  that  the  center  of  gravity  of 
the  human  body  lies  in  the  upper  lumbar  region,  in  most 
cases  to  the  right  of  the  median  plane,*  which  might  help 
to  explain  the  greater  frequency  of  primary  lumbar  curves 
and  the  preponderance  of  the  left  lumbar  and  right  dorsal 
position,  since  in  balancing  the  body  there  would  be  a  tend¬ 
ency  to  bring  the  upper  lumbar  vertebrae  to  the  left  of  the 
median  plane,  in  order  to  place  the  center  of  gravity  over 
the  middle  of  the  base  line. 

The  observation  has  been  madef  that  scoliosis  is  rarely 
seen  among  people  who  have  been  trained  from  childhood 
to  carry  loads  on  the  head,  like  the  peasants  of  some  parts 
of  Europe  and  of  some  of  the  West  India  Islands.  I  have 
been  struck  with  the  firm,  erect  carriage  of  fencers.  Both 
fencing  and  the  carrying  of  loads  on  the  head  are,  in  part, 
exercises  in  the  fine  and  diffused  muscular  adjustments 
of  balancing,  and  contain  hints  for  the  training  of  these 
cases. 

Is  it  not  possible  that  scoliosis,  pre-eminently,  so  far  as 
we  are  informed,  an  affection  of  civilized  countries  and  cul¬ 
tivated  classes  so  called,  is  fundamentally  but  one  expres¬ 
sion  of  the  faulty,  one-sided  training  of  certain  areas,  with 
corresponding  starvation  and  atrophy  of  others  that  these 
conditions  impose  upon  muscles  and  mind  ? 

As  to  mechanical  support  to  the  spine,  in  addition  to 
the  measures  already  spoken  of,  my  position  is  that  it  is  of 
substantial  benefit  when  properly  managed  in  selected  cases, 
and  my  aim  is  never  to  employ  it  whenever  the  patient  can 


do  as.well  without  it.  This  is  a  matter  for  observation  and 
judgment,  but  in  practice  only  a  certain  proportion  of  the 

*  Vide  a  paper  by  Dr.  John  Struthers,  Edinburgh  Med.  Journal , 
June,  1863,  p.  1086. 

f  By  Dr.  C.  Fayette  Taylor. 


severer  cases  are  so  treated.  The  aim  of  mechanical  sup¬ 
port  should  be  not  only  to  correct  or  hold  the  spinal  de¬ 
formity,  but  also  to  relieve  cramped,  stretched,  and  atro¬ 
phied  parts  of  undue  strain  by  the  restoration,  so  far  as  may 
be,  of  a  more  normal  dynamical  equilibrium. 

For  this  purpose  we  use  a  light  steel  apparatus  acting 
on  the  principle  of  lateral  leverage,  and  worn  only  during 
the  daytime,  while  the  weight  of  the  body  is  acting  upon 
the  spine. 

The  details  vary  in  each  case  according  to  the  indica¬ 
tions,  but  a  general  idea  of  a  common  form  employed  and 
its  action  may  be  gathered  from  the  cuts  (Figs.  5  and  6), 
which  were  taken,  with  slight  modifications,  from  photo¬ 
graphs  of  the  same  patient,  and  within  a  few  minutes. 

A  light  steel  band,  closed  at  one  side  by  a  strap  and 
buckle,  passes  around  the  hips  above  the  level  of  the  tro¬ 
chanters.  To  this  an  H-shaped,  braced  steel  upright,  which 
carries  a  broad  band  of  leather  on  its  upper  end  for  pressure 
against  the  projecting  ribs  of  the  convexity,  is  fixed  at  right 
angles,  and  the  whole  is  held  in  position  by  a  flexible  hip- 
piece  fitted  over  the  ilium  of  the  side  of  the  prominent 
curve,  and  buckled  to  the  hip-band.  This  hip-piece  serves 
as  a  fulcrum  when  leverage  is  applied  by  the  perineal  strap, 
which  unites  the  two  ends  of  the  hip-band,  passes  under  the 
leg  on  the  side  opposite  the  main  curve,  and  is  regulated  at 
the  buckle  behind.  The  counter  pressure  on  the  side  of  the 
trunk  opposite  the  main  curve,  higher  or  lower,  as  is  me¬ 
chanically  more  advantageous  in  the  particular  case  in  hand, 
is  given  by  a  similar  firm  leather  band  supported  on  the  up¬ 
per  ends  of  a  separate  steel  H-piece,  which  is  completed  be¬ 
low  by  a  strap  over  the  hip.  The  two  H-shaped  side-pieces 
are  fastened  together  in  front  by  an  adjustable  bowed  steel 
U-piece,  with  a  key-hole  at  each  end 
which  slips  over  a  screw  head  about 
half  way  up  the  front  bars  of  the 
Il-piece  (Fig.  7) ;  behind,  by  a  strap 
and  buckle,  by  which  the  pressure  of 
the  apparatus  is  adjusted.  By  working 
from  fixed  points  on  the  pelvis  (hip- 
piece  and  perineal  strap),  the  swaying 
to  one  side  of  the  trunk  en  masse,  which  is  often  one  of 
the  main  difficulties,  is  directly  opposed  (Figs.  5  and  6). 
This  apparatus  requires  the  nicest  judgment  in  design  and 
the  greatest  care  in  its  adaptation,  and  must  be  modified 
from  time  to  time  to  meet  special  requirements,  as  the  case 
progresses.  It  is  only  a  tool,  like  a  violin,  which  is  capable 
of  being  manipulated  to  produce  definite  results  by  one  who 
is  skilled  in  its  use.  Here,  as  everywhere  in  orthopaedy,  it 
is  a  question  of  method  not  means,  principles  not  rules, 
and  men  not  machines. 

I  have  but  briefly  mentioned  some  of  the  methods  we 
have  found  useful,  fully  realizing  that  there  is  much  more 
to  learn  than  we  now  know  in  regard  to  this  difficult  and 
important  subject ;  but,  in  spite  of  our  defective  knowledge 
on  many  points,  we  expect  good  results  in  the  milder  and 
earlier  cases,  and  gratifying  amelioration  in  all  but  the  worst 
of  the  more  advanced  cases,  provided  we  can  secure  hearty 
and  full  co-operation. 

201  West  Fifty-fourth  Street. 


Nov.  15,  1890. J 


PETERSON:  THE  CATAPHORETIC  USE  OF  DRUGS. 


543 


NOTE  ON 

A  NEW  SYSTEM  OF  EXACT  DOSAGE  IN 
THE  CATAPHORETIC  USE  OF  DRUGS. 


A  TYPHOID  SEQUEL* 

By  J.  0.  CROSSLAND,  A.  M.,  M.  D., 

ZANESVILLE,  OHIO. 


By  FREDERICK  PETERSON,  M.  D. 

In  a  paper  of  mine,  published  in  th e  New  York  Medical 
Journal ,  April  27,  1889,  there  are  figured  two  cataphoretic 
electrodes  devised  for  the  anodal  diffusion  of  drugs  through 
the  skin.  The  great  drawback,  until  this  present  moment, 
has  been  the  difficulty  of  accurately  regulating  the  amount 
of  drug  introduced.  For  this  purpose  rather  complicated 
electrodes  have  hitherto  been  required,  and  even  these  have 
been  unsatisfactory.  I  have  recently  found,  however,  that 
all  difficulties  are  easily  obviated  by  the  use  of  a  new  and 
exceedingly  simple  method.  Messrs.  Waite  and  Bartlett 
have  made  for  me  a  cataphoretic  electrode  of  metal.  In- 
enng  it ,  as  before,  with  sponge,  the  ordinary 
metal  surface  is  overlaid  with  a  thin  disc  of  platinum,  and 
around  the  edge  of  this  is  placed  a  narrow  rim  of  soft  rub 
ber.  The  drug  to  be  used  is  put  drop  by  drop  upon  a  disc 
of  ordinary  tissue  paper  cut  to  fit  the  disc  of  platinum. 
Filtering  paper  or  linen  cloth  may  be  used  instead  of  tissue 
paper.  A  disc  two  or  three  centimetres  in  diameter  will 
hold  from  one  to  four  drops  of  the  solution.  When  the 
medicated  disc  is  placed  upon  the  metal  surface  of  the  elec 
trode,  and  the  latter  then  applied  to  the  skin,  it  is  evident 
that  there  is  a  thin  capillary  layer  of  the  drug  in  solution 
exposed  to  the  cataphoretic  power  of  the  anode,  between 
the  electrode  and  the  skin,  and  that  the  quantity  of  the 
drug  used  may  be  accurately  estimated.  The  current  is  al¬ 
lowed  to  flow  if  desired  until  the  medicated  disc  becomes 
perfectly  dry.  In  this  way  we  may  drive  in  one  or  more 
drops  of  chloroform,  methyl  chloride,  ether,  ten-to-twenty- 
per-cent.  solutions  of  cocaine,  a  one-per-cent,  solution  of 
helleborin,  solutions  of  iodide  of  potassium,  corrosive  subli¬ 
mate,  aconitine — in  fact,  any  drug  we  wish  to  employ  in  this 
manner;  and  at  the  same  time  we  know  exactly  how  much 
we  are  using. 

To  further  simplify  the  method,  I  have  had  medicated 
cataphoretic  discs  prepared  by  a  pharmacist  for  use  at  any 
time,  for  the  paper  discs  may  be  charged  with  any  amount 
of  a  watery  solution,  and,  the  water  being  allowed  to  evapo¬ 
rate,  they  may  be  kept  on  hand  indefinitely,  ft  is  only 
necessary  to  add  two  or  three  drops  of  water  to  the  disc  in 
administering  the  drug  by  electricity. 

Mr.  Otto  Boeddiker,  the  apothecary,  of  954  Sixth 
Avenue,  has  made  for  me,  and  is  prepared  to  supply  any 
one  with,  the  following  cataphoretic  discs  :  Discs  of  menthol, 

2  grains;  ot  helleborin,  grain  ;  of  strychnine  nitrate, 
grain  ;  of  iodol,  2  grains  ;  of  corrosive  sublimate,  A  grain  ; 
of  cocaine  hydrochloride,  grain  ;  of  aconitine,  -gL-  grain- 
of  potassium  iodide,  4  grains;  of  mercury  succinimide,  I 
grain ;  of  lithium  chloride,  4  grains. 


Pineapple  Juice  for  Diphtheria. — “  It  is  reported  that  the  negroes 
of  Louisiana  frequently  employ  pineapple  juice  in  the  treatment  of  diph¬ 
theria  ;  and  this  treatment  is  alleged  to  be  successful.” — Druggist's 
Circular  and  Chemical  Gazette. 


On  Apiil  25,  1889,  I  attended  Blanche  R.,  a  girl  of  eighteen 
years,  in  confinement.  Her  labor  was  natural  but  prolonged. 
According  to  her  statement,. she  had  always  had  a  rather  weak 
back.  In  the  latter  months  of  her  pregnancy  she  did  consid¬ 
erable  hard  and  heavy  labor.  During  this  period  she  com¬ 
plained  of  pain,  principally  in  the  left  shoulder,  which  after 
parturition  seemed  to  alternate  in  the  shoulders.  I  saw  her  the 
next  day  atter  confinement,  and  her  condition  was  satisfactory. 
On  the  7th  day  of  May  I  was  called  to  see  her,  and  found  her 
suffering  from  pneumonia,  involving  the  entire  left  lung.  The 
lower  lobe  of  the  right  lung  was  subsequently  affected.  This 
disease  was  grave  and  eventuated  in  suppurative  pneumonitis, 
which  continued  for  several  weeks.  In  the  hitter  part  of  this 
trouble  the  patient  was  seized  with  typhoid  fever.  She  lay 
sick  of  the  fever  about  eight  weeks.  The  fever,  entailed  upon 
such  a  grave  disease  as  pneumonia,  as  you  would  readily  infer, 
brought  the  patient  nigh  unto  death— so  near  that  a  physician 
of  large  experience,  who  saw  her  several  times  iu  con.-ultation, 
made  a  fatal  prognosis  each  time.  However,  the  patient  made 
an  incomplete  recovery.  She  so  far  recovered  as  to  be  able  to 
go  about  the  house  and  help  administer  medicine  to  the  other 
members  of  the  family,  five  in  number,  varying  in  age  from 
twelve  to  sixty-five  years,  all  of  whom  were  sick  with  the 
fever.  A  few  weeks  after  the  patient  was  able  to  leave  the  bed 
she  began  to  experience  severe  pain  in  the  dorsal  and  lumbar 
regions  of  the  spine  and  along  the  sides  of  the  chest  in  the  re¬ 
gion  ot  the  sixth  to  the  tenth  ribs,  inclusive.  There  was  tender¬ 
ness  to  pressure  in  these  regions,  with  slight  elevation  of  tem¬ 
perature,  pain  on  any  motion  of  the  back,  a  sensation  of  pressure 
against  the  back,  and  an  aching  pain  in  the  lower  extremities. 
This  condition  of  things  persisted,  with  remissions  and  exacer¬ 
bations,  until  November,  when  the  patient  began  to  notice  loss 
of  sensibility,  first  in  the  right  foot,  then  in  the  left.  Loss  of 
motion  and  a  staggering  gait  were  next  observed.  In  the  lan¬ 
guage  of  the  patient,  when  she  tried  to  put  her  foot  in  one  place, 
it  would  go  somewhere  else.  This  loss  of  sensibility  and  motion 
increased  and  extended  as  far  as  the  waist.  There  was  spas¬ 
modic  action  of  both  the  extensor  and  flexor  muscles  of  the 
lower  extremities,  also  of  the  lumbar  muscles;  while  she  was  in 
the  dorsal  decubitus  there  was  a  tendency  to  tonic  spasms  of  the 
flexor  muscles.  These  spasms  would  last  sometimes  for  an  hour, 
and  then  be  followed  by  spasms  of  the  extensor  and  erector 
spinae  muscles.  This  condition  of  things  persisted  until  there 
was  almost  complete  paraplegia.  Spasmodic  muscular  action 
existed  throughout  the  trouble.  The  bowels  were  in  no  way  af¬ 
fected.  There  was  no  retention  of  fasces  and  no  involuntary 
stools.  For  several  weeks  the  urine  was  greatly  diminished,  and 
was  voided  at  times  at  intervals  of  twenty-four  hours.  No  blad¬ 
der  trouble,  however,  arose  from  this  urinary  abnormity.  There 
was  marked  emaciation  of  the  lower  extremities.  In  the  mean 
time,  while  the  spinal  trouble  was  advancing  to  the  paralytic 
stage,  the  sternal  ends  of  the  sixth,  seventh,  eighth,  ninth,  and 
tenth  ribs,  and  their  cartilages,  became  very  prominent,  pro¬ 
jecting  outward  and  upward  in  such  a  manner  as  to  form  a  sup¬ 
port  or  table  upon  which  the  mammary  glands  rested.  After 
the  more  acute  inflammatory  symptoms  had  somewhat  sub¬ 
sided,  I  did  not  see  the  patient  until  the  paralysis  had  become 
well  marked. 

In  the  early  stage  of  the  spinal  trouble  my  treatment  con- 


*  Read  before  the  Hildreth  District  Medical  Association. 


544 


HAMMOND:  ANEDRYSM  OF  THE  ARCH  OF  THE  AORTA. 


[N.  Y.  Med.  Joob.,' 


sisted  of  occasional  narcotics,  liniments,  sinapisms,  and  blisters 
over  the  spinal  column,  tepid  baths,  occasional  small  doses  of 
calomel,  rest  in  the  recumbent  posture  as  much  as  possible,  and 
as  highly  nutritious  a  diet  as  the  patient’s  humble  circumstances 
would  allow.  In  other  words,  I  .followed  the  line  of  treatment 
recommended  by  Flint  for  the  affection  which  I  suspected. 
After  the  stage  of  paralysis  had  been  reached,  I  gave  small 
doses  of  mercury.  I  tried  iodide  of  potassium,  which  disagreed 
and  was  withdrawn.  Strychnine  also  disagreed.  In  fact,  this 
patient  had  so  many  idiosyncrasies  that  it  seemed  there  was 
little  to  be  hoped  from  medicines.  Fortunately,  the  patient’s 
appetite  and  digestion  remained  fairly  good,  and  much  reliance 
for  a  time  was  placed  on  the  vis  medicatrix  natures. 

After  the  paralytic  symptoms  had  reached  their  height,  a 
galvano-faradaic  battery  was  used  two  or  three  times  a  week. 
About  the  1st  of  April  and  some  three  or  four  weeks  after  be¬ 
ginning  the  use  of  the  electricity  the  patient  began  to  improve. 
At  the  present  time  she  is  almost  entirely  recovered.  She 
has  recently  walked  as  far  as  a  mile  at  one  time.  The  costo- 
cartilaginous  deformity  still  exists,  but  is  not  so  marked.  There 
is  an  anterior  curvature  in  the  dorso- cervical  region,  which  ren¬ 
ders  the  spinous  processes  of  the  first  four  dorsal  vertebrae  very 
prominent.  In  the  lower  dorsal  region  there  is  a  slight  poste¬ 
rior  curvature,  with  some  tenderness  in  that  region.  The  left 
side  of  the  chest  is  diminished  in  size  and  asymmetrical.  The 
left  shoulder  droops,  but  there  is  no  real  lateral  spinal  curvature. 

I  have  not  been  able  to  find,  in  the  literature  to  which 
I  have  access,  any  similar  condition  of  things  following 
typhoid  fever.  The  most  light  I  have  been  able  to  obtain 
on  the  subject  is  in  an  article  in  the  New  York  Medical 
Journal  of  November  30,  1889,  by  Dr.  Gibney,  of  New 
Y  ork. 

This  case,  in  its  early  stage,  presents  a  striking  simi¬ 
larity  to  one  or  two  of  Dr.  Gibney’s  cases.  Possibly,  with 
fair  advantages,  in  this  case  the  disease  might  have  been 
arrested  and  brought  to  a  more  speedy  termination.  It 
was  not  until  I  had  read  Dr.  Gibney’s  article  that  I  made 
the  diagnosis  of  periostitis  complicated  with  chronic  spinal 
meningitis,  and  to  him  I  am  also  indebted  for  my  lucky 
prognosis. 

I  am  inclined  to  the  opinion  that  the  pneumonia  is  ac¬ 
countable,  in  whole  or  part,  for  the  costo-cartilaginous  de¬ 
formity,  and  possibly  it  may  have  been  a  factor  in  the  pro¬ 
duction  of  the  spinal  trouble. 

I  have  been  actuated  in  the  report  of  this  case  not  by 
the  desire  to  claim  any  merit  for  the  result,  for  the  patient’s 
poverty  was  so  great  and  her  advantages  were  so  few  that 
medicine  and  surgery  were  of  comparatively  little  avail  to 
her,  but  for  the  purpose  of  recording  what  seems  to  me  a 
good  result  from  a  series  of  grave  and  rare  affections. 

It  is  a  good  illustration  of  the  healing  power  of  Nature. 


ANEURYSM  OF  THE  ARCH  OF  THE  AORTA.* 
By  C.  N.  HAMMOND,  M.  D., 

BENTLEY  CREEK,  PA. 

On  April  2,  1890,  I  was  called  to  see  Miss  D.,  aged  twenty- 
five  years,  who  was  suffering  from  neuralgic  pains  in  her  right 
shoulder  and  arm.  She  informed  me  that  she  had  been  suffer¬ 

*  Read  before  the  Bradford,  Pa.,  County  Medical  Society,  September 
2,  1890. 


ing  about  two  weeks,  and  could  get  no  relief  from  any  remedies 
she  had  used.  She  said  she  had  had  a  similar  attack  some  two  or 
three  years  before,  and  had  had  some  form  of  fever.  Her  family 
history  was  very  obscure,  she  being  a  foundling. 

During  my  examination  I  observed  her  to  cough,  which  in¬ 
duced  me  to  examine  her  lungs,  and  I  discovered  dullness  over 
the  right  supramammary  region.  There  being  no  rise  of  tem¬ 
perature,  I  thought  there  might  be  some  caseation  or  latent 
congestion.  I  prepared  her  remedies  which  I  thought  were 
indicated,  and  left  her.  The  following  day  I  called  and  found 
her  feeling,  as  she  expressed  herself,  “  much  better.” 

On  April  6th  I  was  again  summoned,  and  found  her  suffer¬ 
ing  severely  with  those  neuralgic  pains ;  and  she  said  her  right 
hand  and  arm  would  get  numb  and  cold  at  times.  I  examined 
her  right  lung,  and  found  pulsation  and  increased  dullness  where 
it  was  on  the  2d.  I  suspected  an  aneurysm  and  examined  her 
carefully ;  but  for  the  most  part  I  got  negative  results.  The 
radial  pulses  were  synchronous,  of  equal  rhythm  and  volume, 
and  I  could  get  no  “aneurysmal  bruit.”  The  tumor,  if  such  it 
was,  was  not  in  the  region  of  any  large  artery,  being  too  low 
down  for  the  subclavian  and  too  far  to  the  right  for  the  right 
carotid  or  aorta;  and  I  came  to  the  conclusion  that  it  was  an 
intrathoracic  tumor,  which  must  come  in  contact  with  some 
large  artery  that  caused  it  to  pulsate,  and  that  its  pressure  on 
some  plexus  of  nerves  caused  the  neuralgia  of  which  she  com¬ 
plained.  I  gave  her  tonics  and  opiates  to  keep  her  comfortable, 
and  ordered  five  grains  of  iodide  of  potassium  three  times  a  day. 
On  the  following  day  her  condition  remained  much  the  same; 
but,  on  examination,  I  heard  a  bruit,  which  was  absent  on 
the  two  succeeding  days.  Her  temperature  at  each  visit  was 
about  normal.  Respiration  20  to  22,  with  no  dyspnoea,  and 
pulse  80. 

On  the  9th,  Dr.  W.  O.  Wey,  of  Elmira,  was  called  in  con¬ 
sultation,  and  he  found  the  symptoms  about  as  before  related, 
except  that  there  was  no  bruit.  Dr.  Wey,  with  a  hypodermic 
needle,  punctured  the  tumor  and  found  the  contents  to  be  blood, 
but  still,  as  other  symptoms  were  absent,  could  not  be  positive 
of  an  aneurysm,  and  the  diagnosis  was  still  unsettled  as  between 
an  intrathoracic  tumor  and  an  aneurysmal  one.  At  my  visit 
on  the  11th  I  again  heard  the  bruit,  and,  from  the  examina¬ 
tion  with  the  hypodermic  needle  by  Dr.  Wey  on  the  9th,  I  was 
convinced  this  must  be  an  aneurysm.  Her  temperature  on  the 
10th  and  11th  rose  to  100°  F. ;  she  was  feeling  considerably 
worse,  and  I  advised  her  to  keep  her  bed.  (Up  to  this  time  she 
was  about  the  house  most  of  the  time  during  the  day.)  At  my 
examination  I  found  the  area  of  dullness  about  three  inches  and 
a  half  in  diameter,  nearly  circular,  and  the  center  about  an 
inch  above  the  right  nipple. 

At  my  visits  on  the  12th  and  13th  I  found  her  more  cheer¬ 
ful  and  feeling  better.  Temperature,  99° ;  pulse,  80;  respira¬ 
tion,  22.  Bruit  quite  clear.  On  the  14th  I  saw  her  about  4  p.  m., 
and  found  her  very  hopeful;  her  appetite  was  improving  very 
much,  and  she  said  she  felt  stronger  and  rested  with  less  opiates. 
I  found  the  area  of  dullness  had  diminished  to  about  two  inches, 
and  I  flattered  myself  that  the  tumor  was  being  absorbed.  1 
got  no  bruit.  About  two  o’clock  that  night  (the  14th)  she 
awoke  and  called  for  a  drink,  joked  and  laughed  with  the 
person  who  waited  upon  her,  and  lay  down  and  went  to  sleep. 
About  6  a.  m.  on  the  15th,  on  going  to  her  room,  she  was  found 
dead,  and,  to  all  appearance,  had  been  dead  for  several  hours. 
An  autopsy  was  held  that  evening,  which  revealed  an  aneurysm 
given  off  from  the  ascending  portion  of  the  arch  of  the  aorta, 
which  had  ruptured,  thereby  causing  immediate  death,  also  hy¬ 
pertrophy  and  dilatation  of  left  ventricle  of  the  heart.  There 
were  also  tubercular  deposits  in  the  right  lung,  which  was  much 
atrophied  and  hepatized.  The  left  was  nearly  normal.  Dr. 


Nov.  15,  1890.] 


CORRESPONDENCE. 


545 


Huff,  Dr.  Colgrove,  and  Dr.  Voorhis,  of  Wellsburg,  N.  Y.,  were 
present,  and  assisted  at  the  autopsy. 

The  treatment  throughout  was  with  tonics,  iodide  of  potas¬ 
sium  (which  was  increased  to  ten  grains  three  times  a  day),  and 

opiates. 

In  reviewing  this  case,  the  peculiar  phases  to  me  are 
that  I  only  got  the  bruit  at  times,  while  at  others  it  was 
absent ;  also  its  location.  I  will  add,  its  shape  was  some¬ 
thing  like  a  pear,  the  body  or  fundus  of  which  reached  to 
the  right  mammary  region,  and  it  touched  the  chest  wall 
only  at  this  point.  There  was  no  necrosis  observed,  and  its 
apparent  diminishing  in  size  (perhaps)  was  its  receding 
from  the  chest  wall  by  gravity  from  her  keeping  in  a  re¬ 
cumbent  posture.  The  case  was  a  very  interesting  and 
instructive  one. 


A  CASE  OF  MORPHINE  POISONING 
TREATED  WITH  NITROGLYCERIN. 

By  A.  T.  SPEER,  M.  D., 

NEWARK,  OHIO. 

0.  R.,  aged  seventeen,  had  been  afflicted  with  disease  of  the 
hip  joint  for  two  or  three  years,  and,  becoming  despondent  be¬ 
cause  he  could  not  go  to  school  with  his  companions,  took  six 
grains  of  sulphate  of  morphine  with  suicidal  intent  at  8  p.  m., 
September  28,  1890.  His  condition  was  not  noticed  until 
10  p.  m.,  when,  as  he  could  not  he  aroused,  physicians  were 
summoned  and  efforts  made  at  once  to  overcome  the  effects  of 
the  morphine.  Presuming  that  the  morphine  had  all  been  ab¬ 
sorbed,  the  stomach-pump  was  not  used.  Atropine — one  thir¬ 
tieth  of  a  grain  hypodermically  every  two  hours,  he  being  un¬ 
able  to  swallow  strong  coffee — was  injected  in  large  quantities 
per  rectum  at  short  intervals.  The  galvanic  battery  was  vigor¬ 
ously  applied.  One  sixth  of  a  grain  of  atropine  in  all  was  ad¬ 
ministered,  the  last  dose  at  6  a.  m. 

I  was  called  in  consultation  at  8  a.  m.  the  following  morn¬ 
ing.  On  examining  the  patient,  I  found  him  almost  completely 
cyanosed,  pulse  160,  respiration  40,  temperature  101°,  loud  mu¬ 
cous  rales  so  as  to  be  heard  in  the  adjoining  room,  abdominal 
respiration  only,  pupils  widely  dilated  (from  atropine).  Dr.  O. 
H.  Stimson,  who  had  charge  of  the  case  and  who  met  me  at  this 
time,  said  he  had  done  all  he  could,  but  had  failed  to  arouse  the 
patient  in  the  least.  I  gave  an  unfavorable  prognosis  ;  in  fact, 

I  did  not  think  the  patient  would  live  more  than  an  hour  or 
two. 

Dr.  Stimson  said  he  had  some  of  Wyeth’s  tablets  of  nitro¬ 
glycerin  which  he  had  thought  of  using  as  a  last  resort.  It  oc¬ 
curred  to  me  at  once  that  it  might  be  of  benefit,  from  the  re¬ 
markable  results  produced  by  it  in  poisoning  from  illuminating 
gas.  We  decided  to  try  it,  and  gave  him  at  once  one  fiftieth  of 
a  grain  hypodermically.  We  waited  an  hour  and  repeated  the 
dose.  In  a  few  moments  I  directed  him  to  be  turned  on  his  side. 
Very  soon  there  was  a  long,  full,  thoracic  inspiration ;  in  about 
half  an  hour  the  patient  vomited  freely  and  became  conscious. 
We  gave  him  a  hypodermic  of  one  one-hundredth  of  a  grain  of 
nitroglycerin,  after  which  he  went  to  sleep,  slept  quietly  two 
hours,  then  awoke  and  was  all  right,  with  the  exception  of  a 
violent  headache,  the  effect  of  the  nitroglycerin. 

1  have  reported  this  case  in  the  hope  that  it  may  induce 
others  to  try  the  nitroglycerin  in  poisoning  by  morphine. 

I  am  fully  satisfied  that  without  its  use  the  patient  would 

have  died. 


Cumspcrntmue, 


LETTER  FROM  DUBLIN. 

The  Introductory  Lectures.— The  Presidency  of  the  Royal  Col¬ 
lege  of  Physicians— The  Royal  Academy  of  Medicine- 
Military  Sanitation  in  Ireland. 

Dublin,  October  23,  1890. 

The  introductory  lectures  at  the  various  medical  schools  and 
hospitals  in  Dublin,  at  the  commencement  of  the  winter  ses¬ 
sion,  are  diminishing  in  number  yearly,  and  very  properly,  as 
they  are  not  only  in  the  vast  majority  of  cases  useless  to  the 
student,  but  an  irksome  and  unthankful  task  to  the  unfortunate 
lecturer.  There  is  no  regularity  in  the  delivery  of  these  ad¬ 
dresses;  for  example,  one  was  given  at  Sir  P.  Dun’s  Hospital 
by  Professor  Bennett  on  the  1st  inst.,  and  the  inaugural  address 
at  the  Adelaide  Hospital  will  not  be  delivered  until  the  27th 
inst.  Professor  Bennett’s  excuse  for  an  address  was  that,  as 
some  new  wards  were  opened,  the  occasion  was  selected  more 
as  an  advertisement  than  for  any  other  reason.  He  pointed 
out  that  the  medical  and  surgical  staff  returned  twenty-five  per 
cent,  of  the  fees  paid  by  students  for  clinical  instruction  to  the 
hospital ;  a  generous  concession  adopted  by  no  other  general 
hospital  in  Dublin.  Some  ot  the  surgeons  and  physicians  of 
our  city  hospitals  have  said  that  they  served  without  fee  or  re¬ 
ward,  and  that  none  of  the  funds  of  the  institutions  with  which 
they  were  connected  went  into  their  pockets.  This  is  true  to  a 
certain  extent,  but  all  the  same  the  students’  fees,  amounting  to 
twelve  guineas  each  for  the  nine  months  of  attendance,  are 
divided  among  the  staff.  I  see  that  it  is  proposed  to  amalga¬ 
mate  some  of  the  Cork  hospitals,  and  the  same  suggestion  has 
been  made  in  reference  to  some  of  the  smaller  Dublin  hospitals, 
but  the  great  difficulty  which  exists  is  the  objection — and  a 
very  natural  one  it  is — that  many  physicians  and  surgeons 
would  have  their  services  discontinued,  and  thereby  lose  their 
fees.  For  if  several  small  institutions  were  amalgamated,  the 
larger  institutions  then  constituted  could  manage  very  well 
with  a  much  smaller  staff  than  the  aggregate  number  at  present 
doing  duty  in  the  various  hospitals. 

On  St.  Luke’s  Day,  the  18th  inst.,  Dr.  J.  Magee  Finny  was 
elected  president  of  the  Royal  College  of  Physicians  of  Ireland 
for  the  ensuing  year,  and  at  the  termination  of  his  year  of  office 
will  be  eligible  for  re-election.  I  can  not  speak  too  highly  of 
this  distinguished  physician,  and  the  fellows  of  the  college 
could  not  have  nominated  a  better  candidate  for  the  high  posi¬ 
tion  of  president  of  their  college. 

The  eighth  annual  meeting  of  the  Royal  Academy  of  Medi¬ 
cine  in  Ireland  will  take  place  on  the  31st  inst.,  when  the  re¬ 
sort  for  the  past  year  will  be  submitted  and  the  officers  for  the 
various  sections  appointed.  The  president  of  the  Academy  is 
.Dr.  Samuel  Gordon,  this  being  his  third  and  last  year  of  office. 

The  sanitary  condition  of  almost  all  the  barracks  in  Ireland 
might  be  improved,  and,  as  the  subject  has  been  brought  under 
the  notice  of  the  Government,  a  sum  of  £900,000  has  been  al- 
ocated  by  the  authorities  for  the  purpose  of  making  the  neces¬ 
sary  alterations.  Lord  Wolseley,  the  new  commander  of  the 
forces,  is  at  present  on  a  tour  throughout  Ireland  inspecting 
the  various  barracks,  and  his  recommendations  will  have  great 
weight.  The  Government  has  appointed  an  army  sanitary 
committee,  which  consists  of  seven  members,  and  the  only  non¬ 
army  mau  appointed  is  Sir  Charles  Cameron,  M.  D.,  the  efficient 
medical  officer  of  health  for  the  city  of  Dublin.  All  questions 
referring  to  the  expenditure  on  barracks  will  come  before  the 
sanitary  committee,  who  will  be  presided  over  by  Sir  Redvers 
Buffer,  Y.  O.,  K.  0.  B. 


546 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jouh., 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  NOVEMBER  15,  1890. 

THE  ETHICS  OF  BOOK  REVIEWS. 

The  ethical  relations  between  the  editor  of  a  periodical,  his 
staff  of  reviewers,  the  publishers,  and  the  authors  of  books  are 
somewhat  complicated.  Without  attempting  to  treat  of  them 
at  all  exhaustively  or  methodically,  we  may  jot  down  a  few 
statements  that  may  prove  interesting  to  the  various  classes  of 
persons  concerned.  In  reviews,  as  in  all  other  editorial  mat¬ 
ter,  a  well-ordered  journal  is  an  impersonal  entity;  the  views 
expressed  in  it  are  not  to  be  taken  as  necessarily  reflecting  the 
editor’s  notions  as  an  individual  merely,  and  so  he  may  con¬ 
scientiously  insert  a  review  differing  decidedly  in  tone  from 
the  impression  the  book  may  have  made  on  him — he  has  put 
it  into  the  hands  of  a  person  whom  he  believes  to  be  competent 
and  fair-minded,  and  be  will  hesitate  before  “changing  the 
politics,”  so  to  speak,  of  a  review  written  by  such  a  person. 
Nevertheless,  he  will  on  some  rare  occasions  feel  constrained 
to  do  so,  and  in  such  instances  he  will  realize  the  advantages  to 
all  concerned  of  the  practice  of  publishing  reviews  unsigned. 
There  seem  to  us  to  be  some  other  advantages  in  that  practice. 
It  shifts  the  responsibility  from  the  reviewer  to  the  editor,  who 
from  his  longer  training  and  more  varied  experience  is  better 
fitted  to  assume  it ;  and  it  relieves  the  reviewer  of  any  suspi¬ 
cion  of  having  colored  his  article  in  accordance  with  either  his 
known  admiration  of  the  author  or  his  dislike  for  him.  If 
reviews  are  to  be  signed  at  all,  we  think  they  should  be  signed 
with  the  writer’s  full  name,  for  we  have  known  a  severe  review 
to  provoke  resentment  against  a  man  who  was  not  its  author, 
simply  because  it  was  signed  with  initials  identical  with  his. 

Books  should  be  reviewed  solely  on  their  merits,  without 
regard  to  the  author’s  praiseworthy  or  reprehensible  perform¬ 
ances  not  directly  pertaining  to  the  book.  Of  course  they 
should  be  reviewed  in  a  spirit  of  fairness — fairness  not  only  to 
the  book,  but  also  to  the  readers  of  the  journal,  who  are  en¬ 
titled  to  the  actual  truth  as  to  a  book  that  they  may  think  of 
buying;  it  seems  to  us  inadmissible  to  say  of  a  book  that  “it 
will  prove  of  great  practical  assistance  to  the  student  and  to 
the  practitioner”  when  both  the  editor  and  the  reviewer  know 
that  that  is  not  the  case.  This  consideration,  however,  need 
not  run  counter  to  the  general  principle  that  it  is  one’s  duty  to 
say  the  best  of  a  book  that  its  character  will  allow  of.  It  is 
well  to  avoid  exaggerated  statements,  such,  for  example,  as  that 
the  book  under  notice  is  “the  best  treatise  on  the  subject  in 
existence.”  There  are  very  few  works  of  which  that  can  be 
said  in  strict  truthfulness ;  of  various  books  on  the  same  sub¬ 
ject,  each  is  likely  to  have  some  points  of  excellence  not  to  be 
found  in  the  others. 

The  foregoing  relates  chiefly  to  reviewers.  As  to  authors, 


they  would  not  be  human  if  they  were  neither  elated  by  lauda¬ 
tory  notices  nor  depressed  or  irritated  by  those  of  a  deprecia¬ 
tory  tone.  As  a  matter  of  fact,  many  of  them  crave  adulation, 
and  some  are  inclined  to  publish  their  resentment  of  the  most 
reasonable  adverse  criticism.  It  is  wfise  to  curb  both  these 
propensities;  certainly,  the  cases  are  very  rare  in  which  it  is 
prudent  for  an  author  to  make  any  public  reply  to  an  unfavora¬ 
ble  review  or  even  to  an  unfair  or  abusive  one.  The  average 
reader  is  usually  just,  and  it  is  not  an  easy  matter  to  float  a 
poor  book  with  puffery,  or  damn  a  good  one  by  misrepresen¬ 
tation. 

The  expectations  of  publishers  are  not  always  borne  out  in 
the  fairest  of  reviews.  Some  of  them  expect  too  much — espe¬ 
cially  our  American  publishers,  who  are  accustomed  to  more 
consideration  than  publishers  get,  for  example,  in  France, 
where-  the  standing  announcement  is  to  be  found  in  many  of 
the  journals  that  every  book  of  which  two  copies  are  sent  will 
be  acknowledged,  and  reviewed  if  the  journal  has  space.  But 
the  conditions  there  are  different  from  ours,  and  custom  war¬ 
rants  our  publishers  in  expecting  reviews  of  all  important 
works.  Fortunate  is  the  editor  if  he  has  not  sent  such  a  book 
to  a  person  who  can  not  be  prevailed  upon  either  to  write  the 
review  or  to  return  the  book. 


MUNK’S  VISUAL  CENTER. 

In  the  Bolnitchnaja  Gazeta  for  February  7th,  Dr.  B.  A. 
Ratimoff  gives  the  history  of  a  case  of  gunshot  wound  of  the 
head  that  he  thinks  supports  Munk’s  ideas  as  to  the  locality  of 
the  visual  center.  A  student,  twenty-two  years  old,  shot  him¬ 
self  accidentally  with  a  revolver.  The  ball  entered  the  right  side 
of  the  head  at  a  point  eight  centimetres  above  the  level  of  the 
external  auditory  canal  and  three  centimetres  behind  it.  Three 
hours  after  the  accident  the  patient  was  perfectly  blind,  but  be 
was  conscious  and  able  to  give  an  intelligible  account  of  his 
case.  His  general  condition  was  good;  the  pulse  and  tempera¬ 
ture  were  normal,  there  was  no  paralysis  or  paresis,  and  none 
of  the  senses  but  that  of  vision  were  impaired.  The  pupils  re¬ 
acted  perfectly  to  light,  and  ophthalmoscopic  examination  re 
vealed  no  abnormity  of  the  fundus  of  either  eye.  The  case  was 
diagnosticated  as  one  oflesion  of  the  visual  center,  but  doubt 
was  felt  as  to  whether  or  not  the  center  on  each  side  had  been 
injured. 

Trephining  wa9  resorted  to,  and  the  opening  made  in  the 
skull  by  the  bullet  was  found  to  be  over  a  centimetre  in  diam¬ 
eter.  A  detached  fragment  of  the  inner  table  lay  at  the  bot¬ 
tom  of  the  wound.  This,  together  with  a  mass  of  clotted 
blood,  was  removed,  and  the  track  of  the  bullet  was  explored 
carefully  with  the  little  finger  and  with  a  probe  to  the  depth 
of  four  centimetres,  but  the  missile  could  not  be  found,  and 
the  wound  was  closed,  a  drainage-tube  having  been  inserted 
into  it.  This  was  on  the  30th  of  September,  1889.  By  the  8th 
of  October  the  patient’s  color-vision  was  perfect  and  he  was 
able  to  read  large  letters  at  a  distance  of  five  feet,  but  the  field 
of  vision  was  found  to  be  restricted  in  the  left  half  of  each  eye. 


Nov.  15,  1890.] 


MINOR  PARAGRAPHS. 


547 


The  ophthalmoscope  revealed  no  change  except  an  imperfec¬ 
tion  of  outline  of  the  papilla  of  the  right  eye.  The  wound 

« 

healed  by  first  intention,  but  on  the  eleventh  day  after  the 
operation  it  took  on  an  unfavorable  course ;  suppuration  took 
place,  the  brain  began  to  protrude,  the  power  of  sight  de¬ 
creased,  and  the  patient  suffered  with  intense  headaches,  rest¬ 
lessness,  delirium,  etc.  On  the  26th  of  November  he  was  in  a 
state  of  profound  stupor  preceded  by  alternate  clonic  and  tonic 
convulsions.  The  stupor  lasted  for  thirty-six  hours,  after 
which  the  speech  was  imperfect,  there  was  paresis  of  the  left 
side  of  the  face  and  of  the  right  upper  limb,  and  vision  was 
considerably  impaired,  with  decided  hemianopia.  Ophthal¬ 
moscopic  examination  showed  nenro-retinitis  of  equal  degree 
in  the  two  eyes,  with  moderate  enlargement  of  the  retinal 
vessels. 

Death  having  taken  place,  it  was  found  that  the  brain  lesion 
was  behind  and  below  the  posterior  end  of  the  fissure  of  Syl¬ 
vius,  in  the  postero-inferior  occipital  convolutions  and  in  the 
part  corresponding  to  the  gyrus  aDgularis.  The  brain  in  gen¬ 
eral  was  somewhat  flattened  on  its  surface,  and  the  posterior 
convolutions  were  almost  effaced.  The  dura  was  firmly  adher¬ 
ent  to  the  brain.  The  direction  taken  by  the  bullet  had  been 
from  before  and  above  on  the  right  side  backward  and  down¬ 
ward  toward  the  left  side,  and  the  missile  had  destroyed  the 
right  visual  center,  passed  through  the  longitudinal  sinus,  and 
entered  the  left  visual  center.  There  was  an  abscess  at  the  site 
of  each  center,  and  the  left  one  contained  the  bullet.  The  au¬ 
thor  thinks  the  features  of  the  case  confirm  Munk’s  views  as  to 
the  locality  of  the  visual  centers  in  the  human  brain. 


MINOR  PARAGRAPHS. 

FATAL  URAEMIA  IN  PERSONS  APPARENTLY  HEALTHY. 

Dr.  A.  Westphal  has  described  an  interesting  case,  in  the 
Berliner  Jclinische  Wochenschrift,  of  uraemic  coma  resulting 
fatally  in  a  person  apparently  in  a  fair  state  of  health.  A 
young  man,  twenty-four  years  old,  a  joiner,  was  admitted  into 
the  hospital  with  sudden  symptoms  of  difficulty  of  breathing, 
palpitation,  swelling  of  the  feet  and  ankles,  and  left-sided  head¬ 
ache.  His  history  was  that  of  a  feeble  childhood,  but  without 
any  serious  illness.  His  feet  had  never  swelled  before,  there 
had  been  no  difficulty  with  the  urine,  and  he  had  always  been 
able  to  attend  to  his  heavy  work.  He  had  not  been  a  drinker, 
had  not  had  syphilis,  and  had  not  been  a  worker  in  lead,  and 
there  was  no  ascertainable  heredity.  His  face  was  swollen, 
his  ankles  were  oedematous,  and  he  was  manifestly  anaemic. 
Th.e  heart  was  hypertrophied  somewhat,  the  sounds  were  weak 
but  pure,  with  no  accentuation  of  the  pulmonary  or  aortic  sec¬ 
ond  sound.  The  pulse  was  small,  regular,  and  without  distinct 
tension.  The  urine  was  clear,  acid,  of  the  specific  gravity  of 
P005,  with  some  albumin,  hyaline  casts,  and  leucocytes.  There 
was  nothing  abnormal  in  the  internal  organs  or  the  blood,  but 
there  was  albuminuric  retinitis.  During  tfie  first  few  days  of 
his  treatment  at  the  hospital  the  subjective  symptoms  light¬ 
ened  up  decidedly,  and  he  expressed  himself  as  feeling  quite 
well  and  gave  the  impression  of  being  not  seriously  ill.  The 
albumin  remained  at  a  small  amount,  and  the  quantity  of  urine 
varied  between  forty-five  and  fifty-eight  ounces  per  diem ,  with 
a  specific  gravity  of  from  I ’003  to  P006.  Five  days  after  his 


admission,  aphasic  symptoms  made  their  appearance  as  the 
forerunner  of  a  severe  uraemic  attack,  which  set  in  with  full 
force  during  the  night;  there  were  both  clonic  and  tonic  con¬ 
vulsions,  frothing  at  the  mouth,  and  loss  of  consciousness.  The 
temperature  rose  to  103'8°  F.,  the  respirations  to  60,  and  the 
pulse  to  160,  the  cardiac  dullness  being  increased  to  the  right. 
Death  ensued  in  deep  coma  from  pulmonary  oedema.  On  au¬ 
topsy,  both  kidneys  were  found  to  be  contracted,  the  right  one 
being  somewhat  peculiarly  displaced,  being  depressed  and  lying 
opposite  the  fourth  and  fifth  lumbar  vertebrae;  it  was  extreme¬ 
ly  small,  not  more  than  two  inches  long  by  less  than  an  inch 
broad,  and  appeared  as  a  grayish-red  fibrous  mass  with  the 
blood-vessels  small  and  not  thickened ;  from  these  facts,  as 
well  as  the  microscopic  appearances,  the  condition  was  judged 
to  be  congenital.  The  case  was  remarkable  as  occurring  in  a 
young  person,  without  previous  uraemic  symptoms,  who  was 
apparently  doing  well  when  he  fell  into  a  state  of  profound 
coma  and  died  in  what  was,  so  far  as  was  known,  his  first 
seizure. 


THE  DISSEMINATION  OF  THE  TYPHOID  BACILLUS  BY 
EDIBLE  VEGETABLES. 

An  item  regarding  the  alleged  absorption  of  the  typhoid 
bacillus  from  the  soil  into  the  juices  of  plants,  where  the  fer¬ 
tilizing  agent  that  has  been  used  has  been  the  night  soil  from 
city  vaults,  has  had  some  currency  in  our  sanitary  periodicals. 
While  the  typhoid  bacillus  can  at  times  be  detected  in  the  ma¬ 
nure  obtained  from  the  scavengers,  no  competent  observer  has, 
we  think,  detected  it  in  the  juices  of  vegetables  that  have  been 
manured  with  that  substance.  The  use  of  such  manure  is, 
however,  not  wholly  free  from  danger,  and  vegetables  that  do 
not  pass  through  the  process  of  boiling  in  their  preparation  for 
the  table  should  be  cleansed  from  all  attached  foreign  matter 
with  unusual  care.  In  the  neighborhood  of  many  of  our  cities 
the  cultivators  of  celery  and  other  garden  vegetables  add  liquid 
night-soil  manure  to  their  fields  in  order  to  advance  the  growth 
of  their  crops.  A  certain  portion  of  this  fertilizer  can  not  fail 
to  lodge  on  the  leaves  and  stems  of  such  edible  plants  as  celery, 
which  filth  will  not  be  all  disengaged  and  washed  away  by  the 
ordinary  processes  of  cleansing  for  table  use.  Celery  is  espe¬ 
cially  mentioned  because  it  is  peculiarly  apt  to  catch  and  hold 
the  solid  constituents  of  the  scattered  cess-pit  manure,  and  in 
this  dirt  the  bacilli  of  typhoid  fever  have  been  detected  time 
and  again. 


THE  OPENING  RECEPTION  IN  THE  ACADEMY  OF  MEDICINE’S 

NEW  BUILDING. 

This  event,  which  is  to  take  place  on  Thursday  evening  of 
next  week,  is  sure  to  be  one  of  great  interest,  and  the  occasion 
one  on  which  both  the  Academy  and  the  profession  at  large  are 
to  be  congratulated.  The  reception  committee  consists  of  Dr. 
Alfred  L.  Loomis,  the  president  of  the  Academy,  Dr.  Fordyce 
Barker,  Dr.  Francis  Delafield,  Dr.  William  H.  Draper,  Dr.  Ever¬ 
ett  Herrick,  Dr.  Samuel  T.  Hubbard,  Dr.  Abraham  Jacobi,  Dr. 
William  T.  Lusk,  Dr.  Charles  McBurney,  Dr.  Henry  D.  Noyes, 
Dr.  George  A.  Peters,  Dr.  William  M.  Polk,  Dr.  Alexander  J. 
C.  Skene,  Dr.  D.  B.  St.  John  Roosa,  and  Dr.  T.  Gaillard  Thomas. 
Dr.  Loomis  is  to  give  an  address  of.  welcome,  Dr.  Edward  L. 
Keyes  will  deliver  the  anniversary  oration,  Dr.  Jacobi  will  speak 
on  the  subject  of  the  library,  Mr.  D.  Willis  James  will  speak  on 
The  Influence  of  Scientific  Associations  upon  Great  Cities,  Dr. 
John  S.  Billings,  of  the  army,  Dr.  S.  Weir  Mitchell,  of  Phila¬ 
delphia,  and  Dr.  Reginald  H.  Fitz,  of  Boston,  will  make  re¬ 
marks,  and  Dr.  Barker  will  add  some  words  of  congratulation. 
The  admission  will  be  by  card  only. 


548 


MI  NO  R  PA  RA  GRA  PBS.— ITEMS. 


[N.  Y.  Med.  Jour., 


SCARLET  FEVER  WITH  BUT  SLIGHT  PYREXIA. 

In  the  Munchener  medicinische  Wochenschrift ,  Dr.  Wert¬ 
heimer  and  Dr.  Beetz  have  reported  four  cases  of  scarlet  fever 
without  the  usual  pyrexia.  In  one  case,  that  of  a  child  of  seven 
years,  the  highest  temperature  observed  was  99‘6°  F. ;  the  pulse 
was  high,  being  from  116  to  120  during  the  greater  part  of 
three  days.  The  other  scarlatinal  symptoms  were  well  marked, 
and  desquamation  took  place  on  the  ninth  day  of  the  eruption. 
Another  child  had  for  its  maximum  temperature  100‘6°,  on  the 
evening  of  the  second  day,  with  the  pulse  high  as  in  the  former 
case.  In  two  of  the  cases  the  condition  of  the  uriue  was  noted 
as  not  albuminous.  In  the  two  others  this  symptom  is  not  re¬ 
ferred  to.  Dr.  Wertheimer  advances  the  opinion  that  the  diag¬ 
nostic  importance  of  a  continuous  high  pulse  in  apyrexial  cases 
may  be  greater  than  has  hitherto  been  recognized  generally. 


FATAL  POISONING  WITH  MALE  FERN. 

An  account  of  a  case  of  this  nature  is  given  in  the  Thera- 
peutische  Monatshefte,  in  which  death  ensued  upon  the  admin¬ 
istration  of  two  drachms  of  the  ethereal  extract  of  male  fern, 
given  as  an  anthelminthic.  A  child,  five  years  and  a  half  old, 
was  given  the  amount  named,  within  an  hour  and  three  quarters, 
in  three  doses.  A  portion  of  the  tapeworm  was  expelled  in  an 
hour  and  a  half;  then  vomiting  set  in,  followed  by  somnolence, 
twitching,  and  trismus  lasting  ten  minutes.  Death  took  place 
in  five  hours  after  the  last  dose  was  given.  At  the  necropsy 
there  was  found  tuberculosis  of  the  lungs  and  abdominal  glands  ; 
and  the  unusual  results  from  a  dose  of  the  extract,  such  as  was 
given,  were  presumably  due  in  part  to  the  impaired  resistance 
to  the  action  of  the  drug  incident  to  a  physique  broken  by  tu¬ 
berculous  disease. 


THE  ANATOMY  OF  THE  ELEPHANT’S  EAR. 

The  anatomy  of  the  elephant’s  ear  forms  the  subject  of  two 
notable  papers  in  the  Transactions  of  the  American  Otological 
Society  for  the  current  year,  by  Dr.  Albert  H.  Buck  and  Dr. 
Huntington  Richards.  Dr.  Buck’s  article  is  a  revision  of  his 
description  of  two  years  ago,  founded  on  further  and  less  re¬ 
stricted  observation  of  the  specimen  in  the  Museum  of  Anatomy 
of  Cornell  University.  The  three  contributions,  taken  together, 
constitute  a  most  valuable  addition  to  our  knowledge  of  the 
structure  of  the  organ  of  hearing. 


THE  ACADEMY  OF  MEDICINE’S  SECTION  IN  GENITO-URINARY 

SURGERY. 

The  first  meeting  of  the  Academy’s  new  Section  in  Genito¬ 
urinary  Surgery  was  held  on  Thursday  evening,  the  18th  inst. 
The  meeting  was  called  for  the  purpose  of  electing  officers,  per¬ 
fecting  the  organization,  and  listening  to  an  address  by  Dr.  Fes¬ 
senden  N.  Otis.  The  standing  of  the  gentlemen  who  are  taking 
part  in  the  work  is  an  ample  guarantee  that  the  new  Section 
will  be  creditable  to  the  Academy  and  to  the  New  Yrork  pro¬ 
fession. 


THE  AMERICAN  ASSOCIATION  FOR  THE  CURE  OF  IN¬ 
EBRIATES. 

This  organization  takes  cognizance  not  only  of  alcoholic  in¬ 
ebriates,  but  also  of  victims  of  the  opium  habit.  It  is  to  hold 
a  series  of  monthly  meetings  in  New  York  for  the  study  of 
medical  problems  connected  with  these  subjects.  The  secre¬ 
tary,  Dr.  Crothers,  of  Hartford,  informs  us  that  all  the  leading 


writers  in  this  field  are  to  present  papers  at  the  monthly  meet¬ 
ings,  and  we  do  not  doubt  that  they  will  prove  of  great  utility. 


THE  ARMY  SURGEON. 

The  British  Medical  Journal  asks  the  army  surgeons  of 
England  to  keep  in  mind  and  cherish  that  motto  of  Ambroise 
Par6  which  says  :  “  He  who  follows  his  profession  for  the  sake 
of  money  and  not  for  honor  and  knowledge  will  accomplish 
nothing.”  The  British  War  Office,  the  Journal  says,  does  not 
intend  to  divert  the  surgical  staff  from  its  highest  aims. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  November  11,  1890: 


DISEASES. 

Week  ending  Nov.  3. 

Week  ending  Nov.  11. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Tvphus  fever . 

0 

0 

0 

0 

Typhoid  fever . . 

25 

6 

25 

9 

Scarlet  fever . 

39 

1 

74 

9 

Cerebro-spinal  meningitis . 

2 

1 

2 

2 

Measles . 

97 

6 

174 

15 

Diphtheria . 

54 

17 

96 

29 

Small-pox . 

0 

0 

1 

0 

Varicella . 

5 

0 

2 

o 

The  Discussion  on  Rabies  at  the  Academy  of  Medicine.— In  the  re¬ 
port  published  in  the  last  issue  of  the  Journal,  the  paragraph  begin¬ 
ning  on  the  first  column  of  page  530  was  an  abstract  of  a  paper  by  Dr. 
Hermann  M.  Briggs.  As  published,  it  appeared  to  be  a  portion  of  Dr. 
Dana’s  paper. 

The  New  York  Obstetrical  Society. — At  the  annual  meeting,  held 
on  October  21st,  the  following  officers  were  elected:  President,  Dr. 
Joseph  E.  Janvrin ;  vice-presidents,  Dr.  Henry  C.  Coe  and  Dr.  Robert 
A.  Murray ;  recording  secretary,  Dr.  Arthur  M.  Jacobus  ;  assistant  sec¬ 
retary,  Dr.  James'R.  Goffe ;  corresponding  secretary,  Dr.  Augustus  H. 
Buckmaster ;  treasurer,  Dr.  Lee  J.  Morrill ;  and  pathologist,  Dr.  Calvin 
T.  Adams. 

The  Society  of  the  Alumni  of  Charity  Hospital. — At  a  meeting  held 
on  Tuesday  evening,  the  11th  inst.,  Dr.  W.  Oliver  Moore  was  announced 
to  read  a  paper  on  The  Necessity  for  the  Early  Correction  of  Errors  of 
Refraction  in  Children,  and  Dr.  W.  L.  Carr  to  report  An  Interesting 
Case  of  Rheumatism  complicated  with  Amygdalitis  and  Chorea. 

The  American  Academy  of  Medicine. — The  Constitution  was  altered 
at  the  last  annual  meeting,  so  as  to  admit,  in  addition  to  those  possess¬ 
ing  the  degrees  of  A.  B.  and  A.  M.,  those  who  can  present  evidences  of 
a  preparatory  liberal  education  equivalent  to  the  same.  Dr.  J.  E.  Em¬ 
erson,  of  Detroit,  chairman  of  the  committee  on  eligible  fellows,  will 
forward  to  any  applicant  copies  of  the  amended  Constitution  and  By¬ 
laws,  List  of  Members,  and  other  information  as  to  the  Academy. 

The  Medico-legal  Society. — The  programme  for  the  meeting  of  No¬ 
vember  12th  announced  papers  as  follows:  The  Legal  Test  of  Lunacy, 
by  Judge  H.  M.  Somerville,  of  the  Supreme  Court  of  Alabama;  The 
Insane  Colony  at  Ghent,  Belgium,  by  Dr.  Margaret  A.  Cleaves ;  and 
Epilepsy  as  a  Defense  for  Crime,  by  Professor  John  J.  Elwell,  of 
Cleveland,  Ohio. 

The  German  Universities. — Dr.  Ernst  Kiister,  of  Berlin,  has  been 
appointed  professor  of  surgery  at  Marburg,  to  succeed  Professor  Braun, 
who  replaces  Professor  Mikulicz  at  Konigsberg,  the  latter  having  been 
transferred  to  Breslau. 

The  New  York  Academy  of  Anthropology. — On  Tuesday  evening, 
the  11th  inst.,  Dr.  William  C.  Wile,  of  Danbury,  Conn.,  gave  a  lecture 
before  the  Academy  on  the  subject  of  Preventive  Medicine. 


Nov.  15,  1890.) 


ITEMS.  — OBITUARIES.— LETTERS  TO  THE  EDITOR. 


549 


\ 


The  Brooklyn  Surgical  Society. — At  the  recent  annual  meeting,  Dr. 
George  R.  Fowler  was  elected  president,  and  Dr.  H.  Beeckman  Delatour 
secretary  and  treasurer. 

The  Jefferson  Medical  College. — The  Medical  News  announces  that 
the  chair  of  therapeutics  and  materia  medica  has  been  declared  vacant. 

Changes  of  Address. — Dr.  W.  H.  Bates,  to  No.  131  West  Fifty- 
sixth  Street;  Dr.  Charles  S.  Collins,  from  Schenectady,  N.  Y.,  to  No. 
163  West  129th  Street,  New  York;  Dr.  Robert  C.  Myles,  to  No.  26 
West  Thirty-sixth  Street. 

The  Death  of  Dr.  Albert  Vogel,  of  Munich,  took  place  on  October 
9th,  in  his  sixty-first  year.  This  eminent  teacher,  author,  and  social 
leader  was  a  native  of  Munich,  who  had  made  his  professional  reputa¬ 
tion  at  the  University  of  Dorpat,  where  he  spent  twenty  years,  chiefly 
in  the  chair  of  paediatrics.  His  book  on  Diseases  of  Children  had 
passed  through  ten  editions  and  had  been  translated  into  several  lan¬ 
guages  ;  his  eleventh  edition  had  engaged  his  attention  during  the  last 
year  of  his  life,  and  was  only  recently  announced.  He  was  the  recipi¬ 
ent  of  many  honors  from  the  Emperor  of  Russia  at  the  time  of  his  re¬ 
tirement  from  Dorpat,  and  his  return  to  Munich  in  1886  was  followed 
by  many  tokens  of  respect  on  the  part  of  the  authorities  of  his  native 
city. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army ,  from  November  2  to  November  8,  1890 : 

Crosby,  William  D.,  Captain  and  Assistant  Surgeon,  is,  by  direction  of 
the  Acting  Secretary  of  War,  granted  leave  of  absence  for  four  days. 
Par.  2,  S.  0.  259,  A.  G.  0.,  Washington,  November  6,  1890. 

La  Garde,  Louis  A.,  Captain  and  Assistant  Surgeon,  is  detailed  as 
member  of  board  for  duty  in  connection  with  the  World’s  Columbian 
Exposition,  and  will  report  by  letter  to  Major  Clifton  Comly,  Ord¬ 
nance  Department,  member  of  the  board  of  control  and  manage¬ 
ment  of  the  Government  exhibit  to  represent  the  War  Department. 
Par.  1,  S.  0.  260,  A.  G.  0.,  Washington,  November  6,  1890. 

Bache,  Dallas,  Lieutenant-Colonel  and  Surgeon,  Medical  Director,  De¬ 
partment  of  the  Platte,  is  granted  leave  of  absence  for  one  month. 
Par.  6,  S.  0.  82,  Department  of  the  Platte,  Omaha,  Neb.,  November 
1,  1890. 

Arthur,  William  H.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Fort  Bayard,  New  Mexico,  and  will  report  in  person  to  the 
commanding  officer,  Fort  Grant,  Arizona  Territory,  for  duty  at  that 
post,  relieving  First  Lieutenant  William  B.  Banister,  Assistant  Sur¬ 
geon.  Lieutenant  Banister,  on  being  relieved  by  Captain  Arthur, 
will  repair  to  this  city  and  report  for  duty  to  the  commanding 
officer,  Washington  Barracks,  District  of  Columbia.  Par.  12,  S.  0. 
264,  A.  G.  0.,  Washington,  D.  C.,  October  30,  1890. 

Wakeman,  William  J.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
duty  at  Fort  Bidwell,  California,  to  take  effect  on  the  final  discon¬ 
tinuance  of  that  post,  and  will  then  report  in  person  to  the  com¬ 
manding  officer,  Fort  Huachuca,  Arizona  Territory,  for  duty  at  that 
station.  Par.  12,  S.  0.  264,  A.  G.  0.,  October  30,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  November  8,  1890 : 
Edgar,  J.  M.,  Passed  Assistant  Surgeon.  Ordered  to  the  U.  S.  Steamer 
San  Francisco.  November  10,  1890. 

Spratling,  L.  W.,  Assistant  Surgeon.  Ordered  to  the  U.  S.  Steamer 
San  Francisco.  November  10,  1890. 

White,  Charles  H.,  Medical  Inspector.  Ordered  to  the  U.  S.  Steamer 
San  Francisco.  November  10,  1890. 

Scott,  Horace  B.,  Passed  Assistant  Surgeon.  Placed  on  the  Retired 
List.  October  31,  1890. 

Ashbridge,  Richard,  Passed  Assistant  Surgeon.  Surveyed  and  sent  to 
hospital,  Philadelphia,  Pa. 

Kennedy,  R.  M.,  Assistant  Surgeon.  Detached  from  Navy  Yard, 
League  Island,  and  ordered  to  U.  S.  Training-ship  Richmond. 

Atlee,  L.  W.,  Assistant  Surgeon.  Ordered  to  the  Navy  Yard,  League 

Island,  Pa. 


Society  Meetings  for  the  Coming  Week : 

Monday,  November  17th:  New  York  County  Medical  Association  ; 
New  York  Academy  of  Medicine  (Section  in  Ophthalmology  and 
Otology) ;  Hartford,  Conn.,  City  Medical  Association  ;  Chicago  Medi¬ 
cal  Society. 

Tuesday,  November  18th:  New  York  Academy  of  Medicine  (Section  in 
Theory  and  Practice  of  Medicine) ;  New  York  Obstetrical  Society 
(private);  Medical  Societies  of  the  Counties  of  Kings  and  Westches¬ 
ter,  N.  Y. ;  Ogdensburgh  Medical  Association ;  Baltimore  Acade¬ 
my  of  Medicine.  * 

Wednesday ,  November  19th :  Tri-State  Medical  Association  of  Missis¬ 
sippi,  Arkansas,  and  Tennessee  (first  day — Memphis) ;  Northwest¬ 
ern  Medical  and  Surgical  Society  of  New  York  (private) ;  Harlem 
Medical  Association  of  the  City  of  New  York  ;  Medico-legal  Society; 
New  Jersey  Academy  of  Medicine  (Newark). 

Thursday,  November  20th:  Tri-State  Medical  Association  of  Missis¬ 
sippi,  Arkansas,  and  Tennessee  (second  day) ;  New  York  Academy  of 
Medicine ;  Brooklyn  Surgical  Society ;  Metropolitan  Medical  Society 
(private) ;  New  Bedford,  Mass.,  Society  for  Medical  Improvement 
(private). 

Friday,  November  21st:  New  York  Academy  of  Medicine  (Section  in 
Orthopaedic  Surgery) ;  Chicago  Gynaecological  Society ;  Baltimore 
Clinical  Society. 

Saturday,  November  22d :  New  York  Medical  and  Surgical  Society 
(private). 


(Winter  us. 


Dr.  Henry  Jacob  Bigelow,  of  Boston,  died  on  October 
30th,  at  the  age  of  seventy  years.  He  had  for  many  years,  be¬ 
ginning  in  1849,  been  the  professor  of  surgery  and  clinical  sur¬ 
gery  at  Harvard  University  and  the  foremost  surgeon  of  New 
England.  Fie  was  the  son  of  an  eminent  physician,  Dr.  Jacob 
Bigelow,  and  was  educated  at  Harvard,  taking  his  medical 
degree  in  1841.  He  was  Boylston  prizeman  in  1844,  with  an 
essay  on  the  subject  of  orthopaedic  surgery,  and  from  that  time 
began  the  publication  of  surgical  papers  that  fixed  his  reputa¬ 
tion  for  originality,  capacity,  and  skill  in  his  art.  His  devel¬ 
opment  of  the  operation  of  lithotrity  extended  his  repute 
abroad,  and  in  1882  the  Academy  of  Medicine  at  Paris  recog¬ 
nized  his  work  in  that  department  of  surgery  by  the  award  of 
a  prize.  In  that  year  he  was  made  emeritus  professor  of  sur¬ 
gery  after  thirty  years  of  active  duty  in  the  Harvard  University 
Medical  Department.  In  1886  Dr.  Bigelow  retired  from  active 
practice.  His  health  had  been  failing  for  some  time  by  reason 
of  gastric  and  hepatic  disease. 


^fitters  to  %  €btlor. 


McBURNEY’S  POINT. 

198  Second  Avenue,  New  York,  October  31,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  In  a  most  excellent  paper,  entitled  A  Contribution  to 
the  Study  of  Appendicitis,  read  before  the  New  York  Surgical 
Society,  October  8,  1890,  and  published  in  the  New  York  Medi¬ 
cal  Journal ,  October  25,  1890,  Dr.  Lewis  A.  Stimson  refers  in 
terms  of  the  most  appreciative  and  well-deserved  admiration  to 
a  paper  by  Dr.  Charles  McBurney  on  Experience  with  Early 
Operative  Interference  in  Diseases  of  the  Vermiform  Appendix, 


550 


LETTERS  TO  TEE  EDITOR. 


[N.  Y.  Med.  Jocr., 


read  before  t lie  same  society  on  November  13,  1889,  and  pub¬ 
lished  in  the  same  journal  for  December  21,  1889. 

I  quote  from  Dr.  Stimson’s  paper :  u  .  .  .  and,  above  all, 
he  [Dr.  Me  Burney]  pointed  out  the  means  by  which  the  pres¬ 
ence  of  the  disease  [appendicitis]  might  be  recognized  at  the 
very  outset.  Perhaps  the  most  valuable  result  of  the  publica¬ 
tion  of  Dr.  McBurney’s  paper  has  been  the  readiness  aud  cer¬ 
tainty  with  which  the  disease  is  now  recognized,  and  the  wide 
extension  that  has  been  given  to  this  addition  to  our  diagnostic 
resources.” 

The  addition  to  our  diagnostic  resources  referred  to  is  thus 
described  in  Dr.  McBurney’s  paper:  “And  I  believe  that  in 
every  case  the  seat  of  greatest  pain,  determined  by  the  pressure 
of  one  finger,  has  been  very  exactly  between  an  inch  and  a  half 
and  two  inches  from  the  anterior  superior  spinous  process  of 
the  ilium  on  a  straight  line  drawn  from  that  process  to  the 
umbilicus.”  As  a  proper  recognition  of  the  value  of  this 
symptom,  Dr.  Stimson  very  gracefully  speaks  of  this  point  as 
“McBurney’s  point.”  And  credit  has  certainly  never  been 
more  justly  awarded. 

Dr.  McBurney  goes  on  to  say:  “  This  may  appear  to  be  an 
affectation  of  accuracy,  but,  so  far  as  my  experience  goes,  the 
observation  is  correct.” 

As  far  as  my  own  experience  goes,  this  is  not  an  affectation 
of  accuracy,  and  the  observation  is  decidedly  correct. 

I  operated  in  my  first  case  of  perity phlitic  abscess  on  March 
15,  1879.  I  had  watched  the  case  from  day  to  day  from  its  in- 
cipiency.  eight  days  before  the  operation,  and  was  particularly 
impressed  with  the  persistence  of  a  small  point  of  greatest  pain 
on  pressure  on  a  direct  line  drawn  from  the  anterior  superior 
spine  of  the  ilium  to  the  umbilicus.  During  the  first  days  it 
was  located  exactly  where  Dr.  McBurney  describes  it  as  inva¬ 
riably  found — two  inches  from  the  anterior  superior  spine  of  the 
ilium.  Later  on,  as  the  abscess  pointed  toward  the  surface,  the 
point  of  greatest  sensitiveness  shifted  along  the  above-described 
line  toward  the  umbilicus,  until  it  reached  a  point  midway  be¬ 
tween  the  navel  and  the  anterior  superior  iliac  spine. 

In  all  the  cases  of  perity  phlitis,  or,  as  in  the  light  of  a  bet¬ 
ter  pathology  we  ought  now  to  call  them,  of  appendicitis,  that 
I  have  encountered  since,  I  have  invariably  noted  the  same  con¬ 
dition.  If  the  case  was  seen  early,  the  point  of  greatest  tender¬ 
ness  on  pressure  was  found  slightly  to  the  outer  side  of  the 
center  of  a  line  drawn  from  the  anterior  superior  iliac  spine  to 
the  umbilicus.  If  seen  later,  whether  a  decided  tumor  had 
formed  or  deep-seated  induration  was  all  that  could  be  felt, 
the  point  of  greatest  tenderness  had  shitted  to  almost  exactly 
the  center  of  the  above-mentioned  line.  The  only  variation 
that  I  have  observed  from  this  rule  was  in  two  or  three  in¬ 
stances  very  late  in  the  disease,  when  the  point  of  greatest 
tenderness  had  shifted  in  the  direction  of  the  thigh  to  half  an 
inch  below  the  center  of  the  line  between  the  umbilicus  and 
the  anterior  superior  iliac  spine. 

In  reporting  a  discussion  on  the  diagnosis  between  pyosal- 
pinx  and  perityphlitic  abscess,  which  occurred  at  a  meeting  of 
the  New  York  State  Medical  Association  on  September  25, 
1889,  nearly  two  months  before  Dr.  McBurney  read  his  paper, 
the  Medical  Record  for  October  5,  1889,  page  385,  says:  “Dr. 
Edebohls  mentioned  two  diagnostic  points  in  distinguishing 
between  perityphlitic  abscess  and  pyosalpinx.  In  tbe  former 
the  tumor  lay  midway  beneath  a  line  drawn  from  the  anterior 
superior  spinous  process  of  the  ilium  to  tbe  umbilicus.  The 
second  point,”  etc. 

The  New  Yorlc  Medical  Journal  of  October  19,  1889,  page 
442,  quotes  me  to  the  same  effect  on  this  point.  I  should  like 
to  take  this  occasion,  however,  to  call  your  attention  to  an  ob¬ 
vious  mistake  on  the  part  of  your  representative,  who  reports 


me  in  the  same  discussion  as  saying:  “He  [Edebohls]  had  often 
found  a  perityphlitic  abscess  six  or  seven  days  old  developed 
enough  to  enable  him  to  reach  it,  whereas  a  pyosalpinx  could 
never  be  reached  in  that  way.”  The  sentence  should  read : 
“He  [Edebohls]  had  never  found  a  perityphlitic  abscess  until 
six  or  seven  days  old  developed  enough  to  enable  him  to  reacli 
it  per  rectum,  whereas  a  pyosalpinx  could  always  be  reached  in 
that  way.” 

My  experience  with  appendicitis  embraces  in  the  neighbor¬ 
hood  of  thirty  cases.  About  one  third  of  these  were  seen  in 
private  practice,  the  remaining  two  thirds  chiefly  in  the  wards 
of  St.  Francis  Hospital.  As  gynaecologist  to  the  latter  institu¬ 
tion,  nearly  all  cases  of  abdominal  tumor  in  the  female  are  re¬ 
ferred  to  me  for  examination  and  diagnosis.  For  many  years 
past  I  have  invariably  taken  the  opportunity,  when  a  case  of 
appendicitis  or  perityphlitic  abscess  presented,  to  call  the  atten¬ 
tion  of  the  house  staff  to  the  value  of  the  sign,  now  known  a 
McBurney’s  point,  in  reaching  a  diagnosis.  The  patients,  after 
a  diagnosis  of  appendicitis  was  established,  were  transferred  to 
the  surgical  division  of  the  hospital. 

This  may  serve  to  account  for  the  fact  that  although  I  have 
seen  and  diagnosticated  a  fair  number  of  cases  of  appendicitis, 
I  have  operated  upon  only  three  patients,  all  of  them  in  private 
practice.  The  first  of  these  operations  took  place  on  March  15, 
1879,  on  the  ninth  day  of  the  illness ;  250  grammes  of  pus  were 
evacuated  and  the  patient  recovered.  The  second  occurred  on 
January  7,  1884,  on  the  seventh  day  of  the  illness ;  acute  puru¬ 
lent  peritonitis  coexisted  with  the  pericsecal  abscess  at  the  time 
of  the  operation,  and  the  patient  died.  The  third  patient  was 
operated  upon  on  July  17,  1889,  sixty- six  hours  after  the  onset 
of  the  disease;  half  a  teaspoonful  of  pus  was  evacuated  aDd  the 
patient  made  a  rapid  recovery. 

Others  may,  like  myself,  have  long  since  learned  by  inde¬ 
pendent  personal  observation  the  value  of  McBurney 's  point  in 
the  diagnosis  of  appendicitis  and  perieaecal  abscess.  Indeed,  it 
is  scarcely  probable  that  so  striking  a  sign  could  so  long  have 
escaped  the  attention  of  all  clinical  observers.  To  Dr.  McBur¬ 
ney,  however,  belongs  tbe  credit  of  having  directed  the  atten¬ 
tion  of  the  profession  to  the  point  now  justly  associated  with 
his  name,  and  of  having  proved  its  diagnostic  importance  in 
appendicitis  by  a  larger  number  of  operations  performed  in  the 
early  stages  of  the  disease. 

In  conclusion,  I  would  be  permitted  to  cite  again  from  Dr. 
McBurney’s  paper,  as  expressing  fully  the  result  of  my  own  ex¬ 
perience  on  the  subject,  the  following  sentence:  “  Much  greater 
tenderness  at  this  [McBurney’s]  point  than  at  others,  taken  in 
connection  with  the  history  of  the  case  and  the  other  well- 
known  signs,  I  look  upon  as  almost  pathognomonic  of  appendi¬ 
citis.”  George  M.  Edebohls,  M.  D. 

Saratoga,  N.  Y.,  November  3,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  Though  firmly  believing  in  the  great  value  of  “the 
McBurney  point”  in  the  diagnosis  of  appendicitis,  the  follow¬ 
ing  case  would  seem  to  illustrate  that,  in  case  the  patient  is  a 
woman,  it  is  not  always  to  be  relied  upon.  On  August  31, 
1890,  I  was  called  in  consultation  to  see  Mrs.  M.,  a  widow,  of 
good  moral  character  and  the  mother  of  one  child.  The  pa¬ 
tient  had  been  taken  acutely  ill  on  the  22d  with  headache, 
slight  chills,  pain  in  the  lower  portion  of  the  abdomen,  nausea, 
and  vomiting,  the  pulse  and]  temperature  ranging  from  96  to 
100  and  99°  to  101°  F.  respectively.  This  continued  until  the 
29tb,  when  all  symptoms  subsided  to  such  an  extent  that  the 
patient  believed  herself  recovering.  On  the  morning  of  the 
31st,  at  nine  o’clock,  she  was  taken  with  a  violent  pain  referred 
to  the  region  of  the  uterus.  This  was  accompanied  by  a  very 


Nov.  15,  1890.] 


LETTERS  TO  THE  EDITOR. 


551 


severe  chill,  which  did  not  cease  until  the  attending  physician 
arrived  and  administered  morphine  subcutaneously.  At  this 
time  her  pulse  was  50  and  her  temperature  96°  F.  The  pre¬ 
vious  history,  as  given  me  by  her  attending  physician,  was  not 
concise  or  well  defined,  for  the  reason  that,  during  the  time 
the  lady  had  been  under  his  care — about  two  years — she  had 
been  somewhat  erratic  in  her  calls  and  to  a  great  degree  uncon¬ 
trollable  by  her  physician.  Prostration,  headache,  dyspepsia, 
and  pain  in  the  lower  portion  of  the  abdomen  were  the  princi¬ 
pal  symptoms  of  which  she  had  complained  during  that  period. 
Speculum  examinations  made  at  the  physician’s  office  at  vari¬ 
ous  times  had  shown  chronic  cervical  endometritis.  At  9  p.  m. 
on  August  31st  I  saw  her  for  the  first  time.  Lying  on  her  back 
with  the  knees  drawn  up  and  supported  by  pillows,  her  face 
pale  and'anxious,  with  sunken  eyes,  she  presented  the  appear¬ 
ance  of  being  very  ill.  Her  pulse  was  130  and  feeble,  her  tem¬ 
perature  102°  F.  An  examination  of  the  abdomen  showed 
considerable  distention  and  soreness  over  its  whole  extent.  The 
McBurney  point  was  exceedingly  tender — far  more  so  than  any 
other  spot  on  the  abdomen.  The  left  side  was  also  tender  at  a 
p  iint  corresponding  to  the  McBurney  point  on  the  right,  yet  to 
not  nearly  the  same  extent  as  the  latter.  This  fact  was  very 
clearly  made  out  and  verified  by  the  other  physicians  who  were 
present  at  the  operation,  two  hours  later.  A  diagnosis  of  sep¬ 
tic  peritonitis  was  made  and,  though  the  chances  of  saving  the 
patient’s  life  seemed  almost  nil,  an  immediate  operation  was 
advised,  as  offering  the  only  hope.  To  this,  consent  was  readily 
granted.  At  11  p.  m.,  with  the  assistance  of  Dr.  Grant,  Dr. 
Inlay,  Dr.  Newell,  and  Dr.  Swan,  who  concurred  in  the  diagno¬ 
sis  of  septic  peritonitis,  and  in  thinking  it  probable  that  disease 
of  the  appendix  was  the  cause,  the  operation  for  the  removal 
of  that  organ  was  done.  On  opening  the  peritonaeum,  thin  pus 
and  flakes  of  lymph  escaped  in  considerable  quantity.  The  ap¬ 
pendix  vermiformis,  about  three  inches  in  length,  was  found 
lying  along  the  lower  side  of  the  caecum,  and  in  a  perfectly 
healthy  condition.  There  was  in  its  appearance  no  apparent 
departure  from  a  normal  state.  Our  light  was  poor — kerosene 
lamps — and  the  origin  of  the  pus  could  not  be  discovered  through 
the  wound.  The  patient  was  in  such  an  enfeebled  condition 
that  it  was  thought  best  to  do  nothing  more  except  a  thorough 
irrigation  of  the  lower  portion  of  the  peritoneal  cavity  with 
warm  Thiersch’s  solution.  This  brought  away  a  quantity  of 
pus  and  lymph  flakes.  A  drainage-tube  was  inserted  well  down 
into  the  iliac  fossa,  stitches  sufficient  to  retain  the  intestine 
were  introduced,  and  the  external  wound  was  dressed  with 
iodoform  and  sublimated  gauze  held  in  place  by  a  bandage. 
After  recovering  from  the  anaesthetic  the  patient’s  pulse  was 
106  and  her  temperature  99°  F.  Two  of  the  physicians  re¬ 
mained  with  her  during  the  remainder  of  the  night,  and,  in  con¬ 
junction  with  the  nurse,  one  remained  with  her  almost  constantly 
until  she  died.  After  the  first  rally  she  grew  more  and  more 
feeble  and  died  thirty-four  hours  after  the  operation.  Seven 
hours  later  an  autopsy  was  had  at  which  Dr.  Grant,  Dr.  Inlay, 
and  myself  were  present.  On  opening  the  abdomen,  the  small 
and  large  intestines  were  found  plastered  over  with  pus  at  in¬ 
tervals  throughout  their  whole  extent.  The  true  pelvis  was 
filled  with  pus  and  flakes  of  lymph.  On  sponging  this  out,  the 
cause  of  the  peritonitis  became  apparent  in  that  the  right  ovary 
had  been  the  seat  of  a  large  abscess  that  had  ruptured  into  the 
peritoneal  cavity.  The  ovary  was  lying  directly  underneath 
the  caput  coli.  The  left  ovary  was  acutely  inflamed,  and  en¬ 
larged  from  cystic  degeneration.  Both  ovaries  were  covered^ 
with  flakes  of  lymph.  The  uterus  was  normal  in  position  and 
size.  The  tubes  appeared  to  be  perfectly  healthy.  No  adhe¬ 
sions  to  any  of  the  surrounding  parts  existed  between  the  uterus, 
ovaries,  or  tubes. 


I  am  induced  to  report  this  case  mainly  from  the  promi¬ 
nence  given  to  the  symptom,  now  very  properly  named  by  Dr. 
Stimson  the  McBurney  point,  in  all  the  recently  published 
articles  on  appendicitis;  the  apparently  almost  pathognomonic 
significance  of  this  symptom;  and  the  fact  that  I  have  not  yet 
seen  reported  a  case  that  has  come  to  operation  wherein  this 
symptom  existed  in  which  the  trouble  has  not  proved  to  have 
been  originally  in  the  appendix.  In  the  paper  read  before  the 
New  York  Surgical  Society  on  October  8th  by  Dr.  Lewis  A. 
Stimson,  and  published  in  the  Journal  for  October  25th,  Case 
XIX  therein  related  has  a- general  history  common  to  both 
these  cases.  In  that  instance  Dr.  Stimson  chose  the  median  in¬ 
cision,  thinking  perhaps  the  peritonitis  had  another  cause  than 
appendicitis.  In  that  case  appendicitis  was  the  cause  of  the 
peritonitis,  while  in  the  case  here  related  no  disease  of  the  ap¬ 
pendix  existed.  I  might  also  add,  my  patient  had  had  none  of 
the  diseases  commonly  said  to  be  the  cause  of  oophoritis — i.  e., 
gonorrhoeal  infection,  puerperal  septic  absorption,  acute  rheu¬ 
matism,  or  the  eruptive  fevers. 

W.  H.  Hodgman,  M.  D. 


MENTAL  WORK  AT  GREAT  ALTITUDES. 

1316  Van  Ness  Avenue,  San  Francisco,  November  6,  1890. 

To  the  Editor  of  the  New  Yorlc  Medical  Journal : 

Sir  :  Your  Journal  of  October  25th  contains  a  most  inter¬ 
esting  article  of  Dr.  Eskridge,  of  Denver,  Ool. — Nervous  and 
Mental  Diseases  observed  in  Colorado.  As  an  appendix  to  it, 
allow  me  to  call  your  attention  to  an  article  by  Dr.  M.  Janssen 
in  the  Semaine  medicate ,  1890,  No.  43,  p.  366,  entitled,  Rap¬ 
ports  entre  l’effort  physique  et  l’&tat  intellectuel  dans  leshautes 
altitudes. 

Let  me  give  you  some  details  about  my  ascension  to  the 
summit  of  Mont  Blanc,  between  4,400  and  4,800  metres  in  al¬ 
titude.  So  far  as  I  know,  I  am  the  only  one  who  enjoyed,  all 
through,  the  integrity  of  my  intellectual  forces  ;  in  fact,  instead 
of  becoming  depressed,  they  were  rather  excited  and  more  pow¬ 
erful,  which  I  attribute  to  the  absence  of  all  physical  effort  dur¬ 
ing  the  whole  expedition,  for  when  I  made  bodily  efforts  during 
previous  ascensions,  I  felt  in  a  light  degree  all  the  troubles  of 
which  travelers  complain  in  high  altitudes.  When  ascending 
Grand  Malets  under  great  efforts,  I  felt  this  mal  de  montagne 
during  the  journey  which  followed  the  ascension.  I  could  not 
think  about  my  observations,  nor  carry  out  any  intellectual 
labor;  I  felt  too  weak  and  nearly  fainting;  so  that  1  had  to  in¬ 
spire  deeply  and  often  to  collect  my  thoughts.  This  time  I 
rested  four  days  in  the  hut  des  Bosses,  and  had  an  excellent  ap¬ 
petite,  though  the  fare  was  not  my  habitual  one,  and  as  long  as 
I  did  not  use  up  ray  bodily  strength  my  mind  remained  clear, 
and  after  the  first  sleep  I  could  perform  mental  work.  Even 
at  the  top  of  Mont  Blanc  I  felt  no  malaise  and  my  intellectual 
faculties  were  in  order  ;  in  fact,  my  excitement  came  from  the 
inward  satisfaction  which  I  felt,  so  that  I  came  to  the  conclu¬ 
sion  that  intellectual  labor  was  possible  in  high  altitudes  as  long 
as  one  abstained  from  all  physical  efforts. 

Living  on  the  Pacific  Coast,  nous  sommes  toujours  trop  tard, 
but  better  late  than  never.  S.  Lilienthal,  M.  D. 


THE  ACADEMY  OF  MEDICINE’S  DELEGATES  TO  BERLIN. 

110  West  Thirty-fourth  Street,  ) 

N  ew  Y ork,  November  8,  1890.  f 
To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  In  to-day’s  Journal ,  on  page  518,  you  publish  a  brief 
editorial  in  which  you  say:  “  The  programme  for  the  meetin 


552 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  JouB.r 


[of  the  New  York  Academy  of  Medicine]  on  Thursday  evening 
of  this  week  consisted  of  reports  of  so-called  ‘  delegates  ’  to  the 
Tenth  International  Medical  Congress — eleven  in  number.  It 
is  well  known  that  these  congresses  are  not  made  up  of  dele¬ 
gates.  It  was  therefore  a  work  of  supererogation  for  the 
Academy  to  appoint  them,  and  to  devote  a  meeting  to  their 
‘  reports  ’  seems  to  us  to  argue  such  a  lack  of  legitimate  mate¬ 
rial  as  ought  not  to  be  encountered  at  this  time  of  the  year.” 

In  order  to  prove  that  this  criticism  is  not  based  on  facts,  I 
have  the  honor  of  referring  you  to  a  circular  of  the  American 
subcommittee  (consisting  of  Dr.  S.  C.  Busey,  Dr.  W.  H.  Draper, 
Dr.  R.  H.  Fitz,  Dr.  H.  Hun,  Dr.  A.  Jacobi,  Dr.  W.  T.  Lusk,  Dr. 
W.  Osier,  Dr.  W.  Pepper,  Dr.  F.  Peyre  Porcber,  and  Dr.  J. 
Stewart)  which  was  sent  to  and  printed  by  a  large  number  of 
American  medical  journals,  and  contained  the  following  sen¬ 
tence :  “  Delegates  of  American  medical  societies  and  institu¬ 
tions,  and  individual  members  of  the  profession,  will  be  admit¬ 
ted  on  equal  terms.” 

This  notice  was  based  on  the  contents  of  an  official  letter  re¬ 
ceived  from  the  secretary-general,  Dr.  O.  Lassar,  dated  Febru¬ 
ary  28,  1890,  part  of  which  reads  as  follows  :  “  It  would  please 
us  very  much  if  our  invitation  were  given  publicity  by  your  na¬ 
tional  committee,  with  your  recommendations.  We  imagine 
that  could  be  best  accomplished  by  a  request  directed  to  all  the 
large  societies  to  participate  in  the  congress,  either  in  corpore 
or  by  delegates.”  This  letter,  Mr.  Editor,  I  shall  take  pleasure 
in  submitting  to  you.  Finally,  I  can  assure  you  that  a  number 
of  names  contained  in  the  official  rolls  of  the  central  office  had 
the  word  “  delegate  ”  added  to  them.  A.  Jacobi,  M.  D. 


APHONIA  CAUSED  BY  LEAD  POISONING  CONTRACTED  BY 
THE  ABUSE  OF  SNUFF. 

69  West  Eleventh  Street,  October  2J+,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal  : 

Sib:  The  following  case  is  unique  and  may  point  a  moral 
for  some  of  our  younger  professional  brethren:  I  wassailed 
to  attend  a  young  woman  suffering  from  acute  aphonia.  She 
was  a  married  woman,  but  of  rather  a  loose  aspect,  so  I  had 
very  little  diffidence  in  making  inquiries  looking  to  a  syphilitic 
origin  of  her  trouble,  but,  to  my  astonishment,  no  such  history 
could  be  evolved.  On  further  inquiry  as  to  her  habits,  I  was 
informed  that  my  patient  “  dipped  ” — i.  e.,  rubbed  snuff  into 
her  gums.  I  examined  her  mouth,  and,  while  doing  so,  was 
rather  surprised  to  notice  the  signs  of  lead  poisoning  round  the 
gums.  I  took  a  portion  of  the  suuff  to  my  office  and  examined 
it  chemically,  and  found  it  strongly  adulterated  with  lead.  This 
was  the  key  to  the  mystery.  The  local  application  of  the  lead 
had  induced  paralysis  of  the  laryngeal  nerve. 

She  was  quite  restored  in  two  days  by  increasing  doses  of 
iodide  of  potassium.  She  stopped  the  “dipping”  in  a  hurry, 
and  has  had  no  recurrence  of  her  trouble  since,  a  year  ago. 

Robekt  Ormsby,  M.  D. 


|3roatitin0$  uf  Socktks. 


NEW  YORK  COUNTY  MEDICAL  ASSOCIATION. 

Meeting  of  October  20,  1890. 

The  President,  Dr.  Geobge  T.  Harrison,  in  the  Chair. 

Omental  Hernia. — Dr.  T.  H.  Manley  exhibited  a  large 
amount  of  omentum  which  he  had  removed  from  a  patient  re¬ 


cently  operated  upon.  The  man,  now  thirty  years  of  age,  had 
as  a  youth  suffered  from  hernia,  which  had  been  cured  by 
wearing  a  truss.  It  had  given  no  indication  of  its  existence 
until  some  six  months  ago,  when  he  had  noticed  some  protru¬ 
sion  on  the  right  side.  This  had  rapidly  developed,  and  no 
mechanical  arrangement  could  be  adjusted  that  could  be  worn 
with  comfort  and  efficiency.  He  had  come  to  the  hospital  for 
radical  relief.  On  cutting  down,  the  sac  was  found  to  contain 
only  omentum,  which  was  removed,  and  the  result  had  been  so 
far  satisfactory.  The  speaker  thought  that,  as  the  cause  had 
been  merely  omental,  and  this  had  been  done  away  with,  there 
was  little  danger  of  recurrence. 

Ectopic  Pregnancy. — Dr.  Manley  also  showed  a  fcetus  and 
secundines  which  he  had  recently  removed.  The  patient,  who 
had  been  treated  by  two  other  physicians  before  the  .speaker 
had  been  called,  was  found  by  him  in  a  pretty  serious  condition. 
Her  bowels  were  inactive,  and  there  were  suppression  of  urine, 
fever,  and  tympanites.  On  the  left  side  there  was  a  decided 
fullness,  and,  from  the  general  condition  of  the  woman,  it  was 
evidently  a  purulent  formation.  He  cut  down  over  this  pro¬ 
trusion  and  came  upon  a  large  sac  formed  by  recent  adhesions 
of  the  intestines.  This  sac  contained  partly  organized  blood- 
clots  in  considerable  quantity.  The  removal  of  these  revealed 
a  foetus.  The  cord  was  found  to  stretch  across  the  abdomen, 
the  placenta  being  attached  upon  the  opposite  side  to  that  on 
which  the  foetus  was  lying.  He  established  drainage  through 
Douglas’s  cul-de-sac.  The  woman  had  made  an  excellent  re¬ 
covery  so  far. 

Lichen  Planus. — This  was  the  title  of  a  paper  by  Dr.  L.  D. 
Bulkley.  (To  be  published.) 

Dr.  A.  R.  Robinson  said  that  he  could  not  agree  with  the 
speaker  as  to  the  ease  with  which  a  case  of  lichen  planus  might 
be  diagnosticated.  A  well-marked  case  might  be,  it  was  true, 
but  many  times,  without  numerous  observations,  it  would,  he 
thought,  be  impossible.  There  were  many  cases  of  eczema 
from  which  it  would  be  difficult  to  distinguish  it,  and  only  by 
watching  the  duration  and  course  could  a  conclusion  be  arrived 
at.  He  thought  too  little  was  understood  of  the  aetiology  of 
the  disease;  when  more  was  known,  the  treatment  might  be 
more  efficacious.  He  considered  it  a  parasitic  disease.  Treat¬ 
ment  based  upon  this  assumption  gave  fair  results.  He  had 
once  been  opposed  to  the  use  of  arsenic,  but  now  believed  that 
a  large  number  of  cases  could  be  cured  with  it.  This  was  no 
proof  that  the  disease  was  not  parasitic.  He  had  made  an 
error  in  the  matter  of  dosage.  The  arsenic  would  be  required 
in  some  cases  to  be  administered  in  very  large  doses.  Any 
statements  to  patients  as  to  the  time  required  for  curing  a  case 
of  lichen  planus  should  be  guarded. 

The  Treatment  of  Fractures. —A  paper,  with  this  title 
was  read  by  Dr.  E.  von  Donhoff.  (See  page  536.) 

Dr.  Joseph  D.  Bryant  said  that  the  writer  of  the  paper  had 
presented  for  consideration  some  suggestions  decidedly  unusual 
as  to  the  treatment  of  fractures,  and  contrary  to  the  methods 
advocated  by  teachers  and  text-books,  as  well  as  those  employed 
in  hospital  practice  and  by  surgeons  at  large.  As  to  the  diag¬ 
nosis  of  fractures,  he  would  state  what  he  believed  to  be  a 
proper  principle  in  making  it.  The  first  step  should  be  a  care¬ 
ful  comparison  of  the  injured  limb  with  the  uninjured  one. 
No  surgeon  should  attempt  to  diagnosticate  a  fracture  without 
making  this  comparison.  He  deprecated  the  plan  of  giving  an 
anaesthetic  for  the  purpose  of  making  a  diagnosis  or  seeking  for 
crepitus.  Its  use  as  an  aid  in  diagnosis  was  admissible  only  in 
the  event  of  the  existence  of  great  swelling  or  for  the  better 
adjustment  of  the  fragments.  The  necessity  of  the  employ¬ 
ment  of  early  passive  motion  was  not  believed  to  be  as  impor¬ 
tant  at  the  present  time  as  in  the  past.  In  fact,  it  was  common 


Nov.  15,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


553 


nowadays  for  reputable  surgeons  to  omit  the  employment  of 
passive  motion  altogether  during  the  treatment  of  the  fracture, 
except,  perhaps,  in  cases  where  the  fracture  communicated  di¬ 
rectly  with  a  joint.  At  all  events,  there  was  good  reason  to 
believe  that  passive  motion  was  not  so  essential  to  successful 
results  as  it  had  formerly  been  considered.  The  late  Dr.  Henry 
B.  Sands,  in  a  paper  read  before  the  New  York  Surgical  So¬ 
ciety,  had  emphasized  this  matter  in  a  most  admirable  and  con¬ 
vincing  manner.  There  seemed  now  to  be  no  doubt  of  the 
fact  that  the  prolonged  confinement  of  an  uninjured  limb  would 
not  result  in  any  danger  of  ankylosis.  He  did  not  agree  with 
the  writer’s  conclusion,  as  drawn  from  Macewen’s  operation  of 
osteotomy.  The  limbs  of  children  when  fractured  always  united 
very  quickly,  and  there  was  no  reason  why  a  fracture  of  a  bone 
of  a  lower  extremity  should  not  unite  sufficiently  in  twelve  or 
fourteen  days,  provided  the  fracture  was  a  transverse  one,  to 
allow  the  weight  of  the  bone  to  be  borne  upon  the  limb.  How¬ 
ever,  he  deemed  it  unwise  that  any  such  condition  as  this 
should  be  construed  to  mean  that  the  appliances  could  be 
removed  with  safety  to  the  limb.  In  the  majority  of  fract¬ 
ures  the  dressings  might  he  dispensed  with  in  about  four 
weeks,  provided  there  was  positive  assurance  against  any  un¬ 
usual  violence  that  might  disturb  the  union.  He  should  not 
feel  disposed,  however,  to  tell  a  patient  to  remove  an  appa¬ 
ratus  during  the  daytime  and  resume  it  at  night.  The  ques¬ 
tion  was  not  what  a  doctor  could  do  with  a  reasonable  degree 
of  safety,  but  rather  what  a  patient  could  be  permitted  to  do 
without  incurring  a  danger  of  disaster.  He  could  recall  an 
instance,  while  he  was  an  interne  at  Bellevue  Hospital,  in 
which  he  had  removed  the  dressing  from  a  thigh  four  weeks 
after  a  fracture  at  the  middle  third.  On  the  morning  following 
the  day  of  the  removal  the  patient  had  sustained  a  refracture, 
and  this,  too,  had  occurred  without  the  patient  having  arisen 
from  the  bed,  but  was  due,  as  he  said,  to  his  having  turned  over 
or  in  some  way  forcibly  exerted  himself  during  the  night.  The 
fact  was  the  speaker  should  have  kept  the  dressing  on  this  pa¬ 
tient’s  thigh  for  at  least  two  weeks  longer,  which  was  done  in 
the  case  of  the  refracture  with  complete  success.  He  was  sorry 
that  the  text-books  did  not  lay  down  more  definite  rules  as  to 
how  long  special  fractures  should  be  confined  in  dressings.  This 
omission  was,  however,  not  so  great  a  fault  as  it  seemed  to  the 
reader  of  the  paper,  since  the  time  taken  for  bone  to  unite 
after  fracture  was  pretty  well  determined,  provided  all  other 
things  were  equal.  The  adoption  of  hard  and  fast  rules  in  re¬ 
spect  to  the  length  of  time  would  lead  to  occasional  disaster, 
since  each  fracture  should  be  largely  treated  upon  an  independ¬ 
ent  basis.  He  failed  to  see  how  any  text-book  on  surgery 
could  successfully  formulate  special  rules,  except  for  special 
cases.  Even  then  he  thought  the  best  results  would  arise  if 
the  fracture  was  given  the  benefit  of  the  doubt  rather  than 
if  it  was  treated  according  to  the  stereotyped  statements  of 
text-books. 

Dr.  S.  T.  Armstrong  said  that  the  treatment  of  a  case  of 
fracture,  like  that  of  all  other  cases  of  surgery,  must  be  based 
upon  the  essential  features  of  the  particular  case.  He  did  not 
think  that  the  author  of  the  paper  had  advocated  the  use  of  an 
anaesthetic  for  the  purpose  of  simplifying  the  making  of  the 
diagnosis,  but  had  argued  that  the  resulting  relaxation  w'ould 
enable  the  surgeon  to  make  more  certain  work  of  the  adjust¬ 
ment  of  the  fragments  and  the  application  of  the  dressings.  1  he 
removal  of  a  fracture  dressing  permanently  after  the  fourteenth 
or  twenty-first  day  would,  in  the  opinion  of  the  speaker,  lay 
the  surgeon  who  allowed  it  open  to  an  action  for  damages 
should  any  accident  ensue  as  the  direct  or  indirect  result  of  the 
permission  or  advice. 

Dr.  von  Donhoff  said  that  he  had  intended  to  convey  the 


idea  that  he  would  give  an  anaesthetic  for  the  purpose  of  ad¬ 
justing  the  fragments  and  of  avoiding  the  struggles  of  the  pa¬ 
tient,  and  not  for  the  mere  purpose  of  making' a  diagnosis.  He 
held  it  to  be  the  business  of  every  surgeon  to  be  able  to  make  a 
diagnosis  from  a  familiarity  with  the  topographical  anatomy  of 
the  parts  involved  unless  the  injury  extended  into  a  joint  cavity. 
Still,  he  thought  that  examination  and  adjustment  under  anaes¬ 
thesia  would  allow  of  quicker  and  better  work  with  less  injury 
to  the  parts  than  was  often  possible  when  no  anaesthetic  was 
used.  He  had  seen  no  mishaps  from  chloroform.  The  use  of 
an  anaesthetic  was  nothing  as  constituting  an  additional  feature 
of  gravity  in  the  case,  but  rather  the  contrary.  As  to  the  gross 
topography  of  a  fracture,  he  thought  it  good  practice  to  study 
the  tissues  themselves,  to  note  the  amount  of  swelling  and  the 
propriety  of  interfering  with  the  same  surgically  ;  to  notice  the 
signs  of  haemorrhage  about  the  fracture,  and  whether  operative 
interference  should  be  employed  for  its  relief;  to  determine  the 
nature  of  the  vascular  lesion,  as  to  whether  there  was  a  large 
bleeding  vessel  likely  to  militate  against  physiological  repair. 
He  did  not  think  it  good  practice  to  put  a  fracture  up  in  a 
permanent  dressing  and  leave  it  to  chance  and  a  prognosis  based 
on  the  outside  appearance  of  the  dressing.  There  was  sure  to 
be  a  subsidence  of  the  swelling  long  before  adequate  union  of 
the  fragments,  and  an  ugly  deformity  might  result  before  the 
limb  was  seen.  He  thought  that  in  the  case  mentioned  by  Dr. 
Bryant  there  could  have  been  no  union  at  all.  Perhaps  there 
had  been  failure  to  get  the  fragments  opposed,  an  accident 
easily  avoided  if  his  method  was  adopted.  Too  much  care  and 
attention  could  not  be  given  to  the  matter  of  ankylosis,  so  ex¬ 
tremely  likely  to  occur  in  the  course  of  the  prolonged  confine¬ 
ment  of  joints  and  so  tedious  and  difficult  to  overcome  when 
once  developed.  Neither  he  nor  the  gentlemen  who  had  con¬ 
tributed  to  the  statistical  tables  mentioned  in  his  paper  had  wit¬ 
nessed  any  secondary  accidents  while  practicing  the  method  he 
had  been  advocating. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  of  October  7,  1890. 

The  President,  Dr.  Landon  C.  Gray,  in  the  Chair. 

Tuberculous  Meningitis. — Dr.  W.  B.  Pritchard  presented 
the  brain  of  a  patient  who  had  died  from  this  cause.  When 
first  seen  by  the  speaker,  the  man  had  been  suffering  from  ob¬ 
stinate  insomnia  and  headache.  A  few  days  subsequently  the 
thermometer' had  shown  some  elevation  of  temperature;  but 
this  had  never  exceeded  103°  at  any  time  until  shortly  before 
death.  The  mental  disturbances  had  been  very  marked  from 
the  beginning.  There  had  been  complete  loss  of  memory, 
right-sided  ptosis,  difficulty  and  finally  loss  of  speech,  and  the 
rapid  development  of  symptoms  of  complete  bulbar  paralysis. 
The  apparent  immediate  cause  of  death  had  been  the  involve¬ 
ment  of  the  vagus.  There  had  been  decided  right  hemiparesis. 
A  very  offensive  purulent  discharge  from  the  nose  had  been 
persistent,  which  had  continued  until  death.  The  autopsy  had 
revealed  over  the  right  parietal  bone  a  cavity  of  about  the  size 
of  a  silver  dime,  the  necrosis  being  presumably  tuberculous 
in  character.  Over  the  patient’s  right  eye  there  had  been  a 
linear  scar  with  a  depressed  fracture,  but  no  apparent  affection 
of  the  brain  from  this  cause.  At  the  base  of  the  brain  there 
was  found  a  thick  tenacious  material.  The  medulla,  pons, 
crura,  and  cranial  nerves  were  involved,  and  the  dura  was 
covered  along  the  convexity  of  both  hemispheres  with  what 
were  presumed  to  be  masses  of  tuberculous  deposit. 

Can  we  diagnosticate  Hyperaemia  or  Anaemia  of  the 
Brain  and  Cord? — Dr.  William  A.  Hammond,  of  Washington, 


554 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


read  a  paper  on  this  subject.  The  writer  had  for  many  years  been 
familiar  with  a  group  of  symptoms  which,  from  their  aetiology  and 
general  characteristics,  were  indicative  of  cerebral  disturbance; 
and  some  twenty-five  years  ago,  after  considerable  observation 
and  many  experiments  performed  upon  living  animals  and  the 
human  subject,  he  had  come  to  the  conclusion  that  they  were 
the  result  of  an  increase  of  the  amount  of  blood  circulating  in 
the  vessels  of  the  brain.  His  conclusions  were  first  published 
in  an  article  on  Insomnia  in  1865,  various  papers  appearing  on 
the  subject  at  subsequent  intervals ;  and  lastly  in  a  monograph, 
issued  in  1884,  entitled  Cerebral  Eypercemia  the  Result  of  Over¬ 
mental  Work  or  Emotional  Disturbance,  in  which  additional  facts, 
the  outcome  of  continued  experience,  were  brought  forward  in 
support  of  the  theory  advanced.  In  the  writer’s  opinion,  there 
were  certain  symptoms  which  positively  indicated  the  existence 
of  cerebral  hypersemia,  and  which  he  had  designated  as  symp¬ 
toms  of  the  first  class.  There  were  others  which  inferentially 
led  to  the  same  conclusion,  especially  when  they  were  associ¬ 
ated  with  symptoms  of  the  first  class.  Those  were  embraced 
under  the  term  symptoms  of  the  second  class.  Others,  again, 
were  indicative  of  derangements  of  various  organs  of  the  bo'dy, 
which,  though  important  as  adding  to  the  discomfort  of  the 
patient,  might  be  due  to  many  different  primary  pathological 
states,  and  therefore  were  not  included  in  the  present  discus¬ 
sion.  The  symptoms  of  the  first  class  were:  first,  wakeful¬ 
ness;  second,  pain,  heat,  a  feeling  of  fullness  or  distention  in 
the  head,  a  sensation  of  a  band  encircling  it,  a  dragging  and 
clawing  sensation  at  the  vertex,  vertigo,  and  hallucinations, 
provided,  and  this  point  was  especially  impressed,  that  those 
symptoms  were  increased  by  any  known  factor  which  increased 
the  amount  of  blood  in  the  brain  ;  and,  third,  a  congested  con¬ 
dition  of  the  tympanum  and  the  optic  disc,  the  retina,  and  the 
chorioid.  The  theory  which  the  writer  had  advanced  repeat¬ 
edly  was  that  natural  sleep  was  due  to  a  comparative  anae¬ 
mic  condition  of  the  brain,  normal  wakefulness  to  an  increase 
of  the  amount  of  blood  in  the  cerebral  vessels,  and  insomnia 
to  an  abnormal  quantity  of  intracranial  blood.  Persistent 
insomnia  was  the  necessary  accompaniment  of  the  pathogno¬ 
monic  symptom  of  the  affection  in  que.-tion.  Without  wake¬ 
fulness  there  was  no  cerebral  hyperaemia;  with  cerebral  hyper- 
aamia  there  was  always  wakefulness.  Numerous  experiments 
made  upon  animals  had  fully  demonstrated  those  facts.  It  was 
well  known  that  during  the  process  of  digestion  there  was  a 
diminished  amount  of  blood  in  the  brain,  and  it  was  for  this 
reason  that  persons  felt  sleepy  after  a  hearty  meal.  Although 
those  observations  and  experiments  were  conclusive  enough, 
further  demonstration  had  been  made  by  means  of  an  instru¬ 
ment  devised  for  the  purpose  of  determining  the  existence 
of  cerebral  hyperaemia.  By  its  means  observations  were  made 
upon  the  movements  of  the  brain  and  the  blood  pressure  within 
the  cranium.  It  consisted  of  a  brass  tube,  which  was  screwed 
into  a  round  hole  made  in  the  skull  with  a  trephine.  Both 
ends  of  this  tube  were  open,  but  into  the  upper  was  screwed 
another  brass  tube,  the  lower  end  of  which  was  closed  by  a 
piece  of  very  thin  sheet  India  rubber,  and  the  upper  end  with 
a  brass  cap,  into  which  was  fastened  a  glass  tube.  This  minor 
arrangement  contained  colored  water,  and  to  the  glass  tube  a 
scale  was  affixed.  This  second  brass  tube  was  screwed  into  the 
first  till  the  thin  rubber  pressed  upon  the  dura  mater  and  the 
level  of  the  colored  water  stood  at  0,  which  was  in  the  middle 
of  the  scale.  Now,  when  the  animal  went  to  sleep,  the  liquid 
fell  in  the  tube,  showing  that  the  cerebral  pressure  had  been 
diminished — an  event  which  could  only  take  place  in  conse¬ 
quence  of  a  reduction  in  the  quantity  of  blood  circulating  in 
the  brain.  As  soon  as  the  animal  awoke  the  liquid  rose  at 
once.  The  experiments  were  performed  upon  dogs  and  rabbits, 


and  in  every  instance  the  pressure  was  lessened  during  sleep 
and  increased  during  wakefulness.  The  writer  thought  that 
nothing  could  exceed  the  conclusiveness  of  experiments  of  this 
character.  Of  the  second  group  of  symptoms,  hallucination, 
being  the  most  remarkable,  was  the  only  one  considered.  A 
number  of  cases  were  cited  from  the  recorded  experience  of 
the  writer  and  other  observers.  In  most  of  the  cases  reported 
the  spectre  or  apparition  had  appeared  to  the  persons  on  re¬ 
tiring  to  rest  or  inclining  forward,  and  vanished  when  the 
erect  posture  was  assumed.  The  explanation  of  such  cases  was 
very  simple.  The  recumbent  posture  facilitated  the  flow  of 
blood  to  the  brain,  and  at  the  same  time  tended,  in  a  measure, 
to  retard  its  exit.  Hence  the  appearances  were  due  to  the  re¬ 
sulting  congestion.  As  soon  as  the  individuals  rose  in  bed  or 
stood  erect,  the  reverse  condition  existed,  the  congestion  dis¬ 
appeared,  and  the  apparitions  went  with  it.  Hallucinations  of 
hearing  were  not  infrequently  produced  by  like  causes.  A 
number  of  cases  were  related  to  illustrate  this  point.  The 
writer  did  not  want  to  be  understood  as  saying  that  there  was 
a  fixed  condition  of  the  fundus  of  the  eye  and  the  tympanum 
which  was  associated  with  cerebral  hyperaemia;  but  that  ob¬ 
servations  should  be  made  from  day  to  day  in  each  case,  when 
it  would  be  found  that  as  the  other  symptoms  of  cerebral  hy¬ 
peraemia  disappeared,  the  retina,  the  chorioid,  and  the  tympa¬ 
num  would  lose  their  congested  appearance,  so  that,  when 
health  was  restored,  the  fundus  of  the  eye  and  the  drumhead 
would  be  found  to  be  very  different  from  what  they  were  when 
the  disease  was  at  its  height.  There  were  certain  agents  which, 
by  their  action,  appeared  to  increase  the  amount  of  blood  in 
the  brain,  and  others  which  apparently  diminished  it,  and 
which  were,  hence,  important  in  their  diagnostic  relations.  If 
to  a  person  suffering  from  insomnia,  pain  in  the  head,  vertigo, 
and  hallucinations,  should  be  given  one  or  two  hundredths  of 
a  drop  of  nitroglycerin,  the  trouble  would  become  augmented 
and  unbearable.  Like  effects  followed  the  use  at  such  a  time 
of  quinine,  strychnine,  and  other  agents.  Among  those  reme¬ 
dies  used  to  diminish  the  amount  of  blood  in  the  brain,  the 
bromides  stood  pre-eminent.  Another  diagnostic  factor  was  in 
the  action  of  ergot.  As  was  well  known,  this  substance  pos¬ 
sessed  the  property  of  constricting  the  organic  muscular  fiber. 
The  writer  was  convinced,  from  personal  investigations,  that 
ergot  did  contract  the  cerebral  vessels,  and  hence  diminished 
the  quantity  of  intracranial  blood.  The  writer  said  in  conclu¬ 
sion  that  when  he  had  a  patient  suffering  from  insomnia,  pain 
in  the  head,  vertigo,  hallucinations,  suffusion  of  the  face,  ce¬ 
phalic  heat,  and  other  striking  symptoms  of  perhaps  less  special 
importance,  and  when  he  found  these  symptoms  disappear 
under  the  influence  of  remedies  such  as  the  bromides,  ergot, 
ice,  and  douches  of  cold  water  to  the  nape  of  the  neck,  cups  in 
the  same  locality,  nasal  bloodletting  or  spontaneous  haemor¬ 
rhage,  position,  and  other  means  calculated  to  diminish  the 
amount  of  intracranial  blood,  he  did  not  see  how  an  escape 
was  possible  from  the  conclusion  that  the  patient  was  suffering 
from  cerebral  hyperaemia. 

Dr.  M.  A.  Starr  said  that  while  he  did  not  wish  to  be  un¬ 
derstood  as  representing  those  who  opposed  Dr.  Hammond’s 
views,  still  his  convictions  at  present  were  those  expressed  by 
Dr.  Gray  in  his  paper  read  recently  before  the  society.  (See 
the  Journal  for  May  24th,  page  561.)  The  symptoms  which 
had  been  explained  by  the  existence,  or  assumed  existence,  of 
cerebral  hypertemia  were,  many  of  them,  symptoms  which 
could  be  produced  by  other  causes ;  such,  for  example,  as 
wakefulness,  which  was  often  noticed  in  individuals  when 
very  much  exhausted  and  in  puerperal  women  who  had  suf¬ 
fered  severe  haemorrhage.  He  had  also  certainly  observed  it 
in  patients  who  were  anaemic.  Therefore,  to  say  that  wakeful- 


Nov.  15,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


555 


ness  necessarily  indicated  a  hyperamiic  brain  was  to  advance 
a  theory  which  was  hardly  tenable.  Certainly  hyperaemia  of 
the  brain  might,  under  certain  conditions,  be  diagnosticated,  but 
it  was  a  very  open  question  whether  this  could  be  done  when 
only  wakefulness  was  present.  As  to  the  question  of  drugs, 
they  had  been  very  much  surprised  to  hear  it  stated  by  Dr.  A. 
H.  Smith  and  Dr.  Peabody,  at  a  meeting  of  the  Practitioners’ 
Society  last  winter,  that  those  gentlemen  bad  been  treating 
cases  of  supposed  hyperemia  of  the  brain  with  nitroglycerin 
and  nitrite  of  amyl.  These  drugs,  which  were  supposed  to 
increase  the  supply  of  blood  to  the  brain,  were  being  given 
upon  the  hypothesis  that  they  dilated  the  entire  arterial  sys¬ 
tem  of  the  body,  and  the  brain  would  thereby  be  relieved  to  a 
certain  extent  of  blood.  The  reasoning,  at  least,  appeared 
sound.  The  speaker  thought  it  impossible  to  base  a  diagnosis 
upon  any  individual  symptom. 

Dr.  J.  Leonard  Corning  thought  this  was  not  scientific 
reasoning.  The  truth  might  probably  be  more  nearly  arrived 
at  by  careful  induction.  If  a  man  came  complaining  of  head¬ 
ache,  having  a  congested  face,  with  a  pulse  of  high  tension, 
whose  symptoms  could  be  promptly  relieved  by  pressure  upon 
the  carotids  or  the  jugulars,  or  by  bandaging  the  legs,  might  such 
a  patient  be  assumed  to  be  suffering  from  congestion  or  anaemia 
of  the  brain  ?  The  speaker  thought  it  was  congestion.  Suppose 
quinine  or  alcohol  should  be  given  to  such  a  patient,  and  it  was 
found  that  the  symptoms  were  aggravated,  it  would  be  cer¬ 
tainly  concluded  that  the  trouble  was  congestion. 

ThePRRsiDENT  said  that  of  course  Dr.  Hammond  spoke  with 
authority;  this  they  were  all  prepared  to  admit.  The  fact  that 
he  was  able  to  do  so  bad  much  to  do  with  the  acceptance  of 
his  conclusions  without  criticism.  Still,  no  dictum  in  relation 
to  a  scientific  point  could  be  allowed  to  stand  on  personal  au¬ 
thority  alone.  The  conclusions  must  bear  the  force  of  investi¬ 
gation  and  be  supported  by  fact.  Dr.  Hammond  must  not 
consider  the  discussion  as  having  the  least  personal  bearing, 
but  as  merely  the  expression  of  a  general  desire  to  elucidate 
the  problem  as  far  as  possible.  Dr.  Hammond  had  stated  the 
symptoms  of  cerebral  congestion  as  being  sleeplessness,  with  a 
certain  feeling  of  compression  or  oppression  about  the  head  and 
a  flushing  of  the  face. 

Dr.  Hammond  here  suggested  that  he  had  said  these  symp¬ 
toms  were  increased  by  the  dependent  posture  or  by  anything 
which  would  increase  the  amount  of  blood  in  the  brain. 

The  President  accepted  the  correction,  and  went  on  to 
enumerate  the  conditions  in  which  these  symptoms  might  be 
found.  For  instance,  insomnia  was  common  enough  in  mental 
diseases  and  worry,  melancholia,  overwork,  constipation,  and 
many  conditions  in  which  there  was  nothing  to  show  that 
there  existed  any  hyperemia  of  the  brain.  In  the  early  stages 
of  intracranial  syphilis  there  was  a  condition  somewhat  of 
the  nature  of  hyperaemia.  But,  then,  in  Bright’s  disease,  in 
which  there  were  hyperaemia  and  congestion,  there  existed  a 
condition  of  stupor.  If  the  list  of  causes  of  insomnia  were 
gone  through,  it  would  be  possible  to  find  a  certain  train  of 
symptoms  which  would  lead  to  the  assumption  of  existing  anae¬ 
mia  in  some  and  hyperaemia  in  others.  Experiments  had  re¬ 
cently  been  made  on  the  brains  of  animals,  the  report  of  which 
differed  from  those  of  other  recorders;  as  to  the  point  made 
that  the  brain  rose  or  increased  in  volume  during  the  waking 
period,  it  was  an  open  question  whether  this  was  not  due  to 
cellular  action  producing  an  increase  of  bulk.  As  to  the  as¬ 
sociation  of  sleeplessness  with  the  recumbent  posture,  of  course 
the  extended  observations  of  the  author  of  the  paper  were 
deserving  of  due  consideration;  but  so  also  were  the  more 
limited  observations  of  the  speaker  in  this  respect,  and  he  had 
not  been  able  to  verify  the  association.  The  question  before 


them  was  not  as  to  the  existence  of  cerebral  hypenemia  or 
anaemia,  but  as  to  whether  it  could  be  clinically  diagnosticated. 
Flushed  face  might  be  dependent  upon  chorea,  general  paresis, 
or  injury  to  the  brain.  It  was  impossible  to  say  whether  the 
symptom  was  brought  on  by  byperaomia  alone.  The  feeling  of 
oppression  and  sense  of  fullness  in  the  head  was  found  associ¬ 
ated  with  errors  of  refraction,  insufficiency  of  the  ocular  mus¬ 
cles,  changes  of  climate,  errors  of  diet,  and  so  forth.  To  as¬ 
sume  that  in  all  those  conditions  there  was  hyperaemia  of  the 
brain  was  assuming  a  good  deal  and  more  than  could  be  proved. 
It  was  a  point  which  had  not  been  demonstrated  by  any  pa¬ 
thologist,  as  to  whether  there  could  exist  by  itself  an  increased 
amount  of  blood  in  the  cellular  tissue  or  other  finer  structures 
of  the  brain  without  causing  disease  of  the  surrounding  parts. 
It  was  strange  that  Dr.  Hammond,  after  five  months’  prepara¬ 
tion  of  the  subject,  had  cited  no  autopsies  in  confirmation  of  his 
theory. 

Dr.  0.  L.  Dana  said  that  he  thought  it  was  now  generally 
agreed  that  there  was  such  a  condition  as  cerebral  hyperaemia 
and  that  it  could  be  recognized  in  its  acute  forms.  Such  a  state 
might  be  produced  by  drugs,  congestive  neuroses,  trauma,  and  so 
forth.  The  question  had  been  and  was,  What  was  the  condition 
at  the  base  of  that  functional  disorder  which  had  gone  by  the 
name  of  cerebral  neurasthenia?  whether  its  initial  stage  was  that 
of  hyperaemia,  or  the  hyperaemia  was  a  secondary  process.  An 
acute  and  a  chronic  hyperaemia  of  the  brain  were  conditions  ad¬ 
mitted  to  exist,  but  it  was  preferable  to  say  functional  cerebral 
neuroses  or  psychoses  where  the  hyperaemia  was  a  secondary 
process,  and  that  seemed  the  inevitable  conclusion  to  those  who 
watched  these  cases.  Many  patients  among  the  neurasthenics 
showed  symptoms  of  congestion  of  the  brain ;  others  of  this 
class  did  not  in  any  way  present  the  symptoms  of  the  classic 
type  of  cerebral  hyperaemia,  but  showed  the  condition  so  shaded 
down  that  it  was  necessary  to  set  aside  all  the  symptoms  gen¬ 
erally  described.  There  was  something  at  the  back  of  the  hy¬ 
peraemia.  The  hyperaemia  of  the  brain  was  secondary  to  some 
disorder  of  the  vaso-motor  nerves  or  to  some  functional  condi¬ 
tion  involving  the  whole  nervous  system.  As  to  insomnia  and 
cerebral  hyperaemia,  that  question  was  obsolete.  To  state  that 
sleep  was  produced  by  anaemia  and  wakefulness  by  the  return 
of  the  normal  amount  of  blood  to  the  head  was,  the  speaker 
thought,  in  the  light  of  modern  neurological  studies,  a  theory 
which  could  be  described  as  unworthy  of  further  investiga¬ 
tion. 

Dr.  Hammond  thought  that  his  points  had  been  unanswered 
in  the  argument.  When  Dr.  Dana  said  that  the  neurologists 
of  to-day  ignored  the  theory  of  the  physiological  changes  dur¬ 
ing  sleep,  a  theory  which  the  speaker  might  claim  as  his  own,  he 
thought  Dr.  Dana  in  error.  He  would  remind  them  that  he  had 
stated  that  headache  presented  innumerable  causes  for  its  exist¬ 
ence,  and  it  was  only  when  he  found  it  with  flushed  face  and 
vertigo  and  when  it  was  increased  by  the  dependent  position  of 
the  head  that  the  diagnosis  was  certain.  Then  he  knew  his 
patient  had  hyperaemia  of  the  brain,  all  the  neurologists  in  the 
world  to  the  contrary  notwithstanding. 

The  Sensation  of  Itching1. — This  was  the  title  of  a  paper 
by  Dr.  E.  B.  Bronson.  He  said  that  it  was  a  somewhat  re¬ 
markable  fact  that  a  manifestation  of  cutaneous  irritability  so 
common  as  itching,  and  one  with  which  as  a  symptom  we  were 
so  familiar,  had  been  almost  entirely  neglected  as  an  independ* 
ent  study.  Of  other  anomalies  of  sensation — such  as  hyperes¬ 
thesia,  anaesthesia,  and  pain — we  had  tolerably  clear  and  definite 
ideas.  But  what  were  the  cause  and  nature  of  pruritus?  what 
was  this  disturbance  of  sensation?  Notwithstanding  the  fact 
that  the  special  senses  in  their  present  state  were  so  far  removed, 
in  respect  to  the  knowledge  they  yielded  to  consciousness,  from 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mun.  Jour., 


556 

common  sensation,  there  doubtless  bad  been  a  period  when  the 
distinction  did  not  exist.  Their  differentiation  had  been  the  re¬ 
sult  of  gradual  and  long-continued  processes  of  evolution.  There 
could  be  little  question  that  the  sensory  organs  to  which  the 
several  senses  owed  their  special  attributes  had  all  originally 
developed  from  simple  nerve  endings  that  gave  but  the  vaguest 
intimations  of  external  objects.  In  this  evolution  the  impelling 
force,  the  directing  impulse,  had  been  derived  from  the  two 
grand  principles  of  life  known  as  the  instinct  of  seU-preservation 
and  the  instinct  of  reproduction.  To  one  or  the  other  of  those 
instincts  every  sensation  that  arose  in  the  body  must  be  directly 
or  indirectly  referred.  All  sensations,  as  had  been  shown,  were 
originally  tegumentary.  To  the  common  integument  must  be 
ascribed  the  source  and  potentiality  of  all  sensations.  As  the 
result  of  specialization,  most  of  those  sensations  had  been  with¬ 
drawn  from  the  exterior.  What  traces  of  the  special  senses  thus 
abstracted  still  persisted  in  the  skin  might  be  infinitesimal. 
There  still  remained  to  the  skin  and  adjacent  mucous  orifices  a 
variety  of  sensations,  others  more  specialized,  including  a  spe¬ 
cial  sense  with  perceptive  faculties,  and  finally  the  most  impor¬ 
tant  representative  of  the  reproductive  instinct,  the  aphrodisiac 
sense.  The  only  sense  with  which  the  skin  was  endowed  that 
could  be  called  perceptive  and  that  was  worthy  of  comparison 
with  seeing,  heariug,  smelling,  and  tasting  was  the  sense  of  pse- 
laphia.  It  included  the  sense  of  contact,  which  was  seen  in  its 
most  primitive  form ;  its  most  important  element  was  the  press¬ 
ure  sense,  while  the  temperature  and  muscular  senses  were 
more  or  less  essential  auxiliaries.  Common  sensation  was  rep¬ 
resented  in  the  integument  in  its  highest  positive  aspect  by  the 
voluptuous  sensations,  in  its  lowest  negative  aspect  by  pain. 
Returning  to  the  question,  What  relation  to  the  sensory  organs 
of  the  skin  and  to  their  sensations  did  the  sensation  of  itching 
bear?  the  author  believed  that  there  was  sufficient  evidence  to 
locate  the  essential  seat  of  pruritus  in  the  epidermis.  Itching 
was  evoked  by  such  irritants  as  acted  upon  this  tissue  much 
more  uniformly  than  by  those  that  acted  on  the  derma.  How¬ 
ever  provoked,  the  sensation  of  itching  was  always  associated 
with  a  presentment  to  consciousness  as  though  a  foreign  body 
were  in  contact  with  the  surface.  It  was  that  sensation  that 
experience  through  many  stages  of  animal  life  had  taught  was 
often  followed  by  a  prick  or  a  sting,  and  the  inclination  to 
escape  the  threatened  hurt  had  grown  into  an  animal  instinct. 
The  cause  of  contact  at  a  minute  portion  of  the  sensitive  surface 
was  immediately  interpreted  to  mean  a  miniature  attack  that 
must  be  repelled.  If  no  attack  had  really  been  made,  but  only 
the  threat,  then  the  excitement  should  disappear  without  re¬ 
turning  the  moment  the  cause  producing  the  sense  of  contact 
was  withdrawn.  But  it  was  this  peculiarity  of  itching  that  it 
persisted  in  spite  of  such  withdrawal,  and  was  only  relieved 
by  the  act  of  scratching.  It  seemed  as  though  the  contact,  or 
whatever  the  change  might  be  that  gave  rise  to  the  irritation, 
produced  a  molecular  commotion  in  the  nerves  that  went  on 
like  the  jangling  of  an  electric  bell,  with  the  continuance  of  the 
sensation  until  such  time  as  the  surcharge  of  nervous  energy 
was  released.  In  pselaphia  the  nerve  force  or  the  molecular 
vibrations  excited  by  the  impact  was  directly  transmuted  into 
some  intelligent  form  of  activity,  and  the  accumulation  of  nerve 
excitation,  the  nervous  engorgement,  did  not  occur.  The  cir¬ 
cuit  was  complete  with  no  point  of  resistance  intervening  to 
produce  obstruction  and  commotion.  With  regard  to  the  effect 
of  scratching  in  relieving  itching,  it  was  analogous  to  that  pro¬ 
duced  by  muscular  exertion,  as  in  those  animals  in  which  the 
platvsraa  rayoides  was  more  highly  developed  than  in  man,  as 
in  the  horse  and  bovine  genera,  a  certain  relief  might  be  af¬ 
forded  to  pruritic  sensation  through  its  energetic  contractions, 
and  this  was  not  wholly  due  to  expulsion  of  the  insect  or  what¬ 


ever  else  might  have  caused  the  sensation.  While  some  of  the 
phases  of  itching  might  be  associated  with  pathological  changes 
in  the  epidermis,  others  had  their  source  more  deeply  situated 
and  were  referable  to  the  nerve  centers.  To  the  latter  be¬ 
longed  the  form  of  neurosis  of  which  pruritus  was  at  the  same 
time  the  symptom  and  the  sole  appellation.  Still  other  sources 
were  doubtless  to  be  found  associated  with  apparently  normal 
physiological  conditions.  While  those  represented  the  most  ob¬ 
vious  sources  of  itching  or  provocations  for  scratching,  there 
was  another  factor  of  which  hitherto  but  little  account  had  been 
taken.  Both  the  English  words  itch  and  itching,  and  the  Latin 
prurio  and  pruritus,  in  their  secondary  significations  conveyed 
the  idea  of  a  longing,  teasing  desire,  while  pruritus  was  com¬ 
monly  used  by  the  Latins  as  a  synonym  for  lasciviousness.  By 
desire,  something  more  was  meant  than  merely  the  inclination 
to  brush  or  scratch  away  a  foreign  body,  of  which  the  sensa¬ 
tion  was  apparently  an  intimation.  It  was  rather  a  kind  of 
desire  closely  akin  to  a  lustful  feeling  and  one  that  sometimes 
made  scratching  veritably  a  sensual  indulgence.  When  pruritus 
reached  a  certain  degree  of  intensity,  the  subject  was  not  con¬ 
tent  with  that  moderate  amount  of  scratching  that  would  ordi¬ 
narily  create  a  sufficient  diversion  to  give  relief,  but  there  was 
a  disposition  to  attack  the  itching  surface  with  a  vehemence 
that  amounted  to  a  passion.  Recognizing  this  peculiar  element 
of  desire  in  pruritus,  the  sexual  excitement  and  depraving  tend¬ 
encies  that  were  so  commonly  associated  with  pruritus  geni- 
talium  were  most  easily  explained.  But  it  was  not  so  surprising 
that  voluptuous  sensations  should  attend  itching  where  they 
had  their  natural  seat;  such  sensations  were,  however,  not 
contined  to  the  genitalia.  They  might  be  concomitants  of  itch¬ 
ing  in  almost  any  situation.  By  means  of  a  violent  excita¬ 
tion  induced  by  severe  scratching,  provoked  by  pruritic  irrita¬ 
tion,  a  liberation  or  discharge  of  nervous  energy  took  place 
accompanied  by  pleasurable  sensations,  together  with  the  re¬ 
lief  of  the  pruritic  irritation.  A  temporary  inertia  and  rest 
followed  and  continued  until  a  renewal  of  the  pruritus  pro¬ 
voked  another  resort  to  the  same  method  of  relief.  As  to  why 
these  processes  were  attended  with  pleasurable  sensations,  it 
sufficed  to  say  it  satisfied  a  law  of  being.  Gratification  of  ap¬ 
petite  was  a  condition  of  life,  either  of  the  preservation  of  life 
or  of  the  reproduction  of  life.  The  sexual,  the  aphrodisiac  ap¬ 
petite  could  only  be  secondary  to  the  instinct  and  appetites  of 
self-preservation.  From  the  foregoing  considerations  the  fol¬ 
lowing  conclusions  were  drawn: 

1.  That  there  was  a  sense  of  contact  independent  of  the 
sense  of  pselaphia. 

2.  That  this  sense  of  contact  was  the  sense  disturbed  in 
pruritus. 

3.  That  it  primarily  concerned  simple  cutaneous  nerves  or 
nerve  endings  situated  superficially  and  probably  in  the  epi¬ 
dermis. 

4.  That  the  disturbance  in  pruritus  was  of  the  nature  of  a 
dyssesthesia  due  to  accumulated  or  obstructed  nerve  excitation 
with  imperfect  conduction  of  the  generated  force  into  correlated 
forms  of  nervous  energy. 

5.  That  scratching  relieved  itching  by  directing  the  excita- 
tion  into  freer  channels  of  sensation— sometimes,  especially  when 
severe,  substituting  for  the  pruritus  either  painful  or  voluptu¬ 
ous  sensations. 

6.  That  the  voluptuous  sensations  which  might  attend  pru¬ 
ritus  were  a  manifestation  of  a  generalized  aphrodisiac  sense, 
repi'esenting'a  phase  of  common  sensation  that  had  its  source 
in  the  sense  of  contact. 

Dr.  L.  D.  Bulkley  considered  Dr.  Bronson’s  paper  one  of 
the  most  scholarly  he  had  ever  listened  to.  He  then  referred 
to  some  studies  he  had  made  as  to  the  reflex  character  of  itch- 


PROCEEDINGS  OF  SOCIETIES. 


557 


Nov.  15,  1890.] 


ing.  For  instance,  if  the  itching  sensation  were  on  the  finger 
of  the  right  hand,  irritation  or  pinching  of  that  finger  would 
cause  a  reflex  sensation  of  itching  in  the  neighborhood  of  the 
scapula  of  the  same  side.  He  had  only  found  one  or  two  in¬ 
stances  in  which  it  was  transferred  to  the  opposite  side. 

Dr.  Starr  asked  whether  it  was  ever  thought  that  itching 
was  a  symptom  of  central  nervous  disease.  Patients  with  loco¬ 
motor  ataxia  were  said  to  be  frequently  troubled  with  itching 
around  the  anus,  scrotum,  and  perinaeum.  He  had  never  seen  a 
case  confirming  this. 

Dr.  B.  Sachs  had  never  seen  it  in  organic  nervous  disease, 
but  in  functional  disorders,  such  as  crural  neuralgia,  he  had 
known  the  itching  to  be  more  obtrusive  than  the  pain.  It  was 
a  frequent  condition  of  profound  antenna,  and  often  observed  in 
hysterical  women  and  in  cases  of  hvstero-epilepsy. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  THEORY  AND  PRACTICE  OF  MEDICINE. 

Meeting  of  October  21,  1890. 

Dr.  Francis  Delafield  in  the  Chair. 

Purpura  Haemorrhagica. — Dr.  G.  R.  Lockwood  read  a 
paper  with  this  title.  As  ordinarily  described,  purpura  hemor¬ 
rhagica,  or  morbus  maculosus,  was  a  disease  characterized  by 
spontaneous  hemorrhages,  not  only  appearing  subcutaneously, 
as  in  simple  purpura,  but  also  from  the  mucous  membranes, 
and  more  rarely  into  the  serous  membranes,  internal  organs, 
and  joints.  This  disease  was  first  described  by  Werlhof  in 
1775,  and  was  known  as  Werlhof’s  disease.  The  patient  usually 
presented  prodromal  symptoms,  which  might  precede  the  actual 
onset  several  days  or  weeks — malaise,  chilly  sensations,  loss  of 
appetite,  and  possibly  a  slight  rise  of  temperature  being  the 
prodromes  most  commonly  seen.  In  other  cases  the  disease 
might  begin  abruptly.  When  the  disease  was  fairly  developed 
there  was  purpura,  the  spots  varying  greatly  in  size,  usually 
upon  the  extremities,  though  they  might  be  generally  distrib¬ 
uted.  There  were  haemorrhages  from  various  mucous  mem¬ 
branes.  In  some  cases  there  was  constitutional  disturbance.  In 
such  cases  the  disease  lasted  from  two  to  four  weeks  and  tended 
to  recovery,  though  relapses  were  to  be  expected.  In  some  cases 
in  children  the  disease  manifested  itself  by  purpura,  pain  and 
spelling  of  the  joints,  and  abdominal  pain  and  tenderness,  with 
tenesmus  and  bloody  stools.  It  was  characteristic  of  the  dis¬ 
ease  for  the  patient  to  suffer  from  a  number  of  these  attacks  at 
short  intervals.  Letzerich,  in  a  recent  monograph,  had  given 
the  result  of  bacterial  examination  of  the  purpuric  spots  in  a 
case  which  he  had  attended.  Long  bacilli  were  found  capable  of 
growth  in  gelatin,  the  pure  cultures  of  which,  injected  into  the 
abdomen  of  rabbits,  reproduced  the  original  clinical  symptoms  in 
all  of  twelve  cases,  and  in  these  the  same  bacilli  were  found  iden¬ 
tical  with  those  of  the  pure  cultures  injected.  The  liver  in  the 
rabbits  was  regularly  enlarged  and  the  portal  capillaries  were 
almost  occluded  by  an  extraordinary  growth  of  the  bacilli. 
Letzerich  considered  the  liver  to  be  the  breeding  place  of  the 
bacilli  in  Werlhof’s  disease,  the  liver  being  to  this  disease  what 
the  spleen  was  to  malarial  fever.  If  he  was  correct  in  this  view, 
it  helped  explain  both  the  scattering  of  the  lesions,  a  bacterial 
embolism  of  the  capillaries,  and  also  the  tendency  of  the  disease 
to  relapse,  as  well  as  the  periodicity  of  the  relapses  seen  in  some 
cases.  A  number  of  cases  of  varying  intensities  were  then 
alluded  to  by  the  author.  When  these  were  considered  to¬ 
gether,  one  was  struck,  he  said,  by  their  similarity  to  the  class 
of  acute  infectious  diseases.  The  absence  of  assignable  cause, 
the  rapidity  of  the  onset,  the  multiplicity  and  the  scattering  of 
the  lesions,  the  enlargement  of  the  liver  and  spleen,  and  the 


constitutional  symptoms  out  of  proportion  to  the  local  lesions 

found,  seemed  to  prove  by  analogy  the  assertion  that  we  were 
here  dealing  with  an  acute  infection.  Purpura  haemorrhagica 
was  but  one  of  a  group  of  diseases  having  two  essential  features 
in  common — tendency  to  spontaneous  haemorrhages  and  consti¬ 
tutional  symptoms.  The  family  resemblance  of  those  diseases 
and  their  relationship  to  the  other  haemorrhagic  disorders  of 
this  group  were  then  dealt  with.  Iu  summing  up,  the  points  to 
which  discussion  was  invited  were  as  follows: 

(1)  Werlhof’s  disease  was  probably  infectious  in  origin,  the 
exact  agent  of  infection  not  having  been  absolutely  proved, 
though  it  might  be  the  bacillus  described  by  Letzerich. 

(2)  There  were  acute  cases  of  this  infection  in  which  death 
resulted  from  acute  anaemia,  from  internal  haemorrhage,  or  from 
sepsis. 

(3)  Purpura  simplex  and  purpura  rheumatica  were  probably 
types  of  different  grades  of  the  same  infection,  and  this  infec¬ 
tion  might  be  the  same  as  that  of  Werlhof’s  disease. 

(4)  Scurvy,  if  proved  an  infectious  disease,  might  be  really 
Werlhof’s  disease  modified  by  the  surroundings  and  poor  con¬ 
dition  of  the  patient,  and  also  by  the  possibility  of  the  infection 
being  more  chronic. 

(5)  Drug  purpura,  ansemic  and  cachectic  purpuras,  purpuras 
in  exanthemata  and  other  infectious  diseases,  purpuras  in  the 
newly  born,  in  endocarditis  and  multiple  sarcomata,  as  well  as 
those  of  neural  origin,  might  present  all  grades  of  severity ;  one 
could  in  each  determine  a  cause,  though  it  was  not  possible  to 
know  exactly  how  the  symptoms  were  produced  by  this  cause, 
whether  by  blood  changes  or  vessel  changes  or  from  nervous 
causes,  but  these  purpuras  were  symptomatic  and  not  essential, 
and  should  not  be  classed  with  purpura  haemorrhagica  or  Werl¬ 
hof’s  disease  until  there  was  more  definite  information  on  the 
subject. 

Dr.  W.  P.  Northrup  related  the  histories  of  two  cases  of  scor¬ 
butus  occurring  in  young  children.  Both  children  were  being 
nursed  by  the  mother  and  were  in  good  general  condition  ;  there 
was  no  evidence  of  rhachitis  about  either  child.  There  were 
haemorrhages  from  the  various  mucous  membranes,  and  also 
subperiosteal  haemorrhages.  From  a  study  ot  the  subject,  the 
speaker  was  convinced  that  scurvy  was  not  a  disease  of  malnu¬ 
trition,  but  that  there  was  an  absence  from  the  blood  of  some 
important  essential  element,  which  changed  condition  allowed 
it  to  permeate  the  walls  of  the  blood-vessels. 

Dr.  L.  E.  Holt  mentioned  a  case  which  had  occurred  in  an 
infant  six  months  old.  The  child  had  been  nursed  by  the 
mother  and  was  well  nourished.  In  this  case  the  first  symptom 
noticed  was  the  development  of  a  suboccipital  tumor,  spots  ap¬ 
pearing  on  the  body  at  a  later  date.  The  temperature  had  at 
no  time  risen  above  101°  to  102°  F.,  and  just  before  death  in¬ 
ternal  haemorrhages  had  taken  place.  The  whole  course  of  the 
disease  w'as  such  as  to  lead  to  the  belief  that  there  was  acute 
infection  of  some  sort  present.  The  speaker  thought  that  these 
cases  belonged  to  the  acute  infectious  class. 

Dr.  Jackson  described  an  interesting  case  which  had  oc¬ 
curred  in  his  practice.  The  patient,  aged  thirty-four,  a  baker 
by  occupation,  was  enjoying  perfect  health  when  haemorrhage 
from  the  bowels  came  on  without  any  known  cause.  This  con¬ 
tinued  at  intervals  for  about  two  weeks,  when  the  patient  died 
from  exhaustion.  The  temperature  had  gradually  risen  before 
death  to  102°  F.  On  autopsy,  careful  examination  revealed  ab¬ 
solutely  nothing  which  could  point  to  a  cause  or  effect  of  the 
haemorrhage. 

Dr.  Gibbs’s  case  was  that  of  a  young,  healthy  man,  aged 
twentv-six.  The  patient  was  of  fine  physique,  and  had  never 
beeD  sick  in  his  life,  being  always  accustomed  to  outdoor  pur¬ 
suits.  After  taking  a  long  walk  on  the  sea-shore,  he  had  felt 


558 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jodk., 


an  uncomfortable  sensation  in  his  lower  limbs,  which  had 
amounted  almost  to  pain.  On  looking  at  the  legs,  haemorrhagic 
spots  were  discovered  reaching  to  the  knee,  in  four  or  five 
days  the  pain  had  become  very  severe  and  the  spots  had  ex¬ 
tended  up  over  the  thighs,  covering  in  a  short  time  the  entire 
body.  Twelve  hours  before  death  the  wrist  joints  and  phalan¬ 
geal  articulations  were  attacked,  these  being  the  only  joints 
involved.  The  entire  skin  was  covered  with  the  spots,  and  all 
the  mucous  membranes  were  involved.  In  the  mouth  there 
could  be  seen  black  sloughs,  which  extended  as  far  as  a  view 
was  possible  into  the  pharynx  and  nares.  There  was  considera¬ 
ble  vomiting  of  altered  blood.  The  whole  course  of  the  disease 
had  terminated  in  two  weeks.  Consciousness  continued  until 
death,  which  was  caused  by  exhaustion  and  collapse.  Careful 
inquiry  into  the  history  of  this  case  could  elicit  nothing  which 
pointed  to  a  cause.  But  the  speaker  had  been  struck  by  the 
close  resemblance  of  its  symptoms  to  those  of  an  acute  infec¬ 
tious  disease. 

Dr.  Wood  gave  the  history  of  a  case  occurring  in  a  pregnant 
woman.  About  the  fifth  month  there  appeared  upon  the  ab¬ 
domen  some  spots  which  excited  considerable  anxiety.  The 
previous  health  of  the  patient  had  been  good,  but  there  were 
several  cases  of  malarial  infection  in  the  same  house,  and  the 
unusual  condition  was  attributed  to  that  cause  when  the  patient 
was  first  seen.  However,  under  the  speaker’s  observation  the 
purpura  had  disappeared,  and  the  woman  was  delivered  at  full 
term,  the  mother  and  child  had  both  done  well  and  were  healthy 
at  the  present  time. 

Dr.  Quinn  related  the  history  of  the  case  of  a  young  man, 
aged  twenty-one  years,  in  perfect  health,  who  was  taken  sud¬ 
denly  with  haemorrhage  from  the  bowels.  This  had  recurred 
periodically  every  eight  days.  There  was  no  high  temperature 
during  the  course  of  the  disease,  but  just  before  death  the  tem¬ 
perature  had  risen  to  101°  or  102°  F.,  the  patient  dying  from 
exhaustion.  In  this  case  the  most  careful  inquiry  failed  to  find 
any  assignable  cause  for  the  disease. 

Dr.  A.  H.  Buokmaster  accorded  entirely  with  the  views  of 
the  author  of  the  paper  and  with  the  gentlemen  who  had  pre¬ 
ceded  him.  He  related  the  history  of  a  case  of  haemorrhagic 
small-pox.  From  his  study  of  haemorrhagic  disorders  he  was 
Jed  to  believe  that  purpura  could  be  produced  by  other  causes 
than  infection.  He  then  spoke  of  the  treatment  of  such  cases 
by  ergot,  and  the  good  results  to  be  obtained  by  this  drug.  He 
did  not  think  that  cases  of  scorbutus  were  due  to  infection,  but 
to  blood  changes  brought  about  by  some  faulty  supply  of  neces¬ 
sary  material  to  it. 

Dr.  A.  Jacobi  said  that  sudden  haemorrhage  and  death  must, 
in  almost  all  cases,  be  caused  by  poisons.  He  had  seen  this  oc¬ 
cur  from  poisoning  by  phosphorus  and  chlorate  of  potassium. 
These  drugs  causing  a  change  in  the  haemoglobin  of  the  blood, 
inquiry  ought  to  be  made  in  every  case  in  regard  to  the  possi¬ 
bility  of  poison  being  a  factor  of  its  cause.  He  thought  that 
Werlhof’s  disease  was  likely  to  appear  more  than  once  in  the 
same  patient.  While  Letzerich  had  made  repeated  experiments 
and  had  been  able  to  isolate  a  bacillus  and  also  to  reproduce  the 
disease,  this  was  by  no  means  conclusive  and  had  not  been  con¬ 
firmed  by  other  observers.  The  disease  might  be  due  to  an  im¬ 
poverished  condition  of  the  blood-vessels,  to  infection,  or  to  a 
bacillus,  but,  as  this  had  not  been  proved,  it  was  just  as  well 
to  accept  any  broad  statements  as  to  the  cause  with  some  de¬ 
gree  of  reserve.  The  speaker  believed  in  the  kinship  of  all  the 
forms  of  the  disease  as  grouped  by  the  author  of  the  paper. 

Dr.  Nortiirup  asked  if  he  might  state  that  recent  investiga¬ 
tions  by  two  Italian  observers,  Dr.  Giovanni  and  Dr.  Tizzoni, 
had  confirmed  the  discovery  of  Letzerich,  and  that  their  entire 
demonstrations  were  practically  identical. 


The  Chairman  thought  that  the  whole  trouble  lay  in  the 
fact  of  our  extreme  ignorance  on  the  subject,  and  that  no  one 
knew  why  the  blood-vessels  at  one  time  retained  their  contents 
and  at  another  time  did  not.  It  was  a  question  whether  the 
haemorrhage  was  due  to  a  rupture  of  the  blood-vessels  or  to 
transudation.  The  speaker  thought  that  the  subject  was  one 
that  required  continued  study,  and  that  Dr.  Lockwood  in  thus 
grouping  the  cases  had  done  all  that  could  be  done  at  the  pres¬ 
ent  time. 

Dr.  Lockwood,  in  reply  to  Dr.  Northrup  as  to  the  confirma¬ 
tion  of  Letzerich  by  other  observers,  said  he  had  no  knowledge 
of  that  having  taken  place.  Letzerich  explained  that  the  liver 
was  the  breeding  place  of  the  bacilli,  and  that  from  there  the 
system  received  or  was  surcharged  with  the  germs,  their  life 
ending  in  the  system. 


AMERICAN  GYNAECOLOGICAL  SOCIETY. 

Fifteenth  Annual  Meeting ,  held  in  Buffalo ,  September  16,  17, 

and  18,  1890. 

The  President,  Dr.  John  P.  Reynolds,  of  Boston,  in  the  Chair. 

( Concluded  from  page  502.) 

The  Comparative  Value  of  the  Biniodide  and  the  Bi- 
chloride  of  Mercury  as  Surgical  Antiseptics.— Dr.  Charles 

Jewett,  of  Brooklyn,  read  a  paper  on  this  subject,  in  which  he 
stated  that  biniodide  of  mercury  was  less  toxic  than  the  bichlo¬ 
ride;  if  used  in  proper  concentration,  it  was  as  potent  as  a 
germicide;  it  was  a  more  stable  chemical  compound;  it  was 
more  agreeable  to  the  operator.  Experiments  made  at  the 
Hoagland  Laboratory  gave  the  following  conclusions  : 

1.  In  equal  concentration,  the  biniodide  was  slightly  infe¬ 
rior  to  the  bichloride  in  germicidal  power.  2.  For  equal  potency 
as  a  sterilizing  agent,  the  biniodide  should  be  used  in  greater 
concentration  than  the  bichloride — say  1  to  1,800.  3.  The  dif¬ 

ference  in  the  efficacy  of  a  l-to-2,000  solution  of  bichloride  and 
a  l-to-1,000  solution  was  insignificant.  4.  The  activity  of  a 
l-to-2,000  solution  of  biniodide  was  materially  greater  than  that 
of  a  l-to-4,000  solution.  Alcohol  should  be  used  before  the 
sterilizing  solution  for  its  hygroscopic  action. 

Tait’s  Flap-splitting  Operation.— Dr.  Horace  T.  Hanks, 
of  New  York,  read  a  report  of  his  recent  experiences  in  the  use 
of  the  flap-splitting  method  of  Tait.  He  presented  the  histories 
of  five  successive  cases  in  which  the  results  were  perfect.  He 
said  that  Tait’s  operation,  which  had  been  frequently  described, 
was  the  best,  the  most  simple,  and  the  most  easily  performed. 
He  insisted  that  one  prominent  and  necessary  detail  to  secure 
perfect  results  was  keeping  the  bowels  loose  from  the  second  to 
the  tenth  day  after  the  operation. 

Dr.  E.  0.  Dudley,  of  Chicago,  had  performed  Tait’s  opera¬ 
tion  formerly,  aod  had  always  succeeded  in  getting  union,  but 
had  since  discarded  it,  as  it  did  not  sufficiently  bring  together 
the  torn  parts — not  being  a  restorative  operation.  He  believed 
the  condition  of  a  lacerated  perimeum  through  the  sphincter 
indicated  simply  an  operation  which  would  restore  the  parts  to 
the  condition  they  were  in  before  the  tear  occurred.  The  first 
step  was  to  bring  together  the  lowest  caruneulae  myrtiforines 
with  two  tenacula,  when  the  direction  of  the  original  rent  and 
cicatrix  could  be  made  out.  The  perineal  body  was  then  restored 
by  the  method  suggested  by  Emmet.  In  thirty-six  to  forty- 
eight  hours  a  cathartic  was  given,  and  before  the  movement  an 
enema  of  warm  water,  and  the  bowels  were  kept  open  until 
union  was  complete. 

Laparotomy  for  Intrapelvic  Pain.— Dr.  Thomas  A.  Ash¬ 
by,  of  Baltimore,  in  a  paper  with  this  title,  said  that  intra¬ 
pelvic  pain  was  associated  with  many  intrapelvic  conditions, 


Nov.  15,  1890.J 


BOOK  NOTICES. 


559 


but  was  not  always  in  proportionate  severity  to  the  disease. 
Besides  the  pain  which  pointed  to  structural  lesions,  there 
were  chronic  ovarian  neuralgias,  which,  before  the  menopause, 
resisted  treatment.  It  was  for  this  class  of  cases  in  particular 
that  laparotomy  was  advised.  Operation  was  also  essential  in 
cases  in  which  a  diagnosis  could  not  be  clearly  made,  and  pain 
was  severe. 

Dr.  Kelly,  of  Baltimore,  eliminating  personalities,  would 
strongly  condemn  the  practice  of  performing  laparotomy  for 
pain,  notwithstanding  that  in  some  cases  it  afforded  the  most 
typical  relief.  He  believed  oophoralgia  was  rarely  heard  of,  the 
condition  which  characterized  it  generally  arising  from  some 
other  disease  of  the  organ.  The  admission  of  laparotomy  for 
this  condition  would  lead  to  the  practice  of  seven  or  eight  years 
ago,  when  laparotomy  was  performed  for  every  known  disease. 
These  ovarian  troubles  could  always  be  diagnosticated  by 
bimanual  palpation  or  combined  rectal  and  vaginal  examina¬ 
tion  in  anesthesia.  The  uterus  could  he  brought  down  to  the 
vaginal  outlet  with  the  tenaculum,  when  the  ovaries  could  be 
easily  reached.  If  extensive  adhesions  existed,  the  uterus  might 
be  brought  down  into  retroposition,  and  rectal  examination 
would  disclose  the  ovary,  a  little,  characteristic,  almond-shaped 
body.  If  it  was  not  found  in  this  way,  the  utero-ovarian  liga¬ 
ment  might  be  looked  for  running  out  to  the  right  or  left  of  the 
uterus.  When  this  was  found,  by  pushing  it  up  it  was  easy  to 
ascertain  whether  the  ovary  was  adherent  or  not.  Radical 
measures  should  not  be  resorted  to  until  all  other  forms  of  treat¬ 
ment  were  exhausted. 

Dr.  A.  Palmer  Dudley,  of  New  York,  was  in  favor  of  lapa¬ 
rotomy  for  the  relief  of  the  conditions  which  produced  pain, 
after  all  other  methods  of  treatment  had  failed.  He  believed  it 
was  impossible  to  diagnosticate  certain  diseased  conditions  of 
the  ovary  by  bimanual  touch,  and  that  laparotomy  was  the  only 
proper  procedure  in  such  cases.  Vascular  disturbance  was  the 
foundation  of  the  majority  of  pelvic  diseases  in  women.  There 
were  no  valves  to  the  ovarian  veins  from  the  ovary  up  to  the 
renal  vein,  and  they  were  pressed  upon  by  the  sigmoid  flexure 
of  the  colon  and  the  transverse  circulation  of  the  kidney,  some¬ 
times  causing  what  might  be  considered  a  varicocele. 

Dr.  Polk,  of  New  York,  understood  Dr.  Ashby  to  refer 
simply  to  an  exploratory  incision  in  these  cases,  and  in  that 
sense  he  thought  he  was  entirely  right.  He  did  not  believe  it 
was  possible  in  all  cases  to  make  out  the  diseased  conditions  of 
the  ovaries  by  rectal  or  vaginal  touch. 

Dr.  Henry  T.  Byford,  of  Chicago,  believed  that  laparotomy 
should  not  he  resorted  to  for  the  cure  of  pain  that  could  be  cured 
otherwise. 

Dr.  Matthew  D.  Mann,  of  Buffalo,  did  not  believe  that  a  di¬ 
agnosis  was  possible  in  all  cases  before  the  abdomen  was  opened. 
He  believed  in  the  exploratory  incision  as  a  means  of  diagnosis. 
He  doubted  whether  minute  disease  of  the  ovary  could  be  recog¬ 
nized  by  a  simple  incision  of  the  organ,  and  was  inclined  to  be¬ 
lieve  that  the  whole  organ  ought  to  be  removed.  He  was  con¬ 
fident  that  in  a  number  of  cases  the  ovaries  and  tubes  had  been 
removed  when  the  trouble  was  entirely  in  the  ureters. 

Officers  for  the  Ensuing  Year.— The  following  were  elect¬ 
ed:  President,  Dr.  A.  Reeves  Jackson,  of  Chicago;  Vice-Presi¬ 
dents,  Dr.  Joseph  Taber  Johnson,  of  Washington,  and  Dr. 
William  H.  Baker,  of  Boston ;  Secretary,  Dr.  Henry  C.  Coe,  of 
New  York;  Treasurer,  Dr.  M.  D.  Mann,  of  Buffalo;  Members 
of  the  Council,  Dr.  H.  P.  C.  Wilson,  of  Baltimore;  Dr.  W.  H. 
Polk,  of  New  York;  Dr.  E.  C.  Dudley,  of  Chicago;  and  Dr.  F. 
II.  Davenport,  of  Boston. 

The  society  adjourned,  to  meet  in  Washington,  the  third 
Tuesday  in  September,  1891,  to  take  part  in  the  proceedings  of 
the  Congress  of  Amercan  Physicians  and  Surgeons. 


ook  Uoftas. 


The  Throat  and  Nose  and  their  Diseases.  With  One  Hundred 
and  Twenty  Illustrations  in  Color,  and  Two  Hundred  and 
Thirty-five  Engravings,  designed  and  executed  by  the  Au¬ 
thor.  By  Lennox  Browne,  F.  R.  C.  S.  E.,  Senior  Surgeon  to 
the  Central  London  Throat  and  Ear  Hospital,  etc.  Third 
Edition,  revised  and  enlarged.  Philadelphia:  Lea  Brothers 
&  Co.,  1890.  Pp.  xxii-716.  [Price,  $0.50.] 

Certainly  a  foreign  medical  work  is  worthy  of  appreciative 
consideration  that  so  fairly  says  :  “  From  no  quarter  have  we 
derived,  in  these  latter  days,  so  many  original  observations  and 
suggestions  of  real  practical  value  as  from  the  members  of  the 
American  Laryngological  Association.”  But,  aside  from  this 
pleasant  compliment,  the  rich  experience  of  the  twelve  years 
that  have  passed  since  the  first  edition  of  this  work  appeared 
has  been  incorporated  in  this  edition,  making  the  book  one  of 
the  most  valuable  works  on  diseases  of  the  throat  in  the  Eng¬ 
lish  language. 

Materially,  the  volume  has  been  expanded  to  double  its 
original  size,  the  author’s  beautiful  plates  have  been  added  to, 
and  the  other  illustrations  have  been  tripled  ;  by  these  latter 
means  the  practical  teaching  value  of  the  work  has  been  in¬ 
creased,  familiarizing  the  reader  with  the  appearance  of  the 
various  pathological  conditions  that  may  be  found.  It  is  re¬ 
grettable  that  the  American  publishers  have  not  arranged  the 
plates  as  the  author  intended,  so  that  they  could  be  opened  out 
‘‘beside  the  book  during  perusal  of  the  text  descriptive  of  the 
disease  pictorially  illustrated.” 

The  author’s  former  uncertainty  regarding  the  value  of  in¬ 
tubation  of  tne  larynx  has  been  dissipated,  and  he  finds  the 
tubes  very  serviceable.  The  chapters  on  the  nose  and  naso¬ 
pharynx,  while  brief,  are  sufficiently  comprehensive. 

The  work  is  still  worthy  of  the  commendation  that  it  first 
received. 


A  Treatise  on  Diseases  of  the  Nose  and  its  Accessory  Cavities. 

By  Greville  Macdonald,  M.  D.  (Lond.),  Physician  to  the 

Hospital  for  Diseases  of  the  Throat.  London  and  New  York  : 

Macmillan  &  Co.,  1890.  Pp.  xvi-362.  [Price,  $3.] 

The  author  has  made  extensive  studies  and  experiments  on 
the  physics  and  pathology  of  the  nose,  quite  a  full  chapter  being 
devoted  to  the  elucidation  of  his  theories  on  this  subject.  The 
chapter  on  nasal  reflexes  and  hay  fever  is  a  historical  review 
of  what  has  been  said  and  written  on  this  much-discussed  ques¬ 
tion,  the  author  defining  the  disease  as  that  of  paroxysmal  sneez¬ 
ing.  He  believes  that  a  name  for  a  disease  should  always  keep 
clear  of  a  theory,  and  that,  as  a  designation,  a  constant  symp¬ 
tom  is  preferable  to  a  varying  cause.  The  remainder  of  the 
work  is  made  up  of  chapters  on  the  usual  subdivisions  of  dis¬ 
eases  peculiar  to  the  nasal  cavities.  The  book  shows  the  au¬ 
thor’s  ability  to  make  sound  deductions  from  a  ripe  experience, 
and  proves  that  he  is  not  at  all  afraid  of  saying  what  he  thinks. 
The  work  is  fairly  illustrated. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

Diseases  of  the  Eye.  By  Edward  Nettleship,  F.  R.  C.  S.,  Ophthal¬ 
mic  Surgeon  to  St.  Thomas’s  Hospital,  etc.  Fourth  American  from  the 
Fifth  English  Edition.  With  a  Chapter  on  Examination  for  Color-per¬ 
ception.  By  William  Thomson,  M.  D.,  Professor  of  Ophthalmology  in 
the  Jefferson  Medical  College  of  Philadelphia.  Philadelphia  :  Lea 
Brothers  &  Co.,  1890.  Pp.  xx-25  to  508.  [Price,  $2.] 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Diseases  of 
the  Male  Sexual  Organs.  By  Samuel  W.  Gross,  A.  M.,  M.  D.,  LL.  D., 
Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery  in  the  Jef- 


MISGELLAN  V. 


[N.  Y.  Mkd.  Jour. 


560 

- - - — — - ■ - - 

ferson  Medical  College  of  Philadelphia,  etc.  Fourth  Edition,  revised 
by  F.  R.  Sturgis,  M.  D.  Philadelphia:  Lea  Brothers  k  Co.,  1890.  Pp. 
vii-16  to  173.  [Price,  $1.50.] 

Text-book  of  Materia  Medica  for  Nurses.  Compiled  by  Lavinia  L. 
Dock,  Graduate  of  Bellevue  Training  School  for  Nurses,  etc.  New 
York  :  G.  P.  Putnam’s  Sons,  1890.  Pp.  201. 

A  Case  of  Brain  Tumor  ( Angeioma  Cavernosum)  causing  Spastic  Pa¬ 
ralysis  and  Attacks  of  Tonic  Spasms  ;  Operation.  By  L.  Bremer,  M.  D., 
and  N.  B.  Carson,  M.  D.,  of  St.  Louis,  Mo.  [Reprinted  from  the  Ameri¬ 
can  Journal  of  the  Medical  Sciences  ] 

A  Study  of  the  Anaesthesias  of  Hysteria.  By  Charles  L.  Dana, 
M.  D.  [Reprinted  from  the  American  Journal  of  the  Medical  Sciences.] 
Lateral  Deviation  of  the  Spine  as  a  Diagnostic  Symptom  of  Pott’s 
Disease.  By  Robert  W.  Lovett,  M.  D.,  Boston.  [Reprinted  from  the 
Boston  Medical  and  Surgical  Journal.'] 

The  Production  of  Immunity  with  the  Chemical  Substances  formed 
during  the  Growth  of  the  Bacillus  of  Hog  Cholera.  By  E.  A.  v.  Schwei- 
nitz,  Ph.  D.,  Washington,  D.  C.  [Reprinted  from  the  Medical  News.] 
Three  Types  of  Cerebral  Syphilis  producing  Mental  Disease.  By 
C.  M.  Hay,  M.  D.,  Morris  Plains,  N.  J.  [Reprinted  from  the  Medical 
News.] 

Suppurating  Endothelioma ;  Myofibroma  in  a  Condition  of  Necro¬ 
biosis  ;  Remarks  on  the  Treatment  of  the  Pedicle,  etc.  By  Mary  A. 
Dixon  Jones,  M.  D.  [Reprinted  from  the  Medical  Record.] 

The  Pendent  Limb  in  the  Treatment  of  Joint  Diseases  of  the  Lower 
Extremity.  By  A.  B.  Judson,  M.  D.,  New  Yrork.  [Reprinted  from  the 
Transactions  of  the  Medical  Society  of  the  State  of  New  York.] 

Remarks  upon  Empyema.  By  Mary  Putnam  Jacobi,  M.  D.,  of  New 
York.  [Reprinted  from  the  Medical  News.] 

The  Treatment  for  the  Radical  Cure  of  Polypi  of  the  Nose.  By  E. 
Harrison  Griffin,  M.  D.  [Reprinted  from  the  Medical  Record.] 

Lymphoid  Hypertrophy  in  the  Pharyngeal  Vault.  By  Jonathan 
Wright,  M.  D.,  of  Brooklyn.  [Reprinted  from  the  Journal  of  the 
American  Medical  Association.] 

Prognosis  in  Pulmonary  Tuberculosis,  based  upon  an  Analysis  of 
Five  Hundred  and  Fifteen  Cases.  By  Karl  von  Ruck,  B.  S.,  M.  D. 
[Reprinted  from  the  Medical  News.] 

Medical  Aspects  of  Mental  Discipline.  Semi-Centennial  Introduc¬ 
tory  Address  of  the  Medical  Department  of  the  University  of  the  City 
of  New  York.  By  W.  H.  Thomson,  M.  D.,  LL.  D. 

The  Caesarean  Operation,  with  the  Report  of  a  Case.  By  A.  Palmer 
Dudley,  M.  D.  [Reprinted  from  the  American  Journal  of  Obstetrics 
and  Diseases  of  Women  and  Children.] 

I.  The  Prevention  of  the  Short  Leg  of  Hip  Disease.  II.  The  After- 
treatment  of  Hip  Disease.  By  A.  B.  Judson,  M.  D.,  New  York.  [Re¬ 
printed  from  the  Transactions  of  the  American  Orthopcedic  Associa¬ 
tion.] 

A  Case  of  Obscure  Disease  of  the  Bladder  treated  by  Suprapubic 
Cystotomy  and  Prolonged  Drainage.  By  L.  Bolton  Bangs,  M.  D.  [Re¬ 
printed  from  the  Journal  of  Cutaneous  and  Genito-urinary  Diseases.] 

Is  there  a  Fundamental  Difference  between  the  Contraction  of  the 
Heart  and  Ordinary  Striated  Muscle?  By  Thomas  J.  Mays,  M.  D., 
Philadelphia.  [Reprinted  from  the  Transactions  of  the  College  of 
Physicians  of  Philadelphia.] 


JJHsr  dl  a  tig. 


The  International  Congress  of  Hygiene  and  Demography. — Dr. 

John  S.  Billings,  of  the  international  permanent  committee,  has  issued 
the  following  circular,  dated  October  27,  1890:  I  am  requested  by  the 
honorary  secretaries  of  the  committee  of  organization  of  the  Seventh 
International  Congress  of  Hygiene  and  Demography  to  call  attention 
to  the  fact  that  this  congress  will  be  held  in  London  during  the  week 
beginning  August  10,  1891.  The  governments  of  all  countries  and  mu¬ 
nicipalities  and  all  public-health  authorities,  universities,  colleges,  and 


societies  occupied  in  the  study  of  the  sciences  more  or  less  immediately 
connected  with  hygiene,  are  invited  to  co-operate  and  appoint  delegates 
to  represent  them  at  the  congress.  The  Prince  of  Wales  will  preside. 
A  committee  of  organization  has  been  formed,  of  which  Sir  Douglas 
Galton  is  chairman  and  Professor  W.  A.  Corfield  and  Mr.  Shirley  F. 
Murphy  are  honorary  secretaries.  An  exhibition  of  articles  of  hygienic 
interest  will  be  held  in  connection  with  the  congress.  The  last  of  these 
congresses  was  held  in  Vienna  in  1887,  and  was  attended  by  over  two 
thousand  persons,  and  it  is  expected  that  the  London  meeting  will  be 
one  of  great  magnitude  and  importance. 

Phenacetin  in  Typhoid  Fever. — “  Phenacetin  has  been  used  with 
great  success  by  Dr.  Sommer  in  the  treatment  of  typhoid  fever,  thus 
confirming  the  favorable  views  of  its  action  which  have  been  expressed 
by  Masius  and  others.  The  dose  employed  for  adults  was  four  grains, 
which  was  repeated  from  two  to  four  times  during  the  twenty-four 
hours.  Children  were  given  only  half  this  dose.  No  less  than  sixty 
cases  were  treated  in  this  way  with  but  one  fatal  case,  after  which  it  is 
noted  that  the  patient  was  not  subjected  to  phenacetin  treatment  until 
three  weeks  from  the  commencement  of  the  attack.  In  no  case  were 
there  any  serious  complications.” — British  and  Colonial  Druggist. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  ”  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles,  we  alivays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  {1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of— we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  ( 3 )  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  became  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter ,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number ,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem 
bers  of  the  prof  cssion  who  send  us  information  of  matters  of  interes 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  v 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  hiti 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  aa 
dressed  to  the  publishers. 


THE  NE W  YORK  MEDICAL  JOURNAL,  November  22,  1890. 


Original  Communications. 


SOME  REMARKS  ON  MY  HYPOTHESIS  OF 
TIIE  SELF-REGULATION  OF  RESPIRATION, 
AND  Dr.  COWL’S  DISCUSSION  OF  IT. 

By  S.  J.  MELTZER,  M.  D. 

In  No.  614  of  this  Journal,  for  September  6,  1890,  Dr. 
W.  Y.  Cowl  published  an  article  entitled  The  Factors  of 
the  Respiratory  Rhythm  and  the  Regulation  of  Respira¬ 
tion.  In  this  paper  the  author  criticises  adversely  my  the¬ 
ory  of  the  self-regulation  of  respiration,  upon  which  criti¬ 
cism  I  wish  to  make  the  following  remarks : 

In  my  article  *  on  Self-regulation  of  Respiration  I  men¬ 
tioned  the  experience  I  had  had  while  stimulating  the  vagi 
with  strong  electrical  currents.  During  the  stimulation  the 
respiration  was  arrested  in  the  expiratory  phase,  the  in¬ 
spiratory  muscles  being  relaxed;  but  after  interrupting  the 
current,  the  arrest  changed  into  an  inspiratory  phase,  a 
tetanic  contraction  of  the  diaphragm.  H.  Head  \  reports  a 
similar  experience  which  he  had  had  with  prolonged  in¬ 
sufflation  of  the  lungs  ;  after  cessation  of  the  insufflation, 
the  expiratory  standstill  changes  into  an  inspiratory  teta¬ 
nus.  This  phenomenon  is  termed  by  Head  “negative  after¬ 
effect.”  Dr.  Cowl  asks  for  evidence  to  show  that  this  inspi¬ 
ratory  after-effect  is  not  dyspnoea  from  non-aeration  of  the 
blood  coursing  through  the  respiratory  center  during  the 
preceding  expiratory  standstill.  This  is  the  evidence  I 
am  able  to  furnish  : 

1.  The  intensity  and  duration  of  the  inspiratory  tetanus 
are  proportionally  increased  with  the  intensity  of  the  stim¬ 
ulation,  and  not  with  its  duration,  or  with  that  of  the  ex¬ 
piratory  standstill.  This  shows  clearly  that  the  inspira¬ 
tory  tetanus  is  a  primary  effect  of  the  stimulation,  and  not 
a  secondary  result  from  dyspnoea. 

2.  Dyspnoea  from  the  arrest  of  breathing  in  the  expira 
tory  phase  never  effects  an  inspiratory  standstill.  If  an 
expiratory  standstill  is  brought  about  by  the  stimulation 
of  the  superior  laryngeal  nerve,  no  inspiratory  tetanus  is 
ever  observed  to  follow  such  a  standstill.  Furthermore,  an 
expiratory  standstill  can  be  effected  in  some  rabbits  by 
stimulating  the  vagus  trunk  itself  with  moderate  electrical 
currents ;  but  here  the  expiratory  effect  rather  outlasts  the 
stimulation,  with  no  inspiratory  after-effect,  no  matter  how 
long  the  standstill  has  lasted. 

Dr.  Cowl  further  objects  to  the  inference  I  am  supposed 
to  have  drawn  from  my  experiments  on  the  trunk  .of  the 
nerve,  that  the  lungs  themselves  are  likewise  provided  with 
inspiratory  nerve  fibers,  and  that  these  fibers  exercise  their 
function  in  ordinary  breathing.  On  this  point  Dr.  Cowl  is 
mistaken  :  I  did  not  draw  any  such  conclusion  from  my 
experiments.  The  logical  connection  between  my  experi¬ 
ments  and  my  hypothesis  is  as  follows : 

*  The  New  York  Medical  Journal  for  January  18,  1890. 

f  Head,  On  the  Regulation  of  Respiration,  Journal  of  Physiology , 

vol.  x,  1889. 


My  experiments  put  me  in  a  position  to  confirm  the 
hypothesis  that  the  vagus  trunk  contains  two  kinds  of 
respiratory  afferent  nerves,  which  are  antagonistic  to  each 
other  in  a  manner  resembling  that  of  the  antagonistic 
nerves  of  the  heart-beat — i.  e .,  that  it  contains  one  kind  of 
nerves  which  inhibit  the  inspiration,  and  another  kind 
which  incite  and  augment  it.  I  could  further  demon¬ 
strate  the  parallelism  between  these  nerve  fibers  and  the 
cardiac  nerves  in  some  particulars.  For  instance,  the 
stimulation  of  the  inhibitors  of  inspiration  has  only  a  short 
after-effect,  as  is  the  case  with  the  inhibitory  nerves  of  the 
heart,  while  the  inspiratory  nerves  show  a  long  after-effect, 
similar  to  the  known  long  after-effect  of  the  nervus  acceler- 
ans  cordis.  Further,  when  both  cardiac  nerves,  vagus  and 
accelerator,  are  stimulated  at  the  same  time,  we  see  during 
the  stimulation  the  inhibitory  effects  alone  influencing  the 
heart-beat,  and  this  is  the  case  also  with  the  respiratory 
nerves;  strong  stimulation  of  the  vagus  trunk  produces 
constantly  merely  inhibition  of  inspiration — expiratory 
standstill.  Now,  if,  after  cessation  of  the  simultaneous 
stimulation  of  the  cardiac  nerves,  the  long  after-effect  of  the 
accelerating  nerve  appears  fully  developed,  we  should  ex¬ 
pect  that  a  similar  phenomenon  might  occur  after  the  simul¬ 
taneous  stimulation  of  the  respiratory  nerves.  In  fact, 
after  interrupting  the  strong  current,  I  have  observed  that 
the  expiratory  standstill  soon  changed  to  an  inspiratory 
tetanus;  and  what  could  this  mean  but  that  the  expected 
phenomenon  had  occurred — i.  e.,  that  the  inspiratory  nerves 
had  been  likewise  stimulated,  that  their  impulses  had  been 
concealed  but  not  destroyed,  and  that,  therefore,  after 
the  short  expiratory  after-effect  died  out,  the  long  inspira¬ 
tory  after-effect  appeared  unrestrained  and  produced  the  in¬ 
spiratory  tetanus  ?  Thus,  as  I  believe,  1  gave  a  satisfactory 
explanation  of  the  phenomenon  of  the  negative  after-effect 
in  my  experiments  on  the  vagus  trunk ;  but  with  this  the 
direct  conclusion  from  my  experiments  ends.  As  regards 
Head’s  “negative  after-effect”  after  long  insufflation  of  the 
lungs,  I  have,  of  course,  applied  to  it  the  same  explanation 
which  I  have  given  of  the  similar  phenomenon  in  my  ex¬ 
periments.  The  question  :  Are  the  lungs  provided  with 
both  kinds  of  nerves  as  they  are  found  in  the  vagus  trunk? 
I  did  not  discuss  at  all.  On  this  point  I  simply  took  the 
same  view  which  Head  himself  holds,  and  which  is  shared 
by  such  eminent  physiologists  as  Hering  and  many  others.* 
What  I  added  is  this :  If  the  lungs  are  provided  with 
two  sets  of  nerves  as  they  are  found  in  the  vagus  trunk, 
which  I  have  no  reason  to  deny,  then  the  same  relations 
ought  to  prevail  between  the  nerves  of  the  lungs  that  are 
found  in  the  vagus  trunk,  and  consequently  the  negative 
after-effect  following  insufflation  of  the  lungs  may  have  the 
same  meaning  as  that  given  to  the  similar  phenomenon  in 

*  I  may  quote  here  an  acknowledged  authority,  Foster,  who  says, 
in  the  latest  (5th)  edition  of  his  standard  text-book,  p.  595 :  “  And, 
assuming  on  the  strength  of  analogy  the  existence  in  the  vagus  of  two 
sets  of  fibers,  we  may  say  that  expansion  stimulates  the  endings  of  the 
fibers  which  inhibit  inspiration  and  concurrently  tend  to  augment  expi¬ 
ration,  while  collapse  stimulates  the  fibers  which  inhibit  expiration  and 
augment  inspiration.” 


562 


MELTZER:  THE  SELF-REGULATION  OF  RESPIRATION. 


[N.  Y.  Med.  Jouk., 


the  experiments  with  the  trunk.  T  hold  the  same  position 
in  my  hypothesis.  I  accepted  the  premises  as  given  by 
Hering  and  Brener,  that  the  lungs  are  provided  with  two 
kinds  of  nerves,  both  of  which  are  taking  part  in  the  reflex 
mechanism  of  the  respiration  ;  but,  while  Hering  and  Breuer 
assume  that  nerves  of  one  kind  are  stimulated  by  expansion, 
and  those  of  the  other  by  the  collapse  of  the  lungs,  1  am  of 
opinion  that  it  is  far  more  rational  to  assume  that  both 
kinds  of  nerves  are  always  stimulated  simultaneously  by 
the  same  stimulus — the  expansion  of  the  lungs — and  that 
the  sequence  of  expiration  and  inspiration  is  due  to  the 
peculiar  mutual  relations  of  the  antagonistic  nerves  (rela¬ 
tions  which  are  known  to  exist  in  the  antagonistic  system 
of  the  cardiac  nerves  and  which  have  been  found  to  exist 
among  the  antagonistic  respiratory  nerve  fibers  of  the 
vaaus  trunk).  In  other  words,  when  both  kinds  of  nerves 
are  stimulated  simultaneously,  the  inhibitory  effect  prevails 
during  the  stimulation,  but  after  its  cessation  the  long  in¬ 
spiratory  after-effect  comes  into  play. 

It  is  obvious  that  whoever  undertakes  to  criticise  my 
theory  of  self-regulation,  whether  adversely  or  favorably,  is 
bound  to  discuss  my  share  in  it — i.  e .,  the  tenableness  of  the 
application  of  the  relations  existing  between  the  cardiac 
nerves  to  the  antagonism  of  the  respiratory  nerves.  I  am 
sorry  that  Dr.  Cowl  has  not  even  touched  this  point,  and 
yet  he  says  sharply  that  my  new  theory  of  respiratory  rhythm 
deserves  further  attention,  “chiefly  because  of  a  disregard 
therein  of  a  mass  of  facts  that  show  a  central  origin  for  in¬ 
spiration.”  As  1  have  to  share  this  reproach  with  quite  a 
number  of  phvsiological  writers,  it  will  be  easier  to  bear  it. 
’There  are  some  very  prominent  physiologists  who  consider 
it  a  disregard  of  facts  to  maintain  that  the  inhibition  of  the 
inspiration  is  not  of  a  central  origin,  still  on  this  point  I 
have  the  pleasure  to  be  on  the  same  side  with  my  critic, 
who  declares  himself  to  be  in  favor  of  Gad’s  theory  of  respi¬ 
ration.  But  let  us  see  the  “  mass  of  facts  ”  which,  accord¬ 
ing  to  Dr.  Cowl,  I  (with  many  others)  have  disregarded. 
Two  points  are  enumerated  Against  my  theory  in  Dr.  Cowl’s 

paper _ the  relation  of  the  blood  to  respiration,  and  Gad’s 

experiment  upon  which  his  theory  of  respiration  is  based. 
•Concerning  the  first  point,  Dr.  Cowl  cites  a  number  of 
authors  who  have  experimentally  demonstrated  the  high 
sensitiveness  of  the  respiratory  center  to  changes  of  the 
constituents  of  the  blood.  While  I  admit  the  perfect  cor¬ 
rectness  of  these  facts,  I  do  not  see  how  they  could  affect 
ray  theory.  Does  Dr.  Cowl  know  of  any  experiment  which 
shows  that  the  blood,  and  that  alone,  is  the  exciting  cause 
of  respiration  ?  On  the  contrary,  there  are  authors  who, 
while  not  denying  the  influence  of  the  blood  on  respira¬ 
tion,  do  not  consider  the  blood  a  necessary  factor  for  the 
continuance  of  respiration.  A.  W.  Volkmann*  observed 
the  continuance  of  respiration  in  a  kitten  forty  minutes 
after  excluding  the  circulation,  and  M.  Marckwaldf  puts  it 
up  as  a  thesis  (the  17th)  that  the  normal  excitation  of  the 
respiratory  center  is  independent  of  the  incentives  of  the 

*  A.  W.  Volkmann,  Ueber  die  Bewegung  des  Athinens.  Muller’s 
Archiv,  1841. 

f  Max  Marckwald,  Die  Athembewegung  und  deren  Innervation  beim 
Kaninchen.  Zeitschrift  fur  Biologic,  1886,  pp.  1-120. 


blood.  As  to  myself,  I  am  not  a  party  to  either  side  in 
this  question,  at  least  so  far  as  my  hypothesis  is  concerned, 
the  necessary  premise  to  my  theory  being  only  the  gener¬ 
ally  admitted  assumption  that  the  afferent  nerves  coming 
from  the  lungs  normally  affect  the  respiration;  and  I  at¬ 
tempted  to  establish  a  hypothesis  on  the  mode  of  their 
peripheral  stimulations,  leaving  it  an  open  question  whether 
there  were  indeed  any  other  causes  for  the  respiration  be¬ 
sides  the  reflex  acts.  But,  aside  from  my  hypothesis,  I  may 
say  this :  In  all  the  discussions  on  the  subject  in  question 
I  miss  the  distinction  between  the  significance  of  the  blood 
as  a  cause  and  only  as  a  favorable  condition  of  respiration 
— a  distinction  which  is  sharply  made  in  the  relation  of  the 
blood  to  the  heart-beat.  There  was  a  time  when  some 
physiologists — Haller,  for  instance — entertained  the  opin¬ 
ion  that  the  venous  blood  was  the  cause  of  the  rhythmic 
motion  of  the  heart,  and  although  in  our  days  the  import- 
tance  of  the  blood  and  its  constituents  for  the  heart-beat 
has  been  studied  and  demonstrated  (by  C.  Ludwig,  H.  Kro- 
necker,  and  their  pupils),  at  all  events  more  convincingly 
than  in  the  experiments  on  the  respiration,  still  at  present 
the  opinion  is  generally  accepted  that  the  blood  is  signifi¬ 
cant  in  the  contraction  of  the  heart  only  as  an  important 
condition  and  not  as  a  cause.  1  do  not  mean  to  say  that 
this  view  should  be  adopted  also  in  the  doctrine  of  the 
respiratory  mechanism,  in  which  I  admit  the  possibility 
that  the  blood,  and  more  especially  its  carbonic-acid  gas, 
may  be  one  of  the  causes  of  the  respiratory  movements, 
but  I  wish  to  point  out  that  such  an  assumption  should 
not  be  made  without  good  proof,  the  more  so  because 
the  blood  is  of  importance  to  the  integrity  and  func¬ 
tion  of  every  organ  in  the  body.  This  fact  seems  to 
demonstrate  the  value  of  the  blood  as  a  general  nutritive 
rather  than  as  a  common  stimulus  for  manifold  different 
functions. 

i  Concerning  the  experiments  of  Gad,  Dr.  Cowl  says  that 
they  involve  facts  which  are  acknowledged  to  show  the 
pulmonic  incitation  of  inspiration.  Gad  observed  that  after 
dividing  the  vagi  without  stimulating  them  (Gad’s  freezing 
method)  the  inspirations  become  more  predominant.  This 
certainly  shows  that  an  inhibitory  tonus  is  removed  by  cut¬ 
ting  the  vagi.  Gad  goes  still  further.  He  concludes  that 
the  vagi  contain  only  inhibitory  nerves,  and  that  inspira¬ 
tion  is  of  central  origin  exclusively.  But  this  part  of  Gad’s 
conclusions  consists  of  mere  admissible  assumptions,  not 
necessarily  inferences  following  from  his  experiments.  I 
could  even  use  the  experiment  cited  as  a  proof  of  my  theory 
thus:  On  stimulating  the  inspiratory  and  inhibitory  nerves 
simultaneously,  the  inhibitory  effect  prevails ;  consequently 
if  there  is  any  tonus  from  the  nerves  of  the  lungs  it  must 
be  of  an  inhibitory  nature ;  therefore  we  see  a  certain  in¬ 
hibitory  influence  disappearing  after  dividing  the  vagi. 
My  explanation  of  the  said  experiment  finds  a  perfect  an¬ 
alogy  in  the  cardiac  nerves  of  the  frog.  According  to  some 
authors,*  the  frequency  of  the  heart-beat  is  increased  after 
division  of  the  vagi.  Should  we  with  Gad  conclude  that 

*  Funke,  Bidder,  Rosenthal,  and  others.  See  Hermann’s  Handbuch 
d.  Physiol .,  Bd.  iv,  1.  Theil,  p.  378. 


Nov.  22,  1890. J 


MELTZER:  THE  SELF-REGULATION  OF  RESPIRATION. 


563 


the  vagi  contain  only  inhibitory  nerves?  We  know  now* 
that  the  vagi  of  the  frog  contain  also  augmenting  nerve 
fibers.  Every  one  explains  the  said  increase  by  the  well- 
established  fact  that  the  inhibitory  tonus  is  the  predomi¬ 
nating  one,  just  as  1  would  explain  the  increase  of  the  in¬ 
spiration  after  dividing  the  vagi.  But  even  leaving  aside 
my  explanation,  why  must  it  follow  that  the  inspiration  is 
of  a  central  origin  ?  We  could  assume,  for  instance,  that 
the  inspirations  and  expirations  were  generated  in  the  re¬ 
spiratory  center  only  by  reflex  acts  from  the  lungs  and  from 
all  other  parts  of  the  body;  but  while  in  the  reflexes  from 
the  lungs  the  impulses  for  expiration  are  at  least  not  over¬ 
shadowed  by  the  inspiratory  impulses,  the  latter  are  pre¬ 
dominating  in  the  reflexes  from  the  other  parts  of  the  body, 
or  at  least  in  some  of  them  ;  therefore  the  predominance  of 
the  inspiration  after  cutting  the  vagi.  I  do  not  mean  to 
defend  this  theory  as  my  own;  I  merely  wish  to  demon¬ 
strate  that  Gad’s  experiments  admit  of  many  other  explana¬ 
tions  than  the  one  given  by  him;  and  Dr.  Cowl  certainly 
goes  too  far  in  considering  the  experiment  in  question  as  a 
fact  against  the  assumption  that  the  lungs  are  provided 
with  inspiratory  nerves.  On  the  other  hand,  if  we  have  no 
sure  proof  that  inspiratory  fibers  are  absent  in  the  lungs, 
we  may  assume,  with  some  degree  of  probability,  that  such 
nerves  exist  there  in  view  of  the  positive  fact  that  inspira¬ 
tory  nerve  fibers  are  contained  in  the  trunk  of  the  vagus. 
For  what  other  purpose  could  these  inspiratory  nerves  be 
contained  in  the  trunk?  As  to  the  expiratory  nerves,  we 
might  believe  that  they  were  for  the  act  of  vomiting ;  but 
of  what  use  could  the  inspiratory  nerves  be  if  not  to  supply 
the  lungs  ? 

The  main  objection  to  an  exclusive  reflex  theory  of  res¬ 
piration  is  that  it  ignores  the  fact  that  respiration  contin¬ 
ues  after  the  division  of  the  vagi.  This  objection  has  not 
yet  been  seriously  discussed  even  by  adherents  of  this  the¬ 
ory.  Though  my  own  position  is  not  affected  by  this  ob¬ 
jection,  since  my  hypothesis  does  not  necessarily  exclude 
other  factors  for  the  regulation  of  respiration,  I  should  like 
to  introduce  here  briefly  some  points  bearing  upon  the  dis¬ 
cussion  of  the  above-mentioned  objection.  As  I  pointed 
out  before,  there  are,  besides  the  reflex  from  the  lungs, 
many  others  from  nearly  all  parts  of  the  body,  which  exert 
an  inspiratory  as  well  as  an  expiratory  influence  on  the 
respiratory  center.  No  one  denies  that  fact.  Consequent¬ 
ly,  a  vast  source  of  respiratory  impulses  remains  even  after 
excluding  the  reflexes  from  the  lungs.  But  while  this  lat¬ 
ter  reflex  furnishes,  in  the  expansion  and  collapse  of  the 
lungs,  an  explanatory  factor  for  the  alternation  of  inspira¬ 
tion  and  expiration,  we  lack  a  similar  factor  in  the  other 
respiratory  reflexes  from  which  we  may  expect  that  the 
impulses  for  inspiration  and  expiration  are  generated  simul¬ 
taneously.  The  question,  therefore,  is  not  as  to  where  the 
impulses  for  respiration  arise  after  the  division  of  the  vagi* 
but  as  to  what  is  the  source  of  the  alternation  of  the  respira¬ 
tory  movements  ?  To  this  we  could  perhaps  answer  that  the 
remainder  of  the  reflexes  might  also  possess  certain  quali¬ 

*  R.  Heidenhain,  Untersuchung  liber  den  Einfluss  des  Nv.  Vagus 
auf  die  Herzthatigkeit.  Pfliiger’s  Archiv  f.  d.  ges.  Physiologie ,  1882. 


tative  differences  between  the  inspiratory  and  expiratory 
afferent  nerves,  which  could  be  construed  in  some  way  or 
other  as  explanatory  factors  for  the  continuance  of  the 
alternate  breathing  after  dividing  the  vagi.  For  instance, 
smaller  degrees  of  stimulation  excite  the  inspiratory  and 
stronger  degrees  the  expiratory  nerves  (Langendorff  *)  ;  or 
the  inspiratory  nerves  become  exhausted  earlier  than  the 
expiratory  nerves  (Burkartf);  and  there  are  many  other 
ways  which  still  remain  to  be  studied. 

But  I  do  not  intend  to  follow  out  these  vague  specula¬ 
tions  any  further.  I  rather  wish  to  bring  forward  another 
reflection  which,  it  seems  to  me,  deserves  serious  con¬ 
sideration.  I  mean  the  introduction  into  our  discussion 
of  the  factors  of  repetition  and  inheritance.  Suppose  the 
respiratory  center  were  not  automatic  and  received  im¬ 
pulses  to  its  working  by  reflex  channels  from  the  whole 
body,  especially  from  the  lungs.  The  impulses  coming 
from  all  parts  of  the  body  are  uninterruptedly  simulta¬ 
neous  for  inspiration  and  expiration  ;  but  the  reflexes  from 
the  lungs,  by  virtue  of  the  steady  sequence  of  the  expan¬ 
sion  and  collapse  of  this  organ,  are  not  simultaneous,  but 
alternately  inspiratory  and  expiratory.  May  we  not  expect 
that  such  a  center,  after  being  life-long  influenced  by  stead¬ 
ily  acting  reflexes  to  a  prompt  alternate  working,  will  ac¬ 
quire,  first,  a  high  degree  of  sensitiveness  so  as  to  respond 
promptly  and  specifically  to  the  smallest  stimuli  from  what¬ 
ever  quarter  they  may  come;  second,  a  tendency  to  re¬ 
spond  alternately  with  inspirations  and  expirations,  even  on 
simultaneously  received  impulses?  (This  would  be  the  case 
still  more  if  there  were  any  qualitative  differences  between 
the  two  kinds  of  afferent  nerves  tending  to  their  alternate 
working.)  We  may  expect,  furthermore,  that  such  acquired 
qualities  of  the  respiratory  center  would  be  transmitted  to 
the  descendants,  and  that  in  the  course  of  many  genera¬ 
tions,  by  the  prompt  repetition  during  the  whole  life  of 
each  generation  and  by  transmission  from  generation  to 
generation,  all  the  newly  acquired  fineness  and  promptness 
of  the  qualities  mentioned  ought  to  constitute  an  insepara¬ 
ble  part  of  the  respiratory  center.  In  this  sense  we  may 
speak  of  an  automatism  of  the  center.  But  we  should  un¬ 
derstand  clearly  that  the  center  itself  does  not  generate 
impulses;  the  impulses  are  always  transmitted  by  some  re¬ 
flex  from  a  peripheral  point ;  the  center  supplies  merely  the 
high  sensitiveness  and  the  readiness  to  respond  alternately 
to  simultaneous  excitation  by  inspiration  and  expiration. 
Now,  we  may  try  to  answer  the  above-mentioned  objection 
to  the  pure  reflex  theory  of  respiration  in  the  following 
way  :  The  impulses  for  inspiration  and  expiration  are  nor¬ 
mally  transmitted  to  the  respiratory  center  by  reflexes  from 
all  parts  of  the  body  ;  the  alternation  of  inspiration  and 
expiration  is  normally  induced  and  maintained  by  the  se¬ 
quence  of  expansion  and  collapse  of  the  lungs.  But,  by 
virtue  of  repetition  and  inheritance,  the  respiratory  center 
possesses  an  automatic  readiness  to  respond  with  alterna¬ 
tion  to  simultaneous  reflexes  for  inspiration  and  expiration 


*  S.  Rosenthal,  Hermann’s  Handb.  d.  Physiol.,  Bd.  iv,  2.  Theil,  p. 
252. 

•}■  Burkart,  Pfluger’s  Archiv  f.  d.  ges.  Physiol.,  Bd.  xvi,  p.  427. 


564 


KAY:  CHILDBED  FEVER . 


[N.  Y.  Med.  Jock., 


which  enables  the  center  to  continue  a  rhythmic  breathing, 
even  after  exclusion  of  the  main  factor  for  the  rhythmic 
respiration — the  lungs. 

In  conclusion,  I  wish  to  add  that  I  am  glad  to  be  in  full 
-accord  with  Dr.  Cowl  in  the  high  appreciation  of  the  in¬ 
valuable  services  rendered  to  the  physiology  of  respiration 
by  Professor  Gad,  whose  investigations  served  me  partly 
as  a  basis  for  my  hypothesis ;  but  this  latter  should  be 
judged  on  its  own  merit  or  demerit,  and  not  by  the  fact 
that  it  differs  from  the  opinion  of  acknowledged  authori¬ 
ties. 

179  East  109th  Street. 


CHILDBED  FEVER* 

By  THOMAS  W.  KAY,  M.  D., 

SCRANTON,  PA. 

Though  childbed  fever  is  a  disease  nearly  as  old  as  the 
human  race,  nothing  was  known  of  its  aetiology  till  1846. 
At  that  time  the  mortality  of  childbirth  had  increased  to 
fifteen  per  cent,  in  the  large  lying-in  hospitals  of  Vienna, 
a  fact  so  appalling  that  Semmelweiss,  an  assistant  physician, 
was  induced  to  study  into  its  cause  and  to  seek  a  means  for 
its  prevention. 

Coming  into  authority  in  1847,  he  had  all  physicians 
and  students  who  attended  his  wards  wash  their  hands  with 
chlorine  water  before  they  were  allowed  to  make  a  vaginal 
examination,  and  by  this  simple  means  he  reduced  the  mor¬ 
tality  in  his  special  wards  in  one  year  from  12’24  per  cent, 
to  1  *2 7  per  cent.  The  results  obtained  at  the  present  day 
are  far  better  even  than  these. 

In  the  summer  of  1888  I  visited  the  lying-in  hospital  at 
Dresden,  and  was  informed  that  of  the  last  fifteen  hundred 
women  confined  not  one  had  died  of  childbed  fever,  unless 
the  disease  had  been  contracted  before  her  removal  to  the 
hospital,  and,  moreover,  there  had  not  been  a  single  case  of 
ophthalmia  neonatorum  among  the  infants. 

In  recent  years  the  stimulus  that  has  been  given  to  bac¬ 
teriological  research  has  given  us  an  insight  not  only  into 
the  proper  treatment  for  childbed  fever,  but  also  into  the 
agents  producing  the  disease.  Without  entering  into  a 
lengthy  discussion  of  the  subject,  it  is  sufficient  to  state  that 
the  Streptococcus  pyogenes  is  the  cause  of  all  forms  of  puer¬ 
peral  fever. 

Vidal  found  that,  though  there  were  various  kinds  of  mi¬ 
crobes  in  the  uterine  cavity  after  parturition,  it  was  only 
the  streptococcus  that  penetrated  its  walls,  and  this  oc¬ 
curred  only  where  a  lesion  of  its  surface  existed.  He  also 
found  the  streptococcus  in  the  pysemic  abscesses  of  the  dis¬ 
ease,  in  the  endothelium  of  the  veins  in  phlegmasia  alba 
dolens,  and  in  the  peritoneal  cavity  in  those  cases  of  child¬ 
bed  fever  where  peritonitis  existed.  Frankel  did  not  find 
the  streptococcus  in  those  cases  of  puerperal  peritonitis 
where  a  fatal  termination  had  not  been  reached  early  in  the 
disease,  and  he  maintains  that  this  was  due  to  the  migration 
of  other  microbes  from  the  intestines  into  the  peritoneal 


*  Read  before  the  Lackawanna  County  Medical  Society,  October  14, 
1890. 


cavity.  These  strange  microbes  either  destroy  the  strepto¬ 
coccus  or  so  moilify  it  that  it  is  very  difficult  to  cultivate 
and  study  it  outside  of  the  body.  The  streptococcus  has 
been  found  by  Zweifel  in  mammary  abscesses,  and  it  is  now 
generally  admitted  that  it  is  also  the  cause  of  erysipelas. 

If,  then,  the  agent  is  the  same  in  every  case,  it  seems 
strange  that  it  is  capable  of  producing  such  dissimilar  re¬ 
sults.  Let  us  remember,  however,  that  these  germs  may 
possess  a  different  degree  of  virulence;  they  may  enter  the 
system  in  small  or  large  numbers,  or  their  point  of  entrance 
mav  affect  the  result  by  offering  a  nidus  more  or  less  suita¬ 
ble  for  their  growth  and  multiplication. 

They  may  also  be  affected  by  the  presence  of  other  mi¬ 
crobes,  as  Professor  Bouchard  has  shown  that  two  non- 
pathogenic  germs  may  become  pathogenic  when  they  enter 
the  system  simultaneously.  The  Bacillus  prodigiosus  and 
the  microphyte  of  charbon  symptomatique ,  each  harmless  in 
itself  to  the  rabbit,  will  produce  a  fatal  result  if  ^introduced 
into  the  system  at  the  same  time. 

Sapraemia,  a  species  of  childbed  fever,  may  be  produced 
by  the  absorption  of  the  products  excreted  by  the  microbes 
without  the  entrance  of  the  microbes  into  the  system.  Mr. 
Ilankin,  an  Englishman  who  has  been  studying  the  poisons 
of  some  of  these  microbes,  finds  that  the  anthrax  bacillus 
owes  its  ability  to  live  in  the  body  to  the  excretion  of  a 
slowly  formed  albumose  which  destroys  the  germ-resisting 
power  of  the  body.  Strong  solutions  of  this  albumose  are 
poisonous,  but  by  using  attenuated  solutions  the  body  be¬ 
comes  accustomed  to  it  and  the  bacillus  dies.  Recently 
many  careful  investigations  have  been  made  into  the  germi¬ 
cidal  properties  of  the  blood.  Chief  among  these  are  those 
of  Buchner,  Nissen,  Foder,  Metschnikoff,  and  Lubarsch,  of 
Europe,  and  Nutall  and  Prudden  of  America. 

The  results  arrived  at  are,  that  fresh  blood  serum  at  the 
normal  temperature  is  deadly  to  the  microbes  of  cholera, 
anthrax,  and  typhoid  fever,  but  is  less  fatal  to  the  strepto¬ 
coccus.  Ascitic  and  hydrocele  fluids  possess  the  same  power, 
but  this  power  decreases  as  the  temperature  is  raised,  and 
it  is  finally  lost  when  it  reaches  121°  F. 

Formerly  great  pains  were  taken  in  drawing  the  line  be¬ 
tween  autogenetic  and  heterogenetic  puerperal  fever,  but 
since  the  disease  has  been  more  carefully  studied  we  see 
that  it  is  impossible  for  it  to  occur  unless  the  germs  are 
present,  and  Ilegar  justly  rejects  the  theory  of  self-infec¬ 
tion  entirely.  He  shows  that  in  Baden  the  mortality  from 
child-bearing  has  remained  about  the  same  for  the  last  forty 
years.  Though  the  mortality  among  those  attended  by  phy¬ 
sicians  has  greatly  decreased,  it  has  increased  in  those  at¬ 
tended  by  mid  wives.  This  fact  he  ascribes  to  their  practice 
of  injecting  carelessly  a  three-per-cent,  solution  of  carbolic 
acid,  and  thus  introducing  germs  into  the  genital  tract. 

All  germs,  then,  are  from  without,  but  they  need  not 
necessarily  be  carried  by  the  physician.  They  may  be  al¬ 
ready  in  contact  with  the  genitals  and  only  waiting  for  a 
suitable  occasion  to  enter  the  system,  or  they  may  find  a 
suitable  nidus  in  the  decomposing  lochia,  and  thus  find  a 
way  into  the  genital  tract. 

Professor  Kehrer  has  made  an  excellent  classification  of 
all  cases  of  childbed  fever.  He  recognizes  three  groups: 


Nov.  22,  1890.] 


KAY:  CHILDBED  LEVEE. 


5H5 


0)  pyemic,  (2)  septic,  and  (3)  putrid  endometritic.  This 
last  corresponds  to  the  saprtemic  of  some  authors.  During 
the  last  year  it  has  been  my  fortune  to  meet  with  six  cases 
of  childbed  fever.  Four  of  the  patients  had  been  attended 
by  midwives;  and  of  these  four,  three  died,  the  only  one 
that  recovered  being  one  with  saprsemia.  The  two  others 
were  attended  by  physicians — one  by  myself,  a  patient  with 
sapraemia,  who  recovered  ;  the  other  had  septicaemia  and 
died  in  the  hands  of  a  brother  practitioner.  The  brief  notes 
of  the  three  following  cases  are  presented  to  show  imperfect 
typos  of  the  three  groups  as  laid  down  by  Kehrer: 

Case  I.  Pyemic  Variety.  —  Mrs.  D.  J.,  a  delicate  Welsh 
woman,  twenty-six  years  of  age,  was  delivered,  by  a  midwife, 
of  her  third  child  on  April  30,  1890.  On  May  7th  I  was  called 
in  to  treat  her  for  “  chills  and  fever,”  from  which  she  had  suf¬ 
fered  since  May  3d.  These  chills  had  been  very  severe,  occur¬ 
ring  once  or  twice  every  day,  and  beeD  followed  by  profuse 
sweats.  The  morning  pulse  was  136  and  the  temperature  was 
103°  F.,  while  the  whole  abdomen  was  sensitive  and  tympanitic. 
Vaginal  examination  revealed  an  enlarged  and  tender  uterus, 
to  the  front  and  right  of  which  was  situated  a  firm,  immovable 
mass.  Her  bowels  were  somewhat  loose  and  there  was  slight 
jaundice  of  the  skin  and  sclerotics.  The  treatment  adopted  was 
with  turpentine  stupes  and  hot  poultices  to  the  abdomen,  fre¬ 
quent  and  copious  vaginal  irrigations  of  hot  antiseptic  solutions, 
and  internal  remedies.  Quinine  and  antipyrine  were  given  to 
reduce  the  temperature,  while  brandy  and  caffeine  were  ad¬ 
ministered  to  stimulate  the  action  of  the  heart.  With  these,  all 
of  the  nourishing  food  was  given  that  the  patient  could  be  in¬ 
duced  to  take. 

With  an  occasional  chill,  her  condition  gradually  improved, 
so  that  on  May  17th  her  temperature  had  fallen  to  99-5°  F. 
I  prescribed  tonics  and  did  not  see  her  again  for  several  days. 
On  the  19th  she  had  another  severe  chill,  with  an  elevation  of 
temperature  to  104°  F.,  which  was  reduced  to  normal  with  qui¬ 
nine,  antipyrine,  and  caffeine. 

She  felt  so  well  on  the  20th  that  I  was  requested  to  cease 
my  visits,  but  I  was  called  again  on  the  25th,  and  found  a  case 
of  phlegmasia  alba  dolens  dextra.  The  nourishment  and  stimu¬ 
lants  were  continued,  and  soothing  liniments  were  applied  to 
the  limb  while  it  was  enveloped  in  cotton  and  elevated  on  pil¬ 
lows.  The  temperature,  which  had  risen  to  103°  F.  with  the 
phlegmasia,  gradually  fell  as  the  swelling  subsided,  so  that  by 
June  2d  the  patient  seemed  almost  convalescent. 

About  this  time,  however,  lung  symptoms  began  to  develop, 
and  on  June  4th  well-marked  pneumonia  existed  in  the  lower 
lobe  of  the  right  lung.  A  day  later,  dullness  could  be  distin¬ 
guished  in  the  posterior  portion  of  the  left  lung,  and  from  this 
time  on  the  disease  progressed  rapidly  to  a  fatal  termination. 
She  died,  June  8th,  at  11.30  p.  m.  No  post-mortem  was  held. 

Though  no  abscesses  could  be  discovered,  the  symptoms 
clearly  pointed  to  the  pyaemic  variety.  Uterine  irrigation 
was  not  suggested,  because  systemic  infection  was  well 
marked,  the  uterus  was  extremely  tender,  and  inflammatory 
deposits  existed  in  its  neighborhood. 

Case  II.  Septicemic  Variety. — Mrs.  J.  H.,  a  fleshy  Welsh 
woman,  thirty-one  years  of  age,  who  had  had  six  children,  had 
been  in  labor  for  twelve  hours,  attended  by  a  midwife,  when  I 
was  sent  for  on  July  23, 1889,  and  delivered  her  without  instru¬ 
ments,  in  two  hours,  of  a  healthy  girl. 

Contrary  to  directions,  the  clothing  and  bed-linen  were  not 
changed  till  the  following  day — some  eighteen  hours  after  de¬ 


livery.  By  that  time  the  heat  had  set  up  decomposition  and  the 
smell  had  become  quite  offensive.  The  woman  was  a  midwife 
herself,  and  she  informed  me  that  she  always  followed  that 
plan.  On  the  morning  of  the  25th  she  was  chilly  and  had  a 
temperature  of  101°  F.,  a  pulse  of  120,  and  a  slightly  tympanitic 
abdomen.  The  lochia  had  become  very  scanty  and  were  some¬ 
what  offensive. 

Intra-uterine  irrigation  was  attempted,  but,  as  the  parts  were 
sore,  she  positively  refused  to  submit.  She  was  informed  as  to 
the  possible  termination  of  the  case,  but  expressed  no  apprehen¬ 
sion,  as  she  had  always  had  “  chills  and  fever  ”  after  her  labors. 
After  opening  the  bowels  freely  with  a  saline  cathartic,  quinine 
and  antipyrine  were  given  and  warm  applications  were  made  to 
the  abdomen.  Under  this  treatment  the  temperature  fell  for  a 
day  to  nearly  normal,  but  rose  again  on  the  27th  to  104°  F.  By 
this  time  the  pulse  had  become  so  depressed  that  alcoholic  stimu¬ 
lants  and  caffeine  had  to  be  resorted  to,  and  all  the  nourishing 
food  given  that  the  woman  could  assimilate.  From  this  time 
to  August  1st  the  temperature  varied  from  102°  to  104°,  and  the 
pulse  from  120  to  140.  On  July  28th  a  miliary  eruption  began 
to  make  its  appearance,  and  by  August  1st  it  had  covered  the 
whole  body,  producing  an  acute  dermatitis  and  lessening  the 
cutaneous  excretion.  At  5  p.  m.  on  August  1st  her  temperature 
was  only  103°  and  she  was  cheerful  and  comfortable,  with  the 
exception  of  some  hiccough.  At  4  o’clock  in  the  morning  of 
the  2d  I  was  sent  for  and  told  that  the  woman  had  fainted.  On 
my  arrival  I  found  her  in  a  comatose  condition,  with  a  scarcely 
perceptible  pulse  of  160  and  an  axillary  temperature  of  109°  F. 
In  fifteen  minutes  she  was  dead — nine  days  after  delivery. 

In  this  case,  if  intra-uterine  irrigation  could  have  been 
used  at  first,  there  is  every  reason  to  believe  that  the  life 
could  have  been  saved.  The  coma  was  probably  due  to  the 
sudden  rise  of  temperature,  which  in  turn  was,  most  prob¬ 
ably,  caused  by  the  stoppage  of  the  cutaneous  exudation. 

Case  III.  Putrid  Endometritic  Variety. — Mrs.  O.  P.,  a  fleshy 
multipara,  twenty-seven  years  of  age,  had  been  delivered  of  tour 
children,  and  in  each  of  the  last  three  confinements  the  labor 
had  been  difficult  and  her  recovery  had  been  slow,  on  account 
of  fever,  which  in  her  last  confinement  had  kept  her  in  bed  for 
eleven  weeks.  I  was  called  to  her  in  her  fifth  confinement,  on 
August  15,  1890,  at  9  p.  m.,  and  at  10.30  she  was  delivered  of  a 
healthy  boy  weighing  from  ten  to  twelve  pounds. 

A  half  hour  later  the  afterbirth  was  expelled  by  Credo’s 
method  and  a  bandage  applied. 

As  she  usually  suffered  from  after-pains,  a  mixture  of  opium 
and  ergot  was  left  which  was  to  be  taken  as  required.  The  tem¬ 
perature  rose  only  0'5°  F.  and  there  were  no  complications  of 
any  kind  except  a  fissured  nipple  of  the  left  breast,  which  healed 
rapidly  under  powdered  boric  acid.  As  the  woman  was  weak  I 
did  not  give  her  permission  to  rise  till  August  24th,  which  she 
did  not  avail  herself  of  because  of  headache.  The  next  morn¬ 
ing  at  10  o’clock,  before  she  had  got  up,  she  was  taken  with 
a  slight  chill  and  I  was  sent  for.  On  my  arrival  the  pulse  was 
140  and  the  temperature  was  104°.  She  was  bathed  in  perspi¬ 
ration,  and  prostration  was  so  great  that  she  could  not  speak 
above  a  whisper  and  was  unable  to  turn  in  bed.  The  abdomen 
was  slightly  distended  and  there  was  some  tenderness  in  the 
right  iliac  region.  The  lochia  were  scanty,  almost  colorless,  and 
somewhat  offensive  in  smell.  A  vaginal  examination  revealed  a 
tender  uterus  with  the  os  pretty  well  closed.  The  uterine  cav¬ 
ity  was  immediately  washed  out  with  a  copious  injection  of  hot 
carbolized  water,  which  brought  away  several  small  clots  of 
blood  and  some  shreds  of  very  offensive  mucus.  The  injection 
was  used  twice  daily,  while  hot  applications  were  made  to  the 


566 


KAY:  CHILDBED  FEVER. 


[N.  Y.  Mbd.  Jour., 


abdomen,  and  quinine,  antipyrine,  caffeine,  and  French  brandy 
were  given  internally.  The  next  morning  the  temperature  was 
subnormal,  but  she  was  so  weak  that  the  brandy  and  caffeine 
were  continued,  with  all  the  nourishing  food  that  could  betaken. 
A  saline  cathartic  was  also  given,  which  produced  two  copious 
discharges.  On  this  day  a  miliary  eruption  made  its  appear¬ 
ance  over  all  the  body  and  did  not  disappear  for  a  week,  when 
slight  desquamation  took  place.  The  intra-uterine  douches  were 
used  till  September  2d,  when,  there  being  no  odor  from  the  parts 
and  no  elevation  of  temperature,  they  were  discontinued.  The 
stimulants  were  continued  a  few  days  longer,  when  tonics  were 
substituted,  and  the  patient  was  discharged. 

This  case  was  clearly  one  of  putrid  endometritis,  where 
the  poisonous  products  had  been  absorbed.  Scrupulous 
care  was  used  during  her  delivery  to  prevent  infection, 
and  she  had  the  most  careful  nursing  by  her  mother,  who 
kept  everything  clean,  but,  in  spite  of  this,  the  trouble  came 
on.  That  such  cases  are  sometimes  unavoidable  will  be 
seen  from  the  reports  of  Karl  Braun’s  clinic,  at  Vienna, 
where  every  precaution  is  used  to  prevent  infection.  From 
March,  1887,  to  September,  1889,  there  were  7,600  deliv¬ 
eries  in  his  clinic,  and  among  these  there  occurred  101  cases 
of  putrid  endometritis.  It  is  worthy  of  note  that  two  thirds 
of  these  happened  in  cases  where  the  placenta  and  mem¬ 
branes  came  away  intact. 

Concerning  the  treatment  of  childbed  fever,  too  much 
stress  can  not  be  laid  on  prophylaxis.  The  physician  should 
thoroughly  cleanse  his  hands  and  finger-nails  with  soap  and 
hot  water  and  a  nail-brush  ;  then  he  should  disinfect  them 
in  a  solution  of  carbolic  acid,  bichloride  of  mercury,  or 
creolin,  and  finally  wash  them  in  alcohol. 

All  towels  and  cloths  used  during  labor  should  be  clean, 
and  before  each  examination  the  hands  should  be  washed 
in  a  disinfectant  solution.  If  it  is  necessary  to  use  instru¬ 
ments,  they  should  be  immersed  for  a  short  time  in  boiling 
water,  and  then  disinfected  before  use. 

The  woman  should  have  a  thorough  bath  during  the 
twenty-four  hours  preceding  labor,  and  when  labor  begins 
the  vagina  should  be  thoroughly  irrigated  with  a  hot  dis¬ 
infectant  solution,  because  many  germs  may  be  found  in  an 
apparently  healthy  vagina.  This  irrigation  should  be  re¬ 
peated  after  the  child  and  the  after-birth  have  been  ex¬ 
pelled,  and  if  during  delivery  it  has  been  found  necessary 
to  invade  the  uterine  cavity  with  hands  or  instruments,  this 
should  also  be  irrigated.  Irrigation  not  only  washes  away 
blood-clots  and  destroys  germs,  but  also  arrests  haemor¬ 
rhage  and  favors  uterine  contraction.  For  this  any  male 
catheter  will  do,  but  the  double  catheters  are  better,  among 
which  may  be  mentioned  that  of  Dr.  A.  Cordes,  of  Switzer¬ 
land. 

After  irrigation,  the  genitals  should  be  thoroughly 
cleansed  and  all  soiled  linen  removed,  and  then  a  broad 
cloth,  folded  several  times  and  moistened  with  a  disinfect- 
tant  solution,  should  be  laid  over  the  genitals  so  as  to  re¬ 
ceive  and  disinfect  the  discharge  and  prevent  the  entrance 
of  germs.  These  cloths  should  be  changed  several  times 
every  day,  and  all  clothing  removed  as  soon  as  soiled. 

If  alter  delivery  we  have  any  reason  to  think — from  head¬ 
ache,  general  malaise,  chilliness,  or  rise  of  temperature — 
that  things  are  going  wrong,  the  uterine  cavity  should  at 


once  be  irrigated  with  copious  hot  disinfectant  solutions. 
The  cause  is  at  first  local  and  situated  in  the  uterine  cavity, 
and,  if  we  expect  to  meet  with  success,  prompt  action  must 
be  taken  to  prevent  general  infection.  After  this  has  taken 
place,  irrigation  may  assist  in  removing  or  destroying  the 
germs  that  remain  in  the  cavity  of  the  uterus,  but  it  can 
have  no  effect  on  those  that  have  found  their  way  into  the 
system. 

In  most  cases  intra-uterine  irrigation  will  be  found  to 
be  sufficient  if  resorted  to  in  time,  but  where  the  microbes 
have  found  their  way  into  the  substance  of  the  mucous 
membrane  it  is  well  to  curette  the  endometrium  and  use 
antiseptics.  Of  the  101  patients  treated  thus  by  Braun,  96 
recovered.  Three  of  those  that  died  had  general  infection 
before  they  were  operated  on.  One  of  the  others  died  from 
peritonitis  due  to  previously  existing  salpingitis,  and  the 
other  died  from  exhaustion  subsequent  to  haemorrhage  from 
injury  to  some  of  the  uterine  vessels.  The  operation  is 
frequently  followed  by  a  slight  chill  and  an  elevation  in 
temperature  of  1°,  but  this  drops  in  a  few  hours,  and  is 
rarely  followed  by  complications. 

In  a  late  number  of  the  Deutsche  Medizinal-Zeitung  a 
case  is  reported  where  Dr.  Stahl  curetted  for  puerperal  sep¬ 
tic  endometritis  in  a  primipara  of  thirty-five  years,  in  whom 
the  membranes  had  been  retained,  but,  as  the  system  became 
infected,  as  was  shown  by  pelvic  venous  thrombus,  he  per¬ 
formed  supravaginal  hysterectomy  and  treated  the  stump 
by  the  extraperitoneal  method. 

I  mention  this  case  more  as  a  curiosity  in  the  line  of 
treatment  than  as  an  example  to  follow.  If  the  bacteria 
have  found  their  way  into  the  peritoneal  cavity  they  will 
multiply  rapidly  and  set  up  puerperal  peritonitis. 

Bouilly  was  the  first  to  suggest  laparotomy  for  this,  and 
in  1887  he  instituted  the  practice  that  has  been  followed 
with  indifferent  success  by  others.  A  successful  case  is  re¬ 
ported  by  M.  Raymond  in  La  Semaine  medicate  for  August 
20th.  The  woman  was  taken  with  a  chill  on  the  third  day 
after  confinement,  and  her  temperature  varied  from  39*8° 
to  40'8°  C.  The  abdomen  was  distended  and  tender  and 
diarrhoea  was  present.  Prostration  was  rapid  and  an  ecchy- 
motic  spot  appeared  at  the  level  of  the  great  trochanter,  in¬ 
dicating  general  septicaemia  and  a  metastatic  abscess.  Lapa¬ 
rotomy  was  performed  on  August  2d  and  four  quarts  of 
purulent  fluid  were  evacuated  with  a  large  mass  of  jelly-like 
false  membrane.  The  cavity  was  irrigated  with  sublimate 
solution  (1  to  10,000),  and  drainage  was  used.  On  August 
13th  the  woman’s  condition  was  normal,  though  she  was 
still  weak. 

When  Max  Runge,  some  years  ago,  insisted  on  alcohol, 
food,  and  sponging,  he  established  a  course  of  treatment 
that  is  being  followed  by  the  best  practitioners  of  to-day. 
In  1876  Breisky  and  Conrad  laid  down  rules  for  the  use  of 
alcohol  in  childbed  fever,  and  since  then  A.  Martin  has 
adopted  that  plan  of  treatment  in  many  cases  with  success. 
Breisky  used  alcohol  for  its  apyretic  effects,  but  Martin  values 
it  chiefly  for  its  stimulating  action  on  the  heart  and  its  power 
of  increasing  the  patient’s  resistance  against  infection.  Out 
of  eighteen  patients  treated  thus,  only  five  died,  of  which 
three  were  from  infection.  The  amount  of  alcohol  that  can 


Nov.  22,  1890.J 


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567 


be  borne  under  such  circumstances  without  the  patient’s 
becoming  intoxicated  is  enormous.  One  patient  in  six 
weeks  took  seventeen  bottles  of  brandy,  thirteen  bottles  of 
Burgundy,  thirty-seven  half-bottles  of  champagne,  four  bot¬ 
tles  and  a  half  of  other  wines,  and  six  bottles  of  porter. 
With  the  internal  treatment  he  uses  all  local  means  that 
are  necessary. 

In  a  recent  number  of  the  Journal  of  the  American 
Medical  Association ,  Dr.  N.  S.  Davis  advises  caution  in  the 
use  of  the  anilides  in  puerperal  fever,  because  they  depress 
the  heart  and  probably  lessen  the  resistance  of  the  blood 
cells.  This  warning  is  timely,  for  there  seems  to  be  a  wide¬ 
spread  practice  of  giving  antipyrine  in  childbed  fever. 

The  blood,  as  we  have  seen,  has  a  germicidal  action  of 
itself,  but  this  action  decreases  with  its  elevation  of  tem¬ 
perature  and  is  finally  lost.  It  is  perfectly  rational,  then,  to 
try  and  keep  the  temperature  down,  and  for  this,  sponging, 
quinine,  and  antipyrine  can  be  used.  To  get  the  best  re¬ 
sults  it  is  well  to  combine  all  three.  Antipyrine  should  not 
be  given  in  doses  larger  than  ten  grains,  which  can  be  re¬ 
peated  as  required,  and  it  should  always  be  combined  with 
caffeine  to  prevent  its  depressing  effects.  Caffeine  is  also 
useful  in  counteracting  the  adynamia  accompanying  the  dis¬ 
ease,  and  Gottschalk  has  obtained  excellent  results  from 
the  simple  administration  of  strong  coffee  in  large  doses. 

Huchard  uses  caffeine  in  all  cases  of  adynamia,  injecting 
hypodermically  from  two  to  three  grammes  a  day.  He  uses 
two  solutions,  the  prescriptions  being  as  follows: 

Mild  Solution. 

B  Sod.  benzoat .  grm.  3  ; 

Caffeinae .  grm.  2  ; 

Aq.  dest .  grm.  6.  M. 

Strong  Solution. 

B  Sod.  salicylat .  grm.  3T0; 

Caffeinae .  grm.  6  ; 

Aq.  dest .  grm.  6.  M. 

Of  these  he  uses  from  four  to  eight  Pravaz  syringefuls  a 
day.  Where  much  tenderness  and  distention  of  the  abdo¬ 
men  exist,  hot  or  cold  applications  may  be  used  according 
to  the  comfort  of  the  patient,  and  occasional  saline  cathar¬ 
tics  may  be  used  to  drain  the  peritoneal  cavity  and  prevent 
intestinal  adhesions.  If  much  nausea  or  vomiting  is  pres¬ 
ent,  small  doses  of  cocaine  will  be  found  to  arrest  it.  Opi¬ 
ates  should  be  given  only  when  the  amount  of  pain  de¬ 
mands  them,  and  arterial  sedatives  should  be  avoided,  as 
they  do  more  harm  than  good.  In  all  cases  a  liberal  sup¬ 
ply  of  the  most  nourishing  food  should  be  insisted  on,  and 
the  most  careful  nursing  obtained  that  is  possible. 

Recent  Literature. 

Bouchard.  The  History  of  Microbian  Products  which  favor 
Infection.  Jour,  of  the  Am.  Med.  Assoc.,  August  30,  1890. 

Braun.  Traitement  de  l’endom^trite  puerp6rale.  par  le 
curage  antisept.ique.  Arch.  f.  Gyn .,  xxxviii,  3,  1890 ;  La  Se- 
maine  medicate ,  30  juil.,  1890. 

Buchner.  Bakterienfeindliche  Wirkung  des  Blutes.  Ctrlbl. 
f.  Chirurg.,  23.  August,  1890. 

Buchner.  Ueber  den  Einfluss  hoherer  Konzentration  des 
Nahrmediums  auf  Bakterien.  Ctrlbl.  f.  Bakteriol.  u.  Parasit ., 

11.  Juli,  1890. 


Buchner.  Ueber  die  Uhrsache  der  Sporenbildung  beim 
Milzbrandbacillus.  Ctrlbl.  f.  Bakteriol.  u.  Parasit .,  28.  Juni, 
1890. 

Cordes.  A  New  Double  Catheter  for  Uterine  Irrigation. 
Jour,  of  the  Am.  Med.  Assoc.,  January  11,  1890. 

Davis.  The  Anilides  in  Puerperal  Fever.  Idem,  Septem¬ 
ber  6,  1890. 

Deipser.  Hot  Irrigations  subsequent  to  Parturition.  Jour, 
de  med.,  9  fev.,  1890  ;  N.  Y.  Med.  Jour.,  August  16,  1890. 

Frankel.  The  Aetiology  of  Peritonitis.  Ctrlbl.  f.  Gyn. ; 
N.  Y.  Med.  Jour.,  January  25,  1890. 

Frankel.  Zur  Lehre  von  der  Identitat  des  Streptococcus 
pyogenes  u.  Streptococcus  erysipelatos.  Ctrlbl.  f.  Balcteriol.  u. 
Parasit.,  10.  December,  1889. 

Gardner.  Saprsemia  and  Septicaemia  during  the  Puerperal 
Period.  Maryland  Med.  Jour.,  October  12,  1889. 

Hankin.  Disease  Germs  restrained  by  the  Inoculation  of 
their  own  Poisons.  Brit.  Med.  Jour. ;  N.  Y.  Med.  Jour.,  Janu¬ 
ary  25,  1890. 

Hegar.  Puerperalinfection.  Volkmann’s  Samml.  klin.  Vor- 
trag.,  1889. 

Hirst.  Three  Laparotomies  in  the  Puerperal  State.  Annals 
of  Gyncecol.  and  Pcediatry,  July,  18’90. 

Huchard.  Action  tonique  et  excitante  de  la  cafeine.  La 
Semaine  medicate ,  25  juin,  1890. 

Klein.  Sur  la  morphologie  des  staphylocoques.  Ann.  de 
microg.,  November,  1889. 

Liemann.  Bakteriologische  Untersuchungen  uber  putride 
Intoxication.  Arch.f.  exper.  Path.  u.  Pharmalcol.,  xxvii,  3. 

Lutz.  Die  Antisepsis  in  der  Hebammenpraxis.  Friedrich’s 
Blatt.f.  gerichtl.  Med.,  March-April. 

Martin.  Alcohol  in  Puerperal  Fever.  Internal,  klin.  Rund¬ 
schau  ;  Jour,  of  the  Am.  Med.  Assoc.,  March  22,  1890. 

Nissen.  Ueber  bakterienfeindliche  Eigenschaften  ver- 
schiedener  Blutserumarten.  Zeitsch.f.  Hyg .,  viii,  3. 

Nutall.  The  Germicidal  Action  of  the  Body  Fluids.  Jour, 
of  the  Am.  Med.  Assoc.,  April  12,  1890. 

Potter.  Antiseptic  Midwifery.  Jour,  of  the  Am.  Med.  Assoc., 
May  31,  1890. 

Prudden.  Germicidal  Action  of  the  Body  Fluids.  Medical 
Record,  January  25,  1890. 

Raymond.  Traitement  chirurgicale  de  la  peritonite  puer- 
perale.  La  Semaine  medicate,  20  aoht,  1890. 

Ruffer.  A  Report  on  the  Destruction  of  Micro-organisms 
during  the  Process  of  Inflammation.  Brit.  Med.  Jour.,  May  24, 
1890. 

Stahl.  Removal  of  the  Puerperal  Septic  Uterus.  Deutsche 
Medizinal-Zeitung  ;  N.  Y.  Med.  Jour.,  August  30,  1890. 

Vidal.  Puerperalinfection.  Prog,  gyn.,  25.  Juil.,  1889. 

Waibel.  Ueber  geburtshilfliche  Antiseptik  in  der  arztlichen 
Privatpraxis.  Munch,  med.  Wochensch.,  4.  Marz,  1890. 

Zweifel.  Lehrbuch  der  Geburtsbulfe.  Stuttgart^  1887. 


THE  IMPORTANCE  OF 

PROMPT  TREATMENT  IN  ALVEOLAR  ABSCESS, 

WITH  CASES. 

By  J.  D.  MaoPHERSON,  M.  D., 

ASSISTANT  SURGEON  TO  THE  PRESBYTERIAN  HOSPITAL  DISPENSARY. 

Although  usually  considered  as  a  somewhat  trivial 
affair,  an  alveolar  abscess,  if  improperly  treated,  may  prove 
serious  enough.  So  many  of  these  cases  have  come  to  my 
notice  lately,  in  both  dispensary  and  private  practice,  that 
I  have  become  impressed  with  their  gravity  and  need  of 


MacPHERSON:  PROMPT  TREATMENT  IN  ALVEOLAR  ABSCESS.  [N.  Y.  Med.  Joes., 


568 

prompt  attention.  These  abscesses  are  of  two  forms,  viz., 
superficial  and  deep. 

The  superficial,  commonly  called  gum  boils,  are  marked 
bv  a  small  puffy  swelling  of  the  mucous  membrane  at  the 
side  of  a  tooth,  and  occur  on  either  the  buccal  or  the  labial 
surface  of  the  alveolus.  They  may  be  due  to  diseased  teeth 
or  to  “  catching  cold,”  or  may  be  idiopathic,  and  are  more 
apt  to  occur  when  the  root  of  the  tooth  causing  the  trouble 
does  not  pass  below  the  fold  of  mucous  membrane  uniting 
the  gum  and  cheek.  They  are  usually  small  in  size,  but 
often  very  tender  and  painful  to  the  touch.  They  are  of 
short  duration  and,  their  walls  being  thin,  either  rupture 
spontaneously  or  by  pressure  of  the  finger,  when  recovery 
rapidly  takes  place. 

The  deep  abscesses  are  much  more  serious ;  these  more 
directly  result  from  diseased  or  dead  teeth  (at  times  from  an 
impacted  wisdom  tooth),  the  exciting  cause  being  usually 
exposure  to  wet  or  cold.  In  the  case  of  diseased  teeth,  the 
irritating  products  of  decomposition  pass  through  the  tooth 
•canal  and  set  up  an  acute  inflammation  of  the  circumdental 
membrane.  This  membrane  being  very  vascular,  inflamma¬ 
tion  proceeds  rapidly  from  the  apex  to  the  neck  of  the  tooth. 
The  swelling  of  the  membrane  pushes  the  tooth  up  slightly 
from  its  cavity,  loosening  it  somewhat.  The  inflamma¬ 
tion  extends  to  surrounding  tissues,  which  become  more 
or  less  swollen  and  painful.  The  inflammatory  process 
may  stop  here  and  recovery  take  place  without  the  forma¬ 
tion  of  pus,  but  frequently  (especially  if  the  tooth  is 
not  drawn)  the  process  continues  and  suppuration  rapidly 
follows. 

The  pus  being  confined  on  all  sides  by  bony  walls,  it 
follows  the  natural  law  and  seeks  an  outlet  where  there  is 
the  least  resistance  by  the  absorption  of  the  thin  alveolar 
process.  In  this  form  tbe  pus  is  below  the  fold  of  the  mu¬ 
cous  membrane  connecting  the  gum  and  cheek,  so  they  do 
not  open  (spontaneously)  into  the  mouth  as  a  rule,  but  the 
pus  burrows  in  all  directions,  forming  an  abscess  of  greater 
or  less  extent,  depending  on  the  severity  of  the  inflamma¬ 
tory  process  and  the  resistance  of  the  surrounding  tissues. 
The  abscess  may  burst  in  several  directions,  sometimes  at 
;a  considerable  distance  from  the  starting  point. 

In  rare  cases,  when  a  tooth  of  the  upper  jaw  is  affected, 
the  abscess  mav  rupture  into  the  nasal  cavity ,  in  the  neigh¬ 
borhood  of  the  hard  palate,  and,  in  case  of  the  bicuspids, 
into  the  antrum  of  Highmore.  In  one  case  of  the  latter, 
which  I  assisted  in  operating  on,  a  sinus  had  opened  on  the 
face  and  had  been  discharging  for  eight  years.  It  healed 
up  promptly  after  the  tooth  had  been  drawn  and  necrosed 
bone  removed.  Abscesses  connected  with  the  lower  teeth 
may  point  under  the  chin,  in  the  neck,  and  even  as  low  as 
the  arm-pit.  .  Such  cases  are  always  serious  and  may  be 
fatal. 

At  Bramann’s  clinic  in  Berlin  I  have  several  times  seen 
him  point  out  a  diseased  lower  molar  as  the  cause  of  an 
abscess  pointing  in  the  neighborhood  of  the  clavicle. 

Not  infrequently  the  pus  burrows  through  the  interven¬ 
ing  tissues  and  bursts  on  the  face,  leaving  a  tortuous  sinus 
filled  with  unhealthy  granulations,  at  the  bottom  of  which 
necrosed  bone  can  usually  be  felt.  These  fistula?  are  gener¬ 


al!  v  very  slow  to  heal,  often  taking  months  and  even  years, 
and  frequently  leave  unsightly  scars.  The  symptoms  vary 
with  the  severity  of  the  case.  In  the  milder  forms  there 
may  be  only  local  tenderness,  increased  by  mastication,  and 
slight  swelling.  In  the  more  severe,  the  affected  tooth  is 
loosened  and  tender,  and  the  paift  is  increased  by  bringing 
the  teeth  sharply  together  or  tapping  on  them  with  some 
hard  object. 

The  formation  of  pus  may  be  accompanied  by  a  chill, 
followed  by  a  rise  of  temperature  (101°  to  103°  F.),  rapid 
pulse,  and  sometimes  considerable  depression.  The  pain 
varies  in  severity  ;  in  some  cases  it  is  very  sharp  and  lanci¬ 
nating,  but  usually  it  is  only  a  dull,  steady  ache. 

In  mild  cases  the  swelling  is  but  slight,  while  in  the 
more  severe  it  may  involve  the  subcutaneous  tissues  of  the 
cheek,  lips,  eyelids,  and  neck  of  the  affected  side,  making 
the  patient  a  most  unsightly  object.  The  tongue  and  mu¬ 
cous  membranes  of  the  mouth  may  also  be  involved,  when 
mastication  will  be  impossible  and  deglutition  difficult  and 
painful. 

In  the  early  stages,  before  the  formation  of  pus,  an  at¬ 
tack  may  sometimes  be  aborted  by  a  brisk  cathartic,  qui¬ 
nine,  gr.  x,  and  the  local  application  of  an  evaporating  lo¬ 
tion.  When  it  is  too  late  for  this,  tbe  diseased  tooth  should 
be  drawn  at  once,  after  which,  unless  the  process  has  gone 
too  far,  the  inflammation  subsides,  and  the  patient  is  well  in 
two  or  three  days. 

About  a  year  ago,  while  making  a  tour  through  the 
Black  Forest  in  southern  Germany  on  foot,  after  exposure 
to  the  wet  one  of  our  party  was  taken  with  pain  in  the  right 
side  of  his  jaw,  evidently  due  to  a  diseased  lower  molar. 
His  face  soon  began  to  swell  and  became  very  painful.  Our 
stock  of  drugs  (a  bottle  of  brandy  and  some  peppermint) 
failed  to  give  any  relief.  We  were  miles  from  the  nearest 
town,  so  the  poor  fellow  had  a  pretty  hard  time  of  it  until 
we  arrived  in  Freiburg.  Here  we  hunted  up  a  dentist,  who, 
for  a  mark  and  a  half  (thirty-seven  cents),  injected  co¬ 
caine,  drew  the  offending  grinder,  and  gave  him  some  po¬ 
tassium  permanganate  to  gargle  with.  The  next  day  all 
pain  and  swelling  had  disappeared  and  he  was  practically 
well.  I  could  cite  some  twenty  such  cases  in  which  early 
extraction  was  performed,  when  the  trouble  at  once  sub¬ 
sided. 

All  dentists  are  not  so  accommodating  as  the  one  just 
mentioned,  and  many  of  them  will  refuse  to  draw  the  tooth 
while  inflammation  is  going  on,  the  reason  for  which  1  have 
never  been  able  to  find  out. 

Patients  frequently  come  to  the  dispensary  with  all  the 
symptoms  of  dental  abscess,  and,  when  they  are  ordered 
to  go  to  a  dentist  and  have  the  tooth  drawn,  the  reply  is: 
“  I  did  go  to  one  yesterday,  but  he  said  he  wouldn’t  pull  it 
till  the  swellin’  went  down.” 

•  Many  of  these  patients  recover,  it  is  true,  but  those  that 
do  not,  and  have  subsequent  necrosis  of  the  jaw  and  a  trou¬ 
blesome  sinus,  make  conservative  measures  appear  decid¬ 
edly  risky,  to  say  the  least.  Generally  this  is  the  patient’s 
own  fault,  and,  unless  the  pain  is  very  severe,  he  would 
rather  bear  it  than  have  the  tooth  extracted. 

The  following  case  will  illustrate  : 


Nov.  22,  1890. J 


MacPHERSON:  PROMPT  TREATMENT  IN  ALVEOLAR  ABSCESS. 


569 


Cask  I.— Mrs.  Iv.,  twenty-eight,  German,  consulted  me  in 
May,  1890,  about  a  painful  swelling  on  the  right  side  of  her  face, 
evidently  due  to  a  carious  lower  molar.  I  advised  her  to  have 
the  tooth  drawn  at  once.  Being  of  a  very  nervous  tempera¬ 
ment  and  dreading  the  pain,  she  put  it  off  tor  a  week,  and  then 
had  it  drawn  under  gas.  About  two  weeks  later  she  came  to 
me  again  ;  the  abscess  had  ruptured  externally,  leaving  an  un¬ 
healthy  fistula,  filled  with  fungous  granulations  and  discharging 
offensive  pus.  The  patient  was  pale  and  anaemic  and  consider¬ 
ably  run  down.  No  necrosed  bone  could  be  felt  at  the  bottom 
of  the  sinus,  so  it  was  cleansed  and  dressed  antiseptically,  and 

I  the  patient  put  on  the  use  of  syr.  ferri  iod.  and  cod-liver  oil. 

Treatment  was  continued  for  about  a  month,  when,  there 
being  no  improvement,  I  concluded  to  operate.  On  July  16th, 
the  patient  etherized,  an  incision  was  made  parallel  to  the 
lower  border  of  the  jaw,  going  down  to  the  bone.  All  broken- 
down  tissue  that  could  be  found  was  removed  with  a  sharp 
scoop.  Wound  thoroughly  cleansed  and  dressed  antiseptically. 
Some  improvement  followed,  but  on  August  20th  it  was  found 
necessary  to  operate  again.  This  time  a  considerable  amount 

Iof  necrosed  bone  was  removed  with  a  chisel,  and  all  diseased 
tissue  carefully  cut  away.  The  wound  was  dressed  antisepti- 
cally.  Since  that  time  the  patient  has  been  taking  tonics  and 
the  wound  carefully  treated  ;  but  repair  has  gone  on  very  slow- 

Ily,  and  it  was  not  until  October  22d  that  the  discharge  had 
ceased  and  the  wound  was  entirely  healed. 

The  debilitated  condition  of  the  patient  in  this  case  be¬ 
fore  the  trouble  began,  probably  had  much  to  do  with  her 
slow  recovery.  Still,  I  have  no  doubt  that,  if  the  tooth  had 
been  drawn  at  first  as  directed,  all  this  trouble  and  suffer¬ 
ing  would  have  been  avoided. 

In  healthy  subjects,  even  after  the  abscess  has  opened 
externally  and  considerable  necrosis  taken  place,  if  treated 
properly,  the  cavity  heals  up  kindly.  The  following  two 
cases,  occurring  in  private  practice,  are  good  examples: 

Case  II. — M.  S.,  a  Bavarian,  always  strong  and  healthy,  came 
to  me  on  June  4th.  About  two  weeks  before,  the  left  side  of  her 

I  face  became  swollen  and  painful;  she  could  not  eat  or  sleep. 
She  began  to  poultice  it.  and  in  three  days  an  abscess  pointed 
and  ruptured  externally.  She  then  went  to  a  dentist,  who 
drew  the  diseased  left  lower  bicuspid  which  caused  the  trouble. 
The  abscess  had  been  discharging  ever  since,  and  she  then  had 
an  ugly  sore  over  the  body  of  the  lower  jaw,  midway  between 
the  ramus  and  the  symphysis.  This  was  filled  with  unhealthy 
granulations,  and  at  the  bottom  of  the  sinus,  found  at  one  point, 
dead  bone  could  be  felt.  On  June  5th  the  patient  was  ether- 

Iized,  the  parts  were  cleansed,  all  unhealthy  granulations  were 
removed  with  a  sharp  scoop,  and  the  sinus  was  scraped.  An 
incision  was  made  parallel  with  the  lower  border  of  the  jaw, 
passing  through  the  sinus  and  going  down  to  the  bone.  A 
grooved  director  was  passed  through  the  alveolar  cavity  into 
the  mouth  and  the  opening  enlarged.  All  necrosed  bone  was 
removed  with  a  small  gouge,  making  a  straight  tract  from  the 
tooth  cavity  to  the  external  wound.  The  wound  was  cleansed 
antiseptically,  a  strip  of  iodoform  gauze  passed  through  into 
the  mouth,  and  the  wound  packed  with  the  same.  The  wound 
granulated  well,  and  on  June  26th  was  entirely  healed,  only, a 
linear  cicatrix  remaining. 

Case  III. — M.  Ii.,  Ireland  ;  never  had  been  sick  before  ;  con¬ 
sulted  me  on  September  15th. 

Two  weeks  before,  a  diseased  right  lower  molar  became 
tender  and  painful  and  soon  after  the  face  began  to  swell.  She 
poulticed  it  for  several  days  without  relief,  then  went  to  a  den¬ 
tist,  who  drew  the  tooth  and  stopped  the  poulticing.  The  face 


was  still  swollen  and  painful  when  I  saw  her.  As  the  abscess 
was  about  to  burst  externally,  it  was  incised  and  dressed  anti¬ 
septically.  Treatment  was  continued  for  a  week,  when,  there 
being  no  improvement  and  necrosed  bone  being  felt  in  the 
wound,  an  operation  was  advised.  On  September  25th  the 
patient  was  etherized  and  the  parts  were  cleansed.  With  a 
sharp  scoop  I  removed  all  fuDgous  granulations  from  the  sinus, 
and  the  opening  was  enlarged  by  an  incision  parallel  with  the 
body  of  the  jaw.  A  director  was  passed  through  a  tortuous 
fistula  into  the  alveolar  cavity  and  the  opening  enlarged.  All 
diseased  bone  was  removed  with  a  small  gouge  and  the  wound 
cleansed  antiseptically.  A  strip  of  iodoform  gauze  was  passed 
through  into  the  mouth  and  the  wound  packed  with  the  same. 
The  patient  was  put  on  soft  diet  and  the  month  washed  fre¬ 
quently  with  weak  carbolic  solution.  The  opening  into  the 
mouth  closed  in  a  few  days,  and  the  wound  did  nicely,  with  but 
slight  discharge  of  pus. 

On  October  19th  it  was  entirely  healed,  leaving  a  small  but 
adherent  cicatrix. 

In  conclusion,  I  would  say  (and  the  facts  seem  to  war¬ 
rant  it)  that  the  proper  treatment  in  these  cases,  when  the 
attack  can  not  be  aborted  in  its  early  stages,  is  the  immediate 
extraction  of  the  affected  tooth.  Even  though  the  tooth  may 
be  a  valuable  one  and  in  a  conspicuous  place,  I  think  it  is 
far  better  to  take  it  out  than  to  run  the  risk  of  an  alveolar 
abscess,  which,  even  if  checked  for  a  time,  may  occur  again 
and  again,  is  liable  to  cause  the  patient  weeks  of  suffering, 
and  may  disfigure  him  for  life.  Modern  dentistry  has  ad¬ 
vanced  so  that  now  an  artificial  tooth  looks  as  well  and  is 
almost  as  serviceable  as  a  natural  one.  Poultices,  as  a  rule, 
do  more  harm  than  good,  as  they  tend  to  make  the  abscess 
open  externally,  and,  I  believe,  help  induce  periostitis, 
especially  before  the  tooth  has  been  drawn.  A  steamed 
fig  or  a  small  roasted  onion  held  in  the  mouth  and  fre¬ 
quently  changed  is  much  better. 

In  two  of  the  cases  cited  in  which  poultices  were  used 
the  abscess  opened  externally  after  the  tooth  had  been  ex¬ 
tracted. 

According  to  most  of  the  text-books,  although  a  sinus 
following  one  of  these  abscesses  may  have  existed  for  years, 
it  will  close  up  directly  after  the  tooth  has  been  drawn. 
Several  of  the  foregoing  cases  will  show  that  this  is  not 
always  so. 

If  drawing  the  tooth  does  not  relieve,  a  free  incision 
should  be  made  over  the  swelling  within  the  mouth  as  soon 
as  fluctuation  is  felt,  when,  even  if  quite  extensive  peri¬ 
ostitis  has  taken  place,  if  the  wound  is  kept  open,  it  will 
usually  heal  up  kindly  from  the  bottom  in  a  healthy  sub¬ 
ject. 

When  an  abscess  opens  externally  and  shows  no  tend¬ 
ency  to  heal  within  a  reasonable  time,  I  believe  it  should 
be  opened  freely,  and  the  alveolar  cavity  cleaned  out  and 
allowed  to  heal  up  from  the  bottom. 


The  Nuclei  of  Biliary  Calculi.  —  “According  to  Dr.  Naunyn,  of 
Strasburg,  biliary  calculi,  though  they  appear  to  have  gathered  round  a 
cholesterin  nucleus,  do  not  arise  primarily  from  masses  of  this  sub¬ 
stance,  but  from  some  soft  matter  shed  by  the  walls  of  the  biliary 
passages,  which  becomes  impregnated  with  cholesterin,  not  so  much 
from  the  bile,  perhaps,  as  from  the  catarrhal  secretion  of  the  mucous 
membrane  of  the  biliary  passages.” — Lancet. 


570 


LEADING  ARTICLES. 


[N.  Y.  Med.  Jour., 


the 


NEW  YORK  MEDICAL  JOURNAL, 


A 

Published  by 
D.  Appleton  &  Co. 


Weekly  Review  of  Medicine. 

Edited  by 

Prank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  NOVEMBER  22,  1890. 

KOCH’S  ALLEGED  CURE  FOR  TUBERCULOSIS. 

In  an  address  before  the  Tenth  International  Medical  Con¬ 
gress,  as  our  readers  are  aware,  Professor  Robert  Koch,  of  Ber¬ 
lin,  intimated  that  be  was  engaged  in  a  course  of  experimental 
research  that  seemed  to  him  likely  to  lead  to  the  successful 
treatment  of  tuberculosis.  Coming  from  such  a  man  as  Koch, 
that  guarded  statement  was  most  encouraging,  for  everybody 
felt  that  he  was  the  last  man  in  the  world  to  take  a  visionary 
view  of  such  a  matter ;  he  had  always  worked  his  problems 
quietly  to  their  indubitable  solution,  and  it  was  taken  for 
granted  that  he  would  do  so  in  this  instance.  Nobody  in  the 
medical  profession  needed  to  be  told  that  such  a  course  would 
require  many  months  of  investigation,  and  there  was  a  firm 
conviction  that  Koch  was  not  the  man  to  jump  to  conclusions. 
Hence  the  repeated  newspaper  statements  that  he  was  soon  to 
proclaim  his  results  and  conclusions  were  received  with  in¬ 
credulity.  But  it  seems  that  he  has  swerved  from  the  line  of 
conformity  to  precedents  established  by  himself,  and  has  pub¬ 
lished  a  statement  of  his  unfinished  work,  in  the  form  of  an 
article  in  the  Deutsche  medicinische  Wochenschrift.  This  has 
been  translated  into  English  and  published  in  the  British  Medi¬ 
cal  Journal  and  in  the  Medical  News;  moreover,  the  gist  of  it 
has  been  telegraphed  to  the  newspapers,  and  they  have  spread 
it  before  the  public,  generally  with  the  accompaniment  of  some 
such  immoderate  statement  as  that  Koch  has  made  a  discov¬ 
ery  of  greater  importance  to  mankind  even  than  that  of  vac¬ 
cination. 

The  communication  deals  almost  entirely  with  the  observed 
effects  of  the  remedy  and  with  the  theory  of  its  action;  noth¬ 
ing  is  said  of  the  manner  of  its  preparation,  and  we  are  kept 
entirely  in  the  dark  concerning  the  experimental  work  that  led 
up  to  its  production.  In  fact,  Koch  expressly  declines  to  say 
more  of  its  nature  than  that  it  is  a  clear,  brownish  liquid 
which  keeps  well  when  undiluted,  but  not  so  well  when  di¬ 
luted  to  the  degree  called  for  in  its  therapeutic  employment, 
although  the  addition  of  a  little  phenol  to  the  diluted  liquid 
overcomes  its  susceptibility  to  change  to  a  certain  extent. 
Practically,  therefore,  it  is  a  secret  remedy,  and,  if  it  had 
originated  in  this  country,  that  fact  would  preclude  its  being 
taken  into  serious  consideration  by  physicians;  but  they  take  a 
different  view  of  such  things  in  Germany,  and  it  must  not  be 
set  down  to  Koch’s  discredit  that  he  has  preferred  to  keep  the 
nature  of  his  remedy  secret  for  the  present,  especially  as  he 
founds  his  decision  on  a  natural  dread  lest  inexperienced  per¬ 
sons  may  attempt  to  make  the  liquid  for  themselves,  with  the 
result  of  producing  an  article  capable  of  doing  much  harm.  In 
further  extenuatiou  of  his  policy  as  to  this  point  is  his  offer  to 


supply  physicians  with  the  liquid  to  as  great  an  extent  as  the 
present  difficulties  attending  its  production  admit  of ;  but  it  is 
already  reported  that  applications  for  it  are  far  in  excess  of 
what  can  be  furnished,  so  that  this  clear,  brownish  liquid  is  the 
veritable  yaka  opviOuv  of  the  day. 

Koch  states  that  the  remedy  has  no  effect  when  taken  by 
the  stomach,  but  must  be  used  subcutaneously.  He  injects  it 
beneath  the  skin  of  the  middle  portion  of  the  back,  even  in 
cases  of  external  tubercular  diseases,  such  as  lupus,  that  might 
readily  be  subjected  to  its  topical  action,  if  it  has  any.  An  in¬ 
jection  of  0*25  of  a  cubic  centimetre  causes  in  a  person  who  is 
not  tuberculous  a  decided  rise  of  temperature,  with  headache,, 
pains  in  the  limbs,  etc.  Like  effects  result  from  much  smaller 
doses  in  those  who  have  lupus,  tubercular  disease  of  the  glands,' 
etc. ;  and  in  persons  with  pulmonary  tuberculosis  so  small  a 
dose  as  0*01  of  a  cubic  centimetre  suffices  for  their  production, 
and  this  is  the  proper  initial  dose,  although  succeeding  doses 
may  safely  be  made  larger  and  larger  with  a  rapidity  that 
Koch  thinks  not  wholly  to  be  accounted  for  on  the  ground  of 
tolerance  in  the  ordinary  sense  of  the  word.  In  cases  of  lupus, 
the  fever  is  followed  by  remarkable  phenomena  in  the  diseased 
part;  it  becomes  red  and  swollen,  in  some  instances  with  vesic-, 
ulation,  and  a  crust  is  formed  which,  when  it  falls  off,  leaves 
a  smooth,  clean  surface — in  some  cases  a  single  injection  suffic-; 
ing  to  bring  about  this  happy  result.  Koch  makes  the  positive 
statements  that  lupus  is  thus  cured  by  his  remedy  alone ;  that 
iD  glandular  and  osseous  tubercular  affections  subsequent  surgi¬ 
cal  intervention  may  be  required  to  remove  the  debris ,  thus 
completing  the  cure;  and  that  cases  of  incipient  pulmonary 
consumption  have  shown  under  the  employment  of  his  remedy 
such  symptoms  of  improvement  as  to  lead  him  to  think  them 
cured,  although  he  is  not  positive  that  relapses  may  not  occur, 
but  thinks  that,  if  they  do,  they  will  be  quite  as  amenable  to 
the  treatment  as  the  original  trouble  was. 

Koch’s  theory  of  the  curative  action  of  the  remedy  is,  not 
that  it  kills  the  bacilli,  but  that  it  sets  up  in  the  diseased  living 
tissue  a  process  that  ends  in  its  necrosis;  and  he  implies  that 
the  bacilli  are  cast  off  with  the  dead  tissue,  and  that  incomplete¬ 
ness  of  this  part  of  the  process  may  lead  to  re-infection,  as  also 
may  failure  of  the  dead  tissue  to  become  wholly  separated  from 
the  organism. 

To  support  all  this,  he  gives  absolutely  no  statistical  evi¬ 
dence  and  not  a  single  clinical  history.  We  have  only  his  state¬ 
ments,  which  in  some  respects  are  rather  vague.  We  may  add 
that  so  astounding  are  these  statements — so  utterly  at  variance 
with  any  known  biological  laws — that  nothing  but  Koch’s 
great  name  and  the  prevalent  confidence  in  his  accuracy,  pro¬ 
duced  by  his  past  successes,  would  lead  one  to  consider  his  arti¬ 
cle  at  all  seriously.  He  states  positively  that  patients  in  the 
first  stage  of  phthisis  were  freed  from  every  symptom  of  dis¬ 
ease,  and  might  be  pronounced  cured  ;  that  patients  with  cavi¬ 
ties  not  yet  too  highly  developed  improved  considerably,  and 
were  almost  cured  ;  but  that  in  very  advanced  cases  there  was 
no  improvement.  He  says  that  by  this  he  is  led  to  suppose 
that  phthisis,  in  the  beginning,  can  be  cured  with  certainty  by 


Nov.  22,  1890.J 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


bis  remedy,  but  he  admits  that,  thus  far,  no  conclusive  experi¬ 
ence  can  be  brought  forward  to  prove  that  the  cure  is  lasting. 

In  regard  to  his  theory  of  the  way  in  which  the  remedy 
acts,  namely,  that  it  destroys  tubercular  tissue  without  affect¬ 
ing  any  other  structure,  whether  healthy  or  diseased,  it  must 
be  said  that  he  professes  to  have  discovered  a  substance  that 
has  this  extraordinary  peculiarity — it  is  destructive  to  the  cells 
concerned  in  the  inflammation  called  tubercular.  Possibly  it 
may  kill  them  directly  because  it  is  poisonous  to  cells  engaged 
in  the  formation  of  tubercle,  or  it  may  kill  them  indirectly  by 
producing  inflammatory  changes  about  them,  or  it  may  destroy 
them  in  some  other  manner.  Whatever  may  be  the  way  in 
which  it  acts,  the  statement  is  positive  that  it  is  an  enemy  of 
tubercular  processes,  not  of  tubercle  bacilli.  Indeed,  the  ba¬ 
cilli  in  the  dead  tissue  may  again  infect  the  organism,  and 
probably  surgical  interference  will  be  needed  to  remove  them. 
No  substance  is  known  that  has  an  effect  at  all  comparable  to 
what  is  alleged  for  this  remedy.  Vaccination,  of  course,  is  by 
no  means  analogous  in  its  action,  since  a  living  organism  is  in¬ 
troduced  which  does  not  destroy  the  small-pox  poison,  but  only 
renders  the  body  proof  against  it,  and,  moreover,  does  not,  so 
far  as  we  know,  seek  out  particular  cells  or  tissues  for  destruc¬ 
tion. 

We  most  earnestly  hope  that  in  this  matter  the  medical  pro¬ 
fession  will  wait  patiently  and  calmly  for  more  facts.  It  is  im¬ 
possible  to  disregard  or  disbelieve  Robert  Koch,  save  after 
careful  and  prolonged  investigation.  So  great  is  his  name — so 
great  his  genius — that  any  observation  of  his  carries  with  it  a 
universally  admitted  probability  of  truth.  In  this  matter,  how¬ 
ever,  we  can  not  see  that  he  has  adduced  proof  sufficient  for 
his  statements;  we  do  not  know  what  he  has  seen.  In  no  dis¬ 
ease  is  the  patient’s  faith  a  more  important  element  in  the 
treatment  than  in  pulmonary  consumption,  so  far,  at  least,  as 
temporary  improvement  is  concerned.  How  often  have  we 
heard  of  a  new  ‘‘cure”  under  the  use  of  which  the  cough,  the 
expectoration,  the  fever,  and  the  night-sweats  were  diminished 
and  there  was  a  gain  of  flesh!  Yet  the  patients  seem  to  have 
died,  after  all.  What  will  be  the  future  of  Koch’s  discovery? 
We  may  hope  much  ;  we  know  nothing.  In  justice  to  Koch,  it 
must  be  said  that  this  seems  to  be  precisely  his  own  view,  at 
least,  so  far  as  phthisis  is  concerned.  In  the  meaji  time,  it  is 
not  necessary  for  physicians  to  go  to  Berlin  at  present  to  learn 
about  this  remedy,  even  if  they  do  not  know  how  to  give  a 
subcutaneous  injection.  This  they  can  learn  at  home,  and  they 
are  not  likely  to  learn  anything  else  about  the  method  abroad. 


APPENDICITIS  OR  ECPHYAD1TIS  ? 

The  renewed  interest  recently  aroused  in  diseases  of  the 
vermiform  appendix  has  brought  to  light  the  dissatisfaction  felt 
by  some  surgeons  and  pathologists  at  the  use  of  the  term  ap¬ 
pendix  as  a  basis  for  the  construction  of  words  indicative  of 
diseases  of  that  organ  or  of  operations  made  necessary  by  them. 
The  reasons  for  this  feeling  are  partly  philological  and  partly 
economical — in  the  interest  of  economy  of  time  and  space.  It 


571 

is  objected  that  appendicitis  is  a  hybrid  word,  a  Latin  root  with 
a  Greek  termination,  a  product  that  all  lovers  of  order  and  uni¬ 
formity  in  language  are  not  inclined  to  employ  ;  further,  that 
it  is  wholly  unsuitable  for  combination  with  the  accepted 
termination  signifying  excision,  ectomy ,  and,  as  removal  of  the 
appendix  is  an  operation  that  has  apparently  “come  to  stay,’’ 
we  need  something  more  convenient  than  that  combination  of 
four  words  to  express  it. 

The  same  objections,  and  others,  apply  to  perityphlitis. 
There  is.no  perityphlon,  consequently  there  is  no  inflammation 
of  it,  no  perityphlitis;  and  perity phi ectomy  would  be  simply 
outrageous.  What  is  the  alternative ?  Liddell  and  Scott  give 
us  entpvaq  and  ano<f>vag  as  signifying  an  appendage,  and  Galen  ap¬ 
plied  eKcfrvag  particularly  to  the  vermiform  appendix.  To  this 
extent  katyvag  may  be  said  to  have  a  title  to  be  employed  as  the 
basis  of  the  terms  necessary  to  be  employed  to  denote  diseases 
of  the  appendix  and  operations  incident  to  them,  and  its  com¬ 
petitor  is  further  handicapped  by  the  use  of  apophysis  to  indi¬ 
cate  a  bony  prominence.  So,  if  we  must  have  inflammation  of 
the  vermiform  appendix,  let  us  respect  it  as  ecphyaditis ,  and 
let  us  find  in  ecphyadectomy  the  means  of  relief  from  the  sup¬ 
purative,  perforative,  and  philological  burdens  it  imposes. 


MINOR  PARAGRAPHS. 

BRANCHIAL  MALFORMATIONS. 

Kostaneoki  and  Mielecki,  in  a  recent  number  of  Virchow’s 
Archiv ,  give  an  exhaustive  review  of  the  literature  and  re¬ 
corded  cases  of  congenital  branchial  fistulse,  pharyngeal  diver¬ 
ticula,  and  branchiogenic  tumors  and  cysts.  The  anatomical  im¬ 
portance  of  the  relation  of  congenital  cervical  fistulas  to  bran- 
chogenic  malformations  has,  according  to  them,  been  clearly 
shown  to  be  the  result  of  arrested  development  of  the  branchial 
clefts.  In  the  development  of  the  embryo  these  clefts  all  close 
with  the  exception  of  the  one  forming  the  external  auditory 
meatus,  the  tympanic  cavity,  and  the  Eustachian  tube.  Should 
any  of  the  clefts  remain  open,  a  cervical  fistula  results,  and  it 
may  be  formed  either  from  without  or  from  within,  and  be 
complete  or  incomplete.  The  branchiogenic  tumors  and  cysts 
found  in  this  connection  are  epithelial  in  origin  and  dependent 
upon  the  branchial  arches.  The  dermoids  of  the  submental 
region  and  of  the  base  of  the  tongue  are  not  considered  homolo¬ 
gous  with  those  of  evolution  or  development,  but  they  stand 
in  relation  to  those  which  occur  in  the  anterior  mediastinum, 
and  are  the  result  of  fusion  of  the  entoderm  with  the  ectoderm. 
The  membranous  and  cartilaginous  excrescences  bear  no  mor¬ 
phological  relation  to  the  cervical  fistulse,  but  are  independent 
products  of  the  visceral  arches,  and  the  ear  and  ear  muscles  are 
heterotopic  reproductions  from  the  same  parts.  The  congenital 
ear  fistulse  stand  in  no  relation  to  the  first  branchial  cleft,  but 
are  disarrangements  of  the  second.  The  cheek  and  lower-lip 
tistuhB  are  considered  to  be  homologous  with  the  cervical, 
which  are  secondary  malformations  in  the  first  branchial  arches. 
Hitherto,  work  on  this  question  has  been  very  much  in  the 
dark  and  problematical,  but  recent  embryological  investiga¬ 
tions  have  given  a  pretty  clear  explanation  of  the  causes  of 
branchiogenic  cervical  fistulse.  The  authors  think  that,  if  phy¬ 
sicians  would  make  an  accurate  anatomical  history  of  congeni¬ 
tal  malformations  coming  under  their  notice,  important  scien¬ 
tific  information  would  be  elicited  to  clear  up  many  doubtful 
points  bearing  on  the  question. 


572 


[N.  Y.  Med.  Jour., 


MINOR  PARAGRAPHS. 


THE  PHYSIOLOGY  OF  THE  LARYNX. 

Dr.  Felix  Semon,  in  a  recent  number  of  tlie  Proceedings  of 
the  Royal  Society ,  gives  the  result  of  considerable  research  and 
experiment  as  to  the  position  of  the  vocal  bands  in  quiet  res¬ 
piration  in  man,  and  as  to  the  reflex  tonus  of  the  abductor  mus¬ 
cles.  While  the  laryngeal  phenomena  attending  the  act  of  res¬ 
piration  in  man  had  attracted  the  attention  of  physiologists  and 
laryngologists,  yet  investigation  on  this  point  had  been  com¬ 
paratively  limited,  and  nothing  like  unanimity  of  views  had 
been  obtained.  The  author,  in  order  to  show  that  the  glottis 
was  wider  open  during  quiet  respiration  than  after  death  or 
after  division  of  the  vagi  or  of  the  recurrent  laryngeal  nerves> 
had  first  drawn  from  corroborating  evidence  of  trustworthy 
observers,  and  then  from  direct  comparative  measurements  of 
the  width  of  the  glottis  during  quiet  respiration  and  after 
death,  and  from  the  results  of  experiments  on  animals.  Though 
the  question  would  demand  further  elucidation,  the  outcome  of 
his  investigation  was:  (1)  That  the  glottis  in  man  was  wider 
open  during  quiet  respiration,  inspiration,  and  expiration  than 
after  death  or  after  division  of  the  vagi  or  of  the  recurrent 
laryngeal  nerves;  (2)  that  this  wider  opening  during  life  was 
the  result  of  a  permanent  activity  (tonus)  of  the  abductors  of 
the  vocal  bands  and  posterior  crico-arytsenoid  muscles,  which, 
therefore,  belonged  not  merely  to  the  class  of  accessory,  but  to 
that  of  regular,  respiratory  muscles;  (3)  that  the  activity  of 
these  muscles  was  due  to  tonic  impulses  which  their  ganglionic 
centers  received  from  the  neighboring  respiratory  center  in  the 
medulla  oblongata,  and  that  the  regular  activity  of  the  ab¬ 
ductors  of  the  vocal  bands  during  life  belonged  to  the  class  of 
reflex  processes;  (4)  that,  in  spite  of  their  additional  innerva¬ 
tion,  the  abductors  of  the  vocal  bands  were  physiologically 
weaker  than  their  antagonists;  (5)  that  these  antagonists,  the 
adductors  of  the  vocal  bands,  had  primarily  nothing  at  all  to 
do  with  respiration,  and  ordinarily  served  the  function  of  pho- 
nation  only,  their  respiratory  functions  being  limited  to  assist¬ 
ance  in  the  protection  of  the  lower  air-passages  against  the  en¬ 
trance  of  foreign  bodies  and  to  assistance  in  the  modified  and 
casual  forms  of  expiration  known  as  coughing  and  laughing. 


BUFFALO  LITHIA  WATER  AS  A  SOLVENT  FOR  VESICAL 

CALCULUS. 

The  solvent  influence  of  the  Buffalo  lithia  water,  from  a 
spring  in  Virginia,  over  uric-acid  gravel  and  calculus  has  been 
the  subject  of  some  recent  communications  to  the  journals.  In 
the  Medical  News  for  November  8th  two  cases  are  reported  by 
Dr.  Samuel  Hannon,  of  Washington,  in  which  the  lithia  water 
afforded  great  relief  by  crumbling  in  pieces  vesical  calculi  of 
considerable  size.  In  one  case,  that  of  a  woman,  thirty-eight 
years  of  age,  the  water  was  used  ad  libitum  for  twelve  weeks; 
in  the  other  case,  that  of  a  man  of  sixty,  it  was  used  ten  weeks, 
reducing  the  vesical  concretions,  apparently  by  dissolving  them, 
and  ameliorating  the  cystitis  which  was  present  in  both  cases 
at  the  time  the  use  of  the  water  was  begun.  In  the  second 
case,  boric-acid  washings  of  the  bladder  were  at  first  used,  and 
a  doubt  is  expressed  by  the  writer  whether  the  crumbling  pro¬ 
cess  may  not  have  been  due,  in  part  at  least,  to  this  agent  as 
well  as  to  the  lithia  water;  at  all  events,  the  diminished  irrita¬ 
tion  along  the  entire  urinary  tract  was  most  marked  and  reacted 
favorably  upon  the  patient’s  general  health,  so  that  the  dyspep¬ 
sia,  insomnia,  and  diarrhoea — his  former  symptoms — began  to 
disappear  before  the  eighth  week.  In  the  first  case,  also,  the 
reaction  upon  the  general  health  was  decided.  Before  the  pa¬ 
tient  began  to  use  the  water  she  had  suffered  from  attacks  of 
renal  colic  for  eighteen  months,  which  were  recurring  with  in¬ 


creased  frequency  ;  she  had  also  had  dyspeptic  symptoms,  hroma- 
turia,  and  one  attack  resembling  uraemic  convulsions.  Afterthree 
or  four  months  the  urine  was  found  normal  and  the  cystitis  had 
vanished.  Dr.  0.  H.  Davis,  of  Meriden,  Conn.,  has  reported  in 
the  J\ew  England  Medical  Monthly  a  case  of  disintegrated  cal¬ 
culus  where  the  analysis  showed  that  it  was  made  up  of  uric 
acid  with  a  trace  of  oxalate  of  calciu  m.  The  Buffalo  lithia 
water  was  used  in  this  case  also.  The  vesical  calculus  in  this 
instance  was  of  two  years’  standing,  and  the  patient  was  op¬ 
posed  to  any  operative  procedure  being  undertaken  for  his  re¬ 
lief.  Within  afew  days  after  the  use  of  the  water  was  begun  he 
commenced  to  get  rid  of  portions  of  his  calculus  when  urinat¬ 
ing.  For  several  days  in  succession  he  passed  as  much  as  a 
teaspoonful  of  detritus,  and  the  passage  of  fragments  was  almost 
constant  until,  at  the  end  of  about  a  year,  be  was  entirely  re¬ 
lieved  of  all  vesical  trouble. 


CARDIAC  AFFECTIONS  OF  CHILDHOOD  TREATED  WITH 

STROPHANTHUS. 

Dr.  Moncorvo,  of  Rio  Janeiro,  has  made  somewhat  exten¬ 
sive  experiments  with  strophanthus  in  the  cardiac  affections  of 
children.  According  to  an  abstract  of  his  paper  in  the  Practi-  i 
tioner ,  this  drug  is  especially  suitable  as  a  cardiac  and  diuretic 
remedy  in  the  diseases  of  childhood,  because  it  is  not  only 
prompt  to  act,  but  completely  harmless,  even  to  children  of  a 
very  tender  age.  Its  action  is  both  even  and  energetic.  Fraser’s 
alcoholic  tincture  has  proved  in  his  hands  the  preferable  form 
of  the  drug,  and  when  given  in  valvular  lesions— both  tricuspid 
and  mitral — with  diminished  urinary  secretion,  promotes  the 
return  of  tonicity  of  the  heart,  regulates  the  rhythm  of  its 
beats,  and  increases  the  amplitude  and  strength  of  the  pulse.  ; 
Its  diuretic  action  is  also  well  marked  in  a  large  proportion  of 
these  cases.  It  is  a  cardiac  tonic  in  children’s  cases  of  pulmo¬ 
nary  and  broncho-pulmonary  affections  that  are  so  frequently 
complicated  with  cardiac  insufficiency.  The  happy  results  of 
the  employment  of  this  remedy  often  last  long  after  its  admin¬ 
istration  has  been  stopped.  Numerous  instances  of  the  pro¬ 
longed  beneficial  influence  of  the  drug  confirm  the  author  in 
his  opinion  that  strophanthus  is  pre-eminently  the  cardiac  tonic 
for  children. 


PAMBUTANO,  A  SUBSTITUTE  FOR  QUININE. 

Dujardin-Beaumetz  has,  according  to  the  Medical  Press  and 
Circular ,  recently  called  attention  to  the  antiperiodic  properties 
of  an  extract  obtained  from  the  root  of  a  shrub  called  pambu- 
tano.  The  aqueous  decoction  of  the  root  has  been  largely  and 
successfully  «sed  in  the  treatment  of  malarial  fevers ;  it  has  been 
beneficial  in  a  number  of  cases  in  which  the  symptoms  did  not 
yield  to  quinine.  The  isolation  of  an  alkaloid  has  not  hitherto 
been  effected,  but  the  plant  contains  various  fatty  bodies  and 
essential  oils  in  addition  to  a  special  kind  of  tannin.  All  the 
active  properties  of  the  root  are  extracted  by  maceration  in 
alcohol  at  60°.  The  writer  in  the  Press  and  Circular  adds  that, 
while  the  high  value  of  quinine  as  a  febrifuge  and  antiperiodic 
is  incontestable,  the  faults  and  failures  of  the  old  favorite  do 
declare  themselves  from  time  to  time,  and  hence  the  discovery 
of  other  vegetable  products  which  have  similar  powers  is  not 
without  importance,  since  some  of  these  may  and  do  succeed 
when  quinine  has  proved  ineffectual. 


THE  OPERATIVE  TREATMENT  OF  MENIERE’S  DISEASE. 

Dr.  Charles  H.  Burnett,  in  a  paper  read  before  the  Ameri¬ 
can  Otological  Society  at  its  last  meeting,  gives  an  account  of  a 


Nov.  22,  1890.] 


MINOR  PA  RA  ORA PUS. — ITEMS. 


case  of  aural  vertigo  which  he  permanently  cured  by  excision 
of  the  membrana  and  the  malleus.  Retraction  of  the  chain  of 
ossicles,  induced  by  chronic  catarrhal  adhesion  of  the  mem¬ 
brana  and  malleus  to  the  inner  wall  of  the  drum  cavity,  was 
supposed  to  be  the  cause  of  the  tinnitus  and  vertigo.  Excision 
of  these  adherent  parts  of  the  conducting  apparatus  was  per¬ 
formed  under  anresthesia,  with  immediate  relief,  and  there  had 
been  tjo  return  of  the  annoying  symptoms,  two  years  and  a 
half  having  elapsed  since  the  operation.  This  seems  to  be  the 
first  case  reported  as  having  been  cured  by  operative  methods. 
The  result  of  treatment  in  this  case  suggests  also  that  the 
origin  of  Meniere’s  disease  is  possibly  often  mechanical  and  not 
neuropathic.  _ 


THE  JOHNS  HOPKINS  UNIVERSITY. 

The  advocates  of  the  admission  of  women  to  the  educational 
privileges  at  this  institution  have  made  favorable  progress.  At 
a  recent  meeting  at  Baltimore  it  was  reported  that  the  ladies 
moving  in  this  matter  proposed  to  continue  their  work  upon  the 
endowment  fund  until  half  a  million  dollars  had  been  pledged 
to  the  Women’s  Medical  School  of  the  university.  Among  the 
active  friends  of  the  movement  are  Miss  Mary  Garrett,  Miss 
Clara  Barton,  Mrs.  Harrison,  the  President’s  wife,  Cardinal 
Gibbons.  Col.  R.  R.  Porter,  Dr.  Richard  H.  Derby,  Dr.  H.  D. 
Noyes,  Dr.  B.  M.  Murray,  Gen.  Felix  Agnus,  and  Col.  Rainey. 
Many  of  them  were  present  at  the  recent  meeting,  above  re¬ 
ferred  to,  going  to  it  from  a  distance  in  order  to  attest  their 
hearty  approval  of  the  project. 


GONORRHCEA  IN  THE  FEMALE. 

The  American  Journal  of  the  Medical  Sciences  reports  the 
work  -of  Prochownick  in  the  electrical  treatment  of  recent 
gonorrhoea  in  the  female,  the  result  of  which  is  published  in  the 
Munchener  medicinische  Wochenschrift.  The  author,  in  testing 
the  antimycotic  action  of  the  positive  pole  of  the  galvanic  cur¬ 
rent,  has  found  that  with  this  pole  introduced  into  the  uterus, 
and  a  current  of  120  milliamperes  used  for  ten  minutes,  in  every 
instance,  after  four  stances  the  specific  micro-organisms  disap¬ 
peared,  and  after  six  or  seven  applications  the  character  of  the 
discharge  was  entirely  changed. 


THE  COOMBE  LYING-IN  HOSPITAL,  DUBLIN. 

It  is  contemplated  to  present  the  master  of  the  hospital 
with  a  testimonial  on  the  occasion  of  his  approaching  retire¬ 
ment  from  that  office,  which  he  has  held  for  the  last  seven 
years,  It  is  probable  that  an  ex-assistant  master  (and  Dr.  Hoey’s 
name  is  mentioned)  will  be  appointed  as  his  successor. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  November  18,  1890: 


DISEASES. 

Week  ending  Nov.  11. 

Week  ending  Nov.  18 

Cases. 

Deaths. 

Cases. 

Deaths. 

Tvphus  fever . 

0 

0 

0 

0 

Typhoid  fever . 

26 

9 

21 

9 

Scarlet  fever . 

74 

9 

69 

7 

Cerebro-spinal  meningitis . 

2 

2 

2 

2 

Measles . 

174 

16 

161 

13 

Diphtheria .  . 

96 

29 

99 

29 

Small-pox . 

I 

0 

0 

0 

Varicella . 

2 

0 

3 

0 

573 

The  Orton  Prize. — Dr.  J.  G.  Orton,  as  president  of  the  New  York 
State  Medical  Association,  has  offered  a  prize  of  $100  for  the  best 
short  popular  essay  on  some  subject  connected  with  practical  sanita¬ 
tion,  under  the  following  conditions:  1.  Competition  to  be  open  to  all. 
2.  Essays  to  be  forwarded  to  the  secretary  of  the  association,  Dr.  E.  D. 
Ferguson,  Troy,  N.  Y.,  not  later  than  August  1,  1891,  accompanied  by 
the  name  of  the  author  under  a  separate  seal.  3.  Examination  and 
award  to  be  made  by  a  committee  appointed  by  the  Council  of  the  asso¬ 
ciation.  4.  The  successful  essay  to  be  read  at  the  next  annual  meeting 
of  the  association,  and,  if  approved  by  the  Council,  to  be  offered  for 
publication  in  the  secular  press,  and  issued  in  tract  form  or  otherwise 
for  general  circulation.  5.  Authors  of  essays,  unsuccessful  as  far  as 
the  prize  is  concerned,  but  found  worthy  of  special  commendation,  to 
receive  intimation  as  to  a  proper  disposition  to  be  made  of  them. 

An  Assault  on  a  Naval  Surgeon  in  Brooklyn. — Dr.  Delevan  Blood- 
good,  medical  director  of  the  laboratory  at  the  Brooklyn  Navy  Yard, 
was,  on  November  8th,  the  victim  of  a  highwayman’s  assault.  He  was 
knocked  senseless  and  robbed  of  all  the  valuables  he  had  upon  his  per¬ 
son  while  returning  at  night  to  his  residence  near  the  Naval  Hospital. 
The  blow  was  probably  given  from  behind  by  means  of  a  sand-bag,  and 
was  only  a  little  short  of  being  murderous  in  its  violence,  but,  fortu¬ 
nately,  no  bones  were  broken  and  no  untoward  symptoms  have  since 
arisen. 

The  Death  of  Dr.  Richard  J.  Levis,  of  Philadelphia,  the  well-known 
surgeon  and  teacher,  occurred  on  the  12th  inst.,  at  Kennett  Square, 
Pa.,  after  a  brief  illness.  He  was  a  native  of  Philadelphia,  born 
sixty-three  years  ago,  the  son  of  a  physician  and  coming  from  a  family 
of  French  origin,  but  having  an  ante-Revolutionary  history.  The  fam¬ 
ily  name  was  De  Levis,  but  the  first  American  representative,  who  came 
over  with  William  Penn  in  1682,  adopted  the  plainer  way  of  writing  it. 
The  heads  of  the  family  have  for  two  hundred  years  or  more  been  prac¬ 
titioners  of  medicine  or  surgery,  with  a  marked  predilection  for  the  lat' 
ter.  Dr.  Richard  J.  Levis  was  an  alumnus  of  the  Jefferson  Medical 
College,  of  the  class  of  1848.  While  pursuing  his  studies  at  that  in¬ 
stitution  he  was  also  an  assiduous  private  student  of  Professor  Mut¬ 
ter’s.  having  in  view  the  perfecting  of  himself  in  surgery  as  a  specialty. 
In  1869  he  was  appointed  surgeon  to  the  Pennsylvania  Hospital.  Dur¬ 
ing  the  war  he  was  surgeon  in  charge  of  two  military  hospitals  which 
were  established  near  Philadelphia  for  the  purpose  of  treating  the  de¬ 
formities  resulting  from  gunshot  wounds,  and  while  in  these  positions 
had  nearly  two  thousand  amputations  under  his  care.  He  became  sur¬ 
geon  to  the  Wills  Hospital  for  diseases  of  the  eye  and  lecturer  in  the 
same  clinical  department  at  the  Jefferson  school.  In  1871  he  was  ap¬ 
pointed  to  the  surgical  staff  of  the  Philadelphia  Hospital,  and  a  few 
years  later,  when  the  Jefferson  College  Hospital  was  built,  he  was  given 
a  like  position  in  it.  He  also  became,  about  the  same  time,  lecturer  on 
clinical  surgery  at  that  college  and  at  the  Philadelphia  Polyclinic  and 
School  for  Graduates.  From  1877  to  1887  he  was  president  of  the 
board  of  trustees  of  the  Jefferson  Medical  College.  He  was  also  at  one 
time  the  president  of  the  State  medical  society,  and  in  1886  of  the 
county  society.  He  retired  from  practice  in  1887  to  his  country  home, 
called  Cedarcroft,  formerly  the  residence  of  the  late  Bayard  Taylor. 
His  fatal  illness  was  pneumonia. 

The  Death  of  Dr.  J.  R.  Q,uinan,  of  Baltimore. — We  regret  to  record 
the  death  of  Dr.  Quinan,  which  occurred  very  suddenly  on  the' 11th  in¬ 
stant.  Dr.  Quinan  was  born  in  Lancaster  County,  Pennsylvania,  but, 
after  completing  his  medical  studies  in  the  Jefferson  Medical  College 
in  1844,  removed  to  Calvert  County,  Maryland,  where  he  remained,  en¬ 
gaged  actively  in  medical  practice,  until  1867.  He  then  went  to  Balti¬ 
more,  and  resided  there  until  his  death.  Dr.  Quinan  was  well  known 
throughout  Maryland  as  a  man  of  fine  literary  taste  and  ability,  of  con¬ 
siderable  learning,  and  of  enormous  industry ;  and  by  the  public  at 
large  he  was  particularly  well  known  for  his  researches  in  historical 
subjects  and  especially  in  the  medical  history  of  his  adopted  State.  To 
the  smaller  circle  of  his  friends  he  was  known  as  a  man  of  singularly 
unselfish  and  generous  character ;  thoroughly  upright  and  honorable, 
alike  in  his  ideas  and  in  his  actions,  loyal  to  his  convictions,  a  genial 
companion,  a  true  friend  ;  one  who,  himself  modest  to  a  fault,  was 


574 


ITEMS.— LETTERS  TO  THE  EDITOR. 


[N.  Y.  Med.  Jock., 


quick  to  appreciate  the  good  points  of  another ;  one  who,  scorning 
everything  base  and  mean  as  something  alien  to  him,  was  yet  full  of 
charity  and  as  far  removed  as  possible  from  Pharisaical  self-righteous¬ 
ness.  Such  men,  though  not  filling  the  place  in  the  world’s  estimation 
which  is  occupied  by  their  more  self-assertive  colleagues,  are  still  the 
true  glory  of  the  medical  profession,  and  never  more  so  than  now> 
when  the  self-seeking  struggle  for  prominence  seems  continually  on  the 
increase,  and  when  the  science  of  medicine  itself,  which  is  distinctively 
the  science  of  benevolence  and  self-sacrifice,  seems  in  danger  of  losing 
its  character,  while  its  votaries  are  being  swept  along  in  the  universa 
rush  for  riches  and  preferment. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army ,  from  November  9  to  November  15,  1890 : 

Alexander,  Charles  T.,  Lieutenant-Colonel  and  Surgeon,  and  Middle- 
ton,  Johnson  Y.  D.,  Major  and  Surgeon,  are,  by  direction  of  the  Sec¬ 
retary  of  War,  appointed  members  of  a  board  of  officers,  appointed 
to  meet,  at  the  call  of  the  senior  officer  thereof,  at  the  rooms  of  the 
Board  of  Engineers,  Army  Building,  New  York  city,  to  examine  such 
officers  of  the  Corps  of  Engineers  as  may  be  ordered  before  it, 
with  a  view  to  determining  their  fitness  for  promotion,  as  contem¬ 
plated  by  the  act  of  Congress  approved  October  1,  1890.  Par.  4, 
S.  0.  261,  A.  G.  0.,  Washington,  I).  C.,  November  1,  1890. 

Cowdrey,  Stevens  G.,  Major  and  Surgeon.  The  leave  of  absence 
granted  in  S.  0.  112,  October  24,  1890,  Department  of  Arizona,  is, 
bv  direction  of  the  Secretary  of  War,  extended  fifteen  days.  S.  0. 
263,  Headquarters  of  the  Army,  A.  G.  0.,  Washington,  November 
10,  1890. 

McElderry,  Henry,  Major  and  Surgeon.  The  extension  of  leave  of 
absence  on  account  of  sickness  granted  in  S.  0.  214,  September  12, 
1890,  from  this  office,  is,  by  direction  of  the  Secretary  of  War,  fur¬ 
ther  extended  two  months  on  surgeon’s  certificate  of  disability. 
Par.  28,  S.  O.  263,  A.  G.  0.,  November  10,  1890. 

Norris,  Basil,  Colonel  and  Surgeon,  and  Sternberg,  George  M.,  Major 
and  Surgeon,  are,  by  direction  of  the  Secretary  of  War,  appointed 
members  of  a  board  of  officers,  appointed  to  meet,  at  the  call  of 
the  senior  officer  thereof,  in  San  Francisco,  Cal.,  to  examine  such 
officers  of  the  Corps  of  Engineers  as  may  be  ordered  before  it,  with 
a  view  of  determining  their  fitness  for  promotion,  as  contemplated 
by  the  act  of  Congress  approved  October  1,  1890.  Par.  5,  S.  O. 
261,  A.  G.  0.,  Washington,  D.  C.,  November  7,  1890. 

Walker,  Freeman  V.,  First  Lieutenant  and  Assistant  Surgeon,  Fort 
D.  A.  Russell,  Wyoming.  Leave  of  absence  for  one  month,  to  take 
effect  on  or  about  the  16th  inst.,  is  granted.  Par.  3,  S.  0.  86, 
Department  of  the  Platte,  November  11,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  States  Navy  for  the  week  ending  November  15,  1890 : 

Owens,  Thomas,  Surgeon.  Ordered  to  the  Museum  of  Hygiene  at  Wash¬ 
ington,  D.  C. 

Martin,  H.  M.,  Surgeon.  Detached  from  the  Receiving-ship  Wabash 
and  ordered  before  the  Retiring  Board. 

Rixky,  P.  M.,  Surgeon.  Continued  in  charge  of  Naval  Dispensary  at 
Washington,  D.  C.,  until  November  20,  1891. 

Green,  E.  H.,  Passed  Assistant  Surgeon.  Promoted  to  Surgeon.  No¬ 
vember  10,  1890. 

Smith,  Howard,  Surgeon.  Placed  on  the  Retired. List.  November  10 
1890. 

Marine-Hospital  Service.— Official  List  of  Changes  of  Stations  and 
Duties  of  Medical  Officers  of  the  United  States  Marine- Hospital  Service 
for  the  three  weeks  ending  November  15,  1890 : 

Carter,  H.  R.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  fifteen  days.  November  14,  1890. 

Guiteras,  G.  M.,  Assistant  Surgeon.  Granted  leave  of  absence  for 
thirty  days.  October  29,  1890. 

Hussey,  S.  H.,  Assistant  Surgeon.  To  proceed  to  South  Atlantic 
Quarantine  Station  for  temporary  duty.  October  28,  1890. 


Geddings,  H.  D.,  Assistant  Surgeon.  Granted  leave  of  absence  for 
fourteen  days.  November  14,  1890. 

Groenevelt,  J.  F.,  Assistant  Surgeon.  To  report  to  the  Superintendent 
of  Immigration  for  temporary  duty.  October  28,  1890. 

Society  Meetings  for  the  Coming  Week  : 

Monday,  November  2 4th :  Medical  Society  of  the  County  of  New  York  ; 
Boston  Society  for  Medical  Improvement ;  Lawrence,  Mass.,  Medical 
Club  (private) ;  Cambridge,  Mass.,  Society  for  Medical  Improve¬ 
ment  ;  Baltimore  Medical  Association. 

Tuesday,  November  25th  :  New  York  Academy  of  Medicine  (Section  in 
Laryngology  and  Rhinology) ;  New  York  Dermatological  Society  ; 
(private) ;  Buffalo  Obstetrical  Society  (private) ;  Jenkins  Medical  , 
Society,  Yonkers,  N.  Y. ;  Boston  Society  of  Medical  Sciences  (pri¬ 
vate). 

Wednesday^,  November  26t  h :  New  York  Surgical  Society;  New  York 
Pathological  Society;  American  Microscopical  Society  of  the  City  of 
New  York;  Medical  Society  of  the  County  of  Albany;  Auburn,  ; 
N.  Y.,  City  Medical  Association  ;  Berkshire,  Mass.,  District  Medical 
Society  (Pittsfield) ;  Philadelphia  County  Medical  Society. 

Thursday,  November  27th:  New  York  Academy  of  Medicine  (Section 
in  Obstetrics  and  Gynaecology);  New  York  Orthopaedic  Society!  j 
Brooklyn  Pathological  Society  ;  Roxbury,  Mass.,  Society  for  Medical 
Improvement  (private);  Pathological  Society  of  Philadelphia. 

Friday ,  November  28th :  York ville  Medical  Association  (private) ;  New 
York  Society  of  German  Physicians;  New  York  Clinical  Society 
(private);  Philadelphia  Clinical  Society  ;  Philadelphia  Laryngologi- 
cal  Society. 


letters  to  %  (Stoite. 


HERMAPHRODITISM. 

161  Fairfield  Ave.,  Bridgeport,  Conn.,  ) 
October  29,  1890.  f 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  The  following  case  was  brought  to  nay  notice  by  the 
commandant  of  police  of  San  Salvador,  Salvador,  0.  A.,  while  I 
was  in  charge  of  the  sanitary  service  of  said  Government.  As 
it  is  a  unique  case,  I  should  like  to  have  it  reported,  with  a  view 
of  ascertaining  whether  a  similar  case  has  ever  been  seen  :  J. 
H.,  a  house  servant  of  masculine  features  and  movements,  aged 
twenty-eight,  height  five  feet  seven  inches,  weight  one  hun¬ 
dred  and  thirty-nine  pounds,  was  arrested  by  the  police  for  vio¬ 
lation  of  the  law  governing  prostitution,  which  compels  prosti¬ 
tutes  to  register  with  the  Direction-General  of  Police  and  pass  a 
weekly  examination  by  a  surgeon  detailed  for  that  purpose.  On 
examination,  both  female  and  male  organs  of  generation  were 
found  in  a  remarkably  well-developed  condition.  The  labia 
majora  were  of  normal  size,  but  flattened  on  their  anterior  sur¬ 
face.  The  labia  minora  and  the  hymen  were  absent.  The  va¬ 
gina  was  spacious,  four  inches  and  a  quarter  long  anteriorly  and 
six  inches  posteriorly.  The  os  uteri  was  torn  on  the  left  side. 
There  was  profuse  leucorrhoea.  Seven  years  before,  she  had 
given  birth  to  a  normal  female  infant.  In  place  of  the  clitoris 
;here  was  a  penis  which  when  in  erection  measured  five  inches 
and  a  quarter  long  by  three  inches  and  five  eighths  in  circum¬ 
ference.  The  glans  penis  and  the  urethra  were  perfectly 
ormed.  The  scrotum,  which  was  two  inches  and  an  eighth 
ong,  contained  two  testicles  about  an  inch  in  length  and  two 
inches  and  a  half  in  circumference.  The  mons  Veneris  was 
sparsely  covered  with  short,  straight,  black  hair.  Both  sets  of 


Nov.  22,  1890.] 


SPECIAL  ARTICLES. 


575 


from  the  penis  and  the  ovaries  being  capable  of  producing  eggs. 
Scanty  menstruation  occurred  every  three  weeks,  and  lasted 
but  two  days.  Sexual  gratification  was  said  to  be  equally  dis¬ 
tributed  between  the  two  sets  of  organs. 

Up  to  about  seven  years  before,  masculine  clothes  had  been 
worn,  but  when  pregnancy  became  apparent  the  local  authori¬ 
ties  compelled  a  change  to  female  attire. 

0.  W.  Fitoh,  M.  D. 


Special  Articles. 


THE  OPENING  RECEPTION  IN  THE  ACADEMY  OF  MEDICINE’S 

NEW  BUILDING. 

The  Academy’s  handsome  and  substantial  new  building  in 
West  Forty -third  Street  has  been  used  for  meetings  for  a  num¬ 
ber  of  weeks  past,  but  has  not  until  now  been  in  the  state  of 
■completion  required  for  such  an  occasion  as  a  formal  opening. 
This  took  place  on  Thursday  evening,  the  20th  inst.  The  recep¬ 
tion  committee,  the  names  of  whose  members  we  have  already 
published,  had  made  arrangements  for  the  comfort  of  a  great 
number  of  guests,  and  the  auditorium  was  occupied  by  the  fel¬ 
lows  of  the  Academy,  by  distinguished  physicians  from  other 
cities,  by  a  few  non-medical  men  interested  in  such  progress  as 
the  occasion  exemplified,  and  by  the  ladies  who  accompanied 
them.  The  president,  Dr.  Alfred  L.  Loomis,  occupied  the 
chair.  * 

The  President’s  Address.— Dr.  Loomis  spoke  as  follows : 
Fellows  of  the  New  York  Academy  of  Medicine,  Ladies,  and 
Gentlemen  :  I  count  myself  most  fortunate  that  it  is  my  privi¬ 
lege  to  speak  to  you  words  of  welcome  in  our  new  home.  The 
only  language  which  my  heart  prompts  me  to  utter  to-night  is 
the  language  of  congratulation — congratulations  for  the  past ,  the 
present,  and  the  future  of  our  Academy.  Forty- four  years  ago 
representative  men  in  different  departments  of  medicine,  actu¬ 
ated  by  a  spirit  of  devotion  to  a  high  scientific  purpose,  founded 
this  Academy.  Interwoven  with  its  early  history  are  the  names 
of  John  Stearns  and  John  W.  Francis,  Alexander  H.  Stephens 
and  Alexander  Flosack,  John  W.  Draper  and  Joseph  M.  Smith, 
Valentine  Mott  and  Francis  Delafield,  and  a  long  list  of  others 
whose  names  and  medical  achievements  made  honorable  the 
medical  profession  of  their  day.  With  such  founders  the  mem¬ 
bership  of  the  Academy  soon  included  most  of  the  active  medi¬ 
cal  workers  in  the  city,  and  became  the  strongest  and  one  of 
the  most  influential  medical  organizations  in  the  State.  From 
year  to  year  it  has  grown  in  professional  esteem  and  public  con¬ 
fidence,  and  its  advancing  history  has  been  stamped  byr  the  life 
and  labors  of  such  noble  ones  as  Willard  Parker,  Alfred  0.  Post, 
James  Anderson,  Alonzo  Clark,  Edmond  R.  Peaslee,  Austin 
Flint,  William  H.  Van  Buren,  James  R.  Wood,  Cornelius  R. 
Agnew,  and  a  host  of  less  prominent,  but  noble,  self-sacrificing 
spirits  around  whose  memories  we  delight  to  linger. 

Time  will  not  permit  me,  at  this  hour,  to  even  mention  the 
many  important  papers  that  have  been  read  and  discussed,  and 
the  large  amount  of  original  work  which  has  become  a  part  of 
the  scientific  history  of  this  Academy.  As  one  reviews  the 
scientific  work  of  those  earlier  years,  he  congratulates  himself 
that  he  is  a  fellow  of  such  a  fellowship.  An  organization  which 
has  given  so  much  to  the  profession  as  ours  has  a  past  for  each 
one  of  us  to  be  proud  of,  and  I  may  well  congratulate  you  this 
evening  on  the  past  of  the  New  York  Academy  of  Medicine. 
We  step,  to-night,  into  a  present  full  of  promise. 


In  my  inaugural  address,  less  than  two  years  ago,  I  stated 
that,  in  order  that  our  Academy  might  become  the  center  of 
the  scientific  activities  of  the  entire  profession  of  this  city,  it 
must  have  a  suitable  home,  a  building  that  should  furnish  ac¬ 
commodations  for  a  large  and  well-selected  library,  with  read¬ 
ing-rooms  and  commodious  meeting- rooms  for  all  our  medical 
societies.  Such  a  building  is  ours  to-night,  more  elegant,  more 
commodious,  and  better  suited  to  our  wants  and  work  than  the 
most  sanguine  could  have  hoped  for  two  years  ago.  With  a 
library  capacity  for  200,000  volumes,  and  a  well-selected  library 
of  50,000  volumes,  supplemented  by  the  largest  and  best  collec¬ 
tion  of  journals  to  be  found  in  this  country,  we  may  rightfully 
maintain  that  we  are  in  some  degree  meeting  the  highest  re¬ 
quirements  of  scientific  medicine.  The  influence  which  such  a 
library  will  have,  not  only  on  the  intellectual  status  and  culture 
of 'the  profession,  but  upon  its  moral  tone,  can  not  be  estimated, 
for  there  is  an  atmosphere  about  a  large  and  well-selected  library 
which  does  not  favor  the  growth  of  a  mean,  money-calculating 
spirit;  it  conduces  to  broadness,  tolerance,  and  a  love  of  the 
higher  and  nobler  attributes  of  man. 

Our  membership  has  reached  nearly  seven  hundred,  and 
includes  most  of  the  active  workers  in  our  profession  in  this 
city  and  many  in  the  State.  Every  specialty  in  medicine  is 
represented  by  those  who  have  become  distinguished  in  their 
chosen  lines  of  work.  There  are  now  established  and  well- 
organized  sections  in  all  the  special  departments  of  medicine 
and  surgery,  so  that  each  fellow  may  find  a  place  with  con¬ 
genial  workers  for  making  public  the  results  of  his  own  obser¬ 
vations  and  experiments,  under  the  sifting  criticism  of  experts  ; 
and  thus  learn  what  may  have  been  done  by  others  in  the  way 
of  support  or  in  opposition  to  his  own  work.  Not  only  are 
the  combined  scientific  labors  of  our  general  meetings  and  sec¬ 
tions,  to  a  large  degree,  leading  and  guiding  tbe  medical  thought 
and  research  of  our  own  country,  but  their  influence  is  being 
felt  in  the  medical  councils  of  Europe.  We  are  also  exerting 
an  increasing  influence  on  public  thought  and  action.  We  are 
becoming  a  power  in  this  city  and  State,  which  is  being  more 
and  more  felt  in  the  legislative  and  economic  work  of  our  com¬ 
monwealth.  The  public  health  and  safety  of  our  citizens  are 
being  more  and  more  committed  to  our  hands,  with  the  convic¬ 
tion  that  by  wise  counsels  and  practical  methods  we  shall  pro¬ 
tect  it  from  the  ravages  of  disease  by  an  ever  broadening  and 
more  perfect  sanitary  science.  Our  fellow-citizens,  in  response 
to  our  appeals  made  to  them  during  the  past  two  years,  have 
shown  by  their  sympathy  and  liberal  donations  that  they  are 
recognizing  more  and  more  the  importance  of  our  work  and  its 
influence  upon  the  general  weal.  Let  us  act  wisely,  energetic¬ 
ally,  and  unitedly,  and  we  may  be  assured  that  in  the  near  future 
we  shall  be  able  to  turn  more  largely  the  influence  of  the  ac¬ 
cumulated  wealth  of  this  great  metropolis  into  channels  for  the 
support  and  encouragement  of  scientific  medicine.  Our  pro' 
fession  was  never  so  full  of  promise  as  at  present — never  before 
were  there  so  many  strong  men  in  its  front  ranks  as  now — never 
were  there  so  many  cultured  and  brilliant  minds  entering  it  as 
to-day.  If  this  great  and  daily  increasing  power  can  be  cen¬ 
tralized,  as  is  possible,  within  these  walls,  its  influence  on  the 
social,  domestic,  business,  and  religious  life  of  our  city  can  not 
be  estimated;  already  the  better  minds  in  all  departments 
of  science  are  turning  to  us  for  help  and  inspiration.  There 
is  no  longer  a  strife  of  sects  or  creeds;  but  a  struggle  for  the 
supremacy  of  intellectual  power  and  broad  culture  over  weak¬ 
ness  and  charlatanism.  There  is  no  place  in  the  broad  field  ot 
scientific  medical  inquiry  for  the  would-be  medical  man  who 
talks  of  the  potential  power  of  infinitesimal  abstractions,  and 
the  so-called  scholastic  illusions.  We  are  living  in  and  are  part 
of  an  age  of  facts,  not  fancies;  work,  not  theories.  This  epoch 


57(3 


SPECIAL  ARTICLES. 


[N.  Y.  Med.  Jour., 


in  medicine  is  indeed  more  brilliant  and  eventful  than  any 
which  has  preceded  it,  and  the  prospect  grows  constantly  more 
encouraging  and  richer  in  possibilities.  The  efforts  of  the 
many  enthusiastic  workers  who  to-day  are  struggling  for  truth 
in  medicine  must  produce  a  general  advance,  notwithstanding, 
as  Dr.  John  W.  Draper  once  said:  “There  has  been  through 
ail  the  ages,  constantly  hovering  about  honest  workers  in  our 
science,  a  host  of  impostors  and  quacks,  who  will  continue  to 
thrive  so  long  as  there  are  weak-minded  and  shallow  men  to  be 
deluded,  and  vain  and  silly  women  to  believe.” 

I  congratulate  you,  then,  that  with  the  most  advanced 
workers  in  every  department  of  scientific  medicine  gathered  in 
our  fellowship  we  meet  to-night  about  our  own  hearth-stone  in 
full  possession  of  all  those  facilities  which  were  needed  to 
render  our  work  most  efficient  and  stimulate  us  to  still  higher 
achievement  in  the  future,  so  that  the  work  done  iD  these  halls 
shall  have  a  forming  and  crystallizing  power  on  the  medical 
literature  of  our  whole  country.  The  days  of  doubt  and  anxiety 
are  past,  success  has  ceased  to  be  a  question,  the  auspicious 
present  marks  the  beginning  of  a  new  and  broader  career 
for  our  Academy.  It  is  here  in  the  center  of  this  great 
city  to  do  its  part  in  stimulating  its  intellectual  and  moral 
forces.  With  increasing  opportunities  come  deeper  obliga¬ 
tions.  Our  f  uture  must  not  be  gauged  by  past  successes  or 
present  advances. 

We  are  under  obligations  to  the  past,  but  under  bonds  to  the 
future;  as  we  in  turn  pass  this  trust  to  our  successors,  to  those 
who  in  the  future  are  to  be  the  exponents  of  the  lofty  mission 
to  which  this  building  is  dedicated  this  evening,  it  must  not 
have  suffered  in  our  hands,  but  have  grown  and  broadened 
under  the  impulse  of  true  enthusiasm  and  faithful  work.  Yester¬ 
day  we  read  the  history  of  the  past,  to-day  we  make  a  history 
for  the  future,  and,  whether  he  will  or  no,  every  fellow  in  our 
number  must  leave  his  mark,  be  it  little  or  much,  in  the  records 
of  this  Academy.  Let  ns  be  inspired,  then,  with  the  thought 
that  our  fellowship  shall  become  a  power  in  raising  our  pro¬ 
fession  to  the  high  place  which  the  future  shall  assign  to  it, 
centralizing  its  influence  and  elevating  it  socially  and  intellectu¬ 
ally  to  a  position  which  was  not  hoped  for  in  the  past  or  at¬ 
tained  to  in  the  present. 

Our  future  must  be  and  will  be  interwoven  with  the  many 
and  rapid  transformations  that  are  to  take  place  in  every  de¬ 
partment  of  science,  and  our  relations  must  become  more  and 
more  intimate  with  the  great  public,  who  are  fast  realizing  that 
the  first  mission  of  our  labors  is  the  prevention  of  disease.  The 
career  of  the  physician  of  the  future  will  be  nobler  and  pleas¬ 
anter,  because  he  will  have  less  of  ignorance  and  prejudice  to 
combat,  but  he  will  require  a  higher  culture  than  his  representa¬ 
tive  of  to-day.  Here  in  this  library  and  in  these  halls  both  the 
medical  profession  and  the  philanthropist  will  find  that  inspira¬ 
tion  which  shall  give  birth  to  a  greater  devotion  to  the  allevia¬ 
tion  of  human  suffering  and  a  better  realization  of  our  duty  in 
the  elevation  of  the  masses  to  a  higher  civilization.  We  must 
never  look  backward,  but  always  forward.  Provided  with  the 
machinery  of  wisdom  we  have  inherited,  but  not  wise  in  our 
own  conceit,  let  us  make  this  building  the  great  workshop 
where  the  fires  of  scientific  enthusiasm  and  persistent  labor  shall 
smelt  from  out  the  ores  of  our  daily  experience  the  pure  metal 
of  truth  that,  cast  in  the  molds  of  patient  thought  and  polished 
by  the  sharp  emery  of  keen  and  kindly  criticism,  may  some  day 
furnish  to  generations  yet  unborn  armor  and  weapons  with 
which  they  will  advance  victorious  over  all  the  forces  of  death 
save  threescore  years  aud  ten. 

So  shall  the  congratulations  w  hich  we  utter  to-night  re-echo 
from  these  walls  when  other  voices  recall  this  day.  Join  with 
me,  then,  in  thanksgiving  to  the  Great  Physician  for  what  has 


been  accomplished,  and  in  this  invocation:  that  these  walls 
may  not  crumble  or  cease  to  shelter  faithful,  earnest,  Christian 
men  until  suffering  humanity  is  free  from  its  bondage  to  lust 
and  excess,  and  is  victorious  in  its  struggle  against  the  invisible 
arrows  of  disease. 

The  Anniversary  Oration  was  then  delivered  bv  Dr.  Ed¬ 
ward  L.  Keyes,  who  said  : 

Mr.  President,  Fellows  of  the  Academy,  Gentlemen,  and 
Ladies:  If  there  are  sermons  in  stone,  then  an  address  has  al¬ 
ready  been  delivered  to  you  to-night  on  entering  these  walls, 
in  a  strain  of  greater  dignity  than  any  to  which  I  may  aspire. 
The  fact  of  the  existence  of  this  building  at  all  in  the  graceful 
form  in  w’hich  you  see  it,  devoted  as  it  is  to  be  to  philanthropic 
and  humanitarian  ends — this  in  itself  is  a  whole  volume,  a  can¬ 
ticle  of  praise  to  the  energy  of  its  promoters,  and  a  paean  of 
gratitude  to  the  liberality  of  those  whose  material  bounty  has 
made  its  erection  a  possibility.  Those  of  us  who  are  to  possess 
this  w'ell-eqnipped  arena  for  scientific  effort,  this  nucleus  from 
which  shall  radiate  ever-hroadening  lines  of  medical  thought, 
have  lived  to  see  a  good  day,  and  to  enter  the  promised  land 
toward  which  our  earnest  expectancy  has  led  us  through  many 
a  long  hour  and  weary  year;  and  in  contemplation  of  the  work 
accomplished,  in  that  grateful  lassitude  which  accompanies  the 
consummation  of  a  successful  effort,  we  might  perhaps  with 
better  grace  muffle  our  ineffective  voices  and  allow’  the  stones 
to  discourse  to  you  in  the  eloquence  of  their  majestic  silence. 
Yet  this  may  not  be.  Some  articulate  words  are  called  for,  and 
if  I,  who  have  been  honored  by  being  made  the  mouth-piece  of 
my  fellow  academicians,  can,  as  an  impersonality,  render  to 
you  for  them  any  words  in  harmony  with  the  occasion,  the  ac¬ 
complishment  of  the  pleasant  duty  will  be  its  fitting  rew’ard. 

An  academy  is  an  institution  sanctioned  by  illustrious  pre¬ 
cedent  in  that  group  of  devoted  followers  who,  in  the  groves  of 
the  suburb  of  Athens  bearing  this  name  in  the  year  348  before 
Christ,  clustered  around  Plato  as  he  “taught  the  truth”;  and 
to  teach  the  truth  alter  investigation  has  been  the  proper  func¬ 
tion  of  the  academy  ever  since  that  day.  The  various  institu¬ 
tions  of  learning  which  in  different  scientific  fields  have  borne 
this  name  have  made  for  themselves  everlasting  renown  and 
have  established  a  criterion  by  which,  if  our  little  body  of  ear¬ 
nest  w’orkers  is  to  be  judged,  it  behooves  us  to  spare  no  effort 
that  our  results  may  be  deemed  worthy  to  be  enrolled  upon  the 
same  scroll  of  honor. 

The  age  in  which  we  live  is  distinguished  notably  along 
three  prominent  lines — by  material  progress,  by  the  broad  dis¬ 
pensation  of  rational  charity,  and  by  the  far  reaching  effective¬ 
ness  of  scientific  study  in  its  practical  application  to  the  needs 
of  mankind.  This  building  in  which  we  are  assembled  repre¬ 
sents  a  crystallization  of  the  essence  of  all  these  lines.  The 
materia]  progress  is  represented  by  the  graceful  outlines  of  the 
building  and  its  commodious  internal  structure,  which  the 
architect  has  ably  conceived  and  the  w  orkmen  have  faithfully 
executed.  The  very  existence  of  the  building  is  the  acme  of  a 
broad  charity,  since  it  stands  for  the  accumulation  of  many 
hard-earned  dollars,  that  this  institution  may  live  and  become 
effective,  not  solely  for  those  who  make  immediate  use  of  it, 
but  that  the  fruit  of  their  labors  may  spread  abroad  through 
the  land  for  the  benefit  alike  of  all  who  are  in  need;  and  it 
stands  for  science,  for  it  is  the  rostrum  from  which  science 
speaks;  it  is  the  arena  in  which  science  contends;  it  is  the  soil 
in  which  are  implanted  the  roots  of  that  treeof  medical  knowl¬ 
edge  in  the  branches  of  which  the  investigator  may  find  the 
bud,  the  flower,  the  ripening  fruit  of  past  experience ;  it  is  the 
fountain  from  which  shall  emanate  rivers  of  refreshing  sweet¬ 
ness  to  cool  aud  succor  the  parched  sufferer  along  the  dusty 
highways  of  disease. 


Nov.  22;  1890.  J 


SPECIAL  ARTICLES. 


577 


And  what  to  say  of  the  academic  body  itself,  of  which  this 
edifice  is  the  outward  and  visible  sign?  Conceived,  as  its  his¬ 
torians  have  often  narrated,  conceived  in  the  spirit  of  good  fel¬ 
lowship  and  brotherly  kindness,  on  the  evening  of  November 
18,  1846,  at  a  dinner  of  the  Society  for  the  Relief  of  Widows 
and  Orphans  of  Medical  Men,  it  took  shape  December  12,  1846, 
with  the  sanction  of  about  two  hundred  and  sixty  physicians, 
under  the  immediate  direction  of  Alexander  H.  Stephens,  assisted 
by  Parker,  Watson,  Mott,  Isaak  Wood,  Smith,  and  others,  was 
born  on  the  6th  of  January,  1847,  and  baptized  by  legislative 
enactment  of  incorporation  on  the  23d  of  June,  1851. 

The  motive  for  its  formation  was  stated  by  its  founders  to 
be  a  “lack  of  harmony  and  concentration  of  effort  for  scientific 
purposes  in  the  profession  ”  and  a  desire  to  elevate  a  barrier 
against  quackery,  which,  at  that  time,  it  appears,  had  reared  a 
more  formidable  front  than  before  or,  possibly,  since  that  day. 
At  its  birth  its  future  functions  were  defined  to  be:  1.  The 
cultivation  of  the  science  of  medicine.  2.  The  advancement  of 
the  character  and  honor  of  the  profession.  3.  The  elevation  of 
the  standard  of  medical  education.  4.  The  promotion  of  the 
public  health. 

The  Academy  is,  therefore,  now  in  its  fifth  decade.  It  has 
lived  through  its  babyhood  and  period  of  riotous  youth,  home¬ 
less  at  first,  and  wandering  about  seeking  shelter,  and  having 
no  roof  to  call  its  own,  until  well  along  in  its  twenty  seventh 
year,  when,  on  December  24,  1874,  it  secured,  largely  through 
the  energy  of  Dr.  S.  S.  Purple,  a  permanent  abiding  place  at 
No.  12  West  Thirty-first  Street. 

There  might  almost  be  said  of  the  Academy  what  has 
been  tersely  written  of  the  life  of  man,  dividing  it  into  de¬ 
cades  : 

At  10,  a  child  ; 

At  20,  wild  ; 

At  30,  sound,  if  ever  ; 

At  40,  wise ; 

At  50,  rich  ; 

At  60,  good,  or  never — 

except  that  the  Academy  has  been  from  the  beginning  good,  a 
quality  which  may  not  be  affirmed  with  equal  confidence  of  all 
men.  For  surely  at  ten  the  Academy  was  a  child  and  a  wan¬ 
derer  in  the  streets ;  at  twenty  we  may  be  pardoned  for  declin¬ 
ing  to  inquire  into  her  follies  ;  at  thirty  she  was  certainly  sound 
— indeed,  there  never  has  been  a  question  of  the  health  of  the 
organization  ;  at  forty  who  shall  deny  that  she  was  wise,  for  it 
was  in  the  early  forties  that  the  necessity  for  expansion  was 
felt,  and  that  spirit  generated  which  has  culminated  in  this  our 
forty-fourth  year  in  the  completion  of  this  modern  home,  in 
which  the  treasures  of  our  library  will  be  adequately  protected 
from  fire,  and  wherein  ample  provision  has  been  made  for  the 
convenience  of  present  work  and  future  expansion.  And  in 
signaling  this  triumph  of  the  Academy’s  fourth  decade,  it  is 
impossible  not  to  pause  and  pay  tribute  to  our  president,  Dr. 
Loomis,  whose  energy,  zeal,  and  ability  have  contributed  so 
largely  toward  the  accomplishment  of  the  result. 

It  is  hardly  necessary  to  carry  the  simile  further.  At  fifty 
the  Academy  can  not  fail  to  be  rich.  She  is  rich  now  in  the 
love  of  her  children,  in  the  respect  in  which  she  is  held  by  the 
community  at  large ;  she  is  rich  in  her  library  and  in  the  accu¬ 
mulation  of  good  work  by  her  members.  This  is  the  material 
wealth  of  a  scientific  body,  and  of  this  she  has  already  a  fund 
and  a  steadily  increasing  store. 

At  sixty  the  Academy  becomes  immortal,  and  will  remain, 
until  the  consummation  of  Time,  a  pillar  of  beauty  and  strength, 
an  integral  part  in  the  grand  temple  of  Science  which  is  being 
reared  by  zealous  and  loving  hands  throughout  the  length  and 
breadth  of  the  entire  earth. 


And  how  has  the  Academy  fulfilled  the  aspirations  of  her 
founders?  Surely  the  end  is  not  yet,  and  more  remains  to  do  ; 
but  in  the  four  directions  which  were  defined  at  her  origin  as 
her  special  lines  of  effort,  her  advance  has  certainly  been  satis¬ 
factory.  The  science  of  medicine  has  been  cultivated;  the  di¬ 
vision  of  labor  into  section  work  has  brought  together  spirits 
scientifically  akin,  and  the  quality  of  the  material  presented  to 
and  digested  by  these  sections  is  of  a  high  order  and  of  steadily 
increasing  excellence. 

The  character  and  honor  of  the  profession  have  been  sus¬ 
tained  *  struggling  factions  have  been  dominated  by  wise  coun¬ 
sels,  and  threatened  rupture  averted  by  the  exhibition  of  a 
broad  spirit  of  professional  charity,  which  has  helped  to  steady 
and  elevate  the  quality  of  the  professional  gentleman  without 
as  well'as  within  the  academic  circle. 

The  weight  of  the  Academy  has  always  been  thrown  into 
the  scale  to  help  to  raise  the  standard  of  medical  educa¬ 
tion,  both  by  the  personal  effort  of  the  fellows,  many  of 
whom  have  occupied  high  positions  as  instructors  in  the  vari¬ 
ous  institutions  of  learning,  and  in  efforts  to  help  shape  legis¬ 
lation  toward  the  accomplishment  of  the  same  result  upon  a 
larger  scale. 

That  the  promotion  of  the  public  health  has  been  an  object 
of  academic  solicitude  is  witnessed  by  the  present  existence  of 
our  efficient  city  Board  of  Health,  which  was  conceived  and 
formed  in  the  bosom  of  this  Academy  in  the  interest  of  the 
citizens  of  New  York. 

The  workers  in  the  academic  field  have  not  been  very  nu¬ 
merous.  The  present  roll,  the  largest  ever  possessed,  numbers 
seven  hundred  ;  but  in  that  number  may  be  found  the  names  of 
nearly  every  living  physician  of  recognized  eminence  in  the 
city  and  immediate  neighborhood,  and  it  is  difficult  to  mention 
any  of  the  illustrious  dead  of  our  profession  whose  names  will 
not  be  found  written  upon  the  roll  of  the  Academy,  as  well  as 
imprinted  upon  the  memory  and  in  the  hearts  of  those  who 
loved  them  for  their  kindliness  during  life.  IIow  shall  I  men¬ 
tion  any  without  slighting  more — Francis,  Mott,  Stephens,  Par¬ 
ker,  with  his  genial  smile;  Watson,  Post,  Peaslee,  Flint,  the 
good  physician,  the  crystallization  of  benevolence ;  Rogers,  Bum- 
stead.  Buck,  Wood,  the  man  of  action;  Delafield,  Clark,  Dal¬ 
ton,  Anderson,  Agnew,  the  Christian  gentleman;  Hamilton, 
Sims,  Van  Buren,  the  man  of  judgment,  the  man  of  dignity,  a 
very  man,  a  prince  among  his  peers — but  why  prolong  the  list  ? 
The  good  men  have  been  ours,  the  good  men  are  ours,  and  their 
work,  the  best  of  it,  is  fostered  by  this  Academy  and  turned  to 
good  account. 

And  yet  the  high  success  of  the  few  is  not  the  measure  of 
the  usefulness  of  the  Academy.  These  illustrious  ones  would 
have  glittered  without  the  Academy.  Their  luster  is  shed  back 
and  illumines  the  whole  body  in  which  they  mingled,  and  mul¬ 
tiplies  there  for  the  good  of  the  community  at  large. 

We  in  our  scientific  struggle  and  effort  are  much  like  chil¬ 
dren.  The  vastness  of  the  field  belittles  our  personality.  The 
pretentious  few  who  arrogate  to  themselves  a  personal  supe¬ 
riority  are  more  than  liable  to  be  left  behind  by  the  patient 
seeker  after  truth,  whose  path  is  lightened  by  the  glowing  ra^s 
of  human  kindness.  Children  we  are  indeed! 

“We  go  forth  like  children  in  the  morning. 

Scattering  to  spend  the  summer  hours; 

One  his  brow  with  laurel  wreaths  adorning, 

One  to  saunter  ’mid  a  grove  of  flower4, 

“One  to  lose  his  way  and  wander,  straying, 

Till  the  twilight,  frighted  and  alone, 

One,  it  may  be,  wearied  with  his  playing, 

Wending  home  his  footsteps  ere  the  noon. 


578 


SPEC  I A  L  AR  77  CL  Es 


[N.  Y.  Med.  Jock., 


“But  whatever  fate  to  us  is  given, 

All,  when  day  is  done,  again  shall  meet, 

And  at  nightfall,  ’neath  the  stars  of  heaven, 

Shall  be  gathered  at  our  Father’s  feet.” 

To  obtain  an  idea  of  tbe  relative  standing  of  this  Academy 
we  must  compare  it  with  other  analogous  institutions.  The 
Imperial  Academy  of  Science  in  Vienna  and  that  of  France  are 
scientific,  not  medical,  bodies.  There  is  a  Royal  Academy  of 
Medicine  in  Belgium,  one  in  Italy,  one  in  Ireland;  there  is  an 
American  Academy  of  Medicine,  one  in  Kansas,  and  one  in 
Detroit,  but  the  moderate  scope  and  importance  of  these  various 
academies  relieves  them  from  comparison.  Germany  is  justly 
proud  of  her  two  distinguished  associations  in  Berlin — the  Medi¬ 
cal  Society,  under  the  presidency  of  Virchow,  and  the  Society 
for  Internal  Medicine,  under  the  leadership  of  Leyden.  Illus¬ 
trious  names  glitter  in  each  of  these  constellations,  but  neither 
has  a  building  of  its  own  yet,  although  the  Medical  Society  is 
now  erecting  one  in  company  with  the  Berlin  Surgical  Society. 
The  library  of  the  Medical  Society  is  of  about  two  thirds  the 
size  of  our  library,  while  that  of  the  Society  for  Internal  Medi¬ 
cine  is  insignificant.  The  great  Austrian  medical  body,  tbe 
Royal  Imperial  Society  of  Physicians  in  Vienna,  justly  re¬ 
nowned  for  the  brilliancy  of  its  work  and  the  standing  of  its 
members,  has  no  building  of  its  own,  and  a  library  of  some¬ 
thing  over  eleven  thousand  volumes — not  one  third  the  size  of 
ours,  although  the  society  is  ten  years  older.  Of  the  Surgical 
Society  of  Paris  and  other  foreign  medical  associations  it  may 
be  said  that,  whatever  their  distinction,  they  are  not  sufficiently 
analogous  bodies  to  be  fairly  compared  with  our  Academy. 

Two  foreign  institutions,  however,  fulfill  the  conditions: 
The  Academy  of  Medicine  in  Paris,  and  the  Royal  Medical  and 
Chirurgical  Society  of  London,  upon  the  general  plan  of  which 
our  organization  was  outlined.  As  between  these  two  and 
ourselves  at  this  date,  in  evidences  of  material  prosperity  at 
least,  our  Academy  holds  its  own.  As  to  the  scientific  standing 
of  its  members,  I  shall  not  draw  comparisons.  It  is  enough  to 
say  that  each  of  them  contains  the  flower  of  the  medical  science 
and  art  in  the  districts  in  which  they  are  respectively  situated. 
In  this  country  there  is  no  other  academy  (except  the  relatively 
unimportant  ones  I  have  mentioned),  although  there  are  many 
notable  medical  and  surgical  societies ;  but  the  extent  of  our  land 
and  the  widespread  distribution  of  its  talent  make  it  probable 
that  others  will  shortly  arise. 

Comparing,  then,  some  of  the  main  points  in  the  three  that 
I  have  selected,  I  may  say  that  each  has  a  building  of  its  own, 
that  of  the  French  Academy  being  a  temporary  one.  They 
have  the  funds  and  propose  constructing  a  suitable  home  in  the 
near  future. 

The  Royal  Medical  and  Chirurgical  Society,  London,  found¬ 
ed  in  1805,  has  a  membership  of  700  ;  the  seating-capacity  of 
its  largest  hall  is  300,  the  area  of  the  hall  being  40  by  50  feet, 
and  the  foundation  area  of  the  building  50  by  200  feet. 

The  Academy  of  Medicine,  Paris,  founded  in  1820,  has  a 
membership  of  110;  the  seating-capacity  of  its  largest  hall  is 
92,  the  area  of  the  hall  being  small,  and  the  foundation  area  of 
the  building  small. 

The  Academy  of  Medicine,  New  York,  founded  in  1847,  has 
a  membership  of  700;  the  seating-capacity  of  its  largest  hall  is 
350,  plus  extra  opened-up  space  250  =  600,  the  area  of  the  hall 
being  42  by  57  feet,  and  two  extra  smaller  rooms  that  may  be 
opened  into  it;  the  foundation  area  is  75  by  100  feet. 

All  have  libraries,  but  on  this  point  we  may  seek  a  wider 
field  for  comparison.  Our  library,  which  is,  I  believe,  tbe 
youngest  on  the  list,  and  which  always  gratefully  recalls  the 
names  of  its  chief  munificent  donors — Purple,  Dubois,  Bum- 


stead,  Stone,  Jacobi,  and  many  others  whom  time  forbids  me  to 
detail — was  founded  by  donations  in  1877,  and  never  bought  a 
book  until  1879,  eleven  years  ago;  yet  now,  safely  boused  in 
a  fire-proof  home,  we  are  proud  in  possessing  the  third  place 
numerically  among  the  medical  libraries  of  America,  and  the 
fourth  place,  as  far  as  I  can  learn,  among  the  purely  medical 
libraries  of  the  world.  In  this  country  the  library  of  the  Sur¬ 
geon-General’s  Office  in  Washington,  founded  in  1865,  is  the 
largest;  that  of  the  College  of  Physicians  in  Philadelphia,  more 
than  one  hundred  years  old,  the  second. 


Comparative  Table  of  Medical  Libraries. 


Date. 

Volumes. 

Journals. 

Current 

Journals. 

Pam¬ 

phlets. 

Academy  of  Medicine,  Paris . 

1820 

130,000 

18, COO 

390 

Surgeon-Gen. ’s  Office,  Washington. 

1866 

97,881! 

33.173 

Over  700 

144,887 

College  of  Physicians,  Philadelphia 

1789 

45,000 

400 

Academy  of  Medicine,  N.  Y . 

1847 

40,000 

400 

Medical  and  tChirurgical  Society, 

London  . 

1S05 

36,000 

150 

Medical  Society.  Berlin . 

1839 

About 

30,000 

Royal  College  of  Surgeons,  Dublin. 

.... 

About 

25,000 

Medical  Library  Assoc.,  Boston  . . . 

.... 

19,365 

381 

19,100 

New  York  Hospital  Library,  N.  Y. 

18,386 

109 

No  rec- 

Royal  Imperial  Society  of  Physi- 

ord  kept 

dans,  Vienna . 

11,069 

132 

Aberdeen  Medical  Society,  Scotland 

6.000 

So  stands  our  Academy,  and  such  she  is  when  compared 
with  other  analogous  institutions  in  other  parts  of  the  world. 
Considering  her  age,  she  need  not  be  ashamed.  To  fulfill  her 
destiny  and  consummate  her  function  requires  only  a  continu¬ 
ance  of  the  zeal  which  has  attended  her  development  from  the 
first  and  a  common  impulse  among  her  members  to  work  for 
work’s  sake. 

Here  in  this-  hall,  now  radiant  with  gracious  smiles  of  ap¬ 
proving  friends,  must  be  fought  out  many  a  desperate  scientific 
battle.  Clad  in  the  armor  of  scientific  method  and  wielding  the 
sword  of  personal  experiment  and  investigation,  contending  in¬ 
dividuals  and  contending  factions  shall  battle  for  the  supremacy 
of  their  ideas  until  these  walls  shall  resound  with  the  din  of 
conflict;  and  from  the  blows  given  and  taken  with  such  weap¬ 
ons  upon  such  honest  armor  there  shall  scintillate  and  radiate 
sparks  and  flashes  of  truth,  living  fire,  to  be  added  to  and 
heaped  upon  tbe  burning  flame  that  glows  forever  upon  that 
common  altar  of  science  at  which  we  all  worship,  a  flame  to 
act  as  a  beacon  of  safety  upon  the  hill-top  to  encourage  those 
for  whom  the  battle  is  fought — the  patient,  suffering  victims  of 
disease — and  a  flame  which,  within  this  academic  body,  shall 
serve  as  a  cloud  of  smoke  by  day  and  a  pillar  of  fire  by  night  to 
guide  and  guard  the  honest  investigator  in  his  never-ending 
endeavor  to  teach  the  truth. 

The  Library. — Dr.  A.  Jacobi  spoke  as  follows: 

Mr.  President,  Ladies,  and  Gentlemen:  A  circular  published 
by  a  special  committee  of  this  Academy  in  January,  1888,  con¬ 
tained  the  statement  that  the  New  York  Academy  of  Medicine 
was  an  incorporated  institution  then  more  than  forty  years  old  ; 
that  its  object  was  the  cultivation  of  medical  science  and  art; 
that  this  aim  was,  among  other  means,  reached  by  maintain¬ 
ing  reading-rooms  which  furnished  nearly  all  the  medical  jour¬ 
nals  of  the  world,  and  by  collecting  a  library  which  was — and 
is  to-day — free  to  the  fellows  of  the  Academy,  to  the  whole 
medical  profession  indiscriminately,  and  to  the  public  at  large. 
Our  library  was  steadily  increasing,  the  capacity  of  its  shelves 
was  strained  to  the  utmost,  the  building  was  not  fire-proof,  and 
our  accumulated  treasures  were  in  constant  danger.  For  these 
reasons  we  appealed  to  both  the  profession  and  the  public  for 
aid  in  procuring  for  our  meetings  and  our  books  a  fire-proof 
building  large  enough  to  accommodate  two  hundred  and  fifty 
thousand  volumes,  spacious  enough  to  afford  quarters  to  all  the 


Nov.  22,  1890.] 


SPECIAL  ARTICLES. 


579 


scientific  societies  of  the  city,  stately  enough  to  worthily  repre¬ 
sent  the  medical  profession  of  the  metropolis,  and  able  to  testify 
both  the  unity  and  earnestness  of  that  profession  and  the  sym¬ 
pathy  of  the  city,  which  at  the  same  time  is  the  largest  in  size 
and  the  greatest  in  commercial  power  of  the  continent. 

This  library  of  the  Academy  of  Medicine  had  a  slow  but 
steady  growth.  Thirty-three  years  ago,  when  I  was  admitted 
to  membership,  in  the  presence  of  the  great  and  good  men  who 
then  were  the  guiding  stars  of  the  profession — Alexander  H. 
Stephens,  Valentine  Mott,  Horace  Green,  Gurdon  Buck,  Edmond 
R.  Peaslee,  Edward  Delafield,  John  Francis,  John  Watson,  Ernst 
Krackowizer — there  was  no  library  at  all,  not  even  a  medical 
reading-room  in  the  city.  It  took  many  years  before  the  Jour¬ 
nal  Association  was  organized,  which  furnished,  in  a  room  fitted 
up  for  the  purpose  at  No.  64 Madison  Avenue,  the  current  medi¬ 
cal  journals.  Other  years  elapsed  until  an  amalgamation  of  the 
Journal  Association  and  the  Academy  of  Medicine,  then  at  No. 
12  West  Thirty-first  Street,  was  brought  about.  The  accumu¬ 
lation  of  the  annual  volumes* and  a  valuable  collection  of  Ameri¬ 
can  journals  and  other  books  presented  by  two  fellows  were  the 
first  stock  of  the  library.  The  journals  were  paid  for  by  an 
appropriation  of  the  Academy,  which,  being  small  in  the  be¬ 
ginning,  for  many  years  amounted  to  from  three  to  four  thou¬ 
sand  dollars  annually.  More  could  not  be  spared.  Thus  it  was 
that  we  could  not  purchase  new  books.  Occasionally  a  sum 
was  raised  by  voluntary  contributions  for  the  purpose  of  buying 
the  collection  of  a  deceased  member,  certain  publishers  would 
present  us  with  their  publications,  authors  donate  copies  of 
their  writings,  fellows  and  others  give  old  and  new  books,  and 
men  interested  in  special  branches  of  literature  furnish  a  shelf¬ 
ful  of  special  works.  That  was  our  library.  Thus  it  grew  slowly 
but  steadily.  In  the  course  of  years  our  stock  of  journals  be¬ 
came  more  and  more  valuable,  but  what  we  wanted  was  a 
regular  supply  of  new  books,  for  which  we  had  no  funds. 

On  the  2d  of  October,  1889,  when  I  had  the  honor  of  ad¬ 
dressing  you  at  the  laying  of  the  corner-stone  of  this  edifice,  I 
could  refer  to  the  fact  that  at  last  we  had,  for  the  purchase  of 
new  books,  a  special  library  fund  of  ten  thousand  dollars,  half 
of  which  was  a  memorial  gift.  For  the  same  purpose  and  in  the 
same  spirit  the  widow  of  a  deceased  fellow  and  vice-president 
has  since  presented  another  special  fund  often  thousand  dollars, 
so  that  one  fifth  of  the  sum  required  for  the  perpetual  endow¬ 
ment  of  the  library  is  now  secured.  We  are  thus  approaching 
the  time  when  New  York  city  will  possess  a  medical  library 
fully  adapted  to  meet  its  ends.  What  are  they  ?  A  large  library, 
besides  being  the  proof  of  existing  culture  and  accumulated  in¬ 
tellectual  labor,  fulfills  its  destiny  by  giving  information.  Here 
the  medical  man  with  scanty  means  will  find  his  text-books  and 
monographs  to  aid  him  in  unraveling  the  obscurities  of  a  diffi¬ 
cult  case  on  hand.  He  with  an  ample  library  of  his  own  will 
come  here  to  consult  rare  books,  old  journals,  expensive  works. 
Here  all  the  journals  of  the  world  may  be  consulted  from  day 
to  day ;  here  those  who  are  engaged  in  literary  pursuits  find 
their  historical  records.  But  what  a  library  is  most  successful 
jn  is  the  inculcation  to  a  great  many  of  the  habits  of  study 
and  research.  In  that  result  the  public  is  very  much  inter¬ 
ested.  Its  safety  and  dignity  require  cultured  and  erudite 
physicians. 

In  the  same  degree  that  the  ethical  and  intellectual  standard 
of  society  is  raised  the  community  will  demand  a  higher  stand¬ 
ard  of  education  and  culture  on  the  part  of  its  liberal  profes¬ 
sions,  among  them  the  medical.  A  profession  is  called  liberal 
in  this,  that  it  is  generous,  charitable,  and  high-minded  ;  in 
this,  that  it  liberates  its  members  from  ignorance  and  mental 
and  moral  hebetude.  But  in  reality  the  medical  profession  of 
the  country  has  been  mostly  liberal  in  this,  that  it  has  admitted 


to  its  ranks  uneducated  persons  of  all  colors,  sexes,  ages,  and 
previous  conditions  of  servitude  and  illiteracy.  Instead  of  being 
a  truly  liberal  profession,  it  has  merely  been  too  liberal.  In 
this  tendency  it  has  been  encouraged,  or  rather  this  inferior 
standard  has  been  forced  upon  the  medical  profession,  by  the 
public.  He  who  requires  manners  in  his  corn  cutter,  and  de¬ 
mands  gentleness  in  his  tailor,  would  often  not  object  to  select¬ 
ing  for  his  family  physician  and  public  hygienist  a  medical  ad¬ 
viser  with  the  orthography  of  a  village  school,  the  touch  of  the 
corner  grocer,  and  the  mental  level  of  a  soap-peddler. 

From  this  depth  the  profession  has  risen  spontaneously  by 
study  and  its  indigenous  moral  development.  Not  all  of  you 
know,  however,  to  what  extent  you  are  under  obligation  to  the 
medical  profession.  Fifteen  years  of  incessant  agitation  were 
required  to  finally  pass  the  bill  for  the  establishment  of  a  State 
Board  of  Medical  Examiners.  If  in  future  you  are  protected 
against  practitioners  who  have  nothing  to  show  besides  their 
diploma  granted  by  a  college— no  matter  of  how  high  or  low 
standing — if  the  license  to  practice  on  you,  your  parents,  and 
children  is  made  dependent  on  a  second  examination,  you  owe 
that  blessing  to  the  exertions  of  the  medical  profession.  You 
might  have  made  the  result  more  striking.  If  the  public  had 
understood  its  interest  you  would  have  worked  with  us,  in  be¬ 
half  of  making  the  State  board  one,  and  not  three. 

Another  achievement  of  tbe  profession  which  concerns  you 
as  much  as  it  does  us  is  the  final  passing  of  the  bill  requiring 
some  degree  of  general  education  on  the  part  of  every  medical 
student  who  expects  to  obtain  his  medical  diploma.  Thus  a 
step  is  made  in  the  direction  of  rendering  the  profession  more 
liberal,  more  cultured,  more  effective,  more  fit  to  take  charge  of 
the  most  sacred  offices  that  can  fall  to  the  lot  of  men.  For  the 
holiest  and  greatest  of  the  objects  of  human  study  and  care  is 
man.  That  is  so  much  a  part  of  the  creed  of  the  medical  pro¬ 
fession  that  you  can  imagine  our  painful  and  contemptuous  sur¬ 
prise  on  learning  that  a  medical  man  in  a  public  position,  but 
fortunately  not  one  of  us,  worked  all  winter  to  have  the  law 
repealed.  Fortunately  not  one  of  us.  For  from  its  very  first 
days  this  Academy  of  Medicine  has  had  the  elevation  of  the 
standard  of  medical  education  and  culture  inscribed  on  its  ban¬ 
ner.  That  object  has  become  such  a  settled  axiom  in  the  mind 
of  every  fellow  that  years  ago  it  was  no  longer  considered  neces¬ 
sary  to  retain  it  in  just  as  many  words  among  the  written  laws. 

In  this  tendency  you  can  sustain  the  efforts  of  the  profes¬ 
sion.  Insist  upon  this,  that  your  physician  be  a  gentleman  and 
a  scientist,  and  do  something  for  that  purpose  yourself;  for 
the  State  does  not  contribute  to  that  end.  The  State  is  only 
society  organized  for  certain  purposes  of  co-operation  and  pro¬ 
tection.  But  medical  education,  though  ever  so  indispensable 
for  the  pursuit  of  health  and  happiness  and  the  training  of  eru¬ 
dite  and  liberal  physicians,  has  not  been  itc<gnized  anr.org 
them.  But  you  who  do  not  say  to  the  hungry,  the  cold,  and 
the  naked,  “  Be  ye  fed,  be  ye  warmed,  be  ye  clothed,”  without 
helping  them  to  food,  fire,  or  clothing,  must  not  expect  a  pro¬ 
fession  that  always  works  in  the  private  and  public  interest  of 
yourself  and  all  those  dear  to  you  and  yours  to  be  at  once 
learned,  erudite,  and  wise,  and  refuse  aid  in  its  efforts  to  per¬ 
fect  itself  and  benefit  the  commonwealth — aid  by  pecuniary 
support,  by  your  social  influence,  and  also  by  some  occasional 
gentle  political  pressure  on  our  representatives  in  Albany. 

Our  greatest  drawback  has  long  been  that  we  had  no  large 
class  of  learned  medical  men,  such  as  study  for  study’s  sake, 
irrespective  of  pecuniary  gain.  Our  profession  has  always  con¬ 
sisted  of  practitioners.  The  necessities  of  life  have  acted  upon 
the  medical  fraternity  as  on  the  community  at  large,  which 
knew  but  exceptionally  of  art,  of  music,  of  philosophical  refine¬ 
ment  so  long  as  the  country  was  still  wrestling  with  the  diffi- 


580 


SPECIAL  ARTICLES. 


[N.  Y.  Med.  Joue., 


culties  of  the  soil,  tbe  insufficiency  of  commerce,  and  the  ham¬ 
pering  of  poverty.  Thus  the  immense  majority  of  the  medical 
men  of  the  country  gloried  in  being  practical,  and  that  only. 
That  there  were  architects  who  never  laid  a  brick,  mathema¬ 
ticians  who  never  triangulated  a  mountain,  astronomers  who 
never  sailed  a  ship ;  that  no  cathedral,  no  coast  survey,  no 
ocean  travel  could  exist  without  them,  that  indeed  there  was 
no  rational  practice  without  an  underlying  theory,  was  not 
considered.  The  very  strongholds  of  medicine,  histology,  physi¬ 
ology,  the  fields  of  experimental  labor  and  microscopical  re¬ 
search,  all  those  branches  which  you  can  not  immediately  ex¬ 
change  for  cash,  have  been  neglected  among  us  until  lately.  Like 
special  laboratories,  it  is  but  a  short  time  since  great  medical 
libraries  have  sprung  up  in  Washington,  Philadelphia,  Boston, 
and  New  York.  The  sooner  we  admit  that  we  have  been  far 
behind  Europe  in  that  respect,  tbe  better  for  our  scientific 
future.  Indeed,  the  intellectual  maturity  of  a  nation  can  best 
be  measured  by  the  amount  of  its  original  and  unpaid  research. 
Europe  knows  that  thoroughly.  The  intellectual  atmosphere 
of  Paris  depends  greatly  on  its  university.  Tbe  universities 
of  Germany,  with  their  independent  workers  and  thinkers, 
have  always  been  the  pride  of  the  nation,  even  in  the  distress 
of  national  poverty  and  political  humiliation.  In  all  of  them 
the  principal  means  of  information,  through  centuries,  have 
been  their  large  libraries.  And  it  will  be  our  library  round 
which  the  scientific  interests  of  the  profession  will  largely  cen¬ 
ter;  but  not  of  the  profession  only,  for  the  Academy,  as  it 
opens  its  doors  to  whosoever  will  attend,  without  regard  to  mem¬ 
bership,  has  always  held  that  in  order  to  increase  the  number 
of  its  beneficiaries,  it  must  make  its  library  free.  This  is  so 
well  understood  and  so  highly  appreciated  that  the  city  has  re¬ 
mitted  the  taxes  on  its  building.  A  medical  library  contains  of 
necessity  many  works  and  journals  of  interest  to  professional 
men  besides  medical.  The  lawyer  and  physician  have  many 
studies  in  common.  There  are  in  the  city  two  societies  for  the 
special  study  of  forensic  medicine  and  medical  jurisprudence, 
both  of  which  can  be  better  studied  in  a  medical  than  in  a  legal 
collection.  Nor  is  a  medical  library  such  as  we  have,  and 
mean  to  increase,  a  forbidden  fruit  to  the  intelligent,  well-in¬ 
formed  non-professional  mao  or  womaD.  Fortunately,  there 
are  a  great  many  good  popular  works,  besides  those  compiled 
for  an  ephemeral  market,  which  treat  of  physiology,  hygiene, 
statistics,  and  other  topics  of  universal  interest. 

Therefore  we  hold  that  the  profession  has  a  right  to  look  to 
the  public  for  appreciation  and  aid.  We  are  not  situated  as 
they  are  in  Europe,  where  educational  institutes,  as  they  are 
controlled,  are  also  supported  by  the  Government,  for  the 
democratic  spirit  of  our  social  and  political  institutions  is  op¬ 
posed  to  centralization  of  that  kind,  and  tbe  generosity  of  the 
citizens  has  often  been  appealed  to  and  hardly  ever  in  vain. 
There  was  a  time  when  the  Church,  centralizing  all  informa¬ 
tion,  beneficence,  and  social  and  political  influence,  was  the 
only  legatee  of  the  rich  and  benevolent.  Now  there  are  a  hun¬ 
dred  opportunities  for  liberal  outlay.  To  select  the  proper 
ones  is  an  art.  I  suppose  it  is  a  great  achievement,  which  only 
a  few  select  ones  can  attain,  to  make  money  ;  but  it  is  a  greater 
art  to  spend  it  both  generously  and  profitably  in  the  interest  of 
science  and  charity.  The  greatest  of  all  charities,  however,  is 
to  benefit  mankind  by  leveling  the  road  of  science.  It  is  not 
millions  we  want.  A  hundred  thousand  dollars  will  clear  this 
temple  of  science  from  debt  and  swell  our  library  fund  to  a  suf¬ 
ficient  sum,  the  interest  of  which  will  forever  supply  us  with 
everything  medical  and  scientific  that  will  appear  in  auy  coun¬ 
try.  Well-to-do  ladies  and  gentlemen  will,  I  hope,  not  leave 
this  building  without  making  up  their  minds  to  contribute  their 
share  to  the  extinction  of  a  debt  which  the  community  owes  to 


the  profession  and  to  itself,  through  improved  educational  fa¬ 
cilities.  “  Let  your  light  so  shine  before  men  that  they  may 
see  your  good  works.” 

In  conclusion,  ray  friends  of  the  profession  may  permit  an 
additional  word  or  two  on  the  subject  of  the  library,  which  is 
so  dear  to  all  of  us  that  it  was  selected  as  the  subject  of  a  spe¬ 
cial  address  to-night.  In  one  of  its  retired  nooks  I  was  sitting 
a  few  days  ago,  contemplating  its  past  and  future.  I  sat  won¬ 
dering  how  long  it  would  take,  and  whether  any  of  us  older 
men  would  see  the  day,  until  America,  after  having  given  the 
political  world  the  guiding  example  of  a  stationary  popular 
government  both  conservative  and  perfectible,  led  the  world  of 
science  as  it  was  leading  that  of  politics  and,  we  hope,  of  health¬ 
ful  social  development ;  wondering  also  how  much  this  head 
center  of  tbe  medical  profession  and  this  ever-growing  library 
would  contribute  to  that  consummation,  which  you  can  hasten 
by  industrious,  honorable,  and  modest  work,  but  by  work 
only. 

This  library  of  yours  started  from  small  beginnings,  like 
medicine  itself.  It  comprises  the  labors  of  thousands  of  work¬ 
ers  assiduously  employed  through  long  centuries.  That  there 
is  one  of  them  that  would  not  be  missed  is  difficult  to  say,  for 
the  co-operation  of  the  many,  the  gradual  development  of  ideas, 
the  slow  changes  in  experience  and  doctrines,  are  of  as  much 
importance  as  the  revolutionary  and  epoch-making  labors  of  the 
greatest;  for  no  single  man  stands  alone,  a  law  to  himself  and 
others.  Even  genius  is  the  child  of  its  time.  No  Washington 
or  Lincoln,  no  Hippocrates  or  Aristotle,  no  Virchow  or  Pas¬ 
teur,  or  even  Koch — none  of  these  immortal  ones  is  a  world  by 
himself  and  an  isolated  self-lit  sun  illuminating  and  warming 
the  universe.  Every  one  has  been  raised  on  the  shoulders  of 
his  predecessors.  By  that  knowledge  it  is  that,  while  hope 
and  energy  are  aroused,  patience  is  taught  to  the  individual 
and  the  profession,  for,  while  life  is  short,  science  and  art  are 
unlimited  and  eternal  ;  and  the  comparison  of  what  you  furnish 
yourself  with  the  existing  mass  of  accumulated  knowledge  in¬ 
culcates  modesty  and  enhances  zealousness.  Thus  good  citi¬ 
zens  are  made  and  model  scientists.  Besides,  what  to  the  pupil 
is  the  information  gathered  from  the  lips  of  his  master,  that  is 
for  you  the  collective  bequests  of  all  centuries  as  represented  in 
your  library.  Thus  an  intellectual  kinship  is  formed  between 
you  the  living  and  the  spirit  of  all  eras  of  history.  That  is 
what  the  study  of  the  history  of  medicine  teaches  us,  which  we 
have  so  long  neglected. 

Pondering  over  the  shelves,  you  behold  abstract  scientific 
treatises,  works  on  practical  therapeutics,  and  books  on  art  and 
appliances — all  of  them  composing  our  beloved  “  medicine.” 
Kemove  the  theoretical  works  on  anatomy,  histology  and  em¬ 
bryology,  experimental  physiology,  physics,  and  chemistry — 
what  remains?  The  wreck  of  the  edifice,  the  foundation  of 
which  is  torn  away. 

Look  at  the  shelves  holding  special  literature.  There  the 
specialist  will  comprehend  that  his  doctrine  and  art  are  but  a 
minimal  trifle  when  compared  with  the  surrounding  wealth, 
and  that  the  basis  and  link  of  all  specialties  is  general  medi¬ 
cine.  Every  one  of  them  was  evolved  from  a  minute  bud  of 
the  great  tree,  and  but  few  have  ever  been  able  to  grow  up 
with  anything  like  independence.  Thus  medical  science  and 
art  is  shown  to  be  an  organism  of  slow,  consistent,  historical 
growth.  Even  the  very  excrescences — call  them  fallacies,  su¬ 
perstitions,  theories,  schools,  or  sects — do  not  disturb  the  or¬ 
ganic  economy.  In  accordance  with  this,  your  very  library, 
the  representative  and  exponent  of  all  medicine,  is  no  longer  a 
mere  collection,  but  a  vitalized  organism. 

That  is  why  there  is  an  atmosphere  of  solemnity  in  your 
large  library,  for  you  are  standing  in  the  presence  of  the  spirit 


Nov.  22,  1890. J  * 


SPECIAL  ARTICLES. 


and  soul  of  all  previous  ages,  each  evolving  from  and  connected 
with  its  neighbor.  That  is  why  a  library  is  to  the  scientist 
what  the  church  to  the  pious,  or  a  museum  of  a  hundred  gems 
like  that  which  a  generous  fellow  presented  to  our  reception- 
room,  to  the  artist.  No  consideration  of  lucre  invites  you 
there.  While  nourishing  your  minds,  you  disconnect  yourself 
from  the  embarrassments  of  trivial  employment  and  deliver 
yourselves  from  the  merely  terrestrial.  In  that  way  the  ideal¬ 
ism  is  nurtured  that  no  feeling  and  thinking  man  is  to  be  with¬ 
out;  idealism,  without  which  no  nation  can  expect  to  live. 

hen  she  lost  it,  even  Hellas  perished,  though  she  had  given 
birth  to  Solon,  Pericles,  Aristides,  and  Sophocles. 

Let  me  suggest  this  reflection  as  a  platform,  my  young  col¬ 
leagues.  It  is  not  a  dream,  but  a  reality,  if  you  will  make  it  so. 
By  so  doing,  not  only  will  you  elevate  your  august  science  and 
the  noblest  of  all  callings,  but  you  will  also  remain  in  constant 
and  indissoluble  intellectual  and  moral  contact  with  the  most 
cultured  elements  of  society.  If  you  do,  this  evening,  which  is 
both  an  anniversary  and  an  inauguration,  will  prove  a  ble>sing 
for  all  future  time  to  both  the  profession  and  the  community. 
Look  upon  this  edifice  not  merely  as  a  new  and  commodious 
building,  but  as  the  visible  portal  into  a  new  epoch.  If  you  do, 
you  will  consecrate  this  solemn  occasion  as  the  Fourth  of  July 
of  American  Medicine. 

Remarks  by  Dr.  John  S.  Billings,  of  the  Army.— Dr. 

Bili.ings  said:  I  beg  to  offer  very  hearty  and  sincere  congratu¬ 
lations  to  you  on  this  occasion  of  \  our  formal  taking  possession 
of  a  comfortable  and  satisfactory  home  of  your  own,  which  I 
hope  will  be  the  beginning  of  a  new  era  of  prosperity  and  use¬ 
fulness.  And  I  offer  these  congratulations  and  good  wishes, 
not  only  as  an  individual  warmly  interested  in  the  welfare  and 
work  of  the  Academy,  but  also  in  behalf  of  the  Medical  Depart¬ 
ment  of  the  Army,  very  many  of  whose  members  have  enjoyed 
your  aid  and  hospitality  while  on  duty  in  this  vicinity. 

There  are  many  features  about  this  medical  home  upon 
which  1  might  comment,  but  to  me  the  central  and  most  im¬ 
portant  feature  is  its  library  and  reading-rooms.  In  this  assem¬ 
bly  hall  you  may  sometimes  meet  and  receive  instruction  from 
many  of  the  famous  living  physicians  of  New  York,  but  in  the 
library  you  may  at  all  times  counsel  with  the  wise  and  illustri¬ 
ous  of  our  profession  of  all  times  and  countries,  living  and  dead, 
upon  whatever  subject  most  interests  you.  You  can  always  find 
good  company  there;  they  are  never  in  a  hurry,  never  obtru¬ 
sive,  and,  while  they  can  not  always  tell  you  what  you  want 
to  know,  they  can  usually  tell  you  something  new  that  you 
ought  to  know,  provided  you  question  them  aright. 

Perhaps  a  very  few  words  about  library  matters,  based  on 
my  experience  in  your  Washington  branch,  the  Library  of  the 
Surgeon-General’s  Office,  will  fatigue  you  as  little  as  anything 
else  I  could  say.  The  kind  of  literature  most  needed  in  a  library 
of  this  kind  is  medical  journals  and  transactions,  and  next  to 
these  come  statistical  reports  relating  to  diseases  and  deaths  in 
different  countries,  States,  cities,  and  institutions.  The  reason 
for  this  is  that  no  physician  would  find  it  worth  while  to  obtain 
and  preserve  in  his  own  library  one  twentieth  part  of  the  peri¬ 
odical  and  medico-statistical  literature  which  is  now  in  course 
of  publication,  and  vet  it  is  the  papers  and  figures  in  these 
which  he  most  frequently  wishes  to  use  to  enable  him  to  solve 
his  own  problems  or  to  instruct  others.  Speaking  roundly,  I 
may  say  that  every  physician  should  take  five  journals.  Every 
medical  teacher  and  every  specialist  should  take  a  dozen.  Every 
Medical  Journal  Club  and  small  library  should  take  from  25  to 
50;  every  large  medical  library  should  take  from  150  to  300; 
and  the  national  collection  in  each  country  had  better  take 
them  all,  say  1,000  or  more.  A  physician  can  almost  always 
procure  the  current  text-books  and  monographs  at  a  compara- 


581 

tively  small  expense;  but  for  the  journals,  transactions,  and  re¬ 
ports  he  must  largely  rely  upon  some  general  library. 

Not  that  the  current  monographs,  or  the  old  classic®,  or 
even  the  inaugural  theses  and  dissertations  will  not  be  wanted 
occasionally,  or  that  these  should  not  be  collected  and  preserved 
as  opportunity  offers;  but  that  by  far  the  greater  portion  of  the 
land,  unless  it  exceeds  five  thousand  dollars  a  year,  had  best  be 
devoted  to  the  procuring,  binding,  and  preserving  of  the  peri¬ 
odical  literature  of  medicine,  and  to  the  making  it  promptly  ac¬ 
cessible  to  those  who  wish  to  use  it.  Few  persons  except  those 
who  have  had  some  practical  experience  in  library  management 
have  any  idea  of  the  time  and  labor  required  to  do  all  this;  it 
seems  to  the  majority  that  two  persons  at  most  ought  to  be  able 
to  do  the  work  required  in  a  library  of  thirty  or  forty  thousand 
volumes  receiving  two  or  three  hundred  journals,  and  that  the 
money  which  would  be  required  to  pay  for  additional  assistants 
had  much  better  be  used  in  buying  more  books. 

This,  however,  is  a  mistake.  In  a  library  of  the  scope  and 
purpose  which  that  of  the  New  York  Academy  of  Medicine 
should  have,  the  whole  time  of  one  skilled,  careful  assistant 
should  be  exclusively  occupied  with  the  periodicals  and  reports, 
and  it  will  require  his  utmost  efforts  to  see  that  the  files  of  these 
are  kept  complete  and  readily  accessible. 

Your  library  ought  to  receive  three  hundred  current  medi¬ 
cal  journals  and  at  least  seventy-five  series  of  transactions  and 
reports,  and  the  task  of  keeping  these  complete  and  in  proper 
order  is  not  a  small  one..  Moreover,  such  a  library  as  this 
should  obtain  and  preserve  a  complete  series  of  documents  re¬ 
lating  to  local  medical  history.  It  should  have  complete  files 
of  the  reports,  scheme  of  organization,  regulations,  catalogues, 
etc.,  of  every  medical  society,  of  every  hospital,  dispensary,  or 
asylum,  of  every  medical  school  or  other  institution  in  its  own 
city,  county,  and  State.  Most  of  these  are  only  to  be  had  by 
writing  for  them  at  the  time  of  their  publication;  they  are 
commonly  said  to  be  very  cheap  and  to  be  had  for  the  asking, 
but  I  think  you  would  be  a  little  surprised,  if  you  tried  to  get 
a  complete  set  for  one  year  only,  to  find  how  much  it  had  cost 
for  stationary,  clerical  labor,  and  postage  to  accomplish  it. 
Therefore,  I  say,  give  your  librarian  a  fair  amount  of  clerical 
assistance  to  enable  him  to  do  all  this,  and  to  keep  his  catalogue 
up  to  date,  to  keep  his  accounts  in  order,  to  spare  ten  minutes 
to  hunt  up  some  references  for  this  member,  ten  more  to  write 
to  the  Washington  branch  for  another  member,  fifteen  more  to 
hunt  among  the  duplicates  for  material  to  exchange,  etc. 

.With  regard  to  the  library  of  the  Surgeon-General’s  Office 
in  Washington,  which  I  have  referred  to  as  your  Washington 
branch,  I  have  to  report  that  it  is  in  fairly  good  condition  and 
ready  to  assist  you  in  the  future  as  it  has  done  in  the  past. 
There  are  some  things  which  it  can  not  do,  however.  A  year 
or  so  ago  the  editor  of  a  leading  New  York  medical  journal 
printed  a  humorous  editorial  notice  to  his  subscribers  to  the 
effect  that  he  could  not  undertake  to  furnish  medical  bibliog¬ 
raphy  and  abstracts  of  medical  literature,  and  those  who  wanted 
them  should  apply  to  the  librarian  of  the  Surgeon-General’s 
Office,  who  would  supply  them  for  a  suitable  pecuniary  consid¬ 
eration.  The  publication  of  this  note  gave  me  a  very  realizing 
sense  of  the  power  of  the  press  as  an  advertising  medium,  and 
also  of  the  existence  of  an  unfilled  want  among  the  medical 
profession  of  the  country.  Within  ten  days  after  this  editorial 
notice  appeared  I  received  a  goodly  number  of  letters  request¬ 
ing  summaries  of  the  latest  and  best  literature  on  measles,  on 
the  treatment  of  disease  of  the  spinal  cord,  on  ptomaines,  on 
orthopaedic  surgery,  on  the  death-rates  of  civilized  countries  for 
the  last* ten  years  as  compared  with  those  a  hundred  years  ago, 
etc.,  with,  in  each  case,  an  estimate  of  cost. 

Now,  I  have  not  the  time  to  do  work  of  this  kind  on  de- 


582 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jouh., 


mand,  and  I  do  not  take  pay  for  what  little  I  can  do  for  my 
friends  who  make  reasonable  requests.  There  were  two  or 
three  young  physicians  in  Washington  who  undertook  this  kind 
of  work  when  they  had  time,  charging  about  a  dollar  an  hour 
for  it;  and  at  times  they  were  kept  busy.  One  of  them  has 
gone  away,  one  of  them  has  now  so  much  practice  that  he  only 
makes  abstracts  for  his  own  use,  and  one  of  them  has  nearly 
gone  out  of  the  business.  No  doubt  we  shall  be  able  to  find 
others  in  course  of  time  who  will  take  their  places  and  to  whom 
I  can  refer  requests  of  this  kind,  which  I  am  always  glad  to  do 
if  possible;  but  I  can  not  promise  that  it  is  always  possible. 
A  definite  question  in  medical  bibliography,  so  far  as  giving 
references  is  concerned,  we  try  to  answer;  if  it  involves  over 
ten  minutes1  clerical  work  in  copying  I  have  it  done  by  some 
one  not  connected  with  the  library,  and  this  must  be  paid  for; 
but  special  researches  and  the  making  of  abstracts  and  transla¬ 
tions  can  not  be  done  by  the  librarian  or  his  assistants,  although 
we  will  do  our  best  to  find  persons  who  can  and  will  do  it. 

Dr.  Andrew,  in  the  last  Harveian  Oration,  says  that  he  re¬ 
gards  the  Index  Medicus  with  special  horror.  So  do  I.  I  wish 
we  could  cut  it  down  to  one  fourth  its  present  dimensions,  but 
we  can  not.  As  it  is,  we  omit  nearly  one  third  of  the  matter 
that  fills  the  pages  of  three  fourths  of  the  medical  journals,  as 
being  not  worth  indexing. 

At  the  present  rate  of  increase  of  printed  medical  literature, 
the  investigators  of  fifty  years  hence  are  likely  to  have  a  hard 
time  of  it,  and  we  must  do  what  we  can  to  provide  for  their 
needs.  The  great  bulk  of  such  literature  is  almost  useless 
within  ten  years  after  it  is  printed,  the  case  and  operation  rec¬ 
ords  having  the  most  permanent  value;  but  there  are  very  few 
books  or  pamphlets  which  are  not  at  some  time  called  for  by 
somebody,  and  hence  there  are  few  which  the  Academy’s 
librarian  can  reject,  although  there  are  many  that  he  should 
not  seek  for. 

My  business  to-night,  however,  is  not  to  advise  but  to  con¬ 
gratulate,  and  I  beg  pardon  for  having  wandered  from  the 
point.  I  have  watched  for  the  last  ten  years  with  great  interest 
the  efforts  which  have  been  made  here  to  secure  a  permanent 
home,  which  is  so  desirable  for  all  medical  societies  in  large 
cities,  and  yet  which  is  thus  far  possessed  by  so  few  in  this 
country  ;  and  I  know  something  of  the  struggle  it  has  cost,  and 
how  much  you  are  indebted  to  the  energy,  perseverance,  and 
tact  of  a  few  of  your  members,  and  especially  of  your  last  three 
presidents,  for  the  marked  success  which  has  been  achieved. 
And  as  this  success,  while  of  prime  importance  and  interest  to 
yourselves,  is  also  a  substantial  contribution  to  the  means  of 
advancement  of  scientific  and  practical  medicine  everywhere, 
you  have  a  right,  and  these  men  have  a  right,  to  the  thanks  of 
the  medical  profession  all  over  the  world  for  this  achievement, 
and  in  behalf  of  that  profession  I  offer  them. 

(To  be  concluded.) 


Ijrombxnp  oi  Socblus* 


RICHMOND  ACADEMY  OF  MEDICINE  AND  SURGERY. 
Meeting  of  September  23 ,  1890. 

The  President,  Dr.  W.  W.  Parkee,  in  the  Chair. 

( Reported  by  Dr.  James  N.  Ellis,  Richmond.)  . 

Placental  Disease  as  a  Cause  of  Premature  Labor.— Dr. 

John  N.  Upshur  read  a  paper  with  this  title,  in  which  he  said 


that  the  sparse  literature  on  placental  pathology  made  a  discus¬ 
sion  of  the  lesions  of  this  viscus  one  of  no  little  difficulty,  and 
it  was  only  by  clinical  observation  and  legitimate  deductions 
from  such  clinical  facts  that  we  could  arrive  at  conclusions  of 
a  practical  nature — these  being  proved  only  by  the  successful 
issue  of  treatment  founded  at  best  upon  theory  suggested  by 
these  clinical  facts.  Reflections  on  this  subject  were  suggested 
to  the  writer  by  a  case  which  was  made  the  text  of  his  article 
and  which  was  one  of  great  interest  and  concern  to  him.  The 
welfare  of  whole  family  connections,  based  upon  pecuniary  con¬ 
siderations,  or  the  domestic  happiness  which  often  centered  in 
fruitful  issue,  could  not  be  overestimated. 

He  had  been  called  to  see  Mrs.  B.,  August  5,  1888,  in  her 
third  pregnancy,  advanced  to  the  fourth  month,  aged  twenty- 
nine,  blonde,  health  always  robust.  She  had  lost  two  children 
at  the  beginning  of  the  seventh  month,  being  attended  by  one 
of  the  leading  physicians  of  this  city.  Careful  inquiry  had 
failed  to  elicit  the  history  of  any  imprudence  on  her  part — a  jar, 
a  fall,  or  any  tangible  cause  for  the  premature  labor.  The 
history  of  both  the  first  and  second  pregnancies  was  identical 
with  the  third.  There  was  no  swelling  of  hands  or  feet,  no 
headache,  and  careful  analysis  had  failed  to  disclose  the  pres¬ 
ence  of  albumin,  or  any  functional  derangement  of  any  organ 
whatever. 

She  was  enjoined  to  be  as  quiet  as  possible,  avoid  going  up 
and  down  stairs,  to  keep  early  hours,  and  given  tincture  of  the 
chloride  of  iron  and  uterine  sedatives,  and  watched  most  care¬ 
fully  and  anxiously.  Soon  after  entering  the  sixth  month  the 
movements  of  the  child  had  become  each  day  more  feeble  and 
irregular,  and  she  had  begun  to  complain  of  a  weight  in  the  hy- 
pogastrium  ;  motions  of  the  foetus  had  ceased  and  labor  had 
come  on  at  the  beginning  of  the  seventh  month,  October  28th. 
Labor  was  easy  and  rapid.  The  foetus  had  cried  feebly  once  or 
twice;  presented  a  swollen  appearance  with  more  or  less  scle¬ 
rotic  condition  of  skin,  cord  empty  of  blood,  placenta  firmly  ad¬ 
herent,  requiring  nearly  three  quarters  of  an  hour  to  remove  it. 
The  uterus  bad  contracted  well  and  firmly.  The  placenta  was 
very  soft,  pale,  and  anaemic — so  soft  as  to  drop  to  pieces  by  its 
own  weight,  or  a  portion  of  it. 

The  patient  had  become  again  pregnant  early  in  January, 
1889.  Carefully  reflecting  on  the  condition  of  the  placenta  and 
the  history  of  the  two  previous  pregnancies  and  deliveries,  the 
speaker  had  concluded  that  the  cause  of  the  death  of  the  foetus  and 
of  thepremature  delivery  was  a  latent  endometritis,  stimulated  to 
active  progress  by  pregnancy  and  the  implantation  and  develop¬ 
ment  of  the  placenta — the  inflammatory  condition  extending  to 
the  placenta,  producing  fatty  change,  cutting  off  the  circulation 
of  the  foetus,  and  consequent  death  so  soon  as  the  pathological 
change  had  progressed  far  enough.  All  history  of  syphilis  could 
be  absolutely  eliminated,  because  both  parents  were  exceedingly 
anxious  for  issue,  and  he  was  confident  that  he  had  elicited  from 
the  husband  the  whole  truth  as  to  the  history  of  his  sexual  life. 
He  had  once  had  a  mild  gonorrhoea  previous  to  marriage — sus¬ 
picion  here,  you  say,  of  urethral  chancre;  but,  if  so,  why  did  he 
not  have  bubo  and  secondary  symptoms  at  the  time,  and  tertiary 
symptoms  succeeding  ?  None  of  which  he  had  ever  had,  nor 
had  he  ever  had  any  syphilitic  treatment.  The  woman  herself 
was  absolutely  above  reproach.  So  soon  as  the  speaker  was  in¬ 
formed  of  the  occurrence  of  pregnancy  for  the  fourth  time  he 
put  the  patient  upon  the  most  active  alterative  treatment  of  the 
bichloride  of  mercury,  red  iodide  of  mercury,  and  chloride  of  gold 
and  sodium,  varying  these  alteratives,  and  keeping  up  the  treat¬ 
ment  for  six  months.  The  patient  also  drank  lithia  water  freely. 
He  desired  in  this  connection  to  especially  commend  the  chloride 
of  gold  and  sodium  as  an  alterative.  Its  action  in  the  dose  of  one 
eighth  of  a  grain  to  one  twentieth  of  a  grain  in  combination 


Nov.  22,  1890.J 


PROCEEDINGS  OF  SOCIETIES. 


583 


with  extract  of  one  of  the  bitter  tonics  was  in  many  respects 
similar  to  that  of  the  iodide  of  potassium,  but  he  believed  it  had 
a  special  influence  in  modifying  inflammatory  conditions  of  the 
endometrium,  and  in  his  hands  had  certainly  been  productive 
of  very  great  benefit.  The  patient  had  progressed  beyond  the 
usual  danger  point  and  was  delivered  safely  at  term.  Labor  was 
easy  and  rapid,  child  a  magnificent  specimen  and  free  from 
every  blemish,  was  now  more  than  a  year  old,  and  had  been 
singularly  exempt  from  the  usual  infantile  maladies.  The  pla¬ 
centa  was  healthy. 

The  speaker  said  that  Galabin  spoke  of  inflammation  of 
the  decidua  which  might  arise  from  previous  endometritis 
existing  prior  to  conception,  and  it  might  exist  in  the  vera, 
or  reflexa,  or  serotina.  He  said  the  study  of  inflammation  in 
this  situation  was  difficult,  because  the  cell  proliferation  of  the 
decidua  was  analogous  to  that  which  took  place  in  the  inflam¬ 
matory  process;  it  was  the  inflammatory  process  in  the  decidua 
serotina  which  chiefly  affected  the  placenta.  Symptoms  of  this 
trouble  were  soreness  and  tenderness  over  the  uterine  globe, 
but  might  be  entirely  absent.  The  same  author  above  quoted 
said  that  fatty  degeneration  might  be  partial,  and  then  the 
foetus  might  be  born  alive,  but  that,  when  “extensive,  it  may 
directly  kill  the  foetus  by  cutting  off  the  supply  of  blood.” 
Parvin  ( Science  of  Obstetrics)  spoke  of  the  distinction  made  by 
Dr.  R.  Barnes  between  fatty  degeneration  and  fatty  metamor¬ 
phosis:  “The  former  begins  in  the  living,  the  latter  is  found 
in  the  dead  tissues.”  In  Cazeaux  and  Tarnier  was  found 
the  expression  of  doubt  as  to  the  ability  to  fix  the  symptoma¬ 
tology  of  this  lesion,  there  being  only  evidence  of  uterine  con¬ 
gestion,  manifested  in  some  cases  by  weight  in  the  lower  part 
of  the  abdomen  and  pain  in  the  loins  and  down  the  thighs.  But 
these  symptoms  might  be  present  when  other  placental  lesions-' 
existed.  There  might  be  apoplexy,  sclerosis,  syphilitic  disease, 
cancer,  etc.  It  was  not  pertinent  to  the  subject  under  discus¬ 
sion  to  consider  these,  nor  would  time  or  space  permit.  He 
had  been  led  to  consider  the  subject  from  its  present  standpoint 
becanse  of  the  success  attending  the  treatment  of  repeated  pre¬ 
mature  delivery,  based  upon  the  theory  enunciated,  and  because, 
in  the  light  of  such  success,  it  might  point  the  solution  to  some 
case  of  similar  difficulty. 

Supplementary  to  his  paper  and  in  reply  to  questions,  Dr. 
Upshur  called  attention  to  Galabin’s  opinion  that  a  peculiar 
pinkish  color  of,  and  the  presence  of  watery  gummata  in,  the 
placenta  was  evidence  of  syphilitic  disease  of  that  organ.  But 
he  was  satisfied  of  the  absence  of  any  syphilitic  taint  in  the 
case  reported.  The  success  of  the  alterative  treatment  might 
also  suggest  syphilis.  But  he  had  seen  decided  improvement 
in  simple  endometritis  from  the  exhibition  of  the  chloride  of 
gold  and  sodium.  He  ascribed  the  good  result  in  the  above- 
cited  case  principally  to  the  use  of  that  salt.  The  general  health 
of  the  patient  was  good. 

Dr.  Hugh  M.  Taylor  was  reminded  of  a  patient  who  had 
lost  her  first  three  children  at  about  the  eighth  month.  In  all 
of  these  pregnancies  preventive  treatment  had  been  adopted. 
Subsequently  she  had  had  three  children  ;  no  preventive  treat¬ 
ment  had  been  attempted,  and  all  of  the  last  three  children  had 
been  born  alive,  strong,  and  robust.  He  thought  we  sometimes 
credited  medicine  with  alterative  influence  which  it  did  not  de¬ 
serve. 

Dr.  Moore  did  not  think  that  conception  could  take  place 
in  a  uterus  which  at  the  time  of  connection  was  the  subject  of 
corporeal  endometritis.  The  leucorrhoea  consequent  upon  such 
diseased  condition  effectually  impaired  the  vitality  of  the  sper¬ 
matozoa,  or  by  its  flow  washed  the  ovum  from  the  uterine 
cavity.  But,  even  if  conception  took  place,  it  was  impossible 
for  gestation  to  progress  safely,  and  abortion  or  miscarriage  re¬ 


sulted.  Where  conception  took  place  in  a  healthy  uterus  and 
endometritis  subsequently  occurred,  the  pathological  changes 
consequent  upon  inflammation  of  the  endometrium  precluded 
the  possibility  of  a  continuation  of  pregnancy  to  term.  Where 
the  neck  only  was  involved,  conception  and  delivery  at  term 
might  occur.  But,  when  both  neck  and  body  were  diseased, 
non-conception  was  the  rule.  Placental  disease  proper  was  fre¬ 
quently  secondary.  Various  morbific  conditions  of  the  blood 
brought  about  abortions — such  as  continued  or  the  eruptive 
fevers  and  syphilis,  especially  secondary.  In  tertiary  syphilis 
the  patient  frequently  went  to  full  term.  Congestions  and  other 
interferences  with  the  circulation  occasioned  by  flexions  or  ver¬ 
sions  produced  fatty  or  amyloid  degeneration,  or  general  uter¬ 
ine  contraction  sufficient  to  detach  the  membranes.  Retro- 
flexions  were  especially  fruitful  in  these  bad  results. 

Dr.  Upshur  did  not  think  that  the  failure  to  abort,  in  the 
case  of  his  patient,  could  be  ascribed  to  coincidence  as  suggested 
by  Dr.  Taylor.  He  referred  to  other  cases  of  endometritis  not 
connected  with  pregnancy  in  his  practice  that  had  been  bene¬ 
fited  by  this  treatment.  A  case  yielding  to  iodide  of  potassium 
or  bichloride  of  mercury  did  not  necessarily  imply  syphilitic  taint. 
It  was  not  common  for  conception  to  take  place  where  there  was 
an  existing  endometritis,  especially  of  the  cervix ;  but  where 
there  was  latent  endometritis  before  marriage  it  might  be  de¬ 
veloped  by  pregnancy.  This  patient  had  had  a  dysmenorrhoea 
before  marriage,  but  had  not  been  treated  for  it,  as  conception 
took  place  so  quickly  he  did  not  have  the  opportunity. 

Convulsions  following  the  Ingestion  of  Unsound  Oysters. 
— Dr.  Upshur  had  been  recently  called  to  see  a  lady  of  usually 
robust  health.  He  had  found  her  with  decided  trismus— spas¬ 
modic  contraction  of  both  flexor  and  extensor  muscles  of  hands 
and  of  the  lower  extremities  ;  spasms,  both  violent  and  painful, 
lasting  several  minutes,  and  excited  by  a  slight  draft  or  current 
of  air.  There  had  been  no  wound  to  give  origin  to  suspicion  of 
traumatic  tetanus,  and  no  probability  of  her  having  obtained 
strychnine.  But  it  seemed  she  had  eaten  a  few  raw  oysters  the 
day  before,  when  the  weather  was  warm.  The  convulsions  had 
been  accompanied  by  choleraic  symptoms — nausea,  vomiting, 
and  purging,  but  no  collapse.  He  had  administered  morphine 
hypodermically  and  chloroform  by  inhalation,  and  had  further 
controlled  them  by  twenty-grain  doses  of  bromide  of  potassium 
every  two  hours.  He  was  satisfied  that  the  convulsions  were 
due  to  eating  unsound  oysters. 

The  President  reported  a  case  of  convulsions  in  a  mulatto 
child  whom  he  had  relieved  of  an  attack  of  nausea  a  month 
before  by  the  use  of  carbolic  acid.  There  had  been  four  or  five 
convulsions  daily,  accompanied  by  a  profuse  flow  of  saliva. 
Suspecting  worms,  a  vermifuge  had  been  administered  with 
negative  result.  He  had  then  given  an  emetic  of  sulphate  of 
zinc  without  relief.  The  fourth  day  he  had  been  present  during 
the  convulsions,  which  were  confined  to  the  upper  portion  of 
the  body  and  the  upper  extremities.  He  thought  them  due  to 
ingestion  of  some  insoluble  substance.  The  patient  had  been 
rubbed  with  croton  oil  along  the  spine  last  night,  and  was  bet¬ 
ter  this  morning. 

Dr.  Hoge  thought  the  convulsions  due  to  some  preputial 
trouble. 

Angina  Pectoris, — Dr.  Edward  T.  Baker  reported  a  case 
of  this  affection  supposed  to  be  caused  by  depressed  fracture  of 
the  skull.  He  had  called  to  see  a  white  man  aged  thirty  ;  height, 
six  feet  two  inches;  weight,  two  hundred  and  five  pounds; 
very  muscular ;  occupation,  striker  in  a  blacksmith-shop.  Prior 
to  1884  (when  he  had  received  the  injury  to  his  head)  he  had 
not  seen  a  day’s  sickness  in  his  life.  This  injury  had  left  him 
with  a  depression  on  the  left  side  of  his  head,  on  a  level  with 
the  top  of  and  an  inch  posterior  to  the  margin  of  the  ear,  and 


584 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mien.  Joor., 


one  inch  and  a  quarter  from  the  tip  of  the  mastoid  process. 
The  depression  had  measured  an  inch  from  the  upper  to  the 
lower  margin,  and  an  inch  and  a  half  from  the  anterior  to  the 
posterior  margin.  He  was  confined  to  his  bed  eight  months 
after  receipt  of  the  injury.  After  he  was  able  to  go  about  he  had 
had  an  attack  of  angina  pectoris,  and  had  had  as  many  as  three 
a  week  since  that  time.  Sometimes  he  would  not  have  one 
for  a  month,  -when  they  would  return  with  increased  severity. 
He  had  been  treated  by  a  number  of  doctors  without  relief.  He 
noticed  that  he  had  had  more  attacks,  and  they  had  been  much 
more  severe  in  character,  since  he  had  had  la  grippe  last  March. 
A  stethoscopic  examination  of  his  chest  had  revealed  the  heart 
sounds  normal,  but  a  little  wyeaker  than  seemed  in  keeping  with 
his  fine  physique  and  general  strength.  He  had  some  dyspeptic 
symptoms,  for  which  elix.  lactopeptine  was  prescribed.  The 
speaker’s  objects  in  reporting  this  case  were — 

1.  To  get  the  opinions  and  advice  of  the  older  members  of 
the  Academy  in  regard  to  the  advisability  of  using  nitrite  of 
amyl  in  this  case.  As  the  patient  noticed  that  when  he  got 
very  warm,  and  especially  when  he  lowered  his  head  in  stoop¬ 
ing,  it  gave  him  pain  in  the  back  of  the  head  just  above  the 
neck,  and  that  he  would  become  unconscious  unless  the  upright 
position  was  immediately  resumed;  as  amyl  produced  about 
the  same  effect  (vertigo,  dizziness,  and  flushing  of  the  face — in 
other  words,  temporary  hyperaemia),  was  it  not  advisable  to 
use  it,  and  thus  substitute  unconsciousness  due  to  congestion  of 
the  brain  for  angina  pectoris? 

2.  Could  we  attribute  the  angina  pectoris  to  the  blow  on 
the  head  which  might  have  fraefured  the  inner  table  of  the 
skull,  and,  by  irritation  of  that  portion  of  brain,  so  interfered 
with  the  action  of  the  pneumogastic  nerve  as  to  cause  the  heart 
trouble  ? 

3.  Could  he  not  be  operated  on  and  the  depressed  bone 
raised  from  the  brain,  and  thus  relieve  both  conditions? 

He  said  that  he  had  been  repeatedly  told  by  physicians  that 
the  wound  was  too  low  down  to  be  operated  on.  He  was  now 
taking  sodium  bromide,  compound  spirit  of  ether,  and  aromatic 
spirit  of  ammonia  three  times  daily,  and  every  two  hours  when 
threatened  with  attacks.  The  speaker  further  said  that  the  at¬ 
tacks  were  not  more  frequent  in  the  recumbent  position  or  at 
night;  mind  clear,  and  that  he  thought  there  was  chronic  con¬ 
gestion  or  inflammation  about  the  brain. 

The  President  thought  it  a  clear  case  for  operation. 

Dr.  Upshur  had  seen  a  case  that,  in  regard  to  epilepsy,  was 
similar  to  Dr.  Baker’s.  The  skin  over  the  temple  had  been  cut 
by  a  falling  timber.  No  ascertainable  depression.  Epileptic 
attacks — two  or  more  daily — had  soon  followed,  dulling  men¬ 
tal  action.  The  skull  had  been  trephined,  and  upon  the  inner 
table  of  the  button  of  bone  removed  had  appeared  a  deposit 
of  callus,  indicating  that  there  had  been  fracture.  There  had 
been  no  convulsions  for  a  week  succeeding  operation,  but  at 
the  end  of  that  time  he  had  fallen  forward  on  his  face — dead. 
Another  case  was  that  of  an  inmate  of  the  Central  Lunatic 
Asylum.  He  had  been  struck  on  his  head  with  an  axe  in  1862, 
and  a  piece  of  bone  had  been  driven  on  the  brain.  The  patient 
had  become  violently  insane,  but  there  had  been  no  epileptic 
convulsions.  He  had  been  trephined  by  Dr.  Hunter  McGuire 
in  1869.  He  had  been  perfectly  rational  upon  recovery  from 
the  operation,  and  had  taken  up  the  thread  of  events  from  the 
time  he  was  struck,  the  intervening  period  being  a  blank.  Sub¬ 
sequently  he  had  died  of  cerebritis. 

Dr.  Hugh  M.  Taylor  had  recently  had  a  case  somewhat 
similar  to  that  cited  by  Dr.  Baker.  A  railroad  employee  had 
received  an  injury  in  the  same  region,  remaining  unconscious 
for  thirty-six  hours  thereafter,  when  his  mind  had  cleared. 
There  was  no  fracture  of  the  skull  diagnosticated.  He  had 


suffered  pain  over  the  frontal  region ;  the  left  eye  had  been 
blood-shot  and  protruded,  evidently  from  some  cerebral  lesion. 
He  had  continued  this  way  for  two  or  three  weeks.  In  six 
weeks  he  had  begun  suffering  from  vertigo,  increased  pain,  and 
depression  of  the  cerebral  functions,  amounting  almost  to  coma- 
This  had  been  followed  by  a  discharge  of  pus  from  the  ear  and 
“  Cheyne-Stokes  ”  respiration.  Abscess  of  brain,  probably  due 
to  depression,  had  been  diagnosticated.  After  consultation 
with  Dr.  C.  W.  P.  Brock,  it  had  been  decided  to  trephine, 
but  the  patient  had  died  on  the  night  before  the  day  selected 
for  operation.  Post-mortem  examination  had  revealed  cere¬ 
bral  abscess  containing  an  ounce  of  pus.  The  speaker  was 
satisfied  that  he  should  have  trephined. 

Another  case  of  abscess  of  the  brain  was  reported  by  Dr.  M. 
D.  Hoge,  Jr.  Two  weeks  ago  he  had  seen  in  consultation  a 
workman  with  suspicious  history  of  previous  syphilis.  He  had 
been  semi-comatose  for  two  days.  There  was  abscess  of  the 
skin  on  the  right  frontal  eminence;  left  leg  paralyzed;  bowels 
and  bladder  under  complete  control;  respiration  accelerated; 
pulse  very  quick  and  small;  temperature,  104°  F.  On  account 
of  the  feeble  and  uncertain  condition  of  the  heart,  it  was  decided 
not  to  trephine.  He  was  put  upon  drachm  doses  of  potassium 
iodide  every  four  hours.  Sixteen  hours  later  be  had  died,  pa¬ 
ralysis  having  rapidly  extended  to  all  four  extremities.  The 
skull  was  trephined  at  post-mortem  at  a  point  selected  in  dis¬ 
cussing  operation  the  day  before;  dura  mater  pale  and  thick¬ 
ened,  a  smoothly-lined  pus  cavity  lying  beneath  of  the  size 
and  shape  of  a  guinea-fowl’s  egg,  occupying  the  right  frontal 
lobe,  and  filled  with  thin,  offensive  fluid.  There  was  no  ap¬ 
parent  communication  between  the  external  abscess  and  the 
interior  of  the  cranium. 

Dr.  Taylor  thought  the  cerebral  abscess  might  have  been 
secondary,  as  subpericranial  suppuration  might  find  its  way  into 
the  skull  by  extension  along  the  venous  sinuses  leading  into  the 
cranium.  A  cerebral  abscess  not  infrequently  occurred  as  a  re¬ 
sult  of  phlebitis  of  the  diploic  veins. 

The  President,  in  calling  attention  to  the  occasional  pres¬ 
ence  of  serious  brain  trouble  without  significant  symptoms, 
spoke  of  a  patient  who  had  suffered  for  some  days  with  frontal 
headache  and  then  had  fallen  suddenly  dead.  The  post-mortem 
had  revealed  an  ounce  of  pus  just  back  of  the  frontal  sinus. 
Cerebral  abscess  was  a  frequent  cause  of  death  in  children.  He 
had  seen  a  child  with  bluish  boils  about  the  neck  which  he  had 
opened,  and  he  had  been  surprised  to  hear  of  death  from  con¬ 
vulsions  on  the  next  day.  The  post-mortem  showed  extensive 
softening  of  the  brain,  which  had  evidently  been  diseased  for 
some  time.  Another  case  was  that  of  a  ten-year-old  boy  whose 
skull  had  been  fractured  by  a  wagon-wheel  passing  over  it, 
death  occurring  several  weeks  subsequently.  His  mind  had 
been  clear  to  within  a  few  hours  of  death.  The  post-mortem  had 
shown  disorganization  of  the  whole  top  of  the  brain.  Query, 
Where  was  the  seat  of  intelligence?  The  speaker  then  spoke 
of  several  cases  of  atypical  typhoid  fever  that  had  recently  come 
under  his  observation  in  which  there  had  been  no  heat  of  the 
skin,  no  furred  tongue,  and  no  loss  of  appetite  for  fluids,  attend¬ 
ed  with  emaciation  and  prostration.  One  had  terminated  in  fif¬ 
teen,  another  in  thirty  days.  In  treating  typhoid,  the  points  to 
be  guarded  were  the  brain,  lungs,  and  bowels.  He  gave  an 
abundance  of  good  milk  and  toddy.  He  had  given  a  girl  one 
quart  of  whisky  every  day  for  six  weeks.  He  thought  it  great¬ 
ly  reduced  the  temperature.  For  the  diarrhoea  he  gave  a  mixt¬ 
ure  of  turpentine,  kino,  paregoric,  and  bismuth. 

Dr.  J.  W.  Henson  reported  a  case  of  fever  which  he  was  un¬ 
able  to  classify.  There  had  been  at  first  griping  pains  over  the 
abdomen  which  had  been  somewhat  distended,  but  no  tender¬ 
ness  or  pain  on  pressure.  Fever  had  run  a  regular  course  of 


Nov.  22,  1890. J 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


585 


morning  remission  and  evening  exacerbation.  Morning  tem¬ 
perature  from  99°  F.  to  99°  +  ,  evening  from  100°  F.  to  100°+  ; 
occasionally  entire  absence  of  fever  for  days.  Pulse  rapid  and 
weak.  The  patient  had  suffered  greatly  at  times  from  cardiac 
weakness  and  a  sense  of  impending  death.  He  had  been  re¬ 
vived  by  stimulants.  There  had  been  slight  delirium  at  times. 
He  had  suspected  lung  trouble,  but  physical  examination  had 
given  no  evidence  thereof.  The  patient  had  been  treated  at 
first  by  mercurial  purgative,  followed  by  quinine,  with  a  tonic 
of  iron  and  arsenic  and  dilute  nitro-hydrochloric  acid ;  milk 
diet,  and  later  whisky  in  frequently  repeated  doses.  The  pa¬ 
tient  had  fattened  while  in  bed.  Suspecting  local  influence  as 
a  cause,  he  had  sent  her  to  the  country  for  the  month  of  June. 
She  had  menstruated  regularly  till  the  beginning  of  sickness, 
when  she  had  missed  one  or  two  periods.  There  had  been  no 
evidence  of  scrofula.  She  was  first  taken  sick  last  December, 
and  still  had  fever,  but  was  otherwise  apparently  well. 

Dr.  W.  S.  Gordon  had  recently  been  consulted  by  a  lady 
just  from  a  malarial  district  where  she  had  been  nursing  a  ty¬ 
phoid  patient.  She  had  fever  and  had  been  taking  large  doses 
of  quinine.  In  each  week  she  would  have  fever  for  four  days 
and  be  free  from  it  the  succeeding  three.  Examination  of  the 
lungs  had  revealed  a  slight  subcrepitant  rale  at  the  apex  of  the 
right  lung.  She  had  no  cough,  but  was  emaciated  ;  no  history 
of  previous  pneumonia.  She  had  been  put  on  creasote  and 
whisky,  followed  by  improvement.  She  had  been  sent  to  the 
country,  and  on  return  there  still  had  been  slight  fever. 

The  President  was  satisfied  that  phthisis  might  exist  in  its 
earlier  stages  when  there  was  no  cough  and  no  evidence  of  its 
presence  was  furnished  by  physical  signs;  and  he  thought 
that  Dr.  Henson’s  patient  had  consumption. 


Reports  on  tlj*  |)ra0wss  of  Iftcbixine. 


HYGIENE. 

By  S.  T.  ARMSTRONG,  M.  D„  Ph.  D. 

Public  Disinfecting  Chambers. — According  to  Le  Mercredi  medical 
of  July  30,  1890,  the  municipal  council  of  Paris  has  voted  for  the 
establishment  of  disinfecting  chambers  for  the  use  of  Hotel  Dieu, 
Charite  Hospital,  Necker  Hospital,  Laennec  Hospital,  Broussais  Hos¬ 
pital,  and  the  two  lying-in  clinics.  At  the  Beaujon  Hospital  the  cham¬ 
ber  is  to  be  used  by  the  public  as  well  ,gs  the  institution.  The  total 
cost  will  be  120,94*7  francs.  The  advantages  that  these  free  disinfect¬ 
ing  establishments  offer  needs  no  comment. 

Disinfection  by  Gases. — Dr.  J.  E.  Gaillard,  in  a  Paris  thesis  of  1889, 
reports  a  number  of  experiments  on  the  germicidal  action  of  nitrous- 
acid  and  sulphurous-acid  gases  on  pure  cultures  of  different  micro¬ 
organisms  ( Staphylococcus  pyogenes  aureus ,  comma  bacillus,  bacteria  of 
eharbon,  bacillus  of  green  diarrhoea,  typhoid  fever,  pneumococcus,  etc.), 
and  also  on  inferior  organisms  contained  in  the  atmosphere  of  a  room. 
He  concludes :  • 

1.  Nitrous-acid  gas  is  a  powerful  disinfectant,  but  difficult  to  em¬ 
ploy  practically  on  account  of  its  corrosive  action. 

2.  Sulphurous-acid  gas  has  an  evident  microbicidal  action  on  germs 
in  the  air. 

3.  Sulphurous-acid  gas  should  be  employed  to  disinfect  contami¬ 
nated  localities,  in  the  strength  of  forty  grammes  to  the  cubic  metre 

of  air. 

4.  The  action  of  sulphurous-acid  gas  is  exercised  very  energetically 
in  the  presence  of  moisture,  hence  the  precept  to  saturate  disinfecting 
chambers  with  steam. 

Permanent  Aeration  of  Rooms  by  Open  Windows. — Dr.  Nicaise,  in 
the  Bulletin  de  V  Academie  de  med.  of  the  25th  of  February,  1890,  refers 


to  Raulins’s  suggestion,  in  1752,  that  tuberculous  patients  should  live 
in  rooms  with  the  windows  kept  open,  and  to  Dettweiler’s  application 
of  this  method  of  treatment — with  regulated  and  generous  alimentation 
— at  Falkenstein.  At  this  place  132  positive  recoveries  had  been  ob¬ 
tained  in  1,022  tuberculous  patients,  while  110  more  patients  were  ap¬ 
parently  cured.  Nicaise,  in  order  to  ascertain  the  value  of  this  method 
of  treating  tuberculosis,  experimented  for  several  months  on  the  tem¬ 
perature  of  the  external  air  and  that  of  a  room  with  a  window  con¬ 
stantly  opened  to  the  southeast,  the  window  blinds  being  shut  at  the 
close  of  day.  He  ascertained  from  minimal  temperature  readings, 
taken  each  day,  that  the  temperature  of  the  room  oscillated  between 
ten  and  fourteen  degrees  centigrade.  The  author  explained  the  main¬ 
tenance  of  the  constant  temperature  by  the  stirring  up  of  heat  during 
the  day,  and  its  emission  during  the  night,  by  the  walls  of  the  room 
and  the  objects  that  it  contained.  [In  his  paper,  however,  he  makes 
no  mention  of  the  germicidal  influence  exercised  by  the  free  sunlight  in 
the  room ;  that  is  probably  as  beneficial  as  the  aeration  and  tempera¬ 
ture  regulation.] 

Cancer  of  the  Stomach  in  Switzerland. — Dr.  H.  Hoeberlin,  in  the 
Deutsches  Arch.  f.  klin.  Med.,  xliv,  p.  461,  finds  that  cancer  of  the 
stomach  is  encountered  twice  as  often  in  Switzerland  as  in  Berlin  or 
Vienna.  Among  2,500  persons,  one  will  die  each  year  from  this  disease  ; 
1'85  per  cent,  of  all  deaths  are  due  to  it ;  and  from  1877  to  1886  cancer 
of  the  stomach  increased  in  the  proportion  of  100  to  165  for  men,  and 
of  100  to  158  for  women.  General  cancerous  diseases  are  more  fre¬ 
quent  in  Switzerland  than  in  Prussia,  Vienna,  or  England,  women  be¬ 
ing  more  subject  to  such  diseases  than  men.  Cancer  of  the  stomach 
bears  the  proportion  to  the  total  mortality  from  cancer  of  31 '9  per 
cent,  in  women  and  51-8  per  cent,  in  men ;  and  in  Zurich  it  is  twice  as 
frequent  in  women  as  cancer  of  the  uterus,  while  in  Vienna  the  con¬ 
trary  is  true. 

The  influences  of  season,  profession,  city  life,  country  life,  or 
the  wealth  of  the  individual,  seem  to  have  no  effect  in  preventing  the 
disease.  But  it  does  seem  that  the  use  of  cider  and  of  acid  wine  in¬ 
creases  the  predisposition  to  cancer  of  the  stomach.  Heredity  seems 
to  have  some  influence,  eight  per  cent,  of  the  patients  observed  having 
had  parents  die  of  cancer  of  the  stomach.  Possibly  a  bad  condition  of 
the  teeth  influences  the  development  of  gastric  carcinoma. 

Cancer  in  Normandy. — Dr.  Arnaudet,  in  a  paper  in  La  Normandie 
medicate ,  April,  1890,  makes  a  study  of  the  proportion  of  deaths  from 
cancer  in  some  cities  (Rouen  and  Havre)  and  communities  in  Nor¬ 
mandy.  He  believes  that  there  is  an  excessive  mortality  from  cancer 
in  certain  regions  in  Normandy,  and  that  the  existence  of  the  disease  in 
certain  foci  and  its  recurrence  in  certain  houses,  as  well  as  its  epidemic 
character,  point  to  the  action  of  a  local  cause  that  is  external  to  the 
organism.  The  great  predominance  of  cancer  of  the  abdominal  viscera 
over  cancerous  affections  of  other  localities  proves  the  importance  of 
the  ingesta  as  exciting  causes.  Water  and  cider,  that  is  largely  used 
as  a  beverage  in  this  locality,  should  be  judged  as  possible  causes  as 
well  as  habitations.  Houses  where  deaths  from  cancer  have  occurred 
are  contaminated  and  should  be  rigorously  disinfected. 

An  Examination  of  the  Soil  of  Old  Cemeteries. — Dr.  L.  de  Blasi  and 
Dr.  G.  Russo  Travali  have,  according  to  the  Revue  des  sciences  medicates 
for  July,  made  an  examination  of  the  bacteriological  characteristics  of 
the  air  and  soil  of  the  old  cemeteries  of  Palermo.  They  found  no 
greater  number  of  micro-organisms  in  the  air  and  soil  from  these 
places  than  in  other  localities  in  the  city.  Without  counting  muce- 
denes,  they  found  twenty-seven  species  of  schizomycetes,  none  of  which 
were  pathogenic.  This  observation  confounds  the  prevalent  idea  of 
the  noxiousness  of  the  soil  of  old  cemeteries. 

The  Frequency  of  Tuberculosis  in  Northern  and  Southern  Coun¬ 
tries. — In  a  general  way  it  has  been  accepted,  says  Dr.  G.  Wykowski 
in  the  Viertelj.  f.  gericht.  Med.,  p.  339,  1890,  that  the  mortality  from 
phthisis  pulmonalis  is  diminished  in  high  northern  latitudes  and  in¬ 
creased  in  southern  countries.  Yet  in  the  most  northern  cities  of  Fin¬ 
land  and  Norway  the  mortality  from  tuberculosis  is  from  2 '3  to  3‘4  in  a 
thousand  living  inhabitants,  while  in  southern  Italy  it  is  but  17  in  a 
thousand  living  ;  so  statistics  refute  current  opinion.  If  the  statistics 
of  the  different  parishes  of  Norway  are  compared,  it  is  evident  that 
the  mortality  from  tuberculosis  decreases  as  we  go  north  ;  but  in  Fin- 


586 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


land  an  increase  in  the  mortality  is  noted  in  the  northward  movement. 
In  the  north  of  Finland,  the  population  of  which  is  3  per  cent.  Lap¬ 
landers,  the  mortality  from  tuberculosis  is  2-7  to  a  thousand  living, 
while  in  the  same  latitude  in  Norway,  with  a  population  of  85  per  cent. 
Laplanders,  the  mortality  from  tuberculosis  is  18  to  a  thousand.  The 
decrease  of  tuberculosis  in  the  latter  country  corresponds  to  the  de¬ 
crease  of  a  mining  and  industrial  population  and  the  large  proportion 
of  people  living  in  the  open  air — the  same  reason  that  exists  for  the 
difference  in  the  number  of  cases  of  tuberculosis  in  the  city  and 
country. 

To  compare  these  figures  with  those  of  Italy,  we  find  only  in  north¬ 
ern  and  central  Italy  the  mortality  from  tuberculosis  reaching  2-3  to  a 
thousand  living  inhabitants,  while  in  southern  Italy  it  is  only  l-7  to  a 
thousand,  in  Sardinia  1*4,  and  in  Sicily  I '3. 

The  Prophylaxis  of  Tuberculosis  at  Meran. — According  to  the  Revue 
des  sciences  medicates  for  July,  the  municipality  of  Meran  has  passed  a 
police  regulation  forbidding  the  use  of  spittoons  made  of  anything  else 
than  porcelain,  stoneware,  or  enameled  metal,  in  taverns,  restaurants, 
boarding  houses,  or  rooms  occupied  by  strangers.  The  spittoons  must 
contain  only  pure  water,  and  must  be' cleansed  daily.  The  use  of  saw¬ 
dust  in  spittoons  is  prohibited. 

The  Distribution  of  Tuberculosis  in  Switzerland  according  to  Alti¬ 
tude. — Dr.  L.  Schroeter,  in  the  Viertelj.  f.  gericht.  Med.  und  bffentl. 
Sanit.,  li,  1889,  p.  125,  has  studied  the  official  statistics  for  eleven  years 
— from  1876  to  1886 — having  had  at  his  disposal  numerous  and  exact 
documents.  He  concludes  that  in  Switzerland  the  annual  mean  of 
deaths  caused  by  pulmonary  tuberculosis  is  2*31  to  a  thousand  living  in¬ 
habitants  ;  there  are  105  deaths  from  tuberculosis  in  a  thousand  deaths 
from  all  causes.  The  greatest  mortality  from  tuberculosis  is  in  the 
cantons  of  Appenzell,  Bale-Ville,  and  Geneva  ;  the  lowest  mortality  is 
in  Uri,  Haut-Unterwald,  and  Schaffouse. 

At  an  altitude  of  200  to  400  metres  there  are  112  deaths  from  tu¬ 
berculosis  in  a  thousand  deaths  from  all  causes ;  at  an  altitude  of  from 
400  to  700  metres,  105  deaths  from  tuberculosis  in  a  thousand;  at  700 
to  900  metres,  106  deaths  in  a  thousand;  at  900  to  1,200  metres,  92 
deaths  in  a  thousand;  above  1,200  metres,  71  deaths  in  a  thousand. 

Tuberculosis  is  endemic  in  all  Switzerland.  The  mortality  from  this 
disease  does  not  decrease  either  regularly  or  proportionally  in  compari¬ 
son  with  what  is  believed  of  altitude.  The  mortality  is  regularly  in¬ 
creased  as  the  proportion  of  the  industrial  population  increases ;  for 
equal  altitudes,  the  industrial  districts  have  a  greater  mortality  from 
tuberculosis  than  the  agricultural  districts. 

The  Influence  of  the  Level  of  Subsoil  Water  on  the  Diffusion  of 
the  Typhoid  Bacillus. — According  to  the  Revue  des  sciences  medicates 
for  July,  1890,  Dr.  L.  de  Blasi  has  recently  published  at  Palermo  the 
results  obtained  with  inoculations  of  the  typhoid  bacillus  in  cylinders  of 
soil,  with  necessary  subsoil  water  levels.  He  concludes  : 

1.  That  the  typhoid  bacillus  preserves  its  vitality  in  the  soil  at  the 
end  of  eighty-six  days. 

2.  That  it  is  not  diffused  in  the  soil  more  than  ten  centimetres  above 
the  position  in  which  it  is  placed. 

3.  But,  in  depth,  it  is  found  from  twenty  to  thirty  centimetres  be¬ 
low  the  site  of  inoculation,  this  diffusion  depending  upon  the  level  of 
the  subsoil  water. 

The  Influence  of  Sand  Filters  on  the  Water  of  Zurich  and  Ber- 
lin- — According  to  the  Revue  des  sciences  medicates  for  July,  Bertschin- 
ger  has  formulated  the  following  conclusions  regarding  the  Zurich  wa¬ 
ter  supply : 

1.  The  filtration  by  sand  that  is  employed  at  Zurich  produces  an 
essential  purification  of  the  water  of  the  lake. 

2.  Normally  the  filter  furnishes  water  free  from  germs  ;  vet,  some 
time  after  filtration,  the  water  will  contain  a  small  number  of  bacteria. 

3.  The  swiftness  of  filtration  (at  least  within  the  limits  of  three  to 
twelve  metres  a  day)  has  no  influence  on  the  character  of  the  water — 
that  is  to  say,  filtered  water  gives  the  same  results  by  chemical  analysis, 
and  contains  an  equal  number  of  bacteria,  whether  filtration  has  been 
more  or  less  rapid,  the  water  of  the  lake  yielding  all  its  cryptogamic 
germs  to  the  superior  layer  of  sand. 

4.  At  first,  after  cleansing  the  filter,  its  action  is  not  normal,  and 
consequently  the  filtered  water  then  contains  a  much  greater  proportion 


IN.  Y.  Med.  Jofr., 

of  germs,  though  the  cleansing  of  the  filter  does  not  exercise  any  appre¬ 
ciable  influence  on  the  quality  of  the  filtered  water. 

6.  When  the  filter  ceases  acting,  the  filtered  water  is  for  some  time 
richer  in  bacteria  than  usual.  The  multiplication  of  bacteria  is  due  to 
the  water  being  undisturbed.  But  a  chemical  analysis  of  the  water 
standing  in  the  filter  is  in  nowise  different  from  that  of  water  fresh 
from  the  filter  in  ordinary  working. 

6.  Neither  chemical  analysis  nor  bacteriological  examination  shows 
any  difference  in  the  action  of  a  filter  that  is  exposed  to  light  and  air 
from  that  of  a  covered  filter.  Each  of  these  filters  retains  in  the  same 
way  the  bacteria  of  the  unfiltered  water. 

Dr.  C.  Fraenkel  has  made  a  small  filter  of  sand  similar  to  the  large 
filters  that  have  been  proposed  for  the  purification  of  the  water  at  Ber¬ 
lin.  He  has  demonstrated  that  this  filter  allows  the  ordinary  bacteria 
of  water,  as  well  as  pathogenic  bacteria — such  as  typhoid  fever  and 
cholera  bacilli — to  pass.  The  number  of  micro-organisms  that  pass 
through  the  filter  is  in  proportion  to  the  number  of  micro-organisms 
that  are  in  suspension  in  the  water  to  be  filtered.  There  seems  to  be 
some  dependence  on  the  rapidity  of  filtration,  the  number  of  micro¬ 
organisms  increasing  when  the  filtration  is  rapid.  It  is  at  the  begin¬ 
ning  and  end  of  the  experiment  that  these  organisms  are  most  in¬ 
creased  ;  at  the  beginning,  because  the  filter  does  not  act  efficiently,  and 
at  the  end,  because  the  pressure  is  considerable,  and  perhaps  because 
the  bacteria  are  reproduced  in  the  filter  during  the  experiment.  There¬ 
fore  the  general  confidence  iu  sand  for  water  filtration  does  not  seem 
to  be  absolutely  justified. 

Charbon  in  Hair-workers  and  Tanners. — In  1887,  says  the  Oat. 
hebd.  des  sci.  med.,  a  commission  was  appointed  in  France  to  study 
charbon  and  the  measures  that  should  be  employed  for  disinfecting 
skins,  hair,  and  horns.  The  dried  hair  of  cows  and  horses  is  import¬ 
ed  in  large  quantities  from  South  America,  and  it  is  packed  in  bales 
of  four  to  five  hundred  kilogrammes  ;  as  soon  as  a  bale  is  opened,  the 
hair  is  picked  over  by  hand.  Preliminary  steam  disinfection  of  the 
hair  causes  such  deterioration  in  its  quality  that  this  process  can  not 
be  employed,  consequently  the  hair-worker  runs  considerable  risk.  The 
risk  run  by  tanners  is  evident,  and  from  1878  to  1889,  inclusive,  forty- 
nine  persons  with  charbon  were  admitted  into  the  St.  Denis  hospital. 
T.;e  conclusions  are  presented — 

1.  The  manipulation  of  French  hair  and  skins  entails  less  danger 
to-day  than  heretofore. 

2.  There  is  very  great  danger  in  working  in  similar  imported  products. 

3.  It  is  necessary  to  study  the  question  of  the  disinfection  of  for¬ 
eign  products  utilized  in  such  industries,  and  it  should  be  referred  to 
the  approaching  International  Congress  of  Hygiene. 

Freire’s  Yellow-fever  Inoculation. — Dr.  G.  M.  Sternberg,  in  a  paper 
on  this  subject  in  the  Journal  of  the  American  Medical  Association,  July 
26,  1890,  reviews  the  statistics  published  by  Freire  to  support  the  value 
of  his  method  of  protection  from  yellow  fever  by  inoculation.  Freire 
maintained  that,  of  1,183  persons  inoculated,  18  died  of  yellow  fever; 
that  is  1  in  every  66  vaccinated.  Dr.  Sternberg,  estimating  that  one  half 
the  population  (400,000)  of  Rio  de  Janeiro  had  been  protected  by  previ¬ 
ous  attacks  of  the  disease  or  long  residence  in  the  city,  accepts  Freire’s 
figures  that  the  total  mortality  from  yellow  fever  in  that  city  was  2,386, 
and  thus  demonstrates  that  in  the  susceptible  population  of  200,000 
only  1  in  84  persons  died  of  the  disease  Dr.  Sternberg  concludes  that 
a  careful  analysis  of  published  results  fails  to  prove  that  Freire’s  inocu¬ 
lations  have  any  prophylactic  value. 

Distinct  Species  of  Comma  Bacilli  in  Cholera. — In  the  May  number 
of  the  Indian  Medical  Gazette  Surgeon-Major  D.  D.  Cunningham — who 
recently  reported  failure  to  obtain  any  evidence  of  the  presence  of 
cultivable  comma  bacilli  in  the  discharges  of  cholera  patients  at  cer¬ 
tain  seasons  of  the  year — reports  that  in  certain  cases  that  in  general 
symptoms,  character  of  discharges,  and  fatality  are  undoubtedly  chol¬ 
era,  he  has  obtained  three  very  distinct  species  of  comma  bacilli.  These 
species  are  not,  as  a  rule,  associated  with  each  other,  are  independent 
of  the  character  of  the  cases  from  which  they  are  obtained,  but  are 
found  in  all  cases  coming  from  the  same  locality. 

Morphologically  there  seems  to  be  no  great  difference,  but  physio¬ 
logically  the  rate  of  growth  varies  in  rapidity  ;  and  on  potatoes  one 
forms  a  thick,  slimy,  creamy  stratum,  with  a  smooth,  glistening  surface 


Nov.  22,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


587 


and  prominent  lobulated  margins.  The  color  at  first  is  pale-yellowish, 
becoming  gradually  primrose,  and  ultimately  strong  yellow,  at  one  stage 
of  the  growth  resembling  a  stratum  of  thick  pus  ;  the  smell  is  yeasty 
and  vinous.  The  second  species  develops  as  a  thin,  diffuse  stratum,  aj 
first  white,  later  brown.  It  is  not  shiny  or  prominent,  and  the  odor 
is  mawkish  and  choleraic.  In  the  third  species  the  growth  is  at  first 
grayish-white,  later  pale  buff ;  it  is  prominent  and  dry-looking,  and 
raised  in  wrinkles  and  folds. 

Microscopically,  the  first  species  shows  at  first  distinct  commas,  but 
in  a  short  time  is  composed  of  micrococcoid  bodies  with  a  few  enor¬ 
mous  commas.  The  second  species  has  more  persistent  commas  of  con¬ 
siderable  thickness.  In  the  third  species  the  commas  are  imbedded  in 
a  tough,  zoogloear  mass  that  stains  deeply  with  gentian  violet. 

With  cultivations  in  nutrient  broth,  nitric  and  sulphuric  acids  (as 
ordinarily  employed  to  develop  cholera  purple)  with  the  first  species 
produce  flocculation  that  is  soon  deposited,  and  the  development  of  the 
purple  tint.  In  the  other  species  the  flocculation  is  persistent  for  many 
hours. 

The  author  believes  that  the  conflicting  statements  made  by  European 
observers  regarding  the  spore  formation  of  Koch’s  comma  bacillus  is 
caused  by  a  different  species  cf  this  bacillus  being  observed  by  the  dif¬ 
ferent  reporters. 

Vital  Statistics  in  France  and  Germany. — The  Journal  of  the 
American  Medical  Association  of  July  26,  1890,  makes  an  interesting 
comparison  of  the  vital  statistics  of  France  and  Germany.  In  1888,  in 
Germany,  there  were  376,654  marriages,  1,828,379  births,  and  1,209,793 
deaths.  In  that  year  in  France  there  were  276,848  marriages,  882,639 
births,  and  837,867  deaths.  In  Germany  the  births  exceeded  the  deaths 
by  618,581,  while  in  France  the  excess  of  the  former  was  only  44,772. 
In  considering  such  statistics  it  is  necessary  to  remember  that,  while  the 
area  of  the  two  countries  is  almost  the  same,  yet,  notwithstanding  the 
vaunted  economy  of  the  French,  their  country  supports  a  population 
averaging  a  little  more  than  187  to  the  square  mile,  while  Germany  has 
a  population  of  a  fraction  over  224  to  the  square  mile.  The  statistics 
of  some  years  past  show  that  there  is  an  increase  in  the  birth-rate  in 
Germany  and  a  decrease  in  France  ;  three  children  is  the  average  to 
each  family  in  the  latter  country,  the  voluntary  limitation  of  offspring 
being  due  to  a  desire  to  provide  for  the  future  of  children. 

In  Canada  the  French  descendants  believe  in  crescite  et  multipli- 
camini  ;  according  to  the  Lyon  medical  for  August,  the  Government  of 
the  province  of  Quebec  has  announced  the  intention  of  giving  one  hun¬ 
dred  acres  to  every  head  of  a  family  who  is  father  of  twelve  children. 
Two  farmers  have,  each,  35  children,  one  has  34,  and  one  21,  and  one 
gentleman  has  baptized  his  thirty-seventh  heir.  Families  of  twelve  are 
not  rare  ;  so  the  transplanted  French  stock  retains  its  vigor. 

The  Effect  of  Tropical  Countries  on  the  Number  of  Red  Corpuscles 
and  the  Haemoglobin. — Dr.  Marestang,  in  the  Revue  de  medeeine  for  June, 
gives  the  results  of  his  examinations  of  the  blood  of  sixteen  soldiers, 
while  on  a  voyage  from  France  to  New  Caledonia.  The  men  were  from 
twenty  to  twenty-two  years  of  age,  mostly  from  Breton,  at  sea  for  the 
first  time,  the  voyage  occupying  three  months  and  a  half,  of  which  two 
and  a  half  were  in  the  tropics.  The  examinations  were  made  at  inter¬ 
vals  of  fifteen  days  during  the  period  of  the  voyage,  the  percentage  of 
haemoglobin  being  estimated  bv  Melassez’s  hsemochromometer.  An 
average  of  the  examinations  shows  that  in  fourteen  the  number  of  red 
globules  increased  from  500,000  to  1,000,000  to  the  cubic  millimetre) 
while  in  two  it  diminished  120,000  and  228,000  corpuscles.  The  pro¬ 
portion  of  haemoglobin  was  increased  in  twelve  men  from  from  1  to  5 
per  cent.,  in  three  men  it  decreased  from  0-5  to  1’5  per  cent.,  and  in 
one  the  proportion  remained  stationary. 

He  abandoned  the  idea  that  the  increase  was  due  to  the  sea  air,  be¬ 
cause  he  found  in  seventeen  convicts  who  had  resided  from  five  to  ten 
years  in  New  Caledonia  an  average  of  5,770,000  red  corpuscles  and 
14-35  per  cent,  of  hemoglobin,  while  at  Tahiti,  in  twelve  marines 
that  had  resided  there  for  two  years  and  three  quarters,  he  found  an 
average  of  6,758,000  red  corpuscles  and  14-2  per  cent,  of  hemoglobin. 

These  results  demonstrate  that  in  Europeans  living  in  tropical  coun¬ 
tries,  who  have  not  incurred  disease,  there  is  an  increase  of  red  cor¬ 
puscles  and  of  hemoglobin.  Maurel,  at  Guadeloupe,  has  arrived  at  the 
same  conclusion  regarding  the  corpuscles. 


This  increased  activity  of  the  hematopoietic  functions  constitutes  a 
simple  phenomenon  of  supply  ;  the  excess  of  corpuscles  and  of  hemo¬ 
globin,  the  fixative  elements  for  oxygen,  has  no  other  end  than  that  of 
furnishing  to  the  organism  the  quantity  of  that  gas  that  is  necessary 

for  the  normal  accomplishment  and  regulation  of  its  functions _ to 

counterbalance,  in  another  word,  the  influence  of  the  meteorological 
elements.  Between  Europeans  living  at  home  and  those  living  in  the 
tropics  there  is,  from  a  physiological  point  of  view,  this  difference: 
that,  while  with  the  former  N  globules  and  haemoglobin  are  required 
for  the  absorption  of  oxygen,  with  the  second  class  N  +  n  is  required. 

The  Regulation  of  Prostitution  in  England  and  France. — The  cru¬ 
sade  against  the  contagious-diseases  act  in  England  has  resulted  in 
what  would  have  been  expected.  From  30  to  50  per  cent,  of  troops, 
quartered  in  garrison  towns,  are  on  the  sick  list  with  venereal  diseases, 
while  during  the  enforcement  of  the  law  the  proportion  so  affected  was 
very  small. 

In  France,  M.  Commenge  recently  stated  at  a  meeting  of  the  Academy 
of  Medicine  of  Paris  that  he  had  collected  the  statistics  of  the  number 
of  diseased  prostitutes  found  in  the  decade  from  1878  to  1887:  First, 
among  women  registered  by  houses  or  cards ;  second,  among  those 
women  that — though  registered — were  the  object  of  more  or  less  fre¬ 
quent  arrests,  and  constituted  a  special  class  under  the  name  of  femmes 
du  depot ;  third  and  lastly,  among  the  uninspected,  or  women  that  lived 
by  clandestine  prostitution. 

He  had  carefully  authenticated  his  figures,  and  the  results  obtained 
were  very  interesting.  The  women  registered  by  cards  were  paid  305,- 
799  visits;  there  were  found  3'12  cases  of  syphilis  in  1,000,  and  3‘06 
in  1,000  were  affected  with  diseases  other  than  syphilis.  Of  the 
women  registered  in  houses,  there  were  recorded  503,712  visits;  2'7 
cases  of  syphilis  in  1,000  were  found  in  this  class,  and  2-52  cases  in 
1,000  of  diseases  not  syphilitic.  To  the  femmes  du  depot  76,740  visits 
were  paid;  23'96  persons  in  1,000  were  syphilitic,  and  14'46  persons 
in  1,000  visits  were  affected  with  non-syphilitic  diseases.  To  the  un¬ 
inspected  women  2,704  visits  were  paid  ;  166  syphilitic  persons  in  1,000 
were  found,  and  134  in  1,000  had  diseases  other  than  syphilis. 

These  figures  demonstrate  the  greater  proportion  of  syphilis  among 
the  uninspected  prostitutes,  and  the  danger  of  the  propagation  of  svphi- 
lis  is  greatest  among  them.  In  the  language  of  Dr.  Commenge,  the 
poorer  women  are  inspected  for  those  that  are  diseased,  and  the  latter 
are  not  returned  to  circulation  until  cured.  The  unregistered,  on  the 
contrary,  continue  to  sow  syphilis  without  anything  being  done  to  re¬ 
strain  them. 

It  is  only  by  the  accumulation  of  such  statistics  that  the  fanatical 
sentiment  against  the  regulation  of  prostitution  can  be  overcome  and 
the  health  of  innocent  women  and  children  protected. 

The  Regulation  of  Prostitution.— Dr.  Thiry,  of  Brussels,  read  a 
paper  on  this  subject  before  the  International  Medical  Congress  (Le 
Mercredi  medical ,  August  20th),  in  which  he  states  that  prostitution  is 
not  only  due  to  moral  depravity,  but  principally  to  a  physiological  func¬ 
tion  that  is  absolutely  dominant  at  a  certain  age;  whether  desirable  or 
undesirable,  it  is  a  necessary  evil;  its  excess  may  be  repressed,  its 
dangers  may  be  limited,  but  it  can  not  be  extirpated.  He  holds,  with 
certain  fathers  of  the  Church,  that,  if  it  were  possible  to  suppress 
prostitution,  society  would  be  afflicted  by  libertinism  ;  there  would  be 
a  reproduction  of  the  syphilitic  epidemics  of  Rome  and  Naples  ;  there 
would  be  an  increase  of  seduction,  of  illegitimate  births,  of  adultery, 
of  i ape,  of  abortion,  etc.  This  necessary  issue  of  human  passion 
should  be  under  surveillance  and  regulated,  like  food,  sewers,  and  collec¬ 
tions  of  filth,  to  which  Parent  Duchatelat  compares  it.  Inspection  is 
the  sole  way  to  protect  prostitutes  and  those  that  use  them  from  dis¬ 
ease.  In  certain  countries  it  is  ignored  on  the  fallacious  theory  that  it 
antagonizes  liberty  and  the  dignity  of  women.  What  is  the  liberty 
that  exists  to  the  prejudice  of  public  health  ?  And  is  not  the  woman 
always  free  to  abandon  her  vocation  ?  Another  error  is  to  regard  pros¬ 
titution  as  a  crime.  The  following  propositions  were  submitted :  1 
The  regulation  of  prostitution  is  necessary  to  restrain  the  propagation 
of  venereal  and  syphilitic  diseases.  2.  Prostitution  that  attracts  atten¬ 
tion  by  the  frequenting  of  streets,  promenades,  and  public  places,  being 
the  most  powerful  cause  of  propagating  venereal  diseases,  should  be 
forbidden.  3.  Women  that  are  known  to  live  habitually  as  prostitutes 


588 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[H.  Y.  Med.  Jotjk. 


should  be  registered  and  given  sanitary  visits.  4.  The  registration  and 
sanitary  visits  should  be  authorized  under  the  safeguard  of  guarantees 
that  should  always  and  everywhere  protect  the  honor  and  the  dignity  of 
the  individual.  5.  The  sanitary  visits  should  be  frequently  and  con¬ 
veniently  made. 

Dr.  Kaposi,  of  Vienna,  considered  there  were  two  ways  to  combat 
prostitution :  by  measures  that  depended  on  administrative  regulation, 
and  by  those  of  a  scientific  nature — the  first  a  matter  of  governmental 
authority,  the  second  a  matter  for  physicians.  The  Austrian  Govern¬ 
ment  in  1889  adopted  measures  for  the  surveillance  of  acknowledged 
and  clandestine  prostitution,  and  for  taking  preventive  and  disciplinary 
measures  against  those  that  communicate  syphilis.  In  all  the  universi¬ 
ties  the  study  of  dermatology  and  syphilography  is  obligatory,  because 
all  physicians  may  have  occasion  to  decide  on  the  existence  of  syphilis 
in  domestics.  Each  prostitute  receives  a  book  containing  a  descriptive 
list,  photograph,  and  a  copy  of  the  laws  relating  to  prostitution  and 
prostitutes.  No  one  under  sixteen  can  be  registered,  and  minors  or 
married  women  must  receive  authority  from  their  legal  guardians  (par¬ 
ents  or  husband)  ;  persons  affected  with  organic  or  constitutional  dis¬ 
eases  or  deformities  can  not  be  registered.  Sanitary  examinations  are 
made  twice  a  week,  by  a  competent  physician,  in  an  appropriate  place ; 
all  diseased  women  are  put  in  hospitals,  primary  syphilitic  cases  being 
quarantined  for  three  months,  and  kept  under  treatment  two  years. 
Clandestine  prostitutes  are  treated  in  the  same  way,  though  they  may 
be  treated  by  their  own  physician. 

Dr.  Nesser  thought  the  examination  should  be  made  for  gonorrhma 
and  syphilis  ;  while  the  examination  of  the  genital  organs,  anus,  and 
mouth  was  certainly  excellent,  it  was  not  absolutely  reliable.  He  thought 
a  cervical  leucoderma  was  a  certain  sign  of  syphilis  ;  and  in  one  year, 
at  Breslau,  he  had  examined  572  prostitutes,  and  found  the  gonococcus 
in  216  patients  in  the  urethra,  uterus,  or  both. 

Dr.  Felix,  of  Bucharest,  Dr.  Drysdale,  of  London,  Dr.  Heinzinger,  of 
Groningen,  and  Dr.  Crocq,  of  Brussels,  opposed  Thiry’s  conclusions, 
particularly  the  limitation  of  prostitution  to  a  few  public  houses,  brand¬ 
ed  by  Felix  and  Heinzinger  by  the  name  of  moral  contagion.  Felix 
held  that  in  the  future  we  should  instruct,  without  false  modesty,  the 
pupils  of  higher  classes  in  colleges  regarding  the  dangers  to  which  they 
were  exposed,  and  instruct  them  primarily  on  the  various  prophylactic 
measures.  The  criticism  was  made  that  this  desideratum  was  possible, 
but  would  not  the  “  professor  of  coitus  ”  be  a  veritable  innovation  for 
the  end  of  this  century  ? 

The  Hygiene  of  the  Dissecting-room. — The  once  familiar  dissecting- 
room,  with  its  wooden  floor  and  plastered  walls  redolent  with  the  foul¬ 
ness  of  years  of  service,  its  wooden  tables  supporting  cadavers  in  vari¬ 
ous  stages  of  decomposition,  and  an  atmosphere  that  remained  a  remi¬ 
niscence  during  an  entire  professional  career,  has  in  many  medical 
schools  given  place  to  composition  or  tiled  floors  and  wainscot,  with 
excellent  ventilation  and  stone  tables  that  are  non-absorbing.  In  some 
institutions  better  methods  are  in  vogue  for  the  preservation  of  the 
cadavers ;  but,  in  view  of  the  character  of  much  of  the  material  and 
the  possibility  of  the  student  acquiring  at  his  work  the  foundation  of 
constitutional  disease,  it  would  seem  desirable  to  pay  more  attention  to 
the  hygiene  of  the  dissecting-room. 

In  the  Gaz.  hebd.  de  med.  et  de  chir.  of  August  23d  the  method  in 
use  at  the  Paris  School  of  Medicine  is  given  as  follows  : 

Many  cadavers  are  lost  in  warm  weather  in  Paris,  because  the  pre¬ 
servative  injections  are  given  too  late ;  they  arrive  at  the  school  in  a 
state  of  putrefaction  for  which  nothing  can  be  done.  This  fact  is  un¬ 
derstood  when  it  is  remembered  that  bodies  are  retained  until  the  last 
minute  in  order  that  they  may  be  reclaimed.  If  the  dead-house  attend¬ 
ant  would  give,  at  the  end  of  the  first  twenty-four  hours,  an  injection 
into  the  carotid  artery  of  a  ten-per-cent,  solution  of  chloride  of  zinc, 
not  only  would  it  delay  putrefaction,  but  also  prevent  the  discoloration 
of  the  skin  of  the  face  that  makes  recognition  of  the  dead  sometimes 
impossible. 

On  arriving  at  the  dissecting-room,  the  body  apertures  are  cleaned 
and  washed  with  a  stick,  and  the  entire  body  is  washed. 

The  body  should  not  be  carried  by  the  hands  and  feet,  thus  disar¬ 
ranging  the  position  of  the  muscles,  but  placed  on  a  movable  table  of  the 
height  of  a  dissecting-table.  The  body  is  numbered  with  a  fatty  print¬ 


ing  ink  that  can  not  be  washed  off,  the  number  being  registered  with 
the  name,  age,  and  hospital.  In  winter  the  cadaver  should  remain  in 
a  room  heated  to  20°  or  25°  C.,  to  soften  the  fat,  that  is  coagulated  by 
cold  and  prevents  the  penetration  of  the  injection. 

The  best  injecting  fluid  is  ten  per  cent,  of  phenic  acid  in  glycerin ; 
in  winter  five  per  cent,  will  do.  Alcohol  may  be  used  with  an  equal 
quantity  of  the  glycerin,  making  the  solution  more  penetrating.  For 
economy  a  saturated  arsenical  solution  may  be  added  to  the  injection ; 
two  thirds  of  the  ten-per-cent,  glycerin  with  one  third  of  arsenical  solu¬ 
tion  will  suffice.  The  preservative  would  be  better  if  composed  of  half 
a  litre  of  chloride  of  zinc  to  half  a  litre  of  the  arsenical  solution  ;  five 
litres  wrould  be  required  for  an  ordinary  subject.  The  injection  mav 
be  made  by  the  carotid,  or,  better,  the  aorta,  and  should  be  given  slowly 
with  moderate  pressure,  using  either  a  syringe  or  an  elevated  recep¬ 
tacle. 

The  room  for  storing  cadavers  should  be  dry,  of  constant  tempera¬ 
ture,  and  scrupulously  clean  and  free  from  odor. 

Dissected  material  should  be  cremated,  and  in  every  way  the  dis¬ 
semination  of  micro-organisms  from  the  cadaver  to  the  student  be  pre¬ 
vented. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 

favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (2)  when  a  manuscript  is  sent  to  this  jour¬ 
nal ,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  typesetters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  'concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  rwte 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  ad  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  oftheprofession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and , 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  November  29,  1890. 

lectures  an  &  ^  b  b  r  ?  s  s  e  s  . 


tup:  dangers  of 

EXCESSIVE  PHYSICAL  EXERCISE. 

A  LECTURE  DELIVERED  BEFORE  THE 
YOUNG  MEN’S  CHRISTIAN  ASSOCIATION  OF  WASHINGTON,  D.  C. 

By  E.  L.  TOMPKINS,  M.  D., 

RESIDENT  PHYSICIAN  OF  THE  HAMMOND  SANITARIUM,  WASHINGTON. 

Gentlemen  :  The  subject  before  us  this  evening  is  one 
of  great  importance  and  interest  to  all  of  us — to  you  as  ath¬ 
letes  and  gymnasts  and  to  me  as  a  member  of  the  medical 
profession.  We  are  very  intimately  associated,  for  when 
you  indulge  in  such  sports  to  excess  you  generally  come  to 
the  physician  for  assistance.  Just  here  in  the  beginning  of 
my  remarks  I  do  not  wish  to  be  understood  as  one  who 
condemns  physical  exercise.  I  greatly  approve  of  it,  and 
congratulated  myself  on  hearing  Dr.  Rosse’s  address  last  Fri¬ 
day  evening,  but  I  can  not  join  with  Dr.  Rosse  in  “com¬ 
bating  the  howl  against  the  imaginary  danger  of  athletics 
set  up  by  some  of  our  shallow  and  pretentious  brethren.” 
I  know  that  so  much  exercise  is  fraught  with  great  danger, 
and  some  of  these  “  shallow  and  pretentious  brethren”  I 
wish  to  quote  later  on.  When  we  speak  of  excessive  physi¬ 
cal  exercise  we  are  bound  to  embrace  every  form  of  work, 
such  as  running,  walking,  lifting,  straining  of  any  kind, 
gymnastics,  foot-ball,  base-ball,  and  the  like. 

The  word  exercise,  in  its  physiological  sense,  means  that 
quantity  of  activity  of  every  anatomical  part  of  the  body 
which  will  require  that  part  to  perform  its  function.  The 
popular  definition  of  exercise  at  the  present  time  is,  I  think, 
contraction  of  the  voluntary  muscles.  That  is  perfectly 
proper,  if  taken  with  moderation,  but  nothing  seems  of  in¬ 
terest  now  unless  in  competition  with  some  one  else.  I 
have  endeavored  to  separate  the  dangers  of  excessive  exer¬ 
cise  into  four  divisions— viz.  :  the  danger  to  the  brain,  to 
the  heart,  to  the  lungs,  and  muscular  system. 

We  will  first  take  the  brain.  In  looking  over  the  liter¬ 
ature  on  the  subject,  I  have,  unfortunately,  not  been  able 
to  gather  very  much  in  which  the  brain  was  directly  af¬ 
fected  by  physical  exercise,  except  in  the  gymnasium,  where 
a  man  hangs  by  his  legs  with  head  downward  and  has  what 
is  commonly  called  “  rush  of  blood  to  the  head.”  We  very 
frequently  hear  a  person  say  he  was  too  tired  to  sleep;  this 
was  probably  due  to  an  excessive  supply  of  blood  to  the 
brain,  and  if  it  goes  on  for  any  length  of  time  he  will  have 
a  disease  of  the  brain  called  cerebral  hyperaemia.  One  of 
the  worst  cases  that  I  have  seen  lately  was  that  of  a  man 
trom  North  Carolina;  he  was  a  farmer  by  occupation  and 
^aid  he  did  nothing  but  walk  over  his  farm  from  daylight 
to  dark,  looking  after  his  crops;  he  was  in  the  habit  of  go- 
ing  to  bed  directly  after  he  got  his  supper — about  ei^ht 
:>’clock— never  read  anything  but  the  Bible  occasionally, and 
iad  nothing  in  particular  to  worry  him;  and  yet  he  couldn’t 
Jeep,  and  had  a  bad  attack  of  byperaemia  of  the  brain,  whirl] 
'as  probably  indirectly  brought  on  by  excessive  physical 
•xercise.  Great  mental  work  and  great  physical  work  are 
ntirely  incompatible,  for  the  human  system  has  only  a  cer¬ 


tain  quantity  of  nerve  force  to  be  expended,  and  if  it  is  all 
used  up  in  muscular  exercise  there  will  not  be  left  any  for 
the  brain.  It  i9  all  very  well  for  boys  and  young  men  to 
exercise  moderately,  but  when  they  become  men  thev  are 
intended  for  something  higher  and  better.  Moreover,  only 
a  small  amount  of  exercise  is  needful  for  health. 

Some  enthusiasts  on  the  subject  of  phvsical  culture  main¬ 
tain  that  it  is  not  only  necessary  for  health,  but  even  for 
life.  Now,  it  is  pretty  certain  that  exercise  is  not  absolutely 
necessary  for  life.  A  physician  from  Jacksonville,  Fla.,  a 
triend  of  mine,  tells  me  of  a  woman  that  he  knows  personal¬ 
ly  who  has  been  in  bed  for  thirty  years,  aqd  is  likely  to  live 
a  long  time  yet.  She  is  not  sick,  but  simply  declared  she 
never  was  going  to  got  out  of  bed  again.  I  have  known  of 
several  persons  myself  that  have  remained  in  bed  ten  and 
fifteen  years.  After  a  while  they  got  tired  of  staying  in 
bed,  and,  without  any  treatment  at  all,  got  up  and  walked. 
One  of  them  is  as  healthy  to-day  as  I  am  and  goes  every¬ 
where  she  wants  to.  Then  look  at  the  many  prisoners  who 
are  closely  confined.  The  majority  remain  fairly  healthy 
without  much  exercise.  A  few  fail  in  health,  and  I  think  it 
is  due  as  much  to  the  mental  worry  as  to  the  close  confine¬ 
ment.  All  prisoners  are  confined,  one  probably  as  closely 
as  the  other,  and  yet  those  whose  health  fails  are  always 
spoken  of  in  the  newspapers,  they  are  so  few. 

Second.  The  effect  on  the  heart  is  well  marked,  and  a 
great  many  physicians  have  written  on  the  subject.  Every 
one  knows  how  his  pulse  quickens ;  he  can  feel  his  heart 
beating  through  his  chest,  has  palpitation  and  short  breath 
when  he  runs  up  the  steps  or  takes  any  violent  or  unusual 
exercise;  these  are  merely  outward  symptoms.  Dr.  F.  A. 
Mahomed,  pathologist  to  St.  Mary’s  Hospital,  made  obser¬ 
vations  on  Weston,  the  noted  pedestrian,  during  the  last 
week  of  his  five-hundred-mile  walk.  By  means  of  a  sphyg- 
mograph  he  was  enabled  to  measure  the  arterial  tension 
every  day.  He  discovered  that  on  the  first  day  Mr.  Weston 
began  his  walk  with  a  perfectly  normal  pulse,  and  during 
the  first  two  days  the  tension  was  somewhat  reduced,  dur¬ 
ing  the  next  three  days  the  tension  gradually  rose,  and  at¬ 
tained  its  highest  point  on  the  fifth  day  of  his  walk.  His 
temperature  was  reduced  simultaneously  with  the  increase 
of  arterial  pressure.  On  the  sixth  day  he  took  a  long  rest 
and  sleep,  his  temperature  went  up,  and  the  arterial  pressure 
was  reduced.  After  resting  thirty-six  hours  and  living 
well,  he  regained  his  normal  pulse  and  temperature.  The 
observations  made  on  the  same  man  by  Dr.  Flint,  of  New 
York,  were  practically  the  same.  These  observations  mere¬ 
ly  went  to  prove  what  Dr.  Mahomed  had  stated  elsewhere 
— that  exercise  produced  two  important  and  opposite  ef¬ 
fects  on  the  circulation,  according  to  the  condition  of  the 
person  under  observation.  In  persons  unaccustomed  to 
exercise  and  not  in  proper  condition  it  reduces  the  arterial 
tension  and  increases  the  temperature.  This  explains  how 
very  warm  one  gets  and  how  freely  he  perspires,  and  how 
soon  he  becomes  exhausted;  his  heart  palpitates  and  is 
actually  weaker  when  he  is  unaccustomed  to  exercise. 

“  When  this  is  carried  to  extreme,  syncope,  from  anaemia 
of  the  brain,  may  occur,  the  brain  being  robbed  of  its  blood 


590 


TOMPKINS:  THE  DANGERS  OF  EXCESSIVE  PHYSICAL  EXERCISE.  [N.  Y.  Med.  Jour., 


by  the  unduly  increased  requirements  of  the  muscles  and 
sudden  failure,  by  paralysis,  of  the  action  of  the  heart.  .  .  . 
On  the  other  hand,  the  arterial  tension  may  be  increased. 
There  are  several  theories  for  the  cause  of  this.  One  is 
that  the  impaired  nutritive  power  in  the  tissues  interferes 
with  what  has  been  called  the  chemico-vital  capillary  power 
and  causes  capillary  obstruction.  Another  theory  is  that 
there  is  contraction  of  the  arterioles,  due  to  irritation  of 
their  vaso-motor  nerves  by  an  irritable  and  exhausted 
brain.  .  .  .  And  still  a  third  cause  is  that  the  heart  is  ex¬ 
cited  to  a  degree  above  that  required  for  the  effectual  cir¬ 
culation  of  the  blood,  the  influx  of  blood  into  the  vessels 
being  in  excess  of  the  afflux  by  the  capillaries,  thus  raising 
the  tension.”  This  condition  was  well  marked  in  Taylor, 
one  of  the  competitors  of  Weston,  and  slightly  so  in  W  es¬ 
ton,  who  was  probably  in  better  training.  Variation  of 
tension  in  this  direction  is  accompanied  by  reduction  of 
temperature.  It  increases  the  work  required  from  the 
heart,  and  failure  of  that  organ  to  meet  the  strain  thrown 
upon  it  gives  rise  to  dilatation.  This  is  known  by  a  num¬ 
ber  of  symptoms,  the  chief  ones  of  which  are  breathless¬ 
ness,  oppression  at  the  praecordia,  vertigo,  coldness  of  the 
extremities  and  reduction  of  the  temperature  of  the  body 
generally,  pallor  and  anxiety  of  the  face,  dilatation  of  the 
pupil,  smallness  and  irregularity  of  the  pulse,  and  irregularity 
and  shallowness  of  respiration.”  Very  often  we  hear  of 
some  old  gentleman,  or  even  lady,  who  drops  dead  after  some 
unusual  exercise,  such  as  going  up  the  steps  fast  or  running 
after  a  street-car.  The  majority  of  street-car  companies 
have  cars  enough  which  follow  one  another  closely,  and  if 
we  are  not  in  time  for  one  we  should  wait  calmly  for  the 
next  and  not  run  such  enormous  risks;  but  such  is  the  de¬ 
sire  with  every  one  at  the  present  time  to  get  ahead  of 
somebody  else  that  he  can  not  wait.  Dr.  Hammond  has 
■collected  seventy  cases  of  death  during  the  last  ten  years 
of  men  running  after  a  street-car  and  dropping  dead  in  the 
street.  These  deaths  were  purely  due  to  the  inability  of 
Ihe  heart  to  meet  the  strain  required  of  it.  Some  of  you 
might  say  that  these  men  had  heart  disease  of  some  sort 
before,  and  that  their  deaths  were  due  to  that,  and  they 
probably  did  ;  but  that  only  goes  to  prove  that  not  every 
•  one  is  in  the  proper  condition  to  take  violent  exercise  of 
any  sort.  I  think  every  one  who  wishes  to  indulge  in  ath¬ 
letics  should  be  thoroughly  examined  by  a  physician  and 
pronounced  perfectly  sound  beforehand,  and  even  then 
there  should  be  a  competent  instructor  who  should  tell  him 
what  to  begin  with,  just  how  long  he  should  exercise,  and 
not  let  him  overtax  his  strength  in  any  way.  Lifting  heavy 
weights  is  not  the  best  way  to  get  strong,  and  yet  a  great 
many  young  men  think  that  in  order  to  increase  the  size 
of  the  muscles  and  be  considered  stronger  than  any  one 
else  they  must  lift  some  weight  far  too  heavy  for  them.  I 
know  a  man,  about  twenty-four  years  old,  in  Atlanta,  Ga., 
who  was  really  quite  strong,  but  he  offered,  for  a  wager,  to 
lift  five  hundred  pounds  from  the  floor  and  put  it  on  a 
table.  While  he  was  straining  with  this  weight  he  felt  a 
very  sharp  pain  in  his  back;  that  pain  has  never  left  him, 
although  it  has  been  about  two  years,  but  his  spinal  column 
has  become  curved  in  two  places;  he  also  has  a  disease  of 


the  spine  called  Pott’s  disease;  his  spinal  cord  has  also  be¬ 
come  affected,  which  has  brought  on  paralysis  of  both  legs, 
and  he  has  been  in  bed  several  months  now,  and  the  proba¬ 
bility  of  his  ever  getting  well  is  rather  uncertain.  Dr. 
Hammond  told  me  of  a  case  that  came  under  his  observa¬ 
tion.  A  man  tried  to  raise  a  window-sash  which  would 
not  go  up ;  he  overstrained  himself,  felt  severe  pain  in  his 
back,  and  was  paralyzed  in  both  legs  immediately. 

The  cases  of  hernia  that  are  caused  by  lifting  and  jump¬ 
ing  are  numerous,  and  I  will  speak  of  them  later.  Dr. 
Moro-an,  in  his  book  called  University  Oars,  relates  some 
very  interesting  cases.  He  was  confident  that  the  bad  re¬ 
sults  of  excessive  exercise  in  rowing  frequently  were  never 
heard  of,  so  he  took  the  names  of  294  who  rowed  in  the 
inter-university  race  in  a  given  time,  and  wrote  letters  to 
them  asking  them  to  give  accounts  of  themselves  as  to 
whether  they  suffered  from  any  disease  that  could  be  at¬ 
tributed  to  rowing.  He  got  replies  from  seventeen  of 
them,  some  written  by  themselves  and  some  by  their  friends 
or  relatives.  The  following  are  extracts  from  their  letters  : 
A  said  that  while  rowing  in  the  college  races  he  suffered 
from  bad  cold  and  pain  at  the  angle  of  his  chest.  In  spite 
of  this,  he  continued  to  row,  and  it  gradually  passed  off. 
The  following  spring  he  had  a  chill  while  traveling  in  a 
stage  coach,  his  breathing  became  affected,  and  an  attack 
of  inflammation  of  the  right  lung  ensued.  This  illness  was 
protracted,  and  he  was  assured  by  his  physician  that  he  had 
permanent  induration  of  the  top  of  the  right  lung,  which 
had  set  in  when  he  was  at  college.  In  this  case,  if  the 
injury  did  not  result  from  overexertion  in  the  boat-race,  it 
was  due  to  the  fact  that  such  exertion  was  undertaken  at  a 
time  when  from  indisposition  the  man  was  not  in  a  fit  state 
to  row.  The  next  case  is  that  of  B,  who,  in  referring  to  his 
own  case,  says:  “I  am  unfortunately  an  illustration  of  the 
evils  which  may  be  induced  by  overexercise.  I  am  forty- 
one  years  of  age  and  quite  obsolete  from  an  hypertrophied 
heart,  which  has  gone  on  to  dilatation  and  its  conse¬ 
quences.”  He  then  goes  on  to  tell  how  he  was  in  the  habit 
of  spending  his  time  then,  which  does  not  concern  us  in 
this  paper.  The  next  is  C.  His  report  is  as  follows: 
“About  a  week  before  the  race  I  felt  a  pain  in  my  left  arm 
as  if  I  had  gotten  rheumatism,  and  it  became  rather  stiff  un¬ 
til  after  the  race,  and  then  severe  inflammation  set  in  in  the 
elbow  joint,  followed  by  abscesses,  and,  after  three  months  in 
bed,  pieces  of  bone  came  away,  and  I  had  the  elbow  joint 
excised,  and  the  arm  is  still  stiff.”  His  friend  confirmed 
his  remarks  by  stating  that  he  was  sure  that  that  particular 
race  did  not  bring  on  all  the  inflammation  that  ensued,  but 
that  he  had  had  no  rest  from  hard  labor  for  two  years, 
besides  going  in  for  every  race  that  took  place,  and  conse¬ 
quently  entered  upon  the  training  for  this  big  race  in  an  al¬ 
ready  exhausted  state.  Dr.  Morgan  then  quotes  the  cases  of 
six  persons  that  have  died — five  from  consumption  and  one 
from  heart  disease — and  their  nearest  relatives  wrote  that 
more  or  less  grave  suspicions  were  entertained  that  the  dis¬ 
eases  that  carried  them  off  were  originally  induced  by  their 
overexerting  themselves  in  rowing  during  their  college  days. 
One  of  them,  D,  died  soon  after  of  consumption.  It  was 
said  of  him  that  his  illness  and  delicate  health  were  sup- 


Nov.  29,  1890.] 


TOMPKINS:  TEE  DANGERS  OF  EXCESSIVE  PHYSICAL  EXERCISE. 


591 


posed  certainly  to  have  arisen  originally  from  the  bursting 
of  a  blood-vessel,  through  his  exertions  in  rowing,  either  in 
the  practice  for  the  inter-university  race  or  in  the  race 
itself.  One  of  his  fellow-oarsmen  said  :  “  D  was  a  very  tine 
oar,  but  he  always  gave  me  the  idea  of  being  an  unsound 
man  ;  he  was  always  pallid  and  looked  ghastly  after  a  long 
and  severe  turn.  I  often  used  to  think  him  likely  to  break 
down  in  training.”  The  next  case  was  that  of  E,  who  died 
of  consumption.  One  of  his  relatives,  in  speaking  of  him, 
said  that  he  had  not  died  until  long  after  he  had  given  up 
rowing,  but  he  had  never  doubted  that  his  failure  of  health 
and  early  death  at  the  age  of  twenty-nine  years  were  due  to 
boat  racing,  as  no  other  member  of  his  family  had  broken 
down  in  the  same  way.  Another  oarsman,  who  died  of 
some  atfection  of  the  chest  which  was  not  stated,  was  spoken 
of  by  his  father  as  follows:  “  I  could  not  feel  assured  that 
the  excessive  training  and  racing  could  be  undertaken  safely 
by  a  growing  and  undeveloped  constitution,  not  robust, 
though  elastic  and  strong.”  Another  person,  G,  died  of  con¬ 
sumption.  One  of  his  friends  writes  that  his  physique  was 
not  such  as  to  stand  the  wear  and  tear  of  these  contests. 
His  exertions  were  of  a  more  than  ordinarily  trying  charac¬ 
ter,  for  he  had  participated  in  many  severe  races  both  on 
the  Thames  and  at  Henley,  and  he  was  a  man,  almost  of  all 
men,  the  least  likely  to  spare  himself.  The  eighth  case 
was  that  of  H.  He  also  died  of  consumption  in  a  few 
years  after  the  race.  It  was  not  knovrn  whether  he  died 
from  overexertion  or  not.  J  was  injured  by  rowing.  He 
was  found  dead  in  his  bed  some  time  after  he  had  stopped 
rowing.  His  friends  said  he  was  an  enthusiast  in  the 
sport,  and  they  had  often  seen  him  exhausted.  All  thought 
his  exertions  brought  on  his  death.  K  recounts  his  case 
as  follows:  “I  rowed  in  a  great  many  races — in  several 
while  yet  a  boy  at  school.  When  I  rowed  at  Putney  I  was 
twenty  years  of  age.  I  experienced  soon  after  this  severe 
pain  in  the  region  of  the  heart  and  was  thoroughly  done 
up,  and  was  forbidden  to  walk  up  hills  and  told  that  unless 
I  was  very  careful  I  should  never  get  over  it.  However, 

I  did  take  care  of  myself,  and  have  been  recovering  health 
and  strength  ever  since.  Though  I  was  never  incapacitated 
from  ordinary  employments,  still  I  was  prevented  from  en¬ 
gaging  in  any  violent  exercise  from  the  certainty  with 
which  it  brought  on  the  old  pain  at  the  apex  of  the  heart.” 
He  then  goes  on  to  relate  some  of  his  occupations  and  to 
speak  of  his  children,  and  finally  concludes  thus:  “At  the 
same  time  the  conclusion  I  should  have  come  to  in  my  own 
case  is  that  I  overexerted  myself  when  too  young,  and,  had 
I  begun  when  I  left  otf  growing  or  a  year  or  two  later,  I 
should  not  have  experienced  any  evil  effects.”  Another 
man  who  overworked  his  strength  was  L.  In  speaking  of 
his  health  he  uses  these  words :  “  I  have  for  the  last  three 
years  suffered  much  from  having  overexerted  myself,  and 
have  only  just  begun  to  go  up  hill  again.  I  should  not 
think  of  attributing  my  ill-health  to  the  university  race 
when  I  know  what  a  very  small  proportion  the  energy  ex¬ 
pended,  and  the  exhaustion  consequent  on  it,  can  bear  to 
that  due  to  the  combined  effect  of  other  races  in  which  I 
have  rowed  and  other  forms  of  violent  exercise  in  which  I 
have  overtaxed  my  strength.” 


M  also  would  appear  to  have  done  too  much.  llis 
brother  says  of  him:  “I  have  no  doubt  M.  seriously  in¬ 
jured  his  health  by  overexertion  in  rowing  and  running;  he 
was  an  enthusiast  in  everything  he  undertook  and  imagined 
nothing  could  hurt  him,  but  soon  after  leaving  the  univer¬ 
sity  he  fell  into  bad  health,  and  died  some  eighteen  years 
after  the  race.”  He  attributes  his  ill-health  to  overexer¬ 
tion.  It  was  the  continuance  for  too  great  a  length  of  time 
of  boat-racing  that  did  him  so  much  injury. 

N  is  also  believed  to  have  suffered.  One  of  hi,  rela¬ 
tives  writes  :  “After  the  university  race  he  fainted  away, 
and  it  was  two  hours  before  they  could  restore  him.  It 
was  always  thought  that  the  part  he  took  in  the  race  in¬ 
jured  a  small  vessel  at  the  heart;  previous  to  that  he  was 
always  a  strong,  muscular  man.  Eleven  years  after  he  was 
suddenly  taken  sick,  and  died  in  a  few  days.” 

0  speaks  of  his  health  in  the  following  manner  :  “  When 
I  went  to  the  university  I  was  healthy  and  strong,  and  my 
weight  was  a  little  over  twelve  stone.  I  began  rowing  at 
once  in  my  college  boat  and  also  in  the  university  crew, 
both  at  Putney  and  Henley.  I  lost  almost  a  stone  in  weight 
during  my  rowing  career,  but  did  not  feel  any  ill  effects 
until  after  my  last  race,  when  I  became  very  weak,  with  pain 
in  my  side.  One  doctor  whom  I  consulted  attributed  these 
symptoms  to  the  overexertion  and  hard  training  1  had  un¬ 
dergone,  but  considered  there  was  no  serious  mischief.  I 
recovered  from  this  attack  in  time,  and  since  then  have  en¬ 
joyed  fairly  good  health,  thougti  I  have  gradually  lost  weight 
and  become  very  weak.  Three  years  ago,  after  taking  a 
little  more  exercise  than  usual,  I  brought  up  a  great  quan¬ 
tity  of  blood.  This,  my  medical  man  said,  came  from  my 
left  lung.”  He  then  states  that  he  had  no  return  of  haem¬ 
orrhage  until  the  following  spring,  when  he  had  another 
attack  of  bleeding  from  his  lung.  After  that  he  had  great 
difficulty  in  breathing,  and  was  much  weaker  than  before, 
although  he  had  no  more  haemorrhages. 

The  next  three  persons,  P,  Q,  and  R,  in  giving  accounts 
of  themselves,  declare  that  they  were  in  good  health  as  long 
as  they  kept  up  such  violent  exercise,  and  only  suffered 
from  their  respective  troubles  after  they  had  taken  up  a 
sedentary  mode  of  living.  The  question  might  be  raised? 
though,  whether  or  not  these  troubles  were  not  the  result  of 
such  excessive  exercise,  and  probably  would  have  appeared 
much  sooner  if  they  had  not  quit  and  commenced  a  seden¬ 
tary  life.  I  have  consumed  rather  more  time  with  the  sub¬ 
ject  of  boat-rowing  than  I  intended,  but  I  wished  to  show 
particularly  the  bad  effects  on  the  heart  and  lungs  that  this 
kind  of  exercise  produces  when  it  is  carried  to  excess. 

Dr.  Charles  W.  Cathcart,  in  his  article  on  Physical  Ex¬ 
ercise  :  its  Use  and  Abuse,  which  appeared  in  Health  Lect¬ 
ures  and  which  is  published  by  the  Edinburgh  Health 
Society,  goes  quite  extensively  into  the  subject.  He  enu¬ 
merates  quite  a  number  of  accidents — such  as  fractures, 
especially  of  the  collar-bone,  dislocations,  sprains,  and  other 
injuries  that  take  place  during  the  different  games,  espe¬ 
cially  foot  ball — and  while  he  encourages  these  games,  if 
taken  moderately  and  by  persons  who  are  fitted  for  such 
exertion,  he  says  that  overgrown  lads  should  be  careful  how 
they  exercise  violently,  as  they  are  particularly  apt  to  suffer. 


592 


TOMPKINS:  THE  DANGERS  OF  EXCESSIVE  PHYSICAL  EXERCISE.  [N.  Y.  Med.  Joub., 


But  I  wish  to  quote  him  verbatim  in  his  remarks  relat¬ 
ing  to  brain  work  and  physical  exercise  :  “  Only  one  other 
point  occurs  to  me  as  specially  deserving  our  attention  just 
now,  and  that  is  the  relation  of  brain  work  to  exercise.  It 
must  be  the  experience  of  most  men  that  the  fullest  amount 
of  brain  work  and  of  muscular  exertion  can  not  be  carried 
on  simultaneously  without  injury  to  whoever  is  bold  enough 
to  try  the  experiment ;  only  a  certain  amount  of  nervous 
•energy  is  available  in  the  system.  There  is  a  reserve  fund 
of  nervous  energy  for  explosive  purposes,  and  when  this  is 
once  exhausted  it  is  rarely  got  back.  This  may  be  ex¬ 
pended  either  chiefly  in  muscle  work  or  chiefly  in  brain 
work,  or  in  a  proportionate  combination  of  both,  but  not 
in  the  fullest  possible  amount  of  both  at  the  same  time. 
Therefore,  when  extra  brain  work  is  called  for,  we  should 
not  expect  from  our  bodies  the  full  amount  of  muscular  ex¬ 
ertion  that  they  are  capable  of.  Sufficient  be  it  for  the 
time  if  we  get  enough  exercise  to  keep  us  in  active  health, 
and,  when  we  again  have  an  opportunity,  we  can  very  soon 
bring  our  muscles  up  to  their  wonted  standard.  But,  since 
this  preponderance  of  brain  work  in  our  modern  life  is  so 
frequently  unavoidable,  it  becomes  all  the  more  necessary 
that,  when  the  frame  is  still  in  its  plastic  condition,  it 
should  be  stamped  with  the  best  possible  physical  impres¬ 
sions.  The  conditions  necessary  to  attain  this  are  not  in¬ 
compatible  with  sound  mental  training  and  earnest  brain 
work,  but  it  can  not  go  along  with  that  mental  worry  and 
and  labor  which  ought  only  to  be  found,  if  at  all,  among 
those  who  have  reached  maturity  and  have  passed  into  the 
active  duties  of  life.” 

He  adds  further  on:  “  I  must,  however,  add  a  word  of 
caution  to  those  who,  in  after-life,  are  unfortunately  obliged 
to  follow  sedentary  occupations.  They  should  be  careful 
how  they  return  to  their  former  activity.  If  caution  be 
not  used,  the  exercise  will  do  them  more  harm  than  good, 
so  that  it  behooves  us  to  be  as  careful  as  we  can,  always  to 
begin  gently  and  increase  by  degrees.” 

It  is  very  certain  that  great  mental  work  and  great  mus¬ 
cular  work  are  incompatible;  and  I  remember  well,  when  I 
was  a  student  at  the  University  of  Virginia,  that  those  stu¬ 
dents  who  did  more  hard  study  than  any  of  the  others 
found  that  a  brisk  walk  of  about  two  miles  a  day  gave 
them  plenty  of  exercise  to  keep  them  in  health,  but  did  not 
fatigue  them  so  much  as  to  prevent  them  from  studying; 
and  those  others  who  took  leading  parts  in  base-ball,  boat¬ 
rowing,  foot-ball,  and  all  kinds  of  athletics,  were,  with  a  few 
exceptions,  not  the  hard  students,  but  rather  the  reverse. 
In  fact,  a  great  many  young  men  enter  colleges,  such  as 
Harvard,  Yale,  and  Princeton,  apparently  only  to  be  mem¬ 
bers  of  the  base-ball  club  or  foot-ball  club  or  boat  crew,  and 
seem  to  think  that  a  greater  honor  than  to  graduate  in  their 
studies.  I  know  of  a  young  man  who  went  to  the  university 
just  to  join  the  base-ball  club.  Professor  Edward  Parkes 
has  calculated  that  walking  one  mile  on  the  level,  unloaded, 
is  equal  to  lifting  17-67  tons  one  foot;  but  if  loaded  with 
a  knapsack  weighing  sixty  pounds,  the  work  done  is  equiva¬ 
lent  to  lifting  24-75  tons  one  foot. 

Moderate  labor  in  the  open  air  is  the  most  healthy  for 
the  average  man  who  engages  in  it.  Now,  according  to 


Professor  Parkes,  the  daily  work  performed  by  him  will 
probably  average  from  250  to  350  tons  lifted  one  foot, 
which  will  be  equivalent  to  a  walk  of  nine  miles,  and  a 
healthy  adult  can  take  this  without  incurring  risks  of  over¬ 
fatigue  ;  but  allowance  must  be  made  for  the  other  exertion 
incurred  by  the  ordinary  business  of  life,  which  in  many 
cases  would  cause  a  considerable  reduction.  We  all  know 
that  every  action  of  the  living  body  is  attended  by  chemical 
changes  in  the  composition  of  its  tissues,  and  that  force  is 
liberated  by  such  changes,  either  in  the  form  of  heat  or 
motion.  The  heat,  of  course,  maintains  the  temperature  of 
the  body.  This  force  is  generated  by  the  combination  of 
the  food  taken  into  the  body  and  the  oxygen  which  is  taken 
in  while  breathing.  Carbonic-acid  gas  is  evolved  by  the 
action  of  the  oxygen  on  the  carbon,  one  of  the  food  prod¬ 
ucts;  therefore  we  breathe  in  oxygen  all  the  time  and 
breathe  out  carbonic-acid  gas. 

The  more  work  or  muscular  exercise  that  is  performed, 
the  faster  and  necessarily  shorter  the  respirations.  The 
physiological  effects  produced  by  muscular  exercise  are  in¬ 
creased  action  of  the  lungs  and  heart. 

Professor  Parkes  has  given  a  concise  table  showing 
the  effects  exercise  has  on  the  absorption  of  oxygen  and 
the  evolution  of  carbonic-acid  gas,  which  shows  that  on  a 
“work  day”  eight  ounces  and  a  half  of  oxygen  were  ab¬ 
sorbed  in  excess  of  that  on  a  “  rest  day,”  and  that  thirteen 
ounces  in  excess  of  carbonic  acid  were  evolved  on  the  work 
day,  although  the  so-called  “  work  day  ”  included  a  period 
of  rest,  the  work  being  done  only  during  working  hours  and 
was  not  excessive.  . 

Therefore  the  more  work,  the  greater  the  amount  of  oxy¬ 
gen  required,  and  therefore  the  greater  number  of  respira¬ 
tions,  and  with  it  necessarily  the  greater  number  of  expansions 
and  contractions  of  the  chest.  It  has  been  proved  that  the 
faster  the  respirations, the  smaller  is  the  quantity  of  carbonic 
acid  exhaled  at  each  expiration.  Now,  the  average  number 
of  respirations  in  the  adult  is  about  eighteen  to  twenty  per 
minute;  but  with  violent  exercise,  such  as  boat-rowing,  run¬ 
ning,  foot-ball,  and  so  on,  they  are  greatly  increased.  It 
might  be  said  that  although  the  quantity  of  carbonic  acid 
is  smaller  in  each  respiration,  if  the  number  of  respirations 
should  be  large  enough,  it  would  accomplish  the  same  re¬ 
sult  by  exhaling  all  the  carbonic  acid.  This  would  be  true 
if  the  power  of  maintaining  strong  and  rapid  respirations 
continued;  but  soon  the  chest  muscles  of  respiration  give 
out  and  the  inhalation  and  absorption  of  oxygen  diminish, 
and  carbonic  acid  accumulates  in  the  blood,  producing 
what  is  called  “out  of  breath.”  The  man  is  practically 
poisoned  by  carbonic-acid  gas.  Many  instances  of  this  are 
seen  in  the  running  and  rowing  races,  where  the  man  falls 
flat  on  his  face,  and  perhaps  faints,  just  as  he  almost 
reaches  the  goal.  He,  as  a  rule,  soon  recovers  if  allowed  to 
remain  perfectly  still  and  get  a  few  long  breaths.  Oxygen 
is  rapidly  taken  in,  and  the  blood  that  was  made  impure  by 
the  accumulation  of  carbonic  acid  is  properly  aerated.  It  is 
claimed,  and  rightly  so,  that  exercise  improves  a  weak 
heart  and  also  weak  lungs;  but  this  is  true  when  exercise 
is  taken  moderately  and  regularly,  so  that  the  arteries  can 
get  accustomed  to  the  increased  action  of  the  heart.  In  ex- 


Nov.  29,  1890.]  TOMPKINS:  THE  DANGERS  OF  EXCESSIVE  PHYSICAL  EXERCISE. 


593 


eessive  exercise  the  action  of  the  heart  is  increased  much 
more  and  has  to  send  an  extra  amount  of  blood  to  all  parts 
of  the  body,  so  that  the  arteries,  which  are  taken  so  sud¬ 
denly,  do  not  allow  the  blood  to  pass  through,  and  there  is 
a  blockage.  The  impure  blood,  laden  with  carbonic  acid 
and  coming  from  the  parts  of  the  body  in  action,  is  not 
sent  on  quickly  enough  to  the  lungs  to  be  replenished. 

This  blockage  up  of  the  blood  does  not  take  place  alone 
in  the  arteries  going  to  the  lungs,  but  throughout  the  entire 
body;  so,  unless  we  begin  very  gradually  and  with  due  prep¬ 
aration,  instead  of  benefit,  much  harm  may  be  done  which 
is  permanent. 

I  am  told  that  only  a  few  nights  ago  one  of  your  num¬ 
ber  fainted  just  after  going  through  some  sort  of  violent  ex¬ 
ercise.  Instead  of  quickening  the  vital  changes,  they  are 
stopped  almost  entirely,  and  the  blood  may  accumulate  in 
the  heart  and  produce  dilatation,  which  is  a  very  serious 
disease.  Therefore  it  is  very  dangerous  for  men  who  lead 
sedentary  lives  to  start  out  suddenly  in  the  summer  on  their 
vacations  to  climb  mountains,  row  boats,  run  or  walk  long 
distances,  and  they  are  frequently  worse  off  after  their  va¬ 
cation  than  before. 

Moderate  exercise  increases  the  appetite;  but  no  doubt 
you  have  frequently  heard  people  say  they  were  too  tired 
to  eat.  It  is  probably  due  to  the  fact  that  the  bodily  powers 
are  fatigued  and  there  is  impairment  in  the  power  of  being 
able  to  take  food.  If  this  continues,  the  health  is  seriously 
affected.  It  is  said  that  the  exhaustion  of  muscles  from 
overwork  is  due  principally  to  want  of  oxygen  to  burn  the 
carbon  elements  which  supply  their  force,  and  also  from 
the  accumulation  of  the  products  of  combustion.  This  of 
course  results  from  the  heart  and  lungs  refusing  to  work 
vigorously  enough.  The  advocates  of  gymnastics  maintain 
that  the  muscles  are  enlarged,  the  chest  expanded,  the  heart 
and  lungs  strengthened,  the  appetite  increased,  and  good 
health  generally  maintained.  That  is  true  enough ;  but  if 
the  muscle  is  exhausted  its  nutrition  is  seriously  impaired, 
which  may  not  be  recovered  from  for  many  days.  Instances 
of  this  are  not  merely  loss  of  power,  but  peculiar,  irregular 
pains  and  cramps,  tremors  and  contractions.  It  is  well 
known  that  if  the  leg  of  a  frog  is  amputated  and  a  cur¬ 
rent  of  electricity  applied  to  the  muscle  itself,  it  will  con¬ 
tract  immediately,  and  if  the  stimulus  be  applied  again,  it 
will  contract  the  second  time,  and  continue  on  in  this  way, 
provided  the  stimulus  is  not  applied  too  often  and  too  rap¬ 
idly.  If  it  is,  the  muscle  soon  begins  to  contract  less  each 
time,  until  it  is  no  longer  affected  by  the  electricity  ;  but  if, 
even  in  that  condition,  the  stimulus  be  applied  to  the  sci¬ 
atic  nerve,  it  will  immediately  contract  as  before,  until  final¬ 
ly  the  muscle  is  exhausted  and  will  no  longer  respond  to 
the  stimulus,  even  when  applied  to  the  nerve  itself.  And 
so  in  health,  during  excessive  exercise,  the  brain  is  the 
stimulus  to  the  nerve,  but  soon  the  muscle  is  exhausted  if 
made  to  work  too  long  and  too  fast.  Not  only  that;  al¬ 
though  exercise  increases  the  size  of  the  muscles,  then  if 
the  exercise  is  continued  too  severely  and  for  too  long  a 
time,  it  is  not  only  exhausted,  but  begins  to  atrophy  or  waste 
away.  Such  cases  are  sometimes  seen  in  the  ballet  dancers. 
Some  of  the  most  active  men  sometimes  have  a  disease  called 


progressive  muscular  atrophy — a  disease  which,  if  not  abso¬ 
lutely  incurable,  is  rarely  cured.  We  had  such  a  case  as 
that  only  a  short  while  ago  at  the  Sanitarium.  The  man 
was  of  tremendous  frame  and  had  led  a  very  active  life.  He 
used  to  brag  that  he  could  jump  off  a  train  moving  at  the 
rate  of  twenty-five  to  thirty  miles  an  hour  and  not  feel  it. 
He  couldn’t  imagine  how  it  w*as  that  his  muscles  were  all 
wasting  away.  These  “  living  skeletons  ”  that  you  see  in 
dime  museums  are  generally  victims  of  progressive  muscu¬ 
lar  atrophy  or  another  disease  which  resembles  it  in  some 
respects,  called  anterior  polio-myelitis.  Virchow  has  taught 
that  a  disease  called  valvular  endocarditis  is  more  common 
in  the  left  side  of  the  heart  than  the  right,  in  consequence 
of  the  great  muscular  force  of  the  left  ventricle,  so  that 
when  aortic  disease  has  led  to  hypertrophy  of  the  left  ven¬ 
tricle,  changes  in  the  mitral  valves  become  frequent,  and 
the  increased  force  with  which  the  mitral  valves  are  closed 
induces  those  nutritive  changes  called  chronic  endocar¬ 
ditis. 

And,  as  Fothergill  says  in  his  interesting  paper,  styled 
Strain  in  its  Relation  to  the  Circulatory  Organs,  in  connec¬ 
tion  with  heart  disease,  that  which  is  more  interesting  and 
of  greater  importance  is  the  change  in  the  aortic  valves 
themselves  and  the  causes  of  that  change.  Placed  at  the 
base  of  the  aortic  column,  they  are  closed  by  the  aortic  sys¬ 
tole  on  the  arterial  recoil.  Every  increase  in  arterial  ten¬ 
sion  will  close  the  semilunar  valves  with  greater  force,  and 
this  causes  valvular  disease  of  the  heart.  He  goes  on  to 
say  that  “  aortic  valvulitis  is  met  with  under  two  totally 
different  circumstances — (1)  in  the  gouty  individual  with 
chronic  kidney  trouble,  (2)  in  the  young  and  robust  who 
pursue  certain  forms  of  labor.  At  first  sight  there  seems 
but  little  in  common  between  the  action  of  gout  poison 
and  that  of  the  laborer;  still  the  morbid  processes  induced 
by  these  two  totally  different  causes  are,  apparently,  not 
only  identical,  but  even  the  manner  of  their  causation  is 
the  same.  In  both  cases  the  aortic  valves  are  exposed  to 
violent  closure  from  increased  arterial  recoil,  and  in  both 
cases  valvulitis  from  strain  results.”  All  of  you  who  know 
anything  about  anatomy  will  remember  how  the  arteries 
run  along  close  to  the  muscles,  sometimes  within  the  mus¬ 
cle,  or  under  it,  or  between  it  and  a  bone,  or  over  or  under 
a  tendon.  Wheu  an  athlete  is  straining  every  muscle  in  the 
gymnasium,  those  muscles  are  in  a  state  of  contraction,  in 
which  condition  they  are  hard  and  press  on  different  arte¬ 
ries  and  obstruct  the  circulation.  The  heart,  continuing  to 
pump  away  with  increased  vigor,  distends  the  arteries,  and 
of  course  there  is  an  augmented  recoil ;  the  heart  first  be¬ 
comes  hypertrophied,  and  then  follows  valvular  disease  of 
the  heart.  You  have  all  seen  how  the  veins  stand  out  on 
the  wrists  of  men  in  the  gymnasium  when  they  are  trying 
to  perform  some  difficult  feat  which  requires  great  muscu¬ 
lar  force.  It  is  because  the  circulation  is  obstructed.  A 
person  who  is  suffering  from  a  mitral  disease  of  the  heart 
frequently  causes  an  atheromatous  condition  of  the  pul¬ 
monary  artery  and  its  branches.  Thus  we  have  valvulitis 
and  atheroma  of  the  arteries  at  the  same  time,  which  is 
seen  frequently.  The  causal  association  between  atheroma 
and  strain  has  been  shown  by  Dr.  Clifford  Allbutt  and  Dr. 


594 


TOMPKINS:  THE  DANGERS  OF  EXCESSIVE  PHYSICAL  EXERCISE.  N.  Y.  Med.  Joub., 


Moxon.  The  latter  says  (1)  that  what  is  called  atheroma 
of  arteries  is  a  subinflammation  of  various  degrees,  of  which 
the  lower  degrees  end  in  fatty  degeneration  of  the  coats, 
along  with  the  inflammatory  products,  and  (2)  that  the 
determining  cause  of  the  occurrence  of  this  change  is  me¬ 
chanical  strain. 

Dr.  Fothergill,  at  the  end  of  his  article,  gives  a  resume 
of  his  opinions,  which  I  wish  to  quote  word  for  word  :  “  1. 
Changes  in  the  right  heart  are  induced  by  increased  strain 
when  the  mitral  valve  is  diseased.  2.  Mitral  valvulitis 
often  results  from  aortic  disease,  in  consequence  of  the 
mitral  valve  being  forcibly  closed  by  a  hypertrophied 
ventricle.  3.  Aortic  valvulitis,  as  well  as  atheroma,  is  inti¬ 
mately  associated  with  mechanical  strain.  4.  Certain  dys- 
crasial  conditions  in  which  these  affections  are  common 
merely  favor  the  occurrence  of  such  changes.  5.  Women 
are  much  less  subject  to  aortic  valvulitis  than  men  are,  and 
this  is  due  to  their  pursuits  rather  than  to  their  sex.  6. 
The  importance  of  mechanical  strain  in  the  production  of 
disease  in  the  circulatory  organs  is  scarcely  yet  sufficiently 
appreciated.” 

Hewetson  says :  “  I  hold  that  nowadays  few  men  can 
train  hard  for  athletics  and  at  the  same  time  excel  in  men¬ 
tal  study  without  overstraining  their  physical  or  nervous 
power.  This  evil  of  attempting  to  combine  the  two  is  un¬ 
doubtedly  gaining  ground  in  the  present  day.”  He  reports 
two  cases  that  came  under  his  observation.  One  was  that 
of  a  man  who  was  running  in  a  severe  contest,  felt  sudden 
pain  in  the  chest,  followed  by  exhaustion  ;  on  examination, 
there  was  found  organic  disease  of  the  heart.  The  other 
was  that  of  a  leading  athlete  who  had  embolism  at  the  base 
of  the  brain. 

I  remember  a  person  that  I  saw  in  one  of  the  hospitals 
of  New  York.  His  history  was  as  follows  :  He  bad  had  pre¬ 
viously  a  severe  attack  of  inflammatory  rheumatism,  which 
had  caused  organic  heart  disease.  During  some  unusual 
exertion,  one  of  the  little  vegetations  which  grew  on  the 
valves  of  the  heart  was  washed  off  and  carried  along  with 
the  current  of  blood  until  it  reached  the  capillaries,  where 
it  could  not  proceed  farther.  This  is  what  is  called  cere¬ 
bral  embolism.  In  this  case  it  produced  paralysis  of  one 
side  of  the  face  and  tongue,  so  that  he  could  not  articulate 
distinctly  and  could  eat  with  difficulty.  Also  one  whole 
side  of  his  body  was  paralyzed. 

Dr.  Edward  Smith  read  a  paper  before  the  Royal  Medi¬ 
cal  and  Chirurgical  Society  on  The  Influence  of  Labor  on 
the  Treadmill  on  the  Pulse  and  Respiration.  He  calcu¬ 
lated  the  quantity  of  air  respired  in  the  sitting  position  and 
then  on  the  treadmill.  During  the  exertion  the  quantity  of 
air  inspired  was  increased  more  than  four  fold  rate,  the 
respiration  was  increased  two  thirds,  the  depth  of  inspira¬ 
tion  two  and  a  half,  and  the  rate  of  pulsation  two  and  a  half 
times.  He  then  proceeded  to  consider  the  effect  of  this 
kind  of  exercise  on  the  system,  and  showed  that  the  exces¬ 
sive  exercise  of  the  heart  and  lungs  must  lead  to  phthisis, 
asthma,  emphysema,  congestion  of  various  organs,  with  a 
thinning  or  thickening  of  the  walls  of  the  heart,  and  with 
persons  of  diminished  vital  capacity  of  the  lungs  and  a 
weak  heart  the  effect  must  be  sooner  serious. 


I  believe  that  cattle-men  have  quit  driving  their  cattle 
and  sheep  long  distances  to  market  on  account  of  the  dif¬ 
ferent  lung  troubles  they  develop  on  the  way  simply  from 
being  overdriven.  A  friend  of  mine  in  Texas,  who  is  a 
large  cattle-raiser,  told  me  that  he  had  stopped  altogether, 
and  always  sent  them  to  Chicago  on  trains;  that  it  paid 
much  better  in  the  end. 

Dr.  Stork,  in  the  Edinburgh  Medical  and  Surgical  Jour¬ 
nal ,  reports  a  very  interesting  case  of  what  he  calls  over¬ 
driving  in  the  human  subject.  A  man  was  driving  some 
cattle  that  broke  and  ran.  He  ran  after  them,  and  it  was 
a  long  time  before  he  succeeded  in  getting  them  together 
again.  By  that  time,  though,  he  was  thoroughly  exhausted 
himself;  he  had  pain  in  his  chest,  began  to  cough  and  spit 
up  bloody  sputum,  had  great  difficulty  in  breathing,  pulse 
very  fast,  and  high  temperature — in  fact,  all  the  symptoms 
of  inflammation  of  the  lungs.  The  overdriving  in  this  case 
is  analogous  to  racing  and  rowing.  I  wish  to  say  just  a 
few  words  in  regard  to  hernia,  or  rupture.  There  are  cases, 
of  course,  that  are  congenital,  and  a  few  are  caused  by  other 
things  than  strain,  but  the  great  majority  of  cases  come  from 
overstraining,  particularly  that  of  lifting  heavy  weights.  In 
looking  over  works  on  hernia,  you  will  find  that  the  majori¬ 
ty  of  cases  belong  to  the  laboring  class,  and  that  men  have 
it  more  frequently  than  women.  I  knew  a  young  physician 
in  New  York  who  was  lifting  a  heavy  woman  from  the  op¬ 
erating-table ;  he  felt  a  sudden  pain  in  the  inguinal  region, 
which  continued,  and  he  soon  found  that  he  had  a  hernia. 
There  are  certain  games  that  are  particularly  apt  to  cause 
hernia;  one  is  called  the  “tug-of-war,”  and  you,  as  gym¬ 
nasts,  of  course  know  what  it  is.  The  cleats  that  were  used 
for  placing  the  feet  against,  in  order  to  pull  harder  without 
slipping,  I  believe  are  being  done  away  with. 

There  used  to  be  a  lifting-machine  in  most  of  the  gym¬ 
nasiums  called  the  health  lift.  A  very  competent  instructor 
in  athletics  told  me  that  that  machine  had  ruptured  more 
men  than  any  other  one  thing  that  he  knew  of.  It  belongs 
to  me  in  this  paper  only  to  point  out  the  dangers  of  exces¬ 
sive  exercise,  but  I  do  not  think  it  would  be  out  of  place 
for  me  to  say  a  word  or  two  in  favor  of  this  particular 
Young  Men’s  Christian  Association.  As  I  understand  it, 
it  is  intended  to  bring  together  young  men  who  perform  a 
Christian  work  by  doing  good  to  others  and  at  the.  same 
time  elevate  themselves  to  what  is  noblest  and  best  in  this 
life.  The  gymnasium  is  only  one  feature  of  the  association, 
and  it  seems  to  me  to  be  very  complete.  You  have  a  good 
instructor,  and  I  don’t  see  how,  under  his  guidance,  you 
can  have  many  accidents.  I  have  seen  Mr.  Sims  go  through 
what  he  calls  the  “  dumb-bell  body  exercise,”  and  it  gives 
thorough  exercise  to  every  muscle  in  the  body.  He  tells 
me  that  he  never  uses  a  dumb-bell  in  this  particular  exercise 
that  weighs  more  than  two  pounds,  and  that  the  Indian 
clubs  that  are  swung  should  weigh  only  four  or  five  pounds, 
instead  o.f  twenty-five  and  thirty,  that  I  have  seen  in  other 
gymnasiums.  And  now,  gentlemen,  I  would  like  to  call 
your  attention  to  the  aged  couple,  both  of  whom  were  cen¬ 
tenarians,  who  were  found  by  a  Boston  reporter  at  merid¬ 
ian  sun  resting  under  the  shade  of  one  of  the  grand  oaks 
of  Massachusetts.  Of  course  he  interviewed  them  as  to 


Nov.  29,  1890.J 


SOL1S-COHEN :  CARDIAC  MEDICAMENTS. 


the  cause  of  their  longevity.  No  doubt,  gentlemen,  he 
went  there  for  that  purpose.  The  reply  he  received  was 
significant:  “  We  led  a  peaceful  life  and  spent  a  great  part 
of  our  time  in  the  open  air.” 

Gentlemen  of  the  Young  Men’s  Christian  Association, 
a  peaceful  life  with  moderate  exercise  in  the  open  air  will 
surely  be  conducive  to  health  and  happiness. 

Note. — Since  writing  the  foregoing  I  have  clipped  the 
following  from  the  Pittsburgh  Dispatch ,  which  speaks  for 
itself :  “  Of  the  thirty-two  all-round  athletes  in  a  New  York 
club  of  five  years  ago,  three  are  dead  of  consumption,  five 
have  to  wear  trusses,  four  or  five  are  lop-shouldered,  and 
three  have  catarrh  and  partial  deafness.  As  far  as  general 
health  and  longevity  go,  the  dry-goods  clerk  outdoes  the 
athlete.” 


THERAPEUTIC  PRINCIPLES  GOVERNING 
THE  SELECTION  OF  CARDIAC  MEDICAMENTS. 

TWO  LECTURES  DELIVERED  IN  THE  COURSE  ON  THERAPEUTICS 

AT  THE  MEDICAL  DEPARTMENT  OF  DARTMOUTH  COLLEGE. 

October ,  1890. 

By  SOLOMON  SOLIS-COHEN,  A.  M.,  M.  D., 

PROFESSOR  OF  CLINICAL  MEDICINE  AND  APPLIED  THERAPEUTICS 
PHILADELPHIA  POLYCLINIC  ;  VISITING  PHYSICIAN  TO,  AND  ’ 
LECTURER  ON  CLINICAL  MEDICINE  AT,  THE  PHILADELPHIA  HOSPITAL,  ETC. 

Lecture  I. 

Gentlemen  :  Having  studied  the  powers  of  the  princi¬ 
pal  agencies  employed  to  influence  therapeutically  the 
heart  and  circulation,  we  shall  now  devote  two  lectures  to 
the  study  of  the  more  important  principles  which  should 
guide  us  in  the  application  of  these  agencies  to  the  treat¬ 
ment  of  morbid  conditions :  whether  with  a  view  to  bring 
about  recovery,  or  merely  to  prolong  life  or  promote  com¬ 
fort.  The  first  lecture  will  be  more  especially  concerned 
with  laying  the  foundations  for  our  subsequent  study  ;  and 
that  these  may  be  sufficiently  broad  and  deep,  it  will  be 
necessary  to  treat  of  matters  which  at  first  sight  may  seem 
remote  from  our  immediate  theme.  But,  as  I  have  through¬ 
out  all  our  studies  endeavored  to  show,  the  observations  of 
the  physician  must  be  comprehensive.  Not  that  in  seek¬ 
ing  far  afield  he  should  neglect  what  lies  close  at  hand, 
but  neither  must  he  so  contract  his  gaze  and  converge  his 
eyes  that  the  tip  of  his  nose  shall  fill  his  farthest  horizon. 

The  interdependence  of  vital  functions  is  so  great  that 
no  part  of  the  body  can  be  successfully  treated,  when  dis¬ 
eased,  without  due  consideration  of  its  relations  with  all 
other  parts  and  with  the  body  as  a  whole.  At  the  bedside 
quick  observation  and  prompt  decision  are  often  demanded. 
There  is  no  time  for  elaborate  reasoning.  But,  in  order 
that  we  may  be  prepared  for  the  emergencies  of  practice, 
we  must  in  the  lecture-room  and  study  fortify  ourselves 
with  knowledge.  We  must  here  ponder  our  facts  and  set 
in  order  our  thoughts,  so  that  we  may  have  ready  for  use  a 
store  of  matured  conclusions. 

Therefore  I  crave  your  patient  attention  while  I  pass  in 
review  some  familiar  facts,  in  order  that  by  repetition  they 
may  become  impressed  upon  our  minds,  and  that,  by  group¬ 
ing  them  about  a  new  center,  a  new  phase  of  their  impor¬ 
tant  relations  may  be  made  clear. 


595 

The  value  of  rest,  local  and  general,  in  the  treatment  of 
diseases  of  the  heart  or  other  pathological  conditions  af¬ 
fecting  the  cii culation  was  treated  at  length  in  the  earlier 
portion  of  our  course,  when  hygienic  therapeutics  was  the 
subject  of  consideration.  Still,  a  few  words  in  reminder 
of  certain  general  principles  may  not  be  inappropriate  at 
this  time. 

We  have  seen  it  to  be  an  absolute  rule,  not  only  in 
biology  but  throughout  all  nature— a  rule  to  which  there 
can  be  no  exception,  because  it  depends  upon  the  very  con¬ 
stitution  of  nature — that  the  period  of  repose  is  the  period 
of  repair ;  the  period  of  activity  is  the  period  of  waste. 
Rest  means  construction,  upbuilding;  a  coming  together  of 
matter,  with  storing  up  of  energy.  Action  means  destruc¬ 
tion,  downthrowing;  a  tearing  apart  of  matter  with  libera¬ 
tion  of  energy. 

Throughout  nature  we  have  that  continual  rhythmic 
alternation  of  attraction,  repulsion  ;  construction,  destruc¬ 
tion  ;  upbuilding,  downthrowing;  which  in  the  study 
of  life-processes  we  call  the  metabolic  rhythm ,  applying 
to  its  two  phases  the  Greek  terms,  anabolism  and  catab¬ 
olism. 

L  pon  the  pVeservation  of  this  rhythm — that  is  to  say 
upon  the  maintenance  of  the  normal  relations  between  ana¬ 
bolism  and  catabolism,  rest  and  action,  repair  and  waste _ 

depends  the  structural  and  functional  integrity  which  con¬ 
stitutes  the  health  of  the  various  tissues  of  the  body,  and 
of  the  great  aggregations  of  tissue  we  terra  organs  or 
viscera. 

Upon  the  preservation  of  this  rhythm — that  is  to  say, 
upon  the  maintenance  of  the  normal  relations  amono-  the 

...  to 

activities  of  the  various  organs — depends  the  proper  bal¬ 
ance  of  function,  the  intrinsic  organic  harmony,  which  con¬ 
stitutes  the  health  of  the  organism  as  a  whole — in  the  case 
of  man,  the  health  of  body  and  mind. 

Upon  the  preservation  of  this  rhythm — that  is  to  say, 
upon  the  maintenance  of  the  normal  relations  between  the 
organism  and  its  environment— finally  depends  the  continu¬ 
ance  of  life. 

Rest  is  valuable  in  therapeutics,  because  it  conserves 
energy,  saving  to  the  organism  as  a  whole  or  to  a  particu¬ 
lar  organ  or  system  of  organs  the  force  that  might  be  dis¬ 
sipated  in  action;  because  it  lessens  waste  and  gives  op¬ 
portunity  for  the  repair  of  impaired  tissues;  because  it 
tends  to  permit  restoration  of  the  disturbed  rhythm  of  in- 
ernal  functions  ;  because  it  places  the  organism  in  a  favora¬ 
ble  relation  with  its  environment. 

Nowhere  is  this  more  manifest  than  in  the  therapeutic 
relations  of  the  heart  and  circulatory  system.  In  the  heart 
itself  we  have  visibly  and  palpably  illustrated  the  necessary 
alternation  of  repose  and  action.  Of  course,  absolute  rest 
is  found  nowhere  in  nature.  All  terms  are  relative.  The 
sun,  which  is  at  rest  in  relation  with  the  system  of  planets 
revolving  about  it,  is  in  motion  in  relation  with  the  so- 
called  fixed  stars,  which  latter  are  fixed  only  in  the  name 
they  have  derived  from  certain  of  their  relations  with  earth. 
And  so,  too,  the  sciences  which  deal  with  the  ultimate  ele¬ 
ments  of  matter  assume  the  incessant  motion  of  these  in 
relation  with  each  other,  even  though  one  aggregation  of 


SOLIS- COHEN:  CARDIAC  MEDICAMENTS. 


[N.  Y.  Med.  Jodk., 


596 

restless  molecules  may  be  at  rest  in  relation  with  another 
such  aggregation. 

Now,  while  the  living  heart  is  never  at  rest,  absolutely 
speaking,  yet  its  two  opposite  motions  may,  in  relation 
with  one  another,  be  considered  periods,  respectively,  of 
repose  and  action,  of  anabolism  and  catabolism.  The  dias¬ 
tole,  mainly  a  passive  state,  is  a  period  of  repair  in  relation 
with  the  systole,  which,  as  an  active  exertion  of  energy,  is  a 
period  of  breaking  down  of  tissue.  In  clinical  studies,  as 
a  rule,  we  speak  of  diastole  and  systole,  simply  meaning 
thereby  the  diastole  and  systole  of  the  ventricles.  But  in 
studies  like  the  present  we  must  bear  in  mind  that  there  is 
another  diastole  and  another  systole — namely,  those  of  the 
auricles — and  that  the  ventricular  and  auricular  motions  are 
not  supplementary,  but  complementary.  Except  for  the 
diastolic  overlapping  in  the  so-called  period  of  pause,  auricu¬ 
lar  diastole  is  synchronous  not  with  the  diastole,  but  with 
the  systole  of  the  ventricles,  while  auricular  systole  coincides 
in  time  with  the  diastole  of  the  ventricles.  When  the  blood 
is  leavino-  the  ventricles  to  enter  the  arteries  it  is  at  the 
other  end  of  the  circuit  entering  the  auricles  from  the  veins. 
When  it  leaves  the  auricles  it  passes  directly  from  them 
into  the  ventricles. 

During  diastole  of  the  auricles,  then,  the  heart  receives 
into  these  chambers  on  the  right  side  from  the  systemic 
.circulation  through  the  venae  cavae,  and  on  the  left  side 
from  the  pulmonic  circulation  through  the  pulmonary  veins, 
the  blood,  which,  during  systole  of  the  auricles  and  coin¬ 
cident  diastole  of  the  ventricles,  passes  into  the  latter,  and 
by  their  systole  is  sent  out  from  the  right  ventricle  through 
the  pulmonary  artery  into  the  pulmonic  circulation,  and 
from  the  left  ventricle  through  the  aorta  into  the  systemic 
circulation.  Following  this  is  a  so-called  period  of  pause, 
both  auricles  and  ventricles  being  relaxed.  Auricular  sys¬ 
tole  then  follows  as  before,  Betinx  of  blood  from  ventri¬ 
cles  to  auricles  or  from  arteries  to  ventricles  is  prevented 
bv  valves.  For  proper  circulation,  both  auricular  and  ven¬ 
tricular  diastoles  and  systoles  must  preserve  normal  rela¬ 
tions  with  each  olher,  with  the  pulmonic  and  general  blood- 
;  pressure,  and  with  the  respiratory  rhythm  ;  while  for  proper 
.maintenance  of  health,  both  pulmonic  and  systemic  circu¬ 
lations  must  preserve  normal  relations  with  each  other  and 
with  organic  functions  generally.  These  relations  com¬ 
prise,  structurally,  on  the  side  of  the  heart  integrity  of  the 
muscle,  of  its  membranous  cover  and  lining,  and  of  the 
valves,  and  the  equal  capacity  of  the  four  chambers.  On 
the  side  of  the  vessels  structural  integrity  relates  to  the 
various  components  of  the  vessel  walls  (fibrous,  muscular, 
and  elastic  tissues)  and  to  the  endothelial  lining  membranes 
(intrinsic  integritv),  as  well  as  to  the  absence  of  any  cause 
of  obstruction  by  pressure  or  otherwise  due  to  causes  ex¬ 
ternal  to  the  vessels  (extrinsic  integrity).  Functionally, 
the  normal  relations  comprise  the  vigor,  extent,  duration, 
and  orderly  succession  of  the  various  phases  of  the  cardiac 
movements,  the  free  play  of  the  valves,  the  synchronous 
action  of  right  and  left  sides.  As  to  the  vessels,  normal 
arterial  tension  is  the  most  potent  factor,  while  proper  con¬ 
stitution  of  the  blood  itself  is  a  most  material  circumstance. 
While  relations  remain  normal,  the  therapeutist  has  no 


function  to  discharge.  When  from  any  cause  normal  rela¬ 
tions  become  disturbed,  the  problem  presented  to  the  thera¬ 
peutist  is,  first,  how  to  avert  the  immediate  dangers  arising 
Tom  such  disturbance;  and,  secondly,  how  to  remedy  the 
disturbance.  Both  phases  of  the  problem  may  coincide, 
and  the  same  measure  solve  both  ;  or  temporary  measures 
may  have  to  be  instituted  to  meet  an  emergency,  which 
may  afterward  be  withdrawn  or  modified  as  the  main  diffi¬ 
culty  comes  under  control.  In  combating  the  main  diffi¬ 
culty  our  measures  may  be  radical — that  is  to  say,  they  may 
aim  to  remove  the  cause  of  the  trouble;  or,  should  this  be 
impracticable,  they  may  aim,  notwithstanding  persistence 
of  the  cause,  to  restore  equilibrium  by  artificial  means. 

Restoration  of  equilibrium — that  is,  of  the  normal  bal¬ 
ance  of  function  which  constitutes  health — may  be  accom¬ 
plished  directly  or  indirectly. 

Direct  restoration  of  equilibrium  implies  exaltation  of  a 
depressed  function  or  depression  of  an  unduly  exalted  func¬ 
tion  to  the  normal  level.  An  example  of  such  direct  restora¬ 
tion  as  accomplished  by  Nature  is  given  by  the  illustration 
of  spontaneous  healing  cited  in  our  first  lecture,  the  com¬ 
pensatory  hypertrophy  of  the  heart  which  frequently  takes 
place  in  cases  of  insufficiency  of  the  mitral  valve.  Here 
the  enlargement  of  the  ventricle  and  the  increased  force  of 
the  systole  compensate  for  the  leakage  of  blood  which  takes 
place  through  the  damaged  valve,  and  the  balance  of  func¬ 
tion  is  preserved.  We  imitate  this  natural  compensation 
when  we  administer  digitalis  to  increase  the  vigor  of  the 
cardiac  contractions. 

Indirect  restoration  of  equilibrium  implies  either  de¬ 
pression  of  normal  functions  to  the  level  of  an  impaired 
function  with  which  they  may  be  correlated,  or,  on  the 
other  hand,  elevation  of  normal  functions  to  the  level  of  an 
unduly  exalted  function  with  which  they  may  be  correlated. 
An  example  of  such  indirect  restoration  of  equilibrium,  at 
least  temporarily,  by  Nature,  is  the  arrest  of  haemorrhage 
by  syncope,  where  the  action  of  the  heart  is  depressed  to 
the  level  of  the  impaired  resisting  power  of  the  injured  ves¬ 
sels.  This  is  therapeutically  imitated  at  times  by  the  ad¬ 
ministration  of  aconite  or  the  application  of  ice  over  the 
praecordium  in  cases  of  haemoptysis  ;  or,  as  is  sometimes 
done  by  military  surgeons  in  cases  of  wound  through  the 
lungs  on  the  battle-field,  by  the  letting  of  blood  from  an 
arm. 

Nowhere  is  the  therapeutic  problem  more  complicated 
by  the  complicated  relations  of  various  functions  than  in 
the  case  of  morbid  derangements  of  the  circulatory  system, 
and  nowhere  are  the  results  of  intelligent  study  of  the 
problem  leading  to  a  proper  adaptation  of  means  to  end 
more  brilliant. 

In  our  study  of  the  blood  we  saw  how  the  scriptural 
phrase,  “The  life  is  in  the  blood,”  might  serve  to  remind 
us  of  a  biological  truth  of  prime  importance. 

As  the  amoeba  and  similar  organisms  live  in  the  water, 
so  do  the  cells  which  make  up  the  tissues  of  higher  forms 
of  life  live  in  the  fluids  which  pass  from  the  terminal  blood¬ 
vessels  into  the  intercellular  lymph-spaces.  Literally,  in 
the  blood  is  the  life.  As  the  amoeba  takes  from  the  water 
materials  for  its  upbuilding  and  discharges  into  the  water 


.Nov.  29,  1890.J 


SOLIS-COIIEN :  CARDIAC  MEDICAMENTS. 


the  waste  products  of  its  activity,  so  do  the  cells  of  our  tis¬ 
sues  take  from  the  nutrient  lymph  the  materials  for  their 
anabolism,  and  discharge  into  it  the  products  of  their  ca¬ 
tabolism.  But  we  have  already  seen  that  the  products  of 
catabolism  are  dangerous  to  the  economy  ;  that  every  living 
thing  is  poisoned  by  the  products  of  its  own  activity.  As 
— to  take  analogous  but  not  exact  illustrations — carbonic 
acid  and  water,  products  of  combustion,  may  be  used  to  ex¬ 
tinguish  conflagration,  and  as  the  products  of  chemical  de¬ 
composition  interfere  with  the  action  of  an  electric  battery, 
so  throughout  the  world  of  life  appears  to  rule  this  general 
law  :  The  end-products  of  an  action  bring  that  action  to  an 
end.  Thus  alkalies  check  the  activity  of  glands  which  se¬ 
crete  alkaline  fluids,  and  acids  restrain  the  secretions  of 
acid-producing  glands.  Thus,  in  the  presence  of  a  certain 
amount  of  peptones,  products  of  its  own  action,  pepsin 
ceases  to  produce  further  change,  renewing  its  activity  when 
the  peptones  have  been  removed.  The  result  of  action 
being  present,  the  stimulus  to  action  is  withdrawn.  When 
hunger  is  satisfied,  appetite  ceases  to  be  manifested.  So, 
unless  the  products  of  the  breaking  down  of  tissue,  which 
are  the  result  of  functional  activity  upon  the  part  of  cells, 
are  withdrawn  from  the  cells,  their  power  for  further  action 
ceases. 

It  is  not  only  “  well,”  as  the  old  song  phrases  it — it  is 
absolutely  necessary  for  our  tissues 

“  to  be  off  with  the  old  love 
Before  they  are  on  with  the  new.” 

As  the  new  is  brought  by  the  nutrient  liquor  which 
passes  out  from  the  capillaries — that  is,  by  the  arterial  or 
aerated  blood — so  the  old  is  taken  up  and  carried  away  bv 
the  lymphatics  and  venous  radicles  ;  that  is,  by  the  venous 
or  carbonated  blood.  In  this  exchange  of  “new  lamps  for 
old  ”  the  functions  of  the  whole  elaborate  system  of  vis¬ 
cera — that  is  to  say,  of  heart  and  vessels,  and  lungs  and 
blood-making  organs,  and  digestive  apparatus  and  eliminat¬ 
ing  organs,  with  their  nerves  and  ganglia,  the  functions  of 
the  whole  system  of  so-called  organic  life — culminate.  It 
is  for  this  end  they  have  being  and  activity.  And  in  this 
final  consummation  the  heart  plays  a  most  important  part  ; 
for  upon  the  proper  rhythmic  activity  of  that  organ  de¬ 
pends  the  constant  circulation  which  renders  the  exchange 
possible. 

We  have  seen  in  our  previous  studies  that  a  thorough 
knowledge  of  anatomy  and  of  physiology  is  absolutely  es¬ 
sential  before  we  can  intelligently  apply  our  knowledge  of 
the  powers  of  the  materia  medica  to  the  study  of  the  treat¬ 
ment  of  the  sick;  that  is,  before  we  can  take  up  the  true 
science  of  therapeutics. 

The  facts  just  passed  in  review  serve  to  again  emphasize 
this  truth  for  us  in  connection  with  the  circulatory  system. 
In  all  our  considerations  of  the  actions  of  drugs  upon  the 
heart  and  vessels  we  must  bear  in  mind  the  terminal  circu¬ 
lation.  We  must  remember  the  interchange  of  gases,  of 
oxygen,  and  carbonic  acid,  not  only  in  the  lungs,  but  also 
in  the  intercellular  lymph  spaces — the  internal  respiration  ; 
and  the  allied  processes  of  final  assimilation  and  initial  ex¬ 
cretion — that  is,  the  bringing  of  the  materials  of  cellular 


597 

anabolism  and  the  taking  away  of  the  products  of  cellular 
catabolism — of  which  it  may  stand  as  type.  We  must  con¬ 
sider,  then,  not  alone  the  state  and  action  of  the  heart,  but 
also  of  the  vessels.  We  must  consider  the  distribution  of 
the  blood,  peripherally,  ventrally,  in  the  various  organs  ; 
the  relative  quantities  of  blood  in  the  venous  and  arterial 
systems;  as  well  as  the  relation  which  the  whole  amount  of 
blood  bears  to  the  propulsive  power  of  the  heart.  We  must 
consider  the  conditions  which  favor  and  oppose  circulation 
not  only  in  the  heart  itself,  the  main  trunks,  and  the  larger 
vessels,  but  also  in  the  capillaries,  in  the  lymph  spaces,  in 
the  venous  radicles.  We  must  consider  the  conditions 
which  favor  and  oppose  the  internal  respiration,  and  also 
the  pulmonary  respiration.  We  must  inquire  into  the  con¬ 
ditions  affecting  the  pulmonary  circulation.  We  must  ex¬ 
amine  the  condition  of  the  great  abdominal  vessels — the 
portal  circle  ;  and  estimate  the  effect  of  our  therapeutic 
measures  upon  the  organs  of  elimination,  especially  the  skin 
and  the  kidneys,  which  are  so  powerfully  influenced  by 
changes  in  blood  pressure  and  in  the  tension  of  the  vessel- 
walls.  Other  considerations,  also,  come  into  view,  which, 
however,  can  be  more  appropriately  discussed  in  their  spe¬ 
cial  relations.  But,  above  all,  we  musf  remember  that  our 
prime  object  is  to  restore  equilibrium ,  to  re-establish  the  bal¬ 
ance  of  function ,  tor  that  constitutes  health.  And,  in  order 
that  we  may  be  able  to  choose  proper  measures  by  which  to 
re-establish  equilibrium,  we  must  inform  ourselves  as  to  all 
the  disturbing  factors.  Thus  it  is  that,  while  so-called 
“polypharmacy” — the  objectless  throwing  together  of  a 
er  of  drugs  in  one  prescription — is  to  be  unhesitating¬ 
ly  condemned,  yet  in  the  application  of  remedies  to  the 
treatment  of  diseases  affecting  the  heart  and  circulation  it 
is  often  necessary  to  intelligently  combine  agents  some  of 
whose  actions  are  in  opposition.  Digitalis,  for  example, 
may  in  some  cases  of  cardiac  dilatation,  while  acting  bene¬ 
ficially  upon  the  heart,  yet,  through  its  action  upon  the  ves¬ 
sels  in  unduly  heightening  arterial  tension,  tend  to  again 
disturb  the  equilibrium  which  its  cardiac  action  tends  to  re¬ 
store.  In  such  cases,  as  has  been  more  especiallv  shown  by 
Bartholow,  we  can,  by  the  simultaneous  administration  of 
nitroglycerin,  which  relaxes  the  terminal  vessels,  modify 
the  digitalis  effect ;  and  the  therapeutic  object — restoration 
of  the  balance  of  function — is  successfully  accomplished. 
This,  however,  will  be  better  discussed  in  our  next  lecture, 
when  we  take  up  special  conditions  and  the  principles  gov 
erning  their  management.  In  the  time  that  now  remains 
to  us  we  must  try  to  gain  some  further  insight  into  the  im¬ 
portant  relations  between  those  two  great  factors  in  the 
circulation  which  the  example  just  cited  shows  us  in  appar¬ 
ent  opposition — the  systolic  impulse  and  the  arterial  ten¬ 
sion.  Here  we  must  again  call  to  mind  the  two  funda¬ 
mental  laws  of  physics  we  have  had  such  frequent  occasion 
to  cite.  “  Motion  takes  place  in  the  direction  of  least  re¬ 
sistance.”  “  Every  action  has  an  equal  and  opposite  reac¬ 
tion.” 

1  he  force  by  which  the  blood-current  overcomes  resist¬ 
ance  is  called  the  blood-pressure.  The  great  cause  of  blood- 
pressure  is  the  systolic  contraction.  Pressure  is  greatest  in 
the  ventricles  during  their  systole,  and  least  in  the  auricles 


598 


SO  LIS-  COHEN :  CARDIAC  MEDICAMENTS. 


[N.  Y.  Med.  Jour.t 


during  their  diastole.  Therefore  these  states,  as  we  have 
seen,  being  coincident  in  time,  the  blood  moves  from  the 
ventricles  (in  systole)  and  toward  the  auricles  (then  in  dias¬ 
tole),  traversing  meanwhile  the  systemic  and  pulmonic  ves¬ 
sels.  These  vessels  afford  the  only  route  of  communication 
between  the  left  ventricle  and  right  auricle  on  the  one  hand 
(systemic  circulation),  and  between  the  right  ventricle  and 
the  left  auricle  on  the  other  hand  (pulmonic  circulation). 
There  must  be  a  gradual  and  continuous  fall  of  pressure 
alono1  these  routes  from  terminal  to  terminal,  in  order  to 
permit  the  movement  of  the  blood,  which  takes  place  in  the 
direction  of  least  resistance.  As  pressure  acts  equally  in 
all  directions,  the  blood-pressure  opposes  the  action  of  the 
heart  in  systole,  and  favors  the  action  of  the  heart  in  di¬ 
astole  ;  in  other  words,  there  is,  in  consequence  of  the 
blood-pressure  in  the  arterial  system,  a  constant  tendency 
toward  reflux  to  the  heart,  which  is  normally  prevented 
during  systole  by  the  higher  pressure  in  the  heart,  and 
during  diastole,  so  far  as  the  ventricles  are  concerned,  by 
the  closure  of  the  pulmonary  and  aortic  valves.  Thus  the 
blood-pressure  at  any  point  represents  the  possibilities  of 
circulation  at  that  point.  It  should  be  higher  than  at 
the  point  beyond,  and  lower  than  at  the  point  preceding. 
Whenever  these  conditions  are  reversed  there  is  obstruc¬ 
tion  to  circulation. 

Passing  over  and  neglecting  anatomical  and  physio¬ 
logical  details  with  which  I  must  assume  you  to  be  familiar, 
we  can,  I  think,  render  the  subject  somewhat  clearer  than 
I  find  it  to  be  in  the  minds  of  most  students  whom  I  have 
had  occasion  to  question,  by  a  diagram  in  which  we  shall 
ignore  the  pulmonic  circulation  and  separate  the  two  ter¬ 
minals  of  the  systemic  circulation — the  left  ventricle  and 
the  right  auricle — considering  only  the  passage  of  blood 
from  the  former  of  these  to  the  latter. 


Let  L.  V.  represent  the  left  ventricle,  whence  the  arte¬ 
rial  blood  flows  in  the  direction  of  the  arrow  through  A.  T., 
the  arterial  trunks,  C,  the  capillaries;  and  now,  taking  up 
waste  products  and  therefore  becoming  venous  blood,  as 
shown  by  the  shading,  on  through  V.  R.,  the  venous  radi¬ 
cles,  and  V.  T.,  the  venou3  trunks,  into  R.  A.,  the  right 
auricle.  At  L.  V.  there  is  positive  pressure  (  +  ),  at  R.  A. 
there  is  a  slight  negative  pressure  ( — ),  or  aspiration;  con¬ 
sequently  the  current,  taking  the  direction  of  least  resist¬ 
ance,  flows  from  L.  V.  toward  R.  A.  There  is  a  gradual 
and  continuous  fall  of  pressure  as  we  proceed  along  the 
vessels,  and  this  renders  possible  a  regular  and  equable 
flow  of  blood.  If  the  pressure  at  any  point  between  L.  V. 
and  R.  A.  were  to  fall  below  that  of  R.  A.,  the  blood  would 
tend  toward  that  point  from  both  terminals,  and  circula¬ 
tion  would  be  correspondingly  impeded.  If.  on  the  other 
hand,  the  pressure  at  any  intermediate  point  should  become 
greater  than  at  L.  V.,the  blood  would  tend  from  that  point 
in  both  directions;  it  would  raise  the  pressure  at  R.  A. 


and  it  would  resist  the  onflow  from  L.  V.,  and  circulation 
would  be  impeded.  Any  intermediate  degree  of  altera¬ 
tion  of  pressure  would  have  effects  proportionate  to  its 
degree. 

Now,  so  long  as  the  caliber  of  the  tube  A.  T.  to  Y.  T. — 
that  is,  of  the  vascular  system — remains  unchanged,  blood- 
pressure  depends  almost  exclusively  upon  the  contraction 
of  L.  V.  But  should  the  tube  contract,  thus  increasing  re¬ 
sistance,  or  dilate,  thus  lessening  resistance,  blood-pressure 
would  rise  at  the  point  of  contraction  and  fall  at  the  point 
of  dilatation  without  reference,  and  perhaps  in  opposition,, 
to  the  action  of  L.  Y.  As  the  blood  presses  equally  in  all 
directions,  it  presses  on  the  walls  of  the  arteries  and  stretches 
them,  or  puts  them  in  a  state  of  tension.  Hence  the  arte¬ 
rial  tension  is  the  measure  of  the  blood-pressure ,  and  the  two 
terms  are  used  interchangeably.  If,  by  contracting  the 
vessels,  we  increase  arterial  tension,  blood-pressure  is  height¬ 
ened.  If,  by  dilating  the  vessels,  we  diminish  arterial  ten¬ 
sion,  blood-pressure  is  lowered.  Conversely,  if,  by  forcing 
more  blood  into  the  arteries,  we  heighten  blood-pressure, 
arterial  tension  is  increased  ;  or  if,  by  diminishing  the 
flow  of  blood,  we  lower  pressure,  arterial  tension  is  di¬ 
minished.  The  one  is  the  measure  of  the  other,  and 
they  rise  or  fall  together.  Practically  it  is  the  same  con¬ 
dition  with  two  names  depending  on  the  side  from  which 
it  is  looked  at. 

Now  let  us  go  one  step  further,  so  that  in  our  next  lecture 
we  may  be  prepared  to  bring  all  our  facts  to  a  focus.  While 
the  blood-pressure  normally  varies,  falling  regularly  from 
L.  V.  to  R.  A.,  there  is  a  certain  average,  or  mean  pressure , 
which  is  an  important  factor  in  the  circulation.  The  mean 
pressure  represents  the  relation  between  L.  V.  and  R.  A. 
If,  for  example,  pressure  should  become  too  low  in  R.  A., 
the  blood  would  tend  to  accumulate  on  the  venous  side, 
unless  a  corresponding  fall  was  brought  about  at  L.  V. 
But  if  there  should  be  a  fall  at  L.  Y.  and  not  throughout 
the  whole  system,  circulation  would  still  be  impeded  pro¬ 
portionately.  Therefore  the  mean  pressure  must  also  fall 
before  equilibrium  can  be  restored.  So  is  it,  too,  in  any 
other  case  of  alteration  at  the  terminals  or  along  the  course 
of  the  vessels.  The  mean  pressure  must  rise  or  fall  to  cor¬ 
respond  with  the  rise  or  fall  at  L.  V.  Now,  this  mean 
pressure  is  very  largely  under  therapeutic  control.  It  is 
governed  by  a  special  nervous  mechanism — the  vaso-motor 
system — which,  by  acting  on  the  muscular  fibers  of  the 
arteries  and  arterioles,  and  probably  on  the  protoplasm  of 
the  capillaries,  causes  them  to  dilate  or  contract.  Local 
contraction  heightens,  and  local  dilatation  lowers,  local 
blood-pressure.  General  contraction  heightens,  and  gen¬ 
eral  dilatation  lowers,  general  or  mean  blood-pressure.  We 
have  many  agents  by  which  we  can  act  locally  and  gener¬ 
ally,  directly  and  indirectly,  on  the  vessels  and  on  the 
nervous  mechanism  which  regulates  their  caliber.  Some 
of  these,  such  as  heat  and  cold,  irritants  and  counter-irri¬ 
tants,  we  have  already  discussed.  Others  will  be  considered 
at  our  next  meeting. 

Change  of  Address. — Dr.  Frank  Ferguson,  to  No.  20  West  Thirty- 
eighth  Street. 


Nov.  29,  1890.] 


THOMPSON:  SOMNAL,  A  NEW  HYPNOTIC. 


599 


#  right  a  l  Communications. 


SOMNAL,  A  NEW  HYPNOTIC.* 

By  W.  GILMAN  THOMPSON,  M.D., 

VISITING  PHYSICIAN  TO  THE  NEW  YORK  AND  PRESBYTERIAN  HOSPITALS  ; 
PROFESSOR  OF  PHYSIOLOGY  IN  THE  NEW  YORK  UNIVERSITY  MEDICAL  COLLEGE- 

Somnal  is  a  new  hypnotic  which  was  introduced  a  year 
ago  by  Radlauer,f  of  Berlin.  It  is  formed  by  a  union  of 
-chloral,  alcohol,  and  urethan,  but  the  resulting  compound 
is  a  complex  body  and  not  a  simple  mixture.  Its  physical 
characters  are  thus  described  by  Dr.  Frank  Woodbury,];  of 
Philadelphia,  who  administered  it  in  several  cases,  in  doses 
of  from  twenty  to  thirty  minims,  with  very  favorable  re¬ 
sult  : 

Physical  Characters. — ■“  Somnal  is  a  colorless  liquid 
resembling  chloroform  in  its  appearance  and  behavior  when 
added  to  cold  water,  in  which  it  forms  globules  and  refuses 
to  mix  or  dissolve.  When  shaken  with  water,  the  mixture 
is  milky,  but  quickly  separates.  It  is  soluble  in  hot  water 
and  alcoholic  solutions,  and  dissolves  resinous  substances 
and  fats.  The  odor  is  faint,  not  very  penetrating  or  dis¬ 
agreeable,  and  resembling  that  of  the  spirits  of  nitrous 
ether,  or  recrystallized  chloral.  The  taste  is  very  pungent, 
and  for  administration  it  needs  free  dilution.  It  may  be 
given  with  whisky  or  syrup  of  licorice.  Somnal  is  in¬ 
flammable,  burning  with  an  alcoholic  flame ;  it  does  not 
evaporate  quickly,  and  leaves  a  greasy  stain  upon  blotting- 
paper.  Specific  gravity  greater  than  water  ;  reddens  litmus 
paper  slightly.” 

I  have  recently  tested  the  physiological  action  and  toxic 
effect  of  the  drug  upon  animals  at  the  Loomis  Laboratory 
as  follows : 

Experiment  I. — Five  cubic  centimetres  were  injected  slowly 
into  the  rectum  of  a  cat.  In  a  miuute  and  a  half  the  tongue  and 
retinal  vessels  became  decidedly  congested.  The  pupils  were 
dilated  and  the  pulse  became  rapid,  but  not  very  feeble.  In  ten 
minutes  slight  paresis  of  the  hind  legs  appeared,  and  the  animal 
staggered  in  walking.  The  fore  legs  were  unaffected.  Defeca¬ 
tion  ensued,  which  was  performed  with  great  muscular  effort. 
When  in  a  sitting  posture  there  was  evident  vertigo,  indicated 
by  swaying  of  the  head  and  body.  The  facial  expression  was 
dull  and  listless,  and  the  animal  was  apparently  sleepy,  but  was 
easily  aroused  by  coaxing,  when  she  would  stand  up  and  walk 
with  an  unsteady  gait,  the  hind  legs  not  being  well  straight¬ 
ened.  I  attributed  the  cat’s  difficulty  in  walking  to  vertigo  rather 
than  to  actual  loss  of  power,  for  the  fore  legs  were  not  affected 
at  all,  and  the  hind  legs  were  voluntarily  used  with  good  co¬ 
ordination  in  scratching  her  sides.  In  twenty  minutes  the  cat 
became  very  quiet  and  sleepy.  Both  pulse  and  respiration  were 
increased  by  about  half  the  normal  rate.  When  aroused  by  a 
call,  the  animal  would  get  up  and  walk  about  with  unsteady 
gait,  but  soon  sought  a  quiet  corner  and  dozed.  In  forty-five 
minutes  she  became  much  steadier  on  her  feet,  and,  after  a  few 
more  naps,  appeared  perfectly  normal.  The  rectal  temperature 
fell  two  tenths  of  a  degree. 

Experiment  II. — Fifteen  cubic  centimetres  of  somnal  were 


*  Read  before  the  New  York  Clinical  Society,  October  24,  1890. 
f  Zeitschrift  des  ApotheJcers-Vereins ,  November,  1889. 

\  Dietetic  Gazette,  July,  1890. 


injected  into  the  stomach  of  another  cat  through  an  oesophageal 
tube.  The  animal  died  in  two  minutes.  The  respiration  ceased 
first,  and  the  heart  stopped  half  a  minute  later.  Post  mortem 
examination  showed  the  liver  and  spleen  both  greatly  congested 
and  enlarged  by  engorgement  with  venous  blood.  The  stomach 
was  congested  and  irregularly  contracted  from  the  local  stimu¬ 
lation  of  the  drug.  Peristaltic  movement  of  the  intestines  and 
tremors  of  the  exposed  voluntary  muscles  lasted  unusually  long. 
The  heart  had  stopped  in  diastole  with  the  right  ventricle  greatly 
distended,  as  in  chloral  poisoning.  The  pupils  were  dilated. 

Experiment  III. — To  a  black-and-tan  dog,  weighing  nine 
pounds  and  a  half,  twenty-five  minims  of  somnal  were  given  by 
hypodermic  injection.  There  was  no  evidence  of  local  irri¬ 
tation.  After  fifteen  minutes  no  effect  was  noted.  In  twenty- 
five  minutes  there  was  slight  vertigo,  indicated  by  swaying  of 
the  body  in  walking.  There  were  muscular  tremors,  especially 
of  the  hind  legs.  The  pupils  were  dilated.  The  dog  walked 
about  wagging  his  tail,  but  seeming  very  restless  and  uneasy. 
When  his  attention  was  diverted  he  appeared  better  and  looked 
brighter.  There  was  no  important  change  in  pulse,  respiration, 
or  temperature.  In  thirty-five  minutes  the  dog  appeared  very 
drowsy,  but  occasionally  opened  his  eyes.  In  a  sitting  posture 
the  body  swayed  to  and  fro  and  the  head  drooped.  In  fifty 
minutes  the  dog  was  fast  asleep.  In  an  hour  and  a  half  the  dog 
was  awakened  and  appeared  normal  in  every  respect. 

Experiment  IV. — To  a  large  bull-dog,  weighing  twenty-three 
pounds  and  a  half,  thirty  minims  of  somnal  were  given  by  hy¬ 
podermic  injections.  There  was  no  local  irritation.  In  ten 
minutes  he  showed  decided  tremors  of  the  muscles  of  the  face 
and  abdomen  and  all  the  extremities.  There  were  no  convul¬ 
sions,  merely  decided  twitching  at  irregular  intervals.  The  ani¬ 
mal  could  walk  well  enough,  but  seemed  to  prefer  quiet.  The 
conjunctivse  were  congested  and  the  pupils  dilated.  In  fifteen 
minutes  the  animal  appeared  extremely  sleepy,  and  it  cost  evi¬ 
dent  effort  to  awaken  when  aroused  by  noises.  In  half  an  hour 
the  tremors  had  diminished,  and  principally  affected  the  hind 
legs.  In  an  hour  and  a  quarter  the  dog  was  again  in  a  perfectly 
normal  condition. 

Experiment  V.  —  A  large  mongrel  dog,  weighing  twenty 
pounds,  was  etherized,  and  a  cannula  was  inserted  into  the  right 
carotid  artery.  The  cannula  was  connected  with  a  mercurial 
manometer,  and  tracings  of  the  normal  arterial  pressure  were 
recorded  by  a  kymographion.  Thirty  minims  of  somnal  were 
injected  into  the  abdominal  wall.  The  subsequent  tracings 
showed  a  decided  increase  of  arterial  tension  occurring  within 
the  first  eight  minutes,  followed  by  a  gradual  return  to  the 
normal  within  a  few  minutes.  The  influence  of  the  respiratory 
curve  on  the  blood-pressure  curve  became  much  less  marked 
than  normal.  No  other  effects  of  the  drug  were  evident  and 
the  dog  recovered  completely. 

These  experiments  show  that — 

I.  The  ordinary  dose  of  somnal  (thirty  minims  for 
man)  may  be  given  by  hypodermic  injection  to  dogs  with¬ 
out  other  effect  than  drowsiness  and  slight  vertigo  and 
muscular  tremor. 

II.  A  dose  of  one  fluid  drachm  and  a  half  failed  to  af¬ 
fect  a  cat  except  in  the  same  manner  as  the  dogs. 

III.  A  fatal  dose  of  half  a  fluid  ounce  stopped  the  res¬ 
piration  before  the  heart  and  caused  congestion  of  all  the 
abdominal  viscera. 

IV.  The  blood-pressure  in  the  arteries  of  a  dog  is  tem¬ 
porarily  increased  by  somnal,  soon  returning  to  the  normal. 

In  the  past  few  months  I  have  given  somnal  fifty-four 
times  in  doses  varying  from  thirty  minims  to  a  drachm.  Tt 


600 


STOWELL:  THE  VALUE -OF  EXPERIMENTAL  MATERIA  MEDIC  A.  [N.  Y.  Med.  Jour., 


was  given  to  forty  different  patients,  and  very  careful  rec¬ 
ords  of  the  effect  in  each  case  were  tabulated,  for  which  I 
am  indebted  to  Dr.  H.  A.  Griffin,  house  physician  to  the 
New  York  Hospital,  and  Dr.  E.  W.  Perkins,  of  the  house 
staff  of  the  Presbyterian  Hospital.  So  far  as  possible,  pa¬ 
tients  were  selected  who  were  in  the  habit  of  sleeping  very 
poorly,  and  not  at  all,  unless  some  hypnotic  was  given 
them.  Every  care  was  taken  to  select  only  those  patients 
who  presented  well-marked  cases  of  insomnia.  Cases  were 
selected  also  with  a  view  to  having  as  great  a  variety  as 
possible  in  the  causes  of  the  insomnia.  The  list  includes, 
therefore,  insomnia  due  to  rheumatism,  phthisis,  bronchitis 
(cough),  typhoid  delirium,  delirium  tremens,  sciatica,  vari¬ 
ous  forms  of  pelvic  pain,  neuralgias,  etc. 

The  records  comprise  the  diagnosis  of  the  case,  the  size 
of  the  dose,  the  time  occupied  in  going  to  sleep,  the  dura¬ 
tion  and  character  of  the  sleep,  condition  on  awakening, 
after-effects,  effect  on  digestion,  etc.  Of  the  fifty-four  in¬ 
stances  in  which  somnal  was  given,  it  produced  sleep  twen¬ 
ty-six  times  within  fifteen  minutes  and  forty-three  times 
within  an  hour.  In  six  cases  only  is  it  noted  as  having 
no  effect  at  all.  In  a  few  other  instances  where  it  failed  to 
induce  sleep  it  was  found  to  have  a  very  soothing  and 
quieting  effect.  Sixteen  patients  slept  practically  all  night 
after  taking  half  a  drachm.  Fifteen  more  slept  between 
three  and  six  hours,  and  the  remainder  for  briefer  inter¬ 
vals. 

In  most  of  the  patients  the  character  of  the  sleep  was 
natural  ;  in  only  one  or  two  cases  did  it  seem  more  pro¬ 
found  than  usual.  There  were  no  after-effects  noted  in  any 
case,  with  one  exception — that  of  a  patient  with  tuberculosis, 
who  slept  seven  hours  and  a  half,  after  a  half-drachm  dose, 
and  felt  depressed  on  awakening.  Most  of  the  patients 
felt  considerably  refreshed,  many  of  them  decidedly  so. 
There  was  no  disturbance  of  the  stomach  or  of  digestion, 
with  one  exception,  where  a  patient  with  endometritis  com¬ 
plained  of  pain  after  taking  a  dose  of  half  a  drachm.  Doses 
of  forty-five  minims,  and  even  sixty  minims,  produced  no 
depression  of  the  circulation  or  respiration — a  very  differ¬ 
ent  effect  from  that  of  large  doses  of  chloral.  A  patient 
with  delirium  tremens  became  drowsy  in  a  few  minutes 
after  taking  a  drachm,  but  soon  had  to  be  quieted  by  other 
remedies.  A  case  of  typhoid  fever  with  active  delirium, 
almost  maniacal,  was  unaffected  by  forty  minims,  but  was 
immediately  quieted  by  hydrobromate  of  hyoscine.  Pain 
or  cough,  if  severe,  was  not  much  relieved,  though  a  sooth¬ 
ing  effect  was  sometimes  observed. 

Conclusions. — 1.  The  effects  of  somnal  are  much  more 
striking  and  certain  than  those  of  urethane,  and  far  less  de¬ 
pressing  than  those  of  chloral. 

2.  There  is  no  vertigo  or  depression  after  taking  som¬ 
nal,  such  as  may  follow  the  use  of  sulphonal. 

3.  The  action  of  somnal  is  usually  very  prompt,  and 
doses  of  half  a  drachm,  disguised  in  a  little  syrup  of  tolu 
or  whisky,  are  always  well  borne,  easily  taken,  and  entirely 
without  deleterious  effect. 

4.  The  drug,  in  doses  of  a  drachm,  is  not  powerful 
enough  to  decidedly  control  delirium  tremens,  maniacal 
delirium,  or  severe  pain. 


5.  In  doses  of  thirty  or  forty  minims  somnal  is  a  safe 
and  reliable  hypnotic  for  ordinary  insomnia. 

Before  making  the  physiological  experiment  above  de¬ 
scribed,  to  determine  the  effect  of  somnal  upon  the  blood- 
pressure,  I  gave  it  continuously  to  a  patient  with  chronic 
interstitial  nephritis  and  endarteritis,  with  phenomenally 
high  tension.  He  had  been  taking  frequent  ten-grain  doses 
of  chloral,  which  reduced  the  tension  very  well.  Thinking 
that  somnal  might  have  a  similarly  favorable  action,  I  gave 
it  in  frequent  doses  instead  of  the  chloral,  but  the  tension 
immediately  returned  to  the  high  degree  that  existed  when 
the  patient  was  first  seen,  and  remained  so  extremely  high 
that  I  was  obliged  to  return  to  the  chloral  with  the  addi¬ 
tion  of  nitroglycerin. 

So  many  of  the  new  hypnotics  have  one  or  more  objec¬ 
tionable  features,  and  their  continuous  use  results  in  so 
many  new  drug  “  habits,”  that  it  is  an  evident  advantage 
to  have  another  remedy  of  this  class  which  can  be  used  in¬ 
terchangeably  with  others  if  desired,  and  which  seems  to  be 
singularly  free  from  injurious  effects  and  yet  strong  enough 
to  act  promptly  and  efficiently  in  ordinary  insomnia  not 
due  to  intense  pain  or  delirium. 


THE  VALUE  OF 

EXPERIMENTAL  MATERIA  MEDICA.* 

Bv  CHARLES  H.  STOWELL,  M.  D., 

WASHINGTON,  D.  C. 

The  materia  medica  of  our  forefathers  consisted  largely 
of  a  mass  of  empirical  facts.  These  Bechat  defined  as  “the 
shapeless  mass  of  inexact  ideas.”  But  out  of  this  mass 
evolved  much  that  was  of  undoubted  value.  As  the  thera¬ 
peutical  art  advanced,  however,  it  was  more  and  more  clear¬ 
ly  seen  that  the  materia  medica  of  the  future  must  be  based 
on  a  study  by  the  physiological  method.  It  was  only  by 
this  physiological  test  that  we  could  enter  into  the  very 
secret  recesses  of  Nature.  And  thus  the  physiological 
action  of  a  drug  became  our  ruling  principle. 

Without  doubt  the  physiological  method  is  not  only 
vastly  superior  to  the  empirical,  but  is  also  rapidly  displac¬ 
ing  it.  It  is  not  the  object  of  this  paper  to  advocate  a 
change  in  this  particular,  but  rather  to  utter  a  word  of  cau¬ 
tion  and  criticism — a  word  of  caution  lest  we  be  too  eager 
to  accept  in  full  the  edicts  of  our  modern  scientific  schools; 
a  word  of  criticism  lest  we  altogether  refuse  to  accept  the 
results  by  the  empirical  method.  We  are  led,  therefore,  to 
ask  the  following  questions:  What  is  the  value  of  experi¬ 
mental  materia  medica?  Can  we  accept  as  a  safe  guide 
the  therapeutical  conclusions  based  upon  observations  made 
on  the  lower  animals  ?  Is  the  action  of  a  drug  the  same  on 
the  well  as  on  the  sick?  If  the  action  of  a  drug  is  one 
thing  on  the  lower  animals  and  a  vastly  different  thing  on 
man,  of  what  value  are  the  extensive  experiments  detailed 
to  us  in  our  current  literature  and  in  our  works  of  refer¬ 
ence?  And  in  the  case  of  new  drugs,  of  what  value  are  the 

*  Read  before  the  Medical  Society  of  the  District  of  Columbia,  Oc¬ 
tober  22,  1890. 


Nov.  29,  1890.J 


STOWELL:  THE  VALUE  OF  EXPERIMENTAL  MATERIA  MED  IGA. 


conclusions  derived  from  a  study  of  their  action  on  the 
frog,  the  dog,  or  the  rabbit?  Again,  if  drugs  affect  some 
of  the  lower  animals  differently  from  others,  who  is  to  de¬ 
cide  which  animal  is  the  proper  one  to  give  us  the  true  (?) 
physiological  action  ?  Then,  again,  if  a  drug  does  not  have 
the  same  action  in  the  various  forms  of  disease,  which  dis¬ 
ease  must  be  chosen  to  give  us  its  standard  effect?  In  con¬ 
clusion,  if  we  are  to  rest  fully  content  with  the  physiological 
method  to  the  abandonment  of  the  empirical,  will  we  not 
be  lost  at  sea  without  a  rudder? 

In  order  to  refresh  our  memories,  let  us  present  the  fol¬ 
lowing  illustrations,  collected  from  standard  writers: 

Chloroform. — The  physiological  effects  of  chloroform 
on  man  are  well  known.  Yet  Nunnely  subjected  the  limbs 
of  frogs  and  toads  to  a  vapor  of  chloroform,  and  then  pro¬ 
ceeded  to  excise  them  piecemeal,  without  the  animals  be¬ 
traying  any  signs  of  pain.  Professor  Simpson  and  Mr. 
Nunnely  easily  produced  local  anaesthesia  on  fish,  frogs,  in¬ 
sects,  etc.  Now,  while  it  is  true  that  many  logical  conclu¬ 
sions  have  been  drawn  from  experiments  on  the  frog,  vet 
we  would  hardly  be  justified  in  beginning  an  amputation 
of  a  finger  simply  after  immersing  it  in  this  anaesthetic. 

Nux  Vomica. — The  experiments  of  Klapp  prove  that  in 
the  cat  and  rabbit  strychnine  slows  the  pulse.  Bartholow 
says  that  in  man  the  heart’s  action  is  accelerated.  He 
thinks  this  apparent  contradiction,  however,  may  be  ex¬ 
plained  by  the  dose  employed.  During  the  spasms  of  dogs 
the  animals  appear  insensible  to  all  impressions.  They 
could  be  cut  with  knives  without  exciting  signs  of  pain, 
but  “in  man  the  mind  remains  clear  and  unaffected  ;  it  is 
probable  that  little  pain  is  experienced.”  In  the  case  of 
the  dog,  either  the  susceptibility  of  the  animal  is  primarily 
affected,  or  the  pain  is  so  severe  that  the  extreme  pain  of 
cutting  is  not  noticed. 

Opium. — We  are  told  that  the  poppy  is  a  favorite  food 
of  the  rabbit.  He  will  actually  thrive  and  get  fat  on  such 
a  diet.  Three  grains  of  the  acetate  of  morphine  have  been 
given  to  this  little  animal  with  no  effect.  Based  upon  these 
experiments,  it  would  seem  safe  to  assume  that. this  is  quite 
a  harmless  weed,  and  that  its  active  principle — morphine — 
is  quite  inert.  Large  doses  of  opium  given  to  dogs  appear 
to  affect  the  motory  powers,  but  do  not  produce  coma.  The 
purely  instinctive  emotions  of  the  lower  animals  remain  un¬ 
affected. 

Quinine. — Stille  says  that  this  drug,  given  to  dogs,  de¬ 
ranges,  enfeebles,  and  finally  extinguishes  nervous  action. 
Thirty  grains  given  to  a  dog  caused  death  in  twenty-four 
hours.  Dr.  C.  W.  Brown  reports  that  two  grains  placed 
on  the  tongue  of  a  full-grown,  healthy  cat  caused  a  violent 
convulsion  within  two  minutes.  The  conclusion  from  this 
would  be  that  quinine  is  a  virulent  poison,  and  should  be 
used  more  cautiously  than  opium. 

Quassia. — If  an  infusion  of  quassia  is  placed  within  the 
reach  of  flies,  they  will  drink  it,  get  benumbed,  and  act  as 
if  dead,  but  will  finally  recover.  A  new  anaesthetic,  sure 
enough  !  Rabbits  are  killed  by  concentrated  preparations 
of  the  drug.  Two  grains  of  the  extract  of  quassia  applied 
to  fresh  wounds  have  caused  the  death  of  rabbits  in  from 
thirty  to  seventy-two  hours.  A  mangy  dog,  washed  in  a 


601 

decoction  of  quassia,  lost  the  use  of  his  hind  limbs  for  seven 
hours. 

Turpentine. — Two  drachms  of  the  oil  of  turpentine  de¬ 
stroyed  the  life  of  a  dog  in  three  minutes,  with  signs  of 
great  suffering.  Half  an  ounce  killed  a  rabbit  in  sixty 
hours.  In  man,  Bartholow  says,  the  only  fatal  cases  have 
been  in  children.  He  says  from  four  to  six  ounces  have 
been  taken  by  adults.  A  child  only  fourteen  months  old 
took  four  ounces  and  yet  recovered.  Yet  experimental 
materia  raedica  would  place  this  among  the  most  danger¬ 
ous  of  drugs. 

Bismuth. — Orfila  states  in  his  Toxicologie  that  the  sub¬ 
nitrate  and  nitrate  of  bismuth  given  to  animals  caused  vom¬ 
iting,  depression,  debility,  dyspnoea,  and  death.  The  gastric  . 
mucous  membrane  was  inflamed,  softened,  and  ulcerated. 
Meyer,  of  Bonn,  verified  these  observations.  Yet  how 
general  is  the  use  of  this  drug !  As  many  as  six  drachms  a 
dav  have  been  given  to  children  only  two  months  old. 

Conium. — It  is  stated  that  the  sheep  and  goat  can  eat 
conium  without  injury.  Rabbits  and  horses  have  no  mis¬ 
chief  resulting  from  its  use.  One  horse  ate  three  pounds 
and  a  half  without  inconvenience.  Cows  may  eat  it  freely 
also. 

Arsenic. — This  powerful  drug  may  be  administered  in 
very  large  doses  to  horses  without  toxic  effects.  Birds 
will  withstand  a  dose  sufficient  to  destroy  an  amphibious 
animal  of  equal  size. 

Potassium  Iodide. — De  Vergine  gave  a  dog  two  drachms 
of  the  iodide  of  potassium  in  an  ounce  of  water,  and  the 
animal  died  on  the  third  day.  Magendie  took  two  drachms 
of  the  tincture,  equal  to  ten  grains  of  iodine,  without  in¬ 
jury.  An  infant  three  years  old  took  three  drachms  of 
the  tincture  at  one  time,  and  no  bad  effects  followed. 

Cod-liver  Oil. — Experiments  have  shown  that  many  of 
the  lower  animals  do  not  thrive  well  when  given  this  food. 

If  pigs  are  given  more  than  from  one  to  two  ounces  a  day, 
or  sheep  more  than  an  ounce,  or  oxen  more  than  from  three 
to  nine  ounces,  the  oil  invariably  disagrees  with  them. 

Alum. — We  are  told  that  there  is  not  a  fatal  case  on 
record  from  the  use  of  alum.  Yet  two  drachms  of  it  in 
solution  were  fatal  to  a  rabbit,  as  reported  by  Mitscherlich. 

Jalap ,  colocynth ,  and  gamboge  are  almost  inert  when 
given  to  the  horse. 

Emetics. — Emetics  given  to  rabbits  fail  to  produce  any 
results,  but  if  given  to  dogs  the  results  are  most  marked, 
because  the  former  never  vomit,  while  the  latter  do  so 
easily. 

Ergot. — In  discussing  the  physiological  effects  of  this 
drug,  Bartholow  notes  the  following:  “An  enormous  rise 
in  the  blood-pressure  has  been  stated  to  occur  by  Eberty, 
Kohler,  and  II.  C.  Wood,  and  their  opinion  was  based  on 
kymographic  observations.  Holmes,  Herrmann,  and  Wer- 
nich,  on  the  other  hand,  maintain  that  the  blood-pressure 
is  actually  reduced.”  From  this  mass  of  contradictory  evi¬ 
dence  how  are  we  to  glean  the  true  from  the  false  ? 

From  a  study  of  these  well-known  drugs  it  is  evident 
that  their  physiological  effect  on  the  lower  animals  is  dif¬ 
ferent  from  that  on  man.  In  this  connection  we  would  call 
attention  to  a  recent  article  by  Dr.  Iluchard  on  The  Physi- 


602 


TYNDALE:  PULMONARY  PHTHISIS. 


[N.  Y.  Med.  Jouk., 


ological  and  Therapeutical  Action  of  Drugs,  read  before  the 
Societe  de  therapeutique,  in  which  he  calls  attention  to  the 
marked  differences  in  the  action  of  some  drugs  in  various 
forms  of  disease.  He  says  that  the  action  of  some  drugs 
is  not  the  same  in  the  well  as  in  the  sick.  He  states  that 
quinine  will  lower  the  temperature  in  typhoid  fever,  but 
will  not  do  so  in  erysipelas.  He  draws  the  conclusion  from 
bis  observations  that  “  it  is  not  safe  to  make  sweeping 
therapeutic  deductions  from  observations  of  the  physiologi¬ 
cal  action  of  drugs.”  Concisely  stated,  he  asserts  that 
<l  physiology  should  not  enslave  medicine.”  In  this  con¬ 
nection  would  we  recall  the  investigations  of  Professor 
Lichtheim  on  resorcin.  He  says  he  noticed  the  greatest 
difference  in  the  power  of  resorcin  to  lower  the  tempera¬ 
ture  in  the  different  fevers.  All  practitioners  are  aware  of 
the  power  of  the  system  to  resist  immense  doses  of  opium 
in  cases  of  peritonitis. 

Now,  if  what  has  been  said  be  accepted,  two  things 
must  logically  follow :  First,  the  physiological  action  of 
any  drug  on  the  lower  animals  must  not  be  accepted  as  its 
physiological  action  on  man  until  fully  corroborated  by 
direct  experiment  on  him.  Second,  direct  observation  of 
the  action  of  a  drug  at  the  bedside  must  be  an  essential 
part  of  the  foundation  of  our  therapeutics.  It  follows, 
therefore,  that  the  value  of  experimental  materia  medica  is 
limited.  Still  further  it  follows  that  the  medical  student  of 
the  future  must  learn  his  therapeutics  in  the  dispensary 
and  hospital. 

Deductions  emanating  from  experimental  laboratories 
should  not  be  accepted  until  repeated  observations  on  the 
human  body,  in  health  and  disease,  had  fully  corroborated 
the  same.  The  physiological  method  is  certainly  vastly 
superior  to  the  empirical,  but  it  will  ultimately  lead  us  into 
confusion  and  chaos  unless  it  goes  hand  in  hand  with 
every-day  experience  and  observation. 


PULMONARY  PHTHISIS 

TREATED  BY  INOCULATION  WITH  ANIMAL  VIRUS. 

By  J.  HILGARD  TYNDALE,  M.  D. 

This  paper  is  intended  as  a  preliminary  report.  The 
forthcoming  report  of  Professor  Koch’s  experiments  is  my 
excuse  for  giving  my  results  to  the  medical  world  at  this 
time.  It  will  save  me  from  being  looked  upon  as  a  plagi¬ 
arist. 

For  the  past  four  months  I  have  been  treating  a  series 
of  six  cases  of  pulmonary  consumption  by  inoculation  with 
animal  virus.  The  cases  selected  were  all  afflicted  with 
actively  destructive  suppurative  processes  of  the  lung,  and 
in  all  the  presence  of  the  Bacillus  tuberculosis  was  demon¬ 
strated. 

For  the  sake  of  brevity,  let  me  present  the  method  under 
four  headings  : 

1.  The  necessity  of  exact  and  localized  diagnosis.  No 
case  of  mere  connective-tissue  processes,  general  or  local¬ 
ized  cirrhosis  of  the  lung  tissue,  or  binding  down  of  the 
lung  by  pleuritic  adhesions.  The  cases  to  be  selected  are 
active  cavities  and  infiltrations,  with  suppurative  expectora¬ 


tion  and  the  presence  of  the  bacillus.  In  all  of  my  cases 
the  temperature  was  persistently  high.  All  but  one  had 
suffered  great  loss  of  flesh  and  were  very  anaemic. 

2.  The  substance  used  for  inoculation  is  the  pure  vac - 
cine  lymph  obtained  from  the  cow.  This  is  not  the  time 
and  place  to  give  the  details  of  the  technique  of  inocula¬ 
tion,  which  is  tedious,  and  requires  an  exact  attention  to 
detail. 

3.  Blood  and  fat  formation,  according  to  the  require¬ 
ments  of  each  particular  case.  This  line  of  treatment  should 
be  inaugurated  from  the  beginning,  or  at  least  shortly  after 
the  first  inoculation. 

4.  Lung  gymnastics.  This  feature  of  my  mode  of 
treatment  is  of  equal  importance  with  the  others  and  should 
never  be  neglected.  It  consists  of  deep  inspirations  at 
stated  intervals. 

Follow  the  cases  : 

Case  I. — Marcus  F.,  aged  thirty,  shoemaker ;  mother  died  of 
phthisis  at  the  age  of  thirty-six.  Large  cavity  at  right  apex. 
Infiltration  with  dullness  down  to  upper  border  of  fourth  rib. 
Temperature,  102°.  No  appetite.  Great  weakness.  Had  three 
haemorrhages  withiu  six  weeks  preceding  inoculation.  Sputa 
not  very  copious,  containing  bacilli  and  pus  corpuscles.  Inocu¬ 
lated  twice.  Present  condition  (existing  since  October  9th) : 
Strength  and  appetite  excellent.  No  further  haemorrhages.  No 
bacilli.  Occasional  dry  cough,  but  no  expectoration.  Cavity 
about  half  the  original  size.  Vesicular  murmur  in  place  of  in¬ 
filtration.  Has  resumed  work. 

Case  II.— Joseph  B.,  aged  thirty-two,  porter.  Sick  for  two 
years.  Temperature,  99°.  General  nutrition  good.  Cavity  at 
left  apex.  Pleuritic  adhesions  along  inner  edge  of  right  scapula. 
Moderate  expectoration,  with  sparse  bacilli.  Inoculated  four 
times.  Present  condition  :  Normal  strength  and  appetite.  Last 
examination  of  sputa  revealed  a  few  bacilli  (October  14th),  since 
which  time  patient  claims  to  be  unable  to  cough  up  material  for 
examination.  No  moist  rales,  but  cavernous  respiration  only 
heard  over  cavity.  Pleuritic  adhesions  disappeared. 

Case  III. — Marcus  F.,  aged  thirty-four,  barber.  Sick  for 
five  years.  Great  emaciation.  Temperature,  101°.  Very  weak 
and  no  appetite.  Moderate-sized  cavity  under  right  clavicle, 
with  dullness  to  interspace  between  second  and  third  rib.  In¬ 
filtration  left  apex  to  lower  border  of  third  rib.  Rapid  and 
feeble  heart’s  action.  Copious  expectoration ;  bacilli  in  great 
number.  Inoculated  three  times.  Present  condition  :  Appetite 
normal  and  bodily  strength  very  much  improved.  Emaciation 
unchanged.  Temperature,  98°.  Professes  to  be  unable  to  fur¬ 
nish  sputa  since  second  inoculation,  as  his  cough  is  a  dry  one. 
Cavity  contracted  and  empty;  friction  rales  in  circumference. 
Infiltration  left  and  right  sides  has  disappeared,  but  respiration 
still  feeble  on  right  side,  with  occasional  dry  crackles. 

Case  IV. — George  D.,  aged  thirty-six,  satchel-maker.  Sick 
eight  months.  Great  emaciation  and  weakness,  and  very  anae¬ 
mic.  No  appetite.  Copious  night-sweats.  Temperature.  103°. 
Feeble  and  rapid  heart’s  action.  Infiltration  of  left  apex  to 
about  lower  edge  of  third  rib ;  infiltration  of  right  apex  to  fourth 
rib.  Expectoration  moderate.  The  first  microscopical  exami¬ 
nation  revealed  pus  corpuscles  and  broken-down  epithelium, 
but  no  bacilli.  The  second  examination  showed  bacilli  “few 
in  number.”  Inoculated  four  times.  Three  weeks  ago  was 
suddenly  seized  with  pleuritic  stitches  on  left  side,  followed  by 
full-fledged  serous  effusion  into  the  pleura.  This  disappeared 
six  days  after  the  fourth  inoculation  and  gave  way  to  vesicular 
murmur.  Present  condition:  Good  appetite  and  increasing 


Nov.  29,  1890.]  STICKLER:  THOUGHTS  AND  OBSERVATIONS  AT  “ HEALTH  RESORTS 


603 


strength  ;  no  notable  gain  in  flesh,  and  paleness  of  skin,  notably 
of  the  face.  Temperature,  98°  for  the  last  ten  days.  Sputa: 
Pus  corpuscles,  no  bacilli.  Says  quantity  of  expectoration  is 
very  much  diminished.  Vesicular  murmur  in  place  of  infiltra¬ 
tion  right  apex,  and,  as  stated  above,  total  disappearance  of 
pleuritic  effusion.  Broncho-vesicular  breathing,  with  sparse 
niles  at  left  apex. 

Case  V. — Max  G.,  aged  thirty-six,  peddler.  Sick  four 
months.  Dr.  Fishman,  of  Rivington  Street,  was  kind  enough 
to  turn  this  case  over  to  me.  Very  feeble;  great  emaciation 
and  anaemia,  and  total  loss  of  appetite.  Temperature,  103°. 
Two  medium-sized  cavities  in  upper  lobe  of  left  lung,  with  sur¬ 
rounding  infiltration.  Infiltration  of  right  lung  to  lower  border 
of  second  rib.  Feeble  respiratory  murmur  over  the  posterior 
portion  of  the  whole  left  lung.  Copious  sputa,  with  abundant 
bacilli.  Inoculated  four  times.  Present  condition:  Strength 
and  appetite  very  much  improved.  Temperature,  99°.  Micro¬ 
scopical  examination  (October  31st):  “  Bacilli  not  very  numer¬ 
ous.  Broken-down  pus  corpuscles.”  Expectoration  diminished 
by  about  one  half;  muco-purulent.  Cavities  of  left  lung  un¬ 
changed.  Normal  vesicular  breathing  over  the  whole  of  poste¬ 
rior  portion  of  left  lung.  Exaggerated  vesicular  murmur  at  right 
apex  where  infiltration  used  to  be.  I  have  my  doubts  whether 
in  this  case  the  remaining  lung  surface  will  suffice  for  a  final 
cure. 

Case  VI. — Johanna  F.,  aged  twenty-nine,  widow.  Family 
history  excellent.  Her  husband  died  of  phthisis  about  a  year 
ago.  Shortly  after,  she  was  seized  with  a  cough  and  has  been 
declining  ever  since.  Moderate  emaciation,  but  very  weak  and 
extraordinarily  pale.  Temperature,  102°.  Expectoration  copi¬ 
ous  and  purulent.  Microscopical  report:  “  Could  never  get  a 
field  which  showed  more  than  two  bacilli.”  Infiltration,  with 
dullness  and  moist  rales  of  both  apices,  with  total  absence  of 
vesicular  murmur.  Inoculated  three  times.  Present  condition: 
Very  much  increased  strength.  Better  color  in  her  face ;  tem¬ 
perature,  100°.  Expectoration  muco-purulent.  “  Bacilli  very 
few  in  number.”  Dullness  gone  over  both  apices.  Feeble 
respiratory  murmur  over  left  apex.  Broncho- vesicular  over 
right  apex. 

Mv  thanks  are  due  to  Dr.  David  Goldstein,  109  St. 
Mark’s  Place,  for  careful  and  frequent  examination  of  the 
sputa.  I  am  also  much  indebted  to  the  gentlemen  in  charge 
of  the  vaccination  department  of  the  Board  of  Health,  and 
to  Dr.  William  C.  Cutler,  of  Chelsea,  Mass.,  for  aiding  me 
in  obtaining  virus  of  excellent  quality  and  ■sufficient  quan¬ 
tity. 

My  original  intention  was  to  allow  six  months  to  pass 
after  the  final  inoculation  of  each  patient  before  presenting 
them  to  the  profession.  Professor  Koch’s  method  will,  I 
trust,  lead  to  success,  and  it  is  more  than  possible  that  ani¬ 
mal  virus  other  than  that  of  cow-pox  will  accomplish  the 
same  object.  The  chances  are  that  therapeutical  successes 
may  from  time  to  time  be  hatched  outside  of  a  laboratory. 

In  conclusion,  I  would  request  my  colleagues  to  draw 
no  final  conclusions  from  wdiat  I  have  done  thus  far.  At 
present  I  merely  desire  to  put  myself  on  record,  and  am  not 
looking  for  cheap  notoriety. 

48  East  Third  Street. 


The  Macon  (Georgia)  Medical  Society. — On  the  18th  inst.,  officers 
were  elected  as  follows :  President,  Dr.  R.  0.  Cotter ;  vice-president, 
Dr.  H.  J.  Williams;  secretary  and  treasurer,  Dr.  H.  P.  Derry;  corre¬ 
sponding  secretary,  Dr.  H.  McHatton;  reporter,  Dr.  W.  A.  O’Daniel; 

librarian,  W.  F.  Holt. 


THOUGHTS  AND  OBSERVATIONS  AT 

“  HEALTH  RESORTS.” 

By  JOSEPH  WILLIAM  STICKLER,  M.  D., 

HOT  SPRINGS,  N.  C. 

Many  invalids  may  be  found  on  mountain-tops  and  in 
the  valleys  who  ought  to  go  home  and  remain  there.  The 
great  majority  of  invalids  who  are  now  in  their  own  homes 
should  stay  there.  Money  can  not  buy  or  friends  provide 
home  comforts  in  hotels  or  boarding-houses.  Big  fees  or 
little  do  not  prevent  “  drummers  ”  coming  and  going  at  va¬ 
rious  and  unseasonable  hours,  and  slamming  doors,  all  of 
which  is  not  conducive  to  sleep  or  helpful  to  persons  who 
go  from  home  to  secure  undisturbed  slumber. 

Patients  who  can  not  sit  upon  the  piazza  at  home  with¬ 
out  risk  after  sundown  may  sometimes  be  seen  knee-deep 
in  a  trout-stream,  or  perched  upon  a  log  or  cold  rock  in  the 
damp  woods  watching  for  deer,  immediately  after  reaching 
the  “  health  resort.”  This  is  not  the  best  and  quickest  road 
to  health. 

Dancing  in  a  hot  and  crowded  parlor  or  ball-room  till 
11  or  12  o’clock  in  the  evening,  with  an  occasional  walk  or 
flirtation  on  the 'piazza  for  the  sake  of  getting  “  coded  off,” 
does  not  appear  to  be  a  satisfactory  method  of  treatment 
for  phthisical  patients,  or  persons  whose  throats  and  lungs 
are  weak. 

The  man  or  woman  who  goes  to  the  mountains  for  fresh 
air  as  a  remedial  agent  and  sits  all  day  in  a  hotel  may  as 
well  go  home  on  the  first  “  limited  express,”  unless  the  in¬ 
dividual  is  to  be  satisfied  with  minimum  instead  of  maxi¬ 
mum  benefit. 

The  invalid  who  stays  at  a  health  resort  just  long 
enough  to  get  rid  of  troublesome  symptoms,  and  then  goes 
back  to  business  or  home  duties  and  responsibilities,  very 
often  goes  home  to  die. 

Damp  sheets  and  a  strong  draught  do  not,  as  a  rule,  tend 
to  re-establish  a  normal  condition  of  body. 

People  who  occupy  rooms  over  foul-smelling  water- 
closets  and  on  the  side  of  the  hotel  where  the  sun  never 
shines  do  not  seem  to  get  well  so  quickly  as  those  who  live 
on  the  sunny  side  and  away  from  cesspool  infection. 

Residence  in  a  fine  hotel  in  a  malarial  district  does  not 
cure  malarial  disease.  A  short  stay  in  an  elevated  region 
which  is  non-malarial  will  often  “  develop  ”  latent  malarial 
poisoning.  This  is  also  true  of  some  low  non-malarious 
districts.  Don’t  leave  either  place  just  because  of  the  oc¬ 
currence  of  a  chill. 

When  an  invalid  finds  a  health  resort  which  furnishes 
what  he  needs  he  should  stay  there  till  he  becomes  strong 
and  well. 

Every  man,  woman,  and  child  who  has  phthisis  in  its 
primary  stage  should  at  once  go  to  the  best  climate  this 
country  furnishes.  _ 

The  Society  for  the  Relief  of  Widows  and  Orphans  of  Medical  Men. 

— At  the  recent  annual  meeting,  officers  were  elected  as  follows :  Presi¬ 
dent,  Dr.  Henry  Tuck;  vice-presidents,  Dr.  Elsworth  Eliot,  Dr.  J.  J. 
Milhau,  and  Dr.  Everett  Herrick ;  treasurer,  Dr.  J.  H.  Hinton ;  man¬ 
agers,  Dr.  J.  W.  Warner,  Dr.  W.  T.  White,  Dr.  A.  F.  Currier,  Dr.  0.  D. 
Pomeroy,  Dr.  Willard  Parker,  Dr.  J.  D.  Bryant,  Dr.  G.  T.  Jackson,  and 
(to  serve  one  year,  to  till  a  vacancy)  Dr.  A.  R.  Hatheson. 


604 


LEADING  ARTICLES. 


IN.  Y.  Med.  Jock., 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  NOVEMBER  29,  1890. 

THE  RENAISSANCE  IN  THERAPEUTICS. 

In  therapeutic  art  and  practice  great  changes  have  taken 
place  during  the  past  fifty  years.  Certain  methods  have  been 
so  transformed  that  the  art  seems  almost  new.  Others  have 
been  guided  to  new  ends,  and  the  scope  of  many  is  much  en¬ 
larged.  In  and  about  1840  medical  poverty  seemed  almost  to 
equal  that  of  Scott’s  country  doctor,  with  his  two  simples  of 
“  calamy  ”  and  “  laudamy.” 

Interesting  indeed  is  Dr.  John  Kent  Spender's  paper,  in  the 
Practitioner  for  October,  on  the  therapeutic  revival.  Patholo¬ 
gy,  he  says,  was  in  great  fashion  between  1845  and  1870,  and 
diagnosis  was  worshiped  and  deified.  Medical  energy  ran  in 
the  direction  of  necropsies  and  microscopes'.  Post-mortems 
that  showed  a  doctor  to  be  right  were  more  esteemed  than  a 
cure  that  proved  him  wrong.  Morbid  anatomy  was  a  passport 
to  fame.  But  afterward  a  more  human  philosophy  altered  the 
current  of  professional  thought,  and  Dr.  Latham  declared  that 
the  treatment  of  a  disease  was  a  part  of  its  pathology.  Sir 
Thomas  Watson  chided  the  profession  for  vagueness  and  want 
of  earnestness  in  the  use  of  drugs.  Nowadays  we  employ  our 
therapeutic  possessions  as  if  we  trusted  them,  and  lean  upon 
the  rock  of  physiological  experiment  and  observation.  And 
this  renaissance  in  therapeutics  has  made  the  medical  profes¬ 
sion  fellows  in  sympathy  and  work,  bringing  liberty  and  fra¬ 
ternity,  and  giving  prominence  to  the  fact  that  all  are  equal 
who  have  equal  knowledge  and  experience. 

The  London  Pharmacopoeia  of  1824,  the  official  guide  to 
pharmacy  and  the  art  of  prescribing,  was  hidden  from  vulgar 
scrutiny  by  the  Latin  tongue.  And  so  one  G.  F.  Collier,  M.  D., 
in  a  fit  of  audacity  for  which  there  was  no  precedent,  wrote  a 
translation,  with  notes  and  criticisms.  This  gave  mortal  offense 
to  tbe  Royal  College  of  Physicians,  who  threatened  to  treat  it 
as  an  illegal  publication.  Publisher  and  printers  were  intimi¬ 
dated,  and  the  latter  refused  to  go  on  without  a  guarantee  of 
indemnity.  The  book  was  published  at  last,  however,  and  it  is 
not  recorded  whether  G.  F.  Collier  was  burned  or  imprisoned, 
or  whether  he  retired  into  decent  obscurity. 

The  last  edition  of  the  Pharmacopoeia  in  Latin  was  pub¬ 
lished  in  1851.  Associated  with  this  epoch  are  the  names  of 
three  distinguished  men — Pereira,  Royle,  and  Copland,  proph¬ 
ets  and  teachers,  all  like  each  other  in  physical  bulk  and  ele¬ 
phantine  fiber.  Pereira’s  story  begins  before  the  flood,  his  re¬ 
searches  going  into  all  lands  and  ail  philosophies.  Royle  knew 
all  the  therapeutic  botany  of  India,  and  reveled  in  the  flora  of 
the  Himalayas.  Copland  enjoyed  a  high  reputation,  and  had  a 
great  London  practice  between  1830  and  1850.  These  three 
giants  died,  and  others  entered  into  their  labors.  The  old 


manners  softened.  The  home  rule  of  separate  pharmacopoeias 
for  England,  Scotland,  and  Ireland  was  voted  an  absurd  bond¬ 
age,  and  in  1864  the  British  Pharmacopoeia  (in  the  vulgar 
tongue)  was  published.  Every  one  found  fault  with  it.  It 
was  called  almost  a  failure.  In  1867  another  edition,  with 
earlier  errors  left  out,  became  the  basis  of  the  authorized 
version  of  1885,  the  convenience  of  which  is  everywhere  recog¬ 
nized. 

An  urgent  problem,  thinks  Dr.  Spender,  is  that  of  how  to 
teach  the  clinical  application  of  therapeutic  science ;  that  is, 
what  amount  of  the  grammar  of  the  language  should  be 
learned  before  attempting  to  speak  it.  The  art  of  prescribing 
is  supposed  to  come  by  nature.  In  reality,  ignorance  of  its 
methods  and  rules  is  keenly  felt  by  many.  A  work  of  art 
should  have  consistency  and  integrity.  And  these  are  the 
special  qualifications  of  a  prescription,  which  ought  to  be  a 
finished  product  of  skill  and  experience. 

The  renaissance  in  therapeutics  exhibits  special  skill  in  the 
analgesic  group  of  medicines.  In  the  dawn  of  some  severe  in¬ 
flammations,  notably  those  of  the  eye,  morphine  in  doses  of 
one  twelfth  of  a  grain  every  hour  quiets  the  storm  and  the 
sympathetic  tumult.  When  detected  by  the  expert  observer, 
it  is  stated  that  the  initial  stage  of  acute  glaucoma  has  been 
checked  by  this  plan.  When  pain  is  only  a  subordinate  symp¬ 
tom  of  inflammation,  like  many  others,  tartar  emetic  is  full  of 
power.  Take,  for  instance,  inflammation  of  the  whole  breast 
after  childbirth.  Administer  fifteen  minims  of  wine  of  anti¬ 
mony — one  sixteenth  of  a  grain — in  water  punctually  every 
hour  for  sixteen  or  twenty  hours.  Everything  must  give  way 
to  it,  even  sleep  itself.  Every  hour  the  trouble  recedes.  Milk 
and  egg  may  be  allowed  in  moderation,  and  no  other  diet.  Al¬ 
cohol  is  poison.  On  the  next  day  every  classic  symptom  of  in¬ 
flammation  will  have  vanished.  This  method  will  also  control 
the  acute  efflorescence  of  psoriasis.  To-day  the  law  that  small 
doses  and  large  doses  of  the  same  drug  exercise  quite  a  differ¬ 
ent  effect  is  distinctly  understood.  A  combination  of  one 
twenty-fourth  of  a  grain  of  morphine  and  three  minims  of 
castor  oil,  taken,  every  half  hour  for  six  or  seven  times,  may 
stop  acute  choleraic  diarrhoea  in  a  most  effective  manner. 
Medicines  of  a  similar  tendency  may  economize  each  other 
when  given  at  the  same  time,  the  drawbacks  of  each  being 
lessened  and  the  efficacy  of  the  total  product  increased ;  for 
example,  those  of  a  bromide  and  chloral. 

The  renaissance  is  glad  to  drop  traditional  baggage,  the  use¬ 
less  material  that  drags  down  the  medical  car.  Drugs  that  do 
no  good  are  not  now  prescribed.  Excess  of  caution  in  dosage 
is  the  cause  of  many  therapeutic  failures.  We  must  guide  the 
treasures  of  the  pharmacopoeia  as  powerful  machines  that  can 
be  made  to  act  with  the  finest  delicacy.  True  courage  is  never 
afraid  of  power.  Systematic  study  of  the  pharmacopoeia  would 
reveal  riches  little  suspected  and  restorative  forces  of  priceless 
worth.  “Medicine  is  an  art  founded  on  many  sciences,”  says 
Sir  Dyce  Duckworth,  “and  a  great  physician  is  a  great  artist.” 
The  revival  in  therapeutics  is  the  birth  of  larger  art  in  medi¬ 
cine. 


Nov.  29,  1890.] 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


605 


FAITH-HEALING  UNSUITABLE  FOR  AFRICAN  FEVER. 

Some  peculiarly  painful  cases  of  loss  of  life  through  “  faith¬ 
healing  ”  have  been  recently  brought  to  light.  One  of  these 
cases  has  been  the  occasion  of  ministerial  correspondence  be¬ 
tween  Great  Britain  and  Mr.  Secretary  Blaine,  dealing  with  a 
report  from  the  colonial  surgeon,  Dr.  Palmer  Ross,  of  Free¬ 
town,  Western  Africa.  This  report  shows  that  three  deaths 
have  taken  place  in  a  band  of  nine  young  missionaries  from  our 
own  Western  States.  These  deaths  took  place  by  fever  soon 
after  the  arrival  of  the  party  at  their  African  station.  Under 
the  guidance  of  their  leader,  an  ardent  believer  in  divine  heal¬ 
ing,  the  sick,  whether  their  cases  were  grave  or  mild,  were  al¬ 
lowed  to  go  untreated  by  medical  means ;  and,  in  the  opinion 
of  Surgeon  Ross,  the  febrile  cases  began  to  assume  an  unneces¬ 
sarily  virulent  type  which  endangered  the  whole  community, 
and  which  impelled  him  to  order  officially  the  adoption  of  sani¬ 
tary  measures,  such  as  isolation,  disinfection,  and  a  speedy 
burial  of  the  dead.  Others  of  the  missionaries  also  took  the 
fever,  but  they  submitted  to  treatment,  some  willingly,  but  oth¬ 
ers  under  protest.  Surgeon  Ross  then  declared  his  intention 
to  report  the  matter  to  the  Governor  and  to  advise  that  all  the 
survivors  be  sent  back  to  America,  on  the  ground  that  a  tropi¬ 
cal  climate  was  not  suited  to  those  who  trusted  alone  to  faith¬ 
healing  and  ignored  the  means  placed  by  Providence  at  their 
disposal  for  the  relief  of  suffering  humanity,  and  that  such  a 
line  of  conduct  was  a  danger  to  the  community  at  large. 

A  late  issue  of  a  missionary  journal,  called  the  Regions  Be¬ 
yond ,  although  very  friendly  to  this  unfortunate  party  in  Afri¬ 
ca,  takes  special  care  to  point  out  the  error  made  by  them  in 
rejecting  medical  treatment,  and  says:  “These  deaths  took 
place  in  July,  and  to  us  it  is  an  additional  pain  to  know  that, 
humanly  speaking,  these  lives  need  not  have  been  lost,  but 
might  have  been  usefully  spent  in  Gospel  service  in  Africa. 
Unfortunately,  in  passing  through  New  York,  on  their  way 
out,  they  came  under  the  influence  of  one  who  teaches  what  is 
called  faith-healing.  From  him  they  received  the  sadly  erro¬ 
neous  doctrine  that,  though  God  has  given  us  medicines  and 
the  skill  to  use  them,  it  is  contrary  to  his  will  we  should  do  so. 
It  is  inexpressibly  sad  that  these  devoted  young  lives  should 
thus  needlessly  have  been  thrown  away  at  the  bidding  of  a  false 
theory.  Very  solemn  and  terrible  is  the  responsibility  of  the 
teachers  of  this  theory  when  they  urge  African  missionaries  to 
dispense  with  quinine  and  other  antidotes  to  deadly  fever.” 
Among  the  other  members  of  the  party  who  also  suffered  from 
fever,  but  who  received  the  usual  medical  treatment,  there 
were  no  deaths  reported. 

MINOR  PARAGRAPHS. 

THE  HYPNOTIC  EFFICIENCY  OF  PARALDEHYDE. 

Paraldehyde  is  represented  as  being  the  sheet  anchor, 
among  the  hypnotics,  in  the  neurological  clinic  at  Dorpat. 
Dr.  H.  Dehio  is  quoted  by  the  British  Medical  Journal  as  say¬ 
ing  that  that  drug  has  been  his  favorite  for  some  time,  and  still 
retains  its  position  as  the  most  reliable  sleep-producer — superior 
to  hypnone,  methylal,  cliloralamide,  amylene  hydrate,  urethane, 


sulpbonal,  and  hydrochloride  of  liyoscine.  Paraldehyde  has 
been  given  by  Dr.  Dehio  in  many  severe  cases,  the  initial  dose 
commonly  being  75  to  90  minims,  which  was  followed  by  an¬ 
other  dose  of  45  to  60  minims;  this  was  found  sufficient  in 
most  of  the  cases  to  give  a  good  night’s  sleep.  As  a  rule,  the 
drug  acted  well,  but  sometimes  only  slight  sleep  followed,  while 
at  other  times  tolerance  was  too  soon  established  ;  but  these 
occasional  disadvantages  were  more  than  counterbalanced  by 
the  fact  that  the  drug,  even  in  large  doses,  did  not  influence 
the  heart  and  respiration.  It  may  upset  the  organs  of  diges¬ 
tion,  causing  diarrhoea.  The  medicine  must  be  pure  beyond 
peradventure,  and  should  not  redden  litmus  paper,;  and  it 
should  be  kept  in  the  dark  and  in  tightly  stoppered  bottles.  If 
this  is  not  done,  it  will  soon  become  acid.  The  prolonged  use 
of  paraldehyde  is  followed  by  the  following  chain  of  symptoms: 
Loss  of  appetite,  gray  coloration  of  the  skin  of  the  face,  dryness 
of  the  surface,  and  loss  of  weight;  at  the  same  time  the  drug 
loses  its  power  to  produce  sleep.  These  symptoms  pass  off'  on 
the  discontinuance  of  its  use.  Headache  and  depression  are 
not  among  the  after-consequences  of  this  remedy,  whereas 
amylene  hydrate  has  those  effects,  but  it  does  not  interfere 
with  the  digestive  apparatus  to  the  same  extent  as  paraldehyde 
does.  In  severe  cases  of  motor  disturbance,  such  as  occurs  in 
delirium  tremens  and  mania,  paraldehyde,  along  with  six  others 
of  the  hypnotics  mentioned  above,  are  practically  useless;  in 
these  cases  Dehio  has  found  the  hydrochloride  of  hyoscine,  in 
TVgrain  doses,  to  be  the  most  reliable  hypnotic  in  such  cases. 


SCIENTIFIC  PROPHYLAXIS. 

An  article  in  the  University  Medical  Magazine  for  Novem¬ 
ber,  upon  the  subject  of  ptomaines,  admits  these  chemical  prod¬ 
ucts  of  bacterial  growth  as  potent  factors  toward  the  fatal  issue 
in  certain  forms  of  disease.  That  such  chemical  compounds 
are  formed  has  been  pretty  conclusively  demonstrated  by  the 
work  of  Brieger  and  others.  It  is  shown  that  these  ptomaines 
are  of  the  character  of  amines.  With  the  cholera-infantum 
germ,  in  addition  to  the  ptomaine  proper,  there  is  also  an  albu¬ 
minoid  body  formed  by  the  growth  of  the  germ  which  is  very 
poisonous  and  is  probably  an  intermediate  stage  before  the 
final  development  of  the  ptomaine.  Immunity  from  anthrax, 
in  guinea-pigs,  has  been  obtained  by  inoculating  them  with 
albumose  resulting  from  sterilized  cultures  of  the  anthrax  germ. 
In  the  Medical  News  for  September  6th  and  October  4th 
Schweinitz  describes  the  ptomaines  and  albumose  which  he  has 
obtained  from  hog-cholera  culture  liquids.  The  culture  liquid 
used  was  a  peptonized  beef  infusion.  He  succeeded  in  isolat¬ 
ing  small  quantities  of  two  old  ptomaines  and  one  new  one  to 
which  he  ascribed  the  formula  C14H36N2.  He  suggests  the 
names  sucholotoxine  for  the  ptomaine  and  sucholoalbumin  for 
the  albumose  obtained  from  the  growth  of  the  hog-cholera 
bacillus.  This  ptomaine,  together  with  the  albumose,  seemed 
to  be  the  potent  poison  in  hog  cholera.  He  also  cites  a  number 
of  experiments  on  the  guinea-pig  with  the  isolated  compounds, 
in  which  the  animals  were  rendered  proof  against  the  disease. 
This  line  of  research  is  only  in  its  infancy,  but  it  is  within  the 
range  of  probability  that  a  certain  class  of  diseases  may  event¬ 
ually  be  kept  in  abeyance  by  scientific  prophylaxis. 


EPITHELIOMA  ADAMANTINE M. 

In  the  Wiener  Minische  Wochenschrift  for  October,  Dr.  Deru- 
jinsky,  of  Moscow,  describes  this  form  of  dental  tumor,  the  oc¬ 
currence  of  which  is  somewhat  rare.  The  varieties  of  dental 
tumors  previously  reported  have  been  ot  the  colloid  form,  the 


606 


MIN  OR  PA  RAG  RA  PES.—I  TKMS. 


[N.  Y.  Med.  Jock., 


result  of  degeneration  in  the  cell  elements.  There  is  no  doubt, 
he  says,  that  these  growths  derive  their  origin  from  epithelial 
remains,  and  that  one  of  the  evidences  of  such  remains  being 
present  is  the  occasional  development  of  supernumerary  teeth 
and  the  growth  of  new  teeth  late  in  life.  From  careful  exami¬ 
nation  of  the  literature  on  the  subject,  the  author,  though  un¬ 
able  to  find  another  case  reported  having  similar  microscopical 
structure,  concludes  that  dental  tumors  are  probably  all  of  a 
•common  origin.  The  growth  in  the  case  under  consideration 
proceeded  directly  from  the  alveolar  process  of  the  maxilla. 
Careful  microscopical  examination  of  the  tumor  showed  the 
structure  to  be  almost  identical  with  that  of  the  normal  enamel 
of  the  teeth.  Cohnheim’s  theory  was  that  all  dental  tumors 
sprang  from  embryological  germ  tissues.  The  author  is  of  the 
opinion  that  the  case  belonged  to  this  class,  and  that  trauma  or 
some  irritation  of  the  maxilla  or  alveolar  process  had  set  up 
chronic  inflammation,  producing  proliferation  of  cells,  and  re¬ 
sulting  finally  in  the  development  of  the  enamel  structure  de¬ 
scribed.  The  tumor  was  non-malignant  but  recurrent,  its  re¬ 
appearance  being  probably  due,  he  thought,  to  some  of  the 
growth  remaining  after  the  first  operation,  as  dental  tumors  are 
for  the  most  part  benign.  * 


BONE  GRAFTING. 

Mk.  A.  G.  Miller,  in  the  Lancet  for  September  20th,  re¬ 
ports  the  history  of  a  case  in  which  he  used  decalcified-bone 
chips  successfully  to  fill  up  a  large  cavity  in  the  head  of  the 
tibia.  A  piece  of  the  rib  of  an  ox  was  used,  being  first  scraped 
and  then  decalcified  in  a  weak  solution  of  hydrochloric  acid. 
After  cleansing  by  pressure,  it  was  placed  for  forty-eight  hours 
in  a  carbolic-acid  solution,  one  to  twenty,  then  removed,  and 
cut  into  small  pieces.  During  the  scraping  out  of  the  cavity  in 
the  knee,  preparatory  to  the  grafting,  a  number  of  small  pieces 
of  bone  were  removed.  These  were  placed  in  a  solution  of  boric 
acid  for  use  later  in  the  operation.  The  cavity  was  then  stuffed 
with  the  decalcified-bone  shavings,  the  pieces  of  fresh  bone 
being  added  last.  The  cavity  thus  filled  was  about  two  inches 
in  diameter.  Granulation  and  healing  took  place  rapidly;  the 
only  pieces  of  bone  that  became  necrosed  were  from  the  pa¬ 
tient’s  own  body.  The  author  is  convinced,  from  his  observa¬ 
tion  of  this  case,  that  the  healing  of  large  bone  cavities,  the  re¬ 
sult  of  injury  or  disease,  is  greatly  facilitated  by  stuffing  them 
with  decalcified-bone  chips,  that  these  are  superior  to  fresh 
bone,  and  that  fresh  bone  not  only  is  of  no  use,  but  actually 
hinders  the  process  of  granulation. 


THE  ORTHOPAEDIC  SECTION  OF  THE  TENTH  INTERNA¬ 
TIONAL  MEDICAL  CONGRESS. 

The  institution  of  this  section  may  fairly  be  said  to  have 
been  due  to  the  efforts  of  our  countrymen.  It  is  pleasant  to 
see  the  fact  frankly  recognized  in  Europe.  In  a  report  of  the 
proceedings,  by  Dr.  Kirmisson,  published  in  the  November 
number  of  the  Revue  d'orthopedie ,  the  credit  of  the  initiative  is 
given  to  Dr.  Newton  M.  Shaffer,  of  New  York,  who,  as  well  as 
Dr.  Bradford,  of  Boston,  became  one  of  the  presiding  officers  of 
the  section.  The  Centralllatt  fur  orthopcidische  Chirurgie  und 
Mechanik ,  in  an  extra  supplement,  expresses  itself  to  much  the 
same  purpose. 

THE  HARVARD  MEDICAL  SCHOOL. 

The  new  laboratory  of  this  institution  is  approaching  com¬ 
pletion.  It  stands  on  the  easterly  side  of  the  main  building,  and 
is  sixty  feet  in  length  and  three  stories  in  height.  The  base¬ 
ment  contains  the  rooms  for  animals  and  apparatus.  The 
animal  rooms  are  unusually  well  lighted  and  ventilated.  The 


ground-floor  is  to  accommodate  the  bacteriological  department, 
with  large  and  small  rooms  for  the  instructor  and  special  work¬ 
ers,  provision  being  made  for  thermostats,  sterilizers,  a  library, 
chemical  and  other  glass  ware,  closets  for  clothing,  etc.  The 
two  upper  stories  will  be  devoted  to  pathological  work  and 
photography.  The  old  laboratory  rooms  in  the  main  building 
will  be  made  over  for  the  use  of  the  undergraduates. 


THE  CARE  OF  THE  INSANE  IN  THE  STATE  OF  NEW  YORK. 

The  recent  sad  incident  of  the  murder  of  Dr.  Lloyd  by  an 
escaped  lunatic  is,  we  presume,  at  the  bottom  of  that  one  of  a 
number  of  new  orders  lately  issued  by  the  State  Commission  in 
Lunacy  which  states  that  no  insane  patient  in  the  custody  of  an 
institution  must  be  allowed  to  go  out  on  parole  who,  in  the 
medical  superintendent’s  judgment,  is  dangerous  to  himself  or 
toothers;  that  no  parole  shall  be  granted  for  a  period  longer 
than  thirty  days;  and  that,  on  the  escape  of  a  patient,  prompt 
and  vigorous  measures  must  be  taken  to  secure  his  return. 
Another  order  is  intended  to  insure  to  insane  persons  compara¬ 
tively  unrestricted  correspondence  with  their  friends  and  wholly 
unrestricted  correspondence  with  State  and  court  officers. 


THE  TETRAHYDRONAPHTHYLAMINES. 

Dr.  R.  Stern,  in  the  Archiv  fur  pathologische  Anatomie  und 
Physiologie  und  fur  klinische  Medicin ,  gives  an  account  of 
some  recent  experiments  made  on  animals  with  the  tetrahydro- 
naphthylamines.  The  preparation  used  was  an  aqueous  solu¬ 
tion  administered  hypodermically.  An  increase  in  temperature 
resulted  in  an  hour,  with  dilatation  of  the  pupil  and  general 
symptoms  of  poisoning.  There  was  an  increase  in  the  quantity 
of  urine  voided,  and  in  its  nitrogenous  and  phosphatic  constitu¬ 
ents,  the  poison  reaching  its  maximum  effect  on  the  second  day, 
when  the  symptoms  gradually  subsided.  The  observer  con¬ 
cluded  that  the  changes  in  the  urine  were  not  those  common  to 
high  temperature,  but  were  consequent  upon  the  specific  poi¬ 
sonous  action  of  the  drug. 


TANNIC  ACID  AS  AN  INTESTINAL  ANTISEPTIC  REMEDY. 

Professor  Cantani  has  written,  in  the  Wiener  medizinische 
Blatter ,  of  his  therapeutical  trials  of  tannic  acid  in  intestinal 
diseases.  Ho  has  found  it,  in^--,  J-,  or  even  1-per-cent,  solutions, 
acting  a  useful  part  as  an  antiseptic,  as  it  hinders  the  vegetative 
activity  of  the  microbes  and  renders  innocuous  many  of  the 
poisonous  ptomaines.  In  diarrhoea  and  dysentery,  therefore,  tan¬ 
nic  acid  becomes  an  important  disinfectant  as  well  as  astringent 
remedy.  Mosler  also  reports  that  this  drng  is  very  beneficial 
in  typhoid  fever,  particularly  for  removing  the  symptoms  of 
meteorism  and  diarrhoea.  Antiseptic  solutions  are  best  intro¬ 
duced  by  enteroclysis,  the  fluid  thus  administered  having  been 
proved,  by  the  subsequent  vomiting  of  some  of  it,  to  reach  not 
only  the  whole  length  of  the  intestines,  but  even  to  the  stomach. 


ITEMS,  ETC. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  November  16  to  November  22,  1890 : 

Moseley,  Edward  B.,  Captain  and  Assistant  Surgeon,  is  granted 
leave  of  absence  for  one  month.  S.  0.  100,  Department  of  Texasf 
November  17,  1890. 

Burton,  Henry  G.,  Captain  and  Assistant  Surgeon,  is,  by  direction 
of  the  Acting  Secretary  of  War,  granted  leave  of  absence  for  six 
months  on  surgeon’s  certificate  of  disability,  with  permission  to  go 
beyond  sea.  Par.  9,  S.  O.  269,  Headquarters  of  the  Army,  A.  G.  0., 
November  17,  1890. 

Phillips,  John  L.,  Captain  and  Assistant  Surgeon,  is,  by  direction  of 


Nov.  29,  1890.] 


ITEMS.— SPECIAL  ARTICLES. 


the  Acting  Secretary  of  War,  relieved  from  further  duty  at  Fort 
Crawford,  Colorado,  to  take  effect  on  his  relinquishing  the  unex¬ 
pired  portion  of  his  present  leave  of  absence,  and  will  report  in 
person  to  the  commanding  officer  at  Camp  Guthrie,  Oklahoma  Ter¬ 
ritory,  for  duty  at  that  station,  reporting  by  letter  to  the  command¬ 
ing  general,  Department  of  the  Missouri.  Par.  7,  S.  0.  269,  A.  G.  0., 
Washington,  November  17,  1890. 

Johnson,  Henry,  Captain  and”Medical  Storekeeper,  is,  by  direction  of 
the  Acting  Secretary  of  War,  granted  leave  of  absence  from  Janu¬ 
ary  1  to  March  24,  1891,  inclusive,  with  permission  to  go  beyond 
sea.  Par.  18,  S.  0.  268,  A.  G.  0.,  Washington,  November  16,  1890. 

Gandy,  Charles  M.,  Captain  and  Assistant  Surgeon,  Fort  Clark,  Texas, 
is,  by  direction  of  the  Acting  Secretary  of  War,  granted  leave  of 
absence  for  three  months.  Par.  10,  S.  0.  266,  Headquarters  of  the 
Army,  A.  G.  0.,  November  13,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 

of  the  United  States  Navy  for  the  week  ending  November  22,  1890 : 

Ayers,  J.  G.,  Surgeon.  Ordered  to  the  U.  S.  Receiving-ship  Wabash. 

Evans,  Sheldon  Guthrie,  commissioned  an  assistant  surgeon  in  the 
U.  S.  Navy. 

Bates,  N.  L.,  Medical  Director.  Ordered  as  president  of  Naval  Medical 
Examining  Board  at  Mare  Island,  Cal. 

Moore,  A.  M.,  Surgeon.  Ordered  as  member  of  Naval  Medical  Examin¬ 
ing  Board  at  Mare  Island,  Cal. 

Society  Meetings  for  the  Coming  Week : 

Monday,  December  1st":  New  York  Academy  of  Sciences  (Section  in 
Biology) ;  German  Medical  Society  of  the  City  of  New  York;  Mor- 
risania  Medical  Society  (private) ;  Brooklyn  Anatomical  and  Sur¬ 
gical  Society  (private) ;  Utica,  N.  Y.,  Medical  Library  Association ; 
Boston  Society  for  Medical  Observation  ;  St.  Albans,  Vt.,  Medical 
Association ;  Providence,  R.  I.,  Medical  Association ;  Hartford,  Conn., 
City  Medical  Association  ;  Chicago  Medical  Society. 

Tuesday,  December  2d:  New  York  Obstetrical  Society  (private) ;  New 
York  Neurological  Society;  Elmira  Academy  of  Medicine;  Buffalo 
Medical  and  Surgical  Association ;  Ogdensburgh  Medical  Associa¬ 
tion  ;  Medical  Societies  of  the  Counties  of  Herkimer  (semi-annua) 
— Herkimer)  and  Saratoga  (Ballston  Spa),  N.  Y. ;  Hudson,  N.  J., 
County  Medical  Society  (Jersey  City) ;  Androscoggin,  Me.,  County 
Medical  Association  ;  Baltimore  Academy  of  Medicine. 

Wednesday,  December  3d:  Society  of  the  Alumni  of  Bellevue  Hospi¬ 
tal  ;  Harlem  Medical  Association  of  the  City  of  New  York ;  Medical 
Microscopical  Society  of  Brooklyn  ;  Medical  Society  of  the  County  of 
Richmond  (Stapleton),  N.  Y. ;  Penobscot,  Me.,  County  Medical  So¬ 
ciety  (Bangor) ;  Bridgeport,  Conn.,  Medical  Association. 

Thursday,  December  Ifth:  New  York  Academy  of  Medicine;  Metro, 
politan  Medical  Society  (private);  Brooklyn  Surgical  Society;  So¬ 
ciety  of  Physicians  of  the  Village  of  Canandaigua ;  Boston  Medico- 
psychological  Association ;  Obstetrical  Society  of  Philadelphia ; 
United  States  Naval  Medical  Society  (Washington). 

Friday,  December  5th  :  Practitioners’  Society  of  New  York  (private) . 
Baltimore  Clinical  Society. 

Saturday,  December  6th  :  Clinical  Society  of  the  New  York  Post¬ 
graduate  Medical  School  and  Hospital ;  Manhattan  Medical  and  Sur¬ 
gical  Society  (private);  Miller’s  River,  Mass.,  Medical  Society. 


Sprnal  Articles. 


THE  OPENING  RECEPTION  IN  THE  ACADEMY  OF  MEDICINE’S 

NEW  BUILDING. 

( Concluded  from  page  582.) 

The  Influence  of  Scientific  Associations  upon  Great 

Cities  was  to  have  been  the  subject  of  remarks  by  Mr.  D.  Wil¬ 
lis  James.  The  president  read  a  letter  of  regret  from  Mr. 
James,  who  said:  Very  highly  I  appreciate  the  honor  of  the 


607 

invitation  to  speak  on  the  important  occasion  of  the  opening  of 
the  new  and  beautiful  home  of  the  Academy  of  Medicine  of 
New  York.  It  is  a  serious  and  great  regret  that  I  am  prevent¬ 
ed  from  being  present.  As  a  citizen  of  New  York,  greatly  in¬ 
terested  in  her  welfare,  progress,  and  fame,  I  feel  impressed 
with  the  vast  importance  to  the  city  of  such  an  institution  as 
the  Academy  of  Medicine  as  a  center  of  most  important  scien¬ 
tific  investigations,  and  I  desire  to  join  in  the  heartiest  con¬ 
gratulations  to  you,  sir,  as  president  of  the  Academy,  and  to 
all  the  members,  on  the  completion  of  the  great  work  in  which 
you  have  labored  so  faithfully.  New  York  can  not  learn  too 
soon  the  fact  that  a  great  imperial  city  can  not  be  built  upon 
material  prosperity  alone.  The  foundations  must  be  deeper, 
broader,  and  more  enduring.  Years  ago  in  the  city  of  Wiirtz- 
burg  I  was  deeply  impressed  by  the  fact  that  the  magnificent 
palace,  began  centuries  ago  as  a  home  for  regal  magnificence, 
luxury,  and  display,  was  going  to  ruin  and  was  shrouded  in 
gloom,  while  the  hospital,  started  at  the  same  time,  to  be  of 
service  to  the  wretched  and  suffering,  was,  after  the  lapse  of 
centuries,  doing  its  beneficent  and  holy  work,  out  of  which  had 
sprung  a  medical  college,  the  fame  of  its  distinguished  profes¬ 
sors  drawing  crowds  to  the  city.  If  New  York  is  to  be  the 
great  imperial  city  of  the  future  we  must  see  to  it  now  that  we 
plant  and  foster,  not  only  churches,  and  galleries,  and  parks, 
but  also  great  universities,  largely  endowed,  and,  as  the  most 
important  parts  of  these  universities,  medical  colleges  magnifi¬ 
cently  and  munificently  endowed,  so  that  they  shall  have  every 
possible  facility  for  accomplishing  the  best  work.  The  begin¬ 
ning  has  been  made  in  the  endowment  of  the  Vanderbilt  clinic 
and  in  the  founding,  by  an  unknown  but  wise  donor,  of  the 
laboratory  which  it  was  wisely  required  should  bear  the  name 
that  has  added  so  much  luster  to  this  city— a  name  honored  and 
beloved  by  every  member  of  this  Academy. 

But  far  more  must  be  done  and  doue  promptly.  Look  at 
the  magnificent  work  the  medical  profession  has  done  and  is 
doing  for  suffering  humanity,  stirred  as  our  enthusiasm  is  by 
the  discoveries  of  such  men  as  Professor  Koch,  of  Berlin,  with 
their  promise  of  lasting  benefit  to  humanity,  let  us,  as  citizens 
of  New  York,  see  to  it  that  in  our  midst  the  means  are  ample 
and  promptly  supplied  for  the  most  complete  scientific  research 
in  all  departments  of  learning.  Let  this  be  especially  so  in 
medical  sciences,  and  let  us  do  promptly  for  New  York  what 
Johns  Hopkins  has  done  for  our  sister  city  of  Baltimore. 

Remarks  of  Dr.  S.  Weir  Mitchell,  of  Philadelphia.— Dr. 
Mitchell,  having  been  introduced  by  the  president,  said:  Such 
an  introduction  will,  I  am  afraid,  convey  the  impression  that  I 
am  prepared  to  give  you  a  poem,  a  novel,  or  a  dose  of  medicine 
equally  well.  A  few  things  have  been  suggested  to  my  mind 
from  what  I  have  heard  to-night.  I  may  call  myself  one  of  the 
fellows  who  come  from  the  immediate  neighborhood.  I  am  an 
honorary  fellow  and  therefore  not  entirely  a  stranger,  but  share 
in  the  congratulations  of  my  fellow-fellows  of  this  Academy. 
How  much  delight  it  gives  me  to  see  what  has  been  done  for 
our  profession  in  this  palace  of  medicine  to-night!  I  was  re¬ 
minded  by  some  of  the  speakers  of  what  I  saw  years  ago  when 
I  visited  the  French  Academy.  I  desired  to  find  a  certain  book, 
but  was  unable  to  do  so;  the  books  were  without  4  catalogue. 
Without  this  a  library  is  of  no  more  use  than  a  man  without  a 
memory.  When  I  inquired  why  this  condition  of  things  existed 
1  was  told  that  they  were  waiting  for  the  Government  to  do 
something  in  the  matter.  You  know  how  long  we  should  have 
to  wait  for  our  Government  to  do  anything  for  us.  We  do 
things  a  little  differently  in  this  country,  and  the  result  is  be¬ 
fore  us  to-night.  I  am  often  struck  with  the  frequency  with 
which  the  term  “our  profession”  is  in  our  mouths,  and  it  is  a 
phrase  which  sometimes  provokes  a  smile.  It  should  be  con- 


608 


SPECIAL  ARTICLES. 


[N.  Y.  Med.  Jocr., 


sidered  rather  a  great  guild  than  a  profession,  and  this  guild  a 
great  and  glorious  and  world-wide  brotherhood.  In  illustration 
of  what  I  mean,  I  fell  ill  in  a  small  town  in  Germany.  A  physi¬ 
cian  attended  me  with  much  care  and  skill.  "When  he  learned 
that  I  also  was  a  physician  he  would  not  allow  me  to  give  him 
any  fee.  He  said  :  “Sir,  I  was  ill  in  St.  Petersburg  and  a  good 
doctor  took  care  of  me  and  would  take  nothing  from  me,  and 
so  you  will  pay  me  by  taking  care  of  some  other  in  that  far 
country  of  yours  across  the  sea.”  The  records  of  these  things 
are  not  written  in  the  books  of  this  world.  This  guild  of  which 
I  have  spoken  possesses  a  creed  drawn  from  the  morals  of 
Christianity — honor,  chastity,  brotherhood,  and  charity.  As  to 
the  charity,  I  ask  what  lawyer  would  sit  down  twice  a  week 
and  give  a  couple  of  hours’  advice  to  any  who  might  come  and 
ask  it,  and  do  this  for  nothing?  What  merchant  would  say  to 
a  needy  customer,  “  I  propose  to  present  you  with  these 
goods?”  Yet  it  is  a  fact  that  two  thirds  of  the  physicians  of 
eminence  give  two  or  three  hours,  sometimes  daily,  to  this  kind 
of  labor,  when  the  experience  to  be  gained  from  it  has  long 
ceased  to  be  of  benefit  to  them.  This  kind  of  work  is  not  fully 
understood  by  the  public,  or  they  would  be  more  willing  to 
come  forward  and  assist  us  in  return  by  aiding  our  great  libra¬ 
ries  in  such  purposes  as  we  are  endeavoring  to  carry  out  around 
you  to-night.  I  must  not  only  on  my  own  part  congratulate 
the  fellows  of  the  Academy  upon  the  completion  of  this  work, 
but  also  offer  the  warm  congratulations  of  the  members  of  the 
Philadelphia  College  of  Physicians.  I  have  been  of  late  their 
president,  and  from  them  I  carry  this  message.  I  was  asked 
the  other  day  by  two  very  intelligent  laymen,  to  whom  I  was 
showing  our  medical  library,  why  the  profession  needed  such  a 
vast  collection  of  books,  and  whether  such  were  not  simply  the 
graveyard  of  theories  and  the  record  of  what  was  now  useless. 
I  replied  that,  while  theories  died,  facts  remained,  and  had  their 
vital  uses  to-day,  and  might  be  quoted  ;  therefore  a  great  libra¬ 
ry  was  a  great  museum  of  facts  which  remained  to  us  perma¬ 
nently.  A  medical  library  showed  the  history  of  the  profession, 
which  had  its  joys,  its  sorrows,  and.  its  romances,  and  upon  its 
shelves  might  be  found  the  record  of  what  the  profession  had 
done  in  the  past  and  the  indications  of  what  would  be  done  in 
the  future.  When  the  physician  of  this  or  any  other  great  city 
ceases  to  desire  to  be  learned  and  accomplished  in  a  great  many 
ways,  and  is  ready  to  forget  the  honorable  traditions  of  his  pro¬ 
fession,  and  is  beginning  to  look  upon  it  as  merely  a  business, 
then  he  will  have  taken  that  one  fatal  step  toward  degradation, 
a  step  from  the  high  level  to  the  lower  one  of  a  merely  useful 
trader. 

Remarks  of  Dr.  Reginald  H.  Fitz,  of  Boston. — Mr.  Presi¬ 
dent  and  Ladies  and  Gentlemen:  To  find  myself  a  guest  on  so 
memorable  an  occasion  as  the  present  is  a  privilege  I  can  not 
value  too  highly.  My  feeling,  however,  is  not  one  of  unalloyed 
pleasure,  since  a  sense  of  envy  arises  as  I  see  commodious  and 
comfortable  appointments  which  are  to  serve  in  the  future  as 
one  of  the  many  medical  centers  of  your  city — one  which  I  feel 
will  not  be  the  least  to  unite  in  harmony  members  of  our  pro¬ 
fession  and  make  us  ever  mindful  that  a  common  aim,  the  wel¬ 
fare  of  suffering  humanity,  is  the  chief  object  of  a  physician’s 
life.  But  my  sense  of  envy  is  somewhat  blunted  as  I  am  re¬ 
minded  that  the  success  of  your  efforts  may  be  attributable  in 
some  measure  to  the  inspiration  which  may  have  been  derived 
from  the  city  I  represent.  My  friend,  Dr.  Chadwick,  reminds 
me  that  not  many  years  ago,  a  few  months  before  you  were 
congratulating  yourselves  and  were  being  congratulated  upon 
the  possession  of  a  new  library  hall,  your  president  of  that 
time,  the  honored  Dr.  Fordyce  Barker,  visited  Boston.  He 
came  to  see  how  we  dedicated  a  new  library  building.  He 
learned  so  much  that  after  his  return  he  was  able  to  say  to 


you  that,  if  you  proved  worthy  of  your  trust,  still  better  things 
might  come  to  you  in  time.  That  he  was  no  false  prophet  he 
who  comes  may  see.  May  my  visit  to  New  York  be  followed 
by  as  brilliant  a  result  as  his  to  Boston !  On  that  memorable 
occasion  when,  in  1879,  your  library  hall  was  dedicated,  Boston 
was  represented  by  one  of  its  distinguished  physicians,  Professor 
George  C.  Shattuck.  He  was  about  to  tell  you  what  we  had 
been  doing  to  obtain  a  suitable  building  for  a  medical  library — 
one  which  might  also  serve  as  a  meeting  house  for  physicians, 
where  they  might  forget  their  disagreements  and  be  stirred  to 
the  accomplishment  of  better  things.  New  York’s  hospitality 
was  so  pressing  that  before  his  story  was  completed  I  find  he 
was  invited  to  partake  of  the  loving  cup.  What  that  may  have 
meant  I  must  ask  those  of  you  who  were  present  to  recall.  I 
may  perhaps  be  permitted  to  finish  what  he  began,  though 
neither  so  well  nor  so  completely,  but  the  tale  may  act  as  a 
suggestion  that  may  not  prove  to  be  without  profit. 

The  Boston  Medical  Library  serves  pre-eminently  as  a  medi¬ 
cal  center  for  our  city.  It  contains  our  largest  collection  of 
medical  works  and  periodicals.  In  its  rooms  the  various  medi¬ 
cal  societies  meet,  and  its  hospitality  is  offered  with  the  great¬ 
est  freedom  to  all  those  seeking  its  aid.  In  these  respects  it 
may  follow  closely  your  footsteps,  r  For  the  community  iu 
which  we  live  it  does  something  more,  a  work  that  is  perhaps 
better  appreciated  by  the  sick  patient  than  all  the  rest — it  fur¬ 
nishes  a  home  for  the  Directory  of  Nurses.  This  means  that  at 
any  time,  night  or  day,  in  reply  to  messenger,  telegram,  or  tele¬ 
phone  call,  a  suitable  nurse  for  any  sort  of  ailment  will  imme¬ 
diately  be  sent  to  the  houses  of  patients,  whoever  they  may  be, 
at  a  trifling  charge.  Nurses  have  been  so  sent  throughout  New 
England,  to  Carolina  and  Florida,  to  Colorado  and  California, 
possibly  to  New  York.  In  the  past  year  nearly  two  thousand 
nurses  were  thus  supplied.  The  directory  is  an  immediate 
benefit  to  the  library,  as  the  income  is  so  far  in  excess  of  the 
expenditure  as  to  constitute  a  considerable  financial  support  to 
the  needs  of  the  library.  Its  convenience  to  patients  and  to 
physicians,  as  well  as  to  nurses,  has  made  it  a  necessity,  it  has 
come  to  stay.  I  have  made  the  story  as  short  as  possible,  and, 
though  your  present  surroundings  suggest  that  you  are  in  no 
need  of  financial  support,  such  an  undertaking  I  am  convinced 
you  would  find,  on  trial,  a  convenience  which  would  make  your 
influence  as  a  medical  center  even  greater  than  now  seems  pos¬ 
sible. 

I  thank  you  for  your  welcome  and  attention,  and  shall  re¬ 
turn  to  my  city  encouraged,  trusting  that  the  day  is  not  far  off 
when  Boston  will  follow  your  example  in  providing  a  medical 
center  worthy  of  its  profession  and  wealth  such  as  this,  which 
is  a  monument  to  the  influence  of  such  men  as  Jacobi  and 
Loomis,  and  to  the  generosity  and  public  spirit  of  its  philan¬ 
thropic  citizens. 

Remarks  by  Dr.  Fordyce  Barker.— Dr.  Barker  said :  Mr. 
President  and  Fellows  of  the  Academy  :  I  must  detain  you  only 
a  few  moments  on  this  joyous  occasion  to  express  my  warm 
congratulations.  It  is  now  nearly  twelve  years  since  I  had  the 
honor  first  to  address  the  Academy  officially,  when  I  expressed 
the  hope  that  the  walls  of  our  then  home  would  soon  be  ex¬ 
tended  for  our  rapidly  growing  library.  Within  a  few  months 
after,  by  the  spontaneous  gift  of  one  whose  name  must  ever  be 
gloriously  perpetuated  and  now  honors  one  of  the  rooms  in  the 
present  building,  our  house  was  greatly  and  beautifully  en¬ 
larged,  and  met  all  our  wants  for  several  years,  until  it  became 
apparent  that  we  must  have  more  room  for  our  books  and  the 
other  requirements  of  the  Academy. 

To  most  of  us  this  probably  seemed  a  dim  perspective  in 
the  future.  Who  could  have  expected  so  speedy  and  noble  a 
result  as  we  now  see?  We  can  now  say  appropriately,  in  a 


Nov.  29,  1890. J 


PROCEEDINGS  OF  SOCIETIES. 


609 


paraphrase  of  the  words  which  Shakespeare  put  into  the  mouth 
of  Gloster,  in  Richard  III:  “Now  is  the  winter  of  our  discon¬ 
tent  made  glorious  summer”  by  these  our  sons  of  York. 

I  must  congratulate  the  Academy  on  its  office-bearers,  all  of 
whom  must  have  worked  most  zealously  to  bring  about  this 
happy  result.  And  1  especially  congratulate  it  on  its  wise  elec¬ 
tion  of  the  present  incumbent  of  the  presidential  chair  and  his 
immediate  predecessor,  both  of  whom  have  labored  together 
with  untiring  earnestness,  great  wisdom,  and  tact,  and  both 
of  whom  possess  means  which  they  have  liberally  contributed 
to  this  end.  I  do  not  hesitate  to  express  the  opinion  that  with¬ 
out  The  combined  efforts  of  these  two  gentlemen  the  glorious 
consummation  which  has  now  arrived  would  have  been  long 
delayed. 

We  have  now  a  central  and  spacious  home  iu  which  the 
profession  will  find  it  pleasant  and  profitable  to  work  together 
for  mutual  improvement  and  the  public  good  in  the  advance¬ 
ment  of  science,  the  promulgation  of  new  truths,  and  the  de¬ 
velopment  of  progressive  skill  in  our  art,  and,  I  will  add,  the 
cultivation  of  those  social  graces  which  bind  us  in  the  friendly 
ties  of  brotherhood  in  a  noble  and  useful  profession.  We  can 
assure  the  profession  that  they  will  be  welcomed  to  a  library 
which  contains  the  accumulated  treasures  of  the  past  on  every 
topic  pertaining  to  medical  science,  and  the  current  periodical 
literature  of  the  day,  so  necessary  for  all  who  would  keep 
abreast  with  the  present  rapid  advance  of  science. 

We  to-night  begin  a  new  era  of  the  New  York  Academy  of 
Medicine.  Who  will  venture  to  cast  a  horoscope  of  its  grand 
future?  New  York,  the  commercial  metropolis  of  the  country, 
should  be  the  metropolis  of  the  medical  thought,  the  medical 
literature,  the  medical  teaching  of  the  country;  and  to  the 
Academy  of  Medicine  belongs  this  great  mission. 

One  thing  we  should  all  remember — that  above  there  is 
room  for  an  additional  hundred  thousand  volumes.  Ever  bear 
in  mind  that  concordia  res  pafvce  crescent ,  discordia  res  maxima 
dilabuntur ;  and  the  future  we  seek  for  this  Academy  is  cer¬ 
tain  to  be  gained. 

Letters  of  Regret  were  read  by  the  president.  Dr.  L.  L. 
Seaman  had  written  :  In  congratulating  the  Academy  upon  the 
acquisition  of  its  new  home,  I  beg,  through  you,  to  present  to 
its  members  a  statue  of  Esmeralda,  hoping  that  within  this  new 
temple  of  science  Art  may  ever  find  a  most  generous  welcome. 

The  Hon.  Grover  Cleveland  regretted  that  a  previous  en¬ 
gagement  prevented  him  from  being  present  on  an  occasion  so 
full  of  interest. 

Dr.  Henry  I.  Bowditch,  of  Boston,  closed  his  letter  with 
the  wish  that  the  New  York  Academy  of  Medicine  might  con¬ 
tinue  the  powerful  influence  in  the  future  that  it  had  had  in  the 
past  for  the  uplifting  of  the  whole  profession  of  America. 

Dr.  N.  S.  Davis,  of  Chicago,  closed  his  letter  with  this  sen¬ 
timent:  The  event  you  celebrate  marks  another  illustration  of 
the  maxim  that  in  union  and  harmony  there  are  both  strength 
and  success. 

Dr.  Bacon,  of  New  Haven,  wrote:  As  in  the  past,  we  shall 
in  the  future  watch  the  doings  of  and  receive  inspiration  from 
the  New  York  Academy  of  Medicine. 

Dr.  W.  H.  Welch,  of  Baltimore,  wrote:  I  feel  confident 
that  the  new  era  inaugurated  by  taking  possession  of  your  new 
building  will  be  one  in  which  not  only  the  members  of  the 
Academy,  but  also  the  entire  profession  in  New  York  and  the 
whole  country  will  take  pride. 

Dr.  Oliver  Wendell  Holmes  wrote:  I  regret  that  I  can  not 
be  present  at  the  opening  reception  at  your  new  building,  but 
in  one  sense  I  shall  be  among  you,  for  the  whole  of  the  medical 
profession  will  be  with  you  in  spirit  and  fellowship.  Acade¬ 
mies  have  too  often  been  thought  of  as  places  of  honorable  re¬ 


tirement  and  dignified  ease — roosts  where  emeritus  professors 
and  needy  men  of  letters,  once  cocks  of  the  walk,  could  sit  in 
quiet  rows,  while  the  fighting,  the  clucking,  and  the  crowing 
were  going  on  beneath  them.  No  doubt  to  be  a  member  of  the 
French  Academy — one  of  the  forty  immortals — is  an  honor 
worth  striving  for,  in  spite  of  Piron’s  epigram.  But  the  acade¬ 
my  which  fulfills  its  true  function  is  a  working  body  which 
deals  with  living  subjects;  which  handles  unsettled  questions ; 
which  sets  tasks  for  its  members  and  furnishes,  so  far  as  it  can, 
the  appliances  required  for  their  prosecution.  It  offers  rewards 
for  meritorious  performances,  and  sits  in  judgment  upon  the 
efforts  of  aspirants  for  distinction.  It  furnishes  the  nearest  ap¬ 
proach  we  can  expect  to  a  fixed  standard  of  excellence,  by 
which  the  work  of  new  hands  and  the  new  work  of  old  hands 
can  be  judged.  It  is  a  barrier,  a  breakwater  against  the  rush 
of  pretensions  which  are  constantly  attempting  to  find  their 
way  into  the  public  confidence.  Nowhere  is  such  a  defense 
more  needed  than  in  the  science  and  arts  which  deal  with  the 
health  of  the  community.  The  public  is  so  ready,  so  eager  to 
be  deceived,  and  the  adepts  in  deception  are  so  willing,  so  hun¬ 
gry  to  deceive  those  who  will  listen  to  them,  that  it  needs  a 
very  solid  wall  of  resistance.  The  various  forms  of  what  I 
will  venture  to  christen  as  pseudopathy  and  pseudo-therapy — 
though  they  are  known  to  the  public  by  other  names — can  never 
loosen  the  hold  of  the  thoroughbred  and  intelligent  physician 
on  the  intelligent  members  of  society  so  long  as  the  best  heads 
of  the  profession  are  banded  together  in  a  noble  iustitution  like 
this  Academy.  Only  let  it  ever  remain  steadfast. 

We  look  to  this  great  and  able  body  of  men  to  guard  the 
sacred  temple  of  Science  against  the  worshipers  of  idols.  The 
medical  profession  will  always  have  to  fight  against  the  claims 
of  the  wrong-headed.  There  is  a  certain  number  of  squinting 
braius,  as  there  is  of  squinting  eyes,  among  every  thousand  of 
the  population.  There  will  always  be  a  corresponding  number 
of  persons  calling  themselves  physicians  ready  to  make  a  living 
out  of  them.  Long  may  it  be  before  the  wholesome  barriers  are 
weakened  that  separate  the  thoroughbred  and  truly  scientific 
physician  from  the  plausible  pretender  with  his  pseudopathy 
and  his  pseudo-therapy.  We  trust  it  will  be  always  enough  for 
the  physician  to  be  able  to  say,  “I  am  a  member  of  the  New 
York  Academy  of  Medicine.” 


JjriHettrtmjs  nf  So  rictus. 

NEW  YORK  SURGICAL  SOCIETY. 

Meeting  of  October  8 ,  1890. 

The  President,  Dr.  Charles  K.  Briddon,  in  the  Chair. 

A  Contribution  to  the  Study  of  Appendicitis.— Dr.  Lewis 
A.  Stimson  read  a  paper  on  this  subject.  (See  page  449.) 

Dr.  Charles  MoBurney  said  he  would  speak  for  a  moment 
on  that  class  of  cases  which  were  being  constantly  held  up  by 
physicians  as  ending  in  rapid  recovery  with  comparatively  mild 
symptoms  and  without  calling  for  operation.  These  mild  cases 
were  numerous,  and  one  physician  might,  in  his  practice,  come 
across  some  three  or  four  of  them  and  draw  his  conclusions 
therefrom.  Another,  with  a  large  practice,  might  not  meet 
with  any  cases  of  appendicitis.  The  speaker  had  tried  to  formu¬ 
late  some  definite  rules  to  enable  one  to  decide  at  once  if  the 
case  presenting  was  one  which  required  operation  or  one  that 
could  safely  be  treated  by  conservative  measures.  He  was 
obliged  to  say  that  he  was,  as  yet,  unable  to  lay  down  any  defi- 


610 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


Bite  rules  for  his  own  guidance  or  that  of  others  who  might  de¬ 
sire  to  study  the  subject.  Much  was  to  be  learned  from  the 
general  expression  of  the  patient  as  to  the  existence  of  steadily 
advancing  disease.  The  character  of  the  pulse  in  almost  all 
cases  gave  a  considerable  amount  of  information  and  was  in 
some  instances  more  important  than  tlie  temperature.  The  lat¬ 
ter  was  a  very  unreliable  diagnostic  sign.  Sometimes  it  would 
remain  below  100°  F.  while  suppuration  was  becoming  pretty 
well  advanced.  Again,  the  sensations  of  pain  were  not  of  great 
value.  The  length  of  time  elapsing  since  the  seizure,  taken  in 
connection  with  the  general  symptoms,  would  often  help  ot 
decide  the  question  of  operation.  He  had  operated  at  various 
stages,  at  the  end  of  the  first,  second,  and  third  day,  and  had 
thought  that  it  was  often  admissible  to  allow  thirty-six  hours 
to  pass  before  deciding  upon  an  operation.  Very  few  accidents 
were  likely  to  happen  during  that  time.  If  this  period  was 
passed  and  there  was  no  increase  in  the  symptoms,  and  the 
pulse  was  nothing  more  than  a  moderately  feverish  one,  then 
the  question  of  operation  might  be  delayed  or  given  up.  But, 
again,  it  was  true  that  following  such  a  rule  might  be  a  very 
unfortunate  proceeding,  for  early  perforation,  with  septic  peri¬ 
tonitis,  might  take  place.  Still,  he  thought  such  conditions 
might  be  recognized  by  the  general  symptoms,  which  would 
sharply  define  them  from  a  case  that  was  steadily  improving. 
Something  definite,  however,  was  needed  to  mark  the  line  be¬ 
tween  the  cases  which  bid  fair  to  end  in  recovery  and  those 
which  did  not,  in  order  to  encourage  operative  procedure  where 
it  was  indicated.  He  would  like  to  see  further  information 
forthcoming  on  this  point.  He  had  within  the  past  year  seen 
twelve  cases  which  had  been  mild  from  the  beginning  and, 
within  forty-eight  hours,  had  become  still  milder  in  character, 
and  the  patients  recovered  rapidly  without  operation.  In  these 
the  operation  had  not  seemed  called  for.  As  to  the  question  of 
recurrence  of  the  disease  with  increased  severity,  say  five  or 
six  attacks,  many  medical  men  asserted  that  the  recurrent  con¬ 
dition  was  a  favorable  state  of  things,  and  that  such  cases 
were  not  likely  to  end  in  perforation.  He  would  cite  the  case 
of  a  young  man  who  had  had  three  or  four  attacks  of  appendi¬ 
citis  of  marked  severity  at  intervals  of  a  few  months.  This 
patient  had  been  under  caretul  observation  by  competent  men. 
The  speaker  had  seen  him  at  the  end  of  the  third  attack,  when 
he  was  getting  better.  An  operation  was  not  urged,  as  it 
seemed  clear  that  no  pus  had  ever  been  present.  It  was  sup¬ 
posed  that  very  strong  adhesions  had  formed  around  the  appen¬ 
dix,  which  would  protect  the  peritonaeum  in  case  of  another 
attack.  Subsequently  another  attack  had  come  on,  and  the 
character  of  the  symptoms  was,  this  time,  so  alarming  as  to 
call  for  prompt  operative  interference.  Instead  of  adhesions, 
there  was  only  one,  and  this  was  not  recent.  In  a  little  pocket 
formed  between  the  appendix  and  the  colon  there  were  about 
three  drachms  of  pus.  It  seemed  evident  that  if  the  patient  had 
even  turned  over  in  bed  he  would  have  spilled  this  material 
into  the  pelvic  cavity.  He  would  like  to  mention  one  rather 
striking  fact.  No  one  who  had  ever  seen  these  operations 
could  have  failed  to  note  how  exposed  the  adjacent  peritoneal 
tissues  were  to  septic  infection  from  instruments  and  sponges, 
no  matter  how  great  the  care  taken  to  avoid  this.  Still,  it  was 
a  fact  that  septic  infection  seldom  arose  from  this  cause.  He 
did  not  know  the  reason.  Perhaps  the  relief  given  from  the 
tension  and  the  resulting  improvement  in  the  circulation  al¬ 
lowed  the  patient  to  dispose  of  a  moderate  amount  of  local 
sepsis. 

Dr.  F.  Lange  said  his  experience  in  these  cases  was  of 
course  not  so  great  as  that  of  the  last  speaker.  Though  he  had 
in  a  good  many  cases  operated  for  perityphlitic  abscess,  he  had 
only  in  five  cases  excised  the  appendix  after  free  laparotomy, 


and  he  was  rather  inclined  to  temporize.  Free  opening  of  the 
peritoneal  cavity  in  encysted  perityphlitic  abscess  was  always 
a  dangerous  operation,  and  wherever  it  could  be  abandoned  in 
favor  of  the  usual  incision  of  older  date,  it  must  be  to  the  ad¬ 
vantage  of  the  patient.  It  must  not  be  forgotten  that  in  former 
years  by  far  the  majority  of  these  cases,  under  cautious  treat¬ 
ment,  had  been  cured  by  simple  incision.  On  the  other  hand, 
there  were  cases  in  which  the  radical  operation  could  not  be 
done  too  early,  and  the  difference  in  the  virulence  of  the  infect¬ 
ing  agent  must  be  very  great  in  the  various  cases,  if  one  saw 
that  there  were  cases  which  would  end  fatally  in  forty*eight 
hours  by  acute  septic  poisoning,  and,  on  the  other  hand,  those 
in  which  there  were  large  quantities  of  pus  with  no  serious  dis¬ 
turbance  of  the  general  condition.  In  some  of  his  own  cases, 
as  well  as  in  several  others,  where  he  had  acted  as  consultant, 
he  had  been  struck  by  the  advanced  stage  of  destruction  com¬ 
pared  with  the  short  time  after  the  onset  of  the  severe  symp¬ 
toms.  By  the  middle  of  the  second  day  there  had  been  found, 
not  only  perforation,  but  extensive  destruction  of  the  appendix 
and  far-gone  infection  of  the  peritonaeum.  In  such  cases  the 
destructive  process  in  the  appendix,  perhaps  a  circumscribed 
formation  of  pus  around  it,  must  have  preceded,  and  the  burst¬ 
ing  of  such  a  formation  must  have  given  rise  to  the  diffuse  peri¬ 
tonitis.  In  other  cases  the  state  of  things  was  quite  different. 
After  repeated  attacks,  the  operation  might  reveal  the  fact  that 
no  formation  of  pus  had  ever  taken  place,  as  Dr.  McBurney  had 
just  cited.  He  recalled  the  case  of  a  young  man,  about  eighteen 
years  of  age,  whom  he  had  presented  to  the  society  about  two 
years  before,  on  whom  laparotomy  had  been  done  twice.  The 
first  operation  showed  the  ascending  colon  constricted  by  adhe¬ 
sions  and  bands.  The  appendix  was  not  found,  as  it  was  im¬ 
bedded  in  a  thick  cicatricial  body  behind  the  colon,  and  ileo- 
colostomy  was  done,  since  it  was  assumed  that  perhaps  the 
narrowness  of  the  colon  had  been  the  real  cause  of  the  attacks. 
The  patient  made  a  good  recovery,  but  the  attacks  did  not  cease. 
Another  laparotomy,  with  careful  dissection  of  the  hard  mass 
behind  the  colon,  brought  to  light  the  dilated  and  thickened  ap¬ 
pendix  with  an  almond-shaped  faecal  concretion  in  it,  but  no¬ 
where  the  slightest  indication  of  any  formation  of  pus  or  disin¬ 
tegration  of  the  walls  of  the  appendix.  The  patient  made  a 
good  recovery  and  was  now  in  perfect  health.  This  case  was 
the  first  one  of  operation  in  New  York  in  the  quiescent  stage. 
In  this  case  the  attacks  had  probably  always  been  due  to  an  ac¬ 
cumulation  of  inflammatory  material  within  the  appendix,  aDd 
the  attacks  had  ceased  by  the  discharge  of  the  fluid  into  the 
gut.  Though  in  most  of  his  five  cases,  four  of  which  had  ended 
in  recovery,  he  had  found  faecal  concretions,  it  was  not  quite 
probable  that  these  mostly  rather  hard,  smooth  bodies  had  been 
the  direct  cause  of  the  attacks. 

The  most  difficult  question  in  the  treatment  of  certain  cases 
of  perityphlitis  in  which  the  operation  was  advisable  was  with 
regard  to  the  temporarily  reduced  general  condition  of  the  pa¬ 
tient.  Some  of  these  patients  would  surely  die  if  not  operated 
upon  ;  in  some  the  operation  might  be  the  immediate  cause  of 
death.  Would  the  patient  stand  what  ought  to  be  done?  To 
decide  this  question  was,  in  his  opinion,  one  of  the  most  difficult 
tasks  in  surgery.  An  apparently  diffuse  peritonitis  would  some¬ 
times  become  circumscribed,  though  several  foci  of  pus  might 
be  formed.  He  had  repeatedly  in  this  society  cited  his  experi¬ 
ence  in  cases  where  extensive  suppuration  bad  taken  place  and 
several  openings  through  the  abdominal  and  rectal  walls  had 
had  to  be  made.  He  was,  however,  not  able  to  give  any  distinct 
rules  according  to  which  in  some  of  these  cases  a  temporizing 
treatment  was  preferable,  while  an  early  operation  might  kill 
the  patient.  The  pulse  and  general  expression  of  the  patient 
gave  a  certain  ground  for  judgment,  but  it  was  always  unsafe, 


Nov.  29,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


611 


and  probably  would  always  remain  so,  since  the  infectiousness 
of  the  poison  and  the  resisting  power  of  the  body  were  two 
factors  which  might  be  guessed  at,  but  for  which  no  safe  stand¬ 
ard  could  exist.  Contrary  to  Dr.  Stimson,  be  bad  found  per¬ 
foration  in  those  of  his  cases  where  suppuration  was  present. 
To  illustrate  how  minute  sometimes  such  a  perforation  might 
be,  a  specimen  of  appendix  was  shown. 

Dr.  Parker  Syms  said  that  the  opinion  held  by  physicians 
that  many  patients  with  appendicitis  recovered  without  surgical 
interference  was  of  course  a  correct  one;  but  in  this  connection 
he  would  call  attention  to  the  fact  that  error  in  diagnosis  was 
frequent.  He  bad  met  with  two  such  instances  recently. 

Dr.  Lewis  S.  Pilcher  said  that,  after  listening  to  the  paper 
read  a  year  ago  by  Dr.  McBurney,  he  had  been  observant  of 
cases  which  might  be  appendicitis,  with  the  view  of  making  the 
diagnosis  in  the  early  stages  audjappreciating  the  symptoms  call¬ 
ing  for  operative  interference.  During  the  year  he  had  met  with 
quite  a  number  of  cases,  but  in  one  case  only  had  the  indications 
been  such  as  to  warrant  early  operative  interference.  In  one 
he  had  been  in  doubt,  and  had  desired  that  a  little  longer  time 
should  be  given  him  before  deciding.  On  the  second  day  an¬ 
other  consultant  was  called  in,  who  also  requested  a  little  time. 
This  second  delay  had  proved  fatal,  for  before  a  decision  was 
arrived  at  the  patient  had  died.  In  other  cases  he  bad  had  no 
hesitation  in  advising  that  no  operation  should  be  done,  and 
resolution  had  taken  place.  Such  resolution,  without  the  for¬ 
mation  of  abscess  requiring  operation,  had  formerly  been  a  fre¬ 
quent  experience  with  him  when  he  had  been  engaged  in  gen¬ 
eral  practice.  During  many  years  he  had  not  met  with  a  case 
of  appendicitis  which  had  not,  under  proper  treatment,  given 
satisfactory  results.  Since  his  cases  had  been  carefully  watched, 
so  that  he  could  be  reasonably  sure  there  was  no  mistake  in 
diagnosis,  he  was  bound,  as  the  result  of  his  own  experience,  to 
adhere  to  the  doctrine  that  many  inflammations  in  the  region 
of  the  appendix  would  result  in  resolution  without  operation. 
In  one  recent  case  such  resolution  had,  after  some  months,  been 
followed  by  a  second  attack,  which  had  resulted  in  suppuration, 
requiring  incision.  In  yet  another  case,  which  he  had  seen  at 
the  beginning  of  the  third  day  and  within  a  few  hours  after  it 
had  first  been  seen  by  any  physician,  there  was  no  tumor,  but 
the  localized  tenderness,  which  they  should  be  pleased  to  recog¬ 
nize  as  the  McBurney  symptom,  was  distinctly  marked.  Symp¬ 
toms  of  rupture  of  the  appendix  and  septic  invasion  of  the 
peritonaeum  were  pronounced,  and  the  general  septic  intoxica¬ 
tion  was  severe.  The  necessity  for  prompt  interference  was 
manifest.  He  had  not  felt  justified  in  refusing  to  operate  in 
this  case,  notwithstanding  the  little  prospect  of  benefit  which  it 
gave.  The  region  of  the  appendix  was  exposed,  and  the  organ 
was  found  buried  in  a  mass  of  dense  adhesions.  The  right 
iliac  fossa  was  filled  with  a  quantity  of  thin,  ichorous,  puriform 
material.  The  adjacent  intestines  were  also  covered  by  exu¬ 
date,  but  not  yet  adherent.  The  patient  was  temporarily  im¬ 
proved  by  the  operation,  but  afterward  succumbed  to  the  septic 
condition  existing  before  the  operation.  The  post-mortem  dem¬ 
onstrated  that  all  the  accumulation  of  septic  material  had  been 
removed  and  that  drainage  had  been  efficient.  In  still  another 
case  a  typical  perityphlitic  abscess  had  formed,  which  had 
opened  into  the  bowel  before  he  saw  it.  This  internal  drainage 
had,  however,  been  inadequate,  and  he  had  been  compelled  to 
make  an  incision  through  the  groin,  after  which  the  abscess  had 
healed  quickly. 

The  President  said  that,  as  to  the  innocuousness  of  a  given 
amount  of  pus  in  certain  cases  where  the  peritonaeum  was  ex¬ 
posed  to  infection  during  an  operation,  he  believed  it  had  been 
demonstrated  that  this  region  could  take  care  of  itself  against 
a  certain  amount  of  septic  material,  provided  the  focus  from 


which  the  material  was  secreted  was  removed  in  time.  In  ex¬ 
periments  on  animals  a  certain  amount  might  be  introduced; 
the  temperature  rose,  but  the  auimal  recovered.  But,  if  the 
material  was  in  large  quantities,  general  sepsis  took  place.  If 
only  a  limited  quantity  was  used,  or  the  focus  of  infection  was 
removed,  it  would  not  produce  general  peritonitis  of  a  fatal 
character.  He  thought  that  the  treatment  of  these  appendici¬ 
tis  cases  by  thorough  drainage  and  the  use  of  such  dressings  as 
iodoform  gauze  had  a  great  deal  to  do  with  the  happy  results 
obtained.  As  to  the  pulse,  he  thought  that,  when  pus  formed 
in  the  pelvic  cavity  to  a  limited  amount  and  became  encysted, 
the  temperature  fell. 

Dr.  Lange  took  exception  to  the  term  “resolution”  which 
Dr.  Stimson  had  employed  for  cases  which  seemed  to  end  in 
spontaneous  recovery,  and  asked  in  what  sense  he  had  used  it. 

Dr.  Stimson  replied  that  he  had  used  it  in  the  sense  in 
which  it  was  sometimes  employed  in  connection  with  other  in¬ 
flammations — namely,  to  indicate  the  subsidence  of  inflamma¬ 
tory  symptoms  without  the  evacuation,  and  apparently  with¬ 
out  the  formation,  of  pus.  He  believed,  however,  that  such 
subsidence  was  not  proof  that  pus  had  not  formed.  He  thought 
a  small  amount  of  pus  might  be  absorbed. 

Dr.  McBurney  doubted  whether  the  pus  was  ever  absorbed. 
He  had  found  it  many  months  after  in  patients  who  had  been 
comparatively  well  in  the  interim.  He  believed  that  many  of 
the  cases  were  those  of  moderate  inflammatory  action.  There 
was  a  certain  amount  of  infiltration.  The  appendix  became 
swollen  and  there  was  strangulation  of  the  blood-vessels,  with 
general  interference  with  the  circulation  of  the  organ.  If  the 
circulation  became  re-established  and  the  patient  got  well,  the 
process  might  be  not  inaptly  termed  resolution. 

Dr.  Stimson  thought  that  the  fact  that  pus  was  found  as 
stated  was  no  proof  that  it  was  never  absorbed.  It  was  known 
that  the  cellular  elements  of  pus  might  undergo  a  molecular 
degeneration  which  fitted  them  for  absorption. 

Dr.  McBurney  showed  an  appendix,  recently  removed,  in 
which  there  was  a  well-marked  gangrenous  area  surrounded  by 
comparatively  healthy  tissue.  Within  the  organ  there  was  a 
small  fecal  concretion,  which  probably  accounted  for  the  origi¬ 
nal  irritation  to  the  mucous  membrane,  the  strangulation  of  the 
vessels,  and  the  resultant  gangrene. 

Exostoses  of  the  Femur  and  Enchondroma  of  the  Meta¬ 
carpus. — Dr.  Lange  exhibited  a  specimen  of  extraordinarily 
large  and  irregular  exostosis  bursata  which  he  had  removed 
with  the  chisel  from  the  femur  of  a  young  lady  in  whom  the 
growth  had  existed  for  a  great  number  of  years;  also  a  speci¬ 
men  of  apparent  exostosis  of  the  metacarpal  bone  of  the  second 
finger,  which  had  proved  to  be  an  enchondroma. 

Prolapse  of  the  Rectum;  Operation;  Recovery.— The 
President  reported  the  following  case:  Emma  H.,  aged  thirty- 
two,  married ;  no  morbid  family  history.  General  health  had 
always  been  good.  Her  present  trouble  dated  back  to  an  early 
period  of  childhood.  With  every  defecation  there  had  been  a 
protrusion  of  the  bowel  through  the  anus,  the  condition  being 
much  aggravated  when  the  bowels  were  constipated.  When 
ridiDg,  traveling,  or  engaged  in  other  active  exercise,  the  pa¬ 
tient  had  always  had  a  feeling  of  insecurity  due  to  a  partial  loss 
of  control  over  the  sphincter.  She  had  had  one  miscarriage 
and  one  normal  labor  nine  years  ago.  For  a  period  of  two 
years  following  the  birth  of  her  child  she  had  suffered  little  in¬ 
convenience  from  the  prolapse.  Her  symptoms  had  all  re¬ 
turned,  however,  and  seven  years  ago  she  had  undergone  the 
operation  of  linear  cauterization,  which  was  followed  by  tem¬ 
porary  relief.  Her  symptoms  had  again  returned  and  she  de¬ 
sired  a  cure  by  operation.  The  perinaeum  having  been  shaved 
and  scrubbed  and  the  parts  made  aseptic,  the  prolapsed  mass, 


612 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Joub., 


five  inches  long,  was  drawn  down  through  the  anus  and  thor¬ 
oughly  exposed,  a  procedure  easily  accomplished  owing  to  the 
relaxed  condition  of  the  sphincter.  The  patient  was  then 
placed  upon  the  back  with  the  thighs  separated  and  elevated  as 
in  the  lithotomy  posture.  An  incision  was  made  transversely 
through  the  mucous  membrane  on  the  anterior  aspect  of  the 
prolapsed  gut,  a  little  below  the  verge  of  the  anus.  The  dissec¬ 
tion  was  then  continued,  the  haemorrhage  being  checked  with 
clamps.  The  peritoneal  pouch  of  Douglas  was  then  opened. 
The  danger  of  infection  at  this  stage  of  the  operation  was  min¬ 
imized  by  frequent  irrigation  with  Thiersch’s  solution.  The 
peritoneal  cavity  was  then  closed  off  by  uniting  the  two  op¬ 
posed  serous  surfaces  by  Lembert  sutures  of  fine  catgut  above 
the  line  of  division.  The  prolapsed  portion  of  rectum  was  then 
ligated  en  masse  with  an  elastic  ligature  and  cut  away  with  a 
few  sweeps  of  the  scalpel,  and  the  proximal  end  of  the  gut 
slipped  up  within  the  anus.  It  was  brought  down,  and,  after 
the  application  of  a  very  large  number  of  ligatures,  which  were 
required  to  control  the  haemorrhage,  its  mucous  membrane  was 
sutured  with  silk  to  the  mucous  margin  of  the  anus.  The  sut¬ 
ures  last  introduced  were  left  long,  the  ends  hanging  from  the 
anus.  The  site  of  operation  was  irrigated,  a  morphine  supposi¬ 
tory  inserted,  and  the  operation  completed  by  the  application 
of  an  antiseptic  dressing  and  a  T-bandage.  The  portion  of  gut 
removed  measured  over  five  inches  in  length.  There  was  some 
rise  of  temperature  on  the  third  day,  with  nausea,  eructations 
of  gas,  and  tympanites.  The  patient  had  convalesced  steadily 
and  regained  perfect  control  over  the  rectal  sphincters. 

Umbilical  Hernia;  Operation;  Recovery. — The  Presi- 
dent  also  reported  the  following  case:  Frances  P.,  aged  forty- 
seven,  housewife.  Eight  years  ago  she  had  an  attack  of  right 
hemiplegia,  from  which  she  had  fully  recovered  in  two  years. 
She  had  had  five  children,  her  confinements  being  easy  except 
the  last,  eight  years  ago,  when  she  was  in  labor  for  three  days. 
Shortly  after  the  birth  of  her  last  child  she  sustained  a  severe 
strain  from  a  fall,  and  three  weeks  later  she  noticed  for  the 
first  time  a  slight  bulging  at  the  umbilicus.  The  tumor  in¬ 
creased  in  size,  and  she  consulted  a  physician  and  was  advised 
to  wear  a  pad  and  binder.  In  spite  of  these  supports,  the 
tumor  continued  to  grow  and  had  recently  become  painful  and 
tender.  There  had  been  no  vomiting  or  disturbance  of  the 
bowels,  and  her  appetite  was  good.  There  has  been  a  marked 
loss  of  strength,  but  no  emaciation.  The  patient  had  come 
under  the  speaker’s  care  at  the  Presbyterian  Hospital,  where  he 
had  operated  as  follows:  The  abdomen  having  been  well 
scrubbed  and  made  aseptic,  the  patient  was  put  into  the  dorsal 
decubitus  and  the  site  of  operation  surrounded  with  aseptic 
towels.  An  elliptical  incision  was  begun  two  inches  above  the 
tumor,  carried  entirely  around  it,  and  prolonged  to  the  same 
distance  below  it.  There  was  a  very  thick  layer  of  abdominal 
fat,  and  the  dissection  was  continued  down  to  the  fascia  of  the 
abdominal"  muscles,  exposing  the  neck  of  the  sac  and  at  one 
point  accidentally  making  an  opening  in  the  sac,  through  which 
a  mass  of  omentum  protruded.  After  carefully  isolating  the 
neck  of  the  sac,  the  peritoneal  cavity  was  opened  and  the  con¬ 
tents  of  the  sac  were  explored.  They  were  found  to  consist 
entirely  of  omentum,  the  pedicle  of  which  was  ligatured  and 
the  entire  mass  cut  away.  The  abdominal  viscera  were  held  in 
place  by  means  of  a  hot  antiseptic  sponge  in  the  wound,  and 
the  incision  in  thp  peritonaeum  was  closed  with  interrupted  sut¬ 
ures  of  stout  catgut.  The  incision  in  the  abdominal  wall  was 
then  closed  by  a  double  row — deep  and  superficial — of  inter¬ 
rupted  sutures,  drainage  being  provided  for  by  the  insertion  of 
one  medium-sized  tube  in  the  most  dependent  portion  of  the 
wound.  The  parts  were  irrigated  and  the  operation  was  con¬ 
cluded  by  the  application  of  an  antiseptic  dressing  and  a  snug 


binder.  The  patient  made  an  uninterrupted  recovery  and,  a 
month  later,  was  fitted  with  an  abdominal  supporter. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  of  November  If,  1890. 

The  President,  Dr.  Landon  Carter  Gray,  in  the  Chair. 

Astasia  and  Abasia. — Dr.  G.  M.  Hammond  showed  a  young 
woman  who  had  never  been  the  subject  of  any  serious  illness 
excepting  Pott’s  disease,  which  had  come  on  during  childhood. 
Over  a  year  ago  the  speaker  had  attended  her  through  an  attack 
of  nervous  prostration.  During  her  illness  she  had  suffered 
from  aphonia.  The  difficulty  in  standing  and  walking  was  not 
discovered  until  she  was  able  to  leave  her  bed.  On  her  regain¬ 
ing  her  strength  sufficiently  to  walk  around,  it  was  observed 
that  she  invariably  walked  by  first  advancing  the  left  leg  and 
then  drawing  the  right  one  up  to  it.  When  she  attempted  to 
walk  naturally,  immediately  that  the  right  foot  touched  the 
ground  her  body  would  revolve  rapidly  to  the  right,  when,  after 
making  a  revolution  and  a  half,  she  would  sink  to  the  floor. 
Physical  examination  of  the  limbs  revealed  nothing  abnormal. 
The  patient  while  seated  or  lying  down  could  move  both  legs 
normally  ;  with  the  right  leg,  however,  more  mental  effort  was 
required  to  make  the  movements.  The  patellar  tendon  reflex 
was  normal  on  both  sides.  There  was  no  ankle  clonus,  anaes¬ 
thesia,  hyperaesthesia,  or  any  other  disorder  of  sensibility  in  any 
part  of  the  body  with  the  exception  of  slight  loss  of  the  muscu¬ 
lar  sense  in  the  right  leg.  The  electrical  reactions,  both  quali¬ 
tative  and  quantitative,  were  normal.  The  field  of  vision  and 
the  color  sense  were  found  normal.  The  senses  of  hearing,  touch, 
pain,  and  temperature  were  tested  without  anything  abnormal 
being  discovered.  There  was  some  resistance  to  passive  flexion 
and  extension  of  the  right  leg.  Those  symptoms,  then,  of  diffi¬ 
culty  instandintr  and  of  inco-ordination  and  ataxia  of  movement 
for  the  act  of  walking,  but  not  for  other  muscular  arts,  corre¬ 
sponded  accurately  to  the  condition  described  by  Bloeg  under 
the  title  of  astasia  and  abasia.  Bloeg  was  of  the  opinion  that 
astasia  and  abasia  was  a  condition  pathologically  similar  to 
agraphia.  The  speaker  did  not  see  anything  in  these  cases  to 
substantiate  this  view.  People  afflicted  with  the  disease  under 
consideration  could  make  the  motions  of  walking  perfectly  well 
if  they  were  allowed  to  lie  down,  but  it  had  never  been  main¬ 
tained  that  an  individual  suffering  from  agraphia  could  write 
any  better  in  one  posture  than  in  another.  The  condition,  it 
seemed  to  the  speaker,  depended  upon  a  loss  of  the  power  of 
adjusting  muscular  contractions  so  as  to  maintain  an  exact  equi¬ 
librium.  This  was,  of  course,  a  defect  of  the  muscular  sense. 
There  was  no  known  tract  in  the  spinal  cord  disease  of  which 
would  be  followed  by  these  symptoms.  Bloeg  had  attempted 
to  make  a  distinct  neurosis  of  this  class  of  cases,  and  maintained 
that  a  diagnosis  between  hysteria  and  astasia  and  abasia  could 
readily  be  made.  In  the  latter  disease  there  were  no  hysterical 
stigmata,  he  stated,  no  constant  paralyses  or  constant  contract¬ 
ures.  But  the  latter  were  by  no  means  characteristic  of  all  cases  of 
hysteria,  and  when  it  was  considered  that  every  case  of  astasia  or 
abasia  had  been  accompanied  by  some  other  symptom  or  symp¬ 
toms,  such,  for  example,  as  hyperaesthesia,  anaesthesia,  aphonia, 
contraction  of  the  visual  field,  and  temporary  color  blindness,  all 
of  which  frequently  accompanied  hysteria,  and  since  the  disease 
under  consideration  was  purely  functional  in  character,  no  ma- 
croscopical  or  microscopical  lesion  ever  having  been  discovered 
in  it,  it  would  not  be  difficult  to  believe  that  a-tasia  and  abasia 
was  merely  an  uncommon  type  of  an  hysterical  affection. 

Dr.  0.  L.  Dana  said  that,  if  it  was  possible  to  exclude  any 
organic  trouble  as  a  factor  in  the  case,  there  seemed  nothing 


Nov.  29,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


613 


left  but  to  give  the  condition  the  name  which  Dr.  Hammond 
had  nsed.  It  was  by  no  means  certain  that  this  so-called  disease 
deserved  a  separate  clinical  position,  and  all  the  vagaries  of  the 
trouble  were  by  no  means  known.  lie  thought  that  the  diag¬ 
nosis  might  be  accepted  as  a  provisionally  correct  one. 

Dr.  Louise  F.  Bryson  said  she  had  recently  been  reading  a 
case  reported  in  a  French  journal  of  what  was  known  as  “left- 
and  right-sided  disease,”  in  which  the  patient  always  had  to 
walk  to  the  right.  Physiologically,  the  muscles  of  the  right  side 
were  stronger  than  those  of  the  left,  and  perhaps  the  case  was 
one  of  exaggerated  function  of  the  muscles  of  the  right  side. 

Dr.  G.  W.  Jaooby  said  that  in  a  recent  number  of  the  Ber¬ 
liner  klinische  Wochenschrift  Dr.  Binswanger  had  stated  his 
belief  that  the  whole  trouble  resulted  from  a  psychical  condi¬ 
tion,  as  the  same  phenomena  were  found  in  other  mental  states. 
He  had  not  seen  a  case  exactly  like  this,  but  others  which  re¬ 
minded  him  very  much  of  it.  He  was  inclined  to  consider  the 
condition  as  a  psychic  manifestation.  Women,  after  long  con¬ 
finement  in  bed,  would  sometimes,  when  attempting  to  walk, 
find  themselves  too  weak  to  do  so,  and  immediately  conclude 
that  they  had  lost  the  power.  While  lying  down  or  sitting, 
they  had  entire  control  of  their  limbs,  but  when  they  essayed 
walking,  then  came  the  fear.  It  was  a  psychic  disturbance  of 
equilibrium.  He  thought  that  Binswanger  had  done  as  much 
to  clear  away  doubt  in  this  class  of  cases  as  others  had  done  to 
produce  confusion. 

The  President  said  he  had  never  seen  anything  like  this 
case.  The  cases  of  hysterical  paralysis  that  he  had  seen  had 
been  typical  forms  of  paraplegia.  He  had  also  read  the  two 
cases  described  by  Russell  Reynolds,  who  had  called  them 
“  paralysis  of  idea.”  He  did  not  think  it  was  well  to  designate 
this  case  as  one  of  hysteria  on  account  of  the  presence  of  some 
spots  of  anaesthesia,  because  it  had  been  shown  that  this  oc¬ 
curred  in  a  great  many  different  nervous  disorders,  both  func¬ 
tional  and  organic.  It  seemed  better  to  accept  the  case  as  a 
clinical  entity  and  hold  any  opinion  in  reserve  as  to  the  cause 
of  the  manifestations. 

Syringomyelia. — Dr.  J.  0.  Siiaw  presented  a  single  woman, 
thirty  years  of  age,  who  had  always  had  good  health  until  about 
six  years  ago,  when  a  weakness  of  her  left  hand  was  noticed. 
This  condition  had  steadily  increased  up  to  the  present  time. 
For  the  past  three  years  she  had  had  a  constant  aching  in  the 
left  arm,  shoulder,  and  side  of  the  neck,  and  lately  on  that  side 
of  the  head.  For  two  years  there  had  been  a  numb  spot  on  the 
inner  side  of  the  left  arm.  She  had  constant  sensations  of  burn¬ 
ing  on  the  left  side  of  the  face  and  neck,  with  flashes  of  heat 
and  cold.  There  was  a  small  spot  on  the  back  of  the  head 
where  this  burning  sensation  was  greater  than  anywhere  else. 
She  presented  an  atrophy  of  the  small  muscles  of  the  left  hand, 
which  had  existed  for  six  years,  and  was  gradually  growing 
worse.  There  was  also  slight  atrophy  in  all  the  muscles  of  the 
left  arm,  shoulder,  and  side  of  the  face.  In  the  area  of  the 
numb  spot  the  tactile  sensibility  was  impaired.  The  thermic 
sense  was  greatly  diminished  over  the  entire  left  side,  and  in 
the  right  lower  extremity  as  well.  The  reflexes  were  exagger¬ 
ated.  While  the  examination  of  the  patient  had  not  been  as 
careful  as  it  might  have  been,  the  speaker  thought  that  it  was 
sufficient  for  the  purpose  of  diagnosis. 

Dr.  B.  Sachs  thought  the  personal  equation  was  a  powerful 
factor  in  this  case.  It  certainly  had  been  so  that  evening.  The 
case  did  not  seem  to  him  to  be  one  of  syringomyelia.  The 
atrophy  was  not  marked  enough,  particularly  about  the  shoul¬ 
der.  The  sensory  symptoms  were  not  so  distinct  as  in  a  typical 
case.  So  far  as  he  could  judge,  the  case  seemed  one  of  amyo¬ 
trophic  lateral  sclerosis,  though  further  examination  or  obser¬ 
vation  might  lead  him  to  a  different  conclusion. 


Dr.  M.  A.  Starr  said  that  there  were  several  features  about 
this  case  which  reminded  him  of  one  that  had  come  under  his 
observation.  He  had  not  brought  these  points  out,  because  he 
did  not  know  that  they  belonged  to  syringomyelia.  One  of 
these  peculiarities  was  the  noise  made  in  the  throat — a  sound 
as  of  alarm.  This  had  been  present  in  his  patient,  who  was  by 
no  means  a  hysterical  girl.  He  had  regarded  it  as  due  to  a 
muscular  contraction  of  the  larynx  during  inspiration.  His  pa¬ 
tient  would  make  the  noise  whether  she  was  quietly  conversing 
in  his  office  or  was  before  a  class  of  students.  This  feature  was 
to  be  taken  into  consideration.  He  thought  that  the  stationary 
condition  of  the  atrophy  in  this  case  indicated  the  existence  of 
syringomyelia  rather  than  that  of  amyotrophic  lateral  sclerosis. 
He  had  demonstrated  pretty  conclusively  the  changes  in  the 
pain-sense  by  sticking  the  point  of  a  needle  into  the  patient’s 
arm  without  her  knowing  it.  There  was  no  mistake  about  it, 
for  he  had  put  the  needle  in  a  quarter  of  an  inch.  Then  there 
was  the  history  of  a  loss  of  temperature  sense.  The  patient 
had  noticed  in  putting  her  hands  into  hot  water  that  there  was 
a  difference  between  the  two  sides.  Therefore,  bearing  in  mind 
the  non-progressive  condition  of  the  atrophy  and  the  existence 
of  changes  in  the  temperature  and  pain  senses,  he  supposed  one 
was  warranted  in  making  a  diagnosis  of  syringomyelia. 

Dr.  SAcns  thought  the  question  depended  upon  the  actual 
condition  of  the  sensory  derangements  in  this  case,  and,  of 
course,  the  examination  had  been  but  cursory. 

Dr.  W.  R.  Birdsall  thought  that  where  the  results  of  ex¬ 
amination  were  so  at  variance  it  would  be  hardly  worth  while 
to  attempt  any  expression  of  opinion  in  the  way  of  diagnosis. 
It  had  been  his  impression,  from  the  descriptions  of  cases  of 
syringomyelia  which  he  had  read,  and  in  which  an  autopsy  had 
been  held  as  confirmatory  evidence,  that  the  histories  had  given 
the  pain  and  temperature  sense  as  having  been  both  affected. 
He  should  say  that  the  case  before  them  was  at  least,  typical  in 
this  respect.  As  to  this  disease,  it  was  a  remarkable  fact  that, 
during  the  past  year,  of  the  cases  in  which  syringomyelia  had 
been  diagnosticated  during  life  there  had  been  no  autopsy, 
while  in  those  autopsies  which  had  revealed  the  existence  of 
the  disease  its  presence  had  not  been  suspected  during  life. 

Dr.  Dana  said  that  last  spring  he  had  had  a  patient  in  his 
hospital  service  who  had  presented  many  similar  symptoms. 
There  had  been  atrophy  in  the  muscles  supplied  by  the  ulnar 
nerve  and  of  the  small  muscles  of  the  hand.  There  was  also 
anaesthesia  involving  the  temperature  and  pain  senses.  The 
atrophy  had  slightly  involved  the  opposite  side.  There  was  also 
a  belt  of  anaesthesia  over  the  lower  portion  of  the  trunk,  and 
extending  to  the  thighs.  Tnere  was  no  disturbance  of  the  sen¬ 
sory  functions.  The  girl  had  gradually  developed  symptoms  of 
bulbar  paralysis  without  any  sensory  symptoms  accompanying. 
He  had  been  obliged  to  regard  this  as  a  typical  case  [of  progres¬ 
sive  muscular  atrophy.  He  had  since  seen  a  case  of  progressive 
muscular  atrophy  in  which  sensory  symptoms  were  present.  If 
the  symptoms  of  bulbar  paralysis  were  developed  in  the  case 
before  them,  it  would,  he  thought,  turn  out  to  be  a  case  of  pro¬ 
gressive  muscular  atrophy.  As  to  amyotrophic  lateral  sclero¬ 
sis,  it  was  simply  another  name  for  the  same  disease. 

The  President  said  the  only  way  to  make  a  diagnosis  of 
syringomyelia  seemed  to  be  to  make  an  autopsy.  The  value  of 
the  loss  of  thermic  sense  in  a  patient  as  a  diagnostic  point  was, 
to  a  great  extent,  vitiated  by  the  fact  that  the  relations  of  this 
sense  to  other  organic  spinal  diseases  were  unknown.  He 
thought  it  would  not  be  possible  to  establish  the  fact  satisfac¬ 
torily  that  this  was  a  case  of  syringomyelia  until  the  woman 
died. 

Spina  Bifida,  with  Suppurative  Meningitis  and  Ependy- 
mitis  of  Bacterial  Origin. — Dr.  L.  Emmett  Holt  and  Dr.  Ira 


614 


PROCEEDINGS  OF  SOCIETIES. 


A  an  Gieson  reported  a  case  of  spina  bitida  in  an  infant  in  which 
the  entrance  of  bacteria  into  the  wall  of  the  sac  had  apparently 
caused  suppurative  spinal  meningitis  and  ependymitis.  The 
child  had  died  at  the  age  of  three  weeks,  having  had  paraplegia, 
marked  irritability,  and  failing  nutrition.  The  center  of  the 
spinal  sac  had  the  appearance  of  a  granulating  surface  and  was 
covered  with  a  sero-purulent  discharge.  There  were  no  physical 
signs  of  hydrocephalus.  At  the  autopsy  the  ventricles  of  the 
brain  were  found  to  he  greatly  distended  with  thin  pus.  The 
pons  Varolii  and  the  cerebellum  were  partially  covered  with  a 
yellowish  exudation,  also  a  portion  of  the  spinal  cord  and  the 
whole  interior  of  the  sac.  There  were  great  numbers  of  small 
cocci,  in  chains,  in  the  wall  of  the  sac,  in  its  inner  coating,  in 
the  central  canal  and  meninges  of  the  spinal  cord,  in  the  exu- 
dition  on  it  and  the  pons  and  cerebellum,  and  in  the  walls  of  the 
lateral  ventricles.  The  microphyte  seemed  to  be  the  Strepto¬ 
coccus  pyogenes.  Dr.  Holt  said  he  had  seen  one  other  of  these 
cases  of  hydrocephalus  in  which  the  disease  had  existed  with¬ 
out  any  symptoms  during  life.  He  thought  there  were  proba¬ 
bly  a  great  many  more  than  was  usually  supposed.  He  had 
been  surprised  to  find  that  the  ventricles  contained  several 
ounces  of  fluid.  He  had  seen  several  cases  of  basilar  meningitis 
in  which  only  a  moderate  amount  of  distention  of  the  ventricles 
was  found.  In  two  of  these  cases  the  entire  contents  of  the 
lateral  ventricles  would  not  have  exceeded  an  ounce. 

Cerebral  Compression.— Dr.  E.  D.  Fisher  read  a  paper 
with  this  title.  He  said  that,  while  he  had  nothing  new  to  pre¬ 
sent,  he  thought  that  he  could  settle  definitely  the  question  of 
the  influence  of  compression  on  the  cerebral  mass  within  the 
skull,  and  whether  the  cerebral  substance  was,  per  se,  com¬ 
pressible  without  interference  with  its  capillary  circulation  or 
function.  Bergnatnis  and  Adamkiewitz  held  that  the  brain 
substance  was  incompressible,  the  only  conditions  of  change 
possible  in  the  cerebral  volume  being  those  dependent  on  the 
displacement  or  variation  in  the  cerebro-spinal  fluid  or  the  cere¬ 
bral  circulation,  these  standing  in  converse  relation  to  each 
other.  The  question  of  the  compressibility  of  the  brain  de¬ 
pended  on  which  of  the  elements  comprising  the  brain  was 
most  liable  to  compression ;  as  the  blood-pressure  was  higher 
than  that  of  the  cerebral  fluids,  it  was  possible  that  the  tissue 
fluids  were  first  affected.  Much  depended  also  on  whether  we 
regarded  the  liquor  cerebri  as  a  secretion  or  as  a  transudation 
from  the  blood-vessels,  as  in  the  latter  case  we  should  have  to 
consider  arterial  tension  as  a  very  important  factor  in  cerebral 
compression.  The  vascular  center  was  situated  not  only  within 
the  medulla,  but  probably  also  within  the  brain— i.  e.,  the  cor¬ 
pus  striatum  or  optic  thalamus.  The  brain  possessed  a  mech¬ 
anism  of  its  own  for  increasing  its  blood-supply  independently 
of  increased  cardiac  action.  Experimentally  it  had  been  proved 
that  cold  acted  deeply  within  the  brain.  Its  good  effect  was 
very  marked  in  the  headaches  of  ansemics,  the  ice-bag  being  an 
efficient  remedy.  The  cold  probably  acted  by  increasing  the 
blood-current  rapidity  in  the  capillaries,  and  by  causing  spastic 
contraction  of  the  arteries.  In  these  cases  the  amount  of  blood 
passed  through  the  brain  by  increasing  the  rapidity  made  up  in 
quantity  for  the  quality,  thereby  maintaining  the  nutrition. 
The  extent  of  a  cerebral  haemorrhage  depended  on  the  arterial 
pressure  or  tension,  the  intracerebral  pressure,  and  also  on  the 
resistance  of  the  brain  substance,  the  latter,  of  course,  depend¬ 
ing  on  the  site  of  the  haemorrhage.  Spastic  contraction  of  the 
arteries  of  the  brain  really  caused  active  hyperaemia,  the  de¬ 
creased  volume  of  the  skull  contents  causing  increased  capil¬ 
lary  circulation.  Paralytic  dilatation  of  the  arteries  caused 
passive  hyperaemia,  which  was,  in  fact,  anaemia,  the  blood  being 
no  longer  in  a  proper  state  to  carry  on  the  nutrition  of  the 
brain,  as  the  increased  volume  of  the  brain  caused  retardation 


[N.  Y.  Med.  Joub., 

of  the  capillary  circulation,  and  probably  also  interfered  with 
the  venous  circulation.  The  speaker’s  experiments  had  been 
made  by  exposing  the  pia  mater  and  observing  the  changes 
produced  in  the  blood-vessels.  Extension  of  the  sciatic  nerve 
produced  increased  volume  of  the  brain.  Compression  of  the 
carotids  caused  marked  loss  of  volume.  Asphyxia  caused  ex¬ 
pansion  of  the  brain.  Chloral  caused  anaemia,  with  marked 
contraction.  Chloroform  contracted  the  brain.  Ether  at  first 
contracted  and  subsequently  expanded  it.  Strychnine  caused 
marked  expansion,  as  did  digitalis  and  small  doses  of  alcohol. 
Caffeine  and  the  acids  caused  expansion,  while  the  alkalies  pro¬ 
duced  the  reverse  result.  From  his  experiments  the  speaker 
concluded  that  the  blood-supply  of  the  brain  varied  directly 
with  the  blood-pressure  in  the  systemic  arteries,  and  that  the 
extensibility  of  the  walls  of  the  cerebral  vessels  allowed  of 
great  variation  in  caliber.  The  vaso-constrictor  centers  were 
excited  directly  by  disturbance  of  the  nutrition  of  the  nervous 
system,  as  in  anaemia,  asphyxia,  etc.  Finally,  the  essential 
product  of  cerebral  metabolism  contained  in  the  lymph-spaces 
bathed  the  walls  of  the  arterioles  and  could  cause  variations  in 
the  caliber  of  the  vessels,  this  mechanism  reacted  on  the  brain, 
and  by  this  means  the  vascular  supply  could  be  varied  locally 
according  to  local  varieties  of  functional  activity. 

Dr.  G.  W.  Jacoby  said  that  tne  demonstration  that  the  nerve 
tissue  could  be  compressed  in  its  molecules  and  anatomical  ele¬ 
ments  had  been  professed  by  one  author.  Another  had  main¬ 
tained  the  non-compressibility  of  these  elements,  but  had  fur¬ 
ther  stated  that  the  effect  of  haemorrhage  was  due  to  anamiia 
of  the  brain.  This  was,  as  a  theory,  substantiated  by  compar¬ 
ing  the  clinical  symptoms  in  such  haemorrhage  with  the  symp¬ 
toms  caused  by  injecting  lycopodium  powder  into  the  cerebral 
vessels,  and  producing  thrombi.  He  then  referred  to  the  ex¬ 
periments  of  one  who  had  demonstrated  the  displacement  of 
the  cerebro-spinal  fluid.  In  one  casein  which  rice  was  injected 
the  aqueduct  of  Sylvius  was  found  to  be  ruptured,  and  the  lat¬ 
eral  ventricles  were  flattened  together.  This  experimenter  had 
inferred  that  the  very  suddenness  with  which  the  compression 
was  exercised  had  caused  the  violent  displacement  of  the  cere- 
bro  spinal  fluid  and  consequent  rupture.  The  same  observer 
had  also  estimated  very  minutely  the  amount  required  to  op¬ 
pose  the  arterial  tension,  and  had  maintained  that,  if  at  any 
time  an  effusion  took  place  on  the  surface  of  the  brain  to  en¬ 
tirely  balance  this,  death  must  result  instantly.  Dr.  Fisher  had 
pointed  out  the  necessity  of  maintaining  arterial  tension,  rather 
than  depressing  it,  upon  this  very  theory.  It  had  been  sug¬ 
gested  that  in  cerebral  haemorrhage  the  head  should  be  hung 
down  to  send  blood  to  the  head  mechanically,  and  thus  oppose 
the  effusion  which  was  taking  place  from  the  ruptured  vessels. 
He  did  not  know  whether  this  had  ever  been  put  into  practice. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  OBSTETRICS  AND  GYNAECOLOGY. 

Meeting  of  October  22,  1890. 

Dr.  E.  H.  Grandin  in  the  Chair. 

Hermaphroditism.— Dr.  J.  K.  Crook  described  a  case  of 
hermaphroditism  which  had  recently  come  under  his  observa¬ 
tion. 

Dr.  Grace  Peckham  said  that  last  spring  she  had  occasion 
to  see  a  woman  whose  external  appearance  was  entirely  mascu¬ 
line  and  in  whom  the  genital  organs  were  of  a  more  pro¬ 
nounced  male  type  than  those  described  in  the  case  of  Dr. 
Crook.  She  had  seen  several  cases  of  this  kind  in  which  the 
persons  were  dressed  as  women. 


Nov.  29,  1890.] 


PROGEEDINOS  OF  SOCIETIES. 


Dr.  I.  II.  Hance  mentioned  a  case  in  which  Dr.  McBurney 
had  recently  operated.  By  a  plastic  operation  upon  the  male 
organ  the  person  had  been  enabled  to  pass  his  urine  in  the  erect 
posture.  The  sexual  disposition  of  this  person  had  varied  ac¬ 
cording  to  the  way  he  or  she  was  dressed.  When  attired  as  a 
male  the  inclinations  were  those  of  a  male  and  the  reverse 
when  dressed  as  a  woman.  Dr.  McBurney  had  said  he  could 
not  be  certain  whether  the  person  was  a  male  or  a  female.  This 
hermaphrodite  had  a  sister  with  exactly  the  same  maladjust¬ 
ment  of  the  genital  organs.  . 

Removal  of  the  Tubes  and  Ovaries,— Dr.  A.  F.  Currier 
showed  several  specimens,  and  described  the  cases,  from  a  num¬ 
ber  of  operations  which  he  had  recently  done  for  the  removal 
of  the  tubes  and  ovaries.  Among  these  he  mentioned  a  case  in 
which  the  patient  had  shown  decided  evidences  of  tubal  preg¬ 
nancy.  There  was  a  history  of  profuse  haemorrhage.  He  had 
found  a  large  tumor  present.  Another  haemorrhage  was  fol¬ 
lowed  by  collapse,  the  patient  becoming  unconscious  and  fall¬ 
ing  down  stairs.  The  specimen  presented  was  a  haematoma 
and  what  had  been  thought  by  the  speaker  to  be  the  remains 
of  a  tubal  gestation  sac.  Examination  had  shown  the  presence 
of  placental  tissue.  In  one  case  the  patient  bad  had  what  had 
been  diagnosticated  as  typhoid  fever  on  the  seventh  day  after 
the  operation,  but,  after  the  attack  had  run  a  course,  she  had 
recovered.  One  patient  from  whom  he  had  removed  the  sut¬ 
ures  on  the  ninth  day  and  had  found  a  small  abscess  developed 
at  the  site  of  one  of  the  sutures,  had  on  the  following  day  suf¬ 
fered  a  collapse,  and  he  had  been  obliged  to  administer  oxygen 
before  she  was  out  of  danger.  All  the  patients  referred  to  had 
eventually  done  well. 

Pregnancy  complicated  by  Circumuterine  Inflammatory 
Deposits. — This  was  the  title  of  a  paper  by  Dr.  Ralph  Waldo. 
He  said  there  had  been  a  time  when  he  had  thought  that  in¬ 
flammatory  deposits  in  the  neighborhood  of  the  uterus  would  in 
most  instances  prevent  impregnation,  and,  if  that  was  not  the 
case,  that  abortion  would  occur  in  the  early  months  of  preg¬ 
nancy.  He  then  gave  the  histories  of  a  number  of  cases  illus¬ 
trating  the  various  phases  of  this  problem.  In  looking  over  the 
histories  of  some  of  his  cases,  he  had  about  decided  that,  while 
it  was  almost  impossible  for  women  with  inflammatory  products 
about  the  uterus  to  become  pregnant,  still  many  of  them  did  so 
and  some  seemed  to  carry  their  children  as  if  nothing  was 
wrong.  Others  would  abort  a  few  times  and  then  give  birth 
to  a  child  at  term,  while  a  third  class  would  continue  to  abort 
during  the  whole  of  the  child-bearing  period.  In  carefully 
searching  out  a  cause  for  this  he  had  found  that  patients  with 
inflammatory  deposits  about  the  uterus,  who  aborted  habitual, 
ly,  in  nearly  every  instance  had  the  fundus  of  the  organ  bound 
by  adhesions,  and  that  the  firmer  it  was  fixed  the  more  persist¬ 
ent  were  the  abortions.  He  believed  it  to  be  of  primary  im¬ 
portance  to  ascertain  the  extent  To  which  the  body  of  the 
uterus  was  fixed  before  making  a  prognosis,  for,  if  the  body  of 
the  organ  was  immovable,  and  especially  if  it  was  retroflexed, 
he  was  of  opinion  that  abortion  would  invariably  result  as  long 
as  the  condition  remained.  On  the  other  hand,  there  might  be 
extensive  deposits  and  adhesions  about  the  lower  part  of  the 
uterus,  which  might  obstruct  the  passage  of  a  child  and  which 
would  still  not  cause  the  uterus  to  prematurely  empty  itself. 

Dr.  II.  C.  Coe  said  that  it  was  not  an  uncommon  thing  to 
find  conditions  of  old  pelvic  inflammation  and  the  symptoms 
arising  from  them,  and  yet  to  have  the  woman  go  on  to  full 
term.  The  involvement  of  the  tubes  and  ovaries  was  another 
thing.  He  should  not  expect  a  woman  to  go  on  to  uneventful 
delivery  if  she  had  a  well-developed  salpingitis,  with  both  ova¬ 
ries  prolapsed  and  fixed;  still  the  adhesions  did  seem  to  stretch. 
The  recognition  of  these  circumuterine  inflammations  would  be 


615 

very  difficult  during  pregnancy,  and  he  did  not  know  how  oue 
would  go  to  work  to  treat  such  a  condition  at  such  a  time. 

Dr.  Crook  said  that  in  cases  where  abortion  occurred  in  the 
presence  of  these  adhesions  he  had  been  inclined  to  refer  the 
accident  to  a  condition  of  endometritis  rather  than  to  the  ad¬ 
hesions. 

Dr.  Currier  thought  that  Dr.  W aldo  had  made  an  important 
distinction  in  referring  to  adhesions  at  the  fundus.  They  all 
knew  of  cases  in  which  perimetritic  inflammation  had  existed 
prior  to  pregnancy,  and  the  patient  had  gone  on  to  full  term 
uninterruptedly.  They  had  also  heard  of  cases  of  well-marked 
tubal  or  ovarian  disease  in  which  pregnancy  had  continued  to 
term.  But  he  could  not  understand  how  this  could  be  expected 
when  the  adhesions  were  attached  to  the  fundus.  It  was  hard 
to  realize  the  immense  amount  of  resistance  which  these  ad¬ 
hesions  offered.  The  endometritis  was  largely  due  to  the  irri¬ 
tation  set  up  by  the  adhesions,  and  in  the  absence  of  these  prod¬ 
ucts  of  inflammation  the  endometritis  alone  would  not  cause 
abortion.  He  did  not  like  the  term  “habit”;  the  body  or  its 
organs  had  no  habits.  This  term  and  the  word  idiopathic 
should  be  expunged  as  applied  to  a  departure  from  a  physi¬ 
ological  condition. 

Dr.  Grace  Peokham  said  that  gynaecologists  recognized  the 
fact  that  a  general  softening  of  the  tissues  took  place  in  these 
perimetritic  inflammations,  and  that  they  gave  less  trouble  than 
might  be  expected.  Still,  the  speaker  was  aware  that  the  idea 
was  prevalent  that  these  adhesions  would  cause  abortion  or 
steiility.  fehe  was  glad  to  indorse  the  opinion  of  the  gentleman 
who  had  referred  to  a  condition  of  endometritis  as  being  a  more 
frequent  cause  of  the  mishap. 

The  Chairman  said  that  where  there  existed  posterior  ad¬ 
hesions,  mentioned  by  the  writer  of  the  paper  as  prone  to  cause 
abortion  at  three  mouths,  it  was  certain  that  they  would  have 
to  rise  with  the  uterus  or  the  fundus  must  become  incar¬ 
cerated.  It  was  a  question  whether  the  adhesions  themselves 
gave  rise  to  the  trouble  or  simply  whether  they  did  not  give 
way  soon  enough  and  thus  caused  the  uterus  to  empty  itself; 
for,  in  the  event  ot  incarceration  and  development  in  the  cav¬ 
ity  of  the  pelvis,  the  uterus  would  have  to  throw  off  its  contents. 
A  woman  was  less  likely  to  become  pregnant  when  suffering 
from  endometritis  than  to  abort  as  the  result  of  it. 

Dr.  R.  A.  Murray  said  he  thought  if  these  circumuterine  ad¬ 
hesions  were  recognized  early  enough  they  could,  by  instituting 
proper  treatment,  be  made  to  stretch.  Any  existing  endome¬ 
tritis  might  also  be  sufficiently  treated  to  allow  of  the  woman 
going  on  to  full  term.  It  was  often  quite  difficult,  however,  to 
say  whether  these  women  were  really  pregnant  or  whether  the 
enlargement  was  due  to  the  inflammatory  products. 

Exploratory  Puncture  of  the  Female  Pelvic  Organs.— 
Dr.  George  M.  Edebohls  read  a  paper  with  this  title.  He  said 
that  the  scope  of  his  paper  did  not  embrace  the  subject  of  the 
diagnosis  of  the  larger  tumors  of  the  abdomen,  whether  origi¬ 
nating  from  the  pelvic  or  abdominal  organs,  but  concerned  it¬ 
self  solely  with  the  differential  diagnosis  of  slight  enlargements 
or  masses,  which  were  either  situated  entirely  within  the  pel¬ 
vis  proper,  or  originated  there,  projected  but  slightly  above 
the  brim  of  the  true  pelvis  into  the  abdomen,  and  which  were 
recognizable  only  by  combined  abdominal  and  vaginal  touch. 
As  an  aid  in  the  differential  diagnosis  of  these  smaller  tumors 
or  masses,  he  had  systematically  practiced  for  two  years  past 
a  method  of  exploratory  puncture  of  the  female  pelvic  organs 
which  he  had  ventured  to  designate  “  abdominal  puncture 
guided  by  combined  vaginal  and  rectal  touch.” 

The  method  as  practiced  was  as  follows:  The  skin  of  the 
lower  part  of  the  abdomen  was  disinfected  as  carefully  as  if 
laparotomy  were  contemplated.  The  middle  finger  of  the  left 


616 


PROCEEDINOS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour. 


hand  was  passed  into  the  rectum,  the  index  finger  of  the  same 
hand  into  the  vagina,  the  ovary,  tube,  small  tumor  or  mass 
to  be  punctured  being  located  by  thefingers.  Thereetal  finger, if 
possible,  readied  around  behind  to  the  upper  limits  of  the  mass, 
the  vaginal  finger  being  applied  to  its  lower  pole.  By  combined 
palpation  a  point  on  the  anterior  abdominal  wall,  directly  over 
the  center  of  the  mass  to  be  punctured,  was  located  by  the 
carefully  disinfected  fingers  of  the  right  hand.  At  this  point 
the  sterilized  needle  was  carried  perpendicularly  through  the 
abdominal  wall  and  all  intervening  tissues  and  organs  into  the 
center  of  the  mass.  The  fingers  in  the  vagina  and  rectum 
fixed  the  diseased  structures,  controlled  the  course  of  the  needle, 
and  guided  it  into  that  part  of  the  mass  it  was  desired  to 
puncture.  An  assistant  then  drew  the  piston,  while  the  opera¬ 
tor’s  right  hand  firmly  grasped  the  barrel  of  the  syringe,  thus 
steadying  it  and  the  needle.  The  armamentarium  consisted  of 
a  syringe  of  a  capacity  of  two  drachms  and  an  exploring  needle 
two  inches  and  three  quarters  long  from  shoulder  to  point.  The 
diameter  of  this  needle  must  not  exceed  No.  15  steel  wire 
gauge.  The  method  was  only  applied  when  a  full  and  entirely 
satisfactory  diagnosis  could  be  reached  without  it.  Abdominal 
exploratory  puncture,  guided  by  combined  vaginal  and  rectal 
touch,  as  compared  with  vaginal  puncture  or  with  abdominal 
puncture  as  usually  practiced,  possessed  the  same  supeiiority 
that  was  usually  conceded  to  bimanual  palpation  as  compared 
with  either  the  vaginal  touch  or  the  abdominal  touch  siDgly. 

He  had  practiced  the  method  in  over  seventy  cases  without 
the  least  untoward  result.  The  guarantees  of  safety  to  his  miud 
were :  (1)  Perfect  asepsis,  (2)  immobility  of  the  syringe  and 
needle,  and  (3)  resistance  of  the  temptation  to  bore  about  in  the 
tissues  with  the  needle. 

Iu  thirteen  out  of  fourteen  cases  in  which  he  had  removed 
the  appendages,  on  one  or  both  sides,  for  pyosalpinx  and  ova¬ 
rian  abscess,  single  or  combined,  he  had  been  able,  by  explora¬ 
tory  puncture  previous  to  operation,  to  prove  the  presence  of 
pus  and  the  futility  of  any  other  treatment  than  by  laparotomy. 
In  a  case  of  very  small  abscess  of  the  right  ovary,  with  normal 
tubes  and  left  ovary,  the  objective  signs  had  been  so  slight, 
almost  indiscernible,  that  he  would  have  refused  to  perform  a 
necessary  laparotomy,  if  exploratory  puncture  had  not  fortu¬ 
nately  revealed  pus.  In  a  case  in  which  aortic  stenosis  and  a 
small  tubo  ovarian  abscess  of  the  right  side  had  coexisted,  and 
the  patient  had  nearly  died  on  the  table  on  the  occasion  of  aD 
examination  under  chloroform,  he  would  have  emphatically 
declined  to  perform  laparotomy  unless  positively  assured  by 
exploratory  puncture  of  the  presence  of  pus. 

In  three  cases  of  hsematosalpinx — one  of  them  a  probable 
early  tubal  pregnancy — he  had  been  able  to  make  the  diagnosis  by 
exploratory  puncture,  and,  as  a  result,  to  avoid  three  unneces¬ 
sary  laparotomies.  In  a  case  of  tubal  pregnancy,  in  the  eighth 
or  ninth  week,  exploratory  puncture,  by  demonstrating  the 
presence  of  blood  free  in  the  peritoneal  cavity,  had  furnished 
positive  proof  that  rupture  had  taken  place,  the  diagnosis  being 
confirmed  by  abdominal  section. 

In  a  case  of  hydrosalpinx  or  small  cystoma  he  had  made  the 
diagno-is  by  exploratory  puncture  and  had  declined  to  perform 
laparotomy. 

In  one  ca*e  exploratory  puncture  had  confirmed  a  probable 
diagnosis  of  parovarian  cystoma. 

In  a  case  of  fibroma  uteri,  exploratory  puncture,  by  proving 
coexistent  disease  of  the  appendages,  had  decided  a  question  of 
practical  therapeutics,  the  choice  lying  between  electricity  and 
salpingo-oophorectomy. 

In  a  case  of  tubal  and  peritoneal  tuberculosis,  exploratory 
puncture  had  furnished  evidence  contributory  to  a  correct  diag¬ 
nosis. 


In  one  case  exploratory  puncture  had  enabled  him  to  diag¬ 
nosticate  the  carcinomatous  character  of  a  small  tumor  involv¬ 
ing  the  posterior  wall  of  the  caput  coli,  the  appendix  vermi- 
formis,  and  the  right  ovary. 

Exploratory  puncture  had  in  several  instances  taken  the 
place  of  an  exploratory  laparotomy  and  rendered  it  unneces¬ 
sary. 

In  conclusion,  he  would  add,  as  a  word  of  caution,  that  ex¬ 
ploratory  puncture,  guided  by  combined  vaginal  and  rectal  touch, 
as  here  delineated* aspired  to  the  dignity  of  a  somewhat  exact 
and  scientific  procedure.  A  sine  qua  non  of  its  safe  and  success¬ 
ful  employment  was  the  possession  of  a  fair  degree  of  skill  aDd 
experience  in  bimanual  palpation  of  the  female  pelvic  organs, 
lie  would  therefore  urge  that  the  method  be  attempted  only 
by  those  whose  tactile  sense  was  sufficiently  educated  by  daily 
practice  to  enable  them  to  apply  it  writh  the  greatest  probability 
of  attaining  good  and  of  avoiding  mischief. 

The  discussion  of  this  paper  was  postponed  till  the  next 
meeting  of  the  Section. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
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ings  will  be  inserted  when  they  are  received  in  time. 

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inserting  the  substance  of  such  communications. 

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All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  December  6,  1890. 


vertigo  and  syncope,  incapability  for  exertion,  weak,  rapid, 
irregular,  perhaps  intermittent  pulse,  oedema  more  or  less 
marked,  that,  together  with  the  physical  signs  obtained 


£*rtures  antr  ^bbresses. 


THERAPEUTIC  PRINCIPLES  GOVERNING 
THE  SELECTION  OF  CARDIAC  MEDICAMENTS. 

TWO  LECTURES  DELIVERED  IN  THE  COURSE  ON  THERA  1’EUTICS 
AT  THE  MEDICAL  DEPARTMENT  OF  DARTMOUTH  COLLEGE. 

October,  1890. 

By  SOLOMON  SOLIS-OOIIEN,  A.  M.,  M.  D., 

PROFESSOR  OF  CLINICAL  MEDICINE  AND  APPLIED  THERAPEUTICS, 
PHILADELPHIA  POLYCLINIC  ;  VISITING  PHYSICIAN  TO,  AND 
LECTURER  ON  CLINICAL  MEDICINE  AT,  THE  PHILADELPHIA  HOSPITAL.  ETC. 

Lecture  II. 

Gentlemen:  We  will  to-day  endeavor  to  apply  the 
knowledge  we  have  gained  of  the  principles  which  underlie 
the  mechanism  of  circulation,  and  of  the  relations  between 
circulation  and  other  functions,  together  with  the  knowl¬ 
edge  we  have  gained  of  the  pathological  conditions  which 
may  affect  the  circulatory  mechanism,  and  of  the  powers 
over  that  mechanism  possessed  by  therapeutic  agencies — 
we  will  to-day  endeavor  to  apply  this  knowledge  to  the 
study  of  the  proper  method  of  treatment  of  certain  chronic 
diseases  and  disorders  of  the  heart.  Our  limited  time  com¬ 
pels  us  to  cover  almost  too  much  ground  for  a  single  lect¬ 
ure,  while  it  likewise  forbids  elaborate  consideration  of  all 
the  topics  that  might  be  included  in  this  study.  We  must 
select  a  few  types  and  study  these  carefully.  The  princi¬ 
ples  thus  learned  will  be  easy  of  extended  application  in 
cases  fundamentally  related  with  these  types,  but  varying 
in  details. 

Here,  as  elsewhere,  our  therapeutic  diagnosis,  which 
must  be  based  on  comprehensive  clinical  diagnosis  and  on 
accurate  pathological  diagnosis ,  is  represented  by  a  triangle. 
The  base  line  is  a  definite  determination  of  what  we  are  to 
do;  the  second  side  is  a  definite  determination  of  how  we 
can  best  do  it ;  the  third  side  is  a  definite  determination  of 
where  the  remedy  may  be  best  applied,  so  that  the  what  and 
how  may  be  accomplished. 

These  three  lines  being  drawn,  the  included  surface 
represents  our  remedy,  and  we  must  find  agencies  to  fill  its 
measure.  But  dropping  metaphor,  which,  if  carried  too 
far,  becomes  unmanageable  and  misleading,  it  is  only  after 
we  have  reached  a  positive  determination  of  the  what  and 
the  hoiv  and  the  where  that  the  therapeutic  which  comes 
up  as  a  question  to  be  answered. 

In  other  words,  we  must  determine  what  properties 
ought  to  be  possessed  by  the  remedy  which  we  are  to  use 
before  we  can  intelligently  select  from  among  those  known 
to  us  the  agent,  measure,  or  combination  most  nearly  ful¬ 
filling  the  conditions. 

But,  as  the  concrete  may  be  grasped  more  readily  than 
the  abstract,  let  me  make  this  clearer  by  means  of  an 

example. 

Let  us  take  as  the  simplest  example  at  command  a  case 
of  simple  dilatation  of  the  heart  without  valvular  lesion. 
With  the  symptoms  of  this  condition  you  are  familiar.  In 
the  natural  order  of  studies  they  come  first.  It  was  the 
palpitation, ^dyspnoea,  coldness  of  extremities,  tendency  to 


upon  auscultation  and  percussion,  led  to  the  diagnosis.  Em¬ 
barrassment  of  circulation  due  to  an  incompetent  heart  was 
the  clinical  diagnosis.  Dilatation  without  valvular  lesion 
was  the  pathological  diagnosis.  Simple  dilatation,  it  is 
true,  is  very  rarely,  indeed  some  say  never,  encountered  at 
autopsies.  Still  it  is  a  condition  precedent  to  some  of  the 
lesions  ordinarily  found  post  mortem  ;  it  is  clinically  recog¬ 
nizable,  and  it  affords  the  best  foundation  for  our  studies. 
The  cause  of  the  morbid  condition  in  this  case  is  in  the 
background.  It  may  have  passed  away,  but  it  has  produced 
its  effect,  and  that  effect  is,  in  the  strict  use  of  words,  incur¬ 
able.  We  can  not  by  therapeutic  measures  restore  the 
heart  to  its  normal  size.  The  indications,  then,  are  to  pro¬ 
long  life  and  promote  comfort. 

Here  we  draw  the  base  line  of  our  triangle.  The  “  what 
to  do  ”  is  to  place  this  patient’s  permanently  damaged 
heart  in  such  relations  with  his  other  organs,  and  the  pa¬ 
tient  himself  in  such  relations  with  his  environment,  that 
life  may  go  on  as  long  as  possible  and  with  as  little  distress 
as  possible. 

The  “how  to  do  it”  is  the  next  point  to  be  deter¬ 
mined.  Evidently  there  are  two  complementary  indica¬ 
tions.  The  one  is  to  reduce  as  much  as  possible  the  work 
placed  upon  the  heart — indirect  restoration  of  equilibrium 
The  other — direct  restoration  of  equilibrium — is  to  strengthen 
the  heart  as  much  as  possible,  and  to  so  regulate  its  action 
as  to  get  the  best  possible  results  from  what  strength  it 
possesses;  in  other  words,  the  maximum  of  product  with 
the  least  expenditure  of  energy. 

Then  the  “where”  naturally  follows;  first  we  apply  our 
remedial  measures  to  the  organism  as  a  whole,  and  second¬ 
ly  to  the  heart. 

The  first  thing  to  be  done  is  to  place  the  patient  in  as 
favorable  a  condition  as  possible  in  relation  with  his  environ¬ 
ment.  We  must  reduce  the  activities  of  the  body  at  large 
to  the  level  of  the  impaired  power  of  the  heart,  and  there¬ 
fore  the  patient  must  not  be  allowed  to  pursue  a  laborious 
occupation,  or  one  which  may  make  sudden  demands  for 
extraordinary  exertion,  either  mental  or  physical.  He  must 
be  protected  from  shocks  and  emotional  disturbances  of  all 
kinds.  This  is  always  difficult  and  sometimes  impossible  of 
accomplishment.  Still  we  must  make  the  effort.  And  here 
a  very  delicate  problem  is  to  be  solved.  We  must  caution 
the  patient  against  undue  exertion  or  excitement,  but  must 
do  it  tactfully,  lest  we  ourselves,  by  the  manner  of  our  cau¬ 
tion,  cause  shock,  and  thus  steer  directly  upon  Charybdis 
while  warning  against  Scylla.  I  know  of  a  case  in  which 
the  physician’s  unguarded  announcement  of  “heart  dis¬ 
ease”  directly  accelerated  the  death  of  the  patient. 

According  to  the  degree  of  dilatation,  the  patient’s  so¬ 
cial  status  and  previous  habits  of  life,  and  the  extent  to 
which  untoward  symptoms  have  developed,  the  phvsician’s 
advice  as  to  occupation,  rest,  and  exercise  will  vary.  Ab¬ 
solute  rest  may  be  necessary  for  a  while,  if  there  be  acute 
or  severe  symptoms  of  embarrassment  of  circulation  or  res- 


S  0  LIS-  CO  HEN:  CARDIAC  MEDICAMENTS. 


[N.  Y.  Med.  Jock., 


618 

piration,  or  if  there  be  much  dropsy, 
a  certain  amount  of  exercise — active  or  passive,  or  both — 
is  necessary,  whenever  no  connterindication  exists.  It  is 
necessary  in  order  that  terminal  circulation  and  internal  res¬ 
piration  shall  be  kept  up,  in  order  that  the  products  of  waste 
shall  be  removed.  It  must  be  gentle  and  intermittent; 
never  allowed  to  become  fatiguing.  Walking  is  the  best 
form  of  active  exercise,  and  this  may  be  supplemented  by 
such  passive  exercise  as  the  simpler  and  gentler  forms  of 
massage — friction  and  stroking.  A  wealthy  patient  may  be 
told  to  take  short  walks  while  his  carriage  follows  him, 
with  instructions  to  enter  the  carriage  as  soon  as  he  has 
gone  the  prescribed  distance,  or  sooner,  should  he  feel  the 
slightest  indication  or  premonition  of  fatigue.  In  the  city, 
patients  who  do  not  have  carriages  should  walk  on  a  street  in 
which  there  is  a  car  track,  and  in  the  opposite  direction  to 
the  cars,  so  that  they  may  ride  home,  and  be  able  to  do  this 
at  any  moment.  Where  this  is  impracticable  the  walk  must 
be  so  divided  that  going  and  returning  shall  not  be  too 
much.  In  all  cases  the  distance  must  be  prescribed  and  not 
left  to  whim  ;  at  first  very  little — half  a  block,  in  the  city 

_ and  gradually  increased  to  whatever  maximum  may  be 

judged  to  be  proper.  This  maximum  must  always  be  a  lit¬ 
tle  short  of  what  is  deemed  to  be  the  limit  of  the  patient's 
ability.  It  is  always  well  if  a  walk  can  be  broken  by  inter¬ 
vals  of  sitting.  We  can  for  this  purpose  let  patients  ride 
to  a  park  or  square,  if  in  the  city,  so  that  in  the  square  they 
may  alternately  walk  for  little  whiles,  and  rest  for  little 
whiles  on  the  benches.  Massage  should  be  employed  as  an 
adjuvant  when  walking  is  possible,  and  as  a  substitute  for 
active  exercise  when  the  latter  is  impossible.  It  should  not 
be  practiced  more  than  fifteen  or  twenty  minutes  at  a  time, 
except  in  special  cases.  It  must  be  gently  and  skillfully 
done,  the  patient  being  in  the  recumbent  posture.  The 
lower  extremities  especially  should  be  manipulated.  As  far 
as  is  wise  in  any  individual  case,  the  effort  should  be  made 
to  act  upon  the  veins  directly,  so  as  to  impel  the  blood  cen- 
tripetally,  yet  not  in  too  great  a  volume  for  the  heart  to 
deal  with.  The  principles  set  forth  in  our  study  of  massage 
must  be  kept  in  mind.  Should  dropsy  be  present,  the  time 
and  manner  of  manipulation  would  be  governed  according¬ 
ly.  Electric  applications  are  of  service  in  some  cases  of 
dropsy,  but  the  consideration  of  this  measure  must  be  post¬ 
poned  until  we  have  studied  the  action  of  the  electric  cur¬ 
rent  more  in  detail. 

In  some  cases  the  patient  will  be  able  and  may  be  per¬ 
mitted  to  engage  in  some  light  occupation  which  itself  al¬ 
lows  opportunities  for  moderate  exercise,  alternating  with 
rest.  In  these  cases  no  special  walks  will  have  to  be  ad¬ 
vised  and  massage  may  not  be  needed.  It  is  necessary  to 
secure  for  all  patients,  however,  a  certain  amount  of  time  in 
the  open  air  every  fair  day,  during  which  they  may  sit,  ride, 
or  walk,  according  to  circumstances.  Where  a  sufficiency 
of  outing  can  not  be  obtained,  inhalations  of  oxygen  or  of 
compressed  air  may  be  administeied.  Oompiessed  air  is 
also  of  advantage  in  equalizing  the  circulation  by  its  me¬ 
chanical  pressure-effects.  This  subject,  however,  will  be 
considered  more  fully  in  another  connection. 

Still  treating  of  the  subject  of  environment,  the  effort 


should  be  made  to  occupy  the  patient’s  mind  in  a  pleasant 
manner,  so  as  to  keep  his  attention  from  his  symptoms  as 
far  as  advisable  or  possible.  All  of  his  senses  should  be 
agreeably  entertained,  without  undue  excitement.  The 
sense  of  taste  must  be  especially  consulted,  in  order  that 
small  amounts  of  the  best-chosen  foods  shall  be  found  sat¬ 
isfying.  In  the  matter  of  food  we  pass  from  extrinsic  har- 
rn o n y — harmony  with  environment — to  intrinsic  harmony 
— balance  of  function. 

The  first  effect  of  impaired  cardiac  power  is  deficient 
circulation.  As  we  have  lowered  the  general  muscular  and 
mental  activities — that  is,  exertions  in  relation  with  ex¬ 
ternal  environment — to  the  level  of  this  impaired  circula¬ 
tion,  so  must  we  lower  what  may  be  called  the  internal  ex¬ 
ertions  to  the  same  level. 

Beginning  our  consideration  of  these  with  the  digestive 
system,  it  is  obvious  thrt  we  must  reduce  the  amount  of 
work  placed  upon  it,  while  at  the  same  time  the  impover¬ 
ished  condition  of  the  heart-muscle  calls  for  the  best  pos¬ 
sible  nutrition.  And  not  only  must  we  endeavor  to  nour¬ 
ish  the  heart  itself,  but  we  must  remember  that,  as  a  further 
consequence  of  impaired  circulation  all  the  organs  and  tis¬ 
sues  have  suffered  in  two  ways — from  lack  of  proper  mate¬ 
rial  for  anabolism,  and  from  defective  removal  of  the  prod¬ 
ucts  of  catabolism.  The  blood  is,  to  a  greater  or  less 
degree,  stagnating  in  the  veins.  It  can  not  get  back  to  the 
lungs  to  be  purified.  So  that  the  comparatively  empty 
arteries  bring  little  new  material  for  upbuilding ;  the  over¬ 
filled  veins  retain  the  poisonous  products  of  the  breaking 
down  of  tissue.  Therefore,  while  diminishing  the  quantity 
of  food  ingested,  in  order  thus  to  diminish  the  work  of  the 
digestive  organs,  we  must  highly  increase  the  nutritive 
value  of  the  food  as  well  as  its  force-producing  value,  and, 
as  far  as  possible,  diminish  the  amount  of  waste  that  will 
be  left  to  deal  with.  Such  foods  then  are  to  be  chosen  as, 
in  our  study  of  the  subject  of  food,  were  found  to  fulfill  the 
indications  mentioned — milk,  oils  and  fats,  especially  but¬ 
ter,  a  moderate  amount  of  properly  prepared  meat,  eggs, 
fish,  rice,  grapes  and  certain  other  fruits  containing  sugar, 
malt  preparations,  alcohol  (malt  liquors,  sw’eet  wines,  and 
spirits)  in  moderation,  and  the  green  vegetables.  Potatoes 
and  other  bulky  foods  are  to  be  interdicted,  as  are  all  sorts 
of  indigestible  cookery.  Predigested  foods,  especially 
preparations  of  peptonized  beef,  and  such  combinations  of 
peptone  and  maltose  as  the  “  peptonized  milk-gruel,’’ arc 
of  great  service.  The  digestive  ferments  are  sometimes 
serviceable,  as  is  also  the  administration  of  dilute  acids, 
during  or  immediately  after  meals.  According  to  circum¬ 
stances,  food  may  be  taken  frequently  in  small  quantities, 
or  in  the  .ordinary  manner  of  three  stated  meals.  Asa 
rule,  a  glass  of  hot  milk  or  milk-punch  should  be  taken  at 
bed-time. 

Respiration,  being  the  “second  digestion,”  must  he 
properly  performed.  We  have  already  spoken  of  exercise 
and  of  inhalations  of  compressed  air  and  of  oxygen.  Solu¬ 
tion  of  hydrogen  dioxide  in  wrater  or  in  ether  (ozonic  ether) 
may  be  given  to  supplement  respiration  by  utilizing  the 
stomach  for  the  direct  introduction  of  ox_\gen  into  the  blood. 
The  so-called  “  fifteen-volume”  aqueous  solution,  properly 


On  the  other  hand, 


Dec.  6,  1890.J 


SOLIS- C 0I1EN :  CARDIAC  MEDICAMENTS. 


619 


diluted,  may  be  given  in  doses  of  from  one  to  four  fluid 
drachms.  The  ozonic  ether  may  be  given  in  doses  of  one 
fluid  drachm,  with  an  equal  quantity  of  glycerin,  in  enough 
water  to  make  a  tablespoonful.  These  agents  also  tend  to 
slow  and  strengthen  the  heart.  The  cardiac  medicaments, 
to  be  considered  later,  likewise  favorably  influence  the 
respiration. 

Extraordinary  attention  must  be  paid  to  the  excretions, 
not  only  for  the  reasons  already  and  sufficiently  dwelt  upon, 
but  also  to  prevent  dropsy  from  accumulation  of  fluids  in  the 
ill-nourished  veins — a  combination  of  circumstances  under 
which  transudation  is  most  likely  to  occur.  Fortunately, 
among  the  medicaments  most  appropriate  to  the  cardiac 
conditions  are  several  of  the  best  diuretics  and  diapho¬ 
retics.  In  addition  to  these,  the  consideration  of  which 
we  will  postpone  for  a  moment,  agents  acting  upon  the 
liver  and  the  intestines  must  be  employed,  continuously  or 
from  time  to  time,  as  indicated. 

Three  indications  are  to  be  fulfilled  by  cholagogue  and 
purgative  medication.  First,  we  avoid  increased  obstruc¬ 
tion  to  the  great  portal  circulation,  already  sufficiently  em¬ 
barrassed.  Secondly,  we  can,  by  the  use  of  suitable  agents, 
remove  from  the  circulation,  by  way  of  the  intestinal  ves¬ 
sels,  a  large  amount  of  fluid,  thus  diminishing  the  volume 
of  blood  to  meet  the  impaired  propulsive  power  of  the 
heart,  and  increasing  the  comparative  richness  of  the  blood 
in  corpuscular  elements.  In  cases  of  dropsy  we  actively 
resort  to  this  method  in  order  to  secure  re  absorption  of  the 
transuded  fluid  to  take  the  place  of  that  removed  by  way  of 
the  bowel ;  but  it  is  better  to  prevent  dropsy  by  continuous 
mild  purgation.  The  third  indication  is  that  of  removing 
waste  products,  the  importance  of  which  by  this  time  we 
fully  understand.  Sodium  phosphate,  cuonymin  and  simi¬ 
lar  resins,  rhubarb,  Epsom  salts,  Rochelle  salts,  various 
mineral  waters,  calomel,  and  jalap,  are  among  the  most  use¬ 
ful  agents,  the  choice  depending  upon  principles  already 
laid  down  in  discussing  cholagogue  and  purgative  medica¬ 
tion.  Calomel  and  Rochelle  salts  have  the  additional  use¬ 
fulness  of  a  certain  amount  of  diuretic  power.  It  is  espe¬ 
cially  in  cases  of  cardiac  impairment  that  the  diuretic  prop¬ 
erties  of  calomel  are  most  available. 

Remedies  to  improve  the  condition  of  the  blood  itself 
are  also  to  be  administered.  These  might  have  been  dis¬ 
cussed  in  connection  with  food,  but  perhaps  are  better  em¬ 
phasized  by  the  separation.  Of  these,  iron  stands  first; 
next  to  it  is  arsenic.  Chloride  of  gold  and  sodium,  bichlo¬ 
ride  of  mercury,  and  chloride  of  calcium  may  sometimes  be 
useful  for  short  periods  in  alternation  with  iron  or  arsenic. 
The  principles  which  apply  here  we  have  already  discussed 
in  our  study  of  the  blood.  Cod-liver  oil  stands  prominent¬ 
ly  forth  as  a  hydrocarbonaceous  food  and  a  blood-former 
of  great  utility.  Phosphorus  and  its  preparations,  more 
especially  the  hypophosphites,  may  in  some  cases  be  ad¬ 
vantageously  combined  with  the  cod-liver  oil.  Given  alone, 
they  are  of  little  use  in  the  class  of  cases  under  considera¬ 
tion. 

And  now,  having  placed  our  patient  in  harmony  with 
his  environment  ;  having  lowered  his  digestive  work  to  the 
capacity  of  his  circulation,  and  improved  both  the  digestive 


product  and  the  blood  itself  in  accordance  with  the  needs 
of  the  impoverished  tissues;  having  done  what  we  could  to 
improve  respiration  so  far  as  it  can  be  improved  independ¬ 
ently  of  circulation  ;  and  having  duly  attended  to  the  ex¬ 
cretions — we  can  devote  our  attention  to  the  organ  which  is 
itself  at  fault. 

The  first  lesson  to  be  drawn  from  the  considerations 
thus  far  passed  in  review  is  this  :  That  the  diseased  organ 
is  not  the  only  organ  to  be  treated,  and  not  always  the 
first;  and  that  direct  treatment  is  not  always  the  first  or 
the  best.  It  is  very  probable  that  the  measures  already 
adopted  will  so  far  have  improved  the  heart  by  their  indi¬ 
rect  influence  as  to  considerably  modify  the  indications  for 
direct  cardiac  remedies. 

While  this  is  the  preferable  method  of  procedure,  yet 
there  is  another  side  to  the  question.  It  may  be  that,  on 
account  of  the  patient’s  necessities  or  the  demands  of  his 
business,  our  advice  as  to  rest  and  regulated  exercise  can 
not  be  carried  out.  Remember,  this  is  the  best  advice.  It 
is  our  duty  to  place  before  the  patient  the  danger  of  neg¬ 
lecting  it.  Still  it  may  be  impossible  to  follow  it.  Then 
we  must  modify  it  to  the  exigencies  of  the  occasion,  and 
the  choice  of  a  remedy  to  act  directly  upon  the  heart  will 
come  up  at  once. 

In  the  case  supposed  of  simple  dilatation  without  valvu¬ 
lar  lesion,  the  indication  is  “  to  empty  the  veins  and  fill  the 
arteries”  ;  and  the  best  agent  at  our  command  is  digitalis. 
The  best  preparation  of  this  drug  to  use  in  the  case  sup¬ 
posed  is  the  powder  of  the  leaves,  which  may  be  made  into 
pill  and  given  in  the  dose  of  from  one  fourth  of  a  grain  to 
one  grain  or  more,  three  times  a  day.  The  tincture  may 
be  employed  in  doses  of  from  two  to  five  drops  or  more, 
three  times  a  day.  Where  a  diuretic  effect  is  specially  de¬ 
sired  the  infusion  is  sometimes  to  be  preferred  in  doses  of 
half  a  fluidounce,  night  and  morning. 

By  prolonging  the  diastole,  digitalis  increases  the  pe¬ 
riod  of  comparative  rest ;  of  anabolism.  It  gives  opportu¬ 
nity  for  increased  nourishment  of  the  muscular  tissue.  It 
gives  opportunity  for  an  increased  accumulation  of  energy 
to  be  later  discharged  in  the  systole.  And  by  increasing 
the  force  of  the  systole  it  compensates  for  a  certain  part  of 
the  lost  original  vigor  of  the  heart.  By  slowing  the  circu¬ 
lation,  it  diminishes  the  relative  expenditure  of  energy  in  a 
given  time.  By  its  action  upon  the  kidney,  it  increases  the 
excretion  of  urine — both  tbe  watery  and  the  solid  constitu¬ 
ents. 

It  may,  however,  have  one  untoward  effect.  It  height¬ 
ens  blood-pressure  by  causing  contraction  of  the  arterioles, 
and  thus  to  a  certain  extent  opposes  the  cardiac  contrac¬ 
tion.  Should  this  action  be  too  pronounced,  we  can  over¬ 
come  it  by  the  simultaneous  administration  of  nitroglycerin, 
or  other  nitrite,  as  already  explained.  The  nitrites,  by  di¬ 
lating  the  vessels,  and  especially  the  peripheral  vessels,  in¬ 
vite  the  blood  into  the  capillary  circulation,  and  take  off 
from  the  heart  a  great  portion  of  its  labor.  As  a  matter  of 
course,  they  must  be  cautiously  employed,  the  smallest  dose 
(one  one-hundredth  of  a  minim  or  less  of  nitroglycerin, 
three  times  a  day)  being  given  at  first,  and  the  quantity 
I  gradually  increased  until  the  desired  effect  is  produced.  Tn 


320 


SOLIS-  GO  HEN  :  CARDIAC  MEDICAMENTS. 


[N.  Y.  Mud.  Jour., 


some  cases  nitroglycerin  or  nitrite  of  sodium  may  be  given 
alone.  The  labor  of  the  heart  being  thus  diminished  and 
its  tone  having  been  improved  by  nutritive  measures,  the 
administration  of  digitalis  will  not  be  necessary.  This  ex¬ 
pedient  is  paiticularly  useful  in  the  treatment  of  fatty  heart, 
in  which  digitalis,  as  we  have  previously  seen,  is,  as  a  rule, 
counterindicated.  In  these  cases  arsenic  and  strychnine 
are  extremely  useful  agents. 

But  to  return  to  digitalis,  we  must  remember  what  was 
emphasized  in  our  special  study  of  that  drug — that  no  sud¬ 
den  change  of  posture  is  to  be  permitted  during  its  admin¬ 
istration.  Especially  dangerous  is  the  change  from  recum¬ 
bency  to  the  erect  posture.  We  must  also  avoid  the  risk 
of  producing  a  cumulative  effect — the  nature  and  causes  of 
which  we  have  previously  studied — and  the  best,  as  it  is  the 
most  obvious,  method  to  avoid  this  danger  is  the  routine 
intermission  of  the  use  of  the  drug  at  intervals  to  be  deter¬ 
mined  by  all  the  circumstances  of  the  individual  case. 

But  what  are  we  to  substitute  for  digitalis  during  these 
periods  of  intermission,  or  in  those  cases  in  which  it  is  not 
well  borne,  though  apparently  indicated  ?  Of  single  agents, 
my  own  experience  leads  me  to  prefer  strophanthus.  Con- 
vallaria  and  adonis  vernalis,  or  their  active  principles,  and 
sparteine,  a  principle  derived  from  scoparius,  are  also  use¬ 
ful,  and  by  some  authors  preferred.  Better  sometimes  than 
any  single  agent  is  the  combination  of  caffeine  or  cocaine 
with  strychnine.  Before  discussing  the  other  agents,  then, 
let  us  briefly  recall  our  knowledge  of  the  action  of  caffeine 
and  of  that  of  strychnine,  and  see  why  it  is  that  this  com¬ 
bination  is  of  such  great  utility.  Strychnine,  in  the  first 
place,  is  a  general  tonic,  improving  digestion  and  increas¬ 
ing  the  capacity  of  .the  individual  for  physical  and  mental 
exertion.  In  addition  to  this,  it  has  distinct  usefulness  as 
an  agent  acting  upon  circulation  and  respiration.  It  affects 
the  centers  of  organic  life,  heightening  their  impressiona¬ 
bility  and  increasing  the  energy  of  their  discharge.  It 
thus  acts  by  central  influence  as  a  stimulant  to  the  heart 
and  to  the  respiratory  muscles.  But  it  also  acts  periphe¬ 
rally  upon  the  motor  ganglia  of  the  heart,  directly  stimulat¬ 
ing  and  heightening  the  energy  of  their  discharge.  It  also 
acts  upon  the  muscular  tissue  itself,  increasing  the  vigor  of 
contraction,  a  fact  of  which  we  have  abundant  clinical  evi¬ 
dence  as  to  man,  w  hatever  may  be  the  laboratory  evidence 
as  to  animals.  It  is  thus  a  catabolic  agent;  but  the  ca¬ 
tabolism  which  it  produces  is  an  effective  catabolism,  giving 
the  highest  force-product  with  the  least  degree  of  waste. 
It  has  some  tendency  to  heighten  peripheral  blood-pressure 
by  contracting  the  vessels,  but  this  is  not  always  marked. 

Caffeine ,  or  perhaps  we  ought  to  say  the  article  of  com¬ 
merce  sold  under  the  name  of  caffeine,  but  which,  as  Mayo 
has  shown,  is  in  reality  a  mixture  of  caffeine  and  theinc — 
so-called  caffeine,  then,  acts  to  some  extent  upon  the  nerv¬ 
ous  supply  of  the  heart,  but  its  chief  action  is  upon  the 
heart  muscle.  It  increases  very  greatly  the  vigor  of  the 
systolic  contractions  and  diminishes  their  frequency.  It 
improves  respiration  both  by  directly  strengthening  the 
respiratory  muscles,  and  indirectly  by  its  action  upon  the 
circulation.  It  is  a  diuretic  of  no  mean  power.  Like  digi¬ 
talis,  caffeine  raises  the  arterial  tension,  but  in  the  case  of 


caffeine  this  effect  is  not  so  likelv  to  be  excessive  as  it  is  in 
the  case  of  digitalis;  so  that  the  conjoint  use  of  the  nitrites 
is  not  often  necessary.  A  moderate  elevation  of  arterial 
tension,  if  well  distributed,  is  beneficial,  as  it  secures  a 
better  distribution  of  the  blood.  In  order  to  get  the  full 
benefit  from  caffeine  it  must  be  used  in  fairly  large  doses — 
five  grains  three  times  a  day,  for  example.  With  this, 
from  one  sixtieth  to  one  thirtieth  of  a  grain  of  a  strychnine 
salt  may  be  combined.  AVhere  in  an  individual  case,  for 
any  reason,  a  more  rapid  effect  is  desired  than  caffeine  usu¬ 
ally  gives,  we  may  have  recourse  to  cocaine,  which  may  be 
given  per  on  in  doses  of  from  one  eighth  to  one  half  of  a 
grain,  or  hypodermically  in  doses  not  exceeding  one  fourth 
of  a  grain.  For  prolonged  administration,  however,  caffeine 
is  to  be  preferred.  Where  neither  caffeine  nor  its  combina¬ 
tion  with  strychnine  seems  to  be  sufficiently  stimulating — 
that  is  to  say,  where,  despite  the  increased  vigor  of  the  car¬ 
diac  contraction,  it  seems  not  to  be  sufficiently  free — a 
minute  dose  of  cocaine,  say  one  sixteenth  of  a  grain,  may 
be  advantageously  combined  with  the  other  agents  for  con¬ 
tinuous  use  for  short  periods,  say  a  week  or  two  at  a  time. 
In  some  cases,  instead  of  adding  cocaine  to  the  pill,  a  good 
wine  of  coca  may  be  given  as  a  beverage  in  appropriate 
doses.  The  patient  should  also  be  advised,  even  while  tak¬ 
ing  digitalis,  to  drink  a  cup  of  strong  coffee  at  each  meal 
and  before  going  to  bed.  In  a  few  cases  of  moderate  im¬ 
pairment  of  cardiac  vigor  the  drinking  of  strong  coffee  has 
sufficed  to  keep  the  patient  comfortable,  without  resort  to 
digitalis  or  other  drug. 

Now  a  few  words  as  to  strophanthus ,  which,  as  already 
said,  I  esteem  more  highly  than  any  other  agent  yet 
brought  forward  to  replace  or  supersede  digitalis.  This 
drug  is  not  yet  official,  and  it  is  difficult  to  get  a  reliable 
preparation.  The  tincture  prepared  according  to  the  di¬ 
rections  of  Fraser,  of  Edinburgh,  is  the  best.  It  may  be 
given  in  doses  of  from  one  minim  to  ten,  or  in  some  cases, 
with  due  caution,  even  twenty  minims,  three  times  a  day ; 
or  a  large  dose  may  be  given  at  first  and  the  impression 
maintained  by  small  doses  at  shorter  intervals.  The  dura¬ 
tion  of  its  effect  gives  to  it  much  of  its  great  usefulness. 
Its  effects  are  similar  to  those  of  digitalis,  in  that  it  slows 
the  rate  of  the  heart,  lengthens  the  interval  between  the 
contractions,  and  increases  the  vigor  of  the  muscular  ac¬ 
tion.  This  is  thought  to  be  due  to  direct  action  on  the 
muscle  substance,  and  not  to  any  effect  upon  the  nervous 
system.  By  its  action  on  the  heart  it  raises  blood-pressure, 
producing  diuresis.  It  does  not,  however,  markedly  con¬ 
tract  the  arterioles  as  does  digitalis,  and  therefore  com¬ 
pensatory  use  of  the  nitrites  is  not  necessary.  It  does  not 
disturb  the  digestive  tract.  A  patient  now  under  my  care, 
in  whom  cardiac  weakness  is  part  of  a  general  muscular 
and  nervous  degeneration,  takes  tincture  of  strophanthus 
and  tincture  of  digitalis  alternately  and  coincidently  in  the 
following  manner:  Having  taken  thrice  daily  for  a  week 
ten  drops  of  the  tincture  of  digitalis,  he  begins  to  diminish 
the  quantity,  substituting  in  each  dose  the  first  day  a  drop 
of  the  tincture  of  strophanthus  for  a  drop  of  the  tincture  of 
digitalis.  The  second  day  two  drops,  the  third  day  three 
drops  are  substituted;  and  thus  during  ten  days  the  digi- 


Dec.  6,  1890.J 


SOL  IS-  COHEN :  CARDIAC  MEDICAMENTS. 


6*21 


talis  is  diminished  and  the  strophanthus  increased  pari 
passu,  until  finally  the  patient  is  taking  ten  drops  of  tinct¬ 
ure  of  strophanthus  and  no  digitalis.  After  a  week  of  stro¬ 
phanthus  he  begins  to  substitute  for  it  the  digitalis,  a  drop 
at  a  time,  reversing  the  previous  process.  This  expedient 
has  been  found  preferable  in  this  particular  case  to  either 
the  uninterrupted  continuance  of  either  drug  or  an  abrupt 
change  from  one  to  the  other. 

Strophantin,  a  glucoside  derived  from  strophanthus,  is 
given  in  doses  of  from  to  of  a  grain  hypodermic¬ 
ally,  repeated  at  long  intervals,  perhaps  of  many  days,  as 
the  effect  is  said  to  be  quite  prolonged.  I  have  not  yet  ac¬ 
quired  sufficient  personal  experience  with  the  use  of  the 
glucoside  to  speak  positively  concerning  it. 

Convallaria  and  its  glucoside,  convallamarin,  have  re¬ 
ceived  high  encomiums  from  See  and  other  authorities; 
but,  as  I  stated  when  considering  this  drug,  neither  clini¬ 
cal  experience  nor  laboratory  studies  warrant  a  decided 
expression  of  opinion  in  its  favor.  In  some  cases  it  is 
highly  useful  as  a  substitute  for  digitalis,  but  it  frequently 
disappoints  us.  Its  properties  as  a  diuretic  are  more  con¬ 
stant  than  its  power  over  the  heart.  It  may  be  that  the 
uncertainty  and  disappointment  I  have  experienced  in  the 
use  of  this  drug  are  to  be  ascribed  to  imperfect  preparations 
rather  than  to  the  drug  itself. 

Adonis  vernalis  and  its  glucoside,  adonidin,  have  been 
found  useful  by  so  eminent  a  clinician  and  careful  observer 
as  Da  Costa.  My  own  experience  with  this  drug  is  very 
limited,  but  is  satisfactory  as  far  as  it  has  gone.  It  is 
similar  in  its  action  to  digitalis  both  in  its  effects  upon  the 
heart  and  vessels  and  its  diuretic  properties ;  but  is  much 
more  powerful,  and  its  use  is  said  not  to  be  attended  with 
risk  of  cumulative  action.  At  present  it  is  employed 
chiefly  as  an  adjuvant  to  digitalis  or  a  temporary  substitute 
therefor,  though  it  is  said  to  succeed  sometimes  when 
digitalis  fails.  According  to  some  authorities  it  is  even 
more  likely  than  is  digitalis  to  produce  symptoms  of  gas¬ 
trointestinal  irritation  (nausea,  vomiting,  and  purgation). 
There  is  no  official  preparation  of  adonis.  An  infusion 
is  made  (one  half  to  two  drachms  of  the  root  to  six  fluid- 
ounces  of  water),  of  which  the  dose  is  half  a  fluidounce 
every  two  to  four  hours.  Adonidin  is  given  in  doses 
of  from  an  eighth  of  a  grain  to  half  a  grain,  repeated  as 
necessary. 

Sparteine,  derived,  you  will  remember,  from  broom, 
may  be  given  (as  sparteine  sulphate )  in  doses  of  from  one 
sixteenth  of  a  grain  to  three  or  four  grains,  the  ordinary 
range  being  from  half  a  grain  to  two  grains.  It  has  re¬ 
ceived  high  encomiums  both  from  experimenters  and  clini¬ 
cians,  and  is  recommended  in  the  warmest  terms  by  so 
practical  an  observer  as  Bartholow.  Nevertheless,  I  must 
confess  to  my  own  frequent  disappointment  in  its  use,  per¬ 
haps  because  I  have  not  yet  mastered  the  art  of  adminis¬ 
tering  it.  There  is  undoubtedly  much  in  the  art  of  admin¬ 
istering  remedies.  As  two  painters  will  produce  different 
effects  with  the  same  pigments — the  inimitable  glow  of 
Turner’s  Venetian  scenes,  or  the  blush  of  shame  that  o’er- 
spreads  the  skies  of  his  copyists — so  may  two  therapeutists 
produce  different  effects  with  the  same  drugs  differently 


applied.  I  have,  however,  in  some  cases,  found  sparteine 
fully  equal  to  my  expectations.  In  these  its  most  marked 
properties  were  a  comparatively  rapid  action  and  a  regulat¬ 
ing  power — that  is,  a  power  to  render  steady  and  continuous 
the  previously  unsteady  and  intermittent  heart-beats — even 
superior  to  that  of  digitalis.  In  these  cases  the  drug  was 
given  in  small  doses,  repeated  four  or  five  times  during  the 
twenty-four  hours.  They  were  not,  however,  cases  of  sim¬ 
ple  dilatation  such  as  we  are  now  discussing,  so  that  per¬ 
haps  the  conclusion  is  justifiable  that  the  peculiar  virtues  of 
this  drug  are  better  applicable  to  the  relief  of  those  disor¬ 
dered  conditions  of  innervation  and  muscular  action  which 
are  manifest  in  the  more  advanced  stages  of  valvular  lesions. 
When  effective,  the  action  of  the  drug  continues  for  twelve 
or  twenty-four  hours,  and,  according  to  some  authorities, 
even  longer.  Sparteine  has  considerable  diuretic  power, 
though,  as  a  diuretic  simply,  it  is,  in  my  experience,  inferior 
to  the  infusion  of  broom.  There  is,  however,  this  drawback 
to  the  use  of  bulky  infusions  in  the  treatment  of  cardiac 
disease — that  the  quantity  of  fluid  ingested  is  likely  to  be 
disadvantageous. 

Erythrophloeum  is  a  drug  which  may  eventually  be  found 
useful  in  the  treatment  of  weak  hearts;  at  present  its  use 
is  almost  exclusively  confined  to  the  laboratories. 

Barium  chloride  has  a  limited  degree  of  applicability, 
and  I  have  had  a  few  satisfactory  results  from  its  employ¬ 
ment,  more  especially  in  the  treatment  of  the  overacting 
heart  and  relaxed  vessels  of  exophthalmic  goitre,  but,  as  was 
stated  in  discussing  this  agent,  I  can  not  advise  you  to  re¬ 
sort  to  it  until  greater  experience  has  been  accumulated  as 
to  its  exact  range  of  usefulness. 

We  are  now  perhaps  in  a  better  position  to  illustrate 
by  a  further  refinement  the  extended  application  of  our 
therapeutic  triangle,  ivhat,  how,  and  where.  As  we  used  it 
in  solving  the  main  problem  of  the  line  of  treatment,  so 
we  can,  indeed  must,  however  unconsciously,  use  it  in 
solving  special  problems  as  to  details  of  treatment.  In  the 
selection  of  a  drug  to  act  upon  the  heart  we  can  choose  one 
which  affects  principally  the  nerves,  or  one  which  affects 
principally  the  muscles,  or  one  which  acts  upon  both.  Or, 
again,  in  its  action  upon  the  nerves  a  drug  may  slow  the 
heart  by  depressing  the  motor  apparatus — cerebral,  periph¬ 
eral,  or  communicating  ;  or  it  may  slow  the  heart  by  stimu¬ 
lating  the  inhibition  apparatus — central,  peripheral,  or  com¬ 
municating.  In  Brunton’s  most  admirable  treatise,  to 
which  I  again  acknowledge  my  own  great  indebtedness, 
you  will  find  suggestive  data  for  the  study  of  this  phase  of 
the  subject.  That  which  makes  digitalis  preferable  in  most 
cases  to  all  the  other  drugs  mentioned  is  the  fact  that  it 
acts  both  on  nerves  and  on  muscle,  both  on  inhibitory  and 
motor  apparatus,  and  that  the  result  of  this  combined  action 
is  to  slow  and  strengthen  the  heart,  by  a  stimulating  effect 
throughout,  without  depression  of  any  kind.  For  the  same 
reason  the  combination  of  caffeine  and  strychnine  is  useful. 
It  is  true  that  in  studying  digitalis  we  classed  it  among 
the  cardiac  sedatives  as  well  as  among  cardiac  tonics.  But, 
as  I  then  stated,  its  sedative  power  is  the  sedative  power 
of  strength;  the  irritation  which  it  calms  is  either  the 
irritation  of  weakness  or  the  irritation  of  loss  of  con- 


622 


80LIS-C0HEN :  CARDIAC  MEDICAMENTS. 


[N.  Y.  Med.  Jotjb., 


trol.  Wood’s  article  may  profitably  be  consulted  on  this 
topic. 

When  sedation  is  required  for  a  heart  which  is  acting 
too  rapidly  or  too  powerfully,  because  it  is  too  strong,  digi¬ 
talis  is  not  an  appropriate  sedative.  If  I  ask  the  class  to 
mention  the  drug  which,  above  all  others,  should  be  used 
to  quiet  an  hypertrophied  heart,  you  answer  “  aconite .” 

In  our  study  of  aconite  we  recognized  in  it  a  depressant 
ah  initio.  Digitalis,  if  pushed  too  far,  may  paralyze  by  ex¬ 
haustion.  But  aconite  is  a  paralyzing  agent  from  the  first. 
It  depresses  nervous  function  without  much  interference 
with  muscular  power  per  se.  While  it  is  true  that  experi¬ 
ments  on  normal  animals  have  not  revealed  any  such  prop¬ 
erty,  I  feel  warranted  in  saying  that  its  prolonged  adminis¬ 
tration,  in  perfectly  safe  medicinal  doses,  seems,  clinically, 
to  cause  a  certain  degree  of  retrograde  metamorphosis  in 
hypertrophied  heart-muscles,  probably  by  influence  on 
trophic  nerves,  or,  in  other  words,  by  interference  with 
anabolism.  Its  peculiar  field  of  usefulness  is  in  cases  where 
we  wish  to  reduce  power,  and  hypertrophy  without  valvular 
lesion  may  serve  as  a  type  of  these  cases. 

In  a  case  of  eccentric  hypertrophy  due,  we  will  say — as 
in  the  case  ot  a  blacksmith  I  have  in  mind — to  excessive 
muscular  exertion,  the  what ,  how ,  and  where  are  self-evident. 

We  can  not  materially  alter  the  condition  of  the  heart- 
muscle.  WTe  must  avert  evil  consequences  by  regulation  of 
the  patient’s  life  and  by  the  use  of  agents  to  diminish  the 
force  of  the  heart’s  action.  Now,  regulation  of  the  patient’s 
life  does  not  imply  that  we  are  to  increase  his  exercise  up 
to  the  level  of  his  heart’s  overaction.  If  we  could  by  so 
doing  increase  the  size  of  all  his  organs,  including  the  skele- 
ton,  proportionately  in  other  words,  if,  having  a  gigantic 
heart  to  deal  with,  we  could,  by  prescribing  giant’s  work, 
transform  the  patient  into  a  Goliath— that  would  be  the 
proper  line  of  treatment;  but  this  is  manifestly  impossible. 
Even  the  heart  itself  is  not  the  subject  of  regular  and  pro¬ 
portionate  enlargement;  the  left  ventricle,  in  the  case  we 
are  considering,  being  disproportionately  increased  both  in 
capacity  and  in  the  thickness  of  its  walls.  AVe  must,  there¬ 
fore,  paradoxical  as  it  seems,  prescribe  rest.  It  is  not  ne¬ 
cessary  in  the  ordinary  case— that  of  the  blacksmith  whom 
I  have  mentioned,  or  that  of  athletes,  a  class  of  men  who 
frequently  suffer  from  a  similar  condition — to  prescribe 
absolute  rest  in  bed,  except  in  the  presence  of  urgent  symp¬ 
toms.  We  must,  however,  at  once  interdict  the  overexer¬ 
tion  which  has  brought  about  the  morbid  condition.  Fur¬ 
thermore,  while  permitting  sensible  exercise,  we  must  not 
allow  it  to  be  too  prolonged  ;  and  all  sudden  or  violent 
exertion  must  be  absolutely  prohibited.  Alcohol,  tobacco, 
immoderate  eating,  and  mental  excitement  must  be  avoided. 
To  prevent  straining  at  stool,  the  diet  must  contain  laxative 
elements,  and  an  occasional  mild  purge  be  exhibited.  All 
conditions  which  tend  to  disturb  the  circulation,  particular¬ 
ly  in  the  abdomen  and  in  the  lungs,  must  be  guarded 
against. 

The  quantity  of  fluid  taken  into  the  stomach  should  be 
limited.  In  the  presence  of  symptoms  of  cerebral  hyper- 
aemia  a  hydragogue  cathartic  may  be  used  to  unload  the 
vessels.  A  blister  may  be  applied  to  the  nape  of  the  neck, 


and  wet  cupping  of  the  chest,  or  even  venesection,  may  be 
performed  in  urgent  cases.  As  a  rule,  however,  rest  and 
the  administration  of  aconite  will  avoid  necessity  for  bleed¬ 
ing.  The  dose  of  the  tincture  of  aconite  root  will  vary  from 
one  to  five  drops,  which  may  be  given  three  times  a  day  or 
at  intervals  of  two  or  three  hours  according  to  circum¬ 
stances.  Sometimes  it  is  well  to  begin  with  larger  doses, 
and  as  the  influence  of  the  drug  becomes  manifest  to  dimin¬ 
ish  the  dose  to  as  little  as  will  keep  up  the  effect.  Very 
often  one  drop  twice  a  day  will  be  efficient.  In  some  cases, 
however,  comparatively  large  doses  will  need  to  be  contin¬ 
ued,  or  at  all  events  to  be  resorted  to,  from  time  to  time, 
for  five  or  six  days  together.  Diluted  hydrocyanic  acid 
in  doses  of  from  two  to  five  drops,  diluted  hydrobromic 
acid  in  doses  of  from  ten  to  thirty  minims,  potassium  bro¬ 
mide  in  doses  of  from  ten  to  thirty  grains,  potassium  iodide 
or  sodium  iodide  in  doses  of  from  five  to  ten  grains,  may  be 
used  as  adjuvants  to  the  aconite,  or  in  its  place.  Belladonna 
has  been  recommended.  I  have  no  experience  in  its  use  in 
this  connection,  for  to  my  mind  it  seems  connterindicated, 
its  action,  as  we  have  seen,  being  both  to  increase  the  ra¬ 
pidity  and  the  vigor  of  the  heart’s  action  and  to  raise  the 
arterial  tension,  except  when  the  opposite  effect  results  from 
paralysis  by  exhaustion  due  to  large  doses. 

There  is,  however,  one  condition  of  overaction  of  the 
heart  in  which  belladonna  is  of  considerable  service — 
namely,  in  the  irritable,  irregular,  and  feebly  overacting 
heart  of  some  cases  of  tobacco  poisoning.  In  this  condi¬ 
tion  the  combination  of  belladonna  (which  is  in  these  cases 
preferable,  by  reason  of  its  antispasmodic  properties,  to  its 
alkaloid,  atropine)  with  strychnine,  digitalis,  or  caffeine  has 
in  my  hands  proved  useful. 

The  difference  between  this  condition  and  the  condi¬ 
tion  of  excessive  strength  we  have  been  considering  is  at 
once  rendered  evident  by  the  fact  that  digitalis  has  been 
enumerated  as  among  the  agents  usefully  combined  with 
the  atropine.  Diluted  hydrocyanic  acid,  cimicifuga,  musk, 
the  bromides,  and  especially  monobromated  camphor,  often 
act  beneficially  in  this  disorder.  Sodium  iodide  in  small 
doses  is  also  useful. 

Having  firmly  fixed  in  our  minds,  then,  the  principles 
which  should  guide  us,  and  the  measures  which  may  be 
most  usefully  applied  in  the  treatment  of  dilatation  with 
weakness,  and  hypertrophy  with  excessive  power,  apart 
from  valvular  lesion,  and  having  briefly  alluded  to  the 
pseudo-hypertrophy  of  irritation  by  tobacco,  we  have  now 
to  consider  how  our  treatment  is  to  be  modified  when  either 
of  these  conditions  coexists  with  a  valvular  lesion.  AVe 
can  do  this  more  briefly  on  account  of  the  wide  range 
which  our  previous  studies  have  taken.  It  will  be  self- 
evident  that  where  hypertrophy  coexists  with  a  valvular 
lesion,  being  itself  not  alone  the  physical  result  of  that  valv¬ 
ular  lesion,  but  also  Nature’s  “spontaneous  healing,”  in 
the  sense  in  which  we  have  agreed  to  use  this  term,  it  will 
be  self-evident  that  where  such  hypertrophy  is  in  degree 
merely  enough  to  compensate  for  the  damaged  condition 
of  the  valve  there  is  no  occasion  for  therapeutic  interfer¬ 
ence.  Conversely,  when  a  valvular  lesion  has  been  thus 
compensated  bv  hypertrophy,  the  condition  of  the  valve 


SOLIS-COHEN:  CARDIAC  MEDICAMENTS. 


623 


Dec.  6,  1890.J 

affords  no  indication  for  therapeutic  interference.  Should 
the  hypertrophy  be  excessive — that  is,  more  than  sufficient 
for  compensation — just  in  the  degree  that  excess  exists 
will  such  excess  afford  indication  for  treatment  with  aconite 
or  a  bromine  salt,  or  both.  In  the  majority  of  cases,  how¬ 
ever,  even  when  the  lesion — for  example,  mitral  regurgita¬ 
tion — is  compensated  by  ventricular  hypertrophy,  it  is 
necessary  to  adopt,  to  some  extent,  the  hygienic  measures 
which  we  discussed  at  length  in  the  case  of  simple  dilata¬ 
tion,  for  the  hypertrophy  which  balances  mitral  regurgita¬ 
tion  is  to  be  looked  upon  as  potentially  a  condition  of  dila¬ 
tation.  It  becomes  actual  dilatation  when  it  no  longer 
suffices  to  overcome  the  obstruction  to  circulation  brought 
about  by  the  regurgitation.  This  is  called  rupture  of  com¬ 
pensation ;,  and  the  treatment  then  is  almost  exactly  that  of 
dilatation,  both  hygienically  and  medicinally.  In  other 
words,  in  cases  of  mitral  regurgitation  the  main  indication 
for  treatment  is  afforded  not  by  the  condition  of  the  valve, 
but  by  the  condition  of  the  muscle  relatively  to  the  valve. 
Clinically,  the  rational  symptoms — that  is  to  say,  the  con¬ 
dition  of  the  circulation  and  respiration,  the  presence  or 
absence  of  dropsies — are  the  data  upon  which  we  base  our 
opinion  as  to  whether  or  not  compensation  exists. 

Somewhat  different  indications  are  afforded  by  aortic 
stenosis,  for  here  not  alone  the  condition  of  the  muscle,  but 
that  of  the  valve  itself  must  be  considered  when  the  selec¬ 
tion  of  medicaments  becomes  necessary — that  is  to  say,  when 
compensation  has  been  ruptured.  For  example,  we  can 
not  resort  to  digitalis  to  strengthen  the  muscle,  as  we  would 
in  a  case  of  mitral  regurgitation  with  ruptured  compensa¬ 
tion,  on  the  principle  that  the  condition  is  practically  a 
condition  of  excessive  dilatation.  Digitalis,  as  we  have 
seen,  raises  peripheral  blood-pressure,  and  would  thus  co¬ 
operate  with  the  obstruction  at  the  aortic  orifice  in  oppos¬ 
ing  exit  of  blood  from  the  ventricle.  By  lengthening  the 
diastole,  it  would  permit  a  quantity  of  blood  to  enter  the 
ventricle  beyond  the  capacity  of  the  ventricle  to  empty 
itself,  thus  increasing  the  embarrassment.  If  regurgitation 
coexists  with  the  stenosis,  as  is  usually  the  case,  the  length¬ 
ening  of  the  diastole  would  also  permit  a  greater  reflux 
from  the  aorta  into  the  ventricle.  The  net  result,  then,  of 
the  action  of  digitalis  in  aortic  stenosis  would  be  to  over- 
fill  the  ventricle,  and  any  increase  of  power  of  contraction 
which  it  would  give  might  tend  to  drive  the  blood  back¬ 
ward  through  the  mitral  orifice,  rather  than  forward  through 
the  obstructed  aortic  orifice  ;  for  it  would  be  quite  possi¬ 
ble  for  the  gradual  increase  in  the  size  of  the  heart,  which 
has  been  brought  about  by  the  lesion,  to  have  rendered 
even  an  intact  mitral  valve  relatively  incompetent  and  not 
able  to  withstand  any  great  strain.  Blood,  like  everything 
else,  moves  in  the  direction  of  least  resistance. 

If  now  we  apply  our  therapeutic  triangle,  we  .see  that 
what  we  want  to  do  is  to  get  the  blood  out  of  the  ventricle 
as  quickly  as  possible,  and  to  have  the  ventricle  again  mod¬ 
erately  refilled  as  quickly  as  possible.  How  to  do  this  is 
to  increase  the  rapidity  of  the  contractions  and  to  diminish 
the  intervals  between  them.  A  moderate  degree  of  in¬ 
creased  vigor  is,  of  course,  necessary  in  order  to  overcome 
the  obstruction  ;  and,  further,  systemic  blood-pressure  should 


be  lowered  as  far  as  is  consistent  with  movement  of  the 
blood  into  the  veins.  These  conditions  are  fulfilled  by 
using  a  combination  of  atropine  and  strychnine,  in  con¬ 
junction  with  nitroglycerin  or  nitrite  of  am\l.  The  atro¬ 
pine,  in  addition  to  its  power  to  hasten  the  rate  and  increase 
the  vigor  of  the  cardiac  contractions,  is,  like  strychnine,  a 
stimulant  to  respiration  also,  while  the  nitroglycerin  keeps 
the  arterial  tension  within  the  required  limits.  The  truth 
of  this  theory  was  abundantly  demonstrated  to  me  by  a 
case  under  my  care  at  the  Philadelphia  Hospital  last  winter, 
which  I  have  recorded  in  detail  in  the  forthcoming  volume 
of  the  Philadelphia  Hospital  Reports.  In  this  case  mi¬ 
tral  regurgitation  coexisted  with  aortic  stenosis,  and  the 
rapid  amelioration  of  symptoms  which  took  place  under 
treatment  was  quite  gratifying.  A  pill,  containing  one  six¬ 
tieth  of  a  grain  of  atropine  sulphate  and  one  thirtieth  of  a 
grain  of  strychnine  sulphate,  was  given  three  times  daily? 
and  nitrite  of  amyl  was  given  in  doses  of  five  minims,  dis¬ 
solved  in  a  fluidrachm  of  alcohol,  every  three  to  four  hours 
as  necessary. 

In  cases  of  mitral  stenosis — that  is  to  say,  when  the  flow 
of  blood  from  the  left  auricle  into  the  left  ventricle  is  im¬ 
peded — the  indications  are  (1)  to  prolong  the  ventricular 
diastole  so  that  as  much  blood  as  possible  may  get  through 
the  narrowed  orifice  ;  (2)  to  strengthen  the  heart  muscle 
so  that  the  auricular  contraction  may  be  as  effective  as  pos¬ 
sible;  and  (3)  when  this  lesion  coexists,  as  it  often  does, 
with  mitral  regurgitation,  to  lower  peripheral  blood-press¬ 
ure.  The  hygienic  measures  already  discussed — iron  and 
arsenic  as  nutritives,  strychnine  and  caffeine  as  cardiac 
tonics — fulfill  the  two  indications  of  uncomplicated  stenosis, 
while  digitalis  and  the  nitrites  are  useful  in  cases  compli¬ 
cated  with  regurgitation. 

Aortic  regurgitation  remains  to  be  considered,  for  un¬ 
complicated  tricuspid  lesions  and  lesions  of  the  pulmonary 
valve  are  very  rare,  and  it  will  not  be  worth  while  to  con¬ 
sume  any  of  the  brief  time  left  to  us  in  their  discussion. 

There  has  been  much  difference  of  opinion  as  to  whether 
or  not  digitalis  should  be  used  in  cases  of  aortic  regurgi¬ 
tation.  As  has  been  more  especially  pointed  out  by  Bartho- 
low,  the  rational  symptoms  rather  than  the  pathological 
condition  must  be  our  guide.  It  will  be  easily  seen  that 
undue  prolongation  of  the  diastole  will  permit  greater  re¬ 
gurgitation,  and  that  when  compensation  can  be  brought 
about  without  digitalis  this  drug  had  better  be  omitted. 
Nevertheless,  the  increased  force  which  results  from  the 
digitalis  action  may  be  sufficient  to  more  than  balance  the 
increased  regurgitation  which  it  permits,  and  in  many 
cases  it  proves  useful.  It  is,  as  will  be  readily  evident 
upon  reflection,  most  efficient  in  those  cases  of  aortic  re¬ 
gurgitation  which  coexist  with  mitral  disease.  My  advice, 
then,  would  be,  in  any  case  of  aortic  regurgitation,  to  post¬ 
pone  the  use  of  digitalis  until  other  measures  have  proved  in¬ 
efficient.  The  most  useful  combination  of  medicaments  which 
I  have  employed  is  that  of  atropine,  strychnine,  and  caffeine^ 
with  the  occasional  use  of  the  nitrites.  The  principles 
which  dictate  this  combination  you  have  already  been  suffi¬ 
ciently  familiarized  with.  In  all  cases,  of  course,  those  meas¬ 
ures  of  hygiene  which  bring  the  patient  into  harmony  with 


624 


SEIBERT:  SUBMEMBRANOUS  TREATMENT  OF  DIPHTHERIA. 


|N.  Y.  Mbd.  Jour., 


his  environment,  and  which  aid  in  restoring  the  interna 
balance  of  function  independently  of  the  medicaments,  are 
to  be  as  carefully  prescribed  as  in  the  case  in  which  we  con¬ 
sidered  such  measures  at  length. 

There  are  other  measures  than  those  mentioned  which 
might  have  been  considered  had  time  permitted.  The 
effects  of  heat  and  cold,  the  use  of  opium  as  a  sedative  and 
as  a  heart-tonic  in  small  doses,  mig-ht  have  been  enlarged 
upon.  Camphor,  and  especially  the  monobromated  cam¬ 
phor,  musk,  ergot,  cimicifuga,  veratrum  viride,  and  other 
drugs  which  have  a  certain  usefulness  in  special  conditions, 
deserve  more  than  mere  mention.  But  we  have  had  to 
choose  the  best  and  the  most  generally  applicable  meas¬ 
ures;  and  then,  too,  we  have  alluded  to  the  virtues  of  these 
agents  in  our  previous  studies.  What  I  most  regret  is  our 
inability  to  make  a  special  study  of  so-called  cardiac  asthma, 
and  of  the  measures  which  more  particularly  improve  the 
pulmonary  circulation.  But  with  some  reflection  the  prin¬ 
ciples  we  have  applied  to  the  relief  of  the  systemic  circu¬ 
lation  may  be  applied  to  the  pulmonary  circulation  also. 
Indeed,  as  both  suffer  together,  both  must  be  relieved  to¬ 
gether. 

I  will  only  say  further  in  this  connection  that  I  believe 
venesection  would  frequently  relieve  a  laboring  right  heart, 
and  should  be  resorted  to  more  than  I  have  as  yet  dared  to 
do.  Ilvdragogue  purgation,  wet-cupping,  drv-cupping, 
counter-irritation,  the  use  of  the  nitrites,  are  among  the 

7  o 

most  efficient  measures  at  our  command. 

In  conclusion,  then,  the  first  problem  which  presents 
itself  in  the  treatment  of  chronic  diseases  of  the  heart  is  to 
determine  whether  or  not  Nature  herself  has  brought  about 
restoration  of  equilibrium.  Where  this  is  the  case,  the 
function  of  the  therapeutist  is  so  to  guide  the  life  of  his 
patient  as  to  postpone  to  the  furthest  time  possible  the 
rupture  of  compensation.  When  compensation  has  been 
ruptured,  or  in  cases  where  it  has  never  been  established, 
the  first  duty  of  the  physician — unless  urgent  symptoms, 
such  as  ascites  or  thoracic  effusions,  call  for  immediate 
measures  to  meet  the  emergency — is  to  institute  those 
hygienic  measures  which  shall  restore  extrinsic  and  intrin¬ 
sic  harmony.  After  this,  if  medicaments  are  necessary, 
their  selection  should  be  based  upon  a  careful  study  of  all 
the  conditions  of  the  individual  case,  taking  due  account 
of  the  mental  and  physical  characteristics  of  the  patient. 


Hernia  of  the  Falloppian  Tube.— “  At  the  Leipsic  Obstetrical  So 
ciety,  Dr.  von  Tischendorf  read  notes  of  an  interesting  case  of  femoral 
salpingocele.  The  patient  was  an  elderly  woman,  with  symptoms  of 
strangulated  femoral  hernia.  The  sac  appeared,  before  operation,  to 
contain  omentum.  When  opened,  no  omentum  was  found,  but  the  left 
Falloppian  tube  much  enlarged  on  account  of  oedema.  It  bore,  close  to 
the  ostium,  a  prominence  of  the  size  of  a  cherry,  caused  by  dilatation 
of  its  walls.  This  prominence  fitted  into  a  corresponding  depression  in 
the  hernial  sac.  Both  tubes  and  sac  were  removed  ;  recovery  was  un¬ 
interrupted.  Dr.  von  Tischendorf  could  only  find  four  cases  of  the  kind 
reported  in  medical  literature,  and  of  these,  two  occurred  many  years 
since.” — British  Medical  Journal. 

A  Test  for  Faecal  Matter  in  Water. — Paradiazobenzolsulphuric  acid 
made  feebly  alkaline  in  a  twenty-per-cent,  solution  will,  when  added  to 
water  which  is  contaminated  with  faecal  matter,  show  a  yellowish  color¬ 
ation  within  five  minutes. — British  and  Colonial  Druggist. 


(Original  Communications. 

A  SUBMEMBRANOUS  LOCAL  TREATMENT  OF 

PHARYNGEAL  DIPHTHERIA. 

By  A.  SEIBERT,  M.  D., 

PROFESSOR  OF  DISEASES  OF  CHILDREN,  NEW  YORK  POLYCLINIC,  AND 
PHYSICIAN  TO  THE  CHILDREN’S  DEPARTMENT  OF  THE  GERMAN  DISPENSARY. 

Primarily  the  diphtheric  process  is  a  local  disease. 
It  is  caused  by  the  invasion  of  bacteria  into  the  mucous 
membrane  of  the  respiratory  tract,  which  produces  an  in¬ 
flammation  of  the  invaded  region.  It  is  now  conceded  by 
most  bacteriologists  that  in  the  majority  of  cases  of  diph¬ 
theria  the  bacillus  found  by  Klebs  and  Loeffler  is  the  chief 
cause  of  this  disturbance.  Inoculations  of  cultures  of  this 
bacillus  upon  guinea-pigs  and  rabbits,  as  well  as  bacterio¬ 
logical  research  by  clinicians  like  Heubner,  leave  little 
doubt  in  this  direction. 

Yet  other  pathogenic  germs  besides  this  one  may  enter 
the  mucous  membrane  in  company  with  the  Loeffler  bacillus 
in  a  large  proportion  of  cases,  thus  causing  clinical  pictures 
varying  as  to  the  aspect  of  the  membrane  produced,  as  well 
as  to  the  extent,  more  or  less  pernicious  character,  and  du¬ 
ration  of  the  diphtheric  invasion.  If  from  a  purely  practi¬ 
cal  standpoint  one  might  venture  to  suggest  an  idea  not  ex¬ 
clusively  belonging  to  clinical  experience,  I  should  say  that 
to  my  mind  these  varying  pictures  of  the  diphtheritic  pro¬ 
cess  in  different  cases  (though  often  observed  in  the  same 
epidemics,  at  the  same  time,  and  in  members  of  the  same 
families)  were  caused  by  the  different  proportions  of  these  dif¬ 
ferent  kinds  of  bacteria,  entering  the  mucosa  at  the  same 
time,  so  that  where  other  pathogenic  germs  than  the  true 
diphtheria  bacillus  of  Loeffler  were  in  the  majority,  this  most 
pernicious  micro-organism  did  not  find  the  surroundings 
favorable  enough  for  a  full  development  of  its  growth,  and 
was  curtailed  in  its  action  on  the  human  tissue  by  this  fight 
for  place,  so  as  to  only  result  in  more  or  less  milder  forms 
of  diphtheria.  At  all  events,  we  at  the  present  time,  mind¬ 
ful  of  the  works  of  Oertel,Brieger  and  Fraenkel,  and  others, 
may  logically  assume  that  the  more  bacilli  of  Loeffler  are 
found  in  a  given  case  of  diphtheria,  the  more  fatal  its 
prognosis,  and  the  smaller  the  quantity  of  these  germs  in  a 
case,  the  milder  its  form. 

Roux  and  Yersin  have  again  called  attention  to  a 
pseudo-bacillus  of  diphtheria,  having  no  virulence,  but 
otherwise  very  much  like  the  true  germ,  which  appears  to 
become  virulent  when  associated  with  Fehleisen’s  coccus  of 
erysipelas.  If  this  can  be  so,  then  other  bacteria  may 
have  the  power  to  decrease  the  virulence  of  others. 

The  changes  brought  about  in  the  tissues  of  mucous 
membranes  by  the  invasion  of  the  bacteria  causing  diph¬ 
theria  have  been  elaborately  demonstrated  by  Oertel  in 
his  great  atlas.  The  histology  of  the  pseudo-membrane 
proper  has  found  a  most  careful  student  and  explicit  dem¬ 
onstrator  in  Heubner.  He  has  examined  the  pseudo¬ 
membrane  in  cases  from  five  hours  to  six  days  old,  and  his 
results  have  thrown  considerable  light  on  the  diphtheritic 
process.  In  a  drawing  from  Heubner’s  work,  showing  the 
normal  conditions  of  the  epithelial  layers  of  the  tonsillar 


Deo.  G,  1890. 


SEIBERT:  SUBMEMBRA N O US  TREATMENT  OF  DIRHTHERI A . 


<125 


mucosa  of  a  eliild  (Fig,  1),  we  find  the  upper  Inver  to 
consist  of  fiat,  horny,  the  middle  of  round,  and  the  lower 


Fig.  1.— a,  upper  epithelial  layer  ;  b ,  middle  epithelial  layer ;  c,  lower  epithe¬ 
lial  layer  ;  below,  the  connective-tissue  layer  of  the  mucosa. 


stratum  of  oval-shaped  epithelial  cells,  helow  which  last  we 
notice  large  round  cells,  connective  tissue,  and  blood-vessels. 
Heubner  found  that  even  the  first  noticeable  trace  of  the 
diphtheritic  pseudo-membrane  (taken  from  the  tonsil  five 
hours  after  the  beginning  of  the  attack)  consisted  of  an  ex¬ 
udate  coming  from  the  inflamed  blood-vessels ,  which  after 
wandering  upward  with  the  numerous  leucocytes  (white 
blood-corpuscles)  between  the  oval  and  round  cells  of  the 
epithelium,  lodged  between  the  horny  upper  cells  and  there 
coagulates,  imbedding  within  it  numerous  bacteria.  This 
stream  of  exuding  fibrin,  from  below  upward,  keeps  on 
steadily  as  long  as  the  action  of  the  bacteria  upon  the  blood¬ 
vessels  and  their  surrounding  tissue  progresses,  ultimately 
resulting  in  all  the  epithelial  layers  being  permeated,  dis¬ 
tended,  and  infiltrated  by  this  coagulated  fibrin,  so  that  (as 


Fig.  2. — a,  epithelium  ;  b,  connective-tissue  layer  of  the  mucosa  ;  c,  false  mem¬ 
brane  ;  d,  infiltrated  lower  epithelium  ;  e,  blood-vessels  ;  /,  extravasated 

blood. 


in  the  exudate  (Fig.  2,  taken  from  Zieglei’s  Pathological 
Anatomy). 

Hie  practical  lesson  we  may  learn  from  these  facts  is 
that  the  appearance  of  the  pseudo  membrane  is  the  sure 
sigm  of  bacterial  action  upon  the  lower  lavers  of  the  mucosa, 
directly  below  this  sign  of  this  invasion. 

All  investigators  unite  in  stating  that  far  more  bacteria 
are  found  in  the  epithelium  and  the  pseudo-membrane  than 
in  the  tissue  below.  No  doubt  many  of  the  active  bacteria 
are  carried  away  by  the  circulation  after  penetrating  the 
blood-vessels,  and  others  are  carried  upward  with  the  flow¬ 
ing  exudate,  to  be  imbedded  in  the  coagulated  mass  at  the 
periphera. 

L.  llrieger  and  C.  Fraenkel  have  lately  demonstrated 
the  chemical  body  produced  by  the  action  of  the  Klebs- 
Loeffier  bacillus  upon  the  albumin  of  the  pseudomem¬ 
brane,  which  getting  into  the  circulation  produces  the  dif¬ 
ferent  varieties  of  diphtheric  paralysis.  This  ptomaine, 
called  by  these  authors  “toxalbumin  ”  of  diphtheria,  is  pro¬ 
duced  in  but  small  quantities  in  the  early  stages  of  each 
case,  but  the  larger  and  older  the  diphtheric  area,  the  moie 
toxalbumin  is  produced.  Injected  into  the  circulation  of 
animals,  this  toxalbumin  invariably  produces  paralysis. 

The  conclusions  as  to  the  treatment  of  diphtheric  pa¬ 
tients  we  may  logically  draw  from  these  facts  are: 


BV 


Sch.  L  FE  Ae.  S 

t’iG.  3. — Ae.  S,  eschar  from  nitrate  of  silver  ;  FE,  Sch.  L,  infiltrated  mucosa  ; 

B  V,  bacteria. 


Heubner  has  it)  while  in  the  beginning  of  a  case  the  ex¬ 
udate  is  imbedded  between  the  epithelium,  in  advanced 
cases  the  epithelium  (or  what  is  left  of  it)  is  imbedded 


1.  The  pseudo-membrane  is  an  exudate  coagulated  in 
the  epithelium  coming  from  the  deeper  layer  of  the  mucous 
membrane,  and  therefore  not  the  disease,  but  the  result  of  it. 


626 


SEIBERT:  SUBMEMBRANOUS  TREATMENT  OF  DIPHTHERIA. 


[.N.  Y.  Med.  Jock., 


2.  Hence  all  treatment  attempting  to  dissolve  or  to 
forcibly  take  awa\  this  pseudo-membrane  is  to  no  purpose, 
as  it  does  not  in  the  least  affect  the  diphtherically  in¬ 
flamed  parts. 

3.  All  medicines  given  by  the  mouth  for  the  purpose  of 
entering  the  invaded  region  of  the  mucosa  are  of  no 
use  whatsoever  in  this  direction,  as  they  can  not  pos¬ 
sibly  penetrate  the  coagulated  fibrin  and  swollen  epi¬ 
thelium  to  reach  the  bacteria  producing  this  affection. 

4.  All  local  applications  of  strong  caustics — as  the 
galvano  cautery,  nitrate  of  silver,  etc. — are  of  no  avail, 
as  the  diphtheric  germs  are  far  beneath  the  reach  of 
these  agents  (Fig.  3,  action  of  nitrate  of  silver  upon 
diphtheric  mucosa.  Oertel,  Plate  No.  XYI). 

Tests  of  Loeffler  and  others  have  shown  that  the  bac¬ 
teria  causing  diphtheria  can  not  be  destroyed  at  all  by  weak 
antiseptic  solutions.  The  bichloride  of  mercury,  for  instance, 
given  internally,  dissolved  in  10,000  parts  of  water,  could  not 
destroy  this  bacillus  even  if  it  were  completely  surrounded 
by  it.  Given  as  it  is  in  teaspoonful  doses  by  the  mouth,  it 
passes  gently  over  the  pseudo-membrane  into  the  stomach 
of  the  patient,  from  there  into  the  circulation,  and  the  little 
of  it  that  may  come  in  contact  with  the  bacilli  in  the  dis¬ 
eased  mucous  membrane  can  possibly  be  of  no  account  in 
even  retarding  their  action.  As  this  remedy  is  one  of  the 
strongest  antiseptics  known  to  act  upon  bacterial  life  and 
in  particular  upon  the  Loeffler  bacillus,  it  at  once  appears 
superfluous  to  speak  of  the  legion  of  other  drugs  which  for 
decades  back  have  been  proposed  for  the  treatment  of  this 
dreadful  disease. 

So  we  can  but  admit  that  the  methods  so  far  employed 
in  attempting  to  aid  the  human  organism  in  resisting  this 
bacterial  poison  and  its  products  have  accomplished  but 
little,  if  anything  at  all,  because  the  remedies  we  were  com¬ 
pelled  to  use  are  too  weak  and  because  they  do  not  reach 
the  seat  of  this  pathological  process.  After  coming  to  this 
conclusion  and  throwing  aside  all  superfluous  clamor,  it  be¬ 
hooves  us  to  now  attempt  to  remedy  these  faults  of  treat¬ 
ment. 

The  first  imperative  necessity  bi'ought  before  us,  then, 
must  be  to  bring  whatever  remedy  we  have  in  direct  con¬ 
tact  with  those  bacilli  which  are  in  full  action  upon  the 
tissues.  As  we  can  not  possibly  use  the  knife  and  cut 
down  upon  the  lower  stratum  of  the  mucous  lining  of 
the  tonsils  and  the  pharynx,  we  must  devise  other 
means  to  bring  our  drug  to  the  right  spot. 

For  this  purpose  I  have  devised  an  instrument,  con¬ 
sisting  of  three  parts:  (1)  A  hypodermic  syringe,  (2)  a 
tube  strong  and  long  enough  to  reach  the  pharynx,  and 
(3)  a  small  hollow  plate  which  can  be  screwed  on  the 
end  of  this  tube,  holding  the  points  of  five  hollow 
needles.  When  screwed  together,  these  three  parts 
form  a  firm,  handy,  and  pliable  instrument  that  may 
easily  be  introduced  over  a  child’s  tongue,  pressing  it 
down,  the  points  of  the  needles  pointing  upward  into  the 
pharynx. 

Supposing  we  had  a  fresh  case  of  diphtheria,  and  a 
pseudo-membrane  of  the  size  of  a  pea  on  the  side  of  the 
right  tonsil.  The  needles,  the  tube,  and  a  part  of  the 


syringe  being  filled  with  an  antiseptic  fluid,  the  instrument 
is  passed  over  the  tongue  to  the  tonsils,  the  returned  toward 
the  pseudo-membrane,  and,  by  a  quick  and  gentle  press¬ 
ure,  the  needles  are  plunged  through  the  pseudo-membrane 
and  some  of  the  mucosa  surrounding  it.  Now,  while  three 


fingers  of  t lie  left  hand  hold  the  instrument  in  this  posh 
tion,  the  fluid  is  gently  pressed  out  of  the  syringe  proper 
and  into  and  below  the  inflamed  mucosa  beneath  the  pseudo¬ 
membrane.  The  plate  only  permits  of  the  needles  passing 
into  the  tissues  to  the  depth  of  an  eighth  of  an  inch,  all 
told.  The  needles  are  then  withdrawn,  and  the  remedy  is 
in  contact  with  the  seat  of  the  disease. 

Five  points  are  used,  as  I  have  thought  it  wise  to  deposit 
five  distinct  little  masses  of  remedial  fluid,  because  the  lat¬ 
ter  would  thus  cause  less  inconvenience  by  pressure,  would 
cover  a  greater  area,  and  be  more  readily  distributed  in  the 
neighborhood.  If  gently  performed,  this  little  operation 
causes  no  pain,  at  least  not  in  adults  and  children  that  are 
sensible  enough  to  speak  for  themselves.  The  fluid  re¬ 
mains  in  the  tissue,  and,  as  a  rule,  not  a  drop  of  blood  is 
lost. 

The  curved  catheter-shaped  tube  may  be  attached  to 
eilher  one  of  the  two  plates,  so  that  by  the  four  different 
combinations  any  part  of  the  visible  pharynx,  and  even  the 
rear  surface  of  a  large  tonsil,  may  be  reached. 

Intratonsillar  injections  with  a  single  hypodermic  nee¬ 
dle  have  been  employed  by  Heubner  in  the  treatment  of 
scarlatinous  amygdalitis  for  the  last  eight  years,  and  but 
lately  he  has  again  recommended  their  use  (with  a  three-per- 
cent.  solution  of  carbolic  acid),  yet  he  does  not  employ 
them  in  primary  diphtheria,  knowing  well  that  a  single  in¬ 
jection  into  the  depth  of  a  tonsil  would  not  reach  the  dis 


ease,  would  be  quickly  absorbed,  and  could  not  be  employed 
in  the  other  parts  of  the  pharynx.  But  lately,  in  speaking 
of  diphtheria,  he  discards  all  active  treatment. 

It  appears  to  me  of  the  greatest  importance  to  bring  the 
drug  directly  into  and  below  the  diseased  part,  and  to  intro- 


Fig.  4. 


Fig.  5. 


Dec.  6,  1890.] 


SEIBERT:  SUB  MEMBRA  NOUS  TREATMENT  OF  DIPHTHERIA. 


ducetlie  needles  through  and  around  the  pseudo-membrane. 
Ihe  active  bacilli  in  the  lower  stratum  of  the  mucosa  will 
thus  be  reached,  the  tissues  there  thus  made  uninhabitable 
to  further  possible  invasions  from  above,  the  exudation  must 
cease,  and  the  whole  process  come  to  a  standstill.  The 
pseudo  membrane,  on  the  other  hand,  is  the  only  true  guide 
to  the  diphtheric  inflammation  below  it. 

After  having  convinced  myself  (by  practical  tests  on 
numerous  patients  suffering  from  various  throat  affections) 
of  the  pliability  of  this  diphtheria  syringe,  I  naturally  looked 
about  for  a  remedy  for  injection.  Carbolic  acid  in  a  three- 
per-cent.  solution  had  a  good  effect  on  a  few  cases  of  ton¬ 
sillar  diphtheria — cases  that  might  possibly  have  ended  as 
favorably  under  the  use  of  chlorate  of  potassium  or  salt  water. 
To  really  have  a  germicidal  action,  it  appeared  to  me  to  be 
essential  to  use  a  very  strong  antiseptic — one  that  would  im¬ 
mediately  destroy  the  vitality  of  the  Loeffler  bacillus.  Here 
a  strong  solution  of  the  bichloride  of  mercury  su^oested  it- 
self,  but  so  far  I  have  been  too  timid  to  make  use  of  it. 
Aniline  had  lately  been  mentioned  as  a  non-poisonous 
antiseptic,  and  encouraged  by  Hr.  von  der  Goltz,  of  this 
city,  who  had  used  the  pure  aniline  in  a  solution  of  1  to 
1,000  in  a  large  number  of  gynaecological  and  obstet¬ 
rical  cases  as  an  antiseptic  wash,  apparently  with  marked 
success,  I  concluded  to  make  some  experiments  to  first  test 
its  possible  poisonous  action  on  the  animal  system  and  then 
its  possible  antiseptic  properties.  Assisted  by  Dr.  von  der 
Goltz,  I  injected  four  grammes  (one  drachm)  of  a  ten-per-cent, 
alcoholic  solution  of  aniline  under  the  skin  of  a  cat,  above 
the  gluteal  muscles.  Thirty  minutes  after  this  injection  the 
animal  ate  a  hearty  supper,  and,  after  having  shown  not  the 
slightest  sign  of  poisoning  (no  change  of  heart  action  or  res¬ 
piration  in  particular),  it  was  killed  rapidly  by  a  large  dose 
of  chloroform.  On  section,  1  found  that  the  aniline  had  per¬ 
meated  all  tissues  surrounding  the  point  of  injection  to  the 
extent  of  about  three  inches,  and  in  particular  the  muscles. 
A  piece  of  muscle  was  then  put  into  a  large  test-tube,  and 
about  a  teaspoonful  of  my  own  saliva  added  to  it.  As  bac¬ 
teria  are  always  present  in  the  oral  cavity  and  as  I  had  no 
cause  to  think  that  they  were  of  a  particularly  virulent  type, 

I  argued  that,  if  at  all  antiseptic,  the  large  quantity  of  ani¬ 
line  in  this  muscle  would  prevent  any  noticeable  bacterial 
action  for  some  time  at  least.  After  forty-eight  hours  this 
muscle,  soaked  full  with  aniline,  was  in  a  high  state  of  de¬ 
composition,  giving  a  most  offensive  smell  and  showing 
grayish  discoloration  on  its  surface.  This  simple  test  was 
sufficient  for  me  to  discard  aniline  as  an  antiseptic. 

J.  Geppert  (Bonn),  in  a  series  of  painstaking  experi¬ 
ments.  tested  some  of  the  stronger  antiseptics  now  in  use 
as  to  their  action  upon  the  anthrax  bacillus.  I  can  here 
but  briefly  mention  his  results,  showing  that  this  bacillus 
will  live  for  days  in  a  7  per-cent,  solution  of  carbolic  acid  ; 
if  hanging  in  the  fibers  of  a  silk  thread  dipped  into  a  solu¬ 
tion  of  the  bichloride  of  mercury  of  1  to  1,000.  will  live  and 
thrive  if  removed  after  twenty  minutes;  and  if  spread  on  a 
cover-glass  and  dipped  into  the  same  solution,  will  breed 
cultures  it  removed  after  five  minutes.  The  next  tests  wTere 
made  with  chlorine  water  (aqua  chlori)  of  a  0-2-percent, 
solution  and  of  a  0'15-pei-cent.  solution,  which  all  resulted 


627 

in  showing  that  the  anthrax  bacillus  was  destroyed  in  ten 
seconds  if  brought  in  contact  with  this  antiseptic,  while  a 
l-to-1,000  solution  of  the  sublimate  could  not  do  the  same 
work  in  fifty  seconds.  Geppert  furthermore  showed  that 
that  antiseptic  was  most  powerful  which  was  capable  of 
penetrating  those  media  containing  the  micro-organisms. 
1  his  also  was  found  to  be  chlorine.  Moist  strata  are  per¬ 
meated  more  readily  than  dry  ones.  The  disinfecting  action 
is  a  chemical  one. 

Instigated  by  these  important  tests  of  Geppert’s,  I  re¬ 
solved  to  try  the  action  of  chlorine  water  upon  the  diph¬ 
theritic  process.  Three  points  had  to  be  considered:  (1) 
if  it  was  safe  to  inject  a  0-2  per-cent,  solution  of  aqua 
chlori  into  the  tissues  without  poisonous  effect;  (2)  to  de¬ 
termine  the  local  irritation  and  readiness  of  absorption  if 
injected;  (8)  to  see  if  chlorine  water  would  penetrate  co¬ 
agulated  blood-albumin  and  tissue,  like  epithelial  cells  and 
leucocytes. 

To  determine  the  safety  of  hypodermic  injections  of  chlo¬ 
rine  water,  I  injected  half  a  gramme  of  a  0-2-per-cent,  solu¬ 
tion  of  it  under  the  mucous  membrane  lining  the  mouth  of 
a  white  rabbit  weighing  four  pounds  and  a  half.  Another 
rabbit  of  the  same  age  and  weight  was  kept  for  comparison. 
No  poisonous  symptoms  appeared.  Even  a  whole  syringe¬ 
ful  of  this  solution,  injected  hypodermically  in  the  gluteal 
region,  did  not  impair  the  animal's  health  in  the  least. 
The  injections  below  the  mucosa  of  the  upper  lip  plainly 
showed  a  hard  zone  for  days,  evidently  due  to  coagulation 
of  albumin  caused  by  the  chlorine  after  the  water  had  been 
absorbed.  From  these  experiments  I  concluded  that  (1)  it 
was  perfectly  safe  to  inject  this  chlorine  wafer  into  the  mu¬ 
cosa  of  a  child,  and  (2)  that  the  local  irritation  caused  was 
not  of  any  account,  and  that  the  chlorine  evidently  imme¬ 
diately  went  into  chemical  combinations  with  the  surround¬ 
ing  tissues  and  was  but  slowly  absorbed.  To  see  if  chlo¬ 
rine  water  would  penetrate  coagulated  blood  albumin,  Mr. 
Otto  Amend  was  kind  enough  to  experiment.  His  answer 
was  an  affirmative  one.  To  see  if  epithelial  cells  and  blood- 
corpuscles  were  acted  upon,  I  took  a  drachm  of  urine  of  a 
patient  suffering  from  pyelitis  and  purulent  catarrh  of  the 
bladder,  divided  the  portion  in  two  equal  halves  in  two  test- 
tubes,  and  added  five  drops  of  the  chlorine  water  to  the 
one.  After  shaking,  I  took  a  drop  of  this  mixture  and 
placed  it  under  the  microscope.  Another  drop  was  taken 
from  the  other  tube,  containing  the  unmixed  urine,  upon 
another  slide.  Upon  comparison,  we  find  that  the  drop 
containing  urine  with  chlorine  water  shows  the  white  blood- 
corpuscles  and  epithelial  cells  acted  upon  in  such  a  way 
that  their  borders  look  heavy,  thickened,  and  somewhat 
irregular,  the  nuclei  and  nucleoli  dark  and  irregular,  and 
corpuscles  as  well  as  epithelium  look  as  though  their  pict¬ 
ures  had  been  first  drawn  by  pencil  and  then  overdrawn  by- 
ink.  The  constituents  of  the  non-chlorated  urine  show 
clear,  transparent,  and  light  pictures.  (Fig.  5.) 

Repeated  experiments  always  gave  the  same  result. 
Evidently  the  dark,  heavy  spots  and  borders  of  corpuscles 
and  epithelium  were  the  work  of  the  chloiine  and  the  result 
of  a  chemical  change  caused  by  the  contact  of  this  drug 
with  the  albumin  of  these  tissues.  1  deduced  from  this 


628 


SEIBERT:  SUBMEMBttANuUS  TREATMENT  OF  DIPHTHERIA. 


[N.  Y.  Med.  Jouk., 


that  if  chlorine  would.  even  penetrate  the  epithelial  cells 
and  the  white  blood-corpuscles,  it  certainly  would  invade 
every  particle  of  mucous  tissue  it  came  in  contact  with. 

I  now  made  chlorine-water  injections  into  the  hypertro¬ 
phied  tonsils  of  adults.  Two  large  drops,  divided  into  rive 
equal  proportions  by  the  five  needle-points,  were  injected 
at  one  time.  The  inconvenience  caused  was  hardly  notice¬ 
able.  A  sense  of  pressure  appeared,  which  left  the  patient 
after  a  few  minutes.  The  introduction  of  the  needle-points 
was  hardly  felt  by  the  patients. 

Being  now  prepared  to  use  this  method  and  this  drug,  I 
made  two  injections  into  the  tonsillar  mucosa  of  a  child  of  three 
years,  two  drops  of  the  0-2-per-cent.  solution  being  used  in 
each  tousil.  This  little  girl  was  suffering  from  a  fresh  attack 
of  diphtheria  of  three  days’  standing,  both  tonsils  showing  well- 
marked  pseudo-membranes  of  doubtless  diphtheric  character. 
Glands  of  neighborhood  infiltrated;  temperature,  103°  F.  Sis¬ 
ter  of  child  had  died  of  diphtheria  a  few  months  before.  Injec¬ 
tion  at  5.30  p.  m.  Temperature  at  9  p.  m.  down  to  101°,  and 
99°  F.  next  morning.  The  surrounding  parts  were  now  pale, 
while  at  time  of  injection  the  whole  pharynx  seemed  very  red 
and  cedematous.  Pseudo-membranes  drop  off  in  two  days. 
Appetite  of  child  appeared  four  hours  after  injection. 

In  my  second  case  (a  boy,  aged  two  years  and  three  quar¬ 
ters,  whose  sister  had  died  of  malignant  diphtheria  ten  days 
before)  I  found  diphtheric  inflammations  on  both  tonsils,  which 
were  in  a  state  of  enormous  chronic  hypertrophy.  The  right 
tonsil  presented  a  fresh  pseudo-membrane,  while  the  left  showed 
a  spot  of  about  a  quarter  of  an  inch  in  diameter,  looking  as 
though  a  drop  of  milk  had  fallen  on  it  and  spread,  the  very  first 
sign  of  a  pseudo-membrane.  Temperature,  101-75°  F. ;  infiltra¬ 
tion  of  glands;  vomiting.  Injections,  10  a.  m.  At  4  p.  m.  tem¬ 
perature  normal;  appetite.  Pseudo  -  membrane  dropped  off 
within  thirty-six  hours. 

Oases  III,  IV,  and  V  were  very  much  like  this  one,  all  three 
patients  being  relatives  of  Case  II. 

Case  VI.— -Boy  of  four  years.  Visited  a  family  where  a 
child  had  been  sick  with  diphtheria  three  months  before.  Boy 
was  given  toys  of  this  child,  especially  a  trumpet,  which  had 
been  used  by  the  diphtheric  child  during  its  illness.  Forty- 
eight  hours  after  this  visit  symptoms  began.  I  did  not  see  the 
child  until  four  days  after  the  visit.  Diagnosis:  Diphtheria  of 
both  tonsils  and  sides  of  pharynx,  stenosis  of  larynx,  trachea, 
and  larger  bronchi,  due  to  diphtheric  invasion.  Injections  of 
-chlorine  water  through  both  pseudo-membranous  patches  in 
-pharynx.  Twelve  hours  later  pharynx  pale,  no  extension  of 
pharyngeal  diphtheria,  the  oedema  of  soft  palate  subsided ;  steno¬ 
sis  worse.  I  now  intubated  the  larynx,  bringing  but  partial  re¬ 
lief,  as  disease  had  previously  extended  far  below  the  reach  of 
the  O’Dwyer  tube.  Two  days  later  the  child  died  of  paralysis 
of  the  heart,  but  the  day  before  the  pseudo-membrane  of  the 
pharynx  had  disappeared  entirely.  Though  in  private  practice, 
the  parents  gave  their  consent  to  a  post-mortem,  which  showed 
an  exquisite  extension  of  the  diphtheric  process  all  along  the 
bronchi  of  the  first  and  second  order,  with  formation  of  pseudo¬ 
membrane.  The  specimen  was  demonstrated  to  my  class  at  the 
New  York  Polyclinic  immediately  after  the  autopsy. 

Case  VII,  the  last  I  shall  report,  concerned  the  nine-year- 
old  brother  of  the  little  girl  in  Case  II.  Illness  began  suddenly 
with  severe  headache  and  vomiting.  Twenty-four  hours  later 
I  found  a  dark,  slate-colored  pseudo-membrane  about  half  an 
inch  in  diameter  on  both  tonsils.  The  whole  pharynx  cedema¬ 
tous,  very  red;  the  uvula  much  enlarged.  Swallowing  very 
difficult.  Glands  swollen.  Temperature,  102-75°  F.  It  needed 


the  assistance  of  the  O’Dsvyer-Denhard  gag  and  of  three  men 
to  overcome  the  struggling  of  the  boy  to  succeed  in  making  the 
first  submembranous  injection.  The  second  one  could  be  made 
easily,  as  the  patient  lost  all  fear  after  the  first  one,  and  stated: 
“  If  that’s  all,  you  can  do  it  again.”  At  the  next  visit  the 
throat  was  pale,  the  swelling  reduced  markedly,  the  tempera¬ 
ture  100-25°  F.,  the  feeling  of  illness  entirely  gone,  and  boy  ask¬ 
ing  for  beefsteak.  The  pallor  of  the  mucosa  surrounding  the 
pseudo-membrane  was  as  distinct  in  this  case  as  in  all  others. 
The  oedema  of  the  uvula  and  soft  palate  had  diminished  consid¬ 
erably.  The  next  day  the  general  improvement  persisted,  the 
left  tonsil  losing  its  pseudo-membrane  till  evening,  that  of  the 
right  growing  smaller  to  one  half  of  its  extent.  But,  as  the 
temperature  showed  a  rise  again  to  101-5°  F.,  I  looked  for  and 
found  a  new  diphtheric  patch  on  the  side  wall  of  the  pharynx 
back,  of  the  right  tonsil.  I  concluded  to  make  another  injec¬ 
tion  at  this  point,  which  now  was  done  without  the  slightest 
resistance  from  the  boy  and  without  the  aid  of  spoon  or  gag. 
Next  day  both  tonsils  were  clean,  temperature  was  normal,  and 
the  pea-like  pseudo-membrane  disappeared  by  evening. 

These  seven  cases  (from  private  practice)  demonstrate 
fully— 

1.  That  this  method  of  treatment  can  be  employed 
without  inconvenience  and  danger  to  children. 

2.  That  the  chlorine  water,  thus  brought  in  contact  with 
the  Loeffler  bacilli  and  the  inflamed  parts,  evidently  tends 
to  check  their  career  in  the  mucous  membrane  and  to 
shorten  the  disease. 

3.  That  it  seems  worth  while  to  give  this  method  a  full 
trial. 

One  word  more  about  the  handling  of  the  apparatus: 
The  chlorine  water  must  be  kept  cold  and  dark,  and  is  best 
carried  constantly  with  the  instruments  in  an  outside  over¬ 
coat  pocket.  This  will  insure  purity  and  correct  strength 
of  the  solution  and,  before  all,  will  avoid  delay,  for  the 
sooner  the  injection  is  made  the  better  the  prognosis  of  the 
case.  I  do  not  expect  to  influence  cases  by  this  method 
where  the  diphtheric  inflammation  has  spread  over  the  half 
or  whole  of  the  oral  cavity,  and  I  hardly  think  that  I  would 
make  any  attempts  at  using  it,  but  I  have  good  cause  to 
think  that  we  may  prevent  such  spreading  by  these  injec¬ 
tions  almost  with  certainty  if  employed  in  time. 

The  needles  and  the  whole  instrument  are  easily  disin¬ 
fected  by  the  same  chlorine  water  and  soap  and  water  exter¬ 
nally  ;  the  inner  surface,  never  coming  in  contact  with  diph¬ 
theria,  is  nevertheless  disinfected  by  the  chlorine. 

The  needle-points  must  be  wired  carefully  and  the 
whole  syringe  clearedof  the  chlorine  water  thoroughly.  Of 
course  some  corroding  will  come  in  time,  and  a  new  needle- 
plate  will  now  and  then  be  necessary;  but  what  is  that  in 
comparison  to  what  we  may  accomplish  with  it  ? 

Whether  the  chlorine  water  will  remain  the  best  chemical 
to  use  or  not,  I  am  not  prepared  to  say.  Other  remedies 
may  also  be  used  with  effect. 

In  speaking  of  future  methods  of  treatment  in  an  arti¬ 
cle  published  last  February  I  said :  ‘‘  If  we  now  vaccinate 
organisms  into  the  circulation  of  healthy  persons  to  pre¬ 
vent  disease,  why  may  we  not  come  to  impregnating  micro¬ 
organisms  into  those  already  diseased  ?  ”  And  so  I  hope 
to  see  the  day  when  Koch  or  one  of  his  pupils  will  give  us 
a  lymph  that  we  may  inject  into  diphtheric  tissues.  By 


Dec.  6,  1890.] 


WALKER:  PERI  SEAL  VERSUS  SUPRAPUBIC  CYSTOTOMY. 


629 


that  time  my  little  instrument  may  be  so  improved  that  it 
will  fully  answer  this  purpose  also,  yet  till  then  even,  I  am 
convinced,  it  will  help  to  save  children  from  an  early  grave 
if  employed  in  time. 

Bibliography . 

Loeffler.  Deutsch.  med.  Wochenschrift ,  Nos.  5  and  6,  1890. 

Spronck.  Centralblatt  f.  palhol.  Anatomie,  April  1,  1890. 

Heubner.  Jahrbuch  f.  Kinderheilk .,  September,  1889. 

P rudden  and  Nortkrup.  Amer.  Jour,  of  the  Med.  Sciences , 
April  and  May,  1889. 

Roux  et  Yersin.  Annales  de  Vinstitut  Pasteur ,  No.  7,  1890. 

Oertel.  Die  Pathogenese  d.  epidem.  Diphtherie ,  Atlas,  1887. 

L.  Brieger  and  0.  Fraenkel.  Berl.  klin.  Woch.,  Nos.  11  and 
12,  1890. 

J.  Geppert.  Berl.  klin.  Woch.,  Nos.  11,  12,  and  13,  1890. 

Seibert.  Medic.  Monatsschrift ,  February,  1890. 

137  East  Nineteenth  Street,  New  York. 


PERINEAL  CYSTOTOMY 
VERSUS  SUPRAPUBIC  CYSTOTOMY.* 

By  H.  O.  WALKER,  M.  D., 

DETROIT,  MICH. 

In  the  choice  of  a  method  of  operation  we  should  be 
governed,  first,  by  its  safety  ;  second,  by  its  simplicity  of 
performance;  third,  by  its  rapidity  of  result;  fourth,  by  its 
general  applicability  in  the  majority  of  cases.  It  is  my  pur¬ 
pose  in  this  paper  to  present  briefly  my  views  concerning 
the  two  methods  of  entrance  into  the  urinary  bladder — viz., 
perineal  cystotomy  and  suprapubic  cystotomy. 

An  all-wise  Providence  evidently  intended  that  the 
bladder  should  be  emptied  from  its  most  dependent  point. 

Our  fathers  in  surgery,  guided  by  this  idea,  followed  it 
out  by  attacking  the  bladder  through  the  perinaeum  for  the 
relief  of  disease,  foreign  bodies,  or  obstruction. 

One  Pierre  Franco,  in  1556,  from  force  of  circumstance, 
opened  the  organ  from  above.  Others,  at  long  intervals, 
did  likewise,  but  all  condemned  the  procedure,  largely  on 
account  of  its  high  mortality,  until  Garson  and  Petersou 
demonstrated  by  distention  of  the  rectum  the  easier  ap¬ 
proach  to  the  bladder  by  the  sectio  alta. 

Since  the  revival  of  this  method  the  medical  press  has 
teemed  with  fulsome  praise  of  its  brilliant  results  by  many 
advocates,  while  few  have  had  the  temerity  to  say  aught 
against  the  tidal  wave  of  opinion  in  its  behalf. 

I  am  aware  that  I  am  in  the  presence  of  gentlemen  dis¬ 
tinguished  in  this  department  of  surgery  who  do  not  agree 
with  my  views. 

It  may  seem  to  you  presumptuous  on  my  part  to  offer 
them  from  my  limited  experience,  having  operated  in  but 
five  cases,  with  but  one  recovery,  and  by  your  indulgence  1 
will  report  them. 

Case  I. — J.  B.,  aged  fifty,  first  came  under  my  observation 
in  June,  1887,  for  severe  haemorrhage  from  the  bladder,  with  a 
history  of  the  trouble  of  this  viscus  of  three  or  four  months’ 
standing.  His  previous  history  was  good,  with  the  exception 


*  Read  before  the  Mississippi  Valley  Medical  Association  at  its  six¬ 
teenth  annual  meeting. 


that,  eight  years  ago,  his  left  arm  was  severely  crushed  by  a 
falling  trip-hammer,  and  at  that  time  I  removed  it  just  below  the 
shoulder  joint.  I  he  haemorrhage  was  controlled  by  large  doses 
of  ergot.  Blood  was  always  present  in  his  urine  alter  this,  with 
evidences  of  more  or  less  cystitis.  The  microscope  never  re¬ 
vealed  anything  further,  but,  from  exploration  of  the  bladder 
with  a  searcher,  I  have  no  doubt  about  the  presence  of  a  growth. 
Medication  and  irrigation  were  of  no  avail  in  abating  his  symp¬ 
toms.  On  November  25,  1887,  as  he  was  gradually  failing,  he 
consented  that  I  should  operate  upon  him.  At  this  time  reports 
by  various  operators  were  made  in  the  journals  extolling  the 
excellence  of  the  suprapubic  method,  especially  for  the  re¬ 
moval  of  tumors  of  the  bladder.  I  therefore  concluded  that 
this  was  a  suitable  case  for  its  trial.  He  entered  St.  Mary’s 
Hospital  on  November  28,  1887.  On  December  2d,  having 
undergone  thorough  antiseptic  preparation,  I  did  the  opera¬ 
tion.  As  I  did  not  have  the  rubber  colpeurynter,  I  used  a 
soft-rubber  ice-bag,  tied  on  to  a  No.  16  English  catheter,  and 
distended  the  rectum  with  ten  ounces  of  warm  water,  also  in¬ 
jecting  eight  ounces  of  boric  acid  solution  into  the  bladder. 
The  incision  was  about  three  inches  and  a  half  in  length,  in  the 
median  line,  to  the  symphysis,  and  down  to  the  prevesical  fat, 
which  was  pushed  and  torn  aside  with  the  finger-nail.  The 
bladder  was  then  seized  with  two  tenacula,  and  a  longitudinal 
incision  made  between  them.  As  soon  as  the  boric  acid  solu¬ 
tion  had  run  out  there  was  no  difficulty  in  feeling  a  tumor  pro¬ 
jecting  on  each  side  and  behind  the  vesical  outlet,  having  its 
origin  from  the  prostate,  although  previously  I  had  not  been 
able  to  recognize  any  enlargement  of  the  gland  by  digital  ex¬ 
amination  of  the  rectum.  The  tumor  was  removed  piecemeal 
with  the  curette,  altogether  probably  of  the  size  of  a  small  egg ; 
it  proved  to  be  an  epithelioma.  The  bleeding  was  profuse,  but 
controlled  with  hot  boric-acid  solution.  A  drainage-tube  was 
introduced  and  the  bladder  sutured  with  catgut,  while  the  ab¬ 
dominal  wound  was  closed  with  several  interrupted  sutures  of 
silk.  The  drainage-tube  was  of  sufficient  length  to  empty  into 
a  vessel  containing  a  twenty-per-cent,  solution  of  carbolic  acid. 
On  December  3d  the  patient  passed  a  restless  night,  with  evi¬ 
dent  dribbling  of  urine  alongside  of  the  tube.  On  the  4th  the 
condition  was  the  same,  with  a  temperature  of  100'5°.  On  the 
5th  the  temperature  was  101-5°;  there  was  constant  escape  of 
urine  from  the  wound  with  suppuration  along  the  course  of  the 
sutures.  He  gradually  grew  worse,  with  a  varying  temperature 
of  100°  to  1 04-5°,  and  died  on  December  28th.  The  wound  never 
closed,  and  the  whole  lower  portion  of  the  abdomen,  together 
with  the  scrotum,  was  excoriated,  as  a  result  of  the  constant 
presence  of  urine.  His  condition  was  pitiable,  especially  for  the 
ast  two  weeks  that  he  lived,  although  extra  effort  was  made  to 
keep  him  dry  with  frequently-renewed  dressings.  A  post-mor¬ 
tem  was  not  permitted. 

Case  II. — A.  L.,  a  Bohemian,  aged  thirty-seven,  first  came 
under  ray  care  on  May  1,  1888,  with  a  history  of  previous  gon¬ 
orrhoeas,  and  an  operation  for  a  stricture  in  the  deep  urethra 
)y  external  perineal  urethrotomy  two  years  before  coming  to 
see  me.  He  had  a  marked  chronic  cystitis,  without  evidence  of 
any  involvement  of  the  kidneys.  It  was  quite  evident  from  his 
listory  that  he  had  had  at  the  time  of  the  urethrotomy  a  cystitis 
which  had  never  got  well.  Although  you  have  observed  that 
my  first  experience  was  disastrous,  yet,  in  view  of  cumulative 
authority,  I  again  decided  to  venture  the  attempt  of  another 
suprapubic  cystotomy,  as  this  was  certainly  a  proper  case  for 
this  method.  The  operation  was  accordingly  done  on  June  2d, 
after  the  manner  of  the  case  just  described.  He  did  fairly  well 
::or  ten  days,  although  suffering  severely  from  the  presence  of 
the  tube,  when  it  wa9  withdrawn,  and  the  wound  kept  open 
by  the  daily  introduction  of  a  catheter.  From  this  time  on  he 


€3<> 


WALKER:  PERI  REAL  VERSUS  SUPRAPUBIC  CYSTOTOMY. 


[N.  V.  Med.  Jock., 


gradually  grew  worse,  and  died  on  July  10th,  evidently  by  the 
extension  of  the  disease  to  the  pelves  of  the  kidneys,  and  possi¬ 
bly  the  kidneys  themselves;  yet  I  was  unable  to  verify  this, 
from  the  fact  that  I  was  out  of  the  city  at  the  time  and  no 
autopsy  was  made 

Case  III. — M.  II  ,  aged  seventy,  had  been  a  sufferer  for  over 
fifteen  years  from  mechanical  obstruction  of  the  urine.  I  saw 
him  for  the  first  time  in  October,  1888;  his  prostate  was 
enormously  enlarged,  and  he  had  all  the  symptoms  common 
in  such  cases.  I  did  not  see  him  again  until  February  (5, 
1889,  in  consultation  with  Dr.  Longyear,  of  Detroit.  At  this 
time  he  was  suffering  severely  from  a  frequent  desire  to  void 
his  urine.  The  microscope  revealed  large  quantities  of  pus, 
some  blood,  and  epithelial  cells,  and  shreds  of  tissue  that  he 
passed  I  found  to  be  portions  of  a  sarcomatous  growth.  I 
explained  to  him  the  possibilities  of  a  suprapubic  cystotomy, 
to  which  he  consented.  I  did  the  operation  on  February  18, 
1889.  The  colpeurynter  was  distended  with  about  six  ounces 
of  water,  and  that  with  difficulty.  The  bladder  I  found  to  be 
of  small  capacity,  holding  but  a  little  more  than  two  ounces 
of  the  boric-acid  solution.  In  cutting  through  the  bladder  it 
g  ive  the  impression  as  if  cutting  through  cartilage.  Introduc¬ 
ing  my  finger,  I  perceived  that  most  of  the  bladder  was  infil¬ 
trated  with  a  growth  undoubtedly  having  its  origin  from  the 
prostate.  It  was  so  extensive  in  character  that  I  did  not  at¬ 
tempt  even  to  remove  any  portion  of  it.  A  drainage-tube  was  in¬ 
troduced,  through  which  urine  continued  to  How  until  his  death, 
which  occurred  on  March  15,  1889.  He  died  from  exhaustion, 
the  natural  result  of  the  disease,  and  not,  in  my  opinion,  has¬ 
tened  in  the  least  by  the  operation. 

Case  IV. — N.  B  ,  aged  fifty-nine,  a  fairly  healthy  farmer, 
consulted  me,  March  14,  1889,  for  obstruction  of  urinary  flow, 
necessitating  the  frequent  use  of  a  catheter.  Examination  re¬ 
vealed  a  very  large  prostate,  an  immense  residuum  of  urine,  and 
a  considerable  cystitis.  He  was  very  desirous  that  something 
should  be  done  in  the  way  of  an  operation,  as  he  had  been  more 
or  less  ot  a  sufferer  for  five  years.  Dr.  Hunter  McGuire’s  re¬ 
port  of  excellent  results  following  suprapubic  drainage  for  the 
relief  of  enlarged  prostates  encouraged  me  to  make  another 
trial.  The  patient  entered  Harper  Hospital  on  March  21,  1889, 
and  was  operated  upon  on  the  23d.  For  two  days  he  did  well, 
with  the  exception  of  constant  severe  pain  and  the  usual  ex¬ 
coriation  from  the  overflowing  urine.  On  the  third  day  he  was 
attacked  with  peritonitis,  although  I  am  certain  that  no  injury 
was  done  the  peritonaeum  at  the  time  of  the  operation.  His 
condition  gradually  became  worse,  and  he  died  on  the  30th. 
Unfortunately,  the  friends  objected  to  an  autopsy. 

Case  V. — A.  S.,  a  German,  aged  seventeen,  small  for  his  age, 
was  sent  to  me  by  Dr.  D.  Inglis  ou  January  8,  1890,  with  a  his¬ 
tory  of  painful  micturition  dating  back  to  the  time  when  he  was 
two  years  of  age.  Examination  with  a  searcher  revealed  a  large 
and  hard  calculus.  Although  my  previous  record  was  bad,  and 
as  this  seemed  a  favorable  case,  I  decided  to  again  try  the  supra¬ 
pubic  method.  He  was  sent  to  Harper  Hospital,  and  on  January 
10th  I  operated.  The  usual  antiseptic  precautions  were  observed, 
both  preparatory  and  immediate.  He  was  chloroformed  and  the 
rubber  colpeurynter  introduced  into  the  rectum  and  tilled  with 
six  ounces  of  warm  water,  and  immediately  the  bladder  was  dis¬ 
tended  with  an  equal  quantity  of  boric-acid  solution.  This 
amount  of  fluid  was  sufficient  to  indicate  the  presence  of  the 
bladder  above  the  symphysis.  The  further  steps  of  the  opera¬ 
tion  were  similar  to  those  in  the  preceding  cases,  somewhat 
tedious  on  account  of  htemorrhage,  and  a  mulberry  calculus  was 
removed  weighing  three  hundred  and  twenty  grains.  The  in¬ 
cision  in  the  bladder  was  earefully  closed  with  interrupted  catgut 
sutures  and  the  integument  coaptated  with  three  deep  silk  sut¬ 


ures,  leaving  an  opening  below  for  a  small  drainage-tube.  The 
ordinary  antiseptic  dressings  were  applied  and  a  rubber  catheter 
was  introduced  through  the  urethra  into  the  bladder  for  drain¬ 
ing  off  the  urine. 

January  11th. — During  the  night,  owing  to  pain  from  the 
tresence  of  the  catheter,  the  patient  pulled  it  out,  and  it  w  as 
quite  apparent  that  the  urine  was  forcing  its  way  through  and 
alongside  of  the  drainage-tube  in  the  wound,  showing  that  I  had 
failed  to  close  the  bladder  completely.  The  catheter  was  again 
introduced,  but  its  presence  was  so  painful  that  it  had  to  be  re¬ 
moved,  and,  in  spite  of  all  that  could  be  done,  the  urine  con¬ 
tinued  to  flow  through  the  wound. 

12th. — For  the  last  twenty-four  hours  the  temperature  has 
ranged  from  100°  to  102°,  indicating  that,  although  we  had  taken 
extra  precautions  for  thorough  antisepsis,  it  was  evident  that 
our  patient  was  suffering  from  septic  infection.  I  mention  this 
fact  for  the  reason  that  several  operators  speak  of  the  beauties 
of  healthy  urine  as  an  antiseptic — to  my  mind  a  delusion  that 
should  not  ensnare  any  operator,  whether  his  operation  is  supra¬ 
pubic  or  perineal.  From  this  time  until  January  18th  the  tem¬ 
perature  varied  from  normal  to  102°.  The  whole  of  the  lower 
portion  of  the  abdomen  and  scrotum  was  excoriated  ;  although 
extra  care  was  taken  to  keep  him  clean,  yet  the  parts  were  con¬ 
stantly  wet  with  urine. 

23d. — The  wound  was  sufficiently  closed  for  the  entire  urine 
to  pass  through  the  urethra. 

29th. — He  left  the  hospital ;  the  wound  was  completely 
healed,  and  he  was  able  to  retain  his  urine  for  three  or  four 
hours. 

The  perineal  method  of  reaching  the  bladder  is  the  old¬ 
est  known  to  us,  although  numerous  modifications  have  been 
made  since  the  hap-hazard  “cut  on  the  gripe”  for  stone 
was  first  done.  For  the  removal  of  stone,  litholapaxy  un¬ 
doubtedly  stands  pre-eminent,  and  can  be  done  upon  subjects 
from  three  years  of  age  upward,  yet  there  are  numerous  re¬ 
strictions  to  this  method,  such  as  stricture  of  the  urethra, 
a  large-sized  stone,  an  enormous  prostate,  etc.  There  can 
be  no  question,  when  cutting  has  to  be  done,  that  the  medio- 
bilateral  method  presents  the  best  advantages,  and  I  can  no 
better  illustrate  what  I  wish  to  say  than  by  quoting  the  con¬ 
clusions  of  Dr.  W.  T.  Briggs,  president  of  the  American 
Medical  Association,  in  his  paper,  The  Choice  of  Operations 
for  the  Removal  of  Vesical  Calculi  in  the  Male:  “First,  that 
it  opens  up  the  shortest  and  most  direct  route  to  the  blad¬ 
der  ;  second,  it  divides  parts  of  the  least  importance  ;  third, 
it  is  almost  a  bloodless  operation;  fourth,  it  affords  a  pas¬ 
sage  for  the  removal  of  any  calculus'  which  can  safely  be 
removed  through  the  perinseum,  and  is  the  best  route  for 
free  drainage;  fifth,  it  reduces  the  death-rate  to  a  mini¬ 
mum.” 

The  treatment  of  enlarged  prostates  with  cystitis  is 
equally  efficacious  by  the  perineal  section  and  drainage,  in 
behalf  of  which  I  will  report  the  following  case — one  of 
many  that  I  have  treated  in  this  manner: 

O.  P.,  aged  seventy  four,  with  a  history  of  prostatic  enlarge¬ 
ment  for  twenty  years,  came  under  my  observation  on  January 
7,  1890,  through  the  kindness  of  Dr.  0.  Raynale,  of  Birming¬ 
ham,  Mich.  Until  about  a  year  previous  he  had  been  able  to 
relieve  himself  with  a  catheter,  and  since  that  time  the  desire 
to  void  urine  had  been  almost  constant,  so  that  he  rarely  held 
it  more  than  an  hour.  I  explained  to  him  the  possibilities  of  a 
perineal  section,  and  after  mature  deliberation  on  his  part  he 


Dec.  6,  1890.] 


LEADING  ARTICLES. 


631 


consented,  and  I  operated  on  January  10,  1890.  The  principles 
of  modern  surgery  were  religiously  observed.  After  dividing 
the  urethra  as  far  as  the  prostate,  I  discovered  an  unusual  me¬ 
dian  projection,  winch  I  divided  down  to  the  floor  of  the  pros¬ 
tate.  The  bladder  was  thoroughly  irrigated  with  a  l-to-10,000 
bichloride  solution.  For  a  drainage  1  used  a  No.  16  common 
English  catheter  with  about  six  feet  of  rubber  tubing  attached. 
The  catheter  was  held  in  place  by  a  silk  thread  attached  to  an 
abdominal  band,  care  being  taken  not  to  permit  the  point  of  the 
catheter  to  touch  the  fundus  of  the  bladder;  this  can  be  pre¬ 
vented  by  placing  next  to  the  perinmum  two  or  three  thicknesses 
of  gauze,  and  then  tying  the  thread  guys  close  to  it  on  the  cathe¬ 
ter,  over  which  the  other  dressings  are  then  applied.  It  is  not 
necessary  to  remove  the  dressings  for  several  days,  until  all 
danger  of  sepsis  is  past.  The  tube  should  be  conducted  into  a 
vessel  containing  an  antiseptic  solution.  On  the  first  night  fol¬ 
lowing  the  operation  he  slept  nine  hours — something  he  had 
not  done  for  years.  The  bladder  was  washed  out  daily  with  a 
boric-acid  solution  through  the  drainage-tube.  For  the  first  ten 
days  he  remained  in  bed;  after  that  he  was  permitted  to  sit  up 
and  take  an  occasional  walk.  During  March  he  had  an  attack 
of  grippe,  to  which  he  nearly  succumbed.  On  July  15th  he 
came  to  my  otfice  informing  me  that  he  had  just  returned  from 
presiding  over  a  two  days’  session  of  the  Michigan  Pioneer  So¬ 
ciety.  Be  still  wears  a  rubber  tube  which  he  keeps  closed  by  a 
wooden  plug,  removing  it  every  four  or  five  hours,  whenever 
he  wishes  to  empty  his  bladder.  I  was  of  the  opinion,  and  so 
informed  him,  that  it  was  unnecessary  to  wear  it  longer,  but,  as 
he  had  had  such  comfort  during  its  use,  he  refused  to  dispense 
with  it. 

It  is  undoubtedly  true  that  by  the  suprapubic  section 
we  are  better  able  to  observe  a  tumor  of  the  bladder,  yet 
it  is  quite  possible  with  a  searcher  to  recognize  its  location 
and  size  with  reasonable  accuracy ;  if  more  is  needed  we 
can  resort  to  the  cystoscope.  Further,  I  see  no  reason 
why  it  is  not  as  easily  removed  through  the  perinaeum  as 
by  the  high  section.  In  looking  up  the  literature  at  my 
command  of  suprapubic  operations  since  1883,  I  find  in 
the  record  of  between  three  and  four  hundred  operations 
an  average  mortality  of  30  per  cent.  A  few  operators 
have  had  a  series  of  cases  ranging  from  three  to  ten  with¬ 
out  a  death.  The  most  remarkable  record  in  this  respect 
is  that  of  the  distinguished  surgeon  Dr.  Hunter  McGuire — 
twenty-one  operations  with  but  a  single  death.  When,  how¬ 
ever,  we  compare  the  many  thousand  operations  by  the 
perineal  method  of  different  collectors,  and  find  a  mortality 
of  but  5,  6,  and  7  per  cent.,  rarely  going  beyond  9  per 
cent.,  I  must  go  back  to  my  original  propositions  and  con¬ 
clude  :  First,  that  it  is  a  safer  operation  ;  second,  that  it  is  a 
simpler  operation  ;  third,  that  it  is  more  rapid  in  its  results; 
fourth,  that  it  is  adapted  to  more  cases  than  that  of  supra¬ 
pubic  cystotomy. 

Prescribing  Liquors. — “  During  the  recent  heated  political  term  in 
South  Carolina  a  convention  met  at  the  county  site.  The  town  being 
a  ‘dry’  one,  delegates  suffered  much  from  thirst,  which  fever  a  thrifty 
physician  sought  to  allay  by  prescriptions  of  whisky  and  beer.  The 
size  of  one  dose,  a  dozen  bottles,  attracted  the  law’s  attention,  and  the 
medical  man  is  now  in  the  law’s  clutch.  From  this  he  attempts  to 
rescue  himself  by  pleading  his  professional  privilege,  but  the  judge 
says  that  while  ‘  prescription  ’  is  broad  enough  to  cover  a  black  draught, 
it  lacks  elasticity  enough  for  a  dozen  black  bottles.” — Druggist's  Cir¬ 
cular  and  Chemical  Gazette. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine.  * 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  DECEMBER  6,  1890. 


THE  KOCH  TREATMENT  OF  TUBERCULAR  DISEASE. 

It  is  not  to  be  woodered  at  that  the  popular  aud  profes¬ 
sional  interest  excited  by  Professor  Koch’s  announcement  of 
his  discovery  of  a  remedy  for  tubercular  disease  should  be  sus¬ 
tained  until  something  decisive  occurs,  but  it  is  rather  re¬ 
markable  that  it  should  be  manifested  by  certain  doings  and 
projects  that  we  have  rumors  of.  Since  our  last  issue,  abso¬ 
lutely  nothing  has  been  made  known  that  goes  far  to  confirm 
or  to  disprove  the  contention  that  the  remedy  is  really  capable 
of  exerting  the  curative  influence  that  Koch  supposes  it  to  pos 
sess,  although  the  announcement  has  been  made  that  he  him¬ 
self  considers  his  work  in  the  matter  at  an  end  and  is  about  to 
enter  upon  investigations  having  for  their  purpose  the  prepara¬ 
tion  of  similar  antidotes  to  other  infectious  diseases. 

Physicians  from  all  parts  of  the  world  continue  to  flock  to 
Berlin  with  the  hope  of  learning  something  more  about  the 
nature  and  use  of  the  contratubercular  “  clear,  brownish 
liquid,”  which  the  newspapers  are  practically  unanimous  in 
calling  u lymph,”  than  is  to  be  made  out  from  what  has  been 
published  on  the  subject.  As  we  have  said  before,  it  is  exceed¬ 
ingly  doubtful  if  they  will  succeed  in  their  object  to  any  note¬ 
worthy  extent;  nevertheless,  we  have  made  arrangements  by 
which  anything  important  about  the  matter  that  may  be  learned 
by  one  of  them  in  Berlin  will  be  given  to  our  readers  promptly. 
The  worst  that  is  likely  to  happen  to  these  gentlemen,  how¬ 
ever,  is  waste  of  time;  it  is  far  different,  unfortunately,  with 
the  subjects  of  tuberculosis  who  are  undertaking  a  pilgrimage 
to  a  distant  city.  Besides  the  fact  that  the  efficacy  of  the  Koch 
treatment  is  far  from  being  established,  there  is  almost  the  cer¬ 
tainty  that  the  great  majority  of  these  sufferers  will  not  have 
an  opportunity  to  be  submitted  to  it  until  after  their  strength 
has  been  so  exhausted  as  to  seriously  impair  the  probability  of 
their  deriving  from  the  treatment  whatever  benefit  it  may  be 
capable  of  conferring  under  favorable  circumstances. 

The  arrival  of  specimens  of  the  curative  liquid  is  now  ex¬ 
pected  by  several  physicians  in  this  country,  and  it  is  an¬ 
nounced  that  certain  hospitals  have*set  apart  wards  for  pa¬ 
tients  on  whom  its  virtues  are  to  be  tested.  If  adequate 
supplies  are  received,  the  profession  here  will  soon  be  able  to 
furnish  data  on  which  to  found  a  judgment  as  to  the  value  of 
the  supposed  discovery. 

Koch  still  keeps  the  secret  of  the  nature  of  the  liquid,  and 
it  is  intimated  that  it  is  his  intention  to  continue  to  do  so  for 
the  present.  Whatever  justification  there  was  for  that  course 
at  the  outset  does  not  seem  to  be  intensified,  but  rather  weak¬ 
ened,  by  the  march  of  events.  The  profession  will  not  long 
rest  content  with  being  told  that  there  is  too  much  danger  of 


632 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Jock., 


their  making  deadly  blunders  in  case  they  should  try  to  make 
the  product  for  themselves.  It  is  stated  that  the  German  Gov¬ 
ernment  intends  to  go  into  the  business  of  making  it,  and  it  is 
announced  that  that  Government  has  already  provided  hand¬ 
somely  for  carrying  the  treatment  into  effect  and  for  Koch’s 
other  studies.  In  the  mean  time,  there  are  reports  of  a  few 
deaths  having  occurred  under  circumstances  that  naturally  give 
rise  to  the  suspicion  of  their  having  been  due  to  the  injections. 
It  still  remains  to  be  seen  whether  Koch’s  treatment  of  tuber¬ 
cular  disease  rests  on  a  wonderful  discovery  or  on  a  delusion; 
but,  whichever  may  turn  out  to  be  the  case,  it  will  undoubtedly 
lead  to  processes  that  will  eventually  develop  our  mastery  over 
disease  most  notably. 

SURGERY  AND  CRUELTY  TO  ANIMALS. 

It  is  unfortunate  that  an  experiment  in  bone  surgery  now 
in  progress  in  one  of  the  hospitals  of  New  York  should  have 
been  made  the  subject  of  sensational  newspaper  reports  on  the 
one  hand,  and  of  condemnation  in  some  of  the  newspapers  on 
the  other.  We  have  reference  to  the  insertion  of  a  segment  of 
a  dog’s  bone  into  a  vacuity  in  the  bone  of  a  boy’s  leg,  the  seg¬ 
ment  being  still  connected  with  its  original  source  of  blood- 
supply,  so  that  the  dog  requires  to  be  kept  almost  motionless 
for  a  long  period,  and  otherwise  treated  by  restraining  meas¬ 
ures.  All  this,  of  course,  would  be  inexcusably  cruel  if  it  were 
done  wantonly  or  with  no  sufficient  laudable  purpose  in  view, 
and  a  portion  of  the  public  is  apt  to  lose  sight  of  the  praise¬ 
worthy  object,  and  dwell  on  the  dog’s  sufferings.  This  tend¬ 
ency  is  necessarily  heightened  wrhen  a  writer  of  ability  argues 
in  one  of  the  daily  papers  that  the  experiment  is  unnecessary 
and  therefore  unjustifiable,  and  when  his  argument  receives 
editorial  support.  This  is  what  has  happened,  and  the  danger 
is  that  a  public  feeling  will  be  aroused  that  will  lead  the  Legis¬ 
lature  to  cripple  experimentation  by  the  enactment  of  more 
stringent  laws  against  cruelty  to  animals.  Legislation  engen¬ 
dered  by  sentiment  is  prone  to  go  too  far,  and,  to  avoid  such  a 
result  in  this  matter,  it  ought  to  be  made  know’n  to  the  good 
people  who  are  distressed  at  the  boy-and-dog  experiment  that 
it  certainly  was  not  undertaken  as  a  mere  exhibition  of  caprice, 
assuredly  not  as  a  piece  of  cruelty.  There  may  be  equally  good 
methods  of  filling  a  bony  gap  with  new  bone ;  there  may  even 
be  better  ones.  That,  however,  has  not  yet  been  made  a  mat¬ 
ter  of  certainty,  although  the  success  obtained  by  Mr.  A.  G. 
Miller,  of  England,  with  the  use  of  decalcified-bone  chips,  al¬ 
luded  to  in  our  last  issue,  has  been  such  as  to  afford  great  en¬ 
couragement  that  it  soon  may  be  demonstrated.  Until  it  has 
been,  a  surgeon  is  justified,  we  think,  in  using  his  own  judg¬ 
ment  in  the  choice  between  a  procedure  involving  suffering  to 
one  of  the  lower  animals  and  one  that  does  not  involve  that  oc¬ 
currence.  This  is  not  a  matter  of  vivisection  in  the  ordinary 
sense  of  the  word,  aud  it  will  not  do  to  cite  the  statements  of 
physiologists  against  the  utility  of  the  operation.  On  the  other 
hand,  members  of  the  medical  profession  can  not  be  too  care¬ 
ful,  when  they  set  about  any  such  procedure,  to  take  all  possi¬ 
ble  pains  to  carry  it  out  with  every  practicable  mitigation  of 


suffering.  We  have  no  reason  to  think  that  this  was  not  done 
in  the  instance  that  has  been  made  the  subject  of  comment. 


MINOR  PARAGRAPHS. 

THE  USE  OF  MENTHOL  IN  DIPHTHERIA. 

The  antiseptic  properties  of  menthol,  especially  in  cases  of 
diphtheria,  have  received  strong  testimony  in  an  article  by  Ur. 
Herman  Wolf  in  the  Therapeutische  Monatshefte  for  September. 
He  adopts  the  following  form  of  application  :  A  powder  is  pre¬ 
scribed  containing  one  part  of  the  drug  to  ten  or  twenty  parts 
of  sugar;  this  to  be  carefully  applied  by  means  of  a  camel’s- 
hair  brush  to  the  inflamed  and  membrane-covered  parts  of  the 
throat,  which  should  have  been  thoroughly  cleansed  from  all 
mucous  secretions  beforehand.  If  the  nasal  passages  also  are 
involved,  the  powder  should  be  blown  into  the  anterior  nares 
and  upon  the  posterior  pharyngeal  wall.  If  the  process  has  in¬ 
vaded  the  bronchi,  menthol  may  be  sprayed  during  inhalation. 
In  a  somewhat  large  experience  with  it,  Wolf  declares  that  be 
has  found  the  drug  free  from  all  toxic  tendencies,  while  at  the 
same  time  it  is  a  complete  and  prompt  local  antiseptic  in  this 
class  of  cases.  As  he  uses  it,  the  drug  is  unobjectionable  in 
odor  and  taste,  and  has  more  potency  than  many  of  the  gar¬ 
gles  and  sprays  that  are  in  common  use,  but  which  are  far 
more  disagreeable.  In  the  light  of  the  latest  investigations  the 
r61e  of  antiseptic  applications  is  strengthened  in  the  treatment 
of  this  disease.  The  recent  experimental  w7ork  of  Wintgens 
and  others  show,  in  regard  to  the  Klebs-Lbffler  bacillus,  that 
it  is  capable  of  producing  an  exceedingly  poisonous  albumin¬ 
oid  when  cultivated  in  suitable  nutrieut  media.  These  re¬ 
searches  confirm  the  cliuical  value  of  those  antiseptic  applica¬ 
tions  that  destroy  the  virulent  bacillus,  of  which  menthol  is  re¬ 
ported  to  be  one. 


DECENTERED  SPECTACLE  GLASSES. 

It  is  the  exception  rather  than  the  rule  to  see  persons,  in 
the  medical  profession  as  well  as  out  of  it,  wearing  spectacles 
and  eye-glasses  the  centers  of  the  lenses  of  which  correspond 
with  the  visual  axes.  That  more  or  less  asthenopia  may  be 
produced  by  a  faulty  position  of  the  lenses  has  been  admitted 
by  ophthalmologists,  and  in  these  days  when  attention  has  been 
directed  so  strongly  to  the  ocular  muscles  it  may  Dot  be  amiss 
to  ask  whether  certain  cases  of  muscular  weakness  are  not  due 
to  an  habitual  faulty  position  of  a  lens  employed  to  correct  a 
refractive  error.  A  lens  may  be  regarded  as  formed  of  an  in¬ 
finite  number  of  minute  prisms,  each  with  a  different  refracting 
angle,  and  the  only  ray  not  refracted  by  a  lens  is  the  one  which 
passes  through  the  center  of  each  surface.  If  the  lens  is  so 
placed  that  these  centers,  instead  of  coinciding  with  the  axis  of 
vision,  are  displaced  in  any  direction,  a  prismatic  effect  is  ob¬ 
tained,  the  line  of  vision  is  bent  toward  the  center  of  the  lens 
if  it  is  convex,  from  the  center  if  it  is  concave,  and  the  cornea 
is  drawn  in  the  opposite  direction  to  counteract  this  effect  and 
restore  the  line  of  vision  to  its  normal  position.  The  muscle  or 
muscles  which  act  to  produce  this  position  of  the  cornea  and 
correct  the  interference  in  the  line  of  vision  are  habitually  over¬ 
worked.  When  the  displacement  is  not  great  in  amount,  the 
additional  work  thrown  upon  this  muscle  is  not  noticed  by  the 
wearer  of  the  lens,  but  it  seems  as  if  it  must  result  in  a  certain 
amount  of  muscle  strain  proportionate  to  the  strength  of  the 
lens  and  the  degree  of  displacement  of  the  center,  which  may 
be  followed  by  asthenopic  symptoms.  These  considerations 
should  induce  a  greater  degree  of  attention  to  the  accurate  ad¬ 
justment  of  the  centers  of  the  lenses  to  the  visual  axes — atten- 


Dec.  6,  1890.] 


MINOR  PARAGRAPHS. 


633 


tion  which  can  be  paid  by  the  general  practitioner  as  well  as  by 
the  ophthalmologist,  but  is  usually  relegated  to  the  local  opti¬ 
cian  or  jeweler,  whose  sole  idea  is  to  sell  his  customer  a  pair  of 
glasses  with  which  he  can  see  well,  and  who  knows  nothin"' 
about  these  evil  after-effects  of  decentered  lenses. 


IRREGULARITIES  IN  THE  CUTANEOUS  MANIFESTATIONS 
OF  TYPHOID  FEVER. 

Dr.  R.  L.  MaoDonnell,  in  a  clinical  lecture,  in  the  Montreal 
Medical  Journal  for  November,  has  pointed  out  some  atypical 
conditions  of  the  skin  among  his  cases  at  the  General  Hospital. 
The  number  of  patients  with  the  disease — seven  men  and  five 
*  women — was  somewhat  larger  than  usual  at  this  season  of  the 
year,  but  the  type  of  the  disease  has,  for  the  most  part,  been  a 
mild  one.  Unilateral  sweating  was  noticed  in  the  case  of  a 
strong  young  Englishman  who  had  a  fairly  severe  attack  of  the 
fever;  on  the  day  of  his  admission  the  one-sided  sweating  was 
well  marked,  but  it  had  disappeared  three  days  later.  In  one 
case  a  pale  scarlatiniform  rash  was  noted  within  a  few  hours 
after  admission,  confined  to  the  neck  and  shoulders;  it  was  of 
short  duration.  No  medicines  had  been  administered.  In  the 
case  of  a  young  girl,  urticaria  in  distinct  wheals  manifested  it¬ 
self  in  the  third  week  of  an  attack  that  had  not  been  severe. 
In  the  case  of  a  pregnant  woman,  who  had  a  protracted  attack 
of  typhoid,  there  was  jaundice  lasting  three  days.  In  the  case 
of  a  man  who  had  a  sharp  attack,  with  extreme  meteorism,  for 
the  relief  of  which  turpentine  stupes  were  used,  pustules  ap¬ 
peared  upon  the  abdomen  at  the  site  of  the  typhoidal  eruptive 
spots;  in  some  of  these  small  abscesses,  containing  from  half  a 
drachm  to  a  drachm  of  pus,  were  formed.  This  accident  Dr.  Mac- 
Donnell  had  noticed  once  before  as  a  result  of  the  use  of  tur¬ 
pentine  stupes  in  fever.  Four  irregular  forms  of  eruption  in 
typhoid  fever  have  been  specified  by  Moore,  of  Dublin,  such 
as  erythema  fugax,  miliary  eruptions,  erythema  simplex  (seu 
scarlatinale),  and  urticaria.  The  scarlatiniform  rash  is  most 
likely  to  show  itself  at  the  end  of  the  first  week  or  in  the  course 
of  the  third  week,  and  when  it  appears  early  it  is  apt  to  give 
rise  to  diagnostic  embarrassment,  but  the  prodromes  of  scarlet 
fever  are  wanting,  and  the  rash  has  been  of  a  lighter  color,  less 
rough  and  punctiform  than  that  of  the  exanthem  ;  the  rash  is  a 
blush  rather  than  an  eruption,  and  may  be  con.-idered  as  a  result 
of  some  disturbance  of  the  peripheral  vaso-motor  system. 


LEPROSY  IN  COLOMBIA. 

An  official  report  on  the  rapid  spread  of  this  disease  is  con¬ 
tained  in  a  recent  number  of  the  Revista  de  Higiene  de  Bogota. 
It  is  the  result  of  systematic  medical  inquiries  throughout  the 
republic  regarding  the  causes  and  phenomena  of  the  disease  by 
the  Central  Junta  of  Hygiene  of  Colombia.  The  propositions 
of  this  medical  commission  are  of  interest  in  respect  of  the  pri¬ 
mary  steps  of  relief  that  will  be  recommended  to  the  executive 
and  legislative  departments  of  the  Government :  1.  To  solicit 
the  next  Congress  to  pass  a  law  providing  for  the  isolation  of 
individuals  affected  with  leprosy  and  elephantiasis.  2.  To  es¬ 
tablish  a  special  tax  to  defray  the  expense  of  observing  the 
method  of  propagation  of  the  disease  and  for  the  erection  and 
maintenance  of  lazarettos;  and  to  include  this  tax  in  the  cen¬ 
tral  budget  of  the  Government. 


lie  baths  which  can  be  kept  clean  and  free  from  contagion.  In 
order  to  accomplish  this,  shower-baths  only  will  be  used,  the 
water  being  allowed  to  flow  off  into  the  sewer  as  fast  as’it  is 
used.  The  buildings  for  this  sort  of  baths  need  not  be  situated 
on  the  river  front,  but  may  be  in  the  very  heart  of  the  city.  It 
is  calculated  that  a  building  on  an  ordinary  city  lot  may  be  so 
arranged  as  to  accommodate  a  thousand  bathers  daily.  Each 
bath  will  be  in  a  separate  compartment,  with  towel  and  soap 
for  each.  The  baths  may  be  divided  into  two  classes— those  ab¬ 
solutely  free,  and  those  for  which  a  charge  of  five  cents  is  made 
for  some  little  additional  attendance.  The  city  authorities  will 
be  asked  to  furnish  the  water  free  of  cost  in  one  or  more  ex¬ 
perimental  bath-houses  that  will  soon  be  established  in  the 
populous  eastern  regions  of  the  city. 


GREEN  COFFEE  IN  MIGRAINE  AND  GOUT. 

Green  coffee,  in  the  form  of  an  infusion  or  fluid  extract, 
was  formerly  somewhat  used  in  migraine,  but  has  fallen  into 
disuse,  partly,  as  we  believe,  from  its  taste  being  essentially  dis¬ 
agreeable  to  many  patients.  Recently  Dr.  Lauderbilco  has  be¬ 
spoken,  in  the  Journal  de  medecine  de  Paris ,  its  retrial.  He 
recommends  the  use  of  the  infusion  in  the  treatment  of  gout, 
gravel,  nephritic  colic,  and  migraine;  the  varieties  of  coffee  to 
be  used  are  Martinique  one  half,  and  Mocha  and  Isle  de  Bour¬ 
bon  berries,  each,  one  quarter.  Six  drachms  of  this  mixture  are 
placed  in  a  glass  of  water  and  macerated  for  twelve  hours;  the 
contents  are  then  strained  and  the  clear  liquid  is  drank,  without 
the  addition  of  sugar  and  while  the  stomach  is  empty,  prefer¬ 
ably  befoie  breakfast.  Food  may  be  taken  soon  afterward. 
The  results  are  described  as  having  been  so  satisfactory  that  the 
author  gives  the  green  coffee  a  strong  recommendation  in  cases 
of  a  gouty  tendency. 


DR.  SOLIS-COHEN’S  LECTURES. 

In  this  issue  we  conclude  the  publication  of  Dr.  Solomon 
Solis-Cohen’s  two  lectures  on  the  Therapeutic  Principles  gov¬ 
erning  the  Selection  ot  Cardiac  Medicaments.  They  were  de¬ 
livered  in  the  course  at  the  Medical  Department  of  Dartmouth 
College.  We  must  congratulate  that  institution  and  the  Phila¬ 
delphia  Polyclinic  on  having  a  lecturer  capable  of  elucidating 
such  a  subject  so  clearly  as  Dr.  Solis-Cohen  unquestionably  has 
done.  It  is  one  that  practitioners  in  general  are  by  no  means 
versed  in,  and  can  not  readily  acquire  exact  information  upon, 
except  by  a  wide  range  of  reading  or  by  some  such  condensed 
but  thorough  exposition  as  is  given  in  these  lectures. 


THE  ATTR ACTIVENESS  OF  CHICAGO  TO  PHYSICIANS. 

It  was  stated  at  the  recent  annual  meeting  of  the  Illinois 
State  Board  of  Health  that  at  no  time  since  the  organization  of 
the  board  had  there  been  such  an  influx  of  physicians  into 
Chicago  as  within  the  preceding  three  months,  during  which 
time  more  than  two  thirds  of  the  licenses  issued  to  practice 
medicine  were  to  practice  in  Chicago.  It  was  also  stated  that 
never  before  had  there  been  such  a  number  of  quacks  trying  to 
get  a  foothold  in  that  city.  This  was  partly  attributed  to  the 
attractiveness  of  the  prospective  fair,  and  partly  to  the  increase 
of  population. 


A  FORECAST  IN  REGARD  TO  CHOLERA. 


THE  VIENNA  SYSTEM  OF  PUBLIC  BATHS. 

Mayor  Grant  has  had  laid  before  him  a  proposal  for  the 
erection  of  free  baths  on  a  plan  like  those  now  in  successful 
operation  in  Vienna.  The  object  of  this  plan  is  to  supply  pub- 


Dr.  J.  II.  Rauch  is  reported  as  having  said,  at  the  recent 
annual  meeting  of  the  Illinois  State  Board  of  Health,  that  a 
conference  with  the  health  officials  of  Great  Britain  and  Ger¬ 
many  had  given  him  the  impression  that  they  agreed  in  think¬ 
ing  that  there  was  great  danger  of  the  spread  of  cholera  next 


634 


ITEMS!. 


[N.  Y.  Med.  Jour., 


year;  and  as  having  added  that,  after  a  careful  review  of  the 
situation,  he  felt  that  this  country  also  was  in  great  danger  of 
its  introduction,  though  by  extreme  vigilance  at  the  maritime 
ports  this  might  be  prevented. 


THE  ILLNESS  OF  THE  SURGEON-GENERAL. 

As  we  go  to  press,  the  news  in  regard  to  General  Baxter’s 
condition  is,  we  regret  to  say,  not  encouraging,  lie  is  reported 
as  still  in  a  state  of  coma,  which  has  been  continuous  since  the 
apoplectic  seizure  that  occurred  on  Monday.  Me  stdl  hope 
for  information  of  a  favorable  change  in  his  case,  for  he  was  in 
the  height  of  his  mental  vigor  when  he  was  stricken  down,  and 
gave  promise  of  much  valuable  service  in  the  medical  corps  of 
the  army.  _ 

ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  December  2,  1890: 


DISEASES. 

Week  ending  Nov.  25- 

WTeek  ending  Dec.  2. 

Cases. 

Deaths. 

Cases. 

Deaths. 

TVnVmft  fever . 

0 

0 

1 

0 

TVnViniH  fever . . 

23 

7 

25 

3 

Searlet  fever . 

70 

8 

93 

9 

Cerebro-spinal  meningitis . 

2 

193 

2 

11 

3 

225 

3 

12 

78 

26 

90 

28 

ppifill-pox . . . 

1 

0 

1 

0 

Varicella . 

5 

0 

12 

0 

The  Muetter  Lectures  of  the  College  of  Physicians  of  Philadelphia. 

—The  course  of  lectures  on  surgical  pathology  provided  in  accordance 
with  the  will  of  the  late  Professor  Thomas  D.  Mutter  will  be  delivered 
during  1890-91,  by  Professor  Roswell  Park,  of  Buffalo,  N.  Y.  The 
first  series  of  five  lectures  will  be  given  in  the  hall  of  the  College  of 
Physicians,  corner  of  Thirteenth  and  Locust  Streets,  on  December  4th, 
5th,  6th,  8th,  and  9th,  at  8.15  p.  m.  The  subjects  are  as  follows:  1. 
Introductory.  Study  of  the  blood  and  of  some  phases  of  the  inflamma¬ 
tory  process.  Thrombosis,  embolism,  haemoglobin  and  oligochromsemia, 
ptomaines.  Conditions  predisposing  to  infection.  2.  A  study  of  pus 
and  of  pyogenic  organisms,  obligate  and  facultative.  8.  Surgical  sepsis 
and  the  organisms  which  produce  it.  Resume  of  experimental  work, 
surgical  fever,  intestinal  toxaemia,  sapraemia,  septicaemia,  and  pyaemia. 
4.  Peritonitis — forms  and  causes.  Testing  the  relative  values  of  anti¬ 
septics.  5.  Tetany  and  tetanus.  The  medical  profession  are  cordially 
invited  to  be  present. 

The  Mattison  Prize. — With  the  object  of  advancing  scientific  study 
and  settling  a  now  mooted  question,  Dr.  J.  B.  Mattison,  of  Brooklyn, 
offers  a  prize  of  $400  for  the  best  paper  on  Opium  Addiction  as  re¬ 
lated  to  Renal  Disease,  based  upon  these  queries  :  Will  the  habitual  use 
of  opium,  in  any  form,  produce  organic  renal  disease  ?  If  so,  what 
lesion  is  most  likely  to  occur  ?  What  is  the  rationale  ?  The  contest 
is  to  be  open  for  two  years  from  December  1,  1890,  to  either  sex  and 
any  school  or  language.  The  prize  paper  is  to  belong  to  the  Ameri¬ 
can  Association  for  the  Cure  of  Inebriety,  and  be  published  in  a  New 
York  medical  journal,  in  the  Brooklyn  Medical  Journal ,  and  in  the 
Journal  of  Inebriety.  Other  papers  presented  are  to  be  published  in 
some  leading  medical  journal,  as  their  authors  may  select.  All  papers 
are  to  be  in  possession  of  the  chairman  of  the  award  committee  on 
or  before  January  1,  1893.  The  committee  of  award  will  consist  of 
Dr.  Alfred  L.  Loomis,  of  New  York,  chairman;  Dr.  H.  F.  Formad,  of 
Philadelphia;  Dr.  Ezra  H.  Wilson,  of  Brooklyn;  Dr.  George  F.  Shrady, 
of  New  York ;  and  Dr.  J.  II.  Raymond,  of  Brooklyn. 

The  Gastric  Juice  in  Diabetes. — “  In  a  long  article  on  the  condition 
of  the  gastric  juice,  saliva,  and  perspiration  in  diabetes,  Dr.  Ponomaroff 
details  a  number  of  observations  which  lead  him  to  dispute  the  asser¬ 
tions  of  some  previous  observers — e.  y.,  Heller  and  Frick,  who  believed 


that  they  had  detected  sugar  in  these  secretions.  With  regard  to  the 
gastric  juice,  Dr.  Ponomaroff  points  out  that  where  this  is  obtained  by 
making  the  patients  vomit,  what  is  obtained  is  not  the  gastric  juice 
alone,  but  an  admixture  of  that  with  a  certain  quantity  of  bile.  This 
generally  contains  sugar,  and  therefore  vitiates  the  result.  When  the 
oesophageal  tube  is  used  and  the  gastric  juice  free  from  bile  is  obtained, 
there  is,  he  states,  never  any  sugar  in  it.”— Lancet. 

The  New  York  Academy  of  Medicine.— At  the  next  meeting  of 
the  Section  in  Surgery,  on  Monday  evening,  the  8th  inst.,  Dr.  W.  T. 
Bull  will  report  Three  Gases  of  Pylorectomy  for  Cancer  of  the  Stom¬ 
ach,  and  Dr.  R.  F.  Weir,  A  Case  of  Gastro-enterostomy  by  Abbe’s  Rings 
for  Pyloric  Stenosis,  with  Remarks. 

At  the  next  meeting  of  the  Section  in  Genito-urinarv  Surgery,  on 
Tuesday  evening,  the  9th  inst..  Dr.  F.  R.  Sturgis  will  read  a  paper  on  i\ 
subject  to  be  announced,  and  Dr.  Robert  W.  Taylor  one  entitled  Cer¬ 
tain  Clinical  Features  of  Chancre  of  the  Fingers. 

At  the  next  meeting  of  the  Section  in  Pediatrics,  on  Thursday 
evening,  the  11th  inst.,  the  chairman,  Dr.  L.  Emmet  Holt,  will  show  a 
patient  who  has  recovered  after  symptoms  indicating  a  tumor  of  the 
brain;  Dr.  W.  E.  Forrest  will  read  a  paper  entitled  Observations  upon 
the  Influence  of  Artificial  Respiration  on  the  Heart  of  the  Newly  Born; 
Dr.  G.  W.  Rachel,  one  on  Polyuria  in  Infancy ;  and  Dr.  B.  Scharlau, 
one  on  The  Treatment  of  Large  Serous  Elfusions  into  the  Chest  by 
Incision. 

The  Brooklyn  Surgical  Society.— The  special  order  for  the  meeting 
of  Thursday  evening,  the  4th  inst.,  was  the  report  of  a  case  of  oeso- 
phagotomy,  by  Dr.  Jarvis  S.  Wight. 

The  Medical  Society  of  Pennsylvania,  according  to  the  Philadelphia 

American ,  has  recently  applied  for  a  charter. 

An  Organization  of  Railway  Surgeons. — The  surgeons  of  the  Pitts¬ 
burgh  and  Lake  Erie  Railroad  have  organized,  with  Dr.  J.  P.  McCord, 
of  Pittsburgh,  as  president,  for  the  purpose  of  improving  their  co-op¬ 
eration  in  their  work. 

The  Journal  of  the  American  Medical  Association. — It  is  stated 
that  a  resolution  will  be  submitted  to  the  next  meeting  of  the  associa¬ 
tion,  making  Washington,  D.  C.,  the  permanent  place  of  publication  of 
the  Journal. 

The  Medical  Societies  of  Louisville  are  reported  to  have  joined  in 
the  undertaking  of  procuring  a  building  for  their  meetings  and  for  a 
library  and  museum. 

The  Buffalo  Medical  College. — It  is  announced  that  the  college 
building  is  to  be  remodeled  and  added  to  so  that  its  area  will  be  207 
feet  on  Virginia  Street  and  55  feet  on  Pearl  Place. 

The  Worcester,  Mass.,  Lunatic  Hospital. — Dr.  Hosea  M.  Quinbv  has 

been  appointed  superintendent. 

The  Maine  Insane  Hospital. — Dr.  P.  H.  S.  Vaughan,  of  Skowhegan. 
has  been  appointed  an  assistant  physician. 

Change  of  Address. — Dr.  Leo  Ettinger,  to  No.  101  East  Sixtv-first 
Street. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department ,  United  States 
Army,  f  rom  November  23  to  November  29,  1890 : 

Ewing,  Charles  B.,  Captain  and  Assistant  Surgeon,  in  addition  to  his 
present  duties,  is  assigned,  by  direction  of  the  Secretary  of  War,  to 
duty  as  examiner  of  recruits  at  St.  Louis,  Mo.  Par.  7,  S.  0.  275, 
Headquarters  of  the  Army,  A.  G.  O.,  November  24,  1890. 

Naval  Intelligence. — Official  List  of  Changes  in  the  Medical  Corps 
of  the  United  Slates  Navy  for  the  week  ending  November  29,  1890 : 
Crawford,  M.  II.,  Passed  Assistant  Surgeon.  Ordered  to  the  Receiv¬ 
ing-ship  Independence. 

Marsteller,  E.  II.,  Passed  Assistant  Surgeon.  Ordered  to  the  U.  S. 
Steamer  Petrel. 

Nash,  Francis  S.,  Passed  Assistant  Surgeon.  Resigned  from  the  U.  S. 
Navy,  to  take  effect  November  23,  1891. 


Dec.  6,  1&90.J 


ITEMS.— LETTERS  TO  THE  EDITOR. 


635 


Cordeiro,  F.  J.  B.,  Passed  Assistant  Surgeon.  Granted  extension  of 
leave  for  four  months,  with  permission  to  leave  the  United  States. 

Lansdale,  Philip,  Medical  Director  (Retired).  Granted  one  year’s 
leave,  with  permission  to  leave  the  United  States. 

Alfred,  Adrian  Richard.  Commissioned  an  Assistant  Surgeon  in  the 
U.  S.  Navy,  from  November  24,  1890. 

Marine-Hospital  Service. — Official  List  of  Changes  of  Stations  and 

Duties  of  Medical  Officers  of  the  United  States  Marine- Hospital  Service 

for  the  week  ending  November  22,  1890 : 

Fessenden,  C.  S.  D.,  Surgeon.  Granted  leave  of  absence  for  fourteen 
days'.  November  22,  1890. 

Austin,  H.  W.,  Surgeon.  Detailed  as  chairman  of  Board  of  Medical 
Officers  to  convene  in  Washington,  D.  C.,  December  1,  1890.  No¬ 
vember  19,  1890. 

Irwin,  Fairfax,  Surgeon.  Detailed  as  member  of  Board  of  Medical 
Officers  to  convene  in  Washington,  D.  C.,  December  1,  1890.  No¬ 
vember  19,  1890. 

Kinyoun,  J.  J.,  Assistant  Surgeon.  Detailed  as  recorder  of  Board  of 
Medical  Officers  to  convene  in  Washington,  D.  C.,  December  1, 
1890.  November  19,  1890. 

Woodward,  R.  M.,  Assistant  Surgeon.  Granted  leave  of  absence  for 
fourteen  days.  November  21,  1890. 

Condict,  A.  W.,  Assistant  Surgeon.  To  proceed  to  Cairo,  111.,  for 
temporary  duty.  November  19,  1890. 

Stimpson,  W.  G.,  Assistant  Surgeon.  To  proceed  to  Cape  Charles 
Quarantine  for  temporary  duty.  November  20,  1890. 

Promotion. 

Kinyoun,  J.  J.,  Passed  Assistant  Surgeon.  Commissioned  as  Passed 
Assistant  Surgeon  by  the  President.  November  21,  1890. 

Appointment. 

Cofer,  L.  E.,  Assistant  Surgeon.  Commissioned  as  Assistant  Surgeon 
by  the  President.  November  21,  1890. 

Society  Meetings  for  the  Coming  Week : 

Monday,  December  8th:  New  York  Academy  of  Medicine  (Section  in 
Surgery);  New  York  Ophthalmological  Society  (private);  New  York 
Medico-historical  Society  (private);  Lenox  Medical  and  Surgical  So¬ 
ciety  (private)  ;  New  York  Academy  of  Sciences  (Section  in  Chemis¬ 
try  and  Technology) ;  Boston  Society  for  Medical  Improvement ; 
Gynaecological  Society  of  Boston;  Burlington,  Vt.,  Medical  and  Sur¬ 
gical  Club ;  Norwalk,  Conn.,  Medical  Society  (private) ;  Baltimore 
Medical  Association. 

Tuesday,  December  9th:  New  York  Academy  of  Medicine  (Section  in 
Genito-urinary  Surgery);  New  York  Medical  Union  (private);  Medical 
Societies  of  the  Counties  of  Chemung  (quarterly — Elmira),  Oswego 
(semi-annual — Oswego),  Rensselaer,  and  Ulster  (quarterly),  N.  Y. ; 
Norfolk,  Mass.,  District  Medical  Society  (Hyde  Park) ;  Newark, 
N.  J.,  and  Trenton  (private),  N.  J.,  Medical  Associations;  Morris, 
N.  J.,  County  Medical  Society  (semi-annual) ;  Baltimore  Gyneco¬ 
logical  and  Obstetrical  Society. 

Wednesday,  December  10th:  New  York  Surgical  Society;  New  York 
Pathological  Society ;  American  Microscopical  Society  of  the  City 
of  New  York  ;  Medical  Societies  of  the  Counties  of  Albany,  Cayuga 
(semi-annual),  Cortland  (semi-annual),  and  Montgomery  (quarterly), 
N.  Y. ;  Pittsfield,  Mass.,  Medical  Association  (private) ;  Philadelphia 
County  Medical  Society. 

Thursday,  December  11th :  New  York  Academy  of  Medicine  (Section 
in  Paedriatics) ;  Society  of  Medical  Jurisprudence  and  State  Medi¬ 
cine  ;  New  York  Physicians’  Mutual  Aid  Association  (annual)  ; 
New  York  Laryngological  Society  (annual);  Brooklyn  Pathological 
Society ;  Medical  Society  of  the  County  of  Cayuga ;  South  Boston, 
Mass.,  Medical  Club  (private — annual)  ;  Pathological  Society  of 
Philadelphia. 

Friday,  December  12th:  Yorkville  Medical  Association  (private);  Ger¬ 
man  Medical  Society  of  Brooklyn;  Medical  Society  of  the  Town  of 
Saugerties. 

Saturday,  December  13th:  Obstetrical  Society  of  Boston  (private). 


letters  to  %  ^brtor. 


ALVEOLAR  ABSCESS ;  A  REPLY  TO  DR.  J.  D.  MacPHERSON. 

104  East  Fifty-eighth  Street,  New'  York,  / 
November  24,  1890.  i 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  Since  the  establishment  of  a  section  in  dental  and  oral 
surgery  in  the  last  two  International  Medical  Congresses,  and 
the  incorporation  of  a  similar  section  in  the  American  Medical 
Association,  the  recognition  of  dentistry  as  a  distinct  specialty 
of  medicine,  when  practiced  by  medical  men,  has  been  gener¬ 
ally  recognized. 

In  behalf  of  the  large  number  of  medical  men  who  devote 
their  entire  energies  to  the  treatment  of  dental  and  oral  diffi¬ 
culties,  I  would  enter  a  protest  against  the  correctness  of  the 
deduction  made  in  an  article  published  in  your  valuable  journal 
for  November  22,  1890,  by  Dr.  J.  D.  MacPherson,  on  The 
Importance  of  Prompt  Treatment  in  Alveolar  Abscess. 

We  as  dentists  have  to  keep  well  informed  in  general  medi¬ 
cine,  yet  constantly  in  practice  are  we  embarrassed  by  the  lack 
of  correct  information  of  the  profession  at  large  on  simple 
dental  topics.  Nothing  illustrates  this  more  readily  than  the 
errors  the  above-mentioned  aut  hor  tails  into  as  soon  as  he  verges 
upon  a  strictly  dental  sphere. 

His  classification  of  alveolar  abscess  into  superficial  and 
deep  is  rather  original,  hut  will  scarcely  be  adopted  by  an  in¬ 
vestigator.  His  term  superficial  evidently  refers  to  an  old 
chronic  abscess  having  an  old  fistula  leading  to  the  source  of 
trouble,  while  by  deep  is  meant  an  acute  attack  of  alveolar  ab¬ 
scess.  His  criticism  on  dentists  failing  to  extract  teeth  when 
the  tissues  are  in  a  state  of  inflammation  must  be  due  to  a  mis¬ 
conception  of  facts  by  the  author.  Never  have  I  known  or 
heard  of  a  dentist  delaying  extraction  when  once  it  had  been 
determined  upon  for  such  a  cause.  Except  for  dispensary 
patients,  it  is  rare  indeed  that  a  tooth  must  be  extracted  on 
account  of  an  alveolar  abscess.  The  main  object  of  this  com¬ 
munication  is  to  combat  the  conclusion  made  that  immediate 
extraction  of  the  tooth  is  demanded.  Dentistry  may  keep  on 
improving,  but  artificial  teeth  will  be  as  good  as  living  ones 
about  the  time  that  artificial  noses,  eyes,  limbs,  etc.,  are  as  good 
as  living  ones.  The  general  medical  practitioner  places  alto¬ 
gether  too  small  a  value  on  the  utility  of  each  individual  tooth 
and  its  function  as  a  part  of  the  general  digestive  apparatus. 

With  some  rare  exceptions,  common  alveolar  abscess  is 
c  uised  by  the  putrefaction  of  a  dead  pulp,  the  gases  of  which, 
escaping  through  the  apex  of  the  tooth,  produce  an  inflamma¬ 
tion  of  the  pericementum  (not  periosteum)  resulting  in  suppu¬ 
ration,  etc.  Let  us  remember  that  in  these  cases  the  tooth 
itself  is  not  necessarily  dead.  In  the  vast  majority  of  cases 
where  treatment  is  properly  instituted,  the  tooth  never  dies, 
but  circulation  is  carried  on  through  the  living  membrane  in 
the  alveolar  socket,  the  pericementum..  The  course  pursued 
by  the  dental  surgeon  in  these  cases  is  to  first  adjust  a  piece  of 
rubber  dam  so  that  no  saliva  can  come  in  contact  with  the  tooth 
and  infect  the  pulp  canal.  An  opening,  if  not  already  found, 
is  drilled  through  the  crown  of  the  tooth  into  the  pulp  chamber 
on  a  line  leading  direct  to  the  apices  of  the  roots.  The  open¬ 
ing  is  made  sufficiently  large  and  deep  for  every  vestige  of  pulp 
tissue  remaining  in  any  of  the  roots  to  be  entirely  removed. 
This  at  once  relieves  the  sufferings  of  the  patient.  The  canals 
are  then  thoroughly  syringed  with  a  solution  of  chemically 
pure  peroxide  of  hydrogen  and  bichloride  of  mercury;  after 
this,  by  means  of  a  cauterizing  wire,  the  canals  are  completely 
dried.  Their  sides  are  then  wiped  with  one  of  the  essential 


636 


LETTERS  TO  TEE  EDITOR. 


[N.  V.  Wed.  Jolr., 


oils,  and  the  apex  of  the  root  is  hermetically  sealed  with  some 
material  like  a  solution  of  gutta-percha  in  chloroform,  and  the 
tooth  is  filled  in  the  customary  manner.  If  any  inflammatory 
action  sets  in  after  such  an  operation  is  properly  performed,  the 
seat  of  the  trouble  is  no  longer  in  the  tooth,  but  in  the  apical 
space,  and  it  is  generally  effectively  treated  by  abortive  meas¬ 
ures;  if  it  is  more  serious,  an  opening  is  made  through  the 
alveolar  process  and  simple  surgical  measures  are  used.  The 
great  danger  in  all  these  cases  arises  from  the  septic  symptoms 
liable  to  occur,  due  to  the  absorption  of  pus.  The  most  danger¬ 
ous  and  insidious  cases  are  those  in  which  there  have  been 
established  fistulas  leading  outside  the  alveolus.  The  pain  sub. 
sides,  and,  the  patient  paying  no  further  attention  to  the  mat 
ter,  the  abscess  lapses  into  a  state  of  chronicity,  classified  as 
superficial  by  Dr.  MaePherson,  because  w’hen,  after  short 
intervals  of  rest,  the  foul  pulp  in  the  tooth  starts  up  the  latent 
abscess,  it  requires  very  little  pressure  for  it  to  force  its  way 
through  its  old  channels  and  out  of  the  alveolus,  leaving  be¬ 
hind  a  zone  of  necrotic  tissue,  affecting  also  the  apex  of  the 
tooth.  Only  in  such  cases  as  these  can  any  part  of  the  tooth 
he  said  to  be  dead.  Even  here,  if  the  tooth  is  treated  as  before 
mentioned,  and  the  alveolar  tract  enlarged  down  to  the  root, 
removing  all  the  dead  portion  of  the  tooth,  as  well  as  the 
necrotic  tissue  surrounding  it,  the  parts  will  all  return  to  a 
condition  of  health  and  the  tooth  continue  to  do  good  service 
even  after  half  of  the  root  is  amputated. 

M.  L.  RnEiN,  M.  D.,  D.  D.  S. 

THE  GONOCOCCUS  OF  NEISSER  AND  ARTHRITIC  EFFUSIONS. 

667  Madison  Avenue,  November  13,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal : 

Sir:  In  an  article  by  Dr.  H.  Koplik,  entitled  Arthritis  com¬ 
plicating  Vulvo-vaginal  Inflammation  in  Children,  published  in 
the  Journal  for  June  21,  1890,  I  note  the  following  :  “  Petrone 
and  Kammerer  relate  cases  in  which  they  have  discovered  the 
diplococcus  in  joint  effusions  in  both  the  male  and  female. 
Kammerer  questions  the  investigations  of  Brieger  and  Ehrlich 
as  to  the  presence  of  the  micro-organism  of  Neisser  in  joint  ef¬ 
fusions,  and  states  that  the  joint  fluid  should  be  examined  very 
soon  after  infection  of  the  urethra — three  to  five  days.  If 
this  be  done  they  can  be  easily  demonstrated.  It  is  an  ungrate¬ 
ful  task  to  criticise  the  work  of  others,  but,  in  a  true  spirit  of 
investigation,  I  beg  to  say  that  I  have  carefully  looked  into  the 
work  of  Kammerer  in  the  two  cases  above  mentioned,  and  find 
only  the  statement  of  the  presence  of  diplococci ;  these  were 
found  simply  free,  not  in  the  pus  cells,  and  there  were  no  cult¬ 
ures  made.” 

I  should  feel  loath  to  question  the  investigations  of  two  such 
workers  in  the  field  of  pathology  as  Brieger  and  Ehrlich.  I 
only  tried  to  give  an  explanation  of  the  unsuccessful  attempt  of 
these  two  gentlemen  to  find  micro-organisms  in  the  effusions  of 
gonorrhoeal  rheumatism,  and  suggested  that  their  cases  might 
have  been  of  older  standing,  in  which  the  cocci  had  disappeared 
in  the  fluid.  But  I  have  nowhere  stated,  as  is  attributed  to  me 
that  gonococci  can  be  easily  demonstrated  in  effusions  from 
three  to  five  days  after  infection  of  the  urethra.  If  the  author 
of  the  paper  had  “  carefully  looked  into  ”  my  work,  I  do  not 
think  he  could  have  attributed  this  statement  to  me.  I  have 
never  asserted  that  gonococci  could  be  “  easily  ”  demonstrated 
in  the  joints  ;  on  the  contrary,  I  distinctly  said  that  in  the  only 
case  in  which  I  had  found  them  they  were  present  in  small 
numbers.  I  stated  at  the  time  of  my  publication  that  the  three 
cases  that  had  yielded  a  positive  result  on  microscopic  exami¬ 
nation  of  the  joint  effusion  had  been  examined  within  five  days 
after  the  appearance  of  the  joint  affections,  but  I  drew  no  gen¬ 
eral  conclusions.  Tbat  I  am,  however,  also  credited  with  hav¬ 


ing  said  the  joint  fluids  should  be  examined  three  to  five  days 
after  injection  of  the  urethra ,  is  an  oversight  on  the  part  «>f  the 
author  difficult  to  explain.  I,  at  least,  have  never  seen  a  joint 
affection  developing  in  so  short  a  time  after  infection  of  the 
urethra,  and  have  consequently  made  no  assertion  to  this  effect. 

That  I  relied  only  on  the  grouping,  staining,  and  size  of  the 
cocci  in  classifying  them  as  the  coccus  of  Neisser,  and  made  no 
cultures,  is  a  matter  I  regret  as  much  as  Dr.  Koplik.  During 
the  summer  of  1883,  when  these  cases  came  under  my  observa¬ 
tion,  the  knowledge  of  the  methods  of  bacteriological  culture 
was  the  privilege  of  only  a  favored  few.  Since  then,  however, 
I  have  become  acquainted  with  the  difficulties  attending  the 
cultivation  of  the  coccus  Neisser  on  blood  serum,  and  on  that 
account,  I  believe,  its  cultivation  from  the  effusions  in  joints 
will  seldom  prove  a  success. 

Whether  the  coccus  Neisser  or  some  pyogenic  germ  is  the 
cause  of  the  joint  affections  in  gonorrhoea]  rheumatism  is,  1  pre¬ 
sume,  still  an  unsettled  question.  Many  observations  in  both 
directions  have  been  published.  Judging  from  the  different 
character  of  the  effusion  and  the  different  clinical  course  which 
these  affections  pursue,  I  think  that  both  modes  of  infection  are 
possible — a  view  which  I  am  not  the  first  to  express.  How¬ 
ever  this  may  be,  I  have  alwmys  believed  that  the  main  value  of 
my  paper,  if  indeed  it  had  any,  lay  in  the  discovery  of  micro¬ 
organisms  in  the  joints,  not  especially  of  the  coccus  Neisser. 

Frederick  Kammerer,  M.  D. 


THE  LIBRARY  OF  THE  NEW  YORK  HOSPITAL; 

AN  ERROR  CORRECTED. 

New  York,  November  29,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal  : 

Sir:  At  the  recent  inauguration  of  the  new  Academy  build¬ 
ing  an  address  was  delivered  by  .me  of  the  speakers,  upon  the 
subject  of  Our  Library,  which  contained  the  following  very  er¬ 
roneous  statement:  “Thirty-three  years  ago,  when  I  was  ad¬ 
mitted  a  member  of  this  Academy,  there  was  no  medical  library 
or  medical  reading-room  in  this  city.” 

Whence  the  writer  got  his  information  I  know  not,  for  so 
frequently  has  the  history  of  the  library  of  the  New'  York  Hos¬ 
pital  been  written  and  published  by  city  compilers  and  by 
United  States  Government  officials  that  it  seems  strange  that 
one  possessed  of  the  general  inforrmition  of  the  speaker  should 
not  have  known  that  the  library  of  the  New  York  Hospital  was 
founded  in  1:96,  and  that  when  he  became  a  member  of  the 
Academy  it  contained  6,180  volumes  and  occupied  three  apart¬ 
ments,  two  of  them  on  the  second  and  third  floors  of  the  old 
hospital,  joined  by  an  iron  staircase.  All  this  was  as  far  back 
as  1857 ;  thus  it  appears  that  our  city  had  a  medical  library  of 
no  mean  capacity  thirty-three  years  ago,  and  was  used  by  the 
profession  and  by  students  of  medicine. 

John  L.  Yandervooet,  M.  D.,  Librarian. 


THE  LARYNGOLOGY  OF  TROUSSEAU  AND  GREEN. 

Home  for  Incurables,  Fordham,  N.  Y.,  October  30,  1890. 
To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  In  your  issue  for  August  30th,  current  year,  there  is  an 
article  on  the  Laryngology  of  Trousseau  and  Dr.  Horace  Green, 
by  Dr.  Frank  Donaldson,  of  Baltimore,  to  which  I  wish  to  add 
a  few  historical  corrections,  so  as  to  make  that  article  complete. 
In  1838  Dr.  Green  went  to  Europe,  accompanying  the  Rev.  Dr. 
Schroeder,  of  Astoria.  It  was  at  that  time  that  Dr.  Green  had 
the  conversation  with  Dr.  James  Johnson,  the  editor  of  the 
Medico-chirurgical  Review.  Subsequently  to  that,  the  British 
and  Foreign  Medical  Review  was  established,  with  Dr.  John 
Forbes  as  editor.  After  Dr.  Green's  return  from  Europe  he 


Dec.  6,  1890  ] 


LETTERS  TO  THE  EDITOR.— BOOK  NOTTChS . 


637 


commenced  to  make  a  practical  application  of  the  treatment 
which  had  been  suggested  to  him  by  Dr.  Johnson  in  his  conver¬ 
sation,  and  in  1846  he  published  his  treatise  on  Bronchitis ,  in 
which  the  results  of  his  work  in  that  direction  were  given  to 
the  public.  In  1849  I  went  to  Europe  and  carried  with  me  a 
number  of  copies  of  Dr.  Green’s  work,  which  had  been  hand¬ 
somely  noticed  by  Dr.  Forbes  in  the  British  and  Foreign  Medi¬ 
cal  Review.  I  remained  in  Europe  until  the  fall  of  1852.  While 
in  Paris,  I  recollect  that  the  author  of  the  article,  Dr.  Frank 
Donaldson,  of  Baltimore,  was  a  fellow-student  at  the  same  time, 
attending  Professor  Trousseau’s  lectures  at  the  Children’s  Hos¬ 
pital.  Until  then  Dr.  Green’s  treatment  had  been  by  means  of 
the  sponge  probang.  During  the  summer  of  1852  1  wrote  to 
Dr.  Green  that  it  was  time  for  him  to  come  abroad  and  look 
after  his  own  interests.  He  accordingly  came,  and  had  an  in¬ 
terview  with  Professor  Trousseau  at  the  H6tel  Meurice  in  Paris. 
I  returned  to  this  country  with  him  in  October  of  that  year. 
In  1854  I  made  a  second  visit  to  Europe,  and  while  in  Paris  I 
had  an  interview  with  Professor  Trousseau,  who  was  then  at 
the  H6tel  Dieu,  having  taken  to  him  a  letter  of  introduction 
from  Dr.  Barker,  who  was  Dr.  Green’s  colleague  in  the  New 
York  Medical  College.  I  attempted  to  demonstrate  upon  a  pa¬ 
tient  in  the  wards  under  Professor  Trousseau  the  feasibility  and 
practicability  of  carrying  a  sponge-armed  probang  into  the 
larynx  and  below  the  vocal  cords  into  the  trachea,  so  as  to  con¬ 
vince  Professor  Trousseau.  He  still  persisted  jn  denying  its 
feasibility,  and  I  accepted  his  invitation  to  demonstrate  it  upon 
a  body  in  the  dead-house  of  the  hospital.  We  all  went  down 
into  the  dead-house.  I  passed  the  instrument,  and  then  per¬ 
formed  on  the  body  the  operation  of  tracheotomy,  and  saw  the 
probang  in  the  larynx  through  the  opening  made  in  the  trachea. 
Professor  Trousseau  then  objected  because  the  vital  conditions 
were  chauged  by  the  death  of  the  subject.  I  then  undertook 
to  make  some  experiments  on  the  dead  body  at  Clamart,  well 
known  to  students  of  anatomy  in  Paris.  I  carried  a  catheter 
which  was  made  more  or  less  firm  by  the  introduction  of  a 
mandrin  which  I  had  made  purposely,  articulated  to  the  end  of 
which  I  secured  a  sponge  of  about  the  size  of  that  used  by  Dr. 
Green  on  the  probangs  in  his  office.  My  experiments  were  suc¬ 
cessful,  and  I  then  received  the  impression  that  a  tube  of  the 
caliber  of  the  catheter  might  be  used  with  success  to  inject 
through  it  a  weak  solution  of  nitrate  of  silver.  The  result  of 
this  experimentation  I  wrote  to  Dr.  Green,  and  while  I  was  on 
shipboard.  On  my  return  home,  Dr.  Green  had  instituted  a 
practice  of  catheterism  of  the  air-passages  by  which  a  weak 
solution  of  nitrate  of  silver  could  be  carried  into  the  trachea, 
and,  as  he  averred,  lower  down  into  the  right  or  left  bronchus, 
at  will.  Until  then  the  term  catheterization  had  not  been  used. 

J.  H.  Douglas,  M.  D. 


HYDROGEN  PEROXIDE  IN  DIPHTHERIA. 

1189  Madison  Avenue,  November  8 ,  1890. 

To  the  Editor  of  the  New  YorTc  Medical  Journal : 

Sib:  I  wTould  suggest  the  following  local  treatment  for  diph¬ 
theria:  The  application  to  the  membrane  of  Marchand’s  solu¬ 
tion  of  peroxide  of  hydrogen,  fifteen  volumes,  with  an  equal 
bulk  of  water,  then  scraping  the  membrane  off  with  a  curette 
and  applyingthe  peroxide  of  hydrogen,  one  third  dilution,  every 
hour  for  six  or  seven  hours,  then  every  two  hours.  If  there  is 
no  reappearance  of  membrane  after  two  days,  spray  the  throat 
occasionally  with  an  antiseptic  spray.  In  this  way  the  mem¬ 
brane  is  removed  at  once.  The  operation  is  done  at  a  period  of 
the  disease  when  there  is  no  danger  of  heart  failure,  so  that  the 
struggles  of  a  child  need  not  be  minded. 

I  am  aware  that  the  removal  of  the  membrane  in  former 


years  was  regarded  as  somewhat  dangerous,  but  at  that  time 
nothing  was  known  of  disinfectants  and  germicides. 

It  would  seem  that  a  remedy  which,  applied  to  the  diph¬ 
theritic  membrane,  removed  it  after  some  hours,  would  prevent 
its  formation.  In  tolerant  patients  the  peroxide  may  be  put  on 
three  or  four  times,  so  as  to  be  sure  of  complete  disinfection 
before  curetting.  A  small  Thomas’s  uterine  curette  answers 
the  purpose  admirably.  A  patient  treated  as  described  was 
comparatively  well  in  two  days.  David  Phillips,  M.  I). 


LIGATION  OF  THE  LIMBS  IN  HAEMORRHAGE. 

Adirondack  Cottage  Sanitarium,  November  11 ,  1890. 

To  the  Editor  of  the  New  YorTc,  Medical  Journal : 

Sib  :  A  certain  contributor  to  the  Journal  of  November  1st, 
page  488,  would  have  us  believe  that  he  was  the  original  dis¬ 
coverer  of  the  process  of  ligating  the  limbs  for  haemorrhage ! 
He  “  would  suggest  the  following  plan,”  and,  having  “  made  ex¬ 
tensive  use  of  these  bands,”  can  “  now  feel  a  good  deal  of  con¬ 
fidence  in  recommending  them  to  others,”  etc.  Does  he  not 
know  that  this  procedure  is  as  old  as  the  hills,  and  is  called  liga¬ 
tion  of  the  base  of  the  extremities  in  every  standard  text- book 
on  minor  surgery,  not  to  mention  the  many  encyclopaedic  arti¬ 
cles  on  haemorrhage  and  haemostasis?  It  would  not  be  just  to 
the  history  of  our  art  to  allow  such  a  presumption  to  pass  un¬ 
noticed.  W.  W.  Skinner,  M.  D. 


do k  Sottas. 


Klinische  und  anatomische  Beitrage  sur  Pathologic  des  Gehirns 
Von  Dr.  Salomon  Ebebhard  IIensciien,  Profes«order  klin- 
ischen  Medicin,  Direktor  der  medicinisehen  Ivlinik  an  der 
Universitat  Upsala.  Erster  Theil.  Mit  36  Tafeln  und  3 
Karten.  Upsala:  Almquist  &  Wiksell,  1890.  4to,  pp.  215. 

These  magnificent  clinical  and  anatomical  contributions  to 
the  pathology  of  the  brain  emanate  from  the  University  of  Up¬ 
sala,  Sweden.  The  book,  however,  is  not  written  in  Sw  edisb, 
but  in  German,  which,  fortunately,  will  make  it  practically  use¬ 
ful  to.  all  natious.  It  is  well  known  that  much  of  our  present 
knowledge  ot  the  physiology  and  pathology  of  the  human  brain 
is  the  result  of  careful  study  of  rather  poorly  reported  cases 
scattered  through  the  literature  of  past  years,  and  collected  at 
a  time  when  the  thoroughness  and  completeness  of  clinical  ob¬ 
servation  were  not  so  great  as  now.  Every  investigator  who 
endeavors  to  make  use  of  this  old  material  for  the  solution  of 
new  problems  soon  ascertains  how  defective  and  often  even 
useless  it  is.  A  new  and  richer  material  is  desirable  to  insure 
the  progress  of  cerebral  pathology.  With  this  object  in  view 
Professor  Henschen  has  issued  this  first  volume  of  his  work,  a 
second  being  also  nearly  ready.  The  author  believes  it  neces¬ 
sary,  in  such  clinico-pathological  studies,  to  accompany  them 
with  systematic  drawings  or  photographs  of  the  pathological 
esions  in  their  natural  size.  Hence  the  issue  of  this  book  in 
quarto  form  to  give  space  for  the  thirty-six  plates  which  illus¬ 
trate  the  text.  It  may  be  remarked  here  that  these  plates  are 
marvels  of  lithographic  art.  A  number  of  them  are  in  color, 
reproducing  perfectly  sections  stained  by  the  Weigert  method. 

This  whole  volume  deals  with  the  clinical  manifestations 
and  pathological  findings  in  lesions  of  the  optic  tract,  and  is 
iased  upon  thirty-six  cases  which  have  come  under  the  author’s 
observation,  in  nearly  all  of  which  autopsies  have  been  made. 
The  histories  of  these  cases,  together  with  the  description  of 
the  autopsies  and  microscopical  examinations — all  of  which  are 


638 


BOOK  NOTICES. 


[N.  Y.  Med.  Jouh., 


written  with  remarkable  scientific  precision  and  detail — are 
grouped  into  fourteen  chapters  with  the  following  headings: 

1.  Secondary  changes  in  the  optic  tract  in  a  case  of  bilateral 
bulbar  atrophy  (one  case). 

2.  The  visual  path  in  one-eyed  persons  (eight  cases). 

3.  Changes  in  the  optic  tract  in  lesion  of  the  corpus  genicu- 
latum  externum  (two  cases). 

4.  Hemianopsia  following  gummatous  basal  meningitis  (one 
case). 

5.  Tumors  of  the  chiasm  (two  cases). 

6.  Hemianopsia  from  haemorrhage  into  the  thalamus  (one 
case). 

7.  Visual  disturbances  from  bilateral  changes  in  the  optic 
radiations  (three  cases). 

8.  Hemianopsia  following  softening  of  the  optic  radiation 
(two  cases). 

9.  Cortical  haemianopsia  (three  cases). 

10.  Tumors  in  the  optic  radiation  without  hemianopsia 
(three  cases). 

11.  Cortical  changes  in  the  occipital  lobe  without  hemian¬ 
opsia  (two  cases). 

12.  The  visual  path  after  lesion  of  the  optic  radiation  (one 
case). 

13.  A  contribution  to  color  hemianopsia  (two  cases). 

14.  Cases  of  hemianopsia  (five  cases). 

It  would  be  impossible  in  a  short  review  to  call  attention  to 
all  the  invaluable  features  of  this  book.  It  is  hoped,  however, 
that  some  idea  of  its  character  may  be  gained  from  the  titles  of 
chapters  given  above,  and  the  following  points,  taken  at  ran¬ 
dom,  will  serve  to  illustrate  some  of  the  new  observations  made 
as  well  as  the  carefulness  with  which  cases  have  been  studied. 
I  he  author  has  observed  hemianopsia  in  two  cases  of  infantile 
spastic  hemiplegia.  Both  patients  had  reached  adult  life,  and 
the  hemianopsia  had  existed  seventeen  or  eighteen  years.  In 
one,  the  hemiopic  pupillary  reaction  was  present.  Hemianop¬ 
sia  has  not  been  noted  in  any  of  the  recent  contributions  to  the 
literature  of  infantile  cerebral  palsy  (Osier,  Sachs,  and  Peter¬ 
son),  although  these  authors  together  describe  nearly  three  hun¬ 
dred  cases.  They  could  not  have  examined  the  patients  for 
that  condition,  for,  had  this  been  done,  undoubtedly  many  would 
have  presented  this  symptom. 

Professor  Henschen  also  relates  three  or  four  cases  of  ho¬ 
monymous  hemiopic  hallucinations,  such  as  were  recently  de¬ 
scribed  in  this  Journal,  but  occurring  with  hemiplegia  and  hemi¬ 
anopsia,  and  not  with  insanity. 

The  microscopical  observations  in  this  work  are  based  upon 
the  laborious  examination  of  some  10,000  specimens. 

In  point  of  typography  and  lithography,  the  volume  is  a 
rare  specimen  of  book-making.  The  second  volume  is  to  ap¬ 
pear  shortly.  The  whole  work  is  one  that  no  neurologist  can 
afford  to  be  without,  and  every  ophthalmologist  should  be  the 
possessor  of  this  first  volume. 

It  is  needless  to  say  that  such  a  work  could  hardly  be  pub¬ 
lished  at  private  expense,  and  it  reflects  credit  upon  the  Swed¬ 
ish  Government  and  the  University  of  Upsala  that  they  should 
have  contributed  a  sum  sufficient  to  make  its  appearance  pos¬ 
sible. 


Dust  and  its  Dangers.  By  T.  Mitchell  Phudden,  M.  D.,  etc. 

New  York:  G.  P.  Putnam’s  Sons,  1890.  Pp.  111.  [Price, 

75  cents.] 

If  this  volume  meets  with  the  popularity  it  deserves,  not 
only  will  it  be  a  source  of  profit  to  its  publishers  and  of  in¬ 
creased  reputation  to  its  able  author,  but — more  important — it 
will  exercise  an  influence  in  domestic  administration  that  will 
be  advantageous  to  the  entire  community. 


A  comprehensive  review  of  the  biological  character  of  dust, 
botli  out  of  doors  and  indoors,  leads  to  the  consideration  of  its 
real  significance  in  relation  to  disease,  and  especially  to  con¬ 
sumption.  With  trenchant  pen  the  author  deals  with  the  dust 
dangers  of  public  streets,  buildings,  and  conveyances,  and  the 
comparison  of  the  sanitary  activity  displayed  when  yellow 
fever,  small- pox,  or  Asiatic  cholera  threatens  a  community, 
with  the  indifference  constantly  shown  toward  consumption  is 
vividly  depicted  in  the  sentence,  "‘yet  the  number  of  victims  of 
these  occasional  and  dramatic  epidemics  is  quite  insignificant 
as  compared  with  those  of  our  omnipresent  consumption.” 

Of  the  measures  preventive  against  dust,  suffice  it  to  say  that 
Dr.  Prudden  believes  that,  as  Opies’s  success  with  colors  con¬ 
sisted  in  mixing  them  “  with  brains,”  so  “  with  brains”  must 
the  dust  question  be  disposed  of. 

The  excellent  illustrations  drawn  by  the  author  are  quite 
valuable  in  emphasizing  the  teaching  of  the  book,  that  can  not 
fail  to  be  as  valuable  to  the  professional  as  to  the  lay  reader. 


Medical  Diagnosis ,  with  Special  Reference  to  Practical  Medi¬ 
cine.  A  Guide  to  the  Knowledge  and  Discrimination  of 
Diseases.  By  J.  M.  Da  Costa,  M.  D.,  LL.  D.,  Professor  of 
Practice  of  Medicine  and  of  Clinical  Medicine  at  the  Jeffer¬ 
son  Medical  College,  Philadelphia.  Illustrated  with  Engrav¬ 
ings  on  Wood.  Seventh  Edition,  revised.  Philadelphia:  J. 
B.  Lippincott  Company,  1890.  Pp.  16-17  to  995.  Price,  $6.] 

That  this  work  has  gone  through  six  editions  is  sufficient 
evidence  of  the  value  placed  upon  it  by  the  medical  profession. 
And,  while  this  present  edition  is  an  improvement  upon  its 
predecessors,  it  is  not  quite  so  thorough  as  the  most  popular 
text-book  ou  the  subject  should  be.  For  instance,  there  is  no 
description  of  the  manner  in  which  the  ophthalmoscope  or  the 
stomach  tube  is  to  be  used — a  deficiency  that  is  manifested 
when  the  careful  description  of  laryngoscopic  methods  is  read. 
Again,  in  such  matters  as  the  method  of  detecting  the  Argyll 
Robertson  pupil,  and  in  the  methods  of  discovering  the  differ¬ 
ent  pathogenic  bacteria,  there  is  a  paucity,  if  not  omission,  of 
detail  that  is  possibly  due  to  the  author’s  assumption  that  most 
of  his  readers  are  as  familiar  with  these  matters  as  he  is. 

In  the  chapter  on  examination  of  the  blood  Hayem’s  latest 
researches  have  been  incorporated;  but  tbe  consideration  of  the 
examination  of  the  blood,  as  in  relapsing  and  malarial  fevers,  is 
not  so  complete  as  it  should  be. 

We  note  these  deficiencies  as  indicating  a  weakness  in  what 
would  otherwise  be  the  best  work  on  medical  diagnosis  in  the 
English  language.  Accustomed  as  we  are  to  the  excellent  in¬ 
dex  in  most  of  our  medical  works,  the  omission  of  references 
to  subject-matter  in  this  volume  suggests  that  the  index  has 
been  completely  forgotten. 

Original  Contributions  to  Ophthalmic  Surgery.  By  J.  R. 
Wolfe,  M.  D.,  F.  R.  G.  S.  E.,  Professor  of  Ophthalmology  in 
St.  Mungo’s  College,  Senior  Surgeon  to  the  Glasgow  Oph¬ 
thalmic  Institution.  With  Illustrations.  London:  J.  &  A. 
Churchill,  1890.  Pp.  2  to  97. 

This  little  work  is  a  brief  abstract  of  clinical  demonstrations 
in  ophthalmic  subjects,  in  three  chapters,  the  first  being  devoted 
to  cataract  extraction.  Dr.  Wolfe  regards  the  use  of  cocaine 
as  detrimental  to  union  after  section  of  the  cornea,  as  it  de¬ 
prives  the  tissue  of  the  necessary  vitality  for  adhesion  to  take 
place.  Ills  operations  for  cataract  extraction  are  always  pre¬ 
ceded  by  iridectomy.  This  is  contrary  to  the  present  practice 
of  many  ophthalmologists,  who  think  that  the  perfection  of  the 
operation  is  in  securing  the  round  pupil.  His  treatment  ofde- 


Dec.  6,  1890.] 


BOOK  NOTICES. 


639 


tached  retina  does  not  differ  materially  from  that  practiced  by 
the  American  operators.  A  short  chapter  is  given  on  plastic 
operations  and  skin  grafting.  The  point  made  is  that  a  pedicle 
is  not  at  all  necessary  to  the  vitality  of  a  flap  or  graft,  and  that 
the  typical  graft,  either  large  or  small,  is  to  be  thin  and  entirely 
devoid  of  areolar  tissue.  It  is  difficult  to  understand  how  the 
author  could  have  imagined  that  such  an  effort  was  essential  to 
the  progress  of  ophthalmology. 

A  Treatise  on  Massage,  Theoretical  and  Practical ;  its  History, 
Mode  of  Application  and  Effects,  Indications  and  Contra¬ 
indications,  with  Results  in  over  Fifteen  Hundred  Cases. 
By  Douglas  Graham,  M.  D.,  Fellow  of  the  Massachusetts 
Medical  Society,  etc.  Second  Edition,  revised  and  enlarged. 
New  York:  J.  H.  Vail  &  Company,  1890.  Pp.  x-342. 

The  author  considers  the  freedom  with  which  his  book  has 
been  quoted  and  stolen  from  on  both  sides  of  the  Atlantic  in  a  cer¬ 
tain  sense  highly  complimentary.  Two  new  chapters  have  been 
added — one  on  local  massage  in  local  neurasthenia,  and  the  other 
on  the  treatment  of  scoliosis  by  means  of  massage.  Attention 
is  called  to  the  fact  that  the  motor  points  which  give  the  best 
contraction  to  faradization  are  the  same  that  give  the  best  con¬ 
traction  to  percussion.  There  are  chapters  on  the  history  of 
massage,  its  method  of  application,  its  physiological  effects,  and 
its  use  in  disease  of  the  nerves,  muscles,  internal  organs,  and 
articulations,  together  with  numerous  histories  of  cases  treated 
and  the  results  obtained,  all  of  which  is  interesting  and  sug¬ 
gestive  reading. 


Lectures  on  Massage  and  Electricity  in  the  Treatment  of  Dis¬ 
ease  (Mass<  -flectrotherapeutic-).  By  Thomas  Stretch 
Dowse,  M.  D.,  Fellow  of  the  College  of  Physicians  of  Edin¬ 
burgh,  etc.  New  York :  E.  B.  Treat  &  Company,  1890.  Pp. 
xix-379.  [Price,  $2.75.] 

Tns  fifteen  chapters  of  this  book  are  devoted  to  the  princi¬ 
ples  of  massage,  the  mode  and  method  of  applying  massage, 
massage  of  the  head  and  neck,  massage  and  induction,  faradaic 
massage  of  the  skin,  massage  of  muscle  and  nerve,  massage  of 
the  venous  aud  lymph  circulations,  the  Weir  Mitchell  treat¬ 
ment,  massage  of  the  chest  and  abdomen,  massage  in  nervous 
exhaustion  and  hysteria,  massage  of  the  spine  and  back,  mass- 
ao®  joint  and  bursal  affections,  massage  in  sleeplessness,  pain, 
dipsomania,  and  melancholia,  massage  in  the  wasting  diseases 
of  children,  and  in  the  diseases  of  sedentary,  changing,  and  ad¬ 
vanced  life,  electro-physics,  and  electro-therapeutics.  The 
value  of  mechanical  measures  is  becoming  thoroughly  recog¬ 
nized  in  England  and  America.  In  Germany  it  has  long  been 
held  in  high  repute  for  the  treatment  of  chronic  disease.  To 
redeem  all  mechanical  measures  from  the  hands  of  the  charla¬ 
tan  is  one  of  the  present  offices  of  the  physician.  What  has 
been  so  ably  done  in  behalf  of  electricity  a  book  like  the  one 
under  consideration  helps  to  do  for  massage.  The  illustrations 
are  excellent  guides  and  the  whole  work  is  practical  and  sug¬ 
gestive. 

Transactions  of  the  Royal  Academy  of  Medicine  in  Ireland. 
Vol.  VII.  Edited  by  William  Thomson,  M.  A.,  F.  R.  G.  S. 
Dublin  :  Fannin  &  Co.,  1889. 

This  volume  is  of  the  same  excellence  as  its  predecessors, 
and  the  Academy  of  Medicine  in  Ireland  is  to  be  congratulated 
on  the  material  that  its  Fellows  bring  for  its  consideration. 
The  papers  are  arranged  as  medical,  surgical,  obstetrical,  patho¬ 
logical,  hygienic,  anatomical,  and  physiological.  As  the  latest 
paper  was  read  in  the  spring  of  1889,  it  will  be  noticed  that 
this  Academy  suffers  from  the  misfortune  of  most  societies  in 


publishing  its  volume  when  active  interest  in  the  subject-matter 
is  cold.  Another  feature  is  the  omission  of  any  dUcussion  on 
the  papers,  and  we  can  hardly  believe  that  they  were  not  worth 
discussing. 

The  Medical  Student's  Manual  of  Chemistry.  By  R.  A.  Witt- 
iiaus,  A.  M.,  M.  D.,  Professor  of  Chemistry  and  Physics  in 
the  University  of  the  City  of  New  York.  etc.  Third  Edition. 
New  York:  William  Wood  &  Co.,  1890.  Pp.  xii-528. 

I  his  standard  work  is  too  well  and  favorably  known  to  our 
leaders  to  make  any  extended  review  necessary.  In  consonance 
with  the  original  plan  of  the  volume,  additions  have  been  made 
to  the  chapters  on  chemical  physics,  mineral  chemistry,  and  the 
chemistry  of  the  carbon  compounds,  so  as  to  introduce  the 
latest  discoveries  on  these  subjects,  and  so  retain  the  Manual 
in  the  foremost  rank  of  medical  test  books. 


Text-book  of  Materia  Medica  for  Nurses.  Compiled  by  La- 
vinia  L.  Dock,  Graduate  of  the  Bellevue  Training  School 
for  Nurses,  Superintendent  of  Grace  Memorial  House.  New 
\ork  and  London:  G.  P.  Putnam’s  Sons,  1890. 

The  name  of  this  work  indicates  its  object — to  furnish  a 
text-book  of  materia  medica  which  will  include  the  points  that 
a  nurse  needs  to  know,  and  exclude  the  portion  which  is  of  use 
solely  to  the  medical  profession.  The  outlines  followed  are 
those  taught  in  the  Bellevue  Training  School,  and  include  some¬ 
thing  of  the  source  and  composition  of  drugs,  their  physiological 
actions,  the  signs  which  indicate  their  favorable  or  unfavorable 
action,  the  symptoms  produced  by  poisons,  with  their  anti¬ 
dotes,  and  practical  points  on  the  administration  of  medicines. 
It  is  written  very  concisely,  and  little  can  be  found  in  it  to  criti¬ 
cise  unfavorably,  except  the  inevitable  danger  that  the  student 
will  imagine  after  reading  it  that  the  whole  subject  has  been 
mastered.  The  subject  of  therapeutics  has  been  omitted  as  not 
a  part  of  a  nurse’s  study,  and  this  omission  is  highly  to  be  com¬ 
mended.  It  will  prove  a  valuable  book  for  the  purpose  for 
which  it  is  intended. 


A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  By  J. 
Lewis  Smith,  M.  D.,  Clinical  Professor  of  Diseases  of  Chil¬ 
dren,  Bellevue  Hospital  Medical  College,  etc.  Seventh 
Edition,  thoroughly  revised.  With  Fifty-one  Illustrations. 
Philadelphia:  Lea  Brothers  &  Co.,  1890.  Pp.  xiv-33  to 
900.  [Price,  $4.50.] 

Among  the  physical  disorders  treated  of  in  this  new  edition 
of  Dr.  Smith’s  valuable  work  on  children's  diseases  not  men¬ 
tioned  in  earlier  editions,  are  conjunctivitis,  icterus,  sepsis,  um¬ 
bilical  diseases,  hsematemesis,  melaena,  sclerema,  oedema,  and 
pemphigus  of  the  new-born.  Epilepsy,  tetany,  appendicitis, 
typhlitis,  and  perityphlitis  also  receive  attention.  Dr.  Joseph 
O’Dwyer  contributes  a  paper  on  intubation  of  the  larynx. 
All  the  important  pertinent  facts  that  modern  research  have 
brought  to  light  are  embodied  in  the  present  volume,  thus 
bringing  it  up  to  date  and  giving  it  the  dignity  of  ultimate 
authority  upon  the  subjects  of  which  it  treats. 

Epilepsy ;  its  Pathology  and  Treatment.  Being  an  Essay  to 
which  was  awarded  a  Prize  of  Four  Thousand  Francs  by 
the  Acad6mie  Royale  de  M6decine  de  Belgique,  December 
31,  1889.  By  Hobart  Amory  Hare,  M.  D.,  Clinical  Pro¬ 
fessor  of  Diseases  of  Children  and  Demonstrator  of  Thera¬ 
peutics  in  the  University  of  Pennsylvania,  etc.  Philadel¬ 
phia:  F.  A.  Davis,  1890.  Pp.  228. 

The  author  states  that  this  essay  upon  epilepsy  was  consid¬ 
ered  by  the  Royal  Academy  of  Medicine  in  Belgium  as  worthy 


040 


BOOK  NOTICES— RETORTS  ON  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Mkd.  Jotjb., 


of  a  prize  of  four  thousand  francs.  This  is  sufficient  reason  for 
its  present  appearance  in  book  form.  It  is  representative  of 
the  present  views  concerning  the  pathology  and  treatment  of 
epilepsy,  aDd,  if  there  is  nothing  new  in  the  two  hundred  and 
twenty-eight  pages,  it  is  because  nothing  new  concerning  the 
disease  and  its  treatment  is  definitely  known. 


Practical  Sanitary  and  Economic  Cooling  adapted  to  Persons 
of  Moderate  and  Small  Means.  By  Mrs.  Mary  Hinman 
Abel.  The  Lomb  Prize  Essay.  Published  by  the  Ameri¬ 
can  Public  Health  Association,  1890.  Pp.  xi-190. 

This  is  a  new-fashioned  cook-book  compiled  with  reference 
to  physiology.  The  dietaries  are  arranged  to  give  the  proper 
proportion  of  proteid,  carbohydrate,  and  hydrocarbon  in  the 
daily  food  of  all  who  desire  the  best  nourishment  for  little 
money.  There  is  an  introduction  explaining  food  principles, 
and  there  are  chapters  devoted  to  methods  of  cooking  meat, 
vegetables,  and  the  cereals,  cookery  for  the  sick,  and  bills  of 
fare  of  the  first,  second,  and  third  class,  with  the  cost  given. 
The  little  book  contains  much  information  of  value.  The  great 
problem  is  to  get  the  class  for  which  it  is  intended  to  read  it. 


Ointments  and  Oleates  especially  in  Diseases  of  the  Skin.  By 
John  V.  Shoemakek,  A.  M.,  M.  D.,  Professor  of  Materia 
Medica,  Pharmacology,  Therapeutics,  and  Clinical  Medicine, 
and  Clinical  Professor  of  Diseases  of  the  Skin  in  the  Medico- 
chirurgical  College  of  Philadelphia,  etc.  Second  Edition, 
revised  and  enlarged.  Philadelphia :  F.  A.  Davis,  1890. 
Pp.  ix-298. 

During  the  past  ten  or  fifteen  years  the  oleates  have  been 
prescribed  with  considerable  advantage.  Since  the  appearance 
of  the  first  edition  of  Dr.  Shoemaker’s  book  in  1885  there  has 
been  marked  improvement  in  the  quality  of  preparations  of 
oleic  acid  and  its  salts.  The  author  lias  aimed  to  make  a  com¬ 
plete  survey  of  fatty  substances  as  applied  to  the  human  body, 
and  has  extended  the  scope  of  the  present  work  so  as  to  include 
a  consideration  of  ointments.  The  official  lists  of  France,  Ger¬ 
many,  and  Austria,  together  with  those  used  in  Italy,  Spain, 
and  the  Spanish  colonies,  have  been  compiled  from  all  accessi¬ 
ble  sources.  And  thus  Ointments  and  Oleates  serves  as  a  con¬ 
spectus  of  the  whole  subject  of  inunction. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

Rhinoplasty.  Being  a  Short  Description  of  One  Hundred  Cases 
treated  by  Tribhovandas  Motichaud  Shah,  L.  M.,  Assistant  Surgeon  and 
Chief  Medical  Officer,  Junagadh.  At  the  Junagadh  Hospital.  With 
Illustrations  and  Remarks.  Printed  at  the  Junagadh  Sarkari  Press, 
1889.  Pp.  130. 

One  Hundred  Consecutive  Cases  of  Cataract,  operated  upon  by  T. 
M.  Shah,  L.  M.,  etc. 

On  the  Treatment  of  Eczema  in  Elderly  People.  By  L.  Duncan 
Bulkley,  A.  M.,  M.  D.,  New  York.  [Reprinted  from  the  Transactions 
of  the  Medical  Society  of  the  State  of  New  YorkJ] 


Reports  on  i\ n  progress  of  Utebkhw. 


DERMATOLOGY. 

By  GEORGE  THOMAS  JACKSON,  M.  D. 

Oleum  Physeteris  seu  Chaenoceti  is  the  euphonious  title  of  a  vehicle 
for  skin  medication  introduced  to  us  by  Dr.  Guldberg,  of  Copenhagen 
Monatshft.  f.  prkt.  Derm.,  1890,  vol.  x,  No.  10).  To  most  of  us  it 


sounds  as  strange  as  the  Syrian  tongue,  though  we  feel  a  little  encour¬ 
aged  when  we  note  that  one  of  its  synonyms  has  the  good  English  ring  of 
“  bottlenose  oil.”  As  a  matter  of  fact,  it  is  a  species  of  whale  oil  taken 
from  a  whale  that  is  found  in  the  fjords  of  Norway,  whose  scientific 
name  is  Balcena  rostrata,  or  Hyperodon  rostrata.  The  oil  has  a  re¬ 
markable  penetrating  power,  as  proved  by  experiments.  It  was  found 
to  pass  through  the  human  skin  in  eight  hours  by  simply  resting  in  con¬ 
tact  with  it,  while  olive  oil  did  not  so  pass  in  twenty-four  hours.  It 
contains  a  large  amount  of  stearin  and  readily  saponifies.  Its  specific 
gravity  is  less  than  that  of  other  animal  oils.  It  would  seem  to  promise 
well  as  a  means  of  lubricating  the  skin,  and  of  causing  medicinal  sub¬ 
stances  to  penetrate  the  skin.  It  combines  readily  with  various  medi¬ 
cines,  such  as  chloroform,  carbolic  acid,  mercury,  lead,  salicylic  acid,  sul¬ 
phur,  naphthol,  aristol,  iodoform,  and  iodine.  We  are  promised  a  fu¬ 
ture  paper  upon  the  subject.  In  the  mean  time  the  above-mentioned 
substances  have  been  used  in  various  combinations  with  the  oil  as  a 
vehicle. 

Aristol,  the  much-lauded  new  drug,  is  now  standing  its  trial.  In 
the  Ann.  de  derm,  et  de  syph.,  1890,  No.  7,  we  find  three  reports  upon 
it:  one  by  Schirren,  from  the  Berlin,  klin.  Wochnsch.,  1890,  p.  252  ; 
one  by  Seifert,  from  the  Wiener  klin.  Wochnsch.,  1890,  p.  342;  and 
one  by  Brocq,  from  the  Bull,  et  mem.  de  la  Soc.  medic,  des  hopitaux ,  1890, 
p.  350.  It  was  found  to  be  unirritating,  slow,  but  effective  in  cur¬ 
ing  psoriasis  in  ten-per-cent,  strength  (Schirren  and  Seifert).  In 
lupus  it  was  useless  in  three  cases  (Schirren  and  Seifert),  and  cura¬ 
tive  in  one  case  (Seifert).  It  proved  curative  for  ulcers  of  the  leg 
and  tertiary  syphilitic  ulcers  (Seifert  and  Brocq),  for  epithelioma- 
tous  ulceration  (Brocq),  and  mucous  patches  (Seifert).  It  helped 
one  case  of  eczema  intertrigo,  and  greatly  irritated  one  of  seborrhcea) 
eczema  (Seifert). 

Another  Method  of  using  Resorcin  in  Skin  Diseases  is  proposed  by 
Dreckmann  (Monatshft.  f.  p.  Dermat.,  1890,  No.  9,  p.  389)  and  is  as 
follows:  The  diseased  part  is  covered  with  a  layer  of  linen  or  lint  satu¬ 
rated  with  au  aqueous  solution  of  resorcin  of  one-  -to  three-per-cent, 
strength,  and  this  is  covered  by  an  impermeable  bandage  of  oil-cloth  (?) 
or  rubber.  It  acts  by  macerating  the  part,  since  it  keeps  it  in  a  moist 
heat ;  it  protects  it  from  injury  ;  and  it  hastens  the  cornification  of 
the  epithelial  cells  on  account  of  the  resorcin.  It  has  proved  useful 
in  moist  eczemas  of  children,  but  is  to  be  discontinued  when  the 
moisture  diminishes.  It  is  then  to  be  followed  by  mild  lead,  zinc,  or  sul¬ 
phur  ointments.  Hyperplastic  thickenings  of  the  skin  resulting  from 
chronic  eczema,  such  as  of  the  scrotum,  do  well  up  to  a  certain  point, 
when  other  means  must  be  used  to  complete  the  cure.  [It  is  a  question 
whether  the  resorcin  has  any  action  in  the  improvement  effected  by  this 
dressing.  We  certainly  have  obtained  more  brilliant  results  in  similar 
cases  by  the  use  of  rubber  alone,  either  with  or  without  the  interposi¬ 
tion  of  a  piece  of  linen  between  the  bandage  and  the  skin.] 

The  Elimination  of  Iodide  of  Potassium  by  the  Kidneys  has 
been  studied  by  Dr.  Elders,  of  Copenhagen  (Annal.  de  derm,  et  de 
syph.,  1890,  1,  383).  He  finds  that,  on  account  of  the  rapid  absorption 
and  elimination  of  the  iodide,  there  is  little  danger  of  intoxication  by  it, 
even  in  large  doses,  so  long  as  the  kidneys  remain  sound.  All  cases  of 
intoxication  by  the  iodide  have  been  in  patients  with  diseased  kidneys, 
and  in  them  it  is  found  that  symptoms  of  iodism  showed  themselves 
when  only  half  of  the  amount  taken  was  excreted  by  the  kidneys. 
Under  normal  conditions,  when  the  patient  is  taking  20  grammes  (about 
300  grains)  of  the  iodide  during  the  day,  the  urine  will  contain  the  salt 
in  the  proportion  of  about  seventy-five  to  eighty  parts  in  one  hundred 
of  urine.  If  more  than  this  amount  is  taken,  absorption  seems  to  be 
incomplete.  All  the  ingested  salt  seems  to  be  eliminated,  no  matter 
what  the  amount  taken,  within  four  or  five  days  after  stopping  the 
drug.  The  only  objection  our  author  sees  to  the  administration  of 
large  doses  of  the  iodide  to  patients  with  normal  kidneys  is  its  cost. 
But  he  makes  the  novel  suggestion  that  this  expense  may  be  reduced 
by  gathering  the  urine  from  these  patients  and  from  it  making  fresh 
iodine  ! 

Pigmentation  of  the  Human  Skin. — Philippson,  of  Hamburg,  has 

studied  with  care  the  subject  of  pigmentation  of  the  human  skin,  and 
now  ( Fortschritte  d.  Med.,  189U,  viii,  216)  gives  us  the  conclusions  be 
has  arrived  at  from  his  observations.  He  thinks  that  there  is  a  differ- 


Dec.  6,  1890.J 


REPORTS  ON  TnE  PROGRESS  OF  MEDICINE. 


641 


ence  between  the  human  skin  and  that  of  salamanders  and  frogs  that 
was  studied  by  Ehrmann,  in  that  thechromatophores  of  the  latter  are  in 
the  human  subject  replaced  by  the  “  mast”  cells  of  Ehrlich,  the  plasma 
cells  of  Waldeyer.  These  form  a  chain  around  the  blood-vessels,  follow 
the  capillaries  into  the  papillae,  and  sooner  or  later  join  the  pigment  cells. 
Our  author  thinks  that  certain  cells  take  from  the  blood  a  colorless 
granular  material,  which  they  pass  on  from  cell  to  cell.  Gradually  this 
material  in  its  passage  becomes  changed  to  pigment,  and  at  last  is  de¬ 
posited  in  the  tissues.  Thus  far  no  explanation  is  forthcoming  of 
how  the  “  material  ”  is  taken  out  of  the  blood  and  changed  into  pig¬ 
ment.  Though  this  theory  can  not  be  anatomically  demonstrated,  it  is 
considered  to  be  justified  by  the  following  facts:  1.  At  the  border  line 
where  “  mast”  cells  and  pigment  cells  are  found  together  in  the  heaps 
of  pigment  granules  a  few  “  mast  ’’-cell  granules  are  found,  and  also 
among  the  mast-cell  granules  a  few  pigment  granules  are  found,  or  two 
collections  of  pigment  granules  are  connected  by  means  of  mast-cell 
granules.  2.  In  the  white  mouse  there  is  absolutely  no  pigment.  In 
the  deeper  layers  of  its  skin  the  mast  cells  are  seen  full  of  granules, 
while  in  the  papillary  layer  of  the  skin  they  have  very  few  granules. 
In  the  gray  mouse  pigmentation  is  but  slight,  and  in  them  the  mast 
cells  have  likewise  little  pigment  in  the  papillae.  3.  In  the  human  skin 
the  pigment  cells  are  placed  in  rows  into  which  mast  cells  are  fre¬ 
quently  inserted.  4.  In  many  preparations  the  mast  cells  are  found 
between  the  epithelial  cells.  5.  In  the  skin  of  the  black  paws  of  the 
guinea-pig  there  are  hardly  any  pigment  cells,  but  mast  cells.  6.  In 
the  adder’s  embryo  there  are  colorless  cells  that  correspond  to  the  mast 
cells,  and  these  at  first  are  in  the  lower  layers  of  the  epidermis.  They 
seem  to  have  some  close  relation  to  the  pigment  formation. 

The  Pathogeny  of  the  Cutaneous  Lesions  is  the  title  of  a  suggestive 
article  by  M.  Jacquet  in  Annales  de  dermatologie  et  de  syphiligraphie, 
1890,  i,  486.  His  idea  is  that  a  great  variety  of  cutaneous  lesions  may 
be  dependent  upon  the  same  underlying  cause — a  vaso-motor  disturb¬ 
ance;  and  that  many  of  our  supposed  distinct  diseases  of  the  skin  are 
not  really  such,  but  merely  forms  of  manifestation  of  the  same  disease — 
a  neurosis.  He  thus  would  find  a  close  relationship,  if  not  identity,  be¬ 
tween  urticaria  and  lichen  ruber,  and  holds  both  as  being  purely  due  to 
an  external  irritation,  so  far  as  the  lesions  are  concerned.  He  points 
out  that  the  pruritus  is  the  first  symptom  in  both  diseases ;  that  this 
induces  the  scratching,  which  in  one  disease  is  followed  by  wheals  and 
in  the  other  by  an  eruption  of  acuminated  papules.  The  external  origin 
of  many  skin  lesions  is,  he  believes,  demonstrated  by  the  simple  experi¬ 
ment  of  wrapping  a  tumefied  part  tightly  in  a  dry  bandage,  when  the 
swelling  will  completely  disappear.  He  did  this  in  an  undiagnosticated 
case  of  tumefaction  of  the  skin  which  had  lasted  more  than  a  year,  and 
saw  the  part  return  to  its  normal  color  and  size  in  less  than  ten  days. 
He  believes  that  the  same  nervous  disturbance  will  produce  now  one 
lesion  and  now  another,  according  to  whether  the  vaso-motor  influence 
acts  on  the  arterial  or  venous  capillaiies  or  the  lymphatics,  and  ac¬ 
cording  to  the  condition  of  the  walls  of  the  vessels  themselves.  As  to 
the  cause  of  the  vaso-motor  disturbance  we  are  still  in  ignorance.  As 
a  working  hypothesis,  we  may  suppose  that  it  is  a  toxine  secreted  in 
the  organism  by  pathological  or  non-pathological  microbes  acting  upon 
a  nervous  system  disturbed  by  a  moral  shock,  alcoholism,  excesses, 
fatigue,  and  the  like. 

A  Case  of  Stigmata  is  reported  by  P.  Ferroud  in  the  Loire  medicate , 
March  15,  1890,  in  the  person  of  a  prostitute,  eighteen  years  old,  who 
was  hysterical.  The  haemorrhages  took  place  from  the  nasal  and  con¬ 
junctival  mucous  membranes,  the  external  auditory  canals,  and  the  skin 
of  different  parts  of  the  body.  They  appeared  most  frequently  one  or 
two  days  after  the  cessation  of  the  menses,  and  lasted  one  or  more 
weeks.  They  began  like  little  vesicles  or  slight  elevations,  and  with 
a  dull  pain.  The  affected  area  slowly  spread. 

Lupus  of  the  Extremities,  according  to  Dr.  F.  Hahn  ( Archiv  f. 
Derm.  u.  Syph.,  1890,  xxii,  473),  is  met  with  very  frequently  in  the  clinic 
of  Professor  Doutrelepont,  of  Bonn,  no  fewer  than  one  hundred  and  five 
cases  having  been  entered  there  from  June,  1882,  to  January,  1890. 
These  formed  245  per  cent,  of  the  entire  number  of  lupus  cases. 
Fifty-eight  of  them  occurred  in  males  and  forty-seven  in  females.  In 
forty-nine  of  the  cases  the  original  location  of  the  disease  was  on  the 
extremities,  while  in  forty-four  it  was  first  seen  on  the  face,  in  nine  on 


the  neck,  and  in  three  on  the  trunk.  In  only  eight  cases  was  the  disease 
on  the  extremities  the  only  symptom  of  tuberculous  disease.  In  the  rest 
there  were  evidences  of  enlarged  glands,  diseased  lungs,  or  hereditary 
tubercular  tendency,  and  in  two  cases  the  mothers  had  lupus.  In  more 
than  one  quarter  of  the  cases  (26-6  per  cent.)  the  disease  began  before 
the  fifth  year  of  life.  The  upper  extremities  were  affected  fifty-five 
times,  lower  extremities  thirty-two  times,  and  the  upper  and  lower  ex¬ 
tremities  together  eighteen  times.  The  extensor  surfaces  were  much 
more  often  affected  than  the  flexor  surfaces.  In  fourteen  cases  there 
were  only  old  lupus  scars  ;  in  thirty-nine,  lupus  serpiginosus  ;  in  four¬ 
teen  each,  lupus  vulgaris,  exulcerans,  and  hypertrophicus  ;  and  in  twelve 
cases  lupus  papillosus.  Under  the  last  division  are  included  cases  of 
tuberculosis  verrucosa  cutis,  which  is  regarded  as  unworthy  of  a  sepa¬ 
rate  title,  its  only  distinguishing  feature  being  its  superficiality.  Lupus 
caused  very  little  interference  with  the  functions  of  the  limbs,  except¬ 
ing  in  cases  where  it  was  very  widely  distributed  and  produced  very 
extensive  scars.  Occasionally  when  the  lupus  process  surrounds  the 
limb,  or  nearly  so,  and  begins  to  cicatrize  in  some  places,  the  pressure 
from  the  cicatrix  will  give  rise  to  obstruction  of  the  circulation,  to 
an  oedematous  state,  and  finally  to  a  condition  of  the  extremity  like  ele¬ 
phantiasis,  and  sometimes  requiring  amputation  for  relief.  Caries  of 
the  joint  may  likewise  give  rise  to  interference  with  the  function  of  the 
limb. 

Tuberculosis  Verrucosa  Cutis  is  the  subject  of  a  contribution  to  the 
Archiv  fur  path.  Anat.  und  Phys.  und  fur  Min.  Med.,  1890,  Heft  3,  by 
Dr.  Brugger,  of  Wurzburg.  In  his  case  the  disease  was  located  on  the 
right  leg  of  a  man  twenty-two  years  old,  of  healthy  parentage,  and  had 
existed  since  his  third  or  fourth  year  of  age.  Apart  from  the  skin  lesion, 
the  man  was  in  good  health.  The  affected  leg  was  covered  with  a 
number  of  cicatrices  and  appeared  somewhat  thickened,  and  its  skin 
felt  hard  and  leathery.  Over  the  tendo  Achillis  and  on  the  back  of  the 
foot  there  was  a  recent  bluish-red  cicatrix,  in  the  neighborhood  of 
which  were  scattered  numerous  large  and  small  elevations  of  the  skin. 
Along  the  side  of  the  foot  there  were  three  ulcerations  with  broad 
bases  and  overhanging  edges.  On  the  inner  side  of  the  thigh  there  were 
several  old  cicatrices  and  one  recent  one.  Sections  from  the  new 
^esions  contained  tubercle  bacilli,  and  inoculation  experiments  upon  a 
guinea-pig  were  successful,  the  animal  dying  of  tuberculosis  within  six 
weeks.  Brugger  believes  that  this  is  the  first  time  that  an  attempt  has 
been  made  to  inoculate  an  animal  with  a  piece  of  a  lesion  of  tubercu' 
losis  verrucosa  cutis,  and  that  the  positive  result  is  of  great  value  in 
deciding  the  nature  of  the  disease.  It  is  to  be  diagnosticated  from 
lupus  by  an  absence  of  the  characteristic  lupus  tubercles,  by  its  having 
no  disposition  to  return  in  the  cicatrices,  and  by  being  more  superficial. 
Otherwise  their  course  is  very  much  alike.  From  syphilis  the  diagnosis 
is  made  by  an  absence  of  the  infiltrated  wall  and  dirty  brown-red  color 
of  the  syphilitic  ulcer,  by  its  much  more  chronic  course,  and  by  the 
more  deforming  cicatrices  that  it  leaves.  It  is  probable  that  the  so. 
called  verruca  necrogenica  is  the  same  as  tuberculosis  verrucosa  cutis- 
Why  infection  of  the  skin  by  the  tubercle  bacillus  should  at  one  time 
produce  lupus,  at  another  time  a  tuberculous  ulcer,  at  another  time  ver¬ 
ruca  necrogenica,  and  at  yet  another  time  tuberculosis  verrucosa  cutis, 
is  a  yet  unanswered  question.  It  is  probable  that  individual  peculiari¬ 
ties  have  something  to  do  with  it.  The  virulence  of  the  poison  may 
also  play  a  part  in  determining  the  nature  of  the  lesion.  It  is  possible 
to  have  a  general  infection  of  the  system  follow  a  local  infection,  though 
this  is  exceptional.  This  event  may  take  place  either  through  the  lym¬ 
phatics  or  through  the  blood. 

The  treatment  must  be  by  destruction  of  the  lesion  by  excision,  by 
scratching  out  with  the  curette,  by  caustics,  or  by  a  combination  of 
either  of  the  first  two  methods. 

Keloid  forms  the  subject  of  an  interesting  study  by  Leloir  and 
Vidal  (Anna/.,  de  derm,  et  de  syph.,  1890,  No.  3).  They  follow  the  usual 
division  into  two  varieties — the  true  keloid,  primary,  developing  sponta¬ 
neously,  and  rare,  which  they  name  the  spontaneous  keloid ;  and  the 
false  keloid,  secondary  to  a  pre-existing  cicatrix,  which  they  denominate 
the  cicatricial  keloid.  Symmetry  in  development  is  regarded  by  them 
as  characteristic  of  the  true  keloid.  The  growths  enlarge  with  more  or 
less  rapidity  till  they  attain  to  a  certain  size,  when  they  remain  station¬ 
ary.  Barely  do  they  undergo  spontaneous  diminution  in  size.  Sometimes 


642 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


|N.  Y.  Med.  Jottr., 


they  form  bands  or  cushion-shaped  or  claw-shaped  figures ;  sometimes 
they  form  flattened,  convex,  or  slightly  concave  plates ;  sometimes  they 
are  quadrilateral,  or  oval,  or  crab-shaped.  Superficially  the  skin  seems  of 
normal  consistence,  the  glandular  orifices  being  preserved  and  the  hairs 
not  destroyed,  though  they  are  generally  of  the  lanugo  variety.  The 
new  growth  is  located  in  the  corium,  so  that  the  epidermal  layer  is 
intact;  and,  as  it  never  goes  beyond  the  thickness  of  the  skin,  the 
tumor  is  always  freely  movable  upon  the  underlying  parts.  The  thick¬ 
ness  of  the  new  growth  is  as  much  as  15  mm.  at  times  (about  five 
eighths  of  an  inch).  The  color  is  rosy,  sometimes  with  teleangeiectases 
over  the  surface  of  the  tumor  and  at  its  periphery.  The  color  may  be 
deeper  at  one  time  than  at  another,  and  menstruation  is  said  to  have 
the  effect  of  darkening  the  color.  The  tumors  are  firm  and  elastic,  in¬ 
dolent  or  painful  on  pressure  or  spontaneously.  True  keloids  are 
more  numerous  in  the  same  subject  than  the  false  variety  and  do  not 
reach  so  great  a  size  as  a  rule.  There  is  a  predisposition  to  these 
growths  inherent  in  the  skin  of  those  who  are  subject  to  them.  Micro¬ 
scopical  examination  of  the  tumors  shows  that  the  epidermis,  interpapil- 
lary  prolongations,  and  papillae  are  of  normal  appearance,  and  this  at 
once  distinguishes  the  true  from  the  false  keloid.  The  true  keloid  is 
located  in  ^the  corium.  In  its  center  there  are  no  glands,  but  in  the 
upper  and  lower  part  of  it  we  find  strangulated  hair  follicles  and  flat¬ 
tened  and  altered  sebaceous  and  sweat  glands,  which  become  of  more 
and  more  normal  appearance  as  we  approach  the  periphery  of  the 
tumor.  No  alteration  of  the  nefves  has  yet  been  found.  The  tumors 
often  seem  to  stand  in  relation  to  an  altered  sebaceous  gland,  and  it 
may  be  that  they  take  origin  in  an  acne  pustule. 

The  false  or  cicatricial  keloid  is  not  identical  with  the  hypertrophied 
cicatrix.  It  arises  secondary  to  some  injury,  no  matter  if  even  so  slight 
a  one  as  the  prick  of  a  pin,  in  a  predisposed  individual.  It  is  specially 
prone  to  follow  a  deep  injury  or  a  burn.  It  may  not  begin  for  years 
afterthe  injury,  but  it  always  begins  in  a  cicatrix.  If  several  scars  are, 
present  on  the  same  part,  all  are  not  affected.  As  in  the  true  keloid, 
the  sites  of  predilection  for  the  tumors  are  the  sternal  and  mammary 
regions,  the  shoulders,  the  posterior  part  of  the  neck,  the  buttocks, 
the  arms,  and  rarely  the  legs.  They  rarely  appear  during  old  age.  The 
size  of  the  tumor  is  in  no  sort  of  proportion  to  the  extent  of  the  injury. 
It  grows  rather  faster  than  the  true  keloid,  and  exceeds  the  limit  of  the 
original  cicatrix,  in  this  differing  from  the  hypertrophied  scar,  which 
does  not  advance  beyond  the  borders  of  the  cicatrix.  Its  surface  is 
mother-of-pearl-like,  shining,  smooth,  without  any  sign  of  papillas 
glandular  orifices,  hair,  or  lanugo.  As  it  enlarges,  the  outer  parts  are 
less  altered  in  appearance.  The  hypertrophied  scar  does  not  go  beyond 
the  original  loss  of  substance,  is  redder,  more  vascular,  and  softer  than 
the  keloid,  and  has  no  prolongations  into  the  sound  skin  ;  it  usually  is 
painless,  and  sometimes  terminates  by  resolution. 

The  treatment  that,  according  to  our  authors,  is  the  most  to  be 
relied  on  is  by  multiple  scarifications.  These  are  to  be  made  at  two 
millimetres'  distance  from  each  other  and  crossed  in  such  a  wav  as  to 
describe  square  or  lozenge-shaped  figures  on  the  skin,  deep  enough 
to  reach  almost  to  the  depth  of  the  tumor,  and  long  enough  to  just  go 
beyond  its  borders.  Before  scarifying,  the  part  must  be  anaesthetized. 
There  is  but  little  loss  of  blood,  and  the  bleeding  is  soon  and  easily 
checked.  Immediately  after  the  operation  the  par#  is  to  be  dressed 
with  boric  acid  and  the  next  day  covered  with  mercurial  plaster,  which 
is  changed  every  morning  and  evening.  These  scarifications  are  to  be 
repeated  until  the  growth  disappears,  which,  it  is  said,  it  will  do. 

A  Case  of  Congenital  Alopecia  is  reported  by  Dr.  P.  de  Molhnes  in 
Annodes  de  dermat.  et  de  syph.,  1890,  i,  548.  The  patient  was  a  girl 
whose  mother  had  had  an  attack  of  alopecia  areata  when  she  was  nine¬ 
teen  years  old,  and  whose  brother  had  gone  through  the  same  experi¬ 
ence  when  he  was  six  years  old.  In  the  mother  and  the  boy  the  dis¬ 
ease  was  promptly  mastered.  The  little  girl  was  born  so  long  after  the 
others  had  recovered  that  contagion  could  not  be  thought  of  as  a  cause. 
The  child  was  born  with  an  almost  imperceptible  down  upon  the  scalp, 
no  eyebrows,  hardly  visible  eyelashes,  and  well-developed  nails.  Upon 
the  nape  of  the  neck  and  occiput  there  was  a  series  of  very  minute 
vascular  naevi.  The  child  was  robust,  well  developed,  and  lively.  At 
five  months  of  age  the  rudimentary  eyelashes  fell  out,  and  the  scalp 
became  white  and  smooth.  At  sixteen  months  of  age  a  hand-glass 


showed  the  hair  follicles  of  the  skin  to  be  open,  but  no  sign  of  hair. 
There  was  no  keratosis  pilaris.  Dentition  was  normal.  Under stimu¬ 
lating  treatment  with  soap  frictions,  ointments,  and  alcoholic  lotions  of 
various  sorts,  the  hair  gradually  grew  in  during  three  years,  so  that 
all  the  scalp  was  covered  but  a  small  piece  behind  the  left  ear.  The 
growth  did  not  begin  until  after  a  year  and  a  half  of  active  treatment. 
There  were  no  characteristic  lesions  in  the  hair,  and  there  were  no 
parasites.  The  case  was  probably  dependent  upon  a  nervous  cause — a 
trophoneurosis  inherited  from  the  mother. 

Alopecia  Neurotica. — The  advocates  of  the  neurotic  origin  of  alo¬ 
pecia  areata  will  find  comfort  and  support  in  an  article  by  Askanazy  in 
the  Archivf.  Derm.  u.  Syph.,  1890,  xxii,  523.  He  cites  two  cases  from 
Professor  Michelson’s  clinic  in  Konigsberg.  In  one,  that  of  a  man 
thirty-one  years  old,  the  hair-fall  was  upon  the  right  side  and  followed 
a  facial  paralysis  of  the  same  side  consequent  upon  the  removal  of  a 
tumor  from  the  right  submaxillary  region.  He  also  had  hyperidrosis  of 
the  right  side.  The  scalp  was  normal.  In  thfe  second  case  the  bald¬ 
ness  occurred  upon  the  face,  temples,  and  pubes.  The  patient  was 
melancholic  and  hypochondriac,  and  suffered  from  severe  headache, 
burning  of  the  top  of  the  head,  and  insomnia. 

Epidemic  Zoster  forms  the  text  for  a  discourse  by  Dr.  Weis,  of 
Prague  ( Arcliiv  fur  Derm,  und  Syph.,  1890,  xxii,  609),  in  which  it  is 
attempted  to  be  proved  that  because  zoster  occurs  not  infrequently  in 
an  epidemic  manner,  which  nobody  can  deny,  therefore  it  is  an  infec¬ 
tious  disease,  which  seems  hardly  proved  as  yet.  The  strongest  part 
of  his  thesis  is  that  in  which  the  theory  of  one  Pfeiffer  is  overthrown. 
The  theory  is  that  the  lesions  of  zoster  are  located  along  the  arterial 
branches  supplied  to  the  skin,  and  not,  as  before  believed,  along  the 
distribution  of  the  cutaneous  nerves.  This  theory  our  author  com¬ 
pletely  upsets,  which  leaves  us  still  free  to  believe  in  the  nervous 
origin  of  the  lesions,  whatever  we  may  regard  as  the  chief  retiologica? 
factor  in  the  disease. 

The  Pathological  Anatomy  of  Psoriasis  has  been  studied  ouce 
again — this  tjme  by  Dr.  E.  Kromayer,  of  Halle  ( Archiv  f.  Derm.  u. 
Syph.,  1890,  xxii,  557).  Before  proceeding  to  the  demolition  of  various 
other  theories  in  regard  to  this  interesting  subject,  all  of  which  have 
been  based  upon  more  or  less  careful  studies  of  microscopical  prepara¬ 
tions  by  competent  observers,  he  has  a  few  words  to  say  about  the 
heretofore  usual  division  of  the  skin  into  three  layers — viz.,  epidermis, 
cutis  vera,  and  subcutaneous  tissues.  He  says  that  this  is  wrong,  his¬ 
tologically,  physiologically,  and  pathologically.  Histologically,  the  upper 
vascular  layers  of  the  skin  are  entirely  different  from  the  rest  of  the 
skin,  not  only  in  regard  to  the  connective  tissue  proper  to  it,  but  also 
as  to  its  blood-vessels,  lymphatics,  and  nerves.  Physiologically,  the 
papillary  layer  of  the  cutis  belongs  to  the  epidermis,  being  its  nutritive 
layer.  Its  only  relation  to  the  rest  of  the  cutis  vera  is  that  through  the 
latter  run  the  blood-vessels  and  nerves  that  are  supplied  to  it.  Regard¬ 
ing  the  skin  as  an  organ  proper,  then,  the  epidermis  would  represent 
the  parenchyma,  while  the  papillary  layer  would  be  the  interstitial  tis¬ 
sue.  Together  they  form  an  organ  in  whose  physiological  functions 
the  cutis  vera  takes  no  part.  Pathologically,  the  union  of  the  epidermis 
and  the  papillary  layer  of  the  skin  is  evidenced  by  the  common  division 
of  inflammatory  skin  diseases  into  superficial  (those  affecting  the  papil¬ 
lary  part  of  the  skin)  and  deep  (those  affecting  the  cutis  vera  and  the 
subcutaneous  tissue).  Further,  as  we  know  that  in  certain  parts  of  the 
skin  the  papilla?  are  entirely  wanting,  it  would  be  best  to  give  this  layer 
a  new  name,  and  designate  it  as  the  cutis  vasculosa.  Inasmuch  as  it 
is  desirable  to  employ  some  system  of  naming  the  parts  of  the  skin  to 
show  that  it  is  a  parenchymatous  organ  similar  to  the  kidneys,  etc., 
the  following  is  proposed,  namely:  1.  Cutis  parenchymatosa,  consist¬ 
ing  of  two  parts — the  epidermis  and  cutis  vasculosa.  2.  Cutis  vera.  3. 
Subcutaneous  connective  tissue  or  hypoderm. 

He  now  proceeds  to  an  examination  of  the  skin  upon  this  basis  of 
histological  division.  The  study  is  far  too  long  for  us  to  give  it  in 
detail  here ;  we  can  only  give  his  conclusions :  He  finds  the  changes  in 
the  epidermis  to  consist  in  (1)  a  proliferation  of  the  epidermis  or  of  its 
epithelium ;  (2)  a  permeation  of  the  epidermis  with  round  cells  which 
are  heaped  up  under  the  horny  layer  in  places ;  (3)  an  irregular 
formation  of  the  stratum  granulosum.  As  to  the  process  of  cornifica- 
tion  of  the  epidermic  cells,  he  says  that  a  normal  cornified  cell  consists 


Dec.  6,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEET  CINE. 


643 


of  a  cornified  cell  mantle  and  of  protoplasmic  cell  contents  which,  with 
the  exception  of  the  nuclear  cavity,  are  entirely  without  structure.  The 
cells  of  the  rete  Malpighii  possess  a  cell  membrane,  which  increases  in 
thickness  and  solidity  the  nearer  we  approach  the  horny  layer.  These 
cell  membranes  show  the  same  physiological  behavior  as  the  corne¬ 
ous  membranes — that  is,  they  are  transformed  into  large  vesicles  by 
the  swelling  of  their  cell  contents.  They  have  the  same  chemical  reac¬ 
tions,  resisting  the  action  of  potash,  hydrochloric  acid,  and  digestive 
agents,  and  differing  from  them  only  in  that  their  powers  of  resistance 
are  somewhat  less.  They  are,  therefore,  corneous  membranes  in  a 
young  and  tender  state.  The  process  of  cornification  is  then  a  gradual 
and  even  progress  through  the  whole  thickness  of  the  epidermis  from 
below  up  to  the  horny  layer,  consisting  in  an  ever-increasing  thickening 
and  solidification  of  the  cell  membrane.  He  regards  the  kerato-hyalin 
as  only  the  histological  expression  of  the  necrobiosis  of  the  cells  of  the 
epithelium. 

His  conclusions  from  his  studies  are  as  follows :  Each  efflorescence 
of  psoriasis  begins  with  a  hyperasmia  of  the  cutis  vaseulosa,  to  which 
an  infiltration  of  cells  is  added.  Soon  after  and  coincidently  with  these 
changes  an  intense  proliferation  of  epithelium  takes  place.  The  cutis 
vaseulosa  and  the  epidermis  increase  at  the  same  time,  and  together 
form  a  thick  papillary  body ;  the  cutis  parenchymatosa  is  hypertro¬ 
phied.  During  these  changes  numerous  migratory  cells  have  perme¬ 
ated  the  epithelium  and  disturbed  the  normal  cornification  ;  thus  are 
formed  the  psoriatic  scales  in  layers.  The  primary  changes  are,  there¬ 
fore,  in  the  cutis  vaseulosa.  These  are  not  of  an  inflammatory  nature, 
as  there  are  lacking  the  five  cardinal  symptoms  of  the  same — namely, 
“rubor,  tumor,  calor,  dolor,  functio  laesa.”  There  are  also  wanting 
fluid  exudation,  pustulation,  granulation,  and  cicatrization.  The  pro¬ 
cess  is  not  inflammatory.  It  is  to  be  regarded  rather  as  a  progressive 
disturbance  of  nutrition,  an  hypertrophy  of  the  parenchymatous  skin 
in  which  the  peculiar  and  characteristic  formation  of  scales  is  due  to 
an  interference  with  the  normal  formation  of  the  corneous  layer  by  the 
migration  of  cells  into  the  epithelial  layer  of  the  skin. 

The  mtiology  of  the  disease  is  still  a  matter  of  doubt,  no  one  of  the 
theories  (parasitic,  dyscratic,  idiosyncratic,  or  neuropathic)  being  satis¬ 
factorily  proved.  The  only  sure  thing  is  that  the  parasite  which 
causes,  or  may  be  the  cause  of,  the  disease  is  not  a  superficial  one. 

Seborrhceal  Warts  form  the  subject  of  a  study  by  S.  Pollitzer  (Mo- 
natshft  f.  prakt.  Perm .,  1890,  xi,  145).  As  it  emanates  from  Unna’s 
laboratory,  we  are  probably  justified  in  reading  “Unna”  written  be¬ 
tween  the  lines.  The  malady  appears  most  often  in  old  people,  and 
takes  the  form  of  more  or  less  numerous,  slightly  elevated,  round  or 
oval,  light-fawn  to  black-colored  spots  on  the  skin.  These  appear  most 
frequently  on  the  middle  of  the  back,  the  lower  half  of  the  abdomen, 
the  sternal  region,  and  the  anterior  and  lateral  surfaces  of  the  lower 
half  of  the  neck.  They  frequently  group  themselves.  In  size  they 
may  be  no  bigger  than  the  head  of  a  pin,  or  they  may  attain  the  diam¬ 
eter  of  a  twenty-five-cent  piece.  Histologically,  they  consist  in  a  some¬ 
what  thickened  stratum  corneum  and  a  markedly  hypertrophied  rete 
Malpighii;  they  show  epithelioid  cells  in  the  papillary  and  subpapillary 
layers  of  the  skin,  which  are  arranged  in  groups  and  lines  and  sepa¬ 
rated  from  each  other  bv  connective-tissue  fibers ;  a  marked  infiltration 
of  fat  pervades  the  epithelium  of  the  neighboring  sweat  glands,  the 
middle  and  papillary  layers  of  the  cutis,  and  the  epithelium  of  the 
rete;  finally,  there  is  atrophy  of  the  sebaceous  glands  and  the  hair 
follicles.  They  are  considered  to  belong  to  the  order  of  lymphangeio- 
fibroma. 

The  Treatment  of  Trichophytosis  Capitis  and  of  Favus  is  discussed 
by  A.  Bertarelli  in  the  Bolletino  della  Poliambulanza  di  Jf llano,  1890 
(Ann.  de  derm,  et  de  syph.,  1890,  i,  596).  He  prefers  the  use  of 
the  pitch  plaster  to  all  other  methods,  and  declares  that  patients  find 
this  manner  of  epilating  much  less  painful  than  that  with  the  for¬ 
ceps.  It  clears  the  scalp  of  hair  much  more  effectively  than  the 
pinchers,  and  absolutely  prevents  self-inoculation.  His  plaster  is  com- 
posed  of  thirty  parts  of  Burgundy  pitch  (rcsine  de  pin),  eight  parts 
of  black  pitch  (pix  navalis),  two  parts  of  Venetian  turpentine,  and 
one  part  of  lard,  spread  upon  small  strips  of  linen.  The  crusts  and 
scales  are  first  removed  from  the  scalp  by  the  free  use  of  grease  and 
lead  plaster,  and  then  the  strips  of  pitch  plaster  are  applied.  They 


are  raised  one  by  one  after  a  day  or  two,  and  any  hair  that  has  escaped 
the  plaster  is  to  be  removed  with  the  epilating  forceps.  The  scalp  is 
then  either  washed  with  soap  and  water  or  bathed  with  a  bichloride-of- 
mercury  solution  or  Lugol’s  solution.  Then  the  pitch  plaster  is  re¬ 
applied,  each  time  a  more  extensive  area  of  the  scalp  being  covered 
until  the  whole  is  enveloped  in  a  true  skull-cap.  Thus  the  patient  is 
gradually  accustomed  to  the  treatment,  which  must  be  continued  for  a 
varying  number  of  months,  say  six  to  eight  for  favus  and  six  to  twelve 
for  ringworm. 

A  Case  of  Syphilitic  Infection  of  a  Wife  by  her  Husband  Four 
Years  and  Nine  Months  after  the  Appearance  of  the  Chancre  has  been 
reported  by  Charles  Mauriac  to  the  French  Society  of  Dermatology  and 
Syphilis  (Ann.  de  derm,  et  de  syph.,  1890,  1,  p.  575).  There  was  no 

reason  to  suspect  that  the  woman  came  by  her  syphilis _ a  chancre 

upon  the  perinseum  and  a  general  erythematous  syphilide — in  any  other 
way  than  by  her  husband.  The  man  had  been  under  thorough  treat¬ 
ment  by  Dr.  Mauriac  from  the  time  of  the  initial  lesion.  The  infection 
of  the  wife  took  place  four  years  and  nine  months  from  the  date  of  the 
initial  lesion  of  the  husband. 

Syphilis  as  an  Infectious  Disease  in  the  Light  of  Modern  Bacteri¬ 
ology  is  the  long  but  attractive  title  to  an  able  article  by  E.  Finger  in 
the  Archie  fur  Derm,  und  Syph.,  1890,  Uft.  3,  fo.  331.  Admitting 
that  hypotheses,  not  exact  knowledge,  still  prevail  in  much  that  is 
written  and  said  about  syphilis,  he  advances  the  theory  that,  besides 
the  specific  virus  of  syphilis,  the  ptomaine,  which  is  the  result  of 
chemical  changes  caused  by  the  presence  of  the  virus,  gives  rise  to 
many  of  the  symptoms  of  syphilis,  and  is  the  agent  by  which  many  a 
feetus  becomes  infected  in  utero.  It  is,  moreover,  the  agent  that  pro¬ 
duces  immunity  to  syphilis,  such  as  is  seen  in  women  giving  birth  to 
syphilitic  children,  themselves  remaining  apparently  free  from  the  dis¬ 
ease,  and  able  to  nurse  the  children  without  infection.  If  the  ptomaine 
is  present  in  a  certain  amount,  or  the  organism  of  the  patient  has  good 
powers  of  resistance,  the  ptomaine  will  only  protect  against  infection 
by  the  virus,  producing  immunity.  If  the  ptomaine  is  present  in  large 
amount,  or  the  organism  has  feeble  powers  of  resistance,  then  it  will 
give  rise  to  such  symptoms  as  cachexia,  loss  of  hair,  and  most  of  the 
manifestations  of  the  so-called  tertiary  stage.  Such  is  a  brief  outline 
of  the  author’s  thesis.  Taking  up  the  article  in  the  order  in  which  it  is 
presented,  and  almost  unpardonably  condensing  it,  we  note  the  following 
as  the  basis  upon  which  he  builds  his  theory :  I.  The  primary  stage  of 
syphilis.  The  initial  lesion  and  multiple  enlargement  of  the  glands  are 
due  to  the  local  increase  of  the  specific  virus,  be  this  a  bacillus  or 
something  else.  At  the  same  time  the  presence  of  the  virus  gives  rise 
to  certain  chemical  changes,  the  product  of  tissue  changes,  which  pro¬ 
duce  alteration  in  the  connective  tissues,  and  contribute  to  the  hard¬ 
ness  of  the  affected  parts.  While  we  do  not  know  the  exact  time  at 
which  the  virus  leaves  the  sclerosis  and  enlarged  glands,  we  are  quite 
sure  that  the  ptomaine  very  early  enters  into  the  blood  and  lymph  cir¬ 
culations  and  is  distributed  throughout  the  body.  The  amount  of  the 
ptomaine  increases  in  geometrical  proportion  to  the  increase  of  the 
virus,  and  produces  that  general  intoxication  of  the  whole  body  seen  at 
this  time.  At  the  same  time  with  the  general  diffusion  of  the  pto¬ 
maine  through  the  circulation  we  have  also  a  diffusion  through  the  tis¬ 
sues  in  the  neighborhood  of  the  initial  lesion.  As  expressions  of  the 
intoxication  we  note:  1.  Immunity  from  further  inoculation  with  the 
virus.  2.  General  symptoms,  such  as  anaemia,  fever,  prostration,  weak¬ 
ness,  pains  in  the  limbs  and  joints,  albuminuria,  icterus,  neuralgia,  and 
hvperaemia  of  the  retina,  all  of  which  are  too  ephemeral  and  unstable 
to  be  due  to  a  deposit  of  the  virus  itself.  The  fact  that  iodide  of 
potassium  exerts  a  healing  effect  on  these  symptoms  while  it  has  little 
if  any  influence  upon  the  sclerosis,  and,  on  the  other  hand,  mercury 
influences  favorably  the  latter  but  not  the  former,  shows  that  there  is 
a  different  chemical  reaction  in  them,  and  strengthens  the  idea  that 
they  are  due  to  different  causes.  II.  The  secondary  stage.  The  various 
secondary  lesions  are  due,  without  doubt,  directly  to  the  virus,  but  the 
constitutional  symptoms  are  probably  due  to  the  ptomaine,  as  well  as 
the  seberrhoea,  alopecia,  and  dryness  of  the  nails.  In  malignant,  pre¬ 
cocious  syphilis  it  is  probable  that  the  profound  intoxication  of  the 
system  by  the  ptomaine  is  responsible  for  the  severity  of  the  symptoms. 
In  the  latent  peiiod  which  follows  the  secondary  stage  we  do  not  know 


644 


MISCELLANY. 


|N.  V.  Mkd.  Joir. 


what  becomes  of  the  virus  in  those  cases  in  which  later  symptoms  show 
themselves.  Nor  do  we  know  when  the  virus  leaves  the  system  in 
those  cases  in  which  complete  recovery  seemingly  takes  place.  During 
this  period  many  subjects  are  not  quite  in  normal  condition.  The  most 
noticeable  fact  of  this  period  is — HI.  The  immunity  against  new  in¬ 
fection.  How  long  this  immunity  may  last  we  do  not  know.  That  it 
probably  is  in  some  cases  limited  is  shown  by  the  well-authenticated 
instances  of  reinfection.  Immunity  does  not  prove  that  the  individ¬ 
uals  are  still  syphilitic  any  more  than  the  immunity  acquired  from  hav¬ 
ing  had  variola  indicates  that  the  individual  still  has  variola.  This  im¬ 
munity  is  due  to  the  influence  of  the  ptomaine  upon  the  tissues,  and 
may  be  acquired  without  passing  through  the  active  stage  of  syphilis. 
This  is  seen  in  the  acquiring  of  immunity  to  infection  on  the  part  of 
the  mother  of  a  child  syphilitic  by  the  father.  While  it  is  possible  for 
the  virus  to  pass  through  the  placenta  from  the  fadus  to  the  mother,  it 
is  uncommon.  But  ptomaines  must  so  pass,  and  while  these  are  not 
capable  of  producing  syphilitic  lesions,  they  do  render  the  mother 
immune  to  further  infection  with  syphilis.  The  same  thing  occurs  and 
produces  like  results  w'hen  a  healthy  child  is  born  to  syphilitic  parents. 
IV.  The  tertiary  stage.  It  is  the  opinion  of  the  majority  of  syphilogra- 
phers  that  this  stage  is  not  the  direct  result  of  the  syphilitic  virus,  but  a 
consecutive  diathesis,  the  virus  having  been  eliminated.  In  support  of 
this  opinion  we  find :  1.  The  relative  rarity  of  tertiary  symptoms.  2. 
Their  late  appearance  after  infection.  3.  The  difference  in  the  disease 
picture.  4.  The  non-contagiousness  of  the  disease  at  this  time.  5. 
The  non-transmissibility  of  the  disease.  6.  The  possibility  of  reinfec¬ 
tion.  7.  The  different  chemical  reaction  to  mercury  and  iodine.  8. 
The  fact  that  tertiary  symptoms,  like  immunity,  can  occur  in  individ¬ 
uals  who  have  never  shown  signs  of  primary  or  secondary  syphilis.  We 
see  this  both  in  the  mothers  who  have  gained  immunity  by  carrying 
syphilitic  foetuses,  and  in  children  of  syphilitic  parents  who,  though 
never  showing  signs  of  active  syphilis,  exhibit  great  disturbances  of 
nutrition,  or  pure  tertiary  lesions,  late  after  birth.  [The  whole  paper 
will  well  repay  perusal,  and  we  commend  it  to  all  students  of  this  very 
interesting  disease.] 


jjjisf  *11  ang. 


Inebriety  and  Life  Insurance. — The  American  Association  for  the 
Study  and  Cure  of  Inebriety  will  hold  the  first  of  a  series  of  monthly 
meetings  at  the  hall  of  the  New  York  Academy  of  Medicine,  on  Decem¬ 
ber  10th,  at  8  p.  m.  The  subject  of  the  evening  will  be  presented  in 
papers  by  Dr.  T.  D.  Crothers,  of  Hartford,  Conn.,  On  Alcoholic  Ine¬ 
briety  and  Life  Insurance,  and  Dr.  J.  B.  Mattison,  of  Brooklyn,  On 
Opium  Addiction  and  its  Relation  to  Life  Insurance.  Other  physicians 
will  participate  in  the  discussion,  and  the  medical  profession  are  invited 
to  be  present. 

Mosquera’s  Beef  Meal  is  an  alimentary  preparation  put  upon  the 
market  by  Messrs.  Parke,  Davis,  &  Co.,  of  Detroit,  who  state  that  it 
represents,  in  actual  nutritive  value,  at  least  six  times  its  weight  of  good 
lean  beef ;  that  it  is  perfectly  palatable,  and  will  be  tolerated  with  ease 
by  the  most  delicate  stomach ;  that  it  admits  of  being  administered  in 
a  variety  of  forms,  thus  avoiding  monotony  in  the  food  ;  and  that  it  is 
the  most  nutritious  as  well  as  the  most  economical  concentrated  food. 

The  late  Dr.  Emil  Neumer. — On  November  4,  1890,  a  joint  meet¬ 
ing  of  physicians  and  laymen  connected  with  St.  Mark’s  Hospital  and 
the  German  Poliklinik,  respectively,  was  held  at  the  residence  of  Dr. 
Beck,  187  Second  Avenue.  The  late  Dr.  Emil  Neumer  had  been  con¬ 
nected  with  said  institutions  for  a  number  of  years. 

The  following  resolutions,  submitted  by  a  committee,  were  unani¬ 
mously  adopted : 

Whereas,  our  friend,  Dr.  Emil  Neumer,  Supervising  Physician  of 
St.  Mark’s  Hospital  and  a  member  of  the  German  Poliklinik,  has  de¬ 
parted  this  life ;  and 

Whereas ,  by  his  untiring  zeal  and  singleness  of  purpose,  he  earned 


the  good-will  and  gratitude  of  all  connected  with  both  institutions ; 
and 

Whereas ,  his  self-sacrificing  labors  contributed  largely  to  undermine 
his  health,  be  it 

Resolved,  That  the  physicians  and  members  of  St.  Mark’s  Hospital 
and  of  the  German  Poliklinik,  at  a  special  joint  meeting  assembled,  do 
express  their  deep  sense  of  grief  at  the  untimely  loss  of  their  iriend 
and  fellow-worker,  Dr.  Emil  Neumer,  and  further  express  their  heart¬ 
felt  sympathy  with,  and  tender  their  condolence  to,  his  bereaved  fam¬ 
ily  ;  and 

Resolved,  That  a  copy  of  these  resolutions  be  published  in  the  medi 
cal  journals. 

The  Committee : 

Dr.  C.  Beck,  )  For 

Dr.  II.  J.  Boldt, 

Mr.  F.  A.  Botty. 

Dr.  Th.  Busche,  1  For  (he 

Dr.  S.  Rohm,  f  German  Poliklinik. 

Dr.  George  W.  Rachel.  j 

Dr.  H.  J.  Garrigues,  Chairman. 

Mr.  Max  Ruttenan,  Secretary. 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “ original 
contributions  "  are  respectfully  informed  that,  in  accepting  such  arti¬ 
cles,  we  ahvays  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (I)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  ( 3 )  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which ,  although  they  may  be  creditable  to  their  authors,  art 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter ,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  pjerson 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor ,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


St.  Mark's  Hospital . 


THE  NEW  YORK  MEDICAL  JOURNAL,  December  13,  1890. 


(Original  Communications. 


1,600,  being  1  in  13-9,  or  7*2  per  cent.  But  of  these,  763 
were  not  born  dead,  633,  or  2-85  per  cent,  of  the  total  births,. 


WHAT  INFLUENCE  WOULD 

A  MORE  PERFECTED  OBSTETRIC  SCIENCE 

HAVE  ON  THE 

BIOLOGICAL  AND  SOCIAL  CONDITION  OF  TEE  RACE?* 

By  ALFRED  L.  CARROLL,  M.  D. 

Whatever  spiritual  sins  of  mine  may  be  stricken  from 
the  books  of  the  Recording  Angel,  as  fully  expiated  by  the 
penitential  attempt  to  answer  the  question  allotted  to  me 
in  this  discussion,  I  fear  that  I  shall  add- to  my  professional 
shortcomings  in  venturing  upon  an  argument  which  de¬ 
pends  almost  entirely  on  an  overstrain  of  the  “  scientific  use 
of  the  imagination.” 

For  a  proper  consideration  of  the  problem  we  should 
possess  statistical  evidence  of  the  mortality  and  morbility 
of  mothers  and  children  respectively,  due,  immediately  or 
remotely,  to  parturition,  and  of  the  degree  in  which  such 
mortality  and  morbility  may  be  regarded  as  preventable. 
This  evidence,  however,  is  in  all  respects  scanty,  and  in 
some  absolutely  non-existent. 

“  Still-births  ”  are  not  officially  registered  either  as  births 
ir  deaths,  and  even  in  the  very  imperfect  occasional  records 


being  classed  as  “  feeble  ” — i.  e.,  “  apoplectic,  premature, 
etc.” — 116,  or  0-52  per  cent.,  as  “abortive”  (non-viable), 
and  14  as  monstrous  or  deformed,  leaving  837,  or  3*76 
per  cent.,  actual  still-births.  This  accords  with  the  few 
later  estimates  founded  on  sufficient  numbers  to  warrant 
generalization.  Farr  opined  that  in  England  the  pro¬ 
portion  was  about  4  per  cent.,  in  Belgium  (1860-1865)  it 
was  reported  as  3-7  per  cent.,  in  France  (1875)  as  3-6  per 
cent. 

There  are  no  means  of  ascertaining  how  many  of  these 
“dead-born”  are  done  to  death  during  the  act  of  parturi¬ 
tion,  but  that  the  number  is  very  great  may  be  inferred 
from  a  comparison  of  spontaneous  and  artificial  deliveries, 
the  latter  of  which  are  usually  performed  on  account  of 
mechanical  obstacles  in  the  genital  passages,  uterine  inertia, 
maternal  haemorrhage  or  convulsions;  or,  on  the  foetal  side, 
malpresentations,  prolapse  of  cord  or  arm,  or  deformities  of 
various  kinds.  From  the  subjoined  condensation  which  I 
have  made  of  Lachapelle’s  tables,  it  is  shown  that  in  all  the 
spontaneous  deliveries  (omitting  those  of  the  shoulder,  in 
which  the  two  still-born  are  specified  as  “  putrid  ”)  the  ratio- 
of  the  dead-born  is  3 -5  per  cent.,  while  in  the  artificial  de¬ 
liveries  it  rises  to  25  per  cent. : 


PRESENTATION  AND  DELIVERY. 

Total. 

Living. 

Dead. 

Feeble. 

Abortive  or 
deformed. 

Total  deaths. 

Excluding  non- 
viable  children. 

Vertex,  spontaneous . 

20,567 

19,450 

635 

462 

20 

1,117  =  5'43$,  or  1  in  18-4 

1  in  18-75 

“  forceps  . 

72 

38 

17 

17 

34  =  46-6$  “  1  “  2-1 

“  version . 

47 

29 

8 

10 

18  =  38-3$  “  1  “  2-6 

Pace,  spontaneous . 

88 

78 

3 

6 

i 

10  =  11-36$  “  1  “  8-8 

“  forceps . 

5 

1 

1 

3 

4  =  80-00$  “  1  “  1-25 

“  version  (inertia) . 

7 

4 

.  .  • 

3 

3  =  42-86$  “  1  “  2-33 

Pelvic,  spontaneous . 

790 

575 

101 

98 

16 

215  =  27-2$  “  1  “  3-67 

1  in  3 -9 

“  version . 

12 

6 

3 

3 

6  =  50-0$  “  1  “  2 

■Shoulder,  spontaneous . 

12 

.... 

2 

... 

10 

12  =  100$ 

“  version . 

106 

63 

26 

17 

43  =  40-57$,  or  1  in  2’5 

Irow,  changed  to  face . 

2 

I 

•  .  • 

1 

1  =  50-0$ 

Traniotomy . 

12 

.... 

9 

. . . 

3 

12 

Ivsterotomy,  after  death  of  mother . 

4 

.... 

2 

2 

4 

Presentation  undetermined,  spontaneous. . 

517 

397 

29 

ii 

80 

120  =  23-2$,  or  1  in  4-3 

1  in  12-9- 

“  “  version . 

2 

1 

1 

Total  spontaneous . 

21,974 

20,500 

770 

577 

127 

1,474  =  6-7$  “  1  “  14-9 

1  in  16.3 

“  artificial . 

269 

143 

67 

56 

3 

126  =  46-8$  “  1  “  2-13 

1  “  2-19 

“  spontaneous  and  artificial . 

22,243 

20,643 

837  ■ 

633 

130 

1,600  =  7-19$  “  1  “  13-9 

1  “  15-13 

>f  them  it  is  impossible  to  separate  the  foetal  deaths  before 
he  beginning  of  labor  from  the  deaths  during  birth  or  soon 
lfter  birth,  the  latter  being  often  reported  under  this  cate¬ 
gory ;  nor  can  we  determine,  outside  of  a  few  hospital  re- 
>orts  which  represent  an  infinitesimal  fraction  of  the  total 
hild-bearings,  the  proportions  of  abnormal  presentations, 
>f  deformed  maternal  pelves,  or  of  spontaneous  or  artificial 
leliveriesin  these  alleged  still-births,  the  vast  volume  of  pri- 
ate  midwifery  being  virtually  a  sealed  book.  Quetelet  com- 
>uted  the  ratio  of  still-births  to  total  births  as  1  in  12'5,  or  a 
ittle  over  8  per  cent.,  but  he  evidently  included  many  chil- 
iren  who  had  breathed  before  dying,  as  is  demonstrated  by 
he  contemporaneous  tabulation  of  Mine.  Lachapelle’s expe- 
ience,  comprising  22,243  births,  with  a  total  mortality  of 


*  Read  before  the  New  York  State  Medical  Association,  October  23, 

890. 


Further  analysis  of  the  presentations  and  accidents 
of  labor  is  necessary  to  gain  a  partial  view  of  the  cases 
in  which  obstetric  science  and  art  may  lessen  this  mor¬ 
tality,  which  means  the  death,  at  or  soon  after  birth,  of 
nearly  seventy -two  thousand  children  out  of  every  million 
born. 

In  the  vertex  presentations,  spontaneously  born,  of  La¬ 
chapelle’s  table,  the  “dead”  were  1  in  32-4,  and  the  “fee¬ 
ble”  (dying  within  a  day  or  two)  1  in  44-4,  the  only  com¬ 
mentary  made  being  that,  in  ten  or  twelve  instances,  the 
cord  was  prolapsed,  half  of  these  dying  during  delivery. 
Of  her  artificially-aided  vertex  deliveries,  the  “dead”  were 
1  in  4-76  and  the  “feeble”  1  in  4-4.  But  in  the  72  appli¬ 
cations  of  the  forceps,  39  were  for  uterine  inertia  or  rigidity 
ot  the  external  genitalia,  8  for  pelvic  contraction,  2  for 
“scirrhus  of  cervix,”  1  for  haemorrhage,  1  for  uterine  ob¬ 
liquity,  8  for  maternal  convulsions,  9  for  faulty  positions 


646 


CARROLL:  OBSTETRIC  SCIENCE. 


[N.  Y.  Med.  Jour., 


of  the  head,  3  for  prolapse  of  the  cord,  1  for  prolapse  of 
arm — that  is  to  say,  in  59,  or  82  per  cent,  of  the  whole, 
the  dystocia  was  due  to  maternal  causes,  the  children  dead 
•or  dying  being  1  in  2*1,  and  to  foetal  causes  in  13,  or  18 
per  cent.,  with  the  same  ratio  of  mortality.  The  versions 
in  head  presentations,  47  in  number,  comprised  24  for  in¬ 
ertia,  6  for  contracted  pelves,  1  for  rigidity,  1  for  recto¬ 
vaginal  cyst,  8  for  haemorrhage,  5  for  prolapsed  cord,  1  for 
prolapse  of  hand,  and  1  for  parietal  position  ;  40,  or  85  per 
•cent.,  maternal  causes,  with  1  in  2*5  children  dead  or  dying, 
ami  7,  or  15  per  cent.,  foetal  causes,  with  a  death-rate  of  1 
in  3-5.  Of  the  cases  due  to  inertia,  convulsions,  and  haemor¬ 
rhage  a  considerable  proportion  would  doubtless  be  averted 
by  hygienic  precautions,  especially  during  pregnancy,  but 
in  the  majority  of  instances,  and  particularly  in  hospital 
practice,  the  physician  has  little  or  no  opportunity  to  en¬ 
force  these  precautions,  and  among  the  poorer  classes  too 
often  the  cooditions  of  health  are  unattainable. 

The  face  presentations  in  Lachapelle’s  catalogue  were 
100  in  number,  or  1  in  222-4.  Of  these,  88  were  sponta¬ 
neously  born;  9,  or  1  in  9-7,  dead  or  dying.  Of  the  5  for¬ 
ceps  deliveries  and  7  versions,  all  were  for  inertia  except  1, 
in  which  a  brow  presentation  was  rectified  by  forceps,  the 
mortality  being  1  in  1*7.  Thus,  in  all  the  face  presenta¬ 
tions,  we  find  a  mortality  of  1  in  6-25,  or  16  per  cent.  Lusk 
•computes  the  ratio  of  these  presentations  as  1  in  255-5,  and 
quotes  Winckel’s  statement  that  the  mortality  of  children 
is  13  percent.  Swayne  estimates  the  frequency  as  1  in 
231.  The  experience  of  Collins  shows  a  mortality  of  1 2 
per  cent.  Most  of  these  records,  however,  concern  only 
•the  children  born  dead,  omitting  those  which  die  soon  after 
‘birth,  so  that  the  estimate  based  on  Lachapelle’s  table  is 
probably  nearest  to  the  actual  death  ratio. 

Pelvic  presentations  (including  breech,  foot,  and  knee) 
are  stated  by  Lachapelle  as  1  in  27  labors;  by  Swayne  and 
Tanner  as  1  in  38,  the  breech  presenting  about  twice  as 
often  as  the  feet  or  knees.  The  mortality,  according  to 
Lachapelle,  is  a  1'ttle  over  25*5  per  cent.;  to  Tanner,  33 
per  cent.;  to  Meigs,  over  20  percent.;  to  Collins,  37  per 
cent. 

'Shoulder  presentations  are,  by  the  estimates  of  different 
-observers,  as  follows:  Lachapelle,  1  in  188-4;  Churchill,  1 
in  252  ;  Spiegelberg,  1  in  180  ;  Depaul,  Dubois,  and  Pinard 
(quoted  by  Lusk),  1  in  117  ;  Swayne  and  Tanner,  1  in  231  ; 
the  infant  mortality  being  about  50  per  cent. 

The  comparative  frequency  of  brow  presentations  is  not 
easily  estimated,  since  many  of  them  are  spontaneously 
converted  into  face  or  vertex  before  a  diagnosis  is  made.  As 
regards  the  mortality  of  children  in  recognized  cases,  Lusk 
cites  34  deliveries:  10  spontaneous  (brow  continuing),  with 
3  deaths  during  labor  ;  10  converted  to  face  or  vertex  natu- 
rally,  with  1  death  ;  9  extracted  by  forceps,  brow  first,  with 
1  death  (from  prolapsed  funis) ;  5  changed  by  forceps  to 
face  or  vertex,  with  no  deaths — a  total  mortality  of  4  attrib¬ 
utable  to  the  presentation,  or  about  12  per  cent. 

Taking  the  averages  of  all  the  data  which  I  have  been 
able  to  obtain,  the  probable  frequency  and  child  mortality 
(excluding  non-viable  foetuses)  of  different  presentations  in 
a  million  births  may  be  thus  approximately  stated  : 


PRESENTATION. 

Total. 

Dead  or  dying. 

Vertex . 

960,000 

53,500 

Face . 

4*000 

30,000 

5,000 

040 

Pelvic . 

9,000 

Shoulder . 

2,500 

Undetermined,  including  forced 

delivery  for  maternal  convul¬ 
sions  or  haemorrhage,  embry- 

\ 

otomies,  contracted  pelves,  etc. 

1,000 

360 

Total . 

1,000,000 

66,000  =  6‘6$,  or  1  in  15. 

In  addition  to  these,  there  will  be  about  5,800  non-via- 
ble  children,  raising  the  death  list  to  71,800=1  in  13-9. 

In  the  course  of  these  million  labors  we  shall  meet  with 
about  600  cases  of  placenta  praevia,  4,000  of  prolapse  of 
the  cord,  1,000  of  contracted  pelvis,  and  2,000  of  maternal 
convulsions  (including  those  which  occur  before  or  after 
delivery  as  well  as  those  during  labor),  with  a  maternal 
mortality  of  1,400.  Artificial  delivery  by  forceps  or  version 
will  be  necessary  in  somewhat  over  12,000  cases,  with  nearly 
5,500  infant  deaths.  Of  these  instances  of  dystocia,  about 
48-5  per  cent,  will  arise  from  maternal  causes,  and  about 
51-5  per  cent,  from  foetal  causes.  In  the  former  category 
uterine  inertia  plays  the  largest  part. 

To  what  extent  this  loss  of  infant  life  may  be  reduced  is  a 
mere  matter  of  surmise,  but  in  its  reduction  obstetric  science 
and  hygiene  must  work  together.  The  correction  or  better 
management  of  malpresentations  is  already  showing  benefi¬ 
cent  effects  in  the  practice  of  experts,  and  will  doubtless 
erelong  improve  the  general  results;  but  even  here  there 
is  room  for  great  advance.  The  mortality  from  either  natu¬ 
ral  or  artificially  induced  pelvic  presentations  is,  in  the  ma¬ 
jority  of  examples,  owing  to  compression  of  the  cord,  and 
this  mortality  is  so  large  as  to  cast  a  shadow  of  doubt  upon 
the  propriety  of  podalic  version  in  many  cases  in  which  it 
is  advocated  by  some  eminent  authorities.  According  to 
Churchill,  version  in  normal  pelves  is  fatal  to  more  than  one 
third  of  the  children,  and  in  contracted  pelves  the  death- 
rate  is,  of  course,  much  larger.  Lusk,  who  is  wisely  conserva¬ 
tive  in  this  respect,  argues  that,  with  a  conjugate  diameter 
of  more  than  three  inches  and  a  half,  nature  is,  as  a  rule, 
adequate  to  accomplish  delivery.  In  the  statistics  cited  by 
him,  version  in  ordinary  flattened  pelves  was  followed  by 
the  death  of  50  per  cent,  of  the  children  ;  version  in  gener¬ 
ally  contracted  pelves  by  about  90  percent,  of  foetal  deaths; 
with  the  use  of  forceps  above  the  brim,  nearly  40  per  cent, 
of  mothers  and  over  60  per  cent,  of  children  died;  while 
in  spontaneous  deliveries  less  than  3  per  cent,  of  mothers 
and  13  per  cent,  of  children  were  lost.  Inasmuch  as  a  large 
proportion  of  deformed  pelves  arises  from  rickets  in  early 
life,  and  a  smaller  from  malacosteon  in  later  years — both 
being  principally  results  of  insanitary  conditions — it  is  not 
only  possible,  but  probable,  that,  as  the  knowledge  and  ap¬ 
plication  of  hygiene  become  more  diffused,  these  causes  of 
dystocia  will  be  vastly  diminished  in  number  ;  indeed,  their 
frequency  is  demonstrably  in  inverse  ratio  to  the  prosperity 
of  a  community.  So,  also,  watchfulness  and  prophylactic 
treatment  during  pregnancy  may  (and  in  the  best  practice 
do)  decrease  enormously  the  percentage  of  puerperal  con¬ 
vulsions. 


Deo.  13,  1890.] 


CARROLL:  OBSTETRIC  SCIENCE. 


647 


Premature  or  abortive  births,  as  they  arise  from  general 
ill  health  or  local  disease  of  the  mother  (including  many 
cases  of  placental  degeneration),  or,  occasionally,  from 
chronic  lead  poisoning,  may  to  a  certain  extent  be  prevent¬ 
able  by  hygienic  or  gynaecological  means  ;  those  from  ex¬ 
ternal  violence  or  nervous  shocks  will  continue  to  hold  their 
place  on  our  records  as  long  as  feminine  impulsiveness,  stair¬ 
cases,  and  brutal  husbands  exist,  and  autocratic  drivers 
usurp  their  reckless  right  of  way. 

As  regards  the  effects  of  dystocia  on  the  later  life  of  the 
child,  little  can  be  learned.  In  patients  whom  we  see  as 
adolescents  or  adults  we  can  rarely  ascertain  the  character 
of  the  birth  or  the  condition  of  infancy.  None  of  us  can 
doubt,  however,  that  the  morbility  from  this  source  is  very 
great.  From  the  French  returns  Farr  calculates  that  out 
of  a  million  children  born,  29,121  die  in  the  first  week, 
22,128  in  the  second  week,  and  22,236  in  the  next  sixteen 
days,  making  a  total  of  73,485  in  the  first  month.  The 
English  Life  Table  computes  a  somewhat  less  mortality — 
i.e.,  46,500  deaths  in  the  first  month,  17,200  in  the  second, 
12,180  in  the  third,  10,100  in  the  fourth,  9,550  in  the  fifth, 
9,030  in  the  sixth,  8,550  in  the  seventh,  8,080  in  the  eighth, 
7,660  in  the  ninth,  7,250  in  the  tenth,  6,870  in  the  eleventh, 
and  6,520  in  the  twelfth,  a  total  of  149,490  to  the  million  in 
the  first  year.  Many  of  these  early  deaths  are  produced  by 
insanitary  conditions,  as  is  proved  by  the  difference  between 
the  “  healthy  districts  ”  of  England  and  Liverpool,  in  the 
former  of  which  36,610  per  million  children  die  within  the 
first  month,  while  in  the  latter  the  mortality  during  the 
same  period  is  (or  was  when  Farr’s  analysis  was  made) 
54,490  to  the  million.  It  is  to  be  regretted  that  the  regis¬ 
tration  of  vital  statistics  is  so  imperfect  in  this  country  as 
to  preclude  any  attempt  to  classify  by  months  the  mortality 
under  one  year ;  but  the  data,  such  as  they  are,  indicate 
that,  in  the  United  States  generally,  about  25  per  cent,  of 
live-born  children  die  during  the  first  twelvemonth. 

It  would  not  be  unreasonable,  perhaps,  to  assume  that 
at  least  half  of  the  deaths  under  one  month  are  attributable 
to  accidents  in  parturition,  and  that  a  large  residuum  of 
those  occurring  in  the  first  year  has  a  similar  origin  ;  but 
the  admirable  reports  of  Farr  mry  enable  us  to  go  a  step 
farther  in  the  field  of  inference.  The  death-rate  under  one 
year  per  10,000  births  in  England,  for  the  three  years  end¬ 
ing  with  1875,  was  1,527.  Of  these,  95  were  ascribed  to 
the  acute  zymoses,  29  to  “teething,”  1 7 1  to  diarrhoea,  263 
to  “  lung  diseases,”  98  to  tuberculosis,  128  to  prematurity, 
267  to  “  atrophy,”  14  to  “  suffocation,”  and  251  to  convul¬ 
sions,  leaving  211  “  not  stated.”  The  deaths  from  prema¬ 
turity,  “  atrophy,”  and  convulsions  constitute  nearly  half 
of  the  mortality,  all  of  the  former  and  a  considerable  pro¬ 
portion  of  the  latter  two  being  referable  to  the  time  or  act 
of  parturition,  and  some  of  the  pulmonary  disorders  having 
their  predisposition,  if  not  their  origin,  in  atelectasis  at 
birth.  In  Farr’s  March  of  an  English  Generation ,  based 
on  the  labor  of  over  thirty  years,  he  computes  that  the  av¬ 
erage  deaths  per  million  under  one  year  will  be  149,493,  of 
which  30,637  will  be  from  diseases  of  the  nervous  system 
and  21,995  from  respiratory  maladies.  West,  taking  a 
wider  view  of  “  nervous  ”  disorders,  ascribes  to  these  30-5 


per  cent,  of  all  the  deaths  under  one  year,  and  to  convul¬ 
sions  alone  73-3  percent,  of  the  “  nervous-system  ”  mortal¬ 
ity — equivalent  to  33,421  to  the  million  births. 

After  the  earlier  weeks  of  this  perilous  first  year,  con¬ 
vulsions,  like  “  atrophy,”  are  often  due  to  maternal  neglect 
or  improper  management  (most  notably  in  the  administra¬ 
tion  of  the  various  atrocious  infant  foods  which  flood  the 
market  and  fill  our  waste-baskets  with  their  “  sample  pack¬ 
ages  ”),  and  sometimes  are  reported  as  causes  of  death  when 
they  are  really  but  forerunners  of  rapidly  fatal  febrile  dis¬ 
orders.  But  in  an  unascertainable  proportion  of  cases  they 
are  unquestionably  the  result  of  compression  of  the  head 
during  delivery,  and  in  such  instances,  according  to  West, 
tend  to  recur  without  obvious  exciting  cause,  and  to  retard 
or  retrograde  mental  development,  leading  very  often  to 
later  epilepsy.  Beau  (quoted  in  Reynolds’s  System )  found, 
out  of  211  epileptics,  17  (8  percent.)  congenital,  and  Hugh- 
lings  Jackson  observes  that  “epileptic  fits  in  adults  not 
rarely  date  from  convulsions  in  infancy.”  Nothnagel  as¬ 
signs  to  overlapping  of  the  cranial  bones  during  forceps  ex¬ 
tractions  or  tedious  and  difficult  labors  the  causation  of 
meningeal  hemorrhage —  usually  extravasation  into  the 
meshes  of  the  pia — from  which  the  children  in  the  major¬ 
ity  of  instances  are  either  born  dead,  or  linger  for  a  short 
time,  or,  rarely,  recover  to  sw7ell  the  morbidity  of  succeed¬ 
ing  years.  Erb  refers  to  the  occurrence  of  spinal  menin¬ 
geal  hemorrhage  from  difficult  or  instrumental  labor.  The 
principal  injuries  to  the  child  in  dystocia  or  instrumental 
interference  are  :  depression  or  fracture  of  cranial  bones, 
with  or  without  laceration  of  brain  ;  “  apoplexy  of  nervous 
centers  ”  ;  too  tight  hold  of  the  forceps,  leading  occasion¬ 
ally  to  hemiplegia ;  and  ruptures  of  viscera. 

Th  ese  considerations  emphasize  the  importance  of  sound 
judgment  to  decide  between  the  dangers  of  compression  of 
the  head  by  the  maternal  genital  passage  or  by  the  forceps, 
and  to  determine  when  to  apply  the  latter  to  the  best  ad¬ 
vantage.  It  is  undeniable  that  many  lives  which  would 
have  been  sacrificed  in  the  days  of  traditional  prejudice 
against  artificial  aid  are  now  saved  ;  but  there  is  reason  to 
fear,  with  Playfair,  that  “  the  pendulum  may  have  swung 
too  far  in  the  opposite  direction.”  Not  alone  in  simply  te¬ 
dious  labors  without  indication  of  incompetence  of  the  natu¬ 
ral  powers,  but  frequently  to  accelerate  normal  parturition, 
for  the  mother’s  comfort,  or  for  economy  of  the  accoucheur’s 
time,  forceps  are  used  with  as  little  regard  for  the  welfare 
of  the  infant  as  the  average  street-car  conductor  has  for  the 
expectant  passenger,  or  the  “  protectionist  ”  legislator  for 
the  interests  of  the  unprotected  consumer,  and,  in  inexpert 
hands,  with  a  plentiful  crop  of  maternal  lacerations  for  the 
lucrative  reaping  of  gynaecologists.  Lawson  Tait’s  disputed 
statement — that  the  infant  mortality  from  forceps  delivery 
in  impacted  labor  is  1  in  7  or  8 — is  corroborated  by  Dr.  J. 
G.  Swayne  (Brit.  Med.  Journal ,  April  26,  1890),  who  re¬ 
ports  21 1  instrumental  extractions  in  difficult  and  protracted 
labors,  “  without  reckoning  complications,”  and  30  foetal 
deaths,  or  1  in  7  ;  pointing  out  a  hitherto  unnoticed  source 
of  danger  in  the  accidental  pressure  of  the  cord  against  the 
child’s  neck  or  head  by  the  blade  of  the  forceps. 

Excessive  mortality — implying  a  still  greater  morbidity 


648 


CARROLL:  OBSTETRIC  SCIENCE. 


|N.  Y.  Med.  Jouk., 


— continues  through  the  first  five  years,  the  deaths  during 
this  period,  in  England,  being  263,182  to  the  million  births. 
In  this  State,  by  the  only  method  of  calculation  possible, 
they  constitute  37  per  cent,  of  the  total  deaths  at  all  ages. 
Deducting  the  first  year’s  fatality,  the  subsequent  fourvears 
produce  113,689  deaths,  of  which  9,428  are  from  diseases 
of  the  brain  and  23.950  from  respiratory  diseases  and  phthi¬ 
sis.  In  Massachusetts  the  registration  reports,  as  cited  by 
Dr.  T.  B.  Curtis  (Buck’s  Hygiene ),  attribute  from  10  per 
cent,  to  15  per  cent,  of  ail  deaths  under  five  to  “  tuberculo¬ 
sis  and  scrofula.”  More  than  half  of  the  death  and  sick¬ 
ness  of  this  first  lustrum  arises  from  insanitary  environment, 
as  is  evident  from  a  comparison  of  the  statistics  in  healthy 
and  unhealthy  districts,  and  is  therefore  amenable  only  to 
general  hygiene,  and  about  one  third  from  zymotic  disor¬ 
ders  ;  but  of  the  remainder  an  important  reduction  may  be 
hoped  for  in  the  progress  of  obstetric  science  and  art.  After 
the  age  of  five  years,  official  statistics  afford  no  ground  for 
even  guessing  the  effects  of  dystocia  or  premature  births 
upon  mortality  and  mortality  ;  but  the  experience  of  most 
observant  physicians  will  support  the  conclusion  that  thev 
are  by  no  means  insignificant. 

Turning  now  to  the  maternal  aspect  of  the  question,  and 
relying,  as  before,  mainly  upon  Farr’s  English  statistics,  we 
find  that  of  the  488,255  girls  born  in  the  hypothetical  mill¬ 
ion  whence  his  “generation”  takes  its  start,  342,281  pass 
the  age  of  fifteen.  Of  these,  79  per  cent.,  or  270,402,  marry. 
According  to  the  inquiries  of  Sir  James  Simpson  and 
others,  about  10  per  cent,  of  marriages  are  sterile;  so  that 
243,362  of  these  wives  bear  children  at  the  rate  of  5-23 
each,  and  6,921  perish  in  consequence  of  the  process,  or  1 
in  35  mothers  in  all  their  childbearings  (2-8  per  cent.), 
which  is  equivalent  to  1  maternal  death  in  every  183  par¬ 
turitions.  These  figures  apply  to  all  classes  of  the  popula¬ 
tion,  and,  of  course,  overstate  the  mortality  where  skilled 
assistance  is  at  hand.  Thus  the  maternal  mortality  from 
childbirth  is  variously  estimated  by  obstetricians  as  from  1 
in  200  to  1  in  212,  while  Dr.  Rigden  (quoted  by  Farr)  in 
4,132  private  cases  had  a  death-rate  of  less  than  1  in  516. 
In  the  records  of  hospitals  and  of  the  experience  of  con¬ 
sulting  obstetricians,  more  difficult  cases,  and  consequently 
a  higher  rate  of  fatality,  are  likely  to  occur.  From  our 
prophylactic  point  of  view,  it  is  desirable  to  discriminate 
the  deaths  directly  due  to  the  act  of  parturition  from  those 
caused  by  secondary  puerperal  diseases,  and  this  has  been 
done  by  Farr  in  his  separate  classification  of  “metria”  and 
“  other  accidents  of  childbirth.”  We  have  further  to  con¬ 
sider  the  influence  of  age  during  the  fertile  period  of 
woman’s  life,  which,  in  temperate  latitudes,  may  be  regarded 
as  extending  from  fifteen  to  a  maximum  of  fifty-five.  The 
following  table  shows  the  ratio  of  deaths  of  mothers  to  the 
number  of  children  born  : 


Age. 

Metria. 

Accidents  of  birth. 

Total. 

15-25 

25-35 

35-45 

45-55 

0'277$,  or  1  in  301-7 

0'148$  “  1  “  575-7 

0454$  “  1  “  649-3 

0-163$  “  1  “  613-5 

0-391$,  or  1  in  255-75 

0-277$  “  1  “  361-7 

0-479$  “  1  “  207-9 

0-720$  “  1  “  138-9 

0-668$,  or  1  in  149’7 

0-425$  “  1  “  235-3 

0  633$  “  1  “  157-9 

0-883$  “  1  “  11,3-2 

15-55 

0-172$,  or  1  in  581-4 

0-358$,  or  1  in  279'3 

0-530$,  or  1  in  188*7 

In  the  State  of  New  York  about  1  per  cent,  of  the  total 
mortality  from  all  causes  is  returned  as  “puerperal,”  but 
this  includes  other  accidents  of  parturition  also. 

Nearly  the  whole  of  the  mortality  under  the  head  of 
metria  ought  to  be  avoidable  by  aseptic  midwifery  and 
after-management,  vastly  diminishing  the  perils  of  the 
lying-in  chamber,  especially  to  primipara?,  and  obstetric 
skill  may  lessen  that  from  other  accidents  of  childbirth. 
We  hear  less  now  than  thirty  years  ago  of  metritis  or 
sloughing  from  too  prolonged  pressure,  of  rupture  of  the 
uterus,  of  fatal  exhaustion  or  post  partum  haemorrhage ;  but, 
even  with  our  better  modern  training,  a  great  part  of  such 
preventable  lethality  will  remain  beyond  our  control  as  long 
as  ignorant  and  uncleanly  mid  wives  conduct  the  majority 
of  labors  among  the  poorer  classes ;  for,  particularly  in 
rural  districts,  nearly  half  of  all  confinements  take  place 
without  the  attendance  of  a  physician.  The  enormous 
amount  of  morbility  entailed  upon  women  who  escape  death 
is  familiar  to  every  one  who  has  seen  much  of  gynaecic  prac¬ 
tice.  Moreover,  it  is  among  the  overworked  and  often 
underfed  poor  that  malpresentations  and  pelvic  deformities 
are  most  prevalent  and  obstetric  skill  most  needed.  To 
demonstrate  how  much  such  skill  may  accomplish,  Dr.  J. 
T.  Uartill  ( Brit .  Med.  Journal ,  September  27,  1890)  has 
recently  reported  the  results  of  2,000  consecutive  confine¬ 
ments,  largely  among  the  wretched  operatives  in  the  “  Black 
Country,”  comprising  14  cases  of  complete  or  partial  pla¬ 
centa  praevia,  61  pelvic  presentations,  24  transverse,  60  con¬ 
tracted  pelves,  29  cases  of  uterine  inertia,  12  of  rigidity  of 
soft  parts,  and  1  of  ovarian  tumor;  164  applications  of  the 
forceps  (1  in  12  of  all  labors);  yet,  despite  these  adverse 
I  circumstances,  there  were  but  8  maternal  deaths  from 
childbirth,  or  1  in  250  mothers,  2  from  subsequent  me¬ 
tritis,  1  from  embolism,  1  from  phthisis,  and  1  from  pneu¬ 
monia — a  total  mortality,  assignable  to  labor,  of  11,  or  1 
in  182. 

The  term  “aseptic  midwifery”  has  been  advisedly  used, 
because  in  obstetrics,  as  in  surgery,  our  duty  should  be  to 
preserve  from  infection  rather  than  to  wait  to  combat  it 
after  it  has  occurred;  and  this  is  usually  practicable  in  the 
domiciles  of  the  well-to-do.  Amid  unwholesome  surround¬ 
ings,  “  antiseptic  ”  measures  may  be  prudently  adopted ;  but 
these  need  hardly  extend  to  a  bichloride  baptism  of  the 
child’s  advancing  head  or  to  its  birth  into  a  carbolized  fog, 
and  enough  cases  of  obstetric  poisoning  by  corrosive  subli¬ 
mate  have  already  been  recorded  to  render  us  cautious  in 
the  employment  of  strong  solutions  of  so  dangerous  an 
agent. 

Imprudence  or  mismanagement  after  parturition  is  a 
fertile  source  of  local  disease  or  general  ill-health,  react¬ 
ing,  almost  of  necessity,  upon  subsequent  offspring,  and 
so,  to  a  certain  extent,  upon  the  biological  condition  of  the 
race. 

Isothing  has  been  said  of  the  graver  ventures  of  modern 
obstetric  surgery,  such  as  Saenger’s  modification  of  the 
Ctesarean  section,  Porro’s  or  Thomas’s  operations,  or  the 
surgical  treatment  of  extra- uterine  pregnancy,  for  the  reason 
that  these  are  still  sub  judice  among  those  to  whom  we  must 
look  for  an  authoritative  opinion,  and  the  cases  requiring 


Dec.  13,  1890.J 


HARTLEY:  CHRONIC  DISTURBANCES  IN  JOINTS. 


649 


them  are  happily  too  few  to  warrant  statistical  deductions. 

•  The  object  1  have  had  in  view  has  been  to  present  sufficient 
data  whereon  to  base  a  conjecture,  if  nothing  more,  of  the 
saving  of  life  and  health  which  may  yet  be  effected  by  ob¬ 
stetric  medicine. 

As  regards  social  conditions,  I  have  little  to  say  beyond 
expressing  the  belief  that  misery  rather  than  midwifery  is 
responsible  for  most  of  the  degradation  which  blots  our 
vaunted  civilization.  It  may  be  that  in  some  cases  such 
misery  is  the  outcome  of  physical  disability  dating  from 
birth  or  parturition,  but  in  more  instances  it  is  the  re¬ 
sult  of  acquired  vicious  habits.  Social  statistics  show 
that  the  numbers  of  murders,  suicides,  and  other  kinds  of 
crime  bear  about  the  same  proportion  to  population  every 
year;  but  of  the  a3tiology  of  criminality  nothing  can  be 
positively  affirmed.  Even  those  who  dogmatically  ascribe 
all  the  ill-doings  of  the  world  to  alcohol  have  still  to  find 
some  antecedent  factor,  and  to  explain  why  the  vast  ma¬ 
jority  of  consumers  of  alcoholic  beverages  refrain  from 
crime.  Inebriety  is  often  the  excitant,  but  the  predisposi¬ 
tion  must  be  sought  behind  it.  u  In  vino  veritas  ”  has  a 
wider  philosophical  meaning  than  they  who  quote  it  ordi¬ 
narily  wot  of. 

Recent  anthropometric  examinations  of  convicts  have 
frequently  detected  cranial  malformation  or  asymmetry;  it 
is  not  yet  proved,  however,  that  this  is  more  common  in 
criminals  than  in  the  law-abiding  classes,  and,  if  it  were, 
the  wildest  flight  of  fancy  would  fail  to  reach  a  guess  of  its 
possible  connection  with  dystocia.  If  it  be  considered  that 
civilized  life  is  artificial,  and  that  the  absolutely  natural  man 
would  be,  in  the  eyes  of  the  civilized  man,  an  habitual 
criminal — gratifying  all  his  animal  propensities  ;  taking, 
furtively  or  forcibly,  whatsoever  he  coveted;  killing  his 
brother  savage  when  prompted  by  any  grievance;  stealthy 
or  violent  in  accordance  to  the  degree  of  his  strength  and 
courage — then  the  “reversions  to  a  lower  type”  which 
police  records  depict  may  be  better  understood,  and  im¬ 
puted,  after  the  hereditary  transmission  of  an  imbruted  or¬ 
ganization,  to  neglected  childhood,  lack  of  moral  training, 
and  evil  communications. 

The  vexed  question  of  heredity  (not  so  much  of  disease 
as  of  proclivity  to  disease)  has  little  relation  to  obstetrics, 
save  as  it  has  led  some  enthusiasts  to  imagine  an  impossible 
prophylaxis  by  forbidding  the  marriage  of  physically,  men¬ 
tally,  or  morally  unhealthy  persons,  and  in  this  way  dimin¬ 
ishing  obstetric  practice,  except  in  illegitimate  births;  and 
it  is  doubtful  if  anything  but  a  destructively  retrogressive 
midwifery  or  an  increasing  prevalence  of  oophorectomy 
can  materially  reduce  hereditary  morbidity,  since  delicate, 
and  especially  consumptive,  women  seem  to  be  more  apt  to 
conceive  and  less  likely  to  miscarry  than  their  more  robust 
sisters.  As  a  “glittering  generality  ”  it  maybe  asserted 
that  every  obstetric  advance  which  saves  mothers  from  in¬ 
validism  and  children  from  incapacity  for  future  effort  must 
promote  the  social  condition  of  the  race;  but  politico- 
economic  rules  and  the  inexorable  operation  of  natural  laws 
will  probably  always  overshadow  in  this  respect  the  influ¬ 
ence  of  medical  science,  or  even  of  congressional  legisla¬ 
tion. 


CHRONIC  DISTURBANCES  IN  JOINTS* 

By  FRANK  HARTLEY,  M.  D. 

My  object  in  presenting  a  paper  upon  this  subject  is 
simply  to  give  expression  to  the  fact  that  I  consider  the 
proper  diagnosis  of  chronic  joint  disturbances  is  the  only 
means  of  deciding  the  treatment.  We  have  now  so  many 
methods  of  treatment  recommended  for  these  disturbances, 
so  many  attestations  to  the  superiority  of  the  one  over  the 
other,  that,  when  we  come  in  contact  with  a  chronic  dis¬ 
turbance  in  a  joint,  we  are  completely  bewildered  in  a  choice. 
For  some  it  is  quite  sufficient  that  the  disturbance  is  chronic 
alone.  The  aetiology,  the  condition  within  the  joint,  and 
the  natural  course  of  the  disease  are  completely  overlooked. 
They  treat  rheumatoid  arthritis,  arthritis  deformans,  arthri¬ 
tis  nodosa,  and  even  neuropathic  joints,  with  antirrheumatic 
and  antisyphilitic  remedies,  apply  splints  and  counter-irri¬ 
tation  to  papillary  and  cartilaginous  synovitis,  look  upon 
syphilitic  arthritis  in  children  as  tubercular,  and  subject  os¬ 
teomyelitic  arthritis  to  a  long  course  of  antirrheumatic  treat¬ 
ment.  Out  of  this  medley  of  opinion  as  to  treatment  the 
best  course  is  a  correct  diagnosis,  for,  if  we  lay  aside  the 
various  remedial  agents  and  begin  at  the  other  end,  estab¬ 
lish  correctly  the  diagnosis,  the  aetiology,  the  condition 
within  the  joint,  and  the  natural  course  of  the  disease,  the 
means  of  cure,  where  such  exists,  become  very  few  in  num¬ 
ber.  I  refer  particularly  to  those  varieties  known  under  the 
head  of  chronic  rheumatic  arthritis,  arthritis  deformans  and 
nodosa,  the  malum  senile,  the  neuropathic,  syphilitic,  and 
metastatic  arthritides. 

An  exact  knowledge  upon  many  of  these  varieties  is 
wanting,  so  that  we  are  forced  to  classify  them,  anatomically 
and  according  to  their  lesions,  as  they  exist  in  the  articular 
ends  of  the  bones,  the  cartilages,  the  synovialis,  the  liga¬ 
ments,  and  the  parasynovial  tissue.  The  bones  and  the 
synovial  membrane  are  important  not  only  as  the  place  of 
origin,  but,  with  the  cartilage,  ligaments,  and  parasynovial 
tissue,  as  giving  us  the  local  manifestations  of  the  lesions. 

The  synovial  membrane,  the  intima  of  which  is  rich  in 
cells,  possessed  of  a  well-marked  vascularity,  and  surround¬ 
ing  a  cavity  filled  with  fluid  favorable  to  the  generalization 
of  any  focus,  responds  quickly  to  disturbances  of  nutrition 
and  inflammatory  irritants. 

In  chronic  disturbances  of  nutrition  and  inflammatory 
processes  the  changes  observed  are  its  increased  vascularity, 
its  thickness,  and  its  greater  density.  The  normal  folds 
and  tufts  which  exist  in  childhood  and  old  age,  at  the  re¬ 
flection  of  the  synovial  membrane  upon  the  bones  near  the 
cartilage,  inclose  within  them  a  rich  network  of  blood-ves¬ 
sels  or  fat,  or  consist  of  a  comparatively  non-vascular  fibril¬ 
lary  tissue,  with  or  without  inclosed  cartilage  cells.  In 
chronic  pathological  processes  these  become  enlarged  and 
vascular,  and,  according  to  the  predominating  changes,  give 
us  the  variety  of  synovitis. 

In  the  chronic  serous  synovitis  (the  hydrops  articu- 
lorum  chronicus)  these  simple  changes  are  present,  with  a 
large  amount  of  serous  fluid,  with  or  without  fibrinous  floe- 


*  Read  before  the  New  York  Clinical  Society,  September  26,  1890. 


650 


HARTLEY:  CHRONIC  DISTURBANCES  IN  JOINTS. 


[N.  Y.  Med.  Jotjb., 


cali  (or  a  fluid  colloid  in  character),  distending  the  capsule 

to  such  an  extent  in  some  cases  as  to  produce  herniae  of  the 
synovial  membrane. 

In  many  cases  of  syphilis,  and  especially  in  arthritis  de¬ 
formans,  newly  developed  and  dendritic  tufts  and  villi  cover 
the  entire  surface  of  the  synovialis,  forming  irregular  and 
dense  sessile  or  pedunculated  outgrowths. 

As  these  papillary  growths  may  consist  of  a  vascular 
network,  fat  or  cartilage,  the  varieties  of  synovitis  have 
been  named  synovitis  chronica  serosa,  papillaris,  prolifera, 
simplex,  cartilaginea,  and  lipomatosa  (lipoma  arborescens 
articulationis).  Moreover,  in  some  cases  a  new  factor  is 
added  in  that  fibrin  is  deposited  upon  the  synovial  mem¬ 
brane  itself,  its  papillae  or  tufts,  producing  in  this  manner  a 
number  of  thick,  rounded,  or  irregularly-shaped  nodules, 
sessile  or  pedunculated. 

Composed  thus  of  fibrin  and  the  contents  of  the  tufts 
and  papillae,  or  of  fibrin  alone,  these,  when  loosened  or 
floating  within  the  joint,  give  rise  to  the  varieties  of  cor¬ 
pora  oryzoidea.  Such  a  condition  is  seen  in  the  chronic 
serous  and  tubercular  synovitis,  and,  together  with  other 
varieties  of  corpora  aliena,  exist  in  arthritis  deformans  and 
neurogenic  arthritis.  In  the  so-called  chronic  rheumatic  ar¬ 
thritis  the  synovialis  presents,  besides  its  vascularity,  a  new 
connective-tissue  growth  with  cicatrization.  This  process, 
synovitis  cicatricans,  exists  not  only  in  this  variety  (best 
seen  in  the  arthritis  rheumatica  chronica  ankylopoietica), 
but  also  in  all  suppurative  processes,  especially  in  catarrhal 
and  gonorrhoeal  synovitis.  In  the  so-called  secondary  pe¬ 
riod  of  syphilis  we  have  to  do  with  a  simple  serous  syno¬ 
vitis ;  but  in  the  tertiary  and  hereditary  syphilis — though, 
so  far  as  the  synovialis  is  concerned,  we  find  about  the  same 
changes  the  prevailing  and  characteristic  marks  are  the 
papillary  growths  and  the  gummata  in  the  subsynovial  fatty 
tissue  at  the  reflection  of  the  synovialis,  in  the  fibrous  cap¬ 
sule,  the  bones,  and  the  neighboring  bursae. 

The  importance  of  the  cartilage  as  a  starting-point  for 
inflammatory  changes  within  a  joint  is  not  of  moment.  It 
is  non-vascular,  it  receives  its  nutrition  by  plasmatic  circu¬ 
lation,  and  is  dependent  upon  its  neighboring  structures  for 
the  changes  which  may  occur  within  it. 

Yet  we  recognize  such  conditions  as  chondritis  pannosa 
granulosa  (cribrosa)  and  hyperplastica,  but  consider  them 

only  as  depending  upon  similar  conditions  in  synovialis  or 
bones. 

In  the  simple  chronic  joint  inflammations  (disturbances 
of  nutrition)  the  cartilages  are  not  generally  involved  other 
than  that  they  are  more  opaque  than  usual.  In  the  chronic 
non-suppurative  processes  the  cartilages  are  at  the  most 
superficially  fibrous  from  an  extension  of  similar  processes 
in  the  synovialis  ;  whereas  in  the  suppurative  and  tubercu¬ 
lar  involvements,  granulation  tissue  from  the  bones  and  the 
synovialis  extends  over  and  into  the  cartilage.  In  the  ac¬ 
quired  syphilis  in  the  tertiary  stage  and  in  the  syphilis  of 
children,  defects  in  the  cartilage  occur,  resulting  in  the  loss 
of  a  portion  of  it  and  its  replacement  by  a  radiating  con¬ 
nective-tissue  scar  from  gummata  in  deeper  portions  "of  the 
articular  ends  of  the  bones,  or  in  the  cartilage  adjacent  to 
the  bone. 


In  the  arthritis  rheumatica  chronica  ankylopoietica  the 
cartilage  is  superficially  fibrous  and  vascular  from  the  ves¬ 
sels  within  the  synovialis  and  spongiosa  of  the  bones.  As 
this  process  advances,  a  gradual  transformation  of  the  car¬ 
tilage  into  connective  tissue  takes  place,  and  opposing  sur¬ 
faces  become  united.  As  this  connective-tissue  transforma¬ 
tion  of  the  cartilage  does  not  involve  the  whole  surface  of 
e  cartilage  at  once,  spaces  covered  with  an  uninvolved 
cartilage  remain  between  these  connective-tissue  areas,  and 
the  original  joint  cavity  becomes  subdivided  into  a  number 
of  smaller  cavities  filled  with  fluid.  In  the  senile  arthritis 
the  cartilages  are  likewise  fibrous,  but  upon  pressure  points 
an  “  Usur  ”  occurs,  which  subsequently  leaves  the  bone  bare 
(the  articular  lamella),  polished,  and  eburnated.  In  the 
arthritis  deformans,  on  the  contrary,  marked  changes  take 
place  in  the  cartilage.  Superficially  it  is  fibrous  and  fis¬ 
sured,  but  in  the  deeper  portions — i.  e.,  near  the  bone _ cir¬ 

cumscribed  foci  of  softening  are  present.  These  changes 
result  in  the  formation  of  a  cancellous  tissue,  which  toward 
the  center  of  the  cartilage  undergoes  a  further  process  of 
absoi  ption,  with  a  gradual  disappearance  of  the  cancellous 
lamellae  and  a  partial  destruction  of  this  osteoid  tissue,  which 
has  here  replaced  the  cartilage  in  its  lower  layers.  Super¬ 
ficially  the  cartilage  remains  fibrous,  sclerosed,  and  fissured. 
On  the  periphery  of  the  cartilage,  on  the  contrary,  tuber¬ 
ous  outgrowths  (stalactites)  occur,  consisting  of  bone  and 
cartilage,  and  so  raising  the  articular  cartilage  that  the 
former  level  is  altered.  This  latter  process,  together  with 
the  central  foci  of  softening,  leads  to  a  complete  transfor¬ 
mation  of  the  joint  in  which  irregular  and  tuberous  out¬ 
growths,  bony  and  cartilaginous,  occur  upon  the  borders  of 
the  cartilages,  while  centrally  it  is  hollowed  out,  grooved, 
and  eburnated.  In  the  severer  neuropathic  arthritis  the 
shape  of  the  joint  is  likewise  altered  in  a  remarkable  man- 
.  he  cartilage  is,  however,  simply  dissolved,  leaving 
the  bony  extremities  bare. 

In  consequence  of  the  use,  the  bone  becomes  smooth 
and  deeply  grooved,  and,  owing  to  its  brittleness,  subject 
to  continual  fracture  and  repeated  haemorrhages.  In  this 
manner  is  explained  the  variety  ot  foreign  bodies  found  in 
such  joints,  the  bony,  the  cartilaginous,  and  fibrinous  coag- 
ula.  They  are  due  in  part  to  the  multiple  fractures,  in  part 
to  the  cartilaginous  and  papillary  synovitis. 

In  the  metastatic  and  severe  purulent  synovitis,  foci  are 
found  in  the  spongiosa  of  the  articular  ends  of  the  bones; 
whereas  in  the  non-tubercular  chronic  inflammations,  the 
senile,  the  neuropathic,  and  the  arthritis  chronica  rheu¬ 
matica  ankylopoietica;  the  bones  are  atrophied,  softened, 
and  give  evidences  of  retrogressive  metamorphosis.  In  the 
arthritis  deformans,  besides  the  gradual  transformation  of 
the  deeper  portions  of  the  cartilage  into  an  osteoid  tissue 
and  a  sclerosis  of  the  superficial  layers,  there  is  an  osteitis 
rareficans  of  the  articular  extremity  in  which  the  salts  of 
ime  being  wanting,  renders  the  bone  softer  than  usual,  so 
that,  on  pressure  point,  grooves  and  fissures  are  found  ;  and 
where  no  pressure  is  exerted,  tuberous  outgrowths  in  vari¬ 
ous  stages  of  calcification  may  be  seen.  In  the  syphilitic 
joint  inflammations  the  bones  are  the  seat  of  a  syphilitic 
caries  (syphilitic  osteomyelitis)  or  of  gummata,  and  in 


Dec.  13,  1890.] 


HARTLEY:  CHRONIC  DISTURBANCES  IN  JOINTS . 


651 


many  cases  of  hereditary  syphilis  of  a  syphilitic  osteo¬ 
chondritis  and  periostitis. 

These  gummata  are  most  frequently  situated,  however, 
upon  the  peripheral  portion  of  the  ends  of  the  bones,  and 
are  rarely  within  the  spongiosa;  whereas  in  tuberculosis 
the  process  begins  near  the  epiphyseal  line  in  the  form  of 
a  grayish-red  or  whitish  mass  of  tubercles  or  granulation 
tissue,  or  in  the  form  of  a  more  diffuse  tubercular  infiltra¬ 
tion  of  the  spongiosa.  The  bones  in  syphilis  are  not  greatly 
changed  in  form,  yet  there  is  always  some  hyperostosis. 

The  changes  occurring  in  the  fibrous  capsule  and  liga¬ 
ments  are  seen  principally  in  relaxation  or  contraction. 

They  are  contracted  in  chronic  polyarticular  rheumatism 
(art.  chronica  rheum,  ankylopoietica),  malum  senile,  and  in 
the  continued  fixation  of  chronically  inflamed  or  even  nor¬ 
mal  joints.  They  are  relaxed  in  arthritis  deformans,  neuro- 
geuic  and  rhachitic  joints.  All  other  changes  occurring 
within  these  structures  are  similar  to  those  occurring  within 
the  joint.  . 

In  a  diagnosis  of  the  variety  of  joint  disease  we  are  to 
examine  carefully  the  condition  of  the  synovial  membrane 
and  bones  principally,  as  well  as  the  cartilage,  ligaments, 
and  parasynovial  tissue.  Unless  such  a  careful  and  accu¬ 
rate  local  examination  is  made,  we  are  prone  to  mingle  one 
form  of  chronic  inflammation  with  another  and  to  neglect 
to  make  use  of  one  of  the  most  important  means  toward  an 
accurate  diagnosis.  So  similar  are  the  changes  in  the 
synovialis  that,  unless  careful  attention  is  given  to  the  rest 
of  the  joint,  the  anatomical  part  of  the  diagnosis  is  over¬ 
looked  and  an  attempt  is  made  to  decide  the  case  upon  sub¬ 
jective  symptoms  alone.  This  very  thing  is  too  often  per¬ 
formed  in  a  perfunctory  manner,  without  an  exact  knowl¬ 
edge  of  characteristics  of  the  diseases  liable  to  cause  a 
disease  within  a  joint.  We  should  not,  however,  be  content 
to  decide  any  case  upon  what  we  can  find  in  the  joint  alone. 
As  far  as  possible,  the  setiological  factor  should  be  sought 
for;  whether  this  irritant  (chemical  or  micro-organic)  ar¬ 
rived  within  the  joint  from  a  wound,  from  the  neighboring 
tissues,  or  from  foci  at  a  distance. 

In  suppurative  processes — osteomyelitis,  tuberculosis,  and 
syphilis — the  joint  invasion  takes  place  from  the  neighbor¬ 
ing  tissues  by  a  process  similar  to  the  original  focus,  either 
by  means  of  the  lymphatics  directly  causing  an  acute  or 
chronic  inflammation,  or  the  focus  itself  advances  and  rupt¬ 
ures,  causing  generally  an  acute  invasion. 

More  frequently,  however,  the  irritant  involves  the  joint 
by  means  of  the  blood-vessels. 

This  is  the  case  in  acute  rheumatism,  gout,  syphilis,  tu¬ 
berculosis,  and  metastatic  inflammations,  the  result  of  the 
infectious  diseases.  .  Possibly  this  is  the  case  in  polyarticu¬ 
lar  arthritis  deformans  and  many  chronic  and  rheumatic 
arth  rites. 

Moreover,  the  irritant  may  exist  in  the  blood  only  occa¬ 
sionally,  and  then  involve  the  joint.  Such  is  probably  the 
case  in  tuberculosis,  metastatic  (gonorrhoeal)  synovitis,  and 
some  chronic  rheumatic  synovitides. 

In  just  these  cases  the  focus  is  to  be  found  in  the  sup¬ 
purative  processes  in  the  skin,  the  subcutaneous  tissue,  the 
bones,  and  mucous  membranes,  especially  in  the  tonsils, 


pharynx,  and  nose,  in  the  lungs,  the  intestines,  and  the 
genital  and  urinary  organs. 

Such  a  method  of  infection  is  thought  to  be  common 
and  is  to  be  considered  in  every  case.  It  is  more  than  prob¬ 
able  that  this  is  the  case  when  we  consider  how  the  ana¬ 
tomical  structure  of  the  spongiosa  favors  the  slowing  of  the 
current  of  blood  and  accumulation  of  an  inflammatory  irri¬ 
tant  within  the  ends  of  the  bones  as  well  as  the  anatomy  of 
the  synovialis  and  the  relation  to  the  joint  cavity  of  its  lym¬ 
phatics.  When  a  joint  is  alone  involved,  either  the  process 
is  a  simple  disturbance  of  nutrition  without  infection,  or  the 
infection  takes  place  from  distant  parts  by  means  of  slight 
injuries  to  the  spongiosa  or  the  synovialis,  in  which  either 
an  extravasation  of  blood  or  a  thrombus  in  the  vessels  ad¬ 
mits  the  infection  and  produces  an  inflammation  of  greater 
or  less  severity,  depending  upon  the  amount  and  intensity 
of  the  agent. 

In  this  manner  new  diseases  may  be  added  to  old  ones. 
Such  may  be  the  case  in  the  tubercular  involvement  of  pre¬ 
vious  simple  synovitis,  metastatic  and  so-called  rheumatic 
arthritis,  as  well  as  in  the  arthritis  deformans  the  out¬ 
growth  of  simple  or  rheumatic  synovitis.  How  heat  and 
cold  act  in  producing  disturbances  of  nutrition  and  inflam¬ 
matory  changes  we  do  not  know.  It  is  probable,  however, 
that  they  cause  disturbances  in  the  walls  of  the  vessels,  in 
the  circulation  of  the  blood,  or  in  the  cellular  elements  in 
the  tissues,  favoring  the  collection  or  escape  of  the  irritant 
not  only  in  the  neighborhood  of  the  joint,  but  also  in  the 
joint  itself. 

Nor  should  our  investigations  be  confined  to  these  meth¬ 
ods  alone.  We  are  to  examine  in  all  cases  to  see  what  dis¬ 
eased  conditions  of  the  nervous  system  are  present  to  pre¬ 
pare  a  point  of  diminished  resistance  to  disturbances  of 
nutrition  or  possibly  secondary  infections.  Wherever  we 
find  any  similarity  to  neurogenic  joints,  we  should  institute 
a  careful  examination  for  the  early  stages  of  locomotor 
ataxia,  syringomyelia,  compression  of  the  cord,  etc. 

As  the  subsequent  course  of  any  disease  within  a  joint 
depends  so  much  upon  this  condition,  it  is  highly  impor¬ 
tant  to  recognize  it  in  its  earliest  stage,  both  for  prognosis 
and  for  treatment. 

It  is  only  by  understanding  specifically  the  point  of  ori¬ 
gin,  the  condition  within  the  joint,  and  the  aetiology,  that  we 
are  able  to  act  rationally  in  our  prognosis  or  methods  of 
treatment. 

The  first  form  which  to  me  seems  of  importance  is  the 
chronic  serous  synovitis.  Under  the  chronic  serous  syno¬ 
vitis  we  include  a  number  of  varieties  depending  upon  the 
changes  within  the  synovialis,  yet  all  these  varieties  are 
characterized  by  the  fact  that  they  are  local  disturbances  of 
nutrition  occasioned  by  a  trauma,  and  appearing  at  first 
either  as  an  acute  or  chronic  process. 

Depending  upon  the  predominating  changes  in  the  sy¬ 
novialis  and  the  chronicity  of  the  process,  it  appears  as  a 
hydrops  articulorum  cbronicus  (chronic  serous  synovitis),  a 
synovitis  papillaris,  a  synovitis  prolifera  simplex,  synovitis 
cartilaginea,  and  synovitis  lipomatosa  (lipoma  arborescens. 
articulationis). 

The  symptoms  likewise  vary  with  the  character  of  the 


652 


HARTLEY:  CHRONIC  DISTURBANCES  IN  JOINTS. 


[.N.  Y.  Med.  Jour., 


changes  in  the  synovialis,  whereas  in  the  hydrops  articulo- 
rum  chronicus  the  characteristic  is  the  large  quantity  of 
fluid,  the  herniae  of  the  synovialis,  and  the  want  of  all  re¬ 
striction  to  motion  within  the  joint;  in  the  synovitis  papil¬ 
laris,  cartilaginea,  and  lipomatosa  these  symptoms  are  not 
marked  nor  have  they  any  diagnostic  value.  Though  there 
may  be  a  quantity  of  fluid  within  the  joint,  it  is  small  in 
amount,  except  during  exacerbations  as  the  result  of  over¬ 
use  or  injury.  The  important  changes  are  seen  on  the  ex¬ 
amination  of  the  synovialis,  and  the  symptoms  diagnostic 
of  any  of  these  varieties  are  dependent  upon  this  condition 
within  the  synovialis  alone.  We  may  thus  have  a  joint  dis¬ 
ease  which  simulates  in  the  exudation  and  in  its  sudden 
attack  the  synovitis  of  scurvy,  morbus  rnaculosus,  and  haemo¬ 
philia  ;  in  the  quantity  of  fluid  and  in  the  character  of  the 
synovialis,  a  deforming  or  neurogenic  arthritis,  a  syphilitic 
or  tubercular  hydrops.  The  presence  of  foreign  bodies 
within  the  joint — blood,  fibrin,  fat,  or  cartilage — whether 
movable  or  free  within  the  joint,  or  pedunculated,  gives  at 
times  a  variety  of  symptoms  with  which  we  are  familiar 
under  the  term  of  foreign  body  within  the  knee  joint. 

The  character  of  the  fluid  within  the  joint  is  one  in 
which  we  find  a  few  white  blood  cells,  portions  of  tufts 
which  have  been  separated  from  the  synovialis,  and  red 
blood  cells  following  manipulation  or  use  of  the  limb.  Fi¬ 
brinous  flakes  of  varying  size  and  shape  (rice  bodies)  are 
frequently  seen,  and  exceptionally  a  fibrinous  deposit  is 
present  to  such  an  extent  as  to  fill  completely  the  cavity 
as  a  mold.  The  fluid  is  rarely  under  great  pressure  within 
the  joint,  nor  are  the  ligaments  stretched  or  loosened  so 
that  the  joint  becomes  flaccid.  The  bones  are  never  involved, 
although  here  and  there  upon  the  cartilage  small  eroded 
surfaces  or  spots  of  chondritis  pannosa  may  be  present.  The 
joints  most  frequently  involved  are  the  knee,  elbow,  foot, 
and  hand. 

It  is  to  be  distinguished  from  the  varieties  of  disease 
above  mentioned  in  the  first  place;  secondly,  we  are  to  de¬ 
termine  as  far  as  possible  the  changes  in  the  synovialis,  for 
upon  these  changes  will  depend  our  treatment  and  ability 
to  cure  with  or  without  ankylosis.  It  is  a  variety  most  fre¬ 
quently  mistaken  for  tubercular  and  syphilitic  hydrops, for 
commencing  arthritis  deformans,  and  a  foreign  body  in  the 
joint. 

A  second  variety  of  importance  for  diagnosis  is  the 
metastatic  variety — a  variety  which,  so  far  as  my  experi¬ 
ence  goes,  is  very  frequently  overlooked. 

In  the  so-called  infectious  diseases  artbrites  are  not  un¬ 
commonly  seen.  In  measles,  scarlet  fever,  small-pox,  cere- 
bro-spinal  meningitis  (epidemic),  pneumonia,  typhus,  dys¬ 
entery,  erysipelas,  pertussis,  epidemic  parotitis,  acute  in¬ 
fectious  osteomyelitis,  puerperal  fever,  p\aemia,  septicaemia, 
gonorrhoea,  catheterismus,  chronic  c\ stitis,  glanders,  and 
malarial  disease  the  joints  may  be  involved  as  a  serous, 
sero-purulent,  or  purulent  arthritis.  Rarely  as  a  diphther¬ 
itic  process  with  small  luemorrhages  they  occur  in  puerperal 
fever,  acute  infectious  osteomyelitis,  erysipelas,  pyaunia, 
septicaemia,  and  glanders.  In  addition  to  these,  in  variola, 
cerebro-spinal  meningitis,  suppurative  parotitis,  and  seailet 
fever  it  is  seen  as  a  puiulent  arthritis.  In  other  diseases 


and  in  milder  infections  in  the  above  it  appears  as  a  serous 
or  sero-purulent  arthritis.  These  varieties  depend  upon 
degrees  of  infection  or  upon  mixed  infections.  In  the 
serous  exudates  the  specific  micro-organisms  are  frequent, 
but  are  always  present  with  other  varieties,  whereas  in  the 
purulent  they  are  scarcer  or  are  not  present  at  all.  They 
are  characterized  by  the  fact  that  they  are  multi-articular 
and  occur  during  the  existence  of  the  disease. 

In  measles,  cerebro-spinal  meningitis,  pneumonia,  paro¬ 
titis,  and  puerperal  fever  they  generally  occur  shortly  after 
the  beginning  of  the  disease  ;  in  catheterismus,  within  a  few 
hours;  in  scarlet  fever,  in  the  period  of  desquamation  ;  in 
variola,  in  the  period  of  suppuration  ;  in  diphtheria,  gon¬ 
orrhoea,  and  dysentery,  toward  the  end  of  the  disease. 

In  the  period  of  convalescence  these  aithrites  are  gener¬ 
ally  monarticular  and  serous  or  sero-purulent. 

When  serous,  they  remain  a  few  days  and  then  recede 
quickly  or  require  a  longer  time  to  disappear.  They  not 
uncommonly  remain,  however,  as  a  chronic  inflammation 
in  one  or  more  joints.  In  gonorrhoea  this  is  especially  the 
case.  The  arthritis  continues  for  weeks  w  ith  moderate  pain, 
or  resolves  completely  to  return  again  with  moderate  pain 
and  swelling.  There  is  thus  in  time  produced  a  thickening 
of  the  synovialis,  the  formation  of  enlarged  tufts  and  villi, 
with  a  moderate  amount  of  fluid  in  the  joint,  and  a  condi¬ 
tion  of  so-called  chronic  relapsing  hydrops.  It  is  indeed 
the  characteristic  of  these  metastatic  inflammations  to  re¬ 
lapse ,  and  is  an  important  factor  in  their  diagnosis.  Such 
synovitides  I  have  seen  in  gonorrhoea,  where  the  disease  re¬ 
mained  as  a  multi-articular  synovitis. 

A  synovitis  papillaris  and  cartilaginea  in  one  knee,  a 
chronic  serous  synovitis  in  the  other  knee,  a  synovitis  cica- 
tricans  in  one  wrist  and  ankle,  an  acute  exacerbation  upon 
a  chronic  serous  synovitis  in  the  other  ankle,  existed  in  one 
patient. 

It  was  the  outgrowth  of  a  gonorrhoea  acquired  three 
years  previously  and  had  been  present  since  that  time. 
Each  exacerbation  of  his  chronic  gonorrhoea  was  generally 
attended  with  some  joint  complication. 

In  cases  where  the  disease  is  catarrhal  they  lead  to 
fibrous  or  bony  ankylosis,  or  resolve  completely.  In  the 
purulent  form,  however,  though  recovery  may  occur,  death 
generally  results. 

Sometimes  without  operation  they  become  chronic,  ex¬ 
isting  as  a  purulent  arthritis  with  necrosis  of  the  articular 
extremities  of  the  bones,  or  become  secondarily  tubercular. 
In  the  period  of  convalescence  the  joint  most  frequently 
involved  is  the  hip,  and  the  diseases  in  which  this  occurs 
are  generally  typhoid,  scarlet  fever,  pneumonia,  and  acute 
infectious  osteomyelitis.  Spontaneous  luxation  is  not  un¬ 
common,  even  where  no  suppuration  was  present.  I  have 
seen  cases  of  this  kind  in  typhoid  fever,  measles,  and  in¬ 
fectious  osteomyelitis. 

Even  when  such  joints  have  not  become  tubercular  they 
are  often  considered  so  because  of  their  chronicity  alone, 
and,  no  matter  how  treated,  whether  by  operation  or  me¬ 
chanically,  are  held  up  to  us  as  examples  of  the  advantages 
of  one  or  the  other  methods  of  treatment  in  this  disease, 
when  the  actual  condition  is  entirely  of  another  character. 


653 


Dec.  13,  1890.]  HARTLEY:  CHRONIC  DISTURBANCES  IN  JOINTS. 


Although  injuries  to  the  joint  in  man  and  the  injection 


Such  errors  in  diagnosis  I  have  not  infrequently  seen  in  the 
acute  multiple  epiphyseal  osteomyelitis.  These  cases  have 
been  indefinitely  treated  as  acute  rheumatism  in  their  first 
attack,  and  in  their  chronic  form  considered  as  rheumatism 
or  tuberculosis.  Hitherto  we  have  paid  attention  mostly  to 
the  osteomyelitis  of  the  shafts  of  bones,  yet  greater  attention 
should  be  given  to  that  of  the  epiphyses,  which  appears  un¬ 
der  the  form  of  an  arthritis  (multi-articular  or  uni-articu¬ 
lar),  simulating  in  the  early  stage  an  acute  multi-articular 
rheumatism  and  in  the  later  stages  varying  according  to  the 
character  of  the  arthritis — i.  e.,  the  degree  of  the  osteo¬ 
myelitis  and  character  of  the  synovialis  (serous,  catarrhal,  or 
purulent).  This  disease  is  that  variety  of  rheumatism,  if  I 
may  so  term  it,  in  which  antirrheumatic  remedies  have  no 
effect  and  in  which  fistulae,  with  or  without  necrosis  or  sim¬ 
ple  catarrhal  or  purulent  arthritis,  succeed  the  acute  attack. 
How  many  of  the  good  results  in  tuberculosis  are  due  to 
this  error  in  diagnosis  I  am  unable  to  say.  I  do  not  think, 
however,  from  rav  experience  in  operations  upon  the  joints 
where  one  is  able  to  see  clearly  the  lesion,  that  all  of  our 
diagnoses  of  tubercular  joints  are  by  any  means  correct. 
Our  errors,  I  am  sure,  give  more  cures  for  tuberculosis  than 
properly  belong  to  it. 

A  third  variety  is  that  to  which  we  give  the  name  of 
chronic  rheumatic  arthritis,  which  includes  several  diseases 
differing  in  their  cause  and  course,  but  having  very  similar 
anatomico-pathological  changes.  These  consist  in  an  infil¬ 
tration  and  thickening  of  the  capsule,  which  becomes  cica¬ 
tricial,  while  the  bones  and  cartilages  are  only  superficially 
destroyed  without  hypertrophic  changes,  and  in  which  the 
tendency  of  the  opposing  surface  is  to  unite.  Yet  these 
cases  differ  so  much  in  their  course  that  it  is  wrong  to  class 
them  under  one  head. 

According  to  many,  they  arise  from  acute  rheumatism 
or  exist  as  primary  chronic  inflammations,  an  uncertainty 
which  seems  to  exist  from  the  fact  that  marked  rheumatism 
is  not  infrequently  present  where  only  slight  fever  exists 
with  a  gradual  but  steady  involvement  of  the  joint,  or  in 
which  the  disease  begins  as  endocarditis,  to  which  the  joint 
complications  are  subsequently  added. 

Yet  others  look  upon  these  joints  as  rheumatic  only 
when  preceded  by  a  distinct  and  veritable  acute  rheuma¬ 
tism,  with  its  relapses  and  complications. 

I  do  not  wish  to  speak  of  the  easily  recognized  varieties 
of  chronic  rheumatism,  either  the  infectious  variety,  arthri¬ 
tis  rheumatica  chronica  ankylopoietica,  or  the  chronic  serous 
synovitis  seen  in  the  outgrowth  of  previous  attacks  of  rheu¬ 
matism,  as  their  characteristics  are  marked  by  constant  re- 
lapses,  gradual  and  increasing  ankylosis,  paresis  of  the  mus¬ 
cles  about  the  joint,  the  subacute  exacerbations  with  oedema 
and  redness,  and  the  multi-articular  character  without  fever; 
or  the  rarer  variety  of  monarticular  chronic  rheumatism. 

Nor  has  it  seemed  to  me  that  the  malum  senile,  arthri¬ 
tis  nodosa,  or  the  multi-articular  variety  of  arthritis  defor¬ 
mans  has  offered  any  great  chances  for  difficulty  in  diag¬ 
nosis.  As  a  monarticular  disease,  however,  arthritis  defor¬ 
mans  certainly  demands  attention,  and  is  not  infrequently 
overlooked. 

Its  astiological  factor  is  not  known. 


of  weak  inflammatory  products  into  the  joints  of  animals 
have  produced  somewhat  similar  conditions — though  cases 
have  been  reported  as  following  synovitis  serosa  and  gon- 
orrhoica — still,  we  are  as  much  in  doubt  about  this  as  a  fac¬ 
tor  as  we  are  of  its  trophoneurotic  origin. 

The  course  of  the  disease,  however,  and  the  objective 
symptoms  give  us  sufficient  data  upon  which  to  base  a  diag¬ 
nosis. 

Existing  in  the  younger  class  of  people,  its  course  is 
much  more  rapid  than  the  multi  articular  variety  in  the  older 
people.  It  not  infrequently  follows  contusions,  distortions, 
and  intra-articular  fractures,  though  it  may  occur  spontane- 
ously — i.  e .,  to  all  appearances.  Commencing  with  moderate 
pain,  crepitation,  and  stiffness  in  the  joint,  there  are  gradu¬ 
ally  added  neuralgic  pains  in  the  limb  of  some  severity. 
Acute  exacerbations,  with  an  increase  of  fluid  within  the 
joint,  occur  from  time  to  time,  persisting  for  two  to  five 
days  and  slowly  receding. 

Yet,  in  all  this  process  there  is  no  ankylosis,  no  fever, 
nor  suppuration.  In  the  examination  of  the  joint,  we  find 
a  thickening  of  the  capsule,  the  formation  of  tufts  within 
the  joint  in  the  forms  of  the  fibroma  papillare  (Virchow), 
lipoma  arborescens,  or  the  cartilaginous  plates.  On  the 
articular  ends  of  the  bones  we  find  an  osteitis  deformans, 
the  result  of  which  is  to  produce  a  softening  and  gradual 
disappearance  of  the  lower  portion  of  the  articular  carti¬ 
lage,  with  a  sclerosis  of  its  superficial  layers  as  well  as  the 
grooves  and  fissures  within  the  joint  at  the  point  of  contact 
of  the  articular  ends.  On  the  borders  of  the  cartilage  the 
advance  of  the  osteitis  is  not  impeded,  and  irregular  out¬ 
growths  occur,  producing  such  changes  in  the  articular  car¬ 
tilages,  by  elevating  and  disturbing  their  natural  position, 
as  to  lead  to  subluxations  or  imperfections  in  their  full  and 
free  use.  This  process  begins  beneath  the  periosteum  and 
gradually  extends  toward  the  medulla.  It  is  similar  in  its 
course  to  an  osteitis  rarificans— i.  e.,  in  the  formation  of 
Howship’s  lacunae  and  the  Haversian  spaces.  As  in  all 
diseases  of  bone,  there  is,  together  with  this  process,  a 
formation  of  new  bone  both  in  the  medulla  and  beneath  the 
periosteum.  This  newly  formed  bone  remains  without  the 
salts  of  lime  for  a  long  time,  is  softer  than  usual,  and  )ields 
readily  to  the  pressure  exerted  upon  it.  The  process  runs 
its  course  with  calcification  and  sclerosis,  so  that  in  older 
portions,  instead  of  a  soft  and  yielding  structure,  a  firm  and 
resisting  deposit  of  new  bone  is  formed. 

The  failure  in  the  deposits  of  the  salts  of  lime  in  the 
earlier  stages  gives  us  a  means  of  explaining  why  such  great 
deformities  occur  within  so  short  a  time  (one  year)  in  such 
joints  as  the  hip,  the  knee,  and  the  elbow. 

As  the  disease  runs  its  course  in  sclerosis  and  calcifica¬ 
tion,  it  justifies  us  in  a  resection,  when  this  is  necessary 
either  from  the  deformity  or  the  severe  pain. 

The  process  is  practically  a  disease  of  the  joint,  yet  the 
joint  symptoms  are  only  a  secondary  process  to  a  disease  in 
the  articular  euds  of  the  bone — an  osteitis  deformans.  The 
objective  signs  are  sufficiently  diagnostic,  yet  they  are  not 
given  their  full  weight  in  the  earlier  stages  of  the  disease. 

It  is  a  very  important  variety  ;  it  is  easy  of  diagnosis  in 


<554 


HARTLEY:  CHRONIC  DISTURBANCES  IN  JOINTS. 


[N.  Y.  Med.  Jouk., 


the  later  stages,  but  in  the  earlier  stages  it  offers  many  ditfi- 
eulties  when  contrasted  with  other  diseases,  as  osteochon¬ 
dritis  dissecans  and  traumatic  arthritis. 

A  fourth  variety,  in  which  I  think  many  errors  in  diag- 

•  tiosis  are  made,  is  the  arthropathies  occurring  in  syphilis. 
It  is  not  so  rarely  seen  that  in  the  acquired  disease  such  a 
process  is  treated  for  acute  rheumatism,  and  in  the  heredi¬ 
tary  form  is  considered  and  treated  as  a  tubercular  process. 

I  have  seen  just  such  cases,  where  the  treatment  was 
'Carried  so  far  as  resection,  or  in  which  an  antisyphilitic 
treatment  was  required  to  cure  a  persistent  rheumatism. 

In  this  disease  we  should  consider  the  arthropathies  both 
in  the  acquired  and  hereditary  forms. 

In  the  secondary  period  we  have  to  do  mostly  with  a 
subacute  or  chronic  serous  exudation  within  several  joints. 
They  are  similar  to  metastatic  arthritis,  with  which  they 
'may  be  classed.  Existing  as  a  multi-articular  or  uni-articu¬ 
lar  process  with  some  fever,  pain,  and  swelling,  with  or 
without  a  serous  exudation  within  the  joints,  especially  if 

-  'the  onset  is  sudden  and  an  eruption  is  not  marked,  or  not 
observed,  or  inquired  into,  it  is  apt  to  be  looked  upon  as 
rheumatic,  and  so  treated.  More  frequent  than  this  vari- 

-  ety,  however,  is  that  occurring  in  the  tertiary  stage.  It  is 
'commonly  uni-articular,  subacute,  or  chronic  in  character, 

-  and  is  attended  with  a  moderate  exudation  within  the  joint. 
The  capsule  is  slightly  thickened,  with  well-marked,  papilli¬ 
form,  thick  tufts  upon  the  synovialis.  The  changes  in  the 
cartilage  are  peculiar,  and  consist  of  a  transformation  of 
the  cartilage  over  circumscribed  areas  into  a  dense  cicatri¬ 
cial  tissue,  somewhat  depressed  beneath  the  level  of  the 
surrounding  cartilage  and  covered  and  bordered  by  small 
tufts.  No  new  cartilage  is  here  produced.  It  is  simply  re¬ 
placed  by  a  dense  connective  tissue  due  to  subchondral 
gummata. 

These  cartilage  defects  and  a  papillary  synovitis  are  pe¬ 
culiar  to  the  disease  and  occur  without,  but  generally  with, 
a  gumma  in  the  bursae*  ligaments,  or  beneath  the  periosteum 
near  the  epiphysis,  or  as  an  accompaniment  of  a  syphilitic 
osteomyelitis  of  the  diaphysis  which  has  advanced  toward 
?the  epiphysis.  The  general  result  of  such  a  process  is  a 
■simple  hydrops,  yet  suppuration  may  occur  either  as  the  re¬ 
sult  of  an  accidental  infection  or  from  the  gradual  or  rapid 
breaking  down  of  a  gumma  which  has  already  involved  the 
joint.  As  a  sero-purulent  or  catarrhal  exudation  it  follows 
-subchondral  gummata,  whereas  in  the  gummata  in  the  bones, 
ligaments,  or  bursae,  fistuhe  are  slowly  formed,  and  the  sup¬ 
puration  is  then  added. 

More  interesting  and  difficult  of  diagnosis,  however,  are 
those  cases  of  this  disease  seen  in  childhood  and  youth,  the 
result  of  “syphilis  hereditaire  tardive.”  Here  we  are  to 

-  observe  particularly  those  symptoms  which  are  characteris- 
.  tic  in  a  general  way. 

The  peculiar  multiplicity  and  symmetry  seen  in  these 
arthritides,  the  age  (three  to  twenty-eight,  five  to  fifteen),  the 
bones  involved— tibia,  ulna,  radius,  humerus,  and  femur — 
their  point  of  involvement,  mostly  the  diaphysis,  not  infre¬ 
quently  the  epiphysis,  subacute  or  chronic  osteo-periostitis 

•  ending  in  hyperostosis,  “  douleurs  osteocopes,”  and  the 
syphilitic  habitus — are  all  symptoms  which  should,  in  any 


case,  lead  us  to  suspect  strongly  the  character  of  the  lesion. 
A  form  most  difficult  of  diagnosis  is  that  in  which  there 
exists  within  a  joint  or  joints  a  subacute  serous  inflamma¬ 
tion,  with  moderate  exudation,  some  swelling  of  the  cap¬ 
sule,  pain  and  redness  in  the  skin,  but  without  any  observa¬ 
ble  changes  in  the  bone.  There  are  present  within  these 
joints  changes  in  the  cartilage  characteristic  of  syphilis, 
:'oci  of  necrosis,  or  sharply  bordered  defects,  while  the 
synovialis  presents  only  an  inflammatory  injection.  The 
epiphyseal  cartilage  is  in  no  way  involved. 

This  variety  I  have  seen  in  only  one  instance.  The 
diagnosis  must  be  made  by  exclusion,  by  the  multiplicity 
and  symmetry,  the  subacute  course,  and  the  joints  involved. 
In  this  particular  instance  the  child,  three  years  old,  was 
cured  in  about  two  months  with  antisyphilitic  treatment, 
and  in  two  years  returned  with  other  manifestations  of 
hereditary  syphilis. 

More  common  and  much  easier  of  diagnosis  are  those 
cases  occurring  as  a  complication  of  a  gumma  in  the  soft 
parts  about  the  joint  or  axis,  seen  in  a  periostitis  and  osteo¬ 
myelitis  of  a  neighboring  long  bone.  Here  the  presence  of 
•;be  gumma  or  the  osteomyelitis  and  periostitis,  with  thick¬ 
ening  of  the  capsule  ami  the  papillary  growth  in  the  syno¬ 
vialis,  makes  the  diagnosis  comparatively  easy.  Such  cases 
have  been  frequently  seen  during  tbe  last  three  years  at  the 
Roosevelt  Hospital.  A  third  variety  in  hereditary  syphilis, 
and  one  which  I  think  is  not  so  very  uncommon,- is  that  in 
which  an  arthritis  follows  an  epiphyseal  periostitis  and  peri¬ 
chondritis  by  simple  extension.  They  appear  with  a  rela¬ 
tively  rapid  swelling  of  the  epiphyseal  periosteum,  with  a 
gradual  serous  exudation  into  the  joint.  As  the  process-: 
advances,  the  capsule  is  thickened  and  papillary  growths 
upon  the  synovialis  are  added.  This  process  may  be  at 
tended  with  a  puriform  exudation  into  the  joint,  whei 
such  a  focus  breaks  into  the  joint,  or  a  complete  separation 
of  the  epiphysis  may  take  place.  A  relatively  rapid  eir 
cum ferential  swelling  of  the  epiphysis,  attended  with  ai 
exudation  within  the  joint,  are  the  characteristic  signs 
The  condition  produced  is  somewhat  similar  to  rhachitis 
but  differs  from  it  in  its  rapidity  and  joint  complication.  ; 

The  joints  most  frequently  involved  in  these  varietie: 
are  the  knee,  the  elbow,  the  metatarsal,  metacarpal,  an< 
digital  joints.  These  varieties  are  of  great  importance  ii 
diagnosis,  and  their  treatment  is  so  evident  and  brillian 
that  fo  make  a  mistake  seems  almost  reprehensible.  W| 
will  all  of  us  make  such  mistakes,  but  we  should  attemp 
at  least  in  all  cases,  especially  in  children,  where  the  differ 
ential  diagnosis  between  syphilis  and  tuberculosis  may  bj 
somewhat  uncertain,  to  give  the  child  the  benefit  of  a  sy phi 
litic  course  of  treatment  if  any  well-founded  suspicions  a 
to  the  character  of  the  process  exist.  It  is  only  in  the  sup 
purating  syphilitic  processes  that  any  operative  measure 
are  necessary.  Even  here  it  is  to  be  made  subordinate  t( 
internal  or  local  antisyphilitic  remedies. 

If  I  might  be  allowed  to  so  express  myself,  Mr.  Presi 
dent,  I  should  say  that,  though  not  frequent,  some  of  nr 
best  results  in  suspected  tubercular  joints  in  children  hav' 
been  cured  in  this  way.  I  have  seen,  in  all,  four  cases  o 
this  disease  subjected  to  operative  treatment.  Two  of  then 


Dec.  13,  1890.] 


SAYRE:  SIMULTANEOUS  DISEASE  OF  THE  HIP  AND  KNEE. 


655-, 


were  gummatous  arthritis  of  the  elbow  ;  resection,  return 
in  both,  cured  bv  internal  treatment  alone.  The  other  two 
cases  had  other  joints  involved.  In  one,  a  knee-joint,  gum¬ 
matous  arthritis  from  subperiosteal  gumma;  resection  re¬ 
turn  ;  cured  by  internal  medication.  The  other  case  was 
one  of  irrigation  and  drainage  of  the  knee.  Return,  cured 
by  internal  medication. 

It  should  be  our  duty  to  recognize  this  variety  of  joint 
disease  when  it  is  present.  In  this  variety,  more  than  in 
any  other,  can  a  good  functional  result  be  obtained  by  in¬ 
ternal  local  medication. 

There  is  still  another  class  of  cases  in  which  the  chances 
of  error  in  diagnosis  are  great.  I  refer  particularly  to  the 
neurogenic  arthritis  occurring  during  the  course  of  locomo¬ 
tor  ataxia,  compression  of  the  cord,  traumatic  lateral  spinal 
paralysis,  acute  myelitis,  multiple  sclerosis,  syringomyelia, 
and  injury  to  peripheral  nerves. 

It  is  not  our  province  here  to  discuss  whether  the  tro¬ 
phic  centers  are  involved,  whether  nutritive  anomalies  in 
the  bones  exist,  rendering  them  more  fragile,  or  whether 
the  bones  maintain  their  normal  density  and  compactness. 
There  can  be  no  doubt  about  the  fact  that  neuropathic  in¬ 
dividuals  are  subject  to  all  possible  forms  of  arthritis  as 
every  one  is.  Yet  the  course  of  their  arthrites  are  so  modi¬ 
fied  by  the  disturbance  in  innervation  that  it  is  of  practical 
value  to  consider  them  as  a  separate  variety. 

The  analgesia  and  the  increased  vulnerability  of  the  tis¬ 
sues  in  neuropathic  individuals  prepare  a  course  distinctive 
for  this  class  of  cases.  It  is  not  necessary  that  an  abnormal 
fragility  of  the  ends  of  the  bones  be  considered  as  a  pre¬ 
requisite  condition.  All  that  one  requires  is  an  intra-articu- 
lar  fracture  and  a  continued  use  of  the  joint  to  develop  a 
condition  similar,  but  not  so  rapid  as  when  it  exists  in  loco¬ 
motor  ataxia.  When,  however,  there  is  added  a  fragility, 
analgesia  and  ataxia,  or  analgesia  alone,  we  may  explain  sat¬ 
isfactorily  the  course  and  the  varieties  of  these  joint  com¬ 
plications. 

They  are  presented  to  us  under  the  picture  of  an  ar¬ 
thritis  traumatica,  deformans,  or  neurogenica  with  its  spon¬ 
taneous  fractures  of  the  articular  ends  of  the  bones,  and  the 
excessive  production  of  callus  both  by  the  periosteum  and 
soft  parts  about  the  joint. 

As  a  traumatic  or  deforming  arthritis,  it  runs  so  latent  a 
course,  on  account  of  the  analgesia,  that  it  is  not  recognized 
by  the  patient  until  crepitation,  dislocation,  or  excessive 
exudation  into  the  joint  and  soft  parts  in  the  neighborhood 
give  evidence  of  it. 

This  is  generally  considered  as  the  beginning  of  the 
process.  It  is  spoken  of  as  sudden  in  its  onset,  yet  it  has 
been  present  for  a  long  time  and  remained  unrecognized  by 
the  patient,  on  account  of  the  analgesia.  Should  the  in¬ 
juries  to  the  joint  be  slight  and  rest  and  care  are  given  it, 
the  course  is  benign,  whereas  the  degree  of  injury,  due  to 
the  analgesia,  ataxia,  and  fragility  of  the  bones,  or  any  com¬ 
bination  of  them,  stamp  the  course  as  malignant — i.  e.,  the 
rapid  destruction  of  the  articular  ends  of  the  bones,  the 
tearing  off  of  the  ligaments,  and  the  excessive  production 
of  callus  extending  to  the  soft  parts,  especially  insertions  of 
the  tendons  and  muscles  about  the  joint. 


In  general,  however,  the  first  symptom  seen  is  an  acute 
or  subacute  swelling  of  the  joint  and  the  neighboring  tis¬ 
sues  without  a  cause,  and  often  during  the  night,  without 
temperature  elevation,  redness  of  the  skin,  or  constitutional 
disturbance.  Such  a  condition  may  remain  days,  weeks,  or 
mont  hs,  and  resolve  in  part ;  yet  there  remains  a  well-marked 
deformity  in  the  joint  with  abnormal  mobility.  The  articu¬ 
lar  cartilages  are  destroyed,  the  epiphyseal  extremities  of 
the  bones  become  polished,  worn  away,  or  destroyed,  and 
replaced  by  irregular  bony  masses.  Crepitation,  foreign 
bodies  within  the  joint  (bony,  cartilaginous,  and  fibrinous 
coagula),  a  papillary  and  cartilaginous  synovitis  with  the 
formation  of  extracapsular  callus  by  the  periosteum,  ten-- 
dons,  and  muscles,  are  the  characteristic  symptoms.  These, 
when  combined  with  the  early  symptoms  of  locomotor 
ataxia,  syringomyelia,  etc.,  render  our  diagnosis,  progno¬ 
sis,  and  treatment  a  certain  one. 

The  deleterious  influence  exerted  by  these  nervous  dis¬ 
turbances  upon  the  course  of  syphilis,  tuberculosis,  and  puru¬ 
lent  infections  in  joints  is  to  be  always  considered  in  any 
prognosis. 

It  has  been  my  intention  in  this  paper  to  bring  before 
the  society  nothing  new — simply  a  statement  of  those  dis¬ 
eases  of  the  joints  I  find  most  difficult  of  diagnosis. 

A  thorough  knowledge  of  the  diseases  causing  joint  in¬ 
flammations  and  an  accurate  examination  of  the  local  con¬ 
dition  is  our  only  guide  to  treatment  and  prognosis.  It  is 
only  when  we  make  the  diagnosis  accurately  that  we  can 
tell  our  patients  of  their  curability  or  incurability.  When 
this  is  accomplished,  the  means  of  cure,  if  any  exist,  are  few 
and  sufficient. 


THE  SIMULTANEOUS  OCCURRENCE  OF 
DISEASE  OF  THE  HIP  AND  KNEE  JOINTS 
IN  THE  SAME  LIMB* 

By  REGINALD  H.  SAYRE,  M.  D. 

The  simultaneous  occurrence  of  disease  in  the  hip  and 
knee  joints  of  the  same  limb  is  so  rare  that  I  have  thought 
it  worth  while  to  report  such  a  case  to  this  Section,  and  to 
describe  a  new  splint  for  the  treatment  of  this  complication. 
As  the  splint  can  be  best  described  in  connection  with  the 
case,  I  will  briefly  outline  the  latter: 

R.  McC.,  aged  six  years,  had  scarlet  fever  when  two  years 
old,  followed  by  suppurating  otitis  on  both  sides,  suppurating 
glands  in  the  neck,  and  an  ischiorectal  abscess.  About  eight  or 
nine  months  after  the  fever  he  had  a  very  bad  fall,  soon  after 
which  be  complained  of  severe  pain  in  the  right  knee,  which 
was  then  fastened  in  a  felt  splint  and  became  apparently  well 
after  some  time.  Just  as  the  knee  became  well  he  fell  out  of  a 
carriage,  and  soon  after  had  great  pain  in  the  right  hip.  He 
was  then  put  to  bed  with  extension  applied  to  the  right  limb 
by  means  of  a  weight  and  pulley,  and  subsequently  wore  a  long 
traction  hip  splint  while  walking  for  about  a  year,  at  the  end 
of  which  time  he  seemed  to  be  cured. 

Some  months  after  this  the  left  knee  began  to  swell  and  be 
painful,  followed  in  turn  by  the  right  knee  and  left  shoulder. 
These  joints  were  wrapped  in  cotton  and  antirrheumatic  reme- 

*  Read  at  the  Tenth  International  Medical  Congress,  Berlin,  1690. 


656 


SAYRE:  SIMULTANEOUS  DISEASE  OF  THE  HIP  AND  KNEE.  [N.  Y.  Mbd.  Joub., 


dies  given,  the  paiu  and  swelling  subsiding  after  a  while,  leav¬ 
ing  the  left  shoulder,  however,  almost  ankylosed. 

In  October,  1888,  the  right  knee  began  once  more  to  flex 
and  give  pain,  and  the  right  thigh  became  flexed  on  the  ab¬ 
domen,  and  at  that  time  the  child  first  came  under  my  observa¬ 
tion.  He  was  pale  and  badly  nourished.  One  ear  still  contin¬ 
ued  to  discharge.  The  right  knee  was  hot,  swollen,  and  tender 
to  pressure,  and  flexed  at  an  angle  of  forty  degrees.  The  right 
hip  joint  was  flexed  at  an  angle  of  forty-five  degrees,  and  the 
adductor  muscles  were  very  rigid.  When  slight  traction  was 
applied  to  the  thigh,  limited  movement  of  the  hip  joint  did  not 
cause  pain. 

He  was  put  to  bed  and  traction  made  on  the  diseased  limb, 
as  shown  in  Fig.  1. 


Adhesive  plaster  was  fastened  to  the  thigh,  and  by  means 
of  a  weight  and  pulley  (A)  traction  was  made  on  the  thigh  in 
the  direction  of  the  deformity,  the  body  being  fastened  flat  to 

the  bed.  By  means  of  other  ad¬ 
hesive  plasters  fastened  to  the 
calf,  a  second  weight  and  pulley 
(B)  made  traction  on  the  knee 
joint  in  the  long  axis  of  the  tibia, 
while  a  third  weight  and  pulley 
(0),  attached  to  a  band  passing 
behind  the  leg  at  the  head  of  the 
tibia,  made  traction  at  right  an¬ 
gles  to  the  long  axis  of  the  tibia, 
thus  overcoming  the  tendency  to 
subluxation  of  the  knee.  After 
six  weeks  of  this  treatment  the 
deformity  was  sufficiently  re¬ 
duced  to  permit  the  application 
of  the  splint,  which  I  shall  now 
describe,  and  which  is  a  com¬ 
bination  of  the  splints  devised 
by  my  father  many  years  ago 
for  the  treatment  of  chronic  dis¬ 
ease  of  the  hip  and  knee  joints 
when  occurring  separately. 

This  instrument  (see  Fig. 
2)  consists  of  a  pelvic  belt 
with  two  perineal  straps,  which 
belt  is  fastened  by  means  of 
a  platform  joint  to  a  rod  run¬ 
ning  down  the  limb  to  the 
ground.  In  the  platform  joint  is  a  screw  for  making  ab¬ 
duction  of  the  limb  if  necessary.  Below  this  is  a  ratchet 


(A)  for  elongating  the  rod.  Attached  to  the  outside  rod  are 
two  steel  collars  (B  and  C),  which  encircle  the  thigh  and 
calf,  and  which  are  connected  together  by  a  second  rod 
running  up  the  inside  of  the  leg.  Both  inside  and  outside 
rods  are  furnished  with  ratchets  (D  and  D'),  to  permit  them 
to  be  lengthened.  These  side  rods  are  continued  below 
the  calf  collar  to  the  ground,  where  they  join  together  in  a 
wooden  shod  foot-piece.  To  apply  the  splint,  strips  of 
heavy  adhesive  plaster,  an  inch  wide  and  long  enough  to 
extend  from  the  top  of  the  patella  to  the  groin,  are  put 
longitudinally  all  around  the  thigh  (see  Fig.  3)  and  tightly 
secured  by  a  bandage,  which  is  carried  as  high  as  the  point 


Fig.  3.  Fig.  4. 

where  the  collar  encircles  the  thigh.  Similar  strips  of  ad¬ 
hesive  plaster,  long  enough  to  reach  from  the  head  of  the 
fibula  to  the  malleolus,  should  then  be  applied  all  around 
the  calf,  the  bandage  being  carried  from  the  knee  down 
to  the  point  where  the  lower  collar  encircles  the  calf  (see 
Fig.  4). 

The  pelvic  belt  is  now  put  around  the  pelvis  and  the 
collars  brought  moderately  tight  about  the  thigh  and  calf, 
and  fastened,  care  being  taken  to  place  a  pad  on  each  side 
of  the  crest  of  the  tibia  to  prevent  chafing  by  the  encir¬ 
cling  collar.  The  adhesive  plasters  are  now  reversed  over 
the  collars,  and  held  in  place  by  another  strip  of  adhesive 
plaster  drawn  tightly  around  the  collars.  A  roller  bandage 
is  now  applied  to  retain  the  ends  of  the  reversed  adhesive 
plasters  in  position.  The  thigh  and  calf  being  now  securely 
fastened  to  the  collars,  traction  can  be  applied  to  the  knee 
by  means  of  the  ratchets  (D,  FT),  the  amount  of  traction 
being  limited  by  the  patient’s  sensations,  stopping  at  the 
point  that  gives  the  greatest  relief. 

The  knee  must  now  be  bound  with  strips  of  adhesive 
plaster  to  prevent  swelling,  and  a  tight  roller  applied  over 
all.  A  bandage  is  then  passed  about  the  thigh,  going  over 
the  thigh  and  under  the  side  bars  of  the  instrument  to  press 
the  lemur  backward,  and  a  second  bandage  is  passed  around 
the  leg,  going  under  the  calf  and  over  the  side  bars  of  the 
instrument  to  force  the  tibia  forward,  thus  taking  the  place 
of  the  pulley  C  (Fig.  1).  A  bandage  is  applied  to  the  foot 
to  prevent  swelling. 

The  knee  having  been  adjusted,  the  pelvic  belt  is  then 


Dec.  13,  1890.] 


WILCOX:  HYDRASTIS ,  VIBURNUM,  AND  PI8CIDIA. 


657 


drawn  tight,  and  the  perineal  straps  are  drawn  sufficiently 
tight  to  bring  the  pelvis  belt  below  the  anterior  superior 
spines  of  the  ilium.  By  means  of  the  ratchet  A  (Fig.  2), 
traction  is  made  on  the  hip  joint  to  the  point  of  greatest 

comfort. 

A  shoe  with  high  heel  and  sole  is  applied  to  the  foot  of 
the  sound  side  to  equalize  the  extra  length  caused  by  the 
projection  of  the  splint  below  the  foot  of  the  lame  side, 
the  patient  walking  on  the  high  shoe  and  the  splint  (see 
Fig.  5)  and  receiving  the  weight  of  his  body  on  the  peri¬ 
neal  straps. 

In  the  case  under  consideration  the  adhesive  plasters 
have  been  changed  four  times  since  the  splint  was  first  ap¬ 
plied  in  December,  1 888 — a  period  of  about  eighteen  months. 
When  removed  last  October  the  knee  was  much  less  tender 
and  swollen  than  at  first,  but  still  sensitive  to  any  move¬ 
ment. 

When  removed  the  next  time,  which  was  in  June,  1890, 
the  knee  was  straight  and  free  from  pain  on  movement, 
though  evidently  not  thoroughly  well.  The  hip  had  free 
movement  and  there  was  no  muscular  spasm. 

The  photographs  do 
not  show  the  knee  as 
straight  as  it  should  be, 
having  been  taken  just 
after  the  last  applica¬ 
tion  of  the  splint,  the 
boy  having  been  with¬ 
out  it  for  ten  days  just 
before  this,  during  the 
time  the  splint  was  be¬ 
ing  repaired,  and  the 
skin  becoming  hard  af¬ 
ter  exclusion  from  the 
air  for  eight  months.  I 
had  bent  the  knee  some¬ 
what  also,  and  the  flexor 
muscles  were  rather  slow 
to  relax.  When  I  re¬ 
moved  the  splint,  the 
knee  was  straigliter  than 
shown  in  the  picture, 
and  is  now  once  more 
becoming  straight. 

It  may  be  asked  why 
I  allowed  motion  at  the 
hip  and  not  at  the  knee. 
In  this  case  limited  mo- 
pIG.  5.  tion  of  the  hip  joint  did 

not  give  pain,  provided 
slight  traction  was  made  on  the  thigh,  and  I  therefore 
thought  the  child  mio-ht  be  allowed  the  additional  comfort 


of  movement  at  the  hip  without  harm  ;  and  the  result  has 
so  proved.  If  motion  of  any  sort  had  given  pain  in  the 
hip,  I  should  have  immobilized  that  joint  also. 

The  extension  of  the  splints  by  its  various  ratchets  and 
the  changing  of  the  bandages  must  be  altered  from  time 
to  time  as  the  improvement  in  the  joint,  the  slipping  of  the 
adhesive  plaster,  or  the  comfort  of  the  patient  demand. 


HYDRASTIS,  VIBURNUM,  AND  PISCIDIA 

IN  DISEASES  OF 

THE  FEMALE  ORGANS  OF  GENERATION.* 

By  REYNOLD  W.  WILCOX,  M.  A.,  M.  D., 

PROFESSOR  OF  CLINICAL  MEDICINE  IN  THE  NEW  YORK  POST-GRADUATE 
MEDICAL  SCHOOL  AND  HOSPITAL  ;  PHYSICIAN  TO  THE  DEMILT  DISPENSARY. 

The  great  interest  that  has  been  excited  by  every  ac¬ 
quisition  to  the  Pharmacopoeia  of  drugs  that  have  a  thera¬ 
peutic  action  upon  the  female  organs  of  generation  proves 
conclusively  that  the  profession  at  large  ask  for  more  than 
merely  surgical  gynaecology.  While  the  surgical  methods 
of  treating  diseases  peculiar  to  females  have  attained  to  a 
high  standard  and  in  technique  leave  but  little  to  be  desired, 
the  requisite  skill  is  by  no  means  sufficiently  widespread, 
nor  indeed  of  low  enough  cost  that  all  suffering  women  may 
be  relieved.  While  our  post-graduate  schools  are  sowing 
broadcast  the  seeds  of  surgical  gvnsecology  and  imparting 
the  results  of  their  experience  to  physicians  from  all  por¬ 
tions  of  this  country,  yet,  nevertheless,  there  remains  a  large 
proportion  of  the  medical  profession  who  seek  to  relieve 
by  methods  other  than  operative.  Further,  it  is  notorious 
that  a  specialist  seeks  the  shortest  road  to  relief  and  is  apt 
to  ignore  other,  perhaps  longer  but  certainly  pleasanter  and 
finally  surer,  methods  of  treatment.  While  I  would  not  in 
the  slightest  degree  belittle  the  brilliant  surgical  results  of 
our  foremost  gynaecologists,  yet  I  would  submit  that  medi¬ 
cal  gynaecology  has  a  very  important  place. 

The  past  decennium  has  given  us  new  drugs,  new  uses 
for  drugs,  and  has  firmly  settled  on  a  physiological  basis 
the  indications  for  the  employment  of  certain  drugs.  In 
January,  1887,  I  read  before  the  Alumni  Association  of  the 
Woman’s  Hospital  of  New  York  a  paper  entitled  Hydrastis 
Canadensis  in  Uterine  Haemorrhage,  which  was  published 
in  the  New  York  Medical  Journal  under  date  of  February 
19,  1887.  In  this  paper  I  presented  the  results  of  the  em¬ 
ployment  of  hydrastis  in  forty-three  cases.  The  chief  indi¬ 
cation  for  its  use  is  uterine  hyperaemia,  resulting  in  menor¬ 
rhagia  and  metrorrhagia.  Secondary  results,  such  as  endo¬ 
metritis  fuugosa,  displacements,  and  permanent  engorge¬ 
ments  of  the  uterus,  were  naturally  relieved  by  its  use.  The 
publication  of  this  paper  was  followed  by  a  greatly  increased 
demand  for  the  drug,  its  use  by  a  large  number  of  practi¬ 
tioners,  and  it  has  become  one  of  the  staple  drugs  of  the 
pharmacy.  When  the  diagnosis  is  well  established  and  the 
drug  is  administered  in  accordance  with  the  indications, 
success  is  as  probable  as  with  any  other  drug  whose  physio¬ 
logical  action  is  well  established.  During  my  earlier  stud¬ 
ies  certain  disadvantages  were  found  ;  menstruation  was  fre¬ 
quently  suppressed,  at  times  pains  would  be  produced,  al¬ 
though  never  the  crampy  pains  of  ergot,  and  all  cases  in 
which  the  amount  of  flow  was  below  the  normal  were  not 
relieved.  Some  of  these  were  errors  in  administration  ; 
others  were  due  to  the  peculiarities  of  the  drug  itself.  Al¬ 
though  in  a  chlorotic  girl  it  might  be  well  to  produce  cessa¬ 
tion  of  the  menses  for  a  time,  yet  the  mental  disturbance 
of  emansio  mensium  is  generally  unadvisable.  The  best 

*  Read  before  the  Clinical  Society  of  the  New  York  Post-graduate 
Medical  School  and  Hospital,  November  29,  1890. 


658 


WILCOX:  HYDRASTIS ,  VIBURNUM,  AND  PISCIDIA. 


N.  Y.  Med.  Jotth., 


results  were  obtained  in  cases  of  chronic  haemorrhage  due 
to  inflammation  of  uterine  tissue,  circumuterine  inflamma¬ 
tions,  and  also  in  displacements  due  to  engorgement. 

The  abominable  taste  of  the -fluid  extract  of  hydrastis 
was  never  concealed,  and  it  was  only  possible  to  continue 
its  administration  when  the  results  obtained  were  so  excel¬ 
lent  as  to  make  its  exhibition  a  necessity.  Earlier  experi¬ 
ments  writh  the  alkaloid  hydrastine  showed  that  the  alka¬ 
loid  did  not  fully  represent  the  drug.  In  the  present  year 
the  observations  of  Falk  with  an  oxidation  product  of  hy¬ 
drastine,  which  is  known  as  hvdrastinine,  have  shown  that, 
so  far  as  menorrhagia,  metrorrhagia,  congestive  dysmen- 
orrhoea,  and  endometritis  are  concerned,  it  seems  to  act 
as  well  as  the  fluid  extract.  The  dose  is  three  quarters  of 
a  grain  hypodermically.  Its  present  great  objection  is  the 
price. 

Viburnum,  since  its  introduction  to  the  profession  by 
Jenks,  nearly  fifteen  years  ago,  has  held  its  own  as  a  remedy 
for  dysmenorrhoea  against  many  drugs  then  lauded  to  the 
skies,  but  now  long  forgotten.  It  will  certainly  relieve 
dysmenorrhoea  if  the  testimony  of  thousands  of  intelligent 
physicians  is  worth  anything.  In  the  nervous  phenomena 
of  the  climacteric  it  will  diminish  reflex  activity,  acting  in 
precisely  the  same  lines  as  the  bromides,  but  without  the 
great  general  depression  of  their  long-continued  use.  Alone 
it  is  not  sufficiently  sedative  to  relieve  pain,  as  is  shown  by 
the  following  case,  when  more  markedly  antispasmodic 
remedies — such  as  hyoscyamus,  cannabis  indica,  camphor, 
conium,  and  avena  sativa — must  be  employed  : 

Miss  S.  M.,  aged  eighteen,  first  seen  on  March  26,  1890. 
Duration  of  illness,  four  years.  Complains  of  poor  appetite,  but 
the  bowels  are  regular;  the  tongue  is  pale  and  flabby  ;  anaemic 
murmur  in  neck.  Menstruation  at  thirteen,  always  irregular, 
every  four  to  seven  weeks,  lasting  one  or  two  days  and  scanty. 
Has  severe  pains  in  groins  and  back  for  twenty-four  to  thirty-six 
hours  before  flow  ;  pain  is  constant  and  sharp,  alternating  with 
cramps  and  dull  pains.  Has  much  neuralgic  headache  during 
periods.  Has  passed  clots  on  several  occasions,  but  without  re¬ 
lief  of  pain.  At  times  has  fainted.  Tenderness  over  lower 
abdomen  quite  marked.  Diagnosis:  congenital  anteflexion,  un¬ 
developed  uterus.  Ordered  fluid  extract  of  viburnum,  thirty 
drops  every  two  hours  during  attack ;  concentrated  tincture  of 
avena  sativa,  twenty  drops  in  hot  water  during  crampy  pains 
every  twenty  minutes  until  three  doses  are  taken.  Hot-water 
bag  to  abdomen;  turpentine  enemata.  Hot  sitz  bath  during 
day  preceding  flow.  Bed  during  menstruation. 

April  28th.— Flow  greater  in  amount  and  pain  much  less. 
Viburnum  alone  does  not  relieve  pain  so  much  as  when  avena 
sativa  is  given  with  it. 

June  12th. — Last  period  was  a  great  improvement  upon  the 
preceding,  due  probably  to  the  free  administration  of  iron  in 
the  interval.  Also  did  not  suffer  from  neuralgic  headaches.  Is 
going  into  the  country. 

September  22d. — Last  two  periods  have  been  almost  entirely 
free  from  pain.  Has  taken  iron  faithfully  since  last  report. 

That  viburnum  is  markedly  sedative,  so  far  as  the  uterus 
is  concerned,  is  shown  that,  if  used  after  labor,  it  is  one  of 
the  best  remedies  for  post-partum  pains,  provided  that  they 
are  not  of  mechanical  origin.  Deficient  menstruation  is 
not  so  great  a  bar  to  the  employment  of  viburnum  as  it  is 
to  that  of  hydrastis.  On  the  other  hand,  viburnum  has  a 


far  more  beneficial  influence  upon  the  heart  and  upon  the 
general  nutrition  than  hydrastis  has. 

Piscidia  as  a  hypnotic  attracted  much  attention  about 
ten  years  ago.  My  own  experiments  were  unsatisfactory, 
and  other  drugs  have  supplanted  it  as  a  hypnotic.  Yet 
Ott’s  investigations  in  the  physiological  laboratory  show 
that  piscidia  has  a  well-defined  action,  and,  in  connection 
with  other  drugs,  undoubtedly  has  its  use.  Ott  found  (1) 
that  piscidia  was  narcotic  to  frogs,  rabbits,  and  men;  (2) 
did  not  affect  the  irritability  of  the  motor  nerves;  (3)  did 
not  attack  the  peripheral  ends  of  the  sensory  nerves;  (4) 
reduced  reflex  action  by  a  stimulant  action  on  the  centers 
of  Setchenow  ;  (5)  produced  a  tetanoid  state  by  a  stimulant 
action  on  the  spinal  cord,  and  not  by  a  paralysis  of  Setche- 
now’s  centers  ;  (6)  dilated  the  pupil,  which  dilatation  passed 
into  a  state  of  contraction  upon  the  supervention  of  as¬ 
phyxia;  (7)  was  a  salivator;  (8)  increased  the  secretion  of 
the  skin  ;  (9)  reduced  the  frequency  of  the  pulse  ;  (10) 
and  increased  arterial  tension  by  stimulation  of  the  mon¬ 
archical  vaso-motor  center;  (11)  that  this  increase  was 
soon  succeeded  by  a  fall,  due  to  weakening  of  the  heart 
itself.  Piscidia,  in  medicinal  doses,  produces  muscular  re¬ 
action,  lowered  sensibility,  increased  action  of  the  heart, 
and  increased  arterial  tension  through  stimulation  of  the 
vaso-motor  center.  Through  its  action  on  the  muscular 
system  it  can  supplement  viburnum  and  neutralize  hydrastis 
in  spasmodic  dysmenorrhoea.  In  all  painful  diseases  of  the 
uterus  and  annexae  it  is  of  service  through  its  power  of 
lowering  sensibility. 

For  the  last  year  I  have  been  experimenting  with  a 
preparation  known  as  liquor  sedans,  manufactured  by 
Parke,  Davis,  &  Co.,  which  has  the  following  formula: 
Hydrastis,  60  grains  (represented  by  the  white  alkaloid); 
viburnum,  60  grains;  piscidia,  30  grains,  to  each  fluid 
ounce  of  the  preparation.  The  drugs  are  combined  with 
aromatics  so  that  the  mixture  is  not  unpalatable,  and  pre¬ 
sumably  these  additions  have  some  therapeutic  effect.  The 
cases  in  which  I  have  made  use  of  this  formula  have  beeD 
those  in  which  an  operation  was  not  possible,  either  be¬ 
cause  the  patient’s  consent  could  not  be  obtained,  or  the 
patient  could  not  be  kept  under  control.  Nor  have  I  in¬ 
serted  cases  in  which  local  treatment  was  the  most  impor¬ 
tant  feature.  While  all  of  these  cases  were  under  observa¬ 
tion  and  reported  from  time  to  time,  yet  none  of  them  had 
regular  local  treatment,  because,  for  various  reasons,  it  was 
not  possible. 

Case  I. — Mrs.  D.  6.,  thirty-five  years  old,  has  been  sick  for 
the  last  six  years  previous  to  the  time  when  she  was  first  seen 
in  1886.  She  complains  of  general  debility,  failure  of  health 
dating  back  to  childbirth,  with  times  of  improvement.  Thin, 
anaemic,  of  sanguino-bilious  temperament.  She  has  poor  appe¬ 
tite,  sometimes  an  accumulation  of  gas,  discomfort  after  eating, 
pain  in  stomach  and  bowels,  distention,  rarely  nausea,  flatulence, 
constipation,  suffers  from  haemorrhoids,  pain  about  heart, 
sometimes  palpitation,  occasionally  faintness  and  shortness  of 
breath  without  exertion.  No  cardiac  or  pulmonary  physical 
signs.  Sometimes  has  stoppage  of  urine  for  twelve  hours ;  at 
times  has  frequent  urination,  every  half  hour,  especially  when 
tired  ;  color  of  urine  varies  much.  Has  pain  in  loins. 

The  catamenia  have  always  been  accompanied  by  great  pain 


Dec.  13,  1890.] 


659 


WILCOX:  HYDRASTIS ,  VIBURNUM,  AND  PISCIDIA. 


daring  her  entire  menstrual  life,  profuse,  lasting  seven  days, 
with  cramps  and  clots,  and  much  foul-smelling  vaginal  dis¬ 
charge.  lias  had  one  child,  six  years  ago.  Her  pains  occur 
five  days  before  the  flow  appears,  in  back  and  sides,  especially 
the  left;  worse  on  exertion.  Has  vertigo,  neuralgia,  sick  head¬ 
aches,  chilly  sensations.  Great  tenderness  on  percussion  over 
eighth  dorsal  vertebra.  Interrupted  sleep.  On  examination, 
the  vesico-vaginal  septum  is  found  to  be  hard,  the  cervix,  with 
laceration  to  the  right, 'soft,  except  at  site  of  tear,  which  is  hard 
and  sensitive.  Some  cervical  cysts,  tenderness  on  the  left  side 
of  the  uterus,  which  is  in  good  position.  Some  thickening  in 
utero-sacral  ligaments,  but  not  especially  tender.  Laceration 
of  perinfeum  with  sensitiveness  on  examination.  Urethral 
opening  reddened.  Some carunculse,  very  sensitive.  Diagnosis: 
subinvolution  of  uterus,  anteversion,  hypertrophy  of  urethral 
mucous  membrane.  During  the  next  six  months  she  improved 
greatly  under  a  small  amount  of  local  treatment,  spending  her 
summer  in  the  country.  Excessive  flow  was  controlled  by  the 
fluid  extract  of  hydrastis,  and  her  general  condition  was  im¬ 
proved  by  diet,  tonics,  and  general  medication.  After  about 
three  years  of  comparative  comfort  she  reported  on  January 
19,  1890,  that  her  symptoms  had  recently  become  much  aggra¬ 
vated  and  that  she  was  in  nearly  the  same  condition  as  in  1886. 
Liquor  sedans,  one  drachm  in  water,  three  times  daily  for  two 
months,  was  ordered. 

May  12th. — Has  had  much  less  pain  in  back  and  left  side 
since  last  report.  Uterine  leucorrhoea  much  improved  and 
vaginal  discharge  much  less;  the  amount  of  menstrual  flow  has 
diminished  about  one  half.  Feels  much  improved  both  in  gen¬ 
eral  health  and  in  regard  to  urinary  symptoms. 

October  1st. — The  gain  has  been  permanent;  although  not 
well,  does  not  think  that  medication  is  necessary. 

Case  II. — Miss  S.  A.,  aged  twenty-two,  was  first  seen  on  July 
13,  1889.  Has  been  sick  for  the  last  six  years,  complaining  of 
fits.  General  surroundings  good.  Digestion  perfect,  excepting 
occasional  constipation  due  to  improper  food ;  rarely  suffers 
from  palpitation  of  the  heart;  occasionally  frequent  urination, 
especially  at  time  of  periods.  Catamenia  at  fifteen,  regular, 
with  normal  flow.  Preceding  are  pains  in  back  and  groins. 
During  flow  has  fits,  falls,  sometimes  localized  convulsions;  no 
frothing  at  mouth  or  biting  of  tongue;  is  sleepy  after  attacks, 
during  which  she  loses  consciousness.  Has  never  injured  her¬ 
self  during  fits.  Has  no  warning  of  impending  attack  ;  eyes  are 
always  closed.  At  times  has  had  opisthotonos,  but  never  gen¬ 
eral  rigidity  or  general  convulsions.  Attacks  have  grown 
worse  during  the  last  two  years,  and  occasionally  has  fits  of 
lesser  severity  in  intermenstrual  period ;  is  alVays  of  good 
temper  and  not  hysterical.  Diagnosis:  anteflexion,  ovarian  hy¬ 
peremia,  hystero-epilepsy.  Ordered  to  take  liquor  sedans  for 
one  week  before  and  during  menstrual  flow,  one  drachm  three 
times  daily  ;  to  use  plain  food,  avoid  all  fried  food,  tea,  coffee, 
cake,  candy;  use  oatmeal  and  plenty  of  fresh  fruit;  avoid 
stimulants;  to  have  hot-water  douches. 

September  30th. —  Has  had  four  attacks  since  last  report. 
Ovarian  sensitiveness  less  marked.  Ordered  to  take  liquor 
sedans  constantly. 

December  22d. — One  marked  and  two  slight  attacks;  ante¬ 
flexion  is  persistent,  but  canal  admits  a  probe  easily.  To  take 
liquor  sedans  only  during  menstrual  flow. 

June  6 ,  1890. — To-day  has  had  her  first  severe  attack  since 
last  report.  Has  been  menstruating  with  less  pain  than  for 
two  years.  Ordered  liquor  sedans  for  two  months. 

Sejjtember  25th. — Has  had  but  one  slight  attack  since  last 
report;  uses  liquor  sedans  only  during  flow. 

Case  III. — Mrs.  H.  A.  H.,  aged  twenty-four  years,  had  been 
ill  for  three  months  before  she  was  first  seen  on  May  17,  1889. 


The  cause  of  her  illness  was  overwork  before  complete  recovery 
from  parturition.  She  complains  of  poor  appetite,  constipa¬ 
tion,  pain  on  movement  before  the  act,  relieved  by  the  pas¬ 
sage.  Rarely  dizziness  ;  sometimes  palpitation  of  the  heart. 
Slight  cough,  but  no  expectoration ;  no  physical  signs  to  be 
found  in  the  chest.  Frequent  urination;  color  of  urine  vary¬ 
ing;  sometimes  pain  and  smarting  during  the  act;  nothing  ab¬ 
normal  found  on  chemical  or  microscopical  examination.  Men¬ 
struation  regular  every  three  weeks,  lasting  five  days,  profuse, 
followed  by  illy-smelling  uterine  and  vaginal  leucorrhoea.  Has 
had  one  child,  eighteen  months  old.  Has  also  pain  in  the  legs; 
feels  as  though  “she  would  fall  to  pieces”  on  walking;  pain 
on  rising  from  a  sitting  position  ;  headaches.  Diagnosis:  ante- 
version,  purulent  endometritis,  exudation  into  left  broad  liga¬ 
ment,  catarrhal  urethritis,  subinvolution  of  uterus.  Ordered 
liquor  sedans,  one  drachm  four  times  daily;  Fowler’s  solution 
with  the  bromides;  full  diet  with  full  Emmet  douche  twice 
daily. 

June  7th. — Much  less  uterine  pain  ;  induration  of  left  broad 
ligament  has  diminished. 

August  7th. — Has  now  no  vaginal  discharge;  pain  much 
lessened;  uterus  now  nearly  normal  in  size;  can  walk  much 
better.  Catamenial  flow  much  lessened.  Is  now  to  use  liquor 
sedans  only  during  flow. 

December  29th. — General  health  has  much  improved.  Ante- 
version  still  remains,  but,  beyond  some  tension  on  the  neck  of 
the  bladder,  does  not  annoy  the  patient. 

April  25,  1890. — Patient  now  considers  herself  much  im¬ 
proved  and  uses  liquor  sedans  only  when  flow  exceeds  the  nor¬ 
mal.  Has  no  vesical  symptoms.  Has  gained  about  fifteen 
pounds  in  weight. 

September  26th. — Patient  reports  that  she  is  well. 

Case  IV. — Mrs.  C.  W.  O.,  aged  thirty-five,  was  seen  on 
January  6,  1890.  Had  been  ill  for  three  years.  Her  previous 
sicknesses  had  been  catarrhal  otitis  media,  resulting  in  deafness, 
and  acute  peritonitis.  She  complained  of  inappetence  with 
marked  constipation  when  enemata  were  not  employed,  faint¬ 
ness,  dizziness,  tinnitus,  frequent  urination  when  fatigued. 
Catamenia  at  fourteen,  recurring  every  four  or  five  weeks; 
generally  scanty  flow,  which  lasts  three  days.  Of  late,  during 
last  two  years,  has  unexpected  attacks  of  flooding,  losing  large 
amounts  of  blood,  these  attacks  being  only  at  or  about  the  nor¬ 
mal  menstrual  periods.  Has  much  constant  pain  in  back,  drag¬ 
ging  pains  on  standing  or  much  walking.  Some  glairy  discharge 
from  the  vagina.  Traces  origin  of  present  attack  to  perito¬ 
nitis  following  excessive  tamponade,  when  she  was  confined  to 
the  bed  for  three  weeks.  Diagnosis:  pelvic  peritonitis,  latero- 
flexion  of  uterus,  induration  of  left  broad  ligament.  Ordered 
Fowler’s  solution,  to  have  liquor  sedans,  one  drachm  four  times 
daily,  during  periods,  nourishing  diet,  Emmet  douche,  bed  dur¬ 
ing  menstrual  epoch. 

March  20th. — Patient  takes  her  medicine  with  considerable 
regularity,  but  as  regards  douche  leaves  much  to  be  desired. 
The  exudation  in  the  broad  ligament  bas  diminished  as  well  as 
the  tenderness. 

July  3d. —  A  fair  amount  of  improvement  in  her  general 
condition,  with  but  little  change  in  local  state  since  last  report. 

October  15th. — Patient  professes  great  benefit  from  remedy. 

Case  V. — Miss  W.  S.,  aged  thirty-three;  when  first  seen  on 
September  3,  1889,  complained  that  she  had  suffered  for  ten 
years  from  dystnenorrhcea.  Always  well  at  other  times  ex¬ 
cepting  slight  headaches.  Appetite  good,  with  excellent  diges¬ 
tion  and  regular  bowels.  Painful  and  frequent  urination  only 
during  periods.  Menstruation  at  thirteen,  always  regular. 
During  the  last  ten  years  her  periods  have  become  more  and 
more  painful.  The  pain  commences,  about  thirty-six  hours 


660 


WILCOX:  HYDRASTIS ,  VIBURNUM ,  AAZ>  PISGIDIA. 


[N.  Y'.  Med.  Jodb., 


before  tbe  flow,  in  the  back,  groins,  and  in  front,  sharp,  and 
obliging  the  patient  to  take  to  her  bed,  with  severe  cramps.  The 
flow  then  begins  and  is  scanty  at  first,  giving  some  relief  to  the 
pain.  It  then  increases  in  amount,  and  much  pain  is  followed 
by  expulsion  of  clots.  The  flow  lasts  three  or  four  days,  and 
recurs  every  twenty-eight  days.  Severe  frontal  headache  dur¬ 
ing  first  two  days  of  flow.  Some  cervical  leucorrhoea.  Diag¬ 
nosis:  congenitaLanteflexion,  retroversion  of  the  third  degree, 
some  prolapsus.  Ordered  to  take  liquor  sedans,  one  drachm 
four  times  daily  for  week  before  and  during  menstrual  flow. 
Fothergill’s  pills  should  the  flow  be  delayed ;  nourishing  food, 
outdoor  exercise. 

January  2 ,  1890. — Periods  are  more  tolerable,  but  still  less 
pain;  uterus  in  good  position  as  regards  version  and  prolapsus. 

March  7th. — Of  late  the  remedy  seems  ineffectual ;  passed 
sound,  and  dilated  internal  os. 

April  12th. — Last  period  with  much  less  pain,  no  headache, 
and  was  not  confined  to  her  bed. 

June  27th. — Last  two  periods  passed  with  much  less  than 
usual  pain.  Application  of  carbolic  acid  made  to  endometrium. 
Canal  patent,  and  there  is  no  leucorrhoea. 

September  20th. — Last  period  practically  painless  while  using 
liquor  sedans. 

Case  VT. — Miss  S.  H.,  twenty-eight  years  old,  after  an  illness 
of  two  years  was  first  seen  November  24, 1889.  Her  lips  are  pal¬ 
lid  ;  is  troubled  with  atonic  dyspepsia,  constipation  and  consid¬ 
erable  abdominal  pain,  faintness,  dyspnoea  on  exertion,  anaemic 
bruit  in  vessels  of  neck.  Frequent  urination  at  times  of  period, 
but  no  pain.  Menstruation  commencing  at  fifteen,  is  regular 
every  four  weeks,  and  lasts  three  days.  Of  late  recurs  every 
fourteen  to  twenty  days  and  lasts  a  week,  with  profuse  flow; 
vaginal  leucorrhoea.  Pain  in  loins  and  back.  Diagnosis:  men¬ 
orrhagia;  retroversion,  second  degree.  Ordered  liquor  sedans, 
one  drachm  four  times  daily  for  week  before  and  during  men¬ 
strual  flow.  Daily  movement  of  bowels  to  be  secured  by  hy¬ 
gienic  methods. 

December  30th. — Result  good ;  interval  is  lengthened  to 
twenty-eight  days,  and  flow  is  nearly  normal. 

February  19,  1890. — Time  of  flow,  three  days;  amount  is 
normal,  and  now  has  no  pain. 

Case  VI I. — Mi>s  S.  M.  P.,  aged  twenty-five,  was  first  seen 
June  2,  1889,  after  an  illness  of  four  years.  She  is  anaemic, 
suffers  from  neuralgia  and  eraansio  mensium  of  six  days’  dura¬ 
tion.  Complains  of  inappetence,  headache,  fullness  of  head, 
throbbing  in  temples,  palpitation,  frequent  urination.  Menstrua¬ 
tion  irregular,  recurring  every  four  to  six  weeks,  lasting  four 
days,  with  small  amount  of  flow,  cramps,  and  clots;  color  pale. 
Pain  iD  back  and  loins,  extending  down  sciatic  nerves.  Head¬ 
ache  at  the  vertex.  Diagnosis:  congenital  anteflexion  with 
retroversion  of  first  degree.  Ordered  to  take  Fothergill’s  pills 
during  premenstrual  week,  and  one  drachm  of  liquor  sedans 
during  flow. 

June  21fth. — Is  much  improved  as  regards  pain  during  her 
last  period.  Flow  still  scanty,  but  did  not  pass  clots. 

February  1,  1890. — Is  still  anaemic,  but  periods  are  passed 
with  comparative  comfort. 

June  5th. — A  severe  fall  is  followed  by  abdominal  tender¬ 
ness,  much  uterine  colic,  and  considerable  pain  extending  down 
both  sciatic  nerves,  more  marked,  however,  upon  the  right 
side.  Retroversion  is  now  of  the  second  degree.  Colic  is  re¬ 
lieved  by  twenty-drop  doses  of  concentrated  tincture  of  avena 
sativa  every  half  hour  in  hot  water. 

20th. — Is  passing  through  period  with  less  than  usual  pain. 
Retroversion  reduced  by  position.  Complains  much  of  sleep¬ 
lessness,  for  which  chloralatnid  in  twenty-grain  doses  is  or¬ 
dered. 


30th. — Greatly  improved  ;  chloralatnid  is  to  be  omitted.  To 
use  liquor  sedans  during  the  flow. 

September  29th. — During  her  stay  in  the  country  has  greatly 
improved.  Periods  are  now  painless  while  using  the  remedy. 

Case  VIII. — Mrs.  M.  J.  N.,  aged  twenty-nine,  was  first  seen 
on  June  1, 1889  ;  has  been  under  great  mental  strain  for  several 
months.  She  was  suffering  from  palpitation  of  the  heart,  faint¬ 
ness,  vesical  tenesmus,  frequent  urination  at  times  of  her  period, 
poor  appetite.  Her  conjunctive  were  yellowish,  liver  dullness 
enlarged,  edge  rounded,  with  some  hepatic  sensitiveness.  Con¬ 
stipation,  pain  in  back,  groins,  and  thighs,  cramps,  and  bearing- 
down  pains.  Catamenia  regular  but  profuse,  backache  worse 
on  walking,  slight  vaginal  leucorrhoea.  Has  also  vertigo,  in¬ 
somnia,  and  general  nervousness.  Diagnosis:  anteversion, 
laceration  of  cervix,  and  cystic  degeneration  of  the  same  caused 
by  a  miscarriage  three  years  previously.  Ordered  to  take 
liquor  sedans,  one  drachm  three  times  daily,  with  thirty  grains 
of  sulphonal  after  dinner.  Full  diet.  Emmet  douche. 

June  16th. — Has  fewer  cramps  and  less  backache;  urination 
nearly  normal,  frequent  only  when  much  upon  her  feet. 

September  30th. — To  use  liquor  sedans  only  during  menstru¬ 
ation. 

February  16,  1890. — Menstruation  nearly  normal  in  amount. 
Constipation  relieved  by  Villacabras  water. 

May  23d. — Has  gained  ten  pounds  in  weight;  sleeps  with¬ 
out  drugs. 

September  20th. — Considers  herself  well. 

Case  IX. — Mrs.  A.  J.,  thirty-five  years  old,  was  first  seen  on 
March  5,  1890.  She  had  been  ill  for  three  months,  complaining 
of  neuralgic  headaches.  Bowels  moderately  regular.  Cata¬ 
menia  at  fifteen.  Has  had  two  children  and  several  miscar¬ 
riages.  During  the  past  three  months  her  menstruation,  al¬ 
though  usually  regular  in  time,  has  recurred  every  twelve  to 
fourteen  days  and  has  lasted  four  days.  This  flow  is  profuse 
and  is  accompanied  by  fainting.  Pain  in  the  back  is  very 
marked  during  flow;  at  times  pains  in  groins;  some  vaginal 
leucorrhoea.  Diagnosis:  laceration  of  peri naeum  of  the  second 
degree,  laceration  of  cervix,  retroversion  of  first  degree,  slight 
prolapsus,  granular  endometritis.  Ordered  to  take  liquor  sedans, 
one  drachm  thrice  daily.  Emmet  douche. 

April  6th. — Flow  now  recurs  every  three  weeks  and  is  less 
in  amount.  No  more  fainting  attacks.  No  leucorrhoea. 

June  25th. — Is  now  in  good  condition.  Prolapsus  re¬ 
lieved. 

July  20th. — To  omit  medication  except  for  three  days  be¬ 
fore  flow. 

October  21st. — Flow  normal  and  pains  very  slight. 

Case  X.— Mrs.  R.  H.  E.,  aged  thirty-five,  was  seen  on  De¬ 
cember  80,  1889.  Her  sickness  dates  back  three  months.  Is 
somewhat  nervous,  has  slight  choreic  twitching  of  the  face, 
rarely  attacks  of  atonic  dyspepsia.  Bowels  move  regularly 
every  day.  Complains  of  frequent  urination,  especially  after 
standing  or  walking.  Has  had  several  miscarriages  and  one 
living  child,  now  three  years  old.  Catamenia  at  thirteen,  always 
regular,  recurring  every  four  weeks,  generally  profuse,  and  last¬ 
ing  five  days.  For  last  three  months  has  noticed  a  yellowish- 
white  vaginal  discharge,  which  has  increased  in  amount.  Has 
considerable  pain  in  the  back,  worse  on  walking,  when  she 
easily  gets  tired.  Some  increase  in  the  amount  of  menstrual 
flow.  Pain  in  back  worse  during  periods.  Diagnosis:  retro¬ 
version  of  the  second  degree,  catarrhal  endometritis,  cervical 
leucorrhoea.  Ordered  to  take  liquor  sedans,  one  drachm  thrice 
daily,  constantly.  Emmet  douche,  with  alum. 

January  19,  1890. — Vaginal  discharge  has  markedly  di¬ 
minished  ;  no  pain  in  back ;  retroversion  relieved  by  tam¬ 
ponade. 


Dec.  13,  1890.] 


CORRESPONDED'  OF. 


66.1 


March  17th. — Patient  much  improved  in  general  health  ;  flow 
normal  in  amount,  and  has  now  no  leucorrhoea;  uterus  is  in  gooc 
position. 

September  2d. — Has  returned  from  the  country  in  excellent 
condition. 

Case  XI. — Mrs.  W.  V.  P.,  aged  thirty-two,  was  first  seen  on 
May  24,  1889.  She  is  thirty-two  years  old  and  has  been  ill  for 
six  years.  She  complains  of  dizziness  and  faintness  at  times, 
but  rarely  of  palpitation.  Has  a  considerable  amount  of  cer¬ 
vical  leucorrhoea.  Catamenia  regular  every  four  weeks,  lasting 
eight  days  and  very  profuse,  with  cramps  and  clots;  pain  in  the 
back,  worse  on  walking;  sometimes  pain  in  the  groin  for  two 
days  preceding  flow.  Headaches,  especially  at  times  of  period. 
Diagnosis:  endometritis  simplex,  anteflexion,  retroversion  of 
first  degree,  with  small  uterine  fibroid  in  anterior  wall.  Or¬ 
dered  liquor  sedans,  one  drachm  four  times  daily.  Emmet 
douche. 

May  27th. — Outerbridge’s  dilator  inserted.  Cervical  leucor¬ 
rhoea  somewhat  diminished  in  amount.  Cervical  canal  will  ad¬ 
mit  a  uterine  sound  without  difficulty.  Uterus  is  in  the  normal 
position. 

October  15th. — Now  has  no  more  cramps,  and  rarely  clots ; 
flow  much  diminished  in  amount.  Takes  liquor  sedans  only 
during  period. 

December  6th. — Periods  are  now  at  full  time  and  occasion¬ 
ally  a  few  days  beyond. 

April  7,  1890. — Has  now  no  pain.  Cervical  canal  patent; 
general  health  much  improved. 

September  12th. — No  pain  or  vaginal  discharge;  is  in  excel¬ 
lent  condition. 

In  the  recording  of  these  cases  I  have  endeavored  to 
give  a  faithful  picture  and  an  accurate  report  of  the  results. 
From  these  we  may  say  that  in  all  cases  of  hypersemia  of 
the  female  reproductive  system  we  have  in  liquor  sedans 
a  safe  and  reasonably  sure  remedy.  In  many  spasmodic 
diseases  and  in  a  few  cases  of  anaemia  of  these  organs  we 
find  the  remedy  also  indicated.  It  certainly  has  a  wider 
field  of  usefulness  than  any  single  drug,  and,  if  used  after  a 
careful  diagnosis  is  established  and  after  thorough  appre¬ 
ciation  of  the  pathological  conditions  that  exist,  we  can  an¬ 
ticipate  a  successful  issue  so  far  as  improvement  is  possible 
from  purely  medical  methods. 

690  Madison  Avenue,  October  31,  1890. 


(f  omsponbence. 


LETTER  FROM  NEW  HAVEN. 

The  First  Koch  Inoculations  in  America. 

New  Haven,  December  8,  1890. 

On  Thursday,  December  4th,  the  people  of  this  usually  quiet 
and  somnolent  town  were  aroused  by  the  announcement  in  the 
morning  papers  that  a  small  quantity  of  Koch’s  “lymph”  for 
the  cure  of  tuberculosis  had  been  received  by  Professor  Chit¬ 
tenden  at  noon  of  the  preceding  day;  that  Professor  Chitten¬ 
den,  desiring  that  it  should  be  used  for  scientific  study,  and  not 
being  himself  engaged  in  practice,  had  intrusted  it  entirely  to 
Dr.  John  P.  C.  Foster  for  experimental  investigation  ;  that  on 
the  preceding  afternoon  Dr.  Foster  had  administered  an  injec¬ 
tion  of  it  to  a  patient  with  pulmonary  tuberculosis;  and  that, 
on  the  afternoon  of  the  day  on  which  the  announcement  was 


made,  an  injection  of  the  precious  fluid  was  to  be  given  to  one 
of  Dr.  Swain’s  patients  who  was  suffering  with  tubercular 
laryngitis,  and  to  a  subject  of  lupus  who  was  a  patient  of  Dr. 
Francis  Bacon’s. 

The  interest  in  the  matter  has  not  been  confined  to  New 
Haven,  if  one  may  judge  from  the  eagerness  with  which  the 
newspapers  of  the  large  cities  have  tried  to  learn  all  the  details, 
and  from  the  prominence  that  has  been  given  to  the  accounts 
of  the  experiments.  Doubtless  many  a  physician  as  he  has  read 
these  accounts  has  wondered  how  it  happened  that  Koch,  who 
is  reputed  to  have  been  so  very  careful  as  to  whom  he  trusted 
to  make  trial  ot  his  curative  “  lymph,”  should  have  sent  a  sam¬ 
ple  of  it  to  New  Haven,  rather  than  to  New  York,  Philadelphia) 
Boston,  or  Baltimore,  or  even  to  Chicago,  Cincinnati,  or  St. 
Louis.  Some  may  have  been  surprised  that  it  was  received  by 
Professor  Chittenden,  a  physiological  chemist,  rather  than  by 
a  pathologist  like  Welch  or  Prudden,  and  that  it  fell  into  the 
hands  of  a  physician  whose  name  they  had  never  seen  attached 
to  an  article  in  any  of  the  journals,  rather  than  into  the  hands 
ot  distinguished  clinicians  and  authors  like  Delafield,  Janeway, 
Loomis,  or  Trudeau.  But  to  the  physicians  of  New  Haven, 
among  whom  thefacts  are  gradually  becoming  generally  known, 
the  arrival  of  the  wonderful  “  lymph  ”  seems  less  strange  now 
than  it  did  last  week.  It  happened  in  this  way.  A  resident  of 
this  city,  a  Mr.  Blake,  has  a  son  who  is  (or  at  least  was  before 
being  subjected  to  the  Koch  treatment)  critically  ill  with  pul¬ 
monary  tuberculosis.  Mr.  Blake  read  of  Koch’s  discovery,  and 
concluded  that  he  would  like  to  have  it  tried  upon  his  son. 
Professor  Chittenden  was  persuaded  to  endeavor  to  obtain 
some  of  the  fluid.  He  is  a  personal  friend  of  Professor  Kiihne’s, 
of  Heidelberg,  and  from  Heidelberg  a  small  quantity  of  the 
liquid,  which — by  special  messenger,  the  newspapers  state — had 
just  been  brought  from  Berlin,  was  sent  to  Professor  Chitten¬ 
den.  Dr.  Foster  is  the  young  man’s  physician  and  also  his  rela¬ 
tive.  It  was  therefore  very  natural  that  the  use  of  the  “  lymph  ’’ 
should  be  intrusted  to  him. 

Fortunately,  Dr.  Foster,  although  he  does  not  contribute  to 
medical  periodicals  and  seldom  takes  an  active  part  in  the  pro¬ 
ceedings  of  medical  societies,  and  therefore  has  not  a  very  wide 
reputation  (or  did  not  have  before  his  name  became  associated 
with  that  of  Koch),  is  nevertheless  a  very  excellent  practitioner. 
He  is  a  man  of  good  education,  having  been  graduated  from 
the  academical  department  of  Yale  University  in  1869,  and 
from  the  medical  department  in  1875.  He  is  instructor  in 
anatomy  in  the  Yale  School  of  the  Fine  Arts  and  acting  assist¬ 
ant  surgeon  of  the  United  States  Marine- Hospital  Service.  He 
belongs  to  one  of  New  Haven’s  old  families,  and  one  of  con¬ 
siderable  social  prominence.  He  is  refined  and  affable  in  man¬ 
ner,  and  moves  in  the  best  society.  He  does  an  active  and  lucra¬ 
tive  practice,  especially  among  students  and  families  of  wealth 
and  social  and  intellectual  distinction.  Altogether  he  is  not 
such  a  man  as  one  would  expect  to  make  any  great  discovery 
in  the  dead-house  or  the  laboratory,  perhaps  not  such  a  one  as 
Koch  himself  would  have  selected  to  make  the  first  trial  of  his 
new  treatment  in  America,  but  nevertheless  a  very  good  man  for 
this  latter  work,  because  he  is  possessed  of  sufficient  scientific 
training  and  intelligence  to  be  able  to  observe  anything  worth 
noting  in  connection  with  the  action  of  the  remedy,  and  because 
he  is  not  likely  to  be  prejudiced  by  any  preconceived  notions  in 
regard  to  its  value. 

Of  the  practical  results  of  the  treatment  as  applied  to  the 
patients  in  New  Haven  it  is  still  too  early  to  speak,  inasmuch 
as  but  five  days  have  elapsed  since  the  arrival  of  the  remedy. 
Enough  has  been  written  to  explain  why  it  happened  to  be  re¬ 
ceived  in  New  Haven,  and  to  show  that  the  investigations  here 
are  being  conducted  by  a  competent  and  careful  practitioner. 


662 


LEADING  ARTICLES.— MINOR  PA  RA  G  EA  P HS. 


[N.  Y.  Mep.  Jock., 


the 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 


Published  by 
D.  Appleton  &  Co. 


Edited  by 

Frank  P.  Foster,  M.  D. 


NEW  YORK,  SATURDAY,  DECEMBER  13,  1890. 


VIVISECTION. 

We  spoke  last  week  of  the  public  notice  that  had  been 
taken  of  an  attempt  made  in  one  of  the  city  hospitals  to  fill  a 
gap  in  a  boy’s  tibia  with  a  piece  of  bone  from  the  leg  of  a  dog, 
and  expressed  our  regret  that  it  should  have  been  made  the 
subject  of  sensational  reports  by  some  newspapers  and  of  un¬ 
sparing  condemnation  by  others.  The  interests  that  may  be 
imperiled  by  such  experiments  and  by  such  notice  of  them  are 
so  important  that  a  word  of  warning  seems  to  be  called  for. 
Twenty-five  years  ago  the  antivivisection  agitation  was  very 
active,  and  resulted  in  the  passage,  in  1866,  by  the  New  York 
Legislature,  of  the  law  under  which  we  are  now  living.  It  is  a 
law  not  only  with  which  we  may  be  satisfied,  blit  of  which  we 
may  well  be  proud,  for  it  gives  ample  protection  to  animals  and 
at  the  same  time  to  properly  conducted  scientific  research.  It 
was  the  result  of  the  efforts  of  the  late  Mr.  Bergh,  the  honored 
president  of  the  Society  for  the  Prevention  of  Cruelty  to  Ani¬ 
mals,  acting  in  behalf  of  the  animals,  and  of  the  late  Professor 
Dalton,  acting  in  behalf  of  the  interests  of  science,  and  under  it 
these  two  interests,  which  in  many  other  regions  are  in  perma¬ 
nent  and  irreconcilable  hostility  to  each  other,  have  here  con¬ 
tinued  in  peace  and  mutual  respect. 

But  with  the  passing  years  there  has  come  a  generation 
“  that  knew  not  Joseph,”  a  generation  that  is  ignorant  of  the 
circumstances  connected  with  the  making  of  the  law  and,  what 
is  worse,  even  of  the  restriction?,  imposed  by  it. 

Most  physicians  appear  to  be  ignorant  of  the  fact  that  the 
law  prohibits  experiments  upon  animals ,  and  makes  an  excep¬ 
tion  only  in  favor  of  “  properly  conducted  scientific  experi¬ 
ments  or  investigations  .  .  .  under  the  authority  of  the  faculty 
of  some  regularly  incorporated  medical  college  or  university  of 
the  State  of  New  York.”  We  know  it  to  be  true  of  some  of  our 
medical  colleges,  and  we  believe  it  to  be  true  of  all,  that  they 
have  fully  appreciated  their  responsibility  under  this  law  and 
have  been  exceedingly  circumspect  and  chary  in  extending  the 
opportunities  thus  placed  under  their  control.  But  many  such 
experiments  have  been  made  without  such  authorization  and 
apparently  without  a  suspicion  that  it  was  required,  and  their 
details  and  results  have  been  freely  published. 

On  the  other  side  there  are  men  and  women  who  are  igno¬ 
rant  of  the  agitation  of  twenty-five  years  ago  and  of  the  honor¬ 
able  agreement  then  reached,  and  who  are  inexpressibly 
wounded  and  shocked  by  the  reports  of  acts  that  seem  to  them, 
and,  it  must  be  admitted,  often  with  reason,  to  have  been  the 
cause  of  atrocious  suffering  without  an  adequate  return.  Many 
of  them  feel  it  a  personal  responsibility  before  God  and  their 
consciences  if  such  practices  are  allowed  to  continue,  and  it 


can  not  be  doubted  that  the  feeling  will  ultimately  take  shape 
in  action.  We  must  even  admit  that  it  is  right  that  it  should. 
As  a  profession,  we  have  taken  a  clear  and  positive  stand  in  the 
matter.  We  were  represented  in  the  discussion  that  pieceded 
the  enactment  of  the  law  by  some  of  our  most  honored  mem¬ 
bers,  and  we  supported  them  by  formal  resolutions  passed  by 
various  county  societies — resolutions  that  have  been  passed 
again  and  again  whenever  the  agitation  was  renewed.  If  now 
individual  members  of  our  body  have  sinned  against  the  law, 
against  a  law  that  we  have  accepted  as  just  and  fair,  we  must 
repudiate  their  acts  and  throw  the  responsibility  upon  the  in¬ 
dividuals  and  upon  those  who  are  charged  with  the  enforce¬ 
ment  of  the  law,  or  we  must  prepare  again  to  fight  against  the 
hasty  and  emotional  legislation  that  will  surely  seek  enactment. 

We  are  not  referring  specifically  to  the  boy-and-dog  experi¬ 
ment.  That  may  or  may  not  have  been  judiciously  conceived 
and  properly  executed.  Whether  or  not  a  graft  from  a  dog  to 
a  boy  is  likely  to  succeed  after  a  graft  from  the  boy  to  himself 
has  failed,  and  whether  or  not  the  radius  of  a  dog  may  be  an 
efficient  substitute  for  the  tibia  of  a  boy,  are  questions  upoD 
which  opposing  opinions  may  perhaps  be  honestly  held.  We 
believe  the  surgeon  was  making  a  sincere  attempt  to  benefit  his 
patient.  We  also  think  the  operation  should  be  classed  as  a 
therapeutic  measure,  and  not  as  such  a  vivisection  experiment 
as  was  contemplated  by  the  law.  But  it  has  been  attended  by 
so  much  notoriety  that  it  may  well  prove  the  starting-point  of 
an  agitation  greatly  to  be  deplored— one  from  which  our  col¬ 
leges,  our  laboratories,  and  our  science  might  receive  serious 
harm.  To  meet  it  we  must  put  ourselves  clearly  in  the  right. 
It  will  not  do  to  disclaim  responsibility;  we  are  responsible  for 
the  maintenance  of  a  public  opinion  within  the  profession  that 
will  aid  the  law  by  frowning  upon  its  infractions  and  by  de¬ 
manding  a  serious,  thoughtful,  and  thoroughly  scientific  basis 
for  any  investigation  that  may  cause  suffering  to  even  the  most 
friendless  brute. 


MINOR  PARAGRAPHS. 

THE  PROGRESS  OF  THE  KOCH  TREATMENT. 

Koch’s  alleged  remedy  for  tubercular  disease  is  now  being 
tried  diligently  in  various  parts  of  the  world,  but  naturally  the 
experiments  in  Berlin  continue  to  be  the  greatest  subject  of 
popular  and  professional  interest.  The  reports  from  that  city 
indicate  that  the  foreign  physicians  who  went  there  to  learn 
something  about  the  matter  are  beginning  to  realize  that  they 
might  as  well  have  stayed  at  home.  Specimens  of  the  liquid 
have  been  received  in  New  York  and  in  New  Haven,  and  its 
employment  in  New  Haven  has  been  under  way  for  several 
days.  One  of  the  subjects  of  the  experiments  is  said  to  be  a 
person  somewhat  advanced  in  pulmonary  phthisis,  so  that,  as 
regards  his  ca*e,  a  fair  test  of  what  Koch  alleges  for  the  remedy 
is  hardly  to  be  expected.  As  to  the  experiments  in  Europe,  the 
fragmentary  reports  received  concerning  them  do  not  seem  to 
us  to  establish  anything,  except  that  the  febrile  reaction  de¬ 
scribed  by  Koch  does  actually  take  place.  It  must  be  months 
yet  before  sufficient  data  can  be  obtained  to  settle  the  question 
of  the  curability  of  tuberculous  disease  by  the  Koch  treatment 
— before,  in  fact,  we  shall  know  whether  to  class  Koch’s  dis¬ 
covery  with  that  of  vaccination  or  with  that  of  “  gleditschine.’ 


Dec.  13,  1890.] 


MINOR  PARAGRAPHS. 


663 


The  experiments  in  New  York  were  begun  on  Wednesday  of 
this  week ;  at  St.  Luke’s  Hospital  by  Dr.  Kinnicutt,  and  at 
Mount  Sinai  Hospital  by  Dr.  Jacobi.  Both  these  gentlemen 
have  the  entire  confidence  of  the  profession,  and  the  conclusions 
they  report  will  have  great  weight. 


OSTEOMALACIA  IN  CHRONIC  DISEASE  OF  THE  CENTRAL 

NERVOUS  SYSTEM. 

Dr.  J.  0.  Bowden,  in  the  Glasgow  Medical  Journal,  reports 
a  case  of  mania  followed  by  hypersesthesia  and  osteomalacia. 
The  post-mortem  examination  revealed  softening  of  all  the 
bones  of  the  body  except  those  of  the  skull.  During  the  course 
of  the  disease  there  had  been  great  pain  and  hvpersesthesia, 
which  kept  the  patient  constantly  in  bed,  masking  the  mollifies 
ossium,  which  was  not  detected  until  the  autopsy.  Dr.  Ivon- 
stantinovsky,  in  the  Medical  Chronicle,  also  contributes  a  mono¬ 
graph  on  this  subject.  The  material  for  his  study  was  derived 
from  examinations  of  the  dead  bodies  of  patients  who  had  suf¬ 
fered  for  varying  periods  with  insanity  in  some  of  its  forms. 
Twelve  of  them  had  had  progressive  general  paralysis;  four, 
dementia  of  various  forms;  two,  imbecility;  four,  acute  or 
chronic  hallucinations ;  one,  brain  tumor;  one,  spinal  myelitis; 
and  two,  endocarditis  and  tuberculosis.  The  last  two  were  ex¬ 
amined  only  casually.  The  chemical  constitution  of  the  ribs, 
the  degree  of  their  brittleness,  the  macroscopical  peculiarities, 
and  the  histological  characteristics  were  all  inquired  into.  In 
summing  up  the  results  of  his  work  the  writer  was  of  the  opin¬ 
ion  that  in  chronic  disease  of  the  nervous  system,  especially  in¬ 
sanity,  the  ribs  were  apt  to  undergo  very  morbid  changes,  giv¬ 
ing  rise  to  brittleness,  and  hence  a  predisposition  to  fracture 
from  the  slightest  violence. 


SECTIONALISM  IN  MEDICINE. 

In  a  recent  discussion  on  intestinal  anastomosis,  at  a  meet¬ 
ing  reported  in  the  Toledo  Medical  and  Surgical  Reporter ,  one 
of  the  speakers  mentioned  a  New  York  surgeon  as  objecting  to 
Senn’s  plates,  aud  as  maintaining  that  the  artificial  channel  of 
communication  would  contract  so  as  to  cause  obstruction  anew. 
The  speaker  added  that  he  did  not  agree  with  the  New  York 
surgeon,  and  proceeded  to  class  him  with  other  surgeons  of  the 
East,  who  would  not  give  credit  for  or  place  faith  in  anything 
that  emanated  from  “  the  rowdy  West,”  simply  because  the  sur¬ 
geons  of  “the  rowdy  West  ”  did  not  “  bend  the  knee  often  enough 
before  the  arrogant,  self-conceited,  autocratic,  and  jealous  East¬ 
ern  surgeons.”  This  fraternal  language  followed  upon  this 
statement  by  the  speaker:  “  Dr.  Senn  has  been  a  great  gleaner, 
and  has  received  much  credit  for  the  ideas  suggested  by  Connel 
and  others.”  Dr.  Senn  lives  farther  west  than  Toledo,  and 
perhaps  he  may  look  upon  the  Toledo  censor  as  “  arrogant, 
self-conceited,  autocratic,  and  jealous,”  and  be  disposed  to  ac¬ 
count  for  the  fact  by  his  not  having  bent  the  knee  often  enough 
before  him.  The  remarks  in  question  were,  of  course,  only  an 
exhibition  of  the  speaker’s  individual  spleen.  There  is  no  sign 
in  the  report  that  their  spirit  was  entertained  by  anybody  else 
present  at  the  meeting,  and  we  feel  sure  that  those  who  cherish 
it,  whether  they  live  in  the  East  or  in  the  West,  are  few  in 
number  aud  utterly  without  influence  to  spread  their  offensive 
sentiments.' 


PAGET’S  DISEASE  OF  THE  BREAST. 

Before  the  Northumberland  and  Durham  Medical  Society, 
at  the  meeting  of  October  9th,  Dr.  Hume  exhibited  a  series 
of  sections  illustrating  the  pathology  of  Paget’s  disease  of  the 
breast,  an  account  of  which  appears  in  the  British  Medical 


Journal.  The.  clinical  history  of  the  case  from  which  the  sec¬ 
tions  were  taken  was  peculiar  from  the  fact  that  the  enlarge¬ 
ment  of  the  axillary  glands  and  the  nodule  in  the  breast  had 
developed  at  the  same  time.  From  microscopical  study  of  the 
sections  Dr.  Hume  was  of  the  opinion  that  the  affection  of  the 
nipple  was  closely  allied  to,  if  not  identical  with,  epithelioma  ; 
that  the  milk-ducts  were  dilated  and  disclosed  an  overgrowth 
of  their  epithelium,  which  took  the  form  of  tufts  or  villi;  that 
the  nodule  in  the  breast  showred  an  inflammatory  small-celled 
exudation,  and  also  groups  of  ducts  and  acini  in  which  the 
epithelium  was  proliferating;  and  that  the  enlarged  glands 
showed  small-celled  infiltration  and  cancerous  structure.  He 
concluded  that  the  growth  at  the  nipple  bad  from  the  begin¬ 
ning  been  cancerous,  and  that  it  had  spread  downward  into 
the  ducts;  that  subsequently  it  had  burst  through  the  ducts 
into  the  stroma  and  become  an  ordinary  cancerous  nodule. 
He  therefore  recommended  that  in  all  cases  of  obstinate  eczema 
of  the  mamma  the  breast  should  be  amputated  at  once  and  the 
axillary  glands  enucleated. 


COLCHICINE  POISONING. 

Dr.  Millot-Carpentier,  in  the  Union  medicale ,  gives  an 
account  of  a  case  of  poisoning  v\  ith  this  drug,  a  report  of  which 
Dr.  Giulio  Sprega  recently  published  in  the  Gazsetta  degli 
ospitali.  Cotoine  had  been  ordered  for  the  patient,  who  had 
been  a  sufferer  for  several  years  with  chronic  intestinal  trouble. 
By  mistake,  colchicine  was  given.  Alarming  symptoms  of  vio¬ 
lent  gastro-intestinal  irritation  soon  followed;  the  pulse  failed 
rapidly,  there  were  involuntary  stools  and  constant  vomiting, 
and  death  occurred  in  four  hours,  notwithstanding  every  effort 
being  made  to  control  the  symptoms.  Before  death  the  skin 
became  insensible  to  the  faradaic  current.  The  autopsy  re¬ 
vealed  cutaneous  emphysema,  diffuse  fatty  degeneration  of  the 
liver,  and  mitral  insufficiency.  Under  the  mucous  membrane 
of  the  stomach  there  was  a  blackish  material,  and  in  the  intes¬ 
tinal  canal  there  was  a  marked  inflammatory  condition  with 
haemorrhagic  spots. 

THE  DEATH  OF  THE  SURGEON-GENERAL. 

The  Surgeon-General’s  illness  has  terminated  fatally,  as  we 
feared  would  be  the  case  when  we  were  closing  up  our  last 
week’s  issue.  Without  questioning  the  wisdom  and  beneficence 
of  Divine  Providence,  we  feel  that  in  expressing  our  own  deep 
regret  at  General  Baxter’s  sudden  death  we  but  give  voice  to 
the  general  feeling  of  the  medical  profession.  His  tenure  of 
office  was  brief,  and  in  the  natural  order  of  things  it  could  not 
have  been  very  much  prolonged,  but  there  was  abundant  ground 
for  hoping  that  it  would  prove  sufficient  for  the  accomplish¬ 
ment  of  much  work  for  which  he  was  peculiarly  well  fitted,  both 
naturally  and  by  his  training  in  subordinate  offices.  The  army 
has  been  deprived  of  an  excellent  chief  medical  officer,  and  the 
medical  profession  has  lost  one  of  its  brightest  ornaments. 


THE  SOCIETY  OF  THE  ALUMNI  OF  CHARITY  HOSPITAL. 

At  a  meeting,  held  on  the  9th  inst.,  Dr.  Newton,  of  Mont¬ 
clair,  N.  J.,  presented  a  specimen,  considered  to  be  one  of  myxo- 
adenosarcoma,  from  the  uterus  of  a  woman  eighty-two  years  of 
age.  Dr.  Brooks  Hughes  Wells  read  a  paper  on  Perimetric  In¬ 
flammations,  in  which  he  took  the  ground  that  no  man  suffering 
from  even  the  slightest  gleet  should  marry,  because  of  the  dan¬ 
ger  of  infecting  his  wife  and  causing  pelvic  trouble.  An  ani¬ 
mated  discussion  followed,  which  was  participated  in  by  Dr. 
Clement  Cleveland,  Dr.  D.  Bryson  Delavan,  Dr.  W.L.  Carr,  Dr. 
J.  B.  Bissell,  and  others. 


664 


MI  NO  R  PA  RA  ORA  PBS.— ITEMS. 


[N.  Y.  Med.  Jottr., 


CORTICAL  EXCISION  IN  THE  TREATMENT  OF  PSYCHOSES. 

Five  cases  of  varied  forms  of  chronic  insanity  are  reported 
by  Dr.  Burkhardt  in  the  Internationale  klinische  Rundschau  as 
having  been  treated  by  removal  of  a  portion  of  the  cortex  of  the 
left  frontal  convolutions  in  three  cases,  and  of  the  left  parietal 
in  two.  There  was  marked  amelioration  of  the  violent  symp¬ 
toms,  with  an  improvement  in  the  mental  condition  in  all  but 
one  of  the  patients.  In  that  case  the  greater  part  of  the  cortex 
of  the  left  parietal  lobe  was  removed.  Word-deafDess  followed 
the  operation.  The  author  is  confident  that  the  bad  result  in 
this  case  was  due  to  carelessness  in  the  operation. 


PROTOPINE. 

In  the  British  Medical  Journal  there  is  a  description  of  a 
new  alkaloid  with  this  name,  derived  from  opium,  but  existing 
in  very  minute  quantities.  It  has  a  formula  of  C2oHi905,  and 
was  first  isolated  by  Hesse  in  1870.  Further  researches  have 
detected  it  in  the  Macleya  cordata  and  the  Chelidonium  majus , 
plants  belonging  to  the  natural  order  Papaveracece.  Dr.  von 
Engel,  in  the  Archiv  f.  exp.  Pathologie,  describes  the  action  of 
protopine  on  frogs.  In  small  doses  it  had  a  narcotic  action, 
while  larger  quantities  acted  as  a  poison  to  the  voluntary  mus¬ 
cles  and  to  the  motor  nerve  terminations,  thus  greatly  obscuring 
any  symptom  of  increased  reflex  action.  The  heart  was  slowed 
and  weakened  and  the  circulation  much  depressed,  but  there 
were  no  prominent  symptoms  of  any  action  on  the  respiration. 


INFECTION  FROM  MILK. 

In  the  Glasgow  Medical  Journal  for  October  there  is  re¬ 
ported  an  epidemic  of  sore  throat  and  erysipelas  occurring  only 
in  families  that  were  supplied  with  milk  from  a  certain  farm. 
The  most  striking  symptom  was  an  intense  inflammation  of  the 
fauces,  resembling  erysipslas  of  the  mucous  membrane,  with 
swelling  of  the  glands  of  the  neck  and  in  some  instances  sup¬ 
puration.  In  some  cases  true  erysipelas  of  the  skin  developed. 
The  temperature  ranged  from  102°  to  105°  F.  during  the  first 
few  days  of  the  attack.  Convalescence  was  marked  by  extreme 
prostration.  No  bacterial  examination  was  made,  but  a  clear 
connection  was  traced  between  the  milk  and  the  epidemic. 


A  TREATMENT  OF  CHOLERA. 

A  simple  method  of  treating  this  very  formidable  disease  is 
given  in  the  Indian  Medical  Gazette  by  Dr.  Harkin,  who  says 
he  has  proved  its  value  in  a  number  of  cases.  The  method  con¬ 
sists  in  the  application  of  a  blistering  fluid  behind  the  right  ear, 
with  the  view  of  stimulating  the  vagus  nerve  so  as  to  inhibit 
the  action  of  the  sympathetic  on  the  abdomen.  The  fluid,  any 
epispastic,  is  applied  with  a  camel’s-hair  pencil  behind  the  ear 
and  extending  in  the  course  of  the  pneumogastric  nerve  as  far 
as  the  angle  of  the  lower  jaw.  The  result  is  at  once  apparent: 
the  purging  and  other  characteristic  symptoms  cease  and  the  pa¬ 
tients  fall  asleep  long  belore  vesication  takes  place  and  awake 
ottred,  or  at  least  tided  over  the  dangerous  period. 


THE  TREATMENT  OF  CONDYLOMATA. 

Dr.  G.  Finco  ( Gazzetta  medica  lombarda ,  June  21,  1890) 
employs  a  mixture  of  one  part  of  corrosive  sublimate  and  ten 
parts  of  collodion.  The  whole  should  be  placed  in  a  small 
bottle  and  well  shaken  in  order  to  insure  a  minute  division  of 
the  insoluble  corrosive  sublimate.  The  larger  condyloinata  are 
first  touched,  a  camers-hair  pencil  being  used,  and  this  is  fol¬ 


lowed  by  an  application  of  cold  water.  The  others  are  treated 
in  the  same  way  on  successive  days  until  their  complete  dis¬ 
appearance  takes  place. 


SALIPYRINE. 

In  the  Medicinische  Revue  Dr.  P.  Guttmann  describes  a 
chemical  compound,  Ci8IIi8N204,  which  contains  in  100  parts 
57'7  of  antipyrine  and  42-3  of  salicylic  acid,  and  to  this  sub¬ 
stance  he  has  given  the  name  salipyrine.  It  is  a  white  crystal¬ 
line  powder,  odorless  and  of  slightly  acid  taste,  insoluble  in 
water  but  soluble  in  alcohol.  Therapeutically,  it  is  an  antipy¬ 
retic  and  antirrheumatic  of  considerable  value,  according  to  the 
experiments  made  by  the  author. 


THE  ST.  LAWRENCE  ASYLUM  IN  NORTHERN  NEW  YORK. 

A  new  asylum,  known  as  the  St.  Lawrence  State  Hospital 
for  the  Insane,  was  opened  on  December  1st  for  the  reception  of 
patients.  When  complefed  this  institution  will  accommodate 
1,500  persons.  The  New  York  State  Commission  in  Lunacy  is 
preparing  to  make  a  transfer  of  the  pauper  insane  now  lodged 
in  the  various  almshouses  in  the  northern  tier  of  counties  to 
this  new  hospital. 


A  QUINTUPLE  BIRTH. 

The  Lancet  has  an  annotation  referring  to  the  recent  ac¬ 
counts,  in  the  newspapers  of  Brittany,  of  the  safe  delivery  of 
a  peasant  woman  of  five  children  at  a  birth.  She  lived  at 
Nozay,  near  Nantes.  At  the  time  of  the  last  report  all  the 
children  were  alive. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  December  9,  1890: 


DISEASES. 

Week  ending  Dec.  2. 

Week  ending  Dec.  £ 

Cases. 

Deaths. 

Cases. 

Deaths. 

Tvphus  fever . 

1 

0 

0 

0 

Typhoid  fever . 

25 

3 

19 

6 

Scarlet  fever . 

93 

9 

77 

6 

Cerebro-spinal  meningitis . 

3 

3 

2 

1 

Measles . 

225 

12 

254 

15 

Diphtheria . 

90 

28 

114 

35 

Small-pox . 

1 

0 

0 

0 

V  aricella . 

12 

0 

4 

0 

w  The  Society  of  the  Alumni  of  Charity  Hospital. — The  following- 

named  gentlemen  were  recently  elected  officers  for  the  ensuing  year: 
Dr.  D.  Bryson  Delavan,  president;  Dr.  Ramon  Guiteras,  vice-president ; 
Dr.  D.  E.  Walker,  secretary;  and  Dr.  A.  T.  Muzzy,  treasurer. 

The  Jenkins  Medical  Association,  of  Yonkers. — At  the  next  meet- 
ng,  on  Thursday  evening,  the  18th  inst.,  a  report  will  be  presented 
from  the  Section  in  Surgery,  and  Dr.  Joseph  D.  Bryant,  of  New  York 
will  read  a  paper. 

The  Massachusetts  Medical  Society. — At  the  meeting  of  the  Section 
in  Clinical  Medicine,  Pathology,  and  Hygiene  of  the  Suffolk  District 
Branch,  on  Wednesday  evening,  the  17th  inst.,  Dr.  W.  N.  Bullard  will 
read  a  paper  on  The  Care  of  Chronic  Pauper  Epileptics. 

The  American  Public  Health  Association  will  hold  its  eighteenth 
annual  meeting  in  Charleston,  S.  C.,  on  Tuesday,  Wednesday,  Thurs¬ 
day,  and  Friday,  the  16th,  17th,  18th,  and  19th  inst.,  under  the  presi¬ 
dency  of  Dr.  Henry  B.  Baker,  of  Lansing,  Mich. 

Change  of  Address. — Dr.  II.  Marion  Sims,  to  No.  4  West  Forty- 
seventh  Street. 


Dec.  13,  1890.] 


ITEMS.— PROCEEDINGS  OF  SOCIETIES. 


665 


The  late  Dr.  Richard  J.  Levis. — At  a  special  meeting  of  the  faculty 
of  the  Philadelphia  Polyclinic  and  College  for  Graduates  in  Medicine 
the  following  preamble  and  resolutions  were  unanimously  adopted  : 

Whereas ;  The  Divine  Ruler  of  the  universe  has  seen  fit  to  remove 
from  among  us  Dr.  Richard  J.  Levis,  our  friend  and  colleague ;  there¬ 
fore,  be  it 

Resolved ,  That,  in  the  emeritus  professor  of  surgery  of  the  Philadel¬ 
phia  Polyclinic,  not  only  we,  but  the  whole  medical  profession,  have 
lost  an  honored  and  faithful  colaborer ;  and  the  community  have  cause 
to  mourn  a  skillful  and  learned  physician,  an  honest  and  sympathizing 
friend. 

Resolved ,  That  by  his  kindness  of  manner,  by  the  thoughtful  inter¬ 
est  which  he  always  manifested  in  the  younger  members  of  the  profes¬ 
sion,  by  his  encouragement,  his  earnestness,  and  his  example,  he  had 
endeared  himself  to  all,  and  that,  to  fitly  honor  and  cherish  his  mem¬ 
ory,  we  must  emulate  his  zeal,  and  vie  with  each  other  in  carrying  for¬ 
ward  the  great  work  in  which  he  was  engaged. 

Resolved ,  That  we  tender  to  his  family  in  this  sad  hour  of  affliction 
our  heartfelt  sympathy. 

Resolved ',  That  these  resolutions  be  handed  to  the  family  of  our  be¬ 
loved  colleague  and  to  the  medical  journals. 

[Signed.]  Thomas  J.  Mays,  President. 

S.  Solis-Cohen,  Secretary. 

Society  Meetings  for  the  Coming  Week : 

Monday,  December  15th:  New  York  County  Medical  Association  ; 
New  York  Academy  of  Medicine  (Section  in  Ophthalmology  and 
Otology) ;  Hartford,  Conn.,  City  Medical  Association  ;  Chicago  Medi¬ 
cal  Society. 

Tuesday,  December  16th:  American  Public  Health  Association  (first 
day— Charleston,  S.  C.);  New  York  Academy  of  Medicine  (Section 
in  Theory  and  Practice  of  Medicine) ;  New  York  Obstetrical  Society 
(private);  Medical  Society  of  the  County  of  Kings,  N.  Y. ;  Ogdens- 
burgh,  N.  Y.,  Medical  Association  ;  Baltimore  Academy  of  Medicine. 
Wednesday,  December  17th:  American  Public  Health  Association  (sec¬ 
ond  day);  Northwestern  Medical  and  Surgical  Society  of  New  York 
(private) ;  Harlem  Medical  Association  of  the  City  of  New  York ; 
Medico-legal  Society  ;  Medical  Societies  of  the  Counties  of  Allegany 
(quarterly)  and  Tompkins  (semi-annual — Ithaca),  N.  Y. ;  Massa¬ 
chusetts  Medical  Society,  Suffolk  District,  Section  in  Clinical  Medi¬ 
cine,  Pathology,  and  Hygiene  (Boston);  Stafford,  N.  H.,  District 
Medical  Society  (annual— Dover) ;  New  Jersey  Academy  of  Medicine 
(Newark). 

Thursday,  December  18th:  American  Public  Health  Association  (third 
day) ;  New  York  Academy  of  Medicine ;  Brooklyn  Surgical  Society ; 
Metropolitan  Medical  Society  (private);  Jenkins  Medical  Associa¬ 
tion,  Yonkers,  N.  Y. ;  New  Bedford,  Mass.,  Society  for  Medical  Im¬ 
provement  (private) ;  Addison,  Vt.,  County  Medical  Society  (annual). 
Friday,  December  19th :  American  Public  Health  Association  (fourth 
day) ;  New  York  Academy  of  Medicine  (Section  in  Orthopafflic  Sur¬ 
gery);  Chicago  Gynaecological  Society  ;  Baltimore  Clinical  Society. 
Saturday,  December  20th :  Clinical  Society  of  the  New  York  Post¬ 
graduate  Medical  School  and  Hospital. 


Jjnmeitinjgs  of  £o<xelies. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  SURGERY. 

Meeting  of  November  10,  1890. 

Dr.  Robert  Abbe  in  the  Chair. 

Rupture  of  the  Short  Head  of  the  Biceps.— Dr.  V.  P 

Gibney  presented  a  man  of  forty  years  of  age  who  had  recently 
come  to  the  hospital  on  account  of  some  injury  to  his  knee. 
The  speaker  had  recognized  the  patient  as  one  he  had  treated 


some  seven  years  ago  for  rupture  of  the  short  head  of  the  bi¬ 
ceps  muscle.  At  that  time  a  photograph  was  taken.  No  treat¬ 


ment  was  instituted,  after  consultation  with  Dr.  Bull.  The  in¬ 
jury  had  resulted  from  lifting  some  heavy  body;  the  man  heard 
a  snap  aud  the  arm  at  once  fell  useless  to  his  side.  Some  two 
or  three  months  after  the  accident  the  patient  had  begun  to 
use  his  arm  again  a  little,  aud  had  gradually  acquired  sufficient 
power  in  it  to  enable  him  to  resume  work.  He  now  found  it 
almost  as  useful  as  ever,  except  in  certain  positions. 

Epithelioma  of  the  Nose.— Dr.  I.  H.  Hance  showed  an 
elderly  woman  upon  whom  he  had  recently  operated  for  this 
condition.  The  epithelioma  had  followed  upon  a  slight  injury 
to  the  face,  the  patient  having  received  a  scratch  some  four¬ 
teen  years  ago  which  had  scabbed  over  but  had  never  entirely 
healed.  The  speaker  had  done  two  operations  on  the  face,  the 
primary  one  consisting  in  taking  a  flap  from  the  cheek  and  turn¬ 
ing  it  over  on  to  the  nose.  The  second  operation  had  included 
the  removal  of  the  scar  and  the  enlargement  of  the  opening 
into  the  nostril,  use  being  made  of  the  redundant  tissue  em¬ 
braced  in  the  pedicle  and  flap. 

The  Chairman  thought  the  result  was  extremely  satisfac¬ 
tory,  and  the  circulation  in  the  flap  seemed  exceptionally  good, 
which  was  due,  perhaps,  to  the  pedicle  being  so  near  to  the 
angular  artery. 

Fracture  of  the  Sternal  End  of  the  Clavicle.— Dr. 

Vaughan  presented  a  boy  who  some  three  weeks  before  had 
suffered  this  injury..  The  fracture  had  been  the  result  of  indi¬ 


rect  pressure,  some  man  having  leaned  his  whole  weight  on  the 
boy’s  shoulder.  There  had  been  but  little  pain  and  only  slight 


666 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jodr., 


swelling  following  the  injury.  The  fractured  sternal  end  of  the 
clavicle  could  be  felt  running  up  internally  to  the  9terno-cleido- 
mastoid.  The  speaker  had  made  every  effort  to  loosen  it  from 
its  position,  but  without  effect.  He  had  then  treated  the  case 
by  continuous  pressure,  and  the  results  so  far  had  been  satisfac¬ 
tory.  Tbe  points  of  interest  were  the  rarity  of  this  form  of 
fracture,  the  apparent  impossibility  of  reduction  at  the  time  of 
the  injury,  and  the  very  fair  results  obtained  after  only  some 
ten  days  of  continuous  pressure. 

Dr.  0.  A.  Powers  said  that  he  had  seen  this  case  soon  after 
the  accident.  The  deformity  was  extremely  marked.  He 
thought  that  these  fractures  within  an  inch  of  the  sternum  were 
rare.  He  had  only  come  across  one  among  a  pretty  fair  num¬ 
ber  of  collar-bone  fractures.  The  condition  in  one  of  these 


cases  wa9  well  shown  in  the  photograph  which  he  exhibited 
and  which  was  taken  a  year  after  the  injury.  It  was  difficult 
to  bring  these  cases  out  perfect,  but  he  thought  that,  no  matter 
how  great  the  resulting  deformity,  the  function  of  the  parts  in¬ 
volved  was  generally  restored. 

Large  Tumors  of  the  Neck. — Dr.  F.  Kammeeer  exhibited 
a  patient  from  whom  he  had  removed  a  large  tumor  of  the 
neck.  His  object  in  bringing  the  case  before  the  Section  was, 
he  said,  to  suggest  the  utility  of  dividing  the  sterno-cleido-mas- 
toid  muscle  in  removing  these  large  tumors  of  the  lymphatic 
glands  of  the  neck  which  included  the  lower  strata  of  glands 
below  the  sterno-mastoid.  It  was  of  the  very  greatest  impor¬ 
tance  to  remove  all  the  glandular  tissue,  and  if  this  were  done 
he  thought  that  the  results  would  be  better. 

Ankylosis  of  the  Jaw. — The  Chairman  showed  a  patient 
upon  whom  he  had  operated  some  ten  years  before  for  anky¬ 
losis  of  the  jaw.  The  results  had  been  happy,  immediate,  and 
continuous.  When  a  boy  of  three  years  old  this  patient  had 
had  scarlet  fever,  followed  by  suppurative  otitis  and  exfoliation 
of  the  ossicles.  The  speaker  had  cut  down,  exposing  tbe  facial 
nerve  and  the  carotid  artery.  The  fibers  of  the  nerve  were 
easily  held  out  of  the  way  of  injury.  He  had  then  cut  out  a 
wedge  shaped  piece  of  bone  at  a  point  about  an  inch  from  the 
articular  surface. 

The  Chairman  then  showed  a  girl  with  the  same  trouble, 
who  had  for  fourteen  years  been  unable  to  open  her  jaws,  her 
food  being  pressed  into  the  mouth  through  the  gap  left  by  two 
absent  incisors.  The  condition  had  resulted  from  an  injury. 
There  was  in  this  case  enough  motion  to  give  a  clew  as  to  which 
side  the  injury  had  been  on.  The  temporal  and  masseter  mus¬ 


cles  showed  vigorous  contractions,  and,  though  there  was  a 
great  deal  of  atrophy  of  the  muscles  around  the  lower  jaw,  he 
thought  there  was  every  prospect  of  a  good  result  from  opera¬ 
tive  interference. 

Dr.  S.  T.  Armstrong  asked  if  the  chairman  had  any  experi¬ 
ence  with  the  Italian  operation,  in  which  the  jaw  was  divided 
from  within  the  mouth  and  motion  persisted  in,  with  the  idea 
that  this  would  prevent  bony  union.  He  believed  that  the 
originator  of  the  operation  had  recorded  several  successful 
cases,  but  had  not  heard  of  any  American  surgeons  taking  the 
operation  up. 

The  Chairman  said  that  the  method  was  that  of  Rizzoli.  It 
had,  however,  been  superseded  by  Esmarch’s  operation,  which 
consisted  in  removing  a  segment  of  the  jaw,  after  external  in¬ 
cision,  thus  insuring  a  false  joint.  He  thought  that  resection 
of  the  neck  of  the  condyle  was  a  satisfactory  procedure.  In 
further  answer  to  a  question,  the  chairman  said  that  the  anky¬ 
losis  found  was  almost  always  fibrous.  Bony  ankylosis  was 
quite  rare. 

Gonorrhoea  in  a  Boy  of  Three  Years  of  Age,  followed 
by  Tight  Urethral  Strictures  Six  Months  later,  requiring 
Internal  and  External  Urethrotomy. — The  Chairman  re¬ 
lated  the  history  of  this  case.  The  patient,  a  healthy  child,  was 
brought  to  him  suffering  with  incontinence  of  urine,  pain  in 
the  urethra,  and  a  slight  discharge  resembling  gonorrhoea.  Nine 
weeks  before,  the  child  had  been  tampered  with  by  a  young 
woman  who  had  been  rescued  from  the  street  and  given  occu¬ 
pation  in  the  house  of  the  child’s  parents.  Within  two  weeks 
it  had  swollen  penis,  urethritis,  incontinence,  and  pain.  It  was 
treated  by  urethral  irrigation  with  l-to-8,000  bichloride-of-mer- 
cury  solution.  Gonococci  were  found  in  the  discharge.  Cure  had 
followed  in  a  short  time.  Six  months  subsequent  to  his  being 
sent  from  the  hospital  cured,  his  mother  had  noticed  him  in  great 
agony,  vainly  trying  to  pass  water.  He  was  again  brought  to 
the  hospital,  when  his  urethra  was  found  strictured  and  impas¬ 
sable  to  the  smallest  instrument.  His  bladder  wa9  aspirated 
and  a  pint  and  a  half  of  urine  removed.  Aspiration  was  re¬ 
peated  until  the  third  day,  when  examination  under  ether 
showed  three  anterior  strictures,  and  one  tight  one  at  the  mem¬ 
branous  portion,  which  just  admitted  a  filiform  bougie.  They 
were  dilated  gently,  but  the  deep  one  was  so  dense  that  ure¬ 
throtomy  was  resorted  to.  The  anterior  ones  were  cut  up  to  No. 
22  French  with  the  Otis  urethrotome,  and  the  deep  one  by  ex¬ 
ternal  perineal  urethrotomy.  It  was  found  to  bo  a  tough,  gristly 
stricture.  Perineal  drainage  by  the  catheter  was  continued  two 
days,  when  a  No.  22  sound  was  readily  passed.  Four  days  later5 
No.  24  was  found  to  slip  easily  and  painlessly  into  the  bladder. 
After  the  seventh  day  all  urine  had  passed  per  urethram.  The 
No.  22  was  passed  occasionally  for  several  weeks. 

Dr.  L.  B.  Bangs  said  that,  although  he  had  seen  the  disease 
in  very  young  subjects,  he  had  never  seen  it  in  one  so  young  as 
this.  The  case  was  interesting  in  that  it  went  to  show  how 
rapidly  the  cicatricial  tissue  following  gonorrhoea  might  be  con¬ 
verted  into  that  recognized  as  stricture  tissue.  This  change  had 
in  the  present  instance  taken  place  in  six  months.  It  was  also 
interesting  to  note  the  relation  between  the  external  measure¬ 
ment  of  the  penis  in  children  and  that  of  the  caliber  of  the 
urethra.  It  was  surprising  to  find  how  easily  instruments  would 
enter  the  normal  parts  of  the  canal. 

Dr.  W.  W.  Van  Arsdale  said  that  he  met  with  a  great 
many  cases  of  what  he  believed  to  be  gonorrhoea  in  very  young 
children.  He  had  seen  three  during  the  last  month.  Theyoung- 
est  child  was  under  ten  months  old.  The  two  others  were  one 
year  and  four  years,  respectively.  These  particular  cases  bad 
not  been  investigated  as  to  the  presence  of  gonococci,  buc  he 
believed  that  the  specific  proofs  would  be  readily  found  if 


667 


Dec.  13,  1890. J  PROCEEDINGS  OF  SOCIETIES. 


searched  for,  as  they  had  been  frequently  demonstrated  in  simi¬ 
lar  cases  in  hospital  practice.  He  met  with  about  ten  such  cases 
on  an  average  every  year.  This  was  in  about  the  proportion  often 
to  every  three  hundred  and  fifty  adults  infected.  When  it  was  re¬ 
membered  how  the  parents  of  many  of  these  children  lived,  am 
the  way  the  families  were  crowded  together,  the  chances  of  in¬ 
fection  would  be  readily  understood  as  being  great.  The  disease 
was  quite  difficult  to  treat,  because  of  the  size  of  the  urethra,  am 
the  cases  often  took  two  or  three  months  before  they  could  be 
satisfactorily  cured.  The  diagnosis  could  be  made  from  the 
course  of  the  disease.  One  troublesome  feature  in  the  case  of 
young  children  was  that  the  external  parts  became  eczematous, 
owing  to  the  accumulation  of  the  discharge,  and  this  led  to 
stricture  of  the  meatus.  To  avoid  this,  he  now  dilated  or  en¬ 
larged  the  orifice  from  the  first  and  then  tried  to  persuade  the 
parents  to  keep  the  penis  open  by  some  moist  dressing. 

Injuries  of  the  Vertebrae  in  Children.— Dr.  D.  J.  Wood¬ 
bury  showed  two  cases  of  fracture  of  the  vertebrm  in  young 
children.  The  first  patient  exhibited  was  a  child  which  had 
fallen  three  stories  through  a  fire-escape.  When  it  was 
brought  to  the  hospital  there  was  a  scalp  wound  exposing 
the  left  parietal  boss,  but  no  fracture  at  this  point.  There 
was  also  a  hsematoma  in  the  left  parietal  region.  There  was 
some  haemorrhage  from  the  mouth  and  nostril.  The  child  was 
conscious  and  there  were  no  symptoms  of  fracture.  It  was 
noted  that  the  child,  after  its  admission  to  the  hospital,  never 
could  hold  its  head  erect.  The  chin  always  rested  on  the  ster¬ 
num  and  could  not  be  raised  without  assistance.  No  attempt 
was  at  this  time  made  to  ascertain  whether  the  child  could  walk 
or  not.  A  diagnosis  of  fracture  at  the  base  was  made,  which 
was,  however,  changed  to  that  of  fracture  of  the  spine.  On 
November  3d  the  child  was  brought  to  the  speaker  in  the  out¬ 
patient  department  at  Roosevelt  Hospital.  It  could  then  neither 
walk  nor  stand,  nor  could  it  sit  up  without  support.  The  head 
was  thrown  forward  on  the  chin  and  rested  on  the  sternum. 
The  slightest  pressure  upon  the  head  apparently  caused  intense 
pain.  There  was  no  constitutional  disturbance.  On  raising 
the  head,  by  giving  support  under  the  chin,  it  was  quite  clear 
that  the  child  was  at  once  relieved.  The  treatment  was  with  a 
plaster-of-Paris  jacket  and  jury-mast.  The  improvement  had 
been  marked  from  the  time  of  the  application  of  the  apparatus. 

The  next  patient  Dr.  Woodbury  presented  to  illustrate  an¬ 
other  phase  of  the  treatment  of  these  cases.  This  child  had 
been  operated  upon  soon  after  being  injured.  From  a  study  of 
the  treatment  of  these  cases,  the  speaker  was  led  to  the  conclu¬ 
sion  that  operation  was  generally  too  long  delayed,  only  being 
turned  to  as  a  last  resort.  This  child  had  fallen  from  a  bed  to 
the  floor,  striking  upon  her  back.  On  admission  into  the  hospital 
on  August  8,  1889,  there  was  incomplete  paraplegia.  There  was 
loss  of  sensation  and  motion  in  the  entire  left  side  and  on  the 
right  side  also,  with  the  exception  of  slight  sensation  to  irrita¬ 
tion  in  the  great  toe  of  that  side.  There  was  incontinence  of 
urine  and  faeces.  The  disposition  was  very  irritable.  There  was 
no  high  temperature,  and  emaciation  was  very  great.  Dr.  Mc- 
Burney  operated,  cutting  down  upon  the  spinous  processes  of 
the  third,  fourth,  and  fifth  dorsal  vertebrae,  removing  the  lami¬ 
nae  with  rongeurs  and  exposing  the  cord.  The  dura  presented 
a  normal  appearance  and  was  not  opened.  All  pressure  being 
thus  removed,  the  wound  was  closed,  a  drainage-tube  being  left 
in  the  lower  angle.  On  the  fifth  day  the  dressing  was  removed. 
Healing  had  taken  place  by  first  intention.  The  dressings  were 
permanently  removed  on  the  fourteenth  day.  Immediately 
after  the  operation  the  irritability  of  the  child  had  diminished 
and  the  general  condition  began  to  improve.  The  muscles  of 
the  back  and  lower  extremities  remained  in  apparently  the 
same  condition  as  before  the  operation,  as  did  also  the  bladder 


and  rectum.  Faradism  was  resorted  to,  but  without  apparent 
effect.  It  was  necessary  to  do  something  in  the  way  of  immo¬ 
bilization,  and  they  had  found  themselves  confronted  with  the 
problem  as  to  how  properly  to  adjust  a  plaster-of-Paris  corset  to 
the  child,  as  it  was  perfectly  limp,  and  under  the  circumstances 
the  idea  of  suspension  in  the  usual  manner  was  not  to  be  enter¬ 
tained.  The  patient  was  simply  an  inert  mass  which  had  to  be 
carried  about  upon  a  pillow.  He  thought  that  it  would  be 
interesting  to  show  how  the  difficulty  had  been  surmounted, 
though  he  did  not  claim  any  originality  for  the  method,  as  it  had 
already  been  practiced  before.  Four  layers  of  common  cheese¬ 
cloth  were  obtained,  about  seven  to  nine  feet  long  and  fourteen 
inches  wide.  One  end  of  this  was  made  fast  to  the  wall  and 
the  other  hitched  to  a  block  and  tackle  so  that  the  tension 
upon  the  cheese-cloth  could  be  adjusted.  Slits  were  then  cut  in 
the  material  at  about  its  center,  corresponding  in  position  to  the 
arms,  legs,  and  face  of  the  child.  The  child  was  then  placed 
face  downward  upon  the  cheese-cloth,  and  its  arms  and  legs 
were  slipped  through  the  slits,  the  face  resting  in  the  slit  pre¬ 
pared  for  it,  thus  allowing  the  child  to  breathe  comfortably.  It 
was  now  only  necessary  to  fix  the  patient  in  this  position, 


which  was  done  by  suitable  bandaging.  The  child  was  now  in 
the  best  possible  position  for  the  satisfactory  application  of  the 
plaster.  In  this  case  a  corset  was  made  that  would  allow  of 
removal  for  the  application  of  electricity,  massage,  and  other 
for  ms  of  treatment.  Within  the  week  there  was  great  improve¬ 
ment  in  the  bladder  and  rectum,  and  sensation  gradually  re¬ 
turned  to  the  lower  extremities.  The  improvement  had  been 
continuous,  and  the  patieDt,  as  presented  to  the  meeting,  was 
able  to  stand  alone  without  support  of  any  kind. 

Dr.  R.  H.  Sayre  said  that  in  all  cases  where  a  plaster  jacket 
was  applied  for  the  treatment  of  fractured  vertebrae  great  care 
was  necessary  lest  more  harm  than  good  be  done.  His  father 
had  been  in  the  habit  of  applying  traction  to  the  spinal  column 
as  soon  as  possible,  followed  by  fixation  with  a  plaster-of-Paris 
bandage.  Three  of  the  patients  so  treated  had  recovered — two 
perfectly,  and  the  other  to  all  appearances.  This  latter  patient 
lad  stated  that  he  could  endure  very  little  fatigue,  and  that  since 
;he  injury  to  his  back  he  had  been  impotent.  The  object  of 
applying  traction  as  soon  as  possible  was  to  endeavor  to  get 


the  spine  into  its  normal  position  and  prevent  pressure  on  the 
cord  by  the  displaced  fragments.  He  thought  the  method 
shown  by  Dr.  Woodbury  was  excellent  in  every  way  and  could 
hardly  be  improved  upon. 

Dr.  Ketofi  said  that  in  reference  to  the  first  case  there  was 


668 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


a  point  which  had  not  been  touched  upon,  and  that  was  the 
possibility  of  the  existence  of  Pott’s  disease  in  the  superior  cer¬ 
vical  region.  Bearing  in  mind  this  fact  might  be  of  service  in 
doubtful  cases.  Of  course  he  did  not  wish  to  be  understood  as 
expressing  the  opinion  that  this  was  such  a  case.  It  was  found 
that  in  disease  of  the  upper  cervical  vertebrae  there  was  always 
interference  with  rotation,  and  on  this  a  diagnosis  could  some¬ 
times  be  made.  Where  there  was  interference  with  flexion,  as 
in  this  first  case,  the  lesion  was  lower  down — between  the 
second  and  third  or  third  and  fourth  vertebrae.  It  had  seemed 
to  him  that  in  this  first  case  the  question  of  fracture  was  a  very 
doubtful  one.  He  remembered  a  case  in  which  a  child  had 
fallen  from  a  very  high  place;  there  was  no  deformity,  and 
the  child  did  not  receive  immediate  care  and  died.  The  post¬ 
mortem  had  shown  dislocation  of  the  upper  cervical  vertebras. 
He  thought  the  cases  might  be  treated  in  an  apparatus  that  gave 
•slight  traction  and  support  to  the  head  in  a  proper  direction. 
He  had  noticed  that  the  patient  with  the  jury-mast  was  allowed 
to  turn  its  head.  He  thought  the  head  should  be  immobilized 
with  a  certain  amount  of  traction.  The  question  of  diagnosti¬ 
cating  locality  in  these  cases  was  very  obscure,  and  if  some  de¬ 
ductions  could  be  made  from  cases  of  Pott’s  disease,  he  thought 
this  was  a  valuable  point. 

Dr.  Woodbury  said  that  rotation  was  now  perfectly  pain¬ 
less  to  the  child.  Before  it  was  treated  with  this  support  mo¬ 
tion  had  been  impossible. 

SECTION  IN  PAEDIATRICS. 

Meeting  of  November  13,  1890. 

Dr.  L.  Emmett  Holt  in  the  Chair. 

Practical  Hints  on  Sterilizing  Milk.— Dr.  Walter  Men- 
delson  read  a  paper  with  this  title.  He  said  that  much  of  the 
confusion  and  dissatisfaction  of  the  laity  in  preparing  sterilized 
milk  was  due  to  the  fact  that  the  theoretical  principles  upon 
which  they  must  work  had  never  been  simply  and  fully  ex¬ 
plained  to  them.  He  thought  that  it  was  not  only  the  physi¬ 
cian’s  duty  to  let  the  one  upon  whom  the  preparation  devolved 
know  the  means,  but  the  object  as  well.  Explain  to  her  or  him 
that  investigation  had  shown  that  not  only  were  the  curdling, 
souring,  and  other  obvious  changes  due  to  the  grojvth  of  bac¬ 
teria  or  minute  germs  in  the  milk,  but  also  that  various  dyspep¬ 
tic  and  diarrhceal  diseases  of  bottle-fed  children  were  caused 
by  the  presence  in  the  milk  of  similar  minute  organisms  which 
might  produce  no  change  in  the  milk  itself.  Tell  them  that  it 
had  been  found  that,  when  milk  had  been  heated  to  the  boiling 
point  and  kept  there  for  some  time,  both  the  plants  and  their 
seeds  were  killed  and  the  milk  was  thus  rendered  fit  for  food. 
After  having  explained  that  the  object  was  to  prepare  a  food 
free  from  germs,  the  next  thing  was  to  show  how  to  ac¬ 
complish  this.  The  milk,  or  suitable  mixture  of  milk,  water, 
cream,  aud  sugar,  should  be  prepared  as  early  in  the  morning  as 
possible,  before  the  heat  of  the  day  had  caused  the  bacteria  to 
multiply.  Great  care  must  be  taken  in  cleansing  the  bottles 
and  nipples,  and  for  this  purpose  “  pearline  ”  seemed  to  answer 
the  best,  using  it  with  hot  water  and  a  bottle  brush.  The  same 
bottle  should  never  be  used  the  second  time  without  washing. 
With  regard  to  stoppers,  the  best  consisted  of  a  plug  made  of 
ordinary  cotton  batting,  folded  into  a  pretty  firm  wad.  and 
pushed  down  for  half  an  inch  or  more  into  the  neck  of  the 
bottle.  The  nipple  should  be  a  plain  conical,  pure  gum  one, 
with  no  constrictions  in  it,  so  that  it  could  readily  be  turned 
inside  out  for  cleansing.  When  not  in  use  it  should  be 
scrubbed  clean  and  placed  in  a  glass  of  water  to  which  a  tea¬ 
spoonful  of  borax  had  been  added.  As  for  the  sterilizer,  any 
apparatus  would  do  that  would  answer  the  purpose  of  keeping 


the  milk  for  about  an  hour  at  the  temperature  of  boiling. 
But  of  the  specially  devised  affairs  for  this  purpose,  “Arnold’s 
steam  sterilizer”  wras  the  most  ingenious  and  at  the  same  time 
simple.  The  sterilizing  of  milk  had  marked  a  great  advance  in 
our  methods  of  infant  feeding,  and,  as  the  triumphs  of  medicine 
in  the  future  would  seem  to  lie  in  the  direction  of  preventing 
illness  rather  than  of  curing  it,  it  should  be  the  pride  and  in¬ 
terest  of  every  physician  to  popularize  the  method  under  dis¬ 
cussion,  for  it  had  already  done  much  to  lessen  the  morbility 
and  mortality  among  infants. 

Results  of  the  Use  of  Sterilized  Milk. — Dr.  H.  Koplik 
read  a  paper  giving  the  results  of  bis  treatment  with  the  steril¬ 
ized  milk  in  one  hundred  and  thirty-four  dispensary  patients. 
(To  be  published.) 

A  member  from  Brooklyn  said  that  they  had  now  perfected 
all  the  arrangements  in  that  city  by  which  one  of  the  large 
dairies  did  the  work  of  thoroughly  sterilizing  a  quantity  of 
milk  daily,  putting  it  up  in  properly  constructed  bottles  for 
delivery  at  the  residences  of  customers.  One  of  the  prepara¬ 
tions  contained  a  proportion  of  cream.  As  to  the  legality  of 
putting  this  upon  the  market  in  such  form  there  had  been  some 
dispute,  but  quite  recently  a  legal  opinion  had  been  given  which 
practically  settled  the  question,  and  there  was  now  no  reason 
why  this  and  other  preparations  of  sterilized  milk  should  not 
be  in  general  use. 

Peritonitis  in  Infancy  and  Childhood.— This  was  the 
title  of  a  paper  by  Dr.  J.  Lewis  Smith.  He  said  that  perito¬ 
nitis  was  likely  to  occur  at  any  age,  but  the  most  interesting 
and  fatal  form  was  that  which  occurred  in  the  newly  born. 
This  form  had  in  times  past  been  quite  commou  in  maternity 
wards  and  in  tenement  houses,  in  degraded  and  filthy  families, 
who  had  no  knowledge  or  thought  of  sanitary  requirements. 
There  was  no  doubt  that  in  the  astiology  of  peritonitis  in  the 
newly  born  microbes  played  a  most  important  part.  The  sep¬ 
tic  matter  no  doubt  entered  the  system  through  the  umbilicus, 
usually  from  the  use  of  foul  dressings,  foul  water  employed  in 
washing,  foul  fingers  of  the  nurse,  or  other  sources.  Umbilical 
inflammation,  with  perhaps  ulceration  and  the  formation  of  a 
phlegmon,  might  occur,  and  septic  matter  be  taken  up  by  the 
umbilical  lymphatics  or  blood-vessels  and  carried  into  the  sys¬ 
tem.  Peritonitis  occurred  in  infancy  and  childhood  from  a 
variety  of  causes.  It  sometimes  resulted  from  extension  of 
inflammation  from  the  abdominal  walls  or  from  one  of  the 
viscera  which  was  the  seat  of  a  tumor  or  adventitious  growth, 
encroaching  upon  and  irritating  the  peritonaeum.  Septic  infec¬ 
tion  occasionally  caused  peritonitis,  when  the  conditions  were 
favorable  for  it,  in  older  children  as  well  as  in  the  newly  born. 
Chronic  degenerative  disease  of  the  kidneys  was  also  a  recog¬ 
nized  cause  of  peritonitis,  but  less  frequently  in  children  than 
iD  adults.  It  was  now  known  that  a  considerable  number  of 
the  diseases  which  were  formerly  supposed  to  be  due  to  taking 
cold  were  caused  by  microbes.  Perhaps  there  was  too  great  a 
tendency  at  the  present  time  to  ignore  thermal  changes  in  the 
atmosphere  or  exposure  to  cold  as  a  cause  of  disease.  In  ill- 
nourished  and  scrofulous  children  inflammation  and  cheesy  de¬ 
generation  of  the  mesenteric  glands  sometimes  gave  rise  to 
inflammation  in  the  portion  of  the  peritonaeum  which  covered 
them.  But  peritonitis  in  infancy  and  childhood  more  frequently 
resulted  from  disease  of  the  hollow  organs  than  from  that  of 
the  solid  viscera.  Intussusception,  attended  by  bloody  stools, 
tenesmus,  vomiting,  abdominal  tenderness,  and  the  occurrence 
of  an  abdominal  tumor,  was  more  common  in  infancy  after  the 
age  of  six  months  than  in  any  other  period  of  life.  Another 
not  infrequent  cause  was  appendicitis  due  to  the  lodgment  of 
a  foreign  substance  in  the  appendix,  or  of  a  concretion,  which 
caused  by  its  presence  pressure  inflammation,  ulceration,  and 


Dec.  13,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


669 


finally  perforation.  Children  less  frequently  than  adults  had 

ulceration  of  Peyer’s  patches  in  typhoid  fever,  but  it  sometimes 
occurred,  ending  in  perforation  or  rupture  and  fatal  peritonitis. 
Peritonitis  had  been  known  to  follow  traumatism  of  the  ab¬ 
domen.  Recently  a  considerable  number  of  cases  had  been 
published  showing  the  microbic  origin  of  peritonitis  in  certain 
instances.  Some  of  the  cases  were  caused  by  accidental  inocu¬ 
lation,  and  others  were  due  to  the  inhalation  of  sewer-gas.  Ex 
periments  had  been  made,  designed  to  elucidate  the  causal  rela¬ 
tion  of  microbes  to  peritonitis.  Prince  had  found  that  the  in 
jection  into  the  abdominal  cavity  of  a  small  amount  of  an  irri¬ 
tant  not  containing  microbes — such  as  mineral  acid,  phenol,  and 
nitrate  of  silver— caused  peritonitis,  but  it  was  always  sero¬ 
fibrinous,  never  purulent.  Grawitz,  in  his  experiments,  had 
shown  that,  as  a  rule,  two  things  were  necessary  for  the  causa 
tion  of  purulent  peritonitis— to  wit,  the  introduction  into  the 
peritonea]  cavity  of  pus-producing  organisms,  and  an  abnormal 
state  of  the  peritonaeum  from  injury  or  contagious  disease. 
Another  observer  had  shown  that  if  the  peritonaeum  was  in  its 
normal  state  it  might  absorb  a  considerable  amount  of  septic 
matter  with  no  serious  result,  but  that  if  it  was  injured  or  the 
subperitoneal  connective  tissue  was  exposed  to  infection,  puru¬ 
lent  peritonitis  was  likely  to  result.  Experiments  thus  far  had 
not  perhaps  been  very  satisfactory  in  throwing  light  on  the 
microbic  origin  of  peritonitis,  but  they  seemed  to  show  that 
purulent  peritonitis,  as  a  rule,  resulted  from  the  action  of 
microbes,  and  the  microbes  known  to  be  pathogeuic  caused 
peritonitis  when  injected  into  the  peritoneal  cavity,  while  the 
non-pathogenic  germs  did  not  produce  such  a  result,  even  in  a 
lesser  degree.  Tubercular  peritonitis  occurred  much  more  fre¬ 
quently  in  infancy  and  childhood  than  in  adult  life.  The  symp¬ 
toms,  when  peritonitis  was  due  to  a  pre-existing  disease,  were,  of 
course,  accompanied  by  the  symptoms  of  that  disease,  by  which 
it  might  be  rendered  more  or  less  obscure.  The  symptoms 
might  begin  in  any  manner,  with  gradually  increasing  tender¬ 
ness  of  the  abdomen,  or  abruptly  with  a  chill  or  rigor.  Con¬ 
stant  pain  increased  by  movements  of  the  body  or  by  pressure 
was  the  distinctive  symptom  occurring  in  localized  peritonitis 
at  the  seat  of  the  inflammation,  but  in  diffuse  peritonitis  it 
began  at  some  point  and  gradually  extended  over  the  abdomen. 
Tenderness  on  pressure  was  seldom  absent,  and  the  pain  inten 
sified  by  coughing  or  a  full  inspiration  was  in  most  cases  seen 
in  the  early  stage  of  the  disease.  The  extension  of  the  inflam 
mation  over  the  intestines  produced  paralysis  of  their  muscular 
layer  so  that  they  became  distended  with  gas.  In  cases  of 
great  abdominal  distention  the  apex  of  the  heart  was  carried 
upward,  the  liver  and  spleen  were  pressed  upward  and  back 
ward,  and  the  distended  transverse  colon  or  portions  of  the 
duodenum  or  jejunum  might  lie  in  front  of  them,  so  that  the 
normal  dullness  on  percussion  over  these  organs  was  replaced 
by  the  tympanitic  resonance.  The  percussion-sound  over  the 
effused  liquid  was,  of  course,  dull.  The  patient  was  quiet  on 
account  of  the  pain,  lying  upon  the  back  or  side  with  the  knees 
flexed  to  relieve  the  tension,  but  the  position  was  not  uniform, 
as  the  legs  might  even  be  found  extended.  Constipation  was 
usually  present  in  the  early  stage.  Vomiting  was  a  common 
and  painful  symptom.  The  pulse  was  accelerated  in  some  cases 
very  frequent  as  well  as  very  feeble.  The  countenance  was 
anxious,  but  the  mind  was  clear,  or  there  might  be  a  mild  de¬ 
lirium,  the  speech  being  incoherent  and  rambling.  Retention 
of  urine  was  common.  In  the  pathological  anatomy  of  local¬ 
ized  peritonitis  the  action  of  the  cause,  as  the  name  implied, 
was  limited  to  a  portion  of  the  peritonaeum.  In  acute  diffuse 
or  general  peritonitis  the  inflammation  commonly  began  at  one 
point,  but  it  rapidly  extended  over  the  peritonaeum.  The  rela¬ 
tive  proportion  of  the  different  inflammatory  products  varied 


greatly  in  different  cases,  and  in  all  not  only  were  serum  and 
fibrin  present,  but  pus-corpuscles  could  be  detected  under  the 
microscope.  The  fibrinous  exudation  upon  the  peritoneal  sur¬ 
face  occurred  either  in  patches  or  continuously  over  a  consid¬ 
erable  part  of  the  visceral  peritonaeum.  It  was  prone  to  form 
a  covering  of  varying  thickness  over  the  large  and  immova¬ 
ble  organs.  The  connective  tissue  underlying  the  peritonaeum 
underwent  proliferation,  producing  granulations,  which,  when 
coming  in  contact  with  opposing  surfaces,  united,  forming  adhe¬ 
sions,  and  these  at  times  involved  the  intestines  and  viscera, 
producing  disastrous  results.  In  purulent  peritonitis,  the  pus 
formed,  being  heavier  than  the  serum,  gravitated  to  the  lowest 
part  of  the  abdominal  cavity.  In  patients  that  recovered  the 
serum  was  the  first  to  be  absorbed,  and  the  fibrin  and  pus  cells 
underwent  fatty  degeneration,  became  granular,  liquefied,  and 
were  absorbed.  Sometimes  collections  of  pus  became  encapsu¬ 
lated  and  remained  inert.  By  careful  attention  to  the  distinctive 
symptoms  a  mistake  in  diagnosis  ought  not  to  occur.  Perito¬ 
nitis  in  children  was  always  a  grave  disease;  in  most  instances 
its  progress  was  rapid  toward  a  fatal  termination.  The  author 
was  confident  that  much  could  be  done  in  the  way  of  prophy¬ 
laxis  in  these  cases  if  a  little  more  attention  was  given  to  the 
matter.  Scarcely  any  disease  more  urgently  required  early  and 
judicious  treatment  than  the  one  under  consideration.  Proper 
selection  of  the  diet  was  a  matter  of  the  greatest  importance. 
Such  food  should  be  recommended  as  was  most  concentrated, 
predigested,  or  easy  of  digestion,  and  such  as  would  give  the 
minimum  amount  of  faecal  matter.  Sterilized  milk  was  by  far 
the  best  food  for  this  purpose.  For  children  over  two  years  of 
age  some  farinaceous  food  could  be  added.  Purgatives  should 
be  avoided.  A  nutritive  or  laxative  enema  was  the  best  for  this 
purpose.  Of  the  drugs,  opium,  camphor,  digitalis,  alcohol,  and 
strophantbus  were  used,  as  the  urgencies  of  individual  cases 
required.  The  removal  of  the  cause  of  a  disease,  if  it  could  be 
effected  safely  without  material  injury  to  the  patient,  evidently 
contributed  greatly  to  recovery. 

The  Chairman  said  that  a  great  deal  of  stress  had  been  laid 
from  time  to  time  upon  the  grape-seed  point.  He  had  never 
yet  found  such  seeds  in  any  appendix  vermiformis.  He  thought 
it  was  a  little  hard  on  children  that,  on  the  strength  of  this 
apprehension,  they  were  to  be  debarred  from  eating  fruit. 

Dr.  J.  E.  Winters  thought  that  the  most  important  causes 
of  peritonitis  in  children  were  typhlitis,  perityphlitis,  appen¬ 
dicitis,  traumatism,  tuberculous  disease,  and  intussusception. 
In  regard  to  the  first  three  conditions,  the  cases,  of  course,  re¬ 
quired  to  be  seen  early,  when  he  thought  that  a  critical  exami¬ 
nation  ought  to  result  in  a  correct  diagnosis.  The  traumatic 
cases  were  more  difficult,  for  the  reason  that  most  children  were 
unwilling  to  acknowledge  the  indiscretion  which  had  led  up  to 
the  traumatism.  In  dispensary  practice  this  was  particularly 
difficult  to  elicit;  but  brutal  treatment  by  the  parents  was  a 
frequent  cause  of  the  peritonitis.  The  tubercular  variety  re¬ 
quired  acquaintance  with  the  family  history,  and  called  for  a 
thorough  examination  as  to  the  existence  of  general  tubercular 
disease  in  the  patient.  Without  all  these  points,  few  physi¬ 
cians  would  be  willing  to  make  a  diagnosis  of  tubercular  disease 
in  the  peritoneal  cavity.  In  intussusception  the  symptoms  were 
sufficiently  pronounced  to  make  a  diagnosis  tolerably  easy.  A 
diagnosis  of  peritonitis  from  either  of  the  three  first-named 
causes  having  been  made,  then  came  the  question  of  management. 
He  thought  that  at  the  present  time  most  men  used  cold.  The 
inflammatory  processes  were  sufficiently  superficial  to  be  influ¬ 
enced  by  the  external  application  of  cold,  and  he  thought  that 
the  results  were,  on  the  whole,  more  favorable  than  from  heat. 
Only  in  the  case  of  absolute  inability  on  the  part  of  the  patient 
to  tolerate  its  application  would  he  use  anything  for  external 


670 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Mkd.  Jour., 


application  except  ice.  If  cold  would  not  relieve  the  pain, 
then  morphine  must  be  used.  It  was  important  to  remove  all 
substances  from  the  large  intestines,  and  for  this  purpose  he 
thought  that  it  was  best  to  employ  small  doses  of  triturated 
calomel. 

The  frequent  injection  of  ice-cold  water  into  the  rectum 
was  desirable  after  the  use  of  the  calomel,  or  of  castor-oil. 
In  the  traumatic  cases,  having  gained  the  confidence  of  the 
child  and  obtained  a  careful  history  of  the  case,  he  thought  that 
cold  applications  and  a  clearing  out  of  the  alimentary  canal 
were,  as  a  rule,  sufficient,  together  with  the  strictest  dietetic 
management.  In  the  tuberculous  cases  the  physician  could  en¬ 
deavor  to  give  relief  by  counter-irritation  by  means  of  iodine. 
In  this  way  the  early  indications  might  be  met.  If  suppuration 
was  expected,  an  operation  might  be  resorted  to.  In  cases  of 
perityphlitis  and  appendicitis,  where,  having  made  a  causal 
diagnosis,  and  having  failed  by  judicious  means  to  relieve  the 
local  symptoms,  laparotomy  should  be  suggested.  As  now  un¬ 
dertaken,  the  operation  was  not  serious,  and  it  was  far  simpler 
at  the  outset  than  after  extensive  adhesions  and  infiltration  had 
taken  place. 

Dr.  Smith  thought  that,  if  the  surgeons  were  to  examine  the 
concretions  carefully  which  they  found  in  the  appendices,  they 
would  often  discover  that  seeds  and  other  foreign  bodies  were 
the  real  cause  of  the  trouble.  He  was  not  inclined  to  with¬ 
draw  from  the  stand  he  had  taken  in  the  matter  of  grape 
seeds. 

SECTION  IN  THEORY  AND  PRACTICE  OF  MEDICINE. 

Meeting  of  November  18 ,  1890. 

Dr.  Francis  Delafield  in  the  Chair. 

The  Medical  Aspect  of  Trephining  in  Epilepsy. — Dr.  J. 

C.  Minor  read  a  paper  with  this  title.  He  said  that,  from  long 
clinical  observation,  he  had  concluded  that  epilepsy  did  not  dis¬ 
appear  spontaneously,  but  that  about  one  half  of  all  the  cases 
presented  for  treatment  were  curable,  whether  the  cases  called 
for  medical  or  for  surgical  treatment.  The  reason  that  surgical 
interference  did  not  offer  better  results  was,  the  speaker  thought, 
due  to  the  cases  not  having  been  properly  selected.  He 
thought  that  the  indications  for  trephining  in  epilepsy  were 
pretty  definitely  marked  out.  The  indications  were  described 
under  three  headings:  1.  Those  that  were  plainly  traumatic 
and  presented  a  depressed  fracture  of  the  skull,  osteitis,  and 
tumors  of  the  brain.  2.  Those  without  any  apparent  lesion  of 
the  skull,  but  with  old  cicatrices  of  the  scalp.  3.  All  those 
cases  of  epilepsy  the  symptoms  of  which  indicated  cortical 
lesions.  The  speaker  was  satisfied  that  more  than  half  the 
cases  presenting  for  treatment  would  come  under  one  of  the 
above  groups.  The  history  of  a  case  was  then  reported.  The 
patient,  a  young  man,  seventeen  years  of  age,  had  five  years 
ago  been  hit  on  the  head  with  a  brick  which  had  fallen  from 
quite  a  height,  producing  only  a  scalp  wound.  Four  years  later 
the  first  attack  came  on,  and  during  the  last  year  epilepsy  had 
become  fully  established.  The  attacks  came  on  with  a  distinct 
aura,  contractions  commencing  in  the  right  hand  and  arm. 
Pressure  on  the  scar  would  firing  on  the  aura  and  produce  a 
typical  attack.  Trephining  in  this  case  had  disclosed  no  injury 
to  the  skull,  but  the  removal  of  the  cicatrix  had  ameliorated 
the  condition.  The  speaker,  from  his  observations  in  this  case, 
was  led  to  the  conclusion  that  it  was  always  well  to  begin  the 
treatment,  in  cases  presenting  cicatrices,  by  removing  the  scar. 
Several  cases  had  been  reported  cured,  treated  in  this  manner, 
and  he  thought  it  was  well  worth  trial.  He  did  not  think  that 
in  trephining  at  the  site  of  injury  the  actual  lesion  caused  by  it 
could  be  found  in  every  case.  The  contra-indications  for  op¬ 


erative  interference  were  in  all  those  cases  where  the  cause  was 
not  clearly  defined  and  in  those  of  long  standing  where  the  pa¬ 
tient’s  mind  had  become  enfeebled  and  the  general  condition 
would  offer  no  hope  of  recovery.  Finally,  when  the  indica¬ 
tions  were  for  surgical  treatment,  the  operation  should  be  done 
promptly,  as  by  so  doing  the  best  possible  chance  would  be 
given  to  the  patient. 

Dr.  Robert  F.  Weir  was  quite  in  accord  with  the  rules 
laid  down  by  the  speaker.  Despite  the  fact  that  operations 
were  being  done  on  the  brain  by  some  of  the  most  careful  sur¬ 
geons,  the  mortality  was  still  quite  high,  averaging  from  fifteen 
to  twenty  per  cent.  His  experience  in  brain  surgery  had  led  to 
the  conclusion  that  much  would  yet  be  done  in  this  direction, 
but  that  when  the  technique  of  the  operation  was  better  under¬ 
stood  the  results  would  be  better. 

Dr.  Robert  Abbe  reported  the  histories  of  two  cases  in 
which  an  operation  had  been  performed,  the  results  of  which 
led  to  the  conclusion  that  conservatism  was  to  be  practiced  in 
operating  in  such  cases. 

Dr.  E.  D.  Fisher  thought  that  it  was  a  difficult  matter  to 
say  which  cases  should  be  operated  on  and  ivhich  not.  He 
thought  that  chronic  epilepsy,  traumatic  lesions  with  conse¬ 
quent  organic  lesion,  congenital  spastic  paraplegias  with  asso¬ 
ciated  epilepsy,  and  a  focal  lesion  becoming  general,  were  cer¬ 
tainly  not  suitable  for  operation.  Cases  had  been  met  with 
where  the  scar  was  a  source  of  irritation,  but  again  it  was  often 
present  when  it  did  not  cause  any  trouble  whatever,  so  he 
could  not  agree  with  the  speaker  in  thinking  that  it  was  a  good 
thing  to  trephine  in  these  cases.  He  had  had  a  case  which  had 
appeared  to  offer  every  indication  for  trephining.  The  operation 
had  seemed  to  be  a  success,  the  patient  had  improved  tor  two 
or  three  weeks,  but  had  after  that  relapsed  into  his  old  condi¬ 
tion.  It  was  the  speaker’s  opinion  that  all  the  cases  of  idio¬ 
pathic  type  of  epilepsy  were  originally  traumatic. 

Dr.  L.  C.  Gray  thought  that,  in  reviewing  the  question  of 
the  indication  for  operation  in  epilepsy,  it  would  be  just  as  well 
to  first  ask  what  was  epilepsy.  It  was  still  a  question  as  to 
whether  epilepsy  was  a  disease  or  a  symptom  of  one,  aud  if 
either,  what  were  the  cause  and  nature  of  it?  Whether  it  might 
not  be  due  to  peripheral  irritation  had  been  pretty  thoroughly 
gone  into,  and  it  was  found  that  after  every  source  of  irritation 
had  been  removed  the  attacks  went  on  the  same  as  before.  The 
histories  and  data  were  wanting  in  definite  value.  This  was 
thought  to  be  due  to  the  fact  that  cases  were  not  kept  under 
observation  long  enough,  and  not  followed  up  with  a  definite 
object.  Idiopathic  epilepsy  with  marked  changes  had  been 
known  to  go  on  for  years  without  a  fit  having  occurred.  There 
was  no  doubt  that  many  of  the  cases  were  organic  in  origin. 
Those  that  were  due  to  meningitis  in  early  infancy  certainly 
could  not  be  operated  upon.  Such  cases  as  were  due  to  the 
same  causes  were  called  in  the  adult  idiopathic,  simply  because 
the  definite  course  of  the  disease  was  not  known.  The  traumatic 
cases  offered  but  little  better  results  for  operative  interference 
on  account  of  the  very  limited  knowledge  of  the  focal  centers. 
The  only  ones  isolated  were  those  of  the  arm,  leg,  speech,  word- 
deafness,  and  luemianopsia;  when  we  undertook  to  go  beyond 
that  point  we  were  in  the  field  of  speculation.  It  was  still  a 
question  whether,  if  operation  were  performed  in  cortical  epi¬ 
lepsy,  the  habit  of  the  explosion  was  not  too  confirmed  to  cease. 
The  speaker  related  the  history  of  a  case  of  subcortical  lesion 
in  which  no  loss  of  consciousness  had  occurred.  He  thought 
the  whole  question  bearing  on  epilepsy  was  still  distinctly  mb 
judice. 

Dr.  Minor  said  that  the  indications  and  rules  laid  down 
by  him  had  been  made  up  principally  from  reports  and  his  own 
clinical  experience.  He  was  sure  that  some  cases  had  been 


BOOK  NOTICES. 


671 


Dec.  18,  1890.] 


cured  of  the  attacks  by  the  operation,  but  he  was  also  of  the 
opinion,  as  Dr.  Gray  had  expressed  it,  that  the  habit  could  not 
be  easily  broken  up  and  that  it  was  likely  to  return.  In  oper¬ 
ating  in  cases  of  idiopathic  epilepsy  where  no  scar  could  be  found 
he  had  never  known  it  to  do  the  patients  harm.  The  operation 
in  these  cases  was  done  on  the  principle  of  cerebral  pressure, 
lie  had  recently  seen  an  old  patient  upon  whom  he  had  operated 
some  twenty  years  ago,  removing  a  large  portion  of  the  frontal 
bone  with  a  quantity  of  brain  tissue.  It  was  interesting  to  know 
that  there  had  never  been  any  development  of  epilepsy,  but 
the  mental  and  moral  degradation  was  complete. 


took  Botrcts. 


Diseases  of  the  Eye.  By  Edward  Netti.eship,  F.  R.  C.  S.,  Oph¬ 
thalmic  Surgeon  to  St.  Thomas’s  Hospital,  etc.  Fourth 
American  from  the  Fifth  English  Edition.  With  a  Chapter 
on  Examination  for  Color-perception,  by  William  Thomson, 
M.  D.,  Professor  of  Ophthalmology  in  the  Jefferson  Medical 
College  of  Philadelphia.  Philadelphia:  Lea  Brothers  &  Co., 
\  1890.  [Price,  $2.] 

This  is  a  well-known  and  a  valuable  work.  It  was  prima¬ 
rily  intended  for  the  use  of  students,  and  supplies  their  needs 
admirably,  but  it  is  far  from  being  a  mere  quiz  compend.  On 
the  contrary,  it  is  as  useful  for  the  practitioner,  or  indeed  more 
so.  It  does  not  presuppose  the  large  amount  of  recondite 
knowledge  to  be  present  which  seems  to  be  assumed  in  some  of 
our  larger  works,  is  not  tedious  from  over-conciseness,  and  yet 
covers  the  more  important  parts  of  clinical  ophthalmology. 

A  supplement  is  made  to  the  present  edition  on  the  practi¬ 
cal  examination  of  railway  employees  as  to  color-blindness  and 
acuteness  of  vision  and  hearing.  This  is  well  written,  and  con¬ 
tains  good  suggestions  for  those  who  may  be  called  upon  to 
make  such  examinations. 

BOOKS  AND  PAMPHLETS  RECEIVED. 

Les  microbes  de  la  bouche.  Par  le  Dr.  Th.  David,  Directeur  de 
l’ecole  dentaire ;  ckirurgien  dentiste  des  Hopitaux  de  Paris.  Precede 
d’une  lettre-preface  de  M.  L.  Pasteur.  Avec  113  figures  en  noir  et  en 
couleurs  dans  le  texte.  Paris  :  Felix  Alcan,  1890.  Pp.  xv-302. 

Memorial  Sketches  of  Dr.  Moses  Gunn.  By  his  Wife.  With  Ex¬ 
tracts  from  his  Letters  and  Eulogistic  Tributes  from  his  Colleagues 
and  Friends.  Chicago:  W.  T.  Keener,  1890.  Pp.  xx-380. 

Household  Hygiene.  By  Mary  Taylor  Bissell,  M.  D.  New  York  : 
N.  D.  C.  Hodges,  1890.  Pp.  83.  [Fact  and  Theory  Papers.] 

A  Manual  of  Weights  and  Measures.  Including  Principles  of  Me¬ 
trology;  the  Weights  and  Measures  now  in  Use;  Weight  and  Volume 
and  their  Reciprocal  Relations;  Weighing  and  Measuring;  Balances 
(Scales)  and  Weights  ;  Measures  of  Capacity  ;  Specific  Weight  and  Spe¬ 
cific  Volume,  etc.  With  Rules  and  Tables.  By  Oscar  Oldberg,  Pharm. 
D.,  etc.  Third  Edition,  revised.  Chicago  :  W.  T.  Keener,  1890.  Pp. 
vi-250. 

A  Clinical  Study  of  Diseases  of  the  Kidneys,  including  Systematic 
Chemical  Examination  of  Urine  for  Clinical  Purposes,  Systematic  Mi¬ 
croscopical  Examination  of  Urinary  Sediments,  Systematic  Application 
of  Urinary  Analysis  to  Diagnosis  and  Prognosis  ;  Treatment.  By  Clif¬ 
ford  Mitchell,  A.  M.,  M.  D.  Chicago:  W.  T.  Keener,  1890.  Pp.  xii- 
431. 

A  Laboratory  Manual  of  Chemistry,  Medical  and  Pharmaceutical, 
containing  Experiments  and  Practical  Lessons  in  Inorganic  Synthetical 
Work  ;  Formulae  for  over  Three  Hundred  Preparations,  with  Explana¬ 
tory  Notes  ;  Examples  in  Quantitative  Determinations  and  the  Valua¬ 
tion  of  Drugs  ;  and  Short  Systematic  Courses  in  Qualitative  Analysis 


and  in  the  Examination  of  Urine.  By  Oscar  Oldberg,  Pharm.  D.,  etc., 
and  John  H.  Long,  Sc.  D.,  etc.  With  Original  Illustrations.  Second 
Edition,  revised  and  enlarged.  Chicago:  W.  T.  Keener,  1890.  Pp. 
3  to  46 7. 

The  Patients’  Record,  for  the  Use  of  Physicians  and  Nurses.  Com¬ 
piled  by  Agnes  S.  Brennan.  New  York:  G.  P.  Putnam’s  Sons,  1890. 
[Price,  $2.] 

Lectures  at  St.  Peter’s  (in  1890)  on  Some  Urinary  Disorders  con¬ 
nected  with  the  Bladder,  Prostate,  and  Urethra.  Bv  Reginald  Harri¬ 
son,  F.  R.  C.  S.,  etc.  London:  Bailliere,  Tindall,  &  Cox,  1890.  Pp. 
6  to  81. 

Differentiation  in  Rheumatic  Diseases  (so  called).  (Read  before  the 
Bristol  Medico-chirurgical  Association.  14th  of  May,  1890.)  By  Hugh 
Lane,  L.  R.  C.  P.,  etc.  [Reprinted  from  the  Lancet .] 

The  Time-relations  of  Mental  Phenomena.  By  Joseph  Jastrow, 
Professor  of  Psychology  at  the  University  of  Wisconsin.  New  York  : 
N.  D..C.  Hodges,  1890.  Pp.  60.  [Fact  and  Theory  Papers.] 

Chloroform  and  the  Hyderabad  Commission.  The  President’s  Ad¬ 
dress  delivered  at  the  Annual  Meeting  of  the  Southwestern  State  Medi¬ 
cal  Society  of  Ohio,  Cincinnati,  October  16,  1890.  By  J.  C.  Reeve, 
M.  D.,  Dayton.  [Reprinted  from  the  Medical  News.] 

Report  on  Surgery.  By  W.  L.  Rodman,  M.  D.,  Louisville.  [Re¬ 
printed  from  the  American  Practitioner  and  Weirs.] 

The  Sensation  of  Itching.  By  Edward  Bennet  Bronson,  M.  D.  [Re¬ 
printed  from  the  Medical  Record.] 

The  Rotary  Element  in  Lateral  Curvature  of  the  Spine.  By  A.  B. 
Judson,  M.  D.  [Reprinted  from  the  Medical  Record.] 

The  Relation  of  Bacteria  to  Practical  Surgery.  The  Address  in 
Surgery  delivered  before  the  Medical  Society  of  the  State  of  Pennsyl¬ 
vania,  June  4,  1890.  By  John  B.  Roberts,  A.  M.,  M.  D. 

Report  of  Three  Hundred  Cases  of  Intubation  of  the  Larynx.  By 
F.  E.  Waxham,  M.  D.  [Reprinted  from  the  North  American  Practi¬ 
tioner.] 

Treatment  of  Scarlet  Fever  and  its  Complications.  By  J.  Henry 
Fruitnight,  A.  M.,  M.  D.,  New  York.  [Reprinted  from  the  Archives  of 
Pcedia  tries.] 

Report  of  Two  Cases  of  Uterine  Fibroid  and  One  of  Stricture  of  the 
Rectum,  treated  by  Electrolysis  and  Surgically.  Also  Presentation  of 
Specimen  of  Dermoid  Cyst.  By  J.  B.  Greene,  M.  D.,  Mishawaka,  Ind. 
(Read  before  the  Chicago  Medical  Society.) 

A  Regional  Study  of  Tumors.  By  W.  L.  Rodman,  M.  D.,  Louisville. 
[Reprinted  from  the  American  Practitioner  and  News.] 

Rotura  espontanea  de  la  matriz  al  cuarto  mes  de  gestacion.  Por  el 
Doctor  Eduardo  F.  Pla.  [Publicado  en  la  Cronica  Medico-quirurgica 
de  la  Habana.] 

Seventeenth  Annual  Report  of  the  Maternity  Hospital,  Philadel¬ 
phia. 

Transactions  of  the  Medical  and  Chirurgical  Faculty  of  the  State  of 
Maryland.  Semi-annual  Session,  held  at  Hagerstown,  Md.,  November, 

1889.  Ninety-second  Annual  Session,  held  at  Baltimore,  Md.,  April, 

1890. 

Report  of  the  Board  of  Trustees  of  the  Eastern  Michigan  Asylum, 
at  Pontiac,  for  the  Biennial  Period  ending  June  30,  1890. 

Twenty-first  Annual  Report  of  the  State  Board  of  Health  of  Massa¬ 
chusetts. 

Lehrbuch  der  allgemeinen  und  speciellen  pathologischen  Anatomie 
fur  Aerzte  und  Studirende.  Von  Dr.  Ernst  Ziegler,  Professor  der  pa¬ 
thologischen  Anatomie  und  der  allgemeinen  Pathologie  an  der  Univer- 
sitat  Freiburg  in  Baden.  Zwei  Baude.  Sechste  neu  bearbeitete  Auf- 
lage.  Zweiter  Band.  Specielle  patjiologische  Anatomie.  Mit  435 
theils  schwarzen,  theils  farbigen  Abbildungen.  Jena :  Gustav  Fischer 
1890.  Pp.  xii-3  to  1024.  [Preis,  Mrk.  16.] 

Rumination  in  Man.  By  Max  Einhorn,  M.  D.,  New  York.  [Re¬ 
printed  from  the  Medical  Record.] 

A  New  Method  of  obtaining  Small  Quantities  of  Stomach  Contents 
for  Diagnostic  Purposes.  By  Max  Einhorn,  M.  D.,  New  York.  [Re¬ 
printed  from  the  Medical  Record.] 

One  Hundred  Consecutive  Cases  of  Labor  at  the  Maryland  Mater¬ 
nity.  With  a  Description  of  the  Methods  practiced  in  that  Institution. 
By  George  H.  Roh6,  M.  D.,  Director,  and  W.  J.  Todd,  M.  D.,  Resident 


672 


MISCELLANY. 


[N.  Y.  Mkd.  Jodb. 


Physician.  [Reprinted  from  the  Transactions  of  the  Medical  and  Chi- 
rurgical  Faculty  of  the  State  of  Maryland.\ 

The  Early  Operation  for  Hare-lip,  with  the  Report  of  a  Case,  Illus¬ 
trations,  etc.  By  Thomas  H.  Manley,  A.  M.,  M.  D.  [Reprinted  from 
the  Medical  Agel\ 

Amputation  of  Roots  as  a  Radical  Cure  in  Chronic  Alveolar  Ab¬ 
scess  ;  in  Pyorrhoea  Alveolaris  complicated  by  Alveolar  Abscess.  By 
M.  L.  Rhein,  M.  D.,  D.  D.  S.,  New  York.  [Reprinted  from  the  Proceed¬ 
ings  of  the  American  Dental  Association .] 

Two  Cases  of  Fractured  Skull.  Recovery  in  One ;  Death  from  Chlo¬ 
roform  in  the  Other.  By  Thomas  H.  Manley,  M.  D.,  New  York.  [Re¬ 
printed  from  the  Medical  Writ's.] 

Rupture  of  an  Ectopic  Sac  in  the  Sixth  Month  of  Pregnancy.  Ab¬ 
dominal  Section  and  Recovery.  By  Dr.  James  Moran  and  Dr.  T.  H. 
Manley,  New  York. 

The  Treatment  of  Contracted  Bladder  by  Hot-water  Dilatation.  By 
I.  S.  Stone,  M.  D.,  Washington,  D.  C.  [Reprinted  from  the  Transac¬ 
tions  of  the  Southern  Surgical  and  Gynaecological  Association .] 

The  Diagnosis  of  Pelvic  Disease,  or  when  to  operate.  By  I.  S. 
Stone,  M.  D.,  Washington,  D.  C.  [Reprinted  from  Practice .] 

Some  Considerations  in  regard  to  Acute  Obstructive  Diseases  of  the 
Lungs.  By  Andrew  H.  Smith,  A.  M.,  M.  D.,  New  York.  [Reprinted 
from  the  American  Journal  of  the  Medical  Sciences .] 

Fourth  Annual  Report  of  the  Training  School  for  Nurses  connected 
with  the  Post-graduate  Medical  School  and  Hospital,  May  31,  1890. 

Medical  Missionaries  in  Relation  to  the  Medical  Profession.  Read 
at  the  Meeting  of  the  China'  Medical  Missionary  Association,  held  at 
Shanghai,  May  19-22,  1890.  By  J.  G.  Kerr,  M.  D.,  Canton,  China. 


SBxsrell  ang. 


Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  December  5th  : 


CITIES. 

Week  ending — 

Estimated  popu¬ 
lation. 

Total  deaths  from 
all  causes. 

DEATHS 

FROM— 

|  Cholera. 

|  Yellow  fever.  | 

Small-pox. 

Varioloid. 

|  Varicella. 

Typhus  lever. 

Enteric  fever,  j 

Scarlet  fever. 

Diphtheria. 

<o 

B 

I 

1 

ti 

f-a 

2  3 
2  8 
£ 

New  York,  N.  Y . 

Nov.  29. 

1,651,798 

654 

Chicago,  Ill . 

Nov.  29. 

1,100,000 

323 

16 

4  23 

i 

6 

Philadelphia,  Pa . 

Nov.  22. 

1,064,277 

359 

4 

9  14 

Brooklyn,  N.  Y . 

Nov.  29. 

853,945 

3533 

.. 

5 

10 

16 

1^ 

5 

St.  Louis,  Mo . 

Nov.  29. 

460,000 

3 

o 

2 

Boston,  Mass . 

Nov.  29. 

446,507 

i59 

5 

2 

Cincinnati,  Ohio . 

Nov.  28. 

325,000 

128 

3 

16 

Cleveland,  Ohio . 

Nov.  15. 

257,774 

70 

1 

6 

Cleveland,  Ohio . 

Nov.  22. 

257,774 

67 

4 

i 

7 

Detroit,  Mich . 

Nov.  15. 

250,000 

57 

i 

5 

Detroit,  Mich . 

Nov.  22. 

250,000 

66 

13 

Pittsburgh,  Pa . 

Nov.  22. 

240,000 

80 

8 

13 

Milwaukee,  Wis . 

Nov.  29. 

220,000 

60 

2 

11 

Newark,  N.  J . 

Nov.  29. 

184,760 

69 

1 

4 

Minneapolis,  Minn... 

Nov.  29. 

1(54,738 

39 

3 

5 

Providence,  R.  I . 

Nov.  29. 

182,043 

37 

2 

Richmond,  Va . 

Nov.  22. 

100,000 

30 

_ O 

4 

Toledo,  Ohio . 

Nov.  28. 

82,652 

20 

1 

4 

Nashville,  Tenn . 

Nov.  29. 

76,309 

35 

o 

Fall  River,  Mass . 

Nov.  29. 

75,000 

24 

2 

i 

Charleston,  S.  C . 

Nov.  22. 

60,145 

34 

1 

Charleston,  S.  C . 

Nov.  29. 

60,145 

45 

1 

1 

l 

Portland,  Me . 

Nov.  29. 

42.000 

9 

Rochester,  N.  Y . 

Nov.  28. 

38.327 

31 

i 

2 

.  1  . 

Binghamton,  N.  Y . . . 

Nov.  29. 

35,000 

13 

1 

Yonkers,  N.  Y . 

Nov.  21. 

32,000 

11 

.  .  .  . 

1 

l  .... 

Yonkers,  N.  Y . 

Nov.  28. 

32,000 

16 

Newport,  R.  I . 

Nov.  6. 

20,000 

4 

Newport,  R.  I . 

Nov.  13. 

20,6(0 

5 

.... 

Newport,  R.  I . 

Nov.  20. 

20,000 

10 

San  Diego,  Cal . 

Nov.  15. 

16,(00 

4 

San  Diego,  Cal . 

Nov.  22. 

16,000 

3 

Pensacola,  Fla . 

Nov.  22. 

15,000 

4 

. .  . . 

Observation  of  Koch’s  Treatment  of  Tuberculosis. — In  accordance 
with  a  resolution  of  the  Dauphin  County  (Pa.)  Medical  Society,  Dr.  E. 


H.  Coover,  Dr.  Hugh  Hamilton,  and  Dr.  Thomas  J.  Dunott  have  been 
appointed  a  committee  to  visit  Philadelphia,  at  the  proper  time,  and 
inspect  the  method  of  employing  Koch’s  remedy  for  tuberculosis  as 
used  in  the  hospitals  there. 

Syphilitic  Infection  from  a  Bite. — “  A  patient  was  recently  shown 
to  the  Berlin  Medical  Society  who  was  said  to  have  contracted  syphilis 
from  the  bite  of  a  man.  The  bite  was  inflicted  on  the  lip,  and  the 
wound  healed  in  two  or  three  days,  but  in  six  weeks  it  reopened  and 
the  lip  became  greatly  swollen.  Five  weeks  later  there  was  an  ulcer 
on  the  inner  surface  of  the  lip  with  great  swelling  and  induration  round 
about ;  the  submaxillarv  and  cervical  glands  were  also  much  enlarged. 
After  some  time  a  typical  syphilitic  eruption  made  its  appearance.  By 
the  use  of  mercurial  frictions  the  swelling  both  of  the  lips  and  of  the 
glands  was  considerably  reduced.” — British  Medical  Journal. 


ANSWERS  TO  CORRESPONDENTS. 

No.  337. — Approval  of  the  diploma  by  the  Board  of  Regents  of  the 
University  of  the  State  of  New  York,  and  subsequent  registration  of 
it  at  the  County  Clerk’s  office. 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 
favoring  us  wijh  communications  is  respectfully  called  to  the  follow - 
ing: 

Authors  of  articles  intended  for  publication  under  the  head  of  “ original 
contributions  "  are  respectfidly  informed  that,  in  accepting  such  arti¬ 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (2)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (3)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  pul 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  arid  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter ,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dales  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters, that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  December  20,  1890. 

(Original  Communications. 


COMPLETE  AND  PERMANENT  RECOVERY  BY 
JEJUNO-ILEOSTOMY  WITH  SENN’S  BONE  PLATES 

IN  INTESTINAL  OBSTRUCTION  DUE  TO 
INTUSSUSCEPTION  AND  SLOUGHING  OF  THE  INTUSSUSCEPTUM. 

By  THOMAS  H.  RUSSELL,  M.  D., 

PROFESSOR  OF  MATERIA  MEDICA  AUD  THERAPEUTICS,  YALE  UNIVERSITY, 
AND  SURGEON  TO  THE  CONNECTICUT  STATE  HOSPITAL. 

On  August  16,  1889,  I  was  summoned  to  visit  a  boy, 
fifteen  years  of  age,  living  on  a  farm  in  Montville,  Conn.  I 
round  that  he  was  suffering  from  very  severe  chronic  ob¬ 
struction  (stenosis)  of  the  small  intestine. 

The  history  of  the  case  was  as  follows  : 

Until  October  2,  1888,  he  had  been  strong  and  in  perfec;; 
lealth,  but  on  that  day,  while  wrestling,  was  attacked  by  an 
■xtremely  acute  pain  in  his  abdomen,  quickly  followed  by  severe 
vomiting  and  obstinate  constipation,  which  persisted  for  five 
lays.  On  the  fifth  or  sixth  day  his  bowels  were  moved,  and  the 
-omiting  became  less  severe.  During  the  next  few  weeks  the 
mesis  was  less  frequent,  the  pain  became  intermittent,  although 
evere,  and  the  coustipation  gradually  changed  to  diarrhoea. 

On  November  1st  (or  soon  after)  a  soft,  fiesby  mass  was  no- 
iced  in  one  of  his  stools. 

During  the  ten  months  preceding  my  visit  and  operation  he 
ad  been  under  the  care  of  Dr.  Smith  and  Dr.  Bishop,  of  Nor- 
nch,  Dr.  Matthewson,  of  Montville,  and  others. 

During  these  ten  months  he  was  confined  to  bed  much  of 
he  time,  and  there  were  occasional  attacks  of  vomiting  and 
•om  three  to  seven  light-colored  liquid  stools  daily,  but  free 
•om  blood.  The  abdomen  was  much  distended  and  tympa- 
itic;  his  appetite  was  poor  and  his  tongue  coated. 

He  became  much  emaciated  and  bad  night  sweats,  but  no 
evation  of  temperature.  During  these  ten  months  he  suffered 
om  severe  attacks  of  abdominal  paiu,  recurring  about  everv 
venty  to  forty  minutes  night  and  day,  and  lasting  from  three 
)  five  minutes.  Each  of  these  attacks  of  pain  was  preceded 
r  accompanied  by  such  violent  intestinal  peristalsis  that  the 
mtour  of  the  intestine  formed  very  prominent  visible  ridges 
i  the  abdominal  wall. 

In  each  attack  the  severe  pain  commenced  after  the  violent 
?ristalsis  had  lasted  one  or  two  minutes,  and  disappeared  sud- 
mly  when,  three  to  five  minutes  later,  there  was  a  loud  sound 
i  of  gas  and  liquid  being  forced  through  a  small  orifice.  Im- 
ediately  afterward  the  pain  and  peristalsis  would  cease,  and 
e  patient  become  comfortable. 

The  pain  was  sometimes  above  the  umbilicus  and  at  other 
nes  below  or  to  the  right  or  left,  and  not  confined  to  any 
ie  point.  All  his  symptoms  were  gradually  becoming  more 
vere.  During  my  visit  on  August  16,  1889,  I  was  able  to  ob- 
rve  a  number  of  these  attacks,  and  it  appeared  probable  (as 
e  laparotomy  next  day  proved  true)  that  they  were  due  to 
arly  complete  obstruction  in  the  small  intestine.  The  regu- 
•ly  recurring,  violent,  and  painful  peristalsis  was  the  effort  of 
e  intestine  to  force  its  contents  through  a  very  small  aperture, 
parotomy  being  indicated,  I  operated  on  the  following  day 
-ugust  17,  1889),  assisted  by  Dr.  Smith,  of  Norwich,  Dr.  Mat- 
ewson,  of  Montville,  and  Dr.  R.  S.  Bradley,  of  New  Haven. 

The  incision  extended  from  the  umbilicus  to  the  pubes.  I 
und  it  impossible  to  locate  the  obstruction  without  removing 
e  small  intestines  from  the  abdomen,  and,  while  doing  so, 
otected  them  with  napkins  wrung  out  of  hot  Thiersch’s  solu¬ 


tion.  The  obstruction  was  found  at  a  point  near  the  junction 
of  the  upper  and  middle  thirds  of  the  small  intestine. 

As  shown  in  the  accompanying  illustration,  the  small  intes¬ 
tine,  5  to  c,  was  so  extremely  contracted  at  a  that  its  diameter 
was  only  about  a  quarter  of  an  inch,  and  at  that  point  it  was 
firmly  bound  down  by  a  strong  old  band  of  adhesion,  a,  to  the 
wmll  of  an  adjacent  loop  of  intestine,  d. 


All  of  the  portion  of  intestine  i  above  the  obstruction  a 
was  distended  to  about  three  times  its  normal  caliber  and  filled 
with  gas  and  liquid  faeces.  All  of  the  portion  of  intestine  c 
below  the  obstruction  was  empty,  contracted,  and  flaccid. 

The  obstruction  was  evidently  an  old  one,  and  it  was  plainly 
impossible  to  restore  the  caliber  of  the  bowel  at  that  point. 
The  best  plan  was  evidently  to  establish  an  intestinal  anasto¬ 
mosis,  as  suggested  by  Professor  Senn.  After  locating  the 
obstruction,  it  was  found  impossible  to  return  the  rest  of  the 
intestine  into  the  abdomen,  owing  to  its  distention  above  the 
obstruction. 

I  therefore  made  a  linear  incision,  an  inch  and  a  half  long, 
at  1c  above  the  obstruction,  and  emptied  all  of  the  contents 
of  the  bowel,  consisting  of  about  a  quart  of  yellow  liquid  fasces 
and  a  large  amount  of  gas,  into  a  pan.  The  intestine  was  then 
easily  replaced  within  the  abdomen.  A  Senn’s  perforated  de- 
calcified-bone  plate  was  then  introduced  through  the  incision 
in  the  bowel  at  £,  and  another  bone  plate  was  introduced 
below  the  obstruction  through  an  incision  at  p.  The  bone 
plates  were  approximated  after  scarifying  the  serous  surfaces, 
and  about  twelve  Lembert  sutures  were  introduced  around  the 
ciicumference  of  the  plates.  Ihe  intestine  was  then  cleansed 
and  the  abdonjen  flushed  with  hot  Thiersch’s  solution,  and  the 
abdomen  closed. 

His  recovery  was  rapid,  perfect,  and  permanent.  Although 
his  temperature  was  taken  every  two  to  four  hours  for  eight 
days,  it  only  once  went  above  normal,  and  then  only  tran¬ 
siently  touched  100-2°  on  the  second  day.  I  did  not  visit  him 
after  the  sixth  day,  the  nurse  was  discharged  on  the  eighth, 
'h®  patient  sat  up  about  the  tenth,  and  was  down  stairs 
about  the  sixteenth  or  eighteenth  day.  Dr.  Smith  made  a 
’ew  visits  afterward.  The  patient  had  a  large  normal  stool 
five  days  after  the  operation,  and  his  bowels  moved  regularly 
afterward.  All  stools  were  examined  for  traces  of  the  bone 
flates.  Nine  days  after  the  operation  the  remains  of  a  bone 
date  (probably  the  distal  one)  were  found  in  one  of  the  stools. 
It  was  of  only  about  a  quarter  of  the  thickness,  half  of  the 
width,  and  two  thirds  of  the  length  of  the  original  plate,  and 
was  so  soft  as  to  require  careful  handling.  A  few  days  later, 
larely  perceptible  remnants  of  the  other  plate  were  evacuated, 
and  none  subsequently.  From  that  time  he  quickly  and  steadi- 
y  improved  in  health  in  every  respect,  and  resumed  his  work 


RICHMOND:  INTESTINAL  ANASTOMOSIS  FOR  FAECAL  FISTULA.  [N.  Y.  Med.  Jock 


674 

on  the  farm.  It  is  now  fifteen  months  since  the  operation,  and 
he  is  in  every  way  enjoying  good  health. 

The  boy  is  strong  and  able  to  do  ordinary  work.  There  is 
every  indication  that  his  recovery  is  absolutely  complete  and 
permanent.  I  believe  that  this  is  the  most  successful  case  of 
the  kind  thus  far  on  record.  It  seems  evident  that  the  com¬ 
mencement  of  his  disease  on  October  2,  1888,  was  an  intussus¬ 
ception  (at  point  A  in  the  diagram),  that  the  soft,  fleshy  mass 
passed  in  oue  of  his  stools  about  a  month  later  was  the  intus- 
susceptum,  which  had  sloughed  out,  and  that  the  subsequent 
stenosis  and  adhesions  were  results  of  that  process. 

My  experience  in  this  case  and  in  another,  in  which  I 
performed  gastro-enterostomy  with  decalcified-bone  plates 
for  cancerous  stenosis  of  the  pylorus,  convinces  me  that  the 
hone  plates  are  much  to  be  preferred  to  the  various  catgut 
substitutes  (rings  and  mats)  and  all  other  substitutes  which 
have  been  suggested.  They  are  admirably  adapted  for  the 
purpose  and  need  no  improvement. 


REPORT  OF 

A  CASE  OF  INTESTINAL  ANASTOMOSIS 
FOR  FaECAL  FISTULA, 

WITH  REMARKS* 

By  CHARLES  H.  RICHMOND,  M.  D., 

LIVONIA,  N.  Y. 

On  the  1st  of  January,  1890,  I  was  called  to  see  W.  W.  R., 
of  Honeoye,  N.  Y.,  in  consultation  with  Dr.  Green  and  Dr. 
Wilbur.  The  patient  was  forty-six  or  forty-seven  years  old,  of 
slight  build,  considerably  emaciated,  showed  spells  of  elevated 
temperature,  and  had  enlargement  of  some  of  the  glands  of  the 
right  groin,  with  tenderness  of  the  adjacent  muscles.  Rectal 
■examination  elicited  no  pelvic  bunches.  The  patient  had  re¬ 
cently  recovered  from  an  attack  of  peritonitis  and  was  still  in 
bed  part  of  the  time.  Some  ten  or  twelve  years  ago  he  had 
peritonitis,  followed  by  venous  thrombosis  of  the  right  limb,  or 
phlegmasia  alba  dolens.  He  has  had  more  or  less  trouble  with 
the  limb  since. 

About  the  1st  of  June  last,  six  months  after  my  visit,  Mr. 
R.  called  at  my  office  in  Livonia  on  his  way  to  Rochester  to 
consult  an  eminent  practitioner.  He  was  markedly  thin  and 
anaamic,  complained  of  lameness  and  distress  in  the  right  iliac 
region,  increased  by  pressure  on  the  back,  and  had  a  tempera¬ 
ture  of  100°.  The  diagnosis  seemed  to  rest  between  disease  of 
the  appendix  and  psoas  abscess,  with  the  probabilities,  in  view 
of  the  history  of  the  case,  of  the  former.  At  that  time  I  ad¬ 
vised  an  exploratory  incision  with  the  object  of  removal  of  the 
appendix  if  found  diseased,  or  the  evacuation  of  an  abscess  if 
already  existing;  but,  there  being  no  concurrence  of  opinion, 
simple  measures  only  were  resorted  to. 

During  the  latter  part  of  July  an  increase  in  the  tenderness 
of  the  parts  about  the  groin  and  hip  joint,  with  elevation  of 
temperature,  took  place,  and  on  the  8th  of  August,  in  the  pres¬ 
ence  of  Dr.  Wilbur  and  Dr.  Green,  I  opened  an  abscess  which 
had  become  manifest  on  the  right  thigh,  a  little  below  the  hip 
joint  and  on  the  outer  aspect  of  the  limb.  It  contained  pus, 
gas,  and  ftecal  matter,  the  odor  of  which  was  the  very  prince 
of  stinks.  The  nature  of  the  trouble  was  now  positively  known, 
but,  the  patient’s  condition  being  bad,  it  was  thought  best  to 
delay  further  operative  procedure  until  he  might  recuperate 

*  Read  at  the  meeting  of  the  Ontario  County  Medical  Society,  held 
at  Canandaigua,  October  14,  1890. 


and  at  the  same  time  be  allowed  time  for  the  possibility  o 
spontaneous  closure  of  the  fistula. 

• 

A  faecal  fistula  occurring  at  the  head  of  the  colon  i 
much  more  disagreeable  and  debilitating  than  an  artifich 
anus  at  the  sigmoid  flexure,  for  the  contents  of  the  gut  ar 
thinner,  causing  a  more  constant  discharge  with  consequen 
local  irritation,  and  the  tract  of  the  fistula,  with  its  pus 
secreting  walls,  is  a  source  of  debility  and  septicaemia. 

I  saw  the  patient  two  or  three  times  within  the  follow 
ing  three  weeks,  during  which  time  ftecal  matter  continued 
to  pour  out  of  the  orifice  of  the  abscess  in  abundance,  ;i 
smaller  portion  passing  per  rectum ,  the  patient’s  conditioi 
meanwhile  growing  no  better,  except  in  a  fall  of  tempera 
tine  to  nearly  the  normal  point  since  the  opening  of  the  abj 
scess.  I  then  began  to  think  seriously  of  an  abdomina 
operation.  After  giving  the  matter  some  thought  and  lay 
ing  the  case  before  some  medical  men,  among  whom  wa 
Dr.  G.  II.  Bosley,  of  New  York,  I  communicated  with  Dr 
Wilbur,  suggesting  the  propriety  of  some  procedure.  Ii 
the  mean  time  Dr.  Frank  Becker,  of  New  York,  had  seeii 
the  patient  and  advised  an  operation,  but  I  do  not  knov 
upon  what  plan.  The  family,  after  a  time,  felt  that  the  onh 
hope  for  life  was  in  having  the  fistula  closed,  and  the  pa 
tient  preferred  death  to  an  open  fistula,  which,  notwith 
standing  frequent  cleansings,  was  exceedingly  offensive 
Dr.  Wilbur  and  Dr.  Green  concurring,  arrangements  for  ai 
operation  were  finally  made. 

Operations  for  the  closui’e  of  faecal  fistulse  have  not,  ai 
a  rule,  succeeded  well.  Laying  aside  the  difficulties  ir 
working  through  adhesions,  a  closure  of  the  gut  is  seldoir 
effective,  while  the  opening  of  the  tract  of  the  fistula  oi 
into  the  abscess  necessarily  exposes  the  abdominal  cavity 
to  the  dangers  of  sepsis.  I  therefore  determined  not  to  at 
tempt  to  find  the  point  of  origin  of  the  fistula,  but  to  divide 
the  gut  on  each  side,  close  the  respective  ends,  and  unite 
the  portions  of  intestine  freed  from  the  adherent  mass,  leav 
ing  the  latter,  together  with  the  tract  of  the  fistula  or  ah 
scess  cavity,  undisturbed. 

On  the  11th  of  September,  five  weeks  after  the  abscess  was 
opened,  ably  assisted  by  Dr.  Wilbur  and  Dr.  Green  of  Honeoye 
Dr.  Goodrich  of  Avon,  Dr.  Guinan  of  Lima,  and  Dr.  Starr  ant 
Dr.  Foster  of  Rochester,  I  opened  the  abdominal  cavity  at  th< 
outer  border  of  the  right  rectus  muscle,  being  careful  not  tej 
carry  the  incision  much  below  a  point  intersecting  a  line  drawij 
from  the  umbilicus  to  the  anterior  superior  spinous  process  o 
the  ilium,  lest  the  abscess  might  be  inadvertently  opened  ;  but 
as  no  adhesions  were  found  between  the  colon  and  the  anterior 
abdominal  walls,  the  opening  was  extended  downward  to  witbir 
an  inch  and  a  half  of  Poupart’s  ligament,  about  five  inches  ii 
extent,  in  order  to  allow  plenty  of  room  for  work.  The  ca3cun 
and  lower  end  of  the  ileum  were  adherent  by  their  inferior  an( 
posterior  aspect  to  the  iliac  fascia,  the  upper  surface  being  free 
A  foot  or  more  was  thus  adherent.  The  appendix  was  not  fount 
and  was  presumably  the  seat  of  the  trouble,  having  been  los 
or  inclosed  within  the  abscess.  The  extent  of  the  abscess  ana 
exact  point  of  the  fistulous  opening  in  the  intestine  could  nol 
be  determined  by  sight  or  palpation,  necessitating  the  elimina¬ 
tion  of  almost  the  entire  adherent  portion — about  a  foot — in 
eluding  the  ileo-csecal  valve.  The  ends  of  the  divided  ascend 
ing  colon  were  closed  with  Lembert’s  suture  of  fine  silk,  tlu 
peritoneal  surfaces  being  in  apposition,  and  the  ileum,  divided 


Dec.  20,  1890.]  ASCII:  DEVIATION  OF  THE  NASAL  SEPTUM.  •  675 


some  two  or  three  inches  above  the  valve,  was  treated  in  the 
same  way.  Flat  sponges  were  placed  beneath  the  gut  while  it 
was  being  operated  upon,  the  contents  of  the  intestine  having 
been  previously  pressed  away  and  held  back  by  coarse  ligatures 
tied  in  a  single  knot  for  the  purpose  of  being  afterward  re¬ 
moved.  While  suturing  the  ileum  it  was  found  that  one  of  the 
ends  of  the  divided  colon  leaked,  whereupon  the  end  was  re¬ 
sutured  and  the  abdominal  cavity  cleansed.  The  ileum  and  colon 
were  then  joined  by  their  lateral  surfaces  by  means  of  Abbe’s 
catgut  rings,  which  I  had  prepared  according  to  his  directions, 
the  suturing  being  done  with  fine  silk.  There  was  no  leakage 
at  any  point,  and  the  apposition  of  the  margins  of  the  openings 
seemed  perfect.  The  parts  were  cleansed,  the  abdominal  cavity 
was  rinsed,  the  intestines  were  replaced  (they  had  been  kept 
warm  by  means  of  sponges  wet  with  a  warm  saline  solution), 
and  the  walls  were  closed  and  dressed  in  the  usual  way,  the 
entire  operation  lasting  about  an  hour  and  forty-five  minutes. 

Every  antiseptic  precaution  was  observed  throughout, 
yet  it  seems  difficult  in  such  procedures  to  prevent  infec¬ 
tion  of  the  peritonaeum  to  some  extent,  for,  in  making  the 
openings,  the  fingers  may  become  contaminated,  and  the 
process  of  suturing  endangers  the  infection  of  the  silk.  The 
fingers  may  be  cleansed,  but  a  thorough  sponging  of  the 
sutures  with  an  antiseptic  solution  may  fail  to  neutralize  all 
the  germs  within  or  beneath  the  fibers  if  they  have  perad- 
venture  penetrated  the  mucous  lining  of  the  intestine.  The 
system  undoubtedly,  in  ordinary  circumstances,  is  capable 
of  resisting  a  certain  degree  of  virulency,  but  in  certain  low 
states  this  power  is  measurably  lost,  so  that  death  may  re¬ 
sult  from  combined  shock  and  septic  inflammation,  pro¬ 
vided  there  is  even  slight  contamination.  Dr.  Wilbur  in¬ 
forms  me  that  this  patient  died  of  peritonitis  and  shock 
forty  hours  after  the  completion  of  the  operation.  There 
was  no  autopsy. 

The  surface  temperature  never  came  up  to  normal. 
About  twenty-four  hours  after  the  completion  of  the  op¬ 
eration  the  rectal  temperature  had  risen  to  101°,  and  twelve 
hours  later  to  104°.  The  pulse,  when  the  patient  was  put 
to  bed,  was  130  a  minute,  and  became  somewhat  less  frequent 
luring  the  fifteen  hours  I  remained  with  him.  Vomiting  was 
occasional  after  the  operation,  and  more  or  less  pain  was 
experienced.  Tympanites  was  not  marked.  Patients  fre¬ 
quently  recover  after  as  much  evidence  of  local  trouble  as 
this  patient  showed,  and  there  may  justly  arise  a  question 
as  to  the  existence  of  actual  septic  peritonitis. 

I  have  been  uncertain  as  to  the  source  of  the  sepsis,  if, 
indeed,  it  was  an  important  factor.  It  was  possibly  due  to 
insufficient  cleansing  of  the  abdominal  cavity  after  the  leak¬ 
age  in  the  colon  took  place,  although  at  the  time  it  seemed 
sufficient.  The  inside  of  the  ends  of  the  cut  intestines  was 
sponged  out  with  a  1-to  2,000  bichloride  solution,  and  after 
the  union  was  completed  the  stitched  parts  were  well 
cleansed.  There  was  more  exposure  of  the  intestines  than 
was  desirable,  made  unavoidable  on  account  of  flatus. 

Here  let  me  say,  from  a  considerable  experience  in  ab¬ 
dominal  work  of  one  sort  and  another,  that  I  am  convinced 
that  an  operation  for  forming  an  anastomosis,  or  in  peritonitis, 
or  in  appendicitis,  is  more  difficult  than  an  uncomplicated 
ovariotomy,  for  the  reason  that  the  intestines  are  always  bulg¬ 
ing  up  in  the  way,  and  that,  with  the  tense  abdominal  walls, 


makes  it  more  difficult  to  get  a  nice  adaptation  of  perito¬ 
neal  edges  when  the  wound  is  closed.  Notwithstanding  the 
instructions  to  keep  the  intestines,  except  the  part  operated 
upon,  within  the  abdominal  walls,  it  will  be  found  in  most 
cases  impossible  to  do  so,  and  there  is  consequently  an  in¬ 
creased  risk  from  exposure  and  manipulation. 

Pus  only  came  from  the  fistula  after  the  operation,  and 
at  death  a  rectal  discharge  of  faeces  was  found  to  have  taken 
place. 

The  principle  originated  by  Senn  in  the  lateral  anasto¬ 
mosis  was  followed.  Its  advantages  over  end-to-end  union 
are  obvious,  not  only  in  affording  greater  security  against 
leakage,  but  also  in  being  stronger  and  more  rapidly  accom¬ 
plished.  Intestinal  anastomosis  has  been  successfully  per¬ 
formed  several  times  in  malignant  disease,  affording  the 
patient  an  increased  length  of  rope,  and  has  been  success¬ 
fully  performed  by  Abbe  for  faecal  fistula  ;  but  iu  no  in¬ 
stance,  so  far  as  I  have  seen,  has  the  procedure  followed  by 
myself  been  adopted  or  suggested.  Although  this  case  ter¬ 
minated  fatally,  owing  in  great  part  to  the  desperate  condi¬ 
tion  of  the  patient,  who  was  unable  to  resist  the  influence 
of  some  unknown  sepsis,  the  principle  of  leaving  the  fistula 
itself  untouched  and  uniting  the  intestine  independently 
seems  entirely  feasible — indeed,  the  only  course  to  follow  in 
similar  cases. 

In  cases  in  which  the  patient’s  condition  is  not  too  low 
there  is  every  reason  for  hope  of  success;  but  there  is  scarce¬ 
ly  a  procedure  which  requires  greater  care  and  watchfulness 
on  the  part  of  the  operator  throughout  than  one  for  intesti¬ 
nal  anastomosis.  The  surgeon  can  not  always  select  his 
cases.  He  sometimes  must  take  a  great  risk  of  failure  for 
the  sake  of  giving  his  patient  the  only  remaining  chance. 
Moreover,  persons  will  seldom  submit  to  an  operation  so 
long  as  there  is  any  other  chance  for  life. 

On  account  of  these  things  this  operation  may  never  pre¬ 
sent  as  favorable  statistics  as  some  other  abdominal  opera¬ 
tions,  but  it  is  none  the  less  legitimate. 

(The  method  of  using  the  rings  and  plates  in  forming 
the  intestinal  union  was  then  demonstrated.) 


A  NEW  OPERATION  FOR 

DEVIATION  OF  THE  NASAL  SEPTUM, 

WITH  A  REPORT  OF  CASES* 

By  MOPvRIS  J.  ASCH,  M.  D. 

The  distress  occasioned  by  a  permanently  occluded  nos¬ 
tril  in  the  shape  of  mouth-breathing  and  the  various  com¬ 
plications  that  accompany  this  condition  is  brought  so  of¬ 
ten  to  the  notice  of  the  nasal  surgeon  that  any  operation 
that  will  easily  remedy  the  difficulty  is  worthy  of  notice. 
The  pathology  and  symptoms  of  a  deviated  septum  have 
been  so  often  described  that  I  will  not  occupy  your  time 
with  them,  but  content  myself  with  calling  attention  to  the 
operative  procedure  by  which  I  remedy  the  defect.  It  is 
particularly  adapted  to  those  cases  in  which  there  is  a  de- 

*  Read  before  the  American  Laryngological  Association  at  its 
twelfth  annual  congress. 


676 


ASCH:  DEVIATION  OF  THE  NASAL  SEPTUM. 


[N.  Y.  Med.  Jock. 


flection  with  increased  length  of  the  septum,  and  where 
there  is  adhesion  to  the  inferior  turbinated  body ;  its  great 
advantage  being  in  its  simplicity  and  in  its  easy  and  rapid 
performance — that  it  involves  no  loss  of  substance  and  en¬ 
tails  but  little  annoyance  to  the  patient  after  the  operation. 
I  have  found  the  operation  to  be  perfectly  satisfactory, 
permanently  relieving  the  obstruction  in  all  cases;  only 
those  in  which  there  existed  deflection  of  the  bony  septum 
discovered  after  the  correction  of  the  cartilaginous  deform¬ 
ity  required  any  further  treatment.  In  one  case  only  was 
there  any  haemorrhage  of  a  severe  character,  which  was 
easily  checked  ;  and  in  one  case — not  among  those  here  re¬ 
ported — there  remained  for  two  or  three  years  a  small  per¬ 
foration  which  has  since  healed. 

In  all  of  these  cases  the  deviation  of  the  septum  was 
toward  the  left,  a  fact  in  accord  with  the  observation  of 
most  writers. 

The  instruments  I  employ  in  this  operation  are — 

1.  A  pair  of  strong  cartilage  scissors,  one  blade  thick 
and  blunt  for  introduction  into  the  obstructed  nostril;  the 
other,  the  cutting  blade,  of  a  curved  wedge-shape,  the 
shanks  curved  outward  so  as  to  admit  of  closing  without 
interfering  with  the  columna.  The  handles  are  of  steel  and 
curved,  like  those  of  a  dental  forceps  (Fig.  1). 

2.  A  curved  gouge  for  breaking  up  any 
adhesions  that  may  exist  between  the  septum 
and  turbinated  body  (Fig.  2). 


Fig.  1. 

3.  An  Adams  forceps,  or  one  with  stout  parallel  blades. 

4.  A  triangular  splint  of  tin,  cut  to  adapt  itself  to  the 
cartilage  of  the  section.  Formerly  I  used  a  splint  of  a  more' 
elaborate  character,  such  as  I  show  you  here  (Fig.  3)  ;  but 
it  had  the  objection  of  being  always  in  sight  and  I  gave  up 
its  use,  although  in  other  respects  it  proved  perfectly  satis¬ 
factory.  If  the  patient  has  a  good  deal  of  nerve,  the  opera¬ 


Fig.  2. 


tion  may  be  performed  with  the  aid  of  cocaine ;  but,  as  i 
rule,  it  is  best  to  use  ether.  Before  the  operation  the  nos 
trils  are  to  be  well  washed  out  with 
a  disinfecting  solution,  such  as  lis- 
terine  or,  what  I  have  been  accus¬ 
tomed  to  use,  Dobell's  solution  with 
the  addition  of  thymol  and  eucalyp- 
tol.  The  patient  then  having  been 
etherized,  the  adhesions  between 
the  septum  and  turbinated  body, 
when  such  exist,  are  broken  up  by 
the  use  of  the  curved  gouge.  The 
blunt  blade  of  the  scissors  is  in¬ 
serted  into  the  obstructed  nostril, 
and  the  cutting  blade  into  the  other;  a  crucial  incision  is 
then  made  as  near  as  possible  at  right  angles  at  the  point  ot 
greatest  convexity.  The  forefinger  is  then  inserted  into  the 
obstructed  nostril  ;  the  segments  made  by  the  incision  are 
pushed  into  the  opposite  one,  and  the  pressure  continued) 
until  they  are  broken  at  their  base  and  the  resiliency  of  the 
septum  destroyed.  On  this  point  depends  the  success  of 
the  operation,  for,  unless  the  fracture  of  these  segments  is 
assured,  the  resiliency  of  the  cartilage  will  not  be  overcome 
and  the  operation  will  fail.  The  septum  is  then  to  be 
straightened  with  the  Adams  or  other  strong  forceps,  and 
the  haemorrhage  checked  before  proceeding  further,  which 
is  usually  accomplished  by  a  spray  of  ice-water,  though 
sometimes  tamponing  may  be  required.  The  nostril  having 
been  cleaned,  the  straightened  septum  is  then  held  in  posi¬ 
tion  by  the  tin  splint  previously  wrapped  with  absorbent 
cotton  moistened  in  a  solution  of  bichloride  of  mercury  of 
1  to  5,000,  and  the  nostril  packed  with  gauze  or  absorbent 
cotton  moistened  with  the  same.  The  tamponing  must  be 
thoroughly  done  or  haemorrhage  will  certainly  recur.  I 
usually  introduce  a  pledget  of  gauze  or  cotton,  to  which  a 
ligature  is  attached,  as  far  into  the  nostril  as  is  possible, 
leaving  the  string  hanging  out,  and  pack  the  moistened 
pledgets  firmly  upon  this.  The  splint  and  tampon  is  al¬ 
lowed  to  remain  undisturbed  for  four  days,  when  they  are 
removed  and  the  parts  cleansed  with  a  disinfecting  solu¬ 
tion  ;  the  splint  and  tampon  are  then  reapplied,  the  parts 
being  straightened,  if  necessary,  with  the  forceps.  This  is 
repeated  two  or  three  times  a  week  for  three  weeks,  by 
which  time  the  parts  have  become  permanently  fixed  in 
their  improved  position  ;  but  it  may  require  at  least  two 
weeks  more  before  the  parts  are  healed  and  the  patient 
breathes  through  an  unobstructed  nostril.  It  sometimes 
happens  that  posteriorly  to  the  cartilaginous  deviation  a 
bony  one  exists.  This  can  then  be  easily  remedied  by  the 
electro-trephine  or  saw.  The  cases  which  I  report  here 
were  all,  with  one  exception,  operated  on  at  the  New  York 
Eye  and  Ear  Infirmary,  and  the  after-treatment  was  carried 
out  by  Assistant  Surgeon  Dr.  Emil  Mayer,  to  whom  I  am  in¬ 
debted  for  their  report.  I  have  delayed  presenting  the  re¬ 
port  of  this  operation  to  you  until  I  had  assured  myself  that 
its  results  would  prove  satisfactory  and  permanent;  but 
now  that  the  operation  has  stood  the  test  of  time,  I  feel 
that  I  am  justified  in  doing  so.  The  operation  is  simple 
and  easy,  requires  but  a  few  minutes  for  its  performance, 


Fig.  3. 


Dec.  20,  1890.J 


LOEBINGER:  A  NEW  LOCAL  THERAPY  OF  TUBERCULOSIS. 


677 


involves  no  loss  of  substance,  and  the  operator  is  not  em¬ 
barrassed  in  his  work  by  the  bleeding — a  practical  point 
which  I  am  sure  all  who  are  familiar  with  nasal  surgery  will 
appreciate.  Of  the  cases  reported,  the  incisions  in  the  first 
two  were  made  by  the  bistoury  instead  of  the  cartilage  scis¬ 
sors,  but  the  principle  of  the  crucial  incisions  with  fracture 
and  tampon  was  the  same. 

Case  I. — A.  W.,  female,  aged  eleven,  patient  of  Dr.  Mayer’s, 
was  brought  to  New  York  for  treatment  for  nasal  stenosis,  said 
to  be  due  to  a  fall  in  infancy.  The  cartilaginous  septum  is  de¬ 
viated  to  the  left  near  the  orifice  of  the  nostril,  which  is  com¬ 
pletely  obstructed,  no  air  passing.  She  is  a  mouth-breather, 
and  the  voice  has  a  nasal  twang.  Operation  performed  under 
ether  on  September  19,  1883.  The  crucial  incisions  were  made 
with  a  knife  through  the  cartilage,  the  fragments  fractured,  and 
the  nostrils  plugged  with  antiseptic  cotton,  which  was  removed 
on  the  third  day.  There  had  been  no  bleeding  and  no  rise  of 
temperature.  After  washing  out  the  nostril,  the  left  side  was 
repacked,  the  parts  being  kept  straight  with  the  Adams  for¬ 
ceps.  On  September  30th  plugs  removed ;  patient  breathes 
freely  through  both  nostrils.  The  straightening  forceps  are  in¬ 
troduced  tri-weekly,  and  on  October  24th  patient  is  discharged 
cored. 

Case  II. — Louise  II.,  aged  seventeen.  Patient  of  Throat 
Clinic,  New  York  Eye  and  Ear  Infirmary.  The  left  nostril  is 
completely  obstructed  by  a  deviated  cartilaginous  septum,  which 
is  firmly  adherent  to  the  inferior  turbinated  body  of  the  same 
side.  Operation  performed  at  infirmary,  September  28,  1884, 
under  ether.  The  adhesions  were  broken  up,  and  the  crucial 
incisions  and  fracture  accomplished.  The  septum  straightened, 
and  held  in  position  by  a  specially  devised  splint  (Fig.  3).  This 
consisted  of  an  external,  lyre-shaped  frame,  to  the  center  of 
which,  on  a  hinged  joint,  two  plaques  of  hard  rubber,  of  a 
shape  similar  to  the  triangular  cartilage,  were  attached.  The 
plaques,  being  adjusted  to  their  place  in  either  nostril,  were 
fastened  in  their  position  by  the  screw  passing  through  the 
outer  frame,  and  the  nostrils  afterward  tamponed.  There  was 
no  constitutional  disturbance.  In  three  weeks  after  tri-weekly 
applications  of  the  straightening  forceps  the  patient  was  dis¬ 
charged  cured. 

Case  III. — Philip  L ,  aged  thirteen,  came  to  the  clinic  of  the 
New  York  Eye  and  Ear  Infirmary  with  nasal  obstruction ;  is  a 
mouth-breather.  Hearing  defective  in  left  ear;  is  dull  and 
apathetic;  the  cartilaginous  septum  is  deviated  to  the  left  and 
is  firmly  adherent  to  the  inferior  turbinated  body,  the  greatest 
convexity  being  an  inch  and  a  quarter  from  the  nasal  orifice. 

The  operation  was  performed  under  ether  at  the  infirmary, 
December  1,  1888.  The  adhesions  having  been  broken  up  by 
the  gouge,  the  cartilage  was  incised  with  the  cartilage  scissors, 
the  segments  fractured,  and  splint  and  tampon  applied.  After 
the  cartilage  was  straightened,  a  long,  bony  obstruction  was 
found  to  exist  behind  it,  which  was  afterward  removed  by 
means  of  the  electro-trephine.  This  was  finally  accomplished 
in  six  weeks,  and  on  February  15th  the  patient  was  discharged 
cured,  breathing  freely  with  closed  mouth,  and  hearing  greatly 
improved.  A  recent  report  from  this  case  shows  the  improve¬ 
ment  to  be  permanent. 

Case  IY. — Fannie  M.,  aged  sixteen,  came  to  the  clinic  of  the 
New  York  Eye  and  Ear  Infirmary  complaining  of  nasal  obstruc¬ 
tion  and  deformity,  the  result  of  violence  when  three  years  old. 
Examination  shows  the  left  nostril  to  be  entirely  occluded  by 
a  deviated  septum,  the  tip  of  the  nose  being  bent  to  the  right. 
She  is  more  anxious  to  be  relieved  of  the  deformity  than  of  the 
obstruction.  The  operation  was  undertaken  with  the  view  of 


curing  both.  Operation  at  infirmary,  December  22,  1888,  un¬ 
der  ether.  Crucial  incisions,  fracture,  splint,  and  tampons. 
After  straightening  the  septum,  a  strip  of  rubber  planter  was 
applied  to  the  tip  of  the  nose,  and  traction  made  by  fastening 
the  end  to  the  left  cheek.  The  traction  was  faithfully  kept  up 
for  some  weeks  after  the  patency  of  the  nostril  was  re-estab¬ 
lished,  and  when  seen  on  May  4,  1890,  by  I)r.  Mayer,  the  de¬ 
formity  had  entirely  disappeared. 

Case  V. — Julius  R.,  aged  sixteen;  clinic  of  the  Manhattan 
Eye  and  Ear  Infirmary.  Operation,  under  ether,  May  22, 1889. 
Operation  and  after-treatmeut  as  in  the  other  cases.  Discharged 
cured  on  June  15,  1889. 

Case  VI. — B.  R.,  male,  aged  seventeen,  referred  to  Throat 
Clinic  of  New  York  Eye  and  Ear  Infirmary  by  Dr.  Rupp,  sur¬ 
geon  in  the  Ear  Department.  The  patient  is  entirely  deaf  in 
left  ear.  Left  nostril  completely  occluded.  Operation,  under 
ether,  February  8,  1890.  Same  procedure  as  in  previous  cases, 
the  resulting  haemorrhage,  however,  being  more  than  ordinary. 
During  the  night  succeeding  the  operation  his  breathing  was 
alarmingly  interfered  with  during  sleep.  On  being  awakened 
by  the  nurse,  he  was  found  to  he  bleeding  from  the  mouth,  and 
large  coagula  were  expelled  from  the  pharynx.  The  tampons 
were  removed,  the  nose  cleansed,  and  the  bleeding  checked  by 
ice,  after  which  the  splint  and  tampon  were  replaced.  On  the 
7th  haemorrhage  recurred  during  the  night,  but  was  checked  by 
ice.  On  the  15th  he  went  to  his  home,  when  bleeding  again 
occurred,  which  was  controlled  by  my  assistant,  who  was  sent 
for.  After  this  there  was  no  further  trouble,  and  the  regu¬ 
lar  after-treatment  was  carried  out.  On  March  20,  1890,  Dr. 
Rupp  reports  marked  improvement  in  the  hearing,  and  on  April 
30th  the  patient  reports  that  he  breathes  freely  through  the 
formerly  obstructed  nostril. 


A  NEW  LOCAL  THERAPY 

OF  TUBERCULOSIS  PULMONALIS. 

By  HUGO  J.  LOEBINGER,  M.  D. 

Never  before  has  the  question  concerning  the  curabil¬ 
ity  of  consumption  possessed  more  intense  interest  than  at 
the  present  time,  when  scientists  of  all  nations  are  striving 
to  solve  the  problem  of  the  cure  of  not  simply  pulmonary 
tuberculosis,  but  tuberculosis  generally ;  and  it  almost 
seems  as  if  its  realization  were  at  hand. 

The  reason  for  this  general  emulation  lies  in  the  fact 
that  since  Koch’s  discovery  of  the  Bacillus  tuberculosis  our 
knowledge  of  the  cause  of  the  disease  has  become  more 
comprehensive  ;  and  that,  in  particular,  the  study  of  the 
life-giving  properties  necessary  to  the  existence  of  the  ba¬ 
cillus,  through  the  cultivation  of  pure  specimens  and  after 
experiments  upon  animals,  warrants  the  hope  that  its  growth 
in  the  organism  may  be  cut  otf — which  the  above-named 
scientist,  Koch,  is  alleged  to  have  already  in  a  measure  ac¬ 
complished.  At  all  events,  we  have  learned,  particularly 
since  the  latest  investigation  by  Cornet,  and  others  before 
him,  to  protect  ourselves  against  them. 

Another  reason  is  the  fact  that  Nature  often  effects  a 
spontaneous  cure  of  pulmonary  consumption,  if  only  in  its 
first  stages. 

Attention  is  here  called  to  the  interesting  records  of 
post-mortem  examinations  at  the  Paris  Morgue,  published 
by  Vibert,  which  treat  of  the  sudden  or  violent  death  of 


678 


L  O  E BIN  PER :  A  NEW  LOCAL  THERAPY  OF  TUBERCULOSIS. 


[N.  Y.  Med.  Joctb. 


numerous  apparently  healthy  persons  whose  lungs,  however, 

simply  showed  evidences  of  healed  tuberculosis.  Clinical 
experience  has  confirmed  the  partial  curability  of  tubercu¬ 
losis  of  the  lungs  and  unconditionally  recognizes  this.  Only 
with  regard  to  the  therapy  is  there  a  division  of  opinion, 
which  runs  in  two  channels.  One  theory  is  that  of  general 
therapeutics,  which  consists  in  the  belief  that  it  is  better 
not  to  attack  the  locus  affectus  directly,  but  rather,  by 
means  of  general  regulations — such  as  good,  even  excess¬ 
ive,  food,  pure  air,  permanent  sojourn  in  the  open  air,  etc. 

to  effect,  as  it  is  asserted  can  be  done,  the  patient’s 
restoration.  As  an  extreme  measure,  internal  aid  is  given 
to  act  on  the  disease  through  the  circulation  of  the  blood, 
as,  for  instance,  by  the  use  of  creasote,  guaiacol,  etc.  In¬ 
terpreted  into  the  language  of  modern  bacteriology,  this 
means  to  rob  the  Bacillus  tuberculosis  of  the  soil  which 
promotes  its  growth.  These  views  are  strengthened  by  the 
happy  results  attained  in  those  institutions  and  establish¬ 
ments  where  such  principles  are  strictly  maintained.  In 
Europe  the  most  renowned  of  these  are  those  of  Dr.  Driver, 
in  Rippoldsgriin  ;  of  Dettweiler,  in  Frankenstein,  Taunus  ; 
the  Bremer’s  institute  in  Gorbersdorf,  etc.  Of  those  insti¬ 
tutions  in  the  United  States  enjoying  transatlantic  reputa¬ 
tion,  Dr.  Trudeau  s  Adirondack  Cottage  Sanitarium  is  the 
leading  one. 

Opposed  to  this  theory  are  the  more  or  less  negative 
results  of  that  therapy  which  has  for  its  first  principle  the 
attack  of  the  locus  affectus  directly — the  local  therapy.  It 
is  true  that,  since  the  failure  of  hot-air  inhalation,  etc.,  there 
exists  among  our  physicians,  as  well  as  in  the  public  mind, 
a  certain  amount  of  distrust  of  all  so-called  local  cures 
for  pulmonary  consumption.  Nevertheless,  it  must  be  con 
ceded  a  priori  that  that  point  of  view  will  be  an  ideal  one 
with  respect  to  lung  therapeutics  (including,  also,  general 
therapeutic  regulations)  which  does  not  prohibit  the  local 
treatment  of  the  diseased  lung.  This  is  therefore  a  sur¬ 
gical  view  of  the  question  ;  precisely  as  a  surgeon  would 
not  content  himself  with  undertaking  the  treatment  of  a 
fungous  inflammation  of  the  knee  joint  simply  with  fresh  air 
and  nourishing  food,  nor  even  with  a  general  contratubercu- 
lous  cure,  by  means  of  inoculation,  etc. 

At  the  last  International  Medical  Congress  one  of  the 
greatest  throat  specialists  of  Europe,  Professor  Heryng, 
of  Warsaw,  most  emphatically  declared  that  no  general 
contratuberculous  cure  should  ever  deter  him,  in  cases 
where  local  therapeutics  was  available,  from  energetically 
employing  tbe  same  ;  as  in  the  larynx,  for  instance. 

Overlooking  the  somewhat  venturesome  attempts  to  in¬ 
ject  medicinal  liquids  through  the  thoracic  wall  into  the 
lung  (which  practice  has  led  to  unfavorable  results,  with 
haemoptysis,  pleuritis,  etc.),  local  therapy  should  be  em¬ 
ployed  only  by  means  of  the  natural  channels  of  respiration. 

It  has  consisted,  heretofore,  merely  in  some  form  of  inhala¬ 
tion.  Effective  inhalation  has  only  .been  undertaken  with 
real  gases  when  it  could  be  foreseen  that  the  same  would 
really  leach  the  lung  tissues  through  respiration. 

The  choice  is,  unfortunately,  very  limited,  as  the  ma¬ 
jority  of  gases  are  partly  irrespirable— *.  they  cause 
spasm  of  the  glottis— partly  irritating  and  toxic  ;  where¬ 


fore  the  selection  has  been  confined  to  the  most  natural  and 
accessible  of  gases — viz.,  the  atmosphere  and  its  single  con¬ 
stituents.  Heated  air  has  been  resorted  to,  as  the  bacilli 

can  not  live  in  a  certain  degree  of  high  temperature _ as 

if  it  were  possible  for  the  lungs,  a  by  no  means  unimpor¬ 
tant  part  of  the  entire  body,  to,  even  for  a  moment,  main¬ 
tain  a  higher  level  of  temperature  than  that  of  the  body  ! 
The  results,  therefore,  remained  not  only  entirely  negative, 
but  it  was  also  demonstrated  experimentally  by  Mosso,  of 
Turin,  that  even  with  inhalation  at  320°  F.  the  tempera¬ 
ture  in  the  trachea  of  a  dog,  with  a  body  temperature  of 
about  102°  F.  in  the  rectum,  showed  100°  F. ;  so  rapid  is 
the  process  of  cooling  in  the  air  channels. 

The  several  component  parts  of  the  air,  oxygen  and  its 
modification  ozone,  and  nitrogen  and  its  modification  azote, 
have  been  applied  as  inhalations  in  the  treatment  of  pul¬ 
monary  consumption.  The  former,  it  is  well  known,  in¬ 
fluences  the  blood-corpuscles,  and  thereon  depends  the  en¬ 
tire  change  of  matter.  The  inhalation  of  oxygen  results  in 
a  more  rapid  diminution  of  oxidation  stages.  Whether 
this  has  a  desirable  influence  on  pulmonary  consumption, 
in  that  an  accelerated  change  with  negative  balance  leads 
to  a  rapid  end,  is  a  question  that  can  readily  be  answered. 
Ozone  has  undoubtedly  (Liebreich)  an  eminently  antizymic 
virtue ;  still  it  operates  more  intensely  than  oxygenium 
upon  the  blood  globules,  being  at  the  same  time  very  irri¬ 
tating.  Besides,  through  the  operation  of  vegetable  germs 
existing  in  the  superior  air-passages,  it  is  restored  to  its 
original  molecular  composition.  Rarefied  oxygen,  so-called 
nitrogen  (or  azote),  though  hindering  the  decay  of  the  dis¬ 
eased  organism  (like  a  sojourn  in  a  high  climate  where  the 
air  is  thin  and  rarefied),  yet,  as  regards  its  influence  upon 
the  process  of  the  disease  itself,  seems  to  be  without  any 
direct  effect  in  its  cure. 

Concerning  the  so-called  vapor  inhalations,  medicaments 
dissolved  in  water — for  example,  creasote,  carbol,  etc. — it  ap¬ 
pears  highly  problematical  whether  the  matter  inhaled  really 
ieaches  the  lung  tissues.  Even  should  we  not  rest  satisfied 
with  inhalations  ot  dispersed  liquids,  but  resort  to  medicinal 
liquids  really  heated  up  to  the  boiling  point,  so  that  the  mat¬ 
ter  would  be  transformed  into  vapor  in  the  same  propor¬ 
tion  as  when  dissolved,  the  intended  result  seems  question¬ 
able.  1  he  same  applies  to  the  spray  inhalation  lately  recom¬ 
mended  by  Jahr,  wherein  heated  air  is  intimately  mingled 
with  the  dispersed  atmosphere,  so  as  to  allow  the  atmos¬ 
pheric  fluids  to  evaporate,  a  process  not  far  different  from 
the  actual  vapor  inhalation.  The  latter,  if  applied  ration¬ 
ally  and  for  the  purpose  of  respiration,  commingled  with 
cold  air,  is  primarily  exposed  to  becoming  cool,  which  cool¬ 
ness  in  the  trachea,  as  above  shown,  becomes  excessive. 
And  as,  in  consequence  of  tbe  breathing  process,  there  is 
continually  present  in  the  air-passages  a  large  quantity  of 
liquid,  the  point  of  satiety  is  more  speedily  reached.  The 
vapor  is  rapidly  condensed  and  falls  again  in  drops. 

Other  mediums  of  solution — like  alcohol,  ether,  chloro¬ 
form,  etc.,  the  boiling  point  of  which  is  much  lower  than 
that  of  water,  and  of  which  we  may  infer,  therefore,  that,  as 
soon  as  they  are  transformed  into  gases,  the  same  will  be 
saved  until  reaching  respiration  in  the  lung.tissues — are,  be- 


Deo.  20,  1890.] 


LOEBINGER  :  A  NEW  LOCAL  THERAPY  OF  TUBERCULOSIS. 


cause  of  their  relative  appearances,  useless, 
time,  up  to  the  present,  creasote,  for  instance,  has  been  the 
most  desirable  contratuberculous  remedy,  being  easily  solu¬ 
ble  in  alcohol  or  in  ether,  but  soluble,  however,  only  in  110 
parts  of  hot  water. 

From  the  foregoing  it  is  deduced  that  vapor  inhalations 
do  not  penetrate  into  the  lungs;  thus  they  are  advisable  only 
in  the  treatment  of  diseased  larynx,  trachea,  and  bronchi. 
Indeed,  in  these  cases  there  is  no  method  or  treatment  that 
can  displace  this.  But  even  with  pure  gas  inhalation  it  is 
questionable  whether  the  gases  reach  the  locus  affectus. 
Aside  from  the  difference  in  the  gases,  the  propelling  motor 
of  the  inhalation  is,  practically,  the  respiratory  movement; 
we  know  that  not  simply  the  diseased  spot  of  the  lungs  re¬ 
mains  in  a  state  of  inactivity,  but  also  the  neighboring 
organs,  in  consequence  of  relaxed  tension,  being  extremely 
sore  and  painful,  and  therefore  aiding  but  little  in  the  re¬ 
spiratory  movement,  the  result  being  that  the  healthy 
portions  of  the  lungs  are  obliged  to  suck  up  more  strongly 
the  inhaled  gases,  and  these,  not  being  intended  for  them, 
cause  irritation  and  often  pernicious  results.  This  physical 
fact  is  not  changed  by  the  use  of  compressed  air  or  gases 
for  inhalation. 

How,  then,  is  it  possible  to  act  with  purely  local  effect 
upon  the  actual  seat  of  disease  in  the  lungs  ? 

The  primary  requirement  is  the  acknowledged  one  of 
first  locating  the  seat  of  disease,  then  to  circumvent  the 
same  after  a  thorough  physical  examination,  not  resting 
content,  in  consequence  of  the  discovery  of  the  bacilli 
found  in  the  sputum,  with  the  general  diagnosis — tubercu¬ 
losis  pulmonalis.  Proceed  then  to  ascertain  the  form  in 
which  medicinal  substances  may  be  conducted  direct  to  the 
diseased  portion  of  the  lung  tissue  and  there  remain,  in 
order  to  discriminate  between  the  inhaled  gases  (whose 
contact  with  the  seat  of  disease  must  of  necessity  be  tran- 
sient)  deposited  for  a  certain  length  of  time,  so  that  not 
merely  a  transitory  effect  will  have  been  attained.  And 
this  is  in  the  form  of  powder !  Can  powder  (or  dust)  be 
conveyed  into  the  lungs? 

Since  Cornet’s  investigation,  we  know  that  the  germ  of 
the  disease — the  Bacillus  tuberculosis — is  conveyed  into  the 
lungs  in  the  form  of  dust;  therefore  the  remedy,  in  order  to 
reach  the  seat  of  disease  in  the  lung,  must  exist  in  this  form. 
The  dust  of  rooms  and  streets,  daily  inhaled,  only  in  part 
remains  in  the  superior  air-passages,  from  there  to  be  again 
expectorated  ;  a  portion  penetrates  into  the  lung-parenchy¬ 
ma,  where,  at  autopsies,  it  is  often  met  with,  representing 
a  portion  of  the  pigment  of  the  lung. 

Who  has  not  heard  of  the  so-called  anthracosis  (coal 
lung),  or  pneumonokoniosis,  and  siderosis  of  persons  fol¬ 
lowing  certain  vocations?  It  is  remarkable  that  here  the 
inhaled  dust— provided,  of  course,  that  the  same  is  free 
from  all  infectious  admixture — following  a  purely  mechan¬ 
ical  path,  will  cause,  first  slight,  then  more  aggravated,  le¬ 
sions  in  the  tissue,  frequently  resulting  in  chronic  absorp¬ 
tion  of  the  lungs,  and,  being  in  the  form  of  so-called  fibrous 
induration,  occasion  cicatricial  formations  in  the  interstices 
of  the  tissue  (viz.,  interalveolar,  interbronchial,  and  sub- 
pleural),  with  consequent  shrinkage. 


679 

That  which  is  here  characterized  as  a  pathological  phe¬ 
nomenon  is  that  art  of  na  ural  cure  which  seeks  to  elimi¬ 
nate  and  make  innoxious  the  destructive  micro-organisms 
by  means  of  reconstruction  of  the  connective  tissue  of  the 
lungs,  producing  an  actual  cicatricial  formation,  taking  the 
place  of  the  decayed  lung  parenchyma,  which  often  occurs 
spontaneously  in  pulmonary  phthisis.  Wherefore  it  is  well 
to  work  upon  this  plan,  indicated,  as  it  were,  bv  nature. 

In  insufflation  of  the  lungs  we  make  use  of  a  compound 
powder  whose  basis  for  the  purpose  of  mechanical  action  in 
the  diseased  tissue  is  calcium  phosphide,  which  becomes  an 
amorphous  powder,  insoluble  in  water,  that,  when  deposited 
in  the  lung  tissue,  is  also  imbibed  by  the  lymph  cells,  which, 
in  turn,  become  migratory  amoeboid  cells,  carrying  the  pow- 
dei  through  the  interstitial  tissue,  and  finally  gaining  a  foot¬ 
hold  in  the  filter  apparatus  of  the  large  bronchial  lymphatic 
glands. 

It  naturally  follows  that  a  portion  of  the  calcium 
phosphate,  mingling  with  the  albumin  of  the  necrosed  tis¬ 
sue,  which  possesses  everywhere  in  the  body  a  well-known 
chemical  affinity  for  calcium,  becomes  chemically  united 
with  it,  representing  calcined  lime  in  the  cheesy  portions. 
Upon  this  premise  it  has  often  been  given  internally  for 
scrofula  and  tuberculosis,  and  also  frequently  applied  exter¬ 
nally  in  cases  of  tuberculous  ulcerations,  strewn  thereon  in 
the  form  of  powder. 

I  beg  here  to  call  attention  to  the  observations  made 
by  Halter,  the  originator  of  hot-air  inhalation,  that,  in  dis¬ 
tricts  where  phthisis  abounded,  those  employed  in  lime¬ 
kilns  lemained,  during  a  period  of  fifteen  vears,  exempt 
therefrom.  Halter  attributes  this  fact  to  the  influence  of 
the  hot  air  present.  How  can  we  explain,  then,  the  fact 
that  persons  working  in  a  much  higher  temperature — as, 
for  instance,  in  furnace-rooms  —  do  not  have  equal  im¬ 
munity  ? 

Excluding  all  specific  effect,  it  must  be  conceded  that 
from  these  particles  of  calcium  phosphide  proceeds  that 
mechanical  irritation  which  gives  to  the  diseased  lung  re¬ 
newed  vigor,  favoring  the  reconstruction  of  the  connective 
tissue  of  the  lungs.  That  the  effect  may  be  a  purely  local 

that  is,  that  the  sound  lung  tissue  may  be  spared _ 

will  be  hereafter  touched  upon. 

To  satisfy  the  demands  of  antisepsis,  which,  without 
fiist  seeking  a  specific  against  the  Bacillus  tuberculosis , 
promises  success  in  view  of  the  fact  that  phthisis  of  the 
lungs,  being  a  mixed  process,  where  other  pathogenic  ba¬ 
cilli  also  come  into  play,  sueh  as,  for  instance,  varieties  of 
streptococcus,  sodium  benzoate  may  be  mentioned  as  a  sec¬ 
ond  constituent  for  the  powder  mixture.  As  the  latter  is 
soluble  in  water,  the  effect  is  not  a  mechanical  but  a  chemi¬ 
cal  one.  Without  expecting,  as  P.  von  Rokitansky  errone¬ 
ously  assumed,  a  specific  contratubercu'lous  effect,  it  never¬ 
theless  possesses  great  antizymic  strength,  acting  in  a 
stronger  degree  than  the  pure  acid. 

According  to  Buchholz,  0-05  to  0-06  per  cent,  of  this 
salt,  in  the  nutritive  liquid  used  by  him,  proved  sufficient 
to  prevent  the  growth  of  bacteria.  But  subsequently 
Schreiber,  after  giving  internally  fifteen  grammes,  observed 
only  insignificant  results,  such  as  dizziness  of  the  head  and 


At  the  same 


680 


LOEBINGER:  A  MEW  LOCAL  THERAPY  OF  TUBERCULOSIS.  [N.  Y.  Med.  Jook, 


a  heightened  pulsation  of  the  heart.  Sodium  benzoate  is 
soon  eliminated  from  the  body,  partly  in  its  original  form, 
partly  in  the  form  of  hippuric  acid. 

Our  third  and  most  significant  constituent  is  either  one 
of  the  ethereal  oils,  in  the  shape  of  an  elmosaccharum,  so 
that  the  whole  may  form  a  fine,  amorphous  powder;  for  the 
powder  consistence  is  lost  if  the  oleaginous  constituents 
rise  above  ten  per  cent.  Formerly  they  were  used  simply 
as  an  addition,  essence,  or  perfume,  except  by  the  old 
Egyptians,  who  used  the  same  for  embalming  their  dead; 
with  the  exception,  perhaps,  of  the  heavier  metallic  com¬ 
pounds — such  as  those  of  mercury,  silver,  and  gold — they 
now  stand  pre-eminently  at  the  head  of  all  antiseptic  and 
specific  contratuberculosis  substances,  according  to  Koch 
and  others.  For  example,  Koch  found  that  oil  of  pepper¬ 
mint,  in  a  solution  of  1  to  33,000,  was  sufficient  to  kill 
anthrax  bacilli,  while  Chamberland,  Meunier,  and  others 
observed  that  oil  of  cinnamon,  in  its  action  upon  tvphoid 
bacilli,  was  equal  to  a  mercurial  sublimate  solution  of  1  to 
200.  This  is  not  surprising  when  we  consider  that  the 
ethereal  oils  are  formed  from  terpenes,  which,  while  causing 
some  reduction,  produce  hydrogen  dioxide,  which  possesses 
antiseptic  powers;  and  from  camphors,  the  contratubercu- 
lous  effect  of  which  has  recently  been  demonstrated  by 
Marpmann  experimentally.  After  having  administered  sev¬ 
eral  chemical  camphor  preparations  to  rabbits,  Marpmann 
succeeded  in  making  them  proof  even  against  inoculation 
of  the  Bacillus  tuberculosis. 

As  soon  as  the  powdered  mixture  is  deposited  the  inter¬ 
mixed  ethereal  oils  pass  away,  in  the  form  of  vapor,  from 
the  particles  to  which  they  clung,  and  enter  the  neighbor¬ 
ing  diseased  tissue. 

This  is  an  important  fact,  for,  if  cavities  do  not  exist 
which  communicate  with  the  bronchi,  then,  in  the  most 
favorable  case,  the  powder  will  reach  only  to  the  vicinity  of 
the  locus  ajfectus,  which  generally  lies  apait  or  excluded, 
and  not  directly  accessible  by  way  of  the  respiratory  pas¬ 
sages.  The  transpiration  of  the  internal  evaporation  of  oils, 
for  which  the  less  important  powder  admixtures  represent 
the  vehicle  only,  is  termed  by  me  “  secondary  internal  in¬ 
halation.” 

The  average  proportion  of  the  individual  constituents  is 
variable.  For  example,  where  the  treatment  of  cavities  is 
concerned,  or  an  aggravated  irritation  in  the  trachea,  the 
quantity  of  calcium  may  be  rated  proportionately  low  ;  it  is 
proportionately  high,  however,  in  cases  of  chronic,  cheesy 
pneumonia,  where  there  is  already  a  proneness  to  cicatricial 
formation  with  shrinkage. 

Although  insufflation  is  generally  relegated  to  the  sim¬ 
plest  medicinal  province,  the  following  difficulties  are 
enumerated  herein,  which,  however,  can  he  very  readily 
overcome  by  any  practical  and  skillful  physician  : 

The  first  step  is  to  pass  through  the  narrow  passage  of 
the  larynx,  whose  glottis  respiratona ,  in  regular  breathing, 
forms  a  fairly  triangular  opening ;  the  same  becomes  ex¬ 
tended,  however,  in  forcible  inhalation  to  a  square,  which, 
by  means  of  the  insertion  of  a  laryngeal  mirror,  permits  a 
deeper  view  into  the  trachea,  as  far  as  its  bifurcation. 

Instruct  the  patient,  therefore,  to  take  a  deep  breath  at 


a  given  signal  while  stretching  forth  the  tongue  so  as  to 
raise  the  epiglottis,  which  covers  the  aditus  laryngis.  Into 
the  mouth  thus  open  a  very  thin  tube  is  inserted,  the  end 
of  which  is  bent  at  about  a  right  angle,  with  the  opening  I 
perpendicularly  over  the  aditus  laryngis.  Naturally,  the 
tube  must  lie  exactly  in  the  median  plane  and  in  the  axis  of 
the  trachea.  The  propelling  force  must  be  sufficiently  strong, 
so  that,  notwithstanding  any  resistance,  the  powder  may 
really  be  thrown  into  the  depths  of  the  lung  tissue,  and  with 
such  rapidity  that  not  the  slightest  evidence  of  suffocation 
will  appear.  This  procedure  may  be  simplified  by  having 
the  tube  of  the  smallest  possible  caliber,  so  that  the  powder  i 
reaches  the  superior  air-passages  in  the  form  of  no  more 
than  a  thin  ray — a  circumstance  which  avoids,  at  the  same 
time,  any  irritation.  It  is  well  to  mention  here  that  the 
ordinary  powder  insufflator,  with  hand-bellows  attachment, 
had  better  be  avoided,  as  the  compression  necessitate  a 
waste  of  time,  and  use  made  instead  of  the  one  customarily 
employed  for  that  purpose — viz.,  Livingstone’s  pneumatic 
spray  producer,*  with  the  assistance  of  which  a  power  of 
from  fifty  to  sixty  pounds  to  the  cubic  inch  is  developed. 

As  the  propelled  powder  pursues  a  straight  line — like 
shot — it  must  pass  through  the  aditus  laryngis  directly  to 
the  seat  of  disease  beyond;  for  without  particular  caution 
it  would  not  pass  beyond  the  bifurcation.  This  difficulty 
can  be  obviated  by  the  position  of  the  patient  himself, 
which  max  be  so  arranged  that  the  powder  will  reach  the 
seat  of  the  disease  directly.  If  the  latter  is  located  on  the 
left  (back)  side,  the  patient  assumes  a  position  as  follows: 
Body  bent  forward  to  the  right  with  head  thrown  back, 
which  last  position  is  commended,  in  order  to  mitigate  as 
far  as  possible  the  force  of  the  propelled  powder  against  the 
walls  of  the  pharynx.  In  this  position  the  patient  must 
practice  respiration.  While,  therefore,  the  healthy  or  less 
affected  side  is  compressed  by  the  simultaneous  closing  of 
the  bronchial  opening  by  this  position,  as  well  as  by  the 
synchronism  with  the  respiration  resultant  from  the  eleva¬ 
tion  of  the  arm  on  the  same  side,  besides  extending  the 
bronchial  tree,  the  latter  can  in  this  manner  regain  its  ex- 
cursional  functions,  and  will  also,  as  a  matter  of  fact,  in¬ 
crease  the  lung  capacity. 

It  is  remarkable  that  the  (among  males)  typical  abdomi¬ 
nal  respiration  may  in  this  position  be  excluded,  and  the 
superior  segment  of  the  thorax,  in  the  ulterior  lung  portions 
of  which  is  usually  located  the  seat  of  the  disease,  is  espe¬ 
cially  benefited  by  this  lung  gymnastics.  These  experiments 
must,  of  course,  be  practiced  with  great  caution,  particu¬ 
larly  in  the  beginning,  to  prevent  haemoptysis. 

Naturally,  the  greatest  care  is  necessary  on  the  part  of 
the  physician,  so  that  the  powder  to  be  applied  may  be  ap¬ 
plied  not  a  moment  too  soon  or  too  late,  for  in  either  case 
the  glottis,  closing  prematurely,  will  cause  the  powder  to 
become  fixed  in  the  larynx.  Further  consequences  would 
be  apparent  irritability  in  the  superior  air-passages,  etc. 

On  the  other  hand,  there  is  the  assurance  and  satisfaction 
of  knowing  that  the  powder,  owing  to  the  peculiar  position 


*  Made  for  my  purpose  by  E.  Ackermann,  of  No.  153  West  Tweatj- 
ninth  Street. 


Dec.  20,  1890.J 


I 

I 

I 

I 


LOKBINOER:  A  NEW  LOCAL  THERAPY  OF  TUBERCULOSIS. 


681 


of  the  patient,  arrives  only  in  that  particular  part  and  neigh¬ 
borhood  of  the  lung  which  is  diseased.  In  fact,  patients 
themselves  designate  the  exact  spot  where  they  feel  the  air 
entering,  they  having  long  felt  a  burning  sensation  within 
the  thorax,  caused  by  the  admixture  of  the  ethereal  oils, 
thus  excluding  any  error  in  indicating  the  spot. 

Also,  by  means  of  physical  examination,  co-operation 
may  be  obtained.  For  example,  in  the  case  of  a  patient, 
above  a  circumscribed  spot  of  the  left  upper  lung  I  ob¬ 
served  a  peculiar  respiratory  whistling,  which  disappeared 
after  every  application,  giving  place  to  a  rattling  sound. 

Aie  these  observations  worthy  of  therapeutic  experi¬ 
ments?  What  have  been  the  practical  results  obtained 
during  the  past  year  and  a  half  in  those  cases  undertaken  by 
the  writer,  with  a  view  to  curing  pulmonary  consumption  ? 

I  will  refrain  from  here  going  more  specifically  into  the 
history  of  all  the  cases;  they  will  be  treated  of  in  detail 
shortly  ;  besides,  minute  explanation  of  the  method  of  the 
cure  will  be  given.  But  I  affirm  that,  of  the  numerous 
cases  of  pronounced  pulmonary  phthisis  which  have  been 
subjected  to  this  treatment,  there  have  been  but  few  nega¬ 
tive  cases  to  record,  and  these  but  apparently  negative,  as 
the  treatment  was  not  continued  long  enough. 

One  of  these  cases,  for  example,  was  that  of  a  young- 
girl  who  was  so  nervous  that  the  vocal  cords  under  the  la¬ 
ryngeal  mirror  were  in  a  continual  state  of  vibration;  here, 
of  course,  the  powder  could  not  reach  beyond  the  larynx! 
Where,  however,  treatment  was  possible  (and  it  is  never 
required  for  a  longer  period  than  three  or  four  months), 
improvement  was  observable  until  the  disappearance  of  the 
bacilli,  except  in  one  case;  and  gradually  the  cough  and 
expectoration  ceased  and  an  increase  of  flesh  was  apparent. 
After  that  it  was  possible  to  undertake  the  physical  treat¬ 
ment  or  cure  of  the  diseased  portions  within  which  the 
desired  cicatricial  formation  had  taken  place. 

Lack  of  space  permits  the  particular  citation  of  but  two 
cases,  taken  from  the  records  of  the  histories  to  be  pub 
lished.  Among  the  numerous  cases  they  are  representec 
as  Case  I  and  Case  VIII. 


Case  I.— Mr.  P.,  engineer,  Scotch,  forty- five  years  of  age, 
for  twelve  years  suffering  with  pectoral  complaint.  For  a  pe¬ 
riod  of  three  years  there  has  been  increased  suffering,  with  a 
rapid  decrease  of  bodily  strength.  The  most  eminent  medical 
authorities  consulted  ;  diagnosis,  phthisis  pulmonalis.  Several 
months’ sojourn  in  the  South  without  beneficial  results.  After¬ 
ward  several  months’ sojourn  in  a  private  hospital  for  consump¬ 
tives,  from  which  he  was  discharged  as  incurable. 

Status  prcesens ,  December  5,  1889.— Patient  is  tall  and  nar¬ 
row-chested  ;  in  a  very  wretched  condition.  Worn  almost  to 
a  skeleton  and  so  weak  that  he  can  not  walk  without  assistance. 
So  short  of  breath  that  speech  is  extremely  difficult.  Complains 
of  a  continual  cough.  Expectoration  aDd  severe  stomach  pains; 
frequent  night  sweats.  Left  half  of  thorax  crippled,  in  conse¬ 
quence  of  the  uneven  healing  of  a  rib  fracture.  Scarcely  exer¬ 
cises  the  respiratory  organs.  Extreme  dullness  of  the  front  half 
ot  the  thorax.  In  the  back,  on  the  same  side,  a  tympanitic 
sound.  In  the  anterior  and  ulterior  parts,  continuous  rattling 
sounds.  Profuse  expectoration ;  numerous  elastic  fibers  ;  indi¬ 
vidual  bacilli.  Treatment  began  December  7,  1889.  Respira¬ 
tion,  40;  weight,  115  pounds. 

Though  the  patient  is  quite  exhausted  and  respiration  ex¬ 


tremely  weak,  he  nevertheless  seems  fit  for  the  treatment 
about  to  be  practiced,  and  undergoes,  several  times  a  day,  the 
above-described  gymnastics  for  the  lungs.  Fir.st  insufflation, 
December  14th  ;  repeated  on  the  17th  and  18th.  Each  time  this 
powder  is  applied  three  times  in  succession  ;  patient  feels  the 
strong  current  of  air  in  his  breast.  Cough  and  expectoration 
rapidly  improve ;  particularly,  the  patient  declares  that  expec¬ 
toration  no  longer  causes  any  effort,  as  formerly.  On  the  20th, 
appetite  good  and  a  gain  in  bodily  strength.  Respiration,  32! 
After  practicing  this  lung  gymnastics  two  weeks  a  decided  in¬ 
crease  is  shown  in  that  half  of  the  thorax  which  was  almost  in  a 
state  ot  cessation  as  regards  its  respiratory  excursional  functions. 
After  an  attack  of  influenza,  exacerbation  follows  as  regards  all 
the  symptoms,  consequently  causing  a  relapse.  Patieot  was 
bedridden  fora  time.  After  resuming  the  lung  treatment  of 
the  now  thoroughly  exhausted  patient,  on  the  5th  of  January, 
1890,  cough  and  expectoration  appeared  to  return  almost  in 
their  original  form.  But  few  bacilli  found  ;  distinct  movements 
of  the  diseased  side  of  the  thorax.  From  this  time  forth,  all 
through  January,  daily  applications.  The  powder  was  found 
to  have  reached  the  inferior  lobe  of  the  lung,  latterly  to  the 
superior,  and  finally  to  the  apex. 

After  a  time  the  bodily  strength  increased ;  slowly  cough 
and  expectoration  passed  away,  and  finally  the  bacilli,  never 
profusely  present,  disappeared  altogether. 

The  following  is  cited  as  an  illustration:  The  inmates 
ot  adjoining  rooms,  having  become  accustomed  to  the  con¬ 
tinual  cough  of  this  patient  (most  severe  at  night),  after 
the  same  ceased,  often  inquired  whether  death  had  already 

relieved  him  of  sufferings. 

© 

Status  prcesens,  February  2,  1890.— The  patient,  whose  face 
formerly  showed  sunken  eyes  and  prominent  cheek  bones,  pre¬ 
senting  a  frightful  appearance,  has,  through  the  accelerated  and 
violent  respiration,  found  adequate  relief,  and  now  seems  live¬ 
lier  and  happier,  being  scarcely  recognizable  as  the  same  man. 
Respiration,  24  a  minute;  coughs  only  early  in  the  morning;  is 
more  active.  Expectoration  almost  gone.  During  the  da\  and 
night  no  coughing.  Increase  in  weight,  six  pounds.  Patient 
walks  without  assistance.  Can  converse  also  for  some  length 
of  time  without  fatigue. 

Results,  as  above  stated,  after  examination.  On  measuring 
by  means  of  the  calipers,  decided  change  of  the  stern o- vertebral 
diameter  (about  one  centimetre)  in  the  second  intercostal  space. 
The  acquired  lung  capacity  measured  with  spirometer.  Left 
side,  tympanitic  echoes,  slight  sounds  of  rattling. 

A  continuation  of  the  treatment  until  the  middle  of  March, 
with  slight  interruptions,  kept  the  lung  symptoms  unchanged; 
the  general  condition  somewhat  wavering,  in  consequence  of 
periodical  stomach  trouble  and  loss  of  appetite.  Formerly  the 
gastric  troubles  often  reached  a  high  degree  of  intensity.  Dis¬ 
missed  and  treatment  discontinued.  The  patient  accepts  a 
position  in  the  South,  whence  he  returns  after  three  months. 
Since  discharge  has  become  stronger;  insignificant  stomach 
trouble;  steady  increase  in  weight.  Patient  coughs  now  and 
then  in  the  morning,  with  slight  discharge  of  phlegm.  Mr.  P. 
is  able  to  follow  his  vocation  without  exertion.  His  only  com¬ 
plaint  now  is  of  frequent  palpitation  of  the  heart;  also,  objec¬ 
tively,  there  is  observable  an  increase  of  cardiac  dullness. 

Resume. — It  is  remarkable  that  the  improvement  of  all 
symptoms  is  so  rapid  in  the  first  week,  while  after  that  the 
progress  is,  comparatively,  much  slower.  Nevertheless,  the 
recovery  of  a  man  so  completely  in  a  decline  and  so  full  of 
suffering  is  assuredly  remarkable.  Perhaps  this  might  be 


682 


BRUSH:  MIMICRY  OF  ANIMAL  TUBERCULOSIS  IN  VEQLTABLE  FORMS.  [N.  Y.  Mei>.  Jouk., 


explained  by  stating  that  this  case,  because  of  the  scarcity 
of  the  presence  of  bacilli  and  the  extreme  shrinkage  of  the 
left  lung,  was  -peculiarly  adapted  to  such  therapeutics, 
which  becomes  still  more  strengthened  during  the  treat- 
ment  by  elimination  of  the  causa  ejftciens  ;  withal,  the  in¬ 
crease  of  the  hypertrophy  of  the  heart  is  in  unison  with  the 
foregoing. 

Case  VIII. — Miss  P.  J.,  thirty-three  years  of  age,  ailing  for 
many  years.  At  first  simply  chlorosis  and  stomach  weakness; 
later,  catarrh  of  nose  and  throat.  Finally,  for  the  past  seven 
years,  pulmonary  symptoms,  such  as  cough,  expectoration,  chest 
depression,  etc.  At  first  only  in  a  limited  degree,  but  during  the 
past  three  years  continually  increasing,  accompanied  by  rapid 
decline  of  bodily  strength,  gradual  lessening  of  appetite,  etc., 
with  frequent  fever  and  night-sweats.  The  patient  was  for¬ 
merly  forewoman  in  a  large  mercantile  house,  but  for  some 
time  past  incapacitated  for  work,  often  being  obliged  to  keep 
to  her  bed. 

Status  pr  mens,  February  17,  1890. — The  patient  is  a  small, 
slight  person,  with  a  pale,  thin  face,  causing  her  to  appear 
much  older.  The  left  half  of  the  thorax  remains  remarkably 
impassive  while  breathing;  the  second  and  third  intercostal 
space  seems  to  be  particularly  sunken ;  over  the  same,  moder¬ 
ate  dullness  with  weakened  respiration  and  dry  rattling  sounds; 
bronchial  respiration  over  the  apex  of  the  lung.  The  right  lung 
is  apparently  unaffected;  patient  complains  of  frequent  cough¬ 
ing,  especially  at  night,  yet  expectoration  is  insignificant.  Micro¬ 
scopic  examination,  repeatedly  undertaken,  discloses  few  scat¬ 
tered  bacilli.  Patient  complains  of  severe  indigestion,  weak¬ 
ness  in  the  feet,  etc.  In  the  exercising  process  the  patient 
proves  very  clever.  As  there  are  no  cavernous  symptoms,  but 
rather  chronic,  running,  cheesy  pneumonia  in  the  left  upper 
lobe,  accompanied  by  shrinkage,  a  larger  admixture  of  calcium 
phosphide  is  resorted  to. 

It  is  interesting  to  note  that  the  patient  after  every  insuffla¬ 
tion,  indicating  accurately  the  spot  in  the  thorax  where  she 
feels  the  inhaled  air  passing,  becomes  exhilarated,  and  imme¬ 
diately  after  prompted  to  repeated,  energetic  respiration,  with¬ 
out  causing  cough  or  irritation.  The  application  is  made  daily 
for  a  period  of  four  weeks.  Within  this  time  a  very  great  im¬ 
provement  is  evidenced  in  the  cough.  Expectoration  becomes 
proportionately  small ;  disappears  entirely  after  a  short  time. 
Within  a  fortnight  after,  the  cough  wholly  disappears;  but, 
notwithstanding,  the  treatment  is  continued.  Presently,  too, 
the  general  health  improves.  Fever  and  night-sweats  cease, 
appetite  returns,  and  proper  nourishment  results  in  satisfactory 
progress.  Patient  feels  very  much  strengthened,  and  an  increase 
of  four  pounds  has  taken  place.  Her  face  has  grown  plump, 
shows  color,  altogether  causing  her  to  appear  much  improved. 
A  deficiency  of  breath  after  active  exercise  is  now  her  only 
complaint.  Worthy  of  note  is  the  fact  that  the  difference  in 
the  sagittal  diameter  of  both  sides  of  the  thorax,  measured 
with  calipers  in  the  mamillary  line,  is  now  equalized.  The  re¬ 
spiratory  sounds  in  the  parts  which  were  affected  still  some, 
what  weakened.  As  an  after-cure,  the  patient  will  sojourn  for 
-a  few  weeks  in  a  mountainous  district.  Her  condition  was  still 
more  improved  on  her  return.  In  the  morning  only  there  is 
slight  expectoration,  but  no  cough,  and  that  the  patient  rightly 
attributes  to  throat  and  nose  catarrh,  which  has  not  yet  disap¬ 
peared.  The  latter  will,  however,  now  be  successfully  treated. 
At  present  (November,  181)0)  the  patient  is  entirely  restored  to 
health.* 


*  Several  other  cases,  with  more  or  less  extensive  cavities,  also  show 
healing  within  a  period  not  much  longer. 


In  conclusion,  it  is  desirable  to  emphasize  that  this  issue 
is  based  upon  a  practical  experience  in  local  therapv  of  pul¬ 
monary  disorders,  which,  it  is  admitted,  excludes  from  con¬ 
sideration  any  complications  caused  by  the  presence  of  the 
Bacillus  tuberculosis  in  other  organs. 

On  the  other  hand,  this  local  treatment  of  the  lungs  in 
the  form  of  insufflation,  which,  so  far  as  is  known,  has  only 
been  used  by  Martel  in  the  form  of  calomel  insufflation, 
may  likewise  be  considered  with  regard  to  other  pulmonary 
disorders — for  instance,  gangrene  of  the  lung,  etc. 

1055  Lexington  Avenue. 


THE  MIMICRY  OF 

ANIMAL  TUBERCULOSIS  IN  VEGETABLE  FORMS  * 
By  E.  F.  BRUSH,  M.  D.. 

MOUNT  VERNON,  N.  Y. 

At  one  time  I  became  deeply  interested  in  reading  the 
travels  of  Livingstone  and  other  brave  and  noted  explorers 
of  Africa,  and,  while  my  mind  was  full  of  the  wonders  and 
mysteries  of  the  Dark  Continent,  I  met  a  gentleman  who  in¬ 
formed  me  that  he  had  resided  many  years  in  Africa.  I 
tried  to  obtain  from  him  some  information  which  I  had 
been  in  search  of.  I  spoke  of  the  geographical  problems  to 
be  solved  and  the  difficulties  to  be  surmounted  in  civilizing 
that  enormous  continent,  and  the  whole  burden  of  his  com¬ 
ments  was  that  Africa  was  a  great  country  and  would  be 
easily  civilized  and  all  obstacles  overcome  if  it  was  only 
properly  drained.  Now,  this  man’s  residence  in  Africa  had 
been  confined  to  the  west  coast,  where  the  notorious 
swampy  and  malarious  districts  lie,  and,  because  he  had  not 
traveled  farther  or  interested  himself  in  the  travels  of 
others,  he  imagined  that  all  Africa  was  like  that  portion  of 
the  country  which  he  did  know  would  be  the  better  for 
draining. 

We  should  all  naturally  be  surprised  at  the  narrowness 
of  this  man’s  views,  who  imagined  that  an  immense  conti¬ 
nent  with  snow-capped  mountains  and  rainless  deserts  of 
vast  extent  could  be  judged  from  the  narrow  limits  of  a 
malarious  swamp,  where  he  had  resided  for  a  few  years  ; 
but,  on  reflection,  the  idea  could  not  but  occur  to  me  that 
we  medical  men,  in  our  studies  of  the  Dark  Continent  of 
disease,  were  often  as  narrow  in  our  views  as  this  man  was 
in  his  views  of  Africa.  For  instance,  a  very  few  years  ago 
Koch  discovered  in  a  tubercle  numerous  bacilli,  and  straight¬ 
way  we  fancy  that  the  tubercle  would  be  harmless  if  it 
were  only  drained  of  its  bacillus,  and  we  put  ourselves  to 
work  with  hot  air,  rectal  injections,  medicated  inhalations, 
etc.,  imagining  all  the  time  that  we  could  subdue  this  terri¬ 
ble  and  mysterious  disease  and  settle  all  the  difficult  ques¬ 
tions  of  pathology  connected  therewith  by  simply  eliminat¬ 
ing  from  the  economy  the  bacillus  of  Koch.  The  bacterial 
region  is  emphatically  now  our  place  of  residence;  we  wade 
through  swamps  of  pus,  blood,  and  morbid  tissues,  pushing 
aside  all  other  forms  and  vital  processes,  after  the  beckon¬ 
ing  specter  of  a  bacillus,  and,  when  we  find  it,  flatter  our- 

*  Read  before  the  New  York  State  Medical  Association  at  its  seventh 
annual  meeting. 


Djc.  20,  1890.J  BRUSH:  MIMICRY  OF  ANIMAL  TUBERCULOSIS  IN  VEGETABLE  FORMS. 


<*>  33 


selves  that  we  have  reached  the  goal  and  discovered  all 
that  is  necessary  to  conquer  a  disease  associated  with  this 
small  organism.  We  hardly  inquire  how  it  gained  its  posi¬ 
tion,  what  its  functions  are  other  than  what  we  imagine  as 
being  concerned  in  the  causation  of  disease,  but  accept  it 
as  the  spirit  and  soul  and  prime  factor  in  the  cause  of  pul¬ 
monary  tuberculosis.  Happily,  the  tendency  now  is  to 
break  beyond  the  bounds  of  this  narrow  bigotry;  hence  l 
think  that  a  study  of  some  of  the  vegetable  forms  that  close¬ 
ly  mimic  animal  tuberculosis  will  help  us  in  our  march 
beyond  the  narrow  swamp  through  which  we  are  still  strug¬ 
gling. 

One  of  the  vegetable  diseases  which  mimic  very  closely 
tuberculous  animal  processes  is  seen  in  the  nut-gall.  The 
nut-galls  are  truly  tubercular  processes  affecting  the  breath¬ 
ing  apparatus  (leaves)  and  the  nutritive  channels  (roots)  of 
plants.  These  galls  are  among  the  most  puzzling  of  natu¬ 
ral  phenomena.  It  is  actually  known  that  the  Cynips,  or 
gall-fly,  a  small  insect  of  the  hymenopterous  order,  punct¬ 
ures  the  leaf  of  a  plant  or  tree,  and  there  deposits  an  egg, 
injecting  at  the  same  time  a  very  minute  drop — the  animal 
itself  is  only  one  tenth  of  an  inch  in  length — of  what  is  de¬ 
scribed  by  entomologists  as  a  poison,  but  which  is,  beyond 
doubt,  a  digestive  ferment.  This  fluid,  injected  by  the  in¬ 
sect  into  the  cavity  that  holds  the  egg,  affects  the  nutritive 
process  of  the  plant  in  such  a  preponderating  manner  that 
it  allows  the  egg  to  rest  in  the  cavity  without  the  irritating 
results  of  the  intrusion  of  a  foreign  body,  and  the  extraor¬ 
dinary  nutrition  caused  by  the  ferment  goes  on  to  form  the 
tubercular  mass  known  as  a  gall. 

Far  more  interesting  and  more  closely  analogous  to  ani¬ 
mal  tuberculosis  is  the  disease  attacking  the  grape-vine 
caused  by  the  insect  called  Phylloxera*  Can  anything  in 
plant-life  more  closely  resemble  a  human  tubercular  lung  than 
a  leaf  of  a  grape-vine  with  the  galls  of  Phylloxera ?  “In 
August,  1885,  Luiz  de  Andrade  Corvo  presented  a  paper 
to  the  Academy  of  Sciences  in  which  he  asserted  that  the 
vine  disease  ascribed  to  Phylloxera  vastatrix  was  really  due 
to  a  bacillus,  or  rather,  according,  to  his  description,  to  a 
bacterium,  which  is  always  found  in  the  tubercles  of  the 
radicles  and  in  the  tissues  of  the  vine  which  are  affected  by 
this  disease,  termed  by  him  tuberculosis.  They  are  also 
found  in  the  body  of  the  insect,  which  thus  becomes  simply 
the  agent  of  contagion.”  f 

Now,  has  not  this  author  narrowed  his  views  down  to  the 
bigotry  of  baeilli-worship?  The  presence  of  a  bacterium  in 
this  disease  of  plant-life  is  only  one  of  many  phases  of  a 
morbid  process.  The  bacillus  he  discovers  here  is  merely 
the  nutritive  ferment  deposited  by  all  gall  insects,  and  often, 
as  we  have  already  said,  called  a  poison.  The  Phylloxera 
vastatrix ,  like  the  Cynips  quercus,  wounds  the  leaf,  depos¬ 
its  its  egg  in  the  wound,  and,  besides,  injects  the  bacterium 
which  is  the  nutritive  ferment  that  produces  the  gall  which 
characterizes  the  disease.  The  following  sketch  of  the 
natural  history  of  the  Phylloxera  is  taken  from  John  Henry 
Comstock’s  Introduction  to  Entomology  :  “  The  grape  Phyl¬ 

*  From  Dr.  C.  V.  Riley,  Missouri  Entom.  Rep .,  vi,  vii. 

f  Microbes ,  Ferments ,  and  Molds.  By  E.  L.  Trouessart.  D.  Apple- 
ton  &  Co.,  New  York,  1886. 


loxera  hibernates  in  the  roots  of  the  grape  mostly  as  a 
young  larva  of  the  first  or  sedentary,  agamic,  wingless 
form.  \\  ith  the  renewal  of  vine  growth  in  the  spring  this 
larva  moults  rapidly,  increases  in  size,  and  soon  commences 
laying  eggs.  These  in  due  time  give  birth  to  young,  which 
soon  become  agamic,  egg-laying  mothers  like  the  first,  and., 
like  them,  always  remain  wingless.  Five  or  six  generations 
of  these  parthenogenetic,  egg-bearing,  wingless  mothers  fol¬ 
low  each  other,  when  (about  the  middle  of  June  in  the  lati¬ 
tude  of  St.  Louis)  some  of  the  individuals  begin  to  acquire 
wings.  Thus  is  produced  the  second  or  migrating,  agamic,, 
w'inged  form.  These  issue  from  the  ground  while  yet  in 
the  pupa  state;  as  soon  as  they  have  acquired  wings  they 
rise  in  the  air  and  spread  to  new  vineyards,  where  they  lay 
their  eggs  usually  in  the  down  of  the  under  sides  of  the 
leaves.  Each  individual  of  this  generation  lays  from  three 
to  five,  and  some  as  many  as  eight  eggs.  These  eggs  are 
of  two  sizes;  the  smaller,  which  produce  males,  are  about 
three  fourths  of  the  size  of  the  larger,  which  produce  fe¬ 
males.  From  these  eggs  are  hatched  in  the  course  of  a 
fortnight  the  third  or  wingless  sexual  form.  It  is  a  very 
remarkable  fact  that  this  form  emerges  from  the  egg  not 
as  larva,  but  as  fully  developed  individuals.  These  sexual 
individuals  are  born  for  no  other  purpose  than  the  produc¬ 
tion  of  their  kind,  and  are  without  means  of  flight  or  tak¬ 
ing  food.  After  pairing,  the  body  of  the  female  enlarges 
somewhat,  and  she  is  soon  delivered  of  a  solitary  egg. 
The  impregnated  egg  gives  birth  to  a  young  louse,  which 
develops  into  the  first  form,  and  thus  recommences  the 
cycle  of  changes.  It  has  been  discovered  that  sometimes, 
the  first  form  during  the  latter  part  of  the  season  lax  s  a  few 
eggs,  which  are  of  two  sizes  like  those  of  the  second  form, 
and  also  produces  males  and  females,  which  are  precisely 
like  those  born  of  the  winged  form,  and,  like  them,  produce 
the  solitary  impregnated  egg.  Thus  the  fact  is  established 
that  even  the  winged  form  is  not  essential  to  the  perpetua¬ 
tion  of  the  species.  Occasionally  individuals  abandon  their 
normal  underground  habit  and  form  galls  upon  the  leaves 
of  certain  varieties  of  grape-vine.  Owing  to  the  great  in¬ 
jury  this  species  has  done  to  the  vineyards  of  France,  hun¬ 
dreds  of  memoirs  have  been  published  regarding  it.  But 
as  yet  no  satisfactory  means  of  destroying  it  has  been  dis¬ 
covered.  The  difficulty  lies  in  the  fact  that  the  insecticide 
must  be  one  that  can  penetrate  the  ground  to  the  depth  of 
three  or  four  feet,  reaching  all  the  fibrous  roots  infested  by 
the  insect.  It  must  be  a  substance  that  can  be  cheaply 
applied  on  a  large  scale  and  that  will  kill  the  insect  without 
injury  to  the  vine.  Where  the  vineyards  are  so  situated 
that  they  can  be  submerged  with  water  for  a  period  of  at 
least  forty  days  during  winter,  the  insect  can  be  drowned. 
It  is  found  that  vines  growing  in  very  sandy  soil  resist  the 
attacks  of  the  grape  Phylloxera.  This  is  supposed  to  be 
due  to  the  difficulty  experienced  by  the  insect  in  finding- 
passages  through  such  soil.” 

Here  we  have  the  whole  natural  history  of  a  bacillary 
tubercular  disease  in  plants.  Notwithstanding  the  fact 
that  every  phase  of  its  life  history  is  well  understood  and 
the  diseased  parts  can  be  seen  and  handled,  yet  its  treat¬ 
ment  is  futile.  This  teaches  us  the  narrowness  of  our 


684 


BHUbH:  MIMICRY  OF  ANIMAL  TUBERCULOSIS  IN  VEGETABLE  FORMS.  IN.  Y.  Med.  Jock., 


study  of  human  tuberculosis  when  we  imagine  that  Koch’s 
discovery  of  the  bacillus  placed  us  in  a  position  to  treat 
this  complicated  disease.  \\  e  do  not  know  the  manner  in 
which  the  bacillus  gains  the  position  it  occupies  in  the  tu¬ 
bercular  mass,  or  why  it  sometimes  attacks  the  lungs,  and 
sometimes  the  glands,  and  sometimes  the  bones.  Is  it  con¬ 
veyed  to  its  position  by  a  host?  Nothing  we  as  yet  know 
indicates  this  supposition  except  the  analogy  of  vegetable 
parasites.  It  is  not  found  in  the  blood  or  in  the  muscular 
juices.  The  present  exclusive  devotion  to  the  observation 
of  bacteria  would  almost  preclude  the  detection  of  a  host 
if  one  did  exist.  Crookshank,  in  an  appendix  to  his  work 
on  Bacteriology ,  says:  “When  examining  blood,  the  bacte 
riologist  must  be  prepared  to  meet  with  minute  organisms, 
which  at  the  first  glance  under  moderate  amplification  may¬ 
be  mistaken  for  vibrionie  or  spiral  forms  of  bacteria.  The 
organisms  referred  to  belong  not  to  the  vegetable  but  to 
the  animal  kingdom.  They  may  occur  associated  with  dis¬ 
ease,  but  they  appear  to  be  more  commonly  found  in  the 
blood  of  apparently  perfectly  healthy  animals.”  Thus  the 
fact  is  stated  by  good  authority  that  parasitic  animals  do 
exist  in  the  blood. 

This  is  not  the  only  parasite  to  illustrate  the  mimicry 
of  animal  and  vegetable  morbid  forms.  There  are  myriads 
of  parasites,  and  parasites  on  parasites,  in  the  descending 
scale  to  the  minutest  forms.  Thus  all  vital  activity  is  kept 
in  unLon  ;  nothing  is  allowed  to  die;  one  living  organism 
ceases  that  others  may  continue,  and  the  others  in  turn  are 
dissolved  to  continue  other  phases  of  vital  activity.  The 
little  germ  that  robs  man  of  his  vital ity  undoubtedly  con 
veys  that  vitality  to  some  other  living  organism,  thus  form¬ 
ing  a  link  in  the  endless  chain  of  organisms  in  action. 

Another  form  of  change  not  parasitic  is  suggestively 
analogous  to  the  bacillary  tubercular  phenomena.  The 
yeast  plant  is  a  germ,  and  undoubtedly  Pasteur’s  noted  re¬ 
searches  on  the  life  history  of  this  plant  formed  the  starting 
point  for  the  universal  study  of  bacteriology  to-day.  No 
thinking  man  could  have  followed  his  reasonings,  conclu¬ 
sions,  and  deductions  without  concluding  that  all  febrile 
conditions  at  least  were  the  result  of'  the  growth  of  germ- 
life,  producing  ptomaines,  extractives,  etc.  There  are  many 
phases  of  alcoholic  fermentation  that  mimic  the  morbid 
processes  of  bacillary  phthisis. 

Thus  we  know  that  the  presence  of  the  tubercular  germ 
in  the  mouth  or  other  parts  of  the  body  is  not  always  fol 
lowed  bv  tuberculosis.  Analogously  we  know  that  the 
presence  ot  yeast  germs  in  a  saccharine  solution  does  not 
always  give  rise  to  alcoholic  fermentation.  The  solution 
must  contain  less  than  twenty  per  cent,  of  the  saccharine  ma 
tenal.  Thus  the  specific  gravity  of  the  solution  is  the  con¬ 
trolling  condition  in  the  activity  of  the  yeast  plant.  The 
same  may  be  true  of  the  human  body.  It  can  easily  be 
understood  that  in  the  human  body  the  specific  gravity  may 
vary.  Thus  an  exceedingly  fat  and  juicy  body  would  be  of 
lighter  specific  gravity  than  a  closely-knit,  hard,  muscular 
body,  and  undoubtedly  the  specific  gravity  of  the  body  has 
something  to  do  with  the  morbid  action  of  many  of  the 
germ  phases  of  disease.  Nor  is  this  all.  Before  Pasteur’s 
enlightening  investigations  it  was  supposed  that  the  yeast 


germ  was  contained  in  the  atmospheric  dust,  but  Pasteur 
proved  conclusively  that  this  was  not  the  case.  He  admitted 
atmospheric  air  and  its  dust  into  sterilized  tubes  of  proper 
saccharine  solutions  for  the  growth  of  yeast,  but  the  alco¬ 
holic  fermentation  was  never  set  up  in  solutions  thus  treated. 
Then  the  question  arose,  A\  here  did  the  yeast  plant  come 
from  ?  and  further  study  revealed  the  fact  that  all  kinds  of 
fruit  contained  on  their  surface  a  germ  termed  by  Engel 
“  apiculated  ferment  ”  (carpozyma).  This  is  a  hibernating 
germ,  and,  unless  the  fruit  is  bruised  and  its  containing  sugar 
in  due  proportion  brought  into  contact,  the  germ  will  not 
grow  or  produce  its  special  changes.  This  plant  does  not 
in  any  way  resemble  the  ordinary  yeast  plant  unless  it  is 
modified  by  its  growth  in  a  fermenting  fluid.  May  we  not 
then  easily  suppose  that  some  germ-forms  exist  normally  in 
the  animal  tissues  prone  to  tubercular  diseases,  and  only 
develop  into  the  forms  in  which  we  find  them  when  some 
anterior  morbid  process  has  been  developed  ?  This  idea  is 
concisely  expressed  in  a  pap.er  read  before  the  New  York 
Medical  Association,  March  17,  1890,  by  Dr.  James  R. 
Learning,  a  gentleman  wdio  has  grown  old  in  the  study  of 
this  disease.  He  says:  “I  have  seen  no  case  of  phthisis 
that  could  not  be  accounted  for  satisfactorily  without  sup¬ 
posing  infection  or  contagion.  I  can  say  more.  I  have  seen 
no  case  ot  phthisis  where  there  was  a  probability  of  pri¬ 
mary  infection  with  no  other  cause. 

I  he  first  physical  evidence  of  dead  atoms  in  the  sys¬ 
tem  is  their  extension  from  the  capillaries  into  the  pleural 
cavities,  as  damaged  leucocytes  or  ptomaines  by  physical 
diagnosis;  and  this  may  be  done  before  the  presence  of  the 
bacilli  can  be  detected  in  the  sputa.  The  bacillus  is  conse¬ 
quent,  not  causative  ;  it  is  true  that  ptomaines  are  in  the 
blood  before  the  expression  of  the  leucocytes,  but,  as  a  rule, 
not  in  abundance  sufficient  to  attract  the  germs.” 

This  explanation  of  one  phase  in  the  development  of  tu¬ 
bercular  disease  will  coincide  exactly  with  the  development 
of  alcoholic  fermentation  in  the  case  of  grapes.  Thus  on  the 
suiface  or  in  connection  with  the  grape  is  a  hibernating 
geim,  and  this  germ  is  never  brought  into  activity  unless 
the  grape  is  bruised  and  forms  a  solution,  when  the  germ 
becomes  active  and  changes  the  sugar  into  alcohol  and  other 
products  of  fermentation,  which  mimic  the  formation  of 
ptomaines  in  the  animal  economy. 

There  are  many  other  forms  of  vital  processes  outside 
of  the  animal  body  that  mimic  its  morbid  processes.  All 
these  forms  are  complicated,  many  of  them  mysterious,  and 
associated  with  an  interminable  train  of  anterior  and  subse¬ 
quent  evolutions  to  the  germ  activity.  My  object  in  alluding 
to  those  enumerated  is  only  to  show  the  apparent  fallacy  of 
our  imagining  that  because  we  have  discovered  the  presence 
of  a  minute  germ,  we  are  also  in  possession  of  sufficient 
knowledge  of  the  morbid  processes  associated  with  this 
germ  to  indicate  a  rational  mode  of  treating  the  disease 
where  the  germ  exists,  without  knowing  definitely  how  much 
other  conditions  outside  the  germ  have  to  do  with  the  pro¬ 
cess.  It  has  ever  been  one  of  the  characteristics  of  scientific 
men  to  make  sweeping  and  hasty  deductions  from  the  dis¬ 
covery  of  some  one  undoubted  fact.  I  do  not  in  any  man¬ 
ner  wish  to  detract  from  the  honor  and  brilliancy  of  Koch’s 


Dec.  20,  1800.] 


GO  RR  ES  POND  ENCE. 


f>85 


discovery,  bat  I  wish  to  protest  against  the  tendency  of  the 
medical  mind  to-day  to  hang  everything  on  the  bacillus. 
For  instance,  if  the  bacillus  was  the  only  cause  of  tubercu¬ 
losis,  it  would  have  to  be  viewed  in  the  light  of  a  foreign 
body  within  the  tissues,  and  we  know  that  foreign  bodies 
always  set  up  inflammatory  action  and  subsequent  suppura¬ 
tion,  which  is  not  always  the  history  of  tubercular  processes. 
These  are  sometimes  organized  or  cretefied.  There  is  a 
germ  disease  where  the  morbid  processes  depend  on  the 
germ  and  the  germ  alone,  and  an  abscess  is  always  formed 
by  this  germ  (actinomycosis),  and  a  cleaning  out  of  the  ab¬ 
scess  and  total  elimination  of  the  germ  cures  the  morbid 
process.  But  I  think  the  presence  of  the  tubercular  bacilli 
must  be  viewed  in  somewhat  the  same  light  as  the  nut-gall 
of  Phylloxera.  In  this  the  presence  of  the  eggs  is  not  the 
cause  of  the  tubercular  growth,  because  if  the  egg  alone 
were  deposited  in  the  leaf  it  would  act  as  a  foreign  body  ; 
it  is  the  material  that  is  injected  into  the  leaf  at  the  same 
time  as  the  egg  is  deposited  which  sets  up  such  an  action 
in  the  nutritive  processes  of  the  leaf  that  the  irritation  of 
the  egg  is  entirely  overcome. 

Without  much  stretch  of  the  imagination  we  can  ima¬ 
gine  the  giant  cell  as  occupying  the  position  in  the  tubercle 
of  human  phthisis  that  the  egg  of  the  Cynips  occupies  in  the 
nut-gall.  According  to  this  view,  the  bacillus  would  be  the 
nutritive  material  causing  the  growth  of  the  tubercle.  These 
surmises  and  similes  could  be  carried  on  ad  infinitum ,  but 
I  think  the  mimicry  is  suggestive  enough  to  indicate  to  us 
that  there  is  vastly  more  to  be  known  of  human  tuberculo¬ 
sis  than  merely  that  a  germ  is  present  in  a  mass  of  morbid 
material. 


Correspondence. 


LETTER  FROM  DUBLIN. 

Dublin  Hospital  Sunday. —  The  Royal  Academy  of  Medicine  in 
Ireland. —  The  Royal  University  of  Ireland.  —  Professor 
Koch's  Treatment  of  Tuberculosis.— Typhoid  Fever  in  Dub¬ 
lin- —  The  Royal  Hospital  for  Incurables. — Sir  J.  T.  Banks , 
K.  G.  B. 

Dublin,  November  25,  1890. 

Collections  in  aid  of  the  Dublin  hospitals  took  place  on 
the  8th  inst.  in  about  two  hundred  and  thirty  churches  in  the 
Dublin  district.  Last  year  the  Dublin  Hospital  Sunday  Fund 
obtained  a  sum  of  £4,155  5s.  4 d.,  and  since  its  institution  the 
total  collected  has  amounted  to  no  less  than  £61,345  15s.  9 d. 

The  eighth  annual  general  meeting  of  the  Royal  Academy 
of  Medicine  in  Ireland  took  place  at  the  close  of  last  month, 
when  the  office-bearers  for  the  ensuing  year  were  elected.  The 
same  evening  the  Academy  lecture,  on  The  Modern  Diagnosis 
of  Diseases  of  the  Stomach,  was  delivered  at  the  Royal  College 
of  Physicians  by  Professor  Purser,  the  chair  being  occupied  by 
Dr.  Samuel  Gordon,  president  of  the  Academy.  Professor 
Purser,  in  the  course  of  his  address,  dealt  with  the  aids  which 
modern  research  has  given  to  obtaining  a  better  insight  as  re¬ 
gards  the  functions  of  the  stomach,  both  in  health  and  in  dis¬ 
ease.  He  recommended  the  removal  of  the  contents  of  the 
stomach  with  a  soft-rubber  tube,  and  then  their  examination  by 
chemical  means  to  see  if  free  hydrochloric  acid  was  present. 
He  showed  that  this  method  was  of  great  practical  importance, 
and  enabled  the  physician  in  some  difficult  cases  to  arrive  at  a 


more  certain  diagnosis  than  had  hitherto  been  possible.  The 
first  meeting  of  the  Surgical  Section  of  the  Academy  was  held 
on  the  14th  inst.,  when  an  interesting  discussion  took  place  on 
a  case  of  enterectomy  described  by  Mr.  Hayes.  The  varieties 
of  sutures  used  were  referred  to,  great  praise  being  accorded  to 
the  method  of  decalcified  bone  plates  as  suggested  by  Professor 
Senn,  of  Milwaukee.  At  the  termination  of  the  meeting  Mr. 
Oroly,  the  president  of  the  college  and  of  the  Section,  enter¬ 
tained  over  a  hundred  guests  at  supper  at  the  College  of  Sur¬ 
geons. 

The  degrees  recently  obtained  by  the  graduates  of  the  Royal 
University  of  Ireland  were  conferred  by  the  Right  Hon.  J.  Ball, 
LL.  D.,  pro-vice-chancellor,  who  in  the  course  of  an  interesting 
address  referred  to  the  fact  that  female  students  were  in  that 
university  permitted  to  compete  for  prizes.  In  every  depart¬ 
ment,  he  said.gthey  had  obtained  honors — classics,  modern  lan¬ 
guages,  literature,  mental  and  moral  science,  and  even  mathe¬ 
matics  and  the  kindred  sciences.  Miss  Robertson  had  won  in 
experimental  physics  the  highest  prize — a  studentship  of  £100 
a  year,  tenable  for  three  years.  In  the  evening  a  conversazione , 
given  byv'the  graduates,  took  place  in  the  university  buildings, 
and  was  a  great  success.  It  was  the  first  of  its  kind,  and  prob¬ 
ably  will  be  repeated. 

Professor  Koch’s  treatment  of  tubercle  has  attracted  con¬ 
siderable  attention,  and  several  of  our  physicians  and  surgeons 
have  gone  to  Berlin  to  see  the  treatment  carried  out  and  to  ob¬ 
tain  the  “lymph”  necessary  for  the  hypodermic  injections. 
The  composition  of  the  fluid  has  not  up  to  this  been  disclosed, 
but  it  is  probable  that,  if  the  results  are  fairly  successful,  the 
method  of  preparation  will  shortly  be  published. 

Typhoid  fever  has  been  rather  prevalent  for  some  time  past 
in  Dublin,  and  numerous  deaths  have  taken  place  from  this  dis¬ 
ease.  As  the  water  is  one  of  the  purest,  the  prevalence  of  the 
fever  is  probably  due  to  defective  drainage.  On  the  other  hand , 
typhus  fever  has  to  a  great  extent  disappeared,  although  some 
years  since  it  was  one  of  the  most  fatal  of  the  zymotic  class  of 
affections. 

The  Royal  Hospital  for  Incurables  has  been  left  the  hand¬ 
some  sum  of  £10,000  by  the  late  Mr.  T.  E.  Ryan,  of  Dublin,  one 
of  the  governors,  who  when  alive  took  considerable  interest  in 
the  working  of  the  hospital. 

Sir  J.  T.  Banks,  K.  0.  B.,  M.  D.,  the  eminent  Dublin  physi¬ 
cian,  will  hold  the  office  of  high  sheriff  for  the  County  Mon¬ 
aghan  for  next  year. 


Albuminuria  in  Infancy. — The  Lancet  for  November  15th  quotes 
Seyournet  in  regard  to  a  newly  recognized  type  of  renal  congestion, 
with  albuminuria,  in  very  young  children,  which  he  believes  is  not  in¬ 
frequent.  It  is  not  the  same  as  scarlatinal  albuminuria.  lie  has  stud¬ 
ied  the  malady  in  children  from  a  year  to  a  year  and  a  half  old.  Many 
of  the  subjects  were  bottle-fed  or  had  been  given  unsuitable  articles  of 
diet,  which  caused  distended  stomach  and  intestines,  with  catarrh  of 
the  latter,  sometimes  with  vomiting  and  diarrhoea,  and  in  a  few  instances 
an  enlargement  of  the  liver.  He  believes  that  the  albuminuria  is  toxic 
and  due  to  the  generation  of  certain  substances  by  fermentative  action 
of  an.  abnormal  nature  within  the  bowels,  and  their  absorption  thence 
into  the  renal  circulation,  the  brunt  of  their  offense  being  expended 
upon  the  latter  organs.  The  disease  was  marked  by  anuria  in  many 
cases  ;  in  some  cases  not  more  than  half  an  ounce  of  urine  was  passed 
in  a  day.  (Edema  of  the  feet,  and  even  of  the  face  and  eyelids,  frt~ 
quently  occurred.  The  duration  of  the  disease  was  from  two  to  four 
weeks.  The  treatment  that  served  the  most  useful  purposes  included 
the  employment  of  intestinal  antisepsis,  salicylate  of  bismuth  and  its 
congeners  being  commonly  employed,  and  a  diet  of  milk  and  lime-water. 
Gentle  aperients  were  used  when  there  was  vomiting,  and  systematic 
massage  over  the  kidneys  in  order  to  reduce  the  congestion  of  those 
organs. 


686 


LEADING  ARTICLES. 


[N.  Y.  Mkl>.  Jock., 


the 


NEW  YORK  MEDICAL  JOURNAL, 


Published  by 
D.  Appleton  &  Co. 


A  Weekly  Review  of  Medicine. 


Edited  by 
Frank  P.  Foster,  M.  D 


NEW  YORK,  SATURDAY,  DECEMBER  20,  1890. 


THE  PROGRESS  OF  THE  KOCH  TREATMENT  OF  TUBER¬ 
CULAR  DISEASE. 

It  appears  now  that  New  Haven  was  not  the  scene  of  the 
first  trials  of  Professor  Koch’s  remedy  in  America;  it  had  been 
in  use  for  several  days  at  the  Hospital  for  the  Ruptured  and 
Crippled,  and  it  is  now  the  subject  of  experiment  at  many  of 
the  New  "iork  hospitals.  So  far  as  inferences  may  be  drawn 
from  what  has  been  observed  here  and  elsewhere,  they  are  sug¬ 
gestive  rather  than  decisive,  and  they  bear  more  upon  the 
physiological  action  of  the  remedy  than  upon  the  radical  ques 
tion  of  whether  or  not  it  is  curative.  We  shall  revert  to  these 
matters  farther  on.  In  the  mean  time  mention  should  be  made 
of  a  remarkable  contribution  that  has  been  made  to  the  litera¬ 
ture  of  the  subject* 

I  he  work  to  which  we  allude  is  a  brochure  of  fifty-eight 
pages,  by  two  London  gentlemen,  and  they  state  that  its  con¬ 
tents  are  the  outcome  of  their  personal  observations  in  Berlin, 
chiefly  at  the  CharitA  The  preface  is  dated  November  29th, 
and  the  book  shows  a  number  of  signs  of  haste  in  its  prepara¬ 
tion,  the  most  noticeable  of  which  is  a  blank  space  where  there 
should  be  an  engraving.  Mr.  Griin  and  Mr.  Severn  seem  to 
have  been  the  first  to  get  out  a  monograph  on  the  Koch  treat¬ 
ment,  and  the  gratification  of  having  done  so  will  no  doubt 
compensate  them  for  any  chagrin  they  might  feel  on  account 
of  the  defects  incident  to  its  hasty  preparation.  They  are  en 
thusiastic  believers  in  the  efficacy  of  Koch’s  treatment,  and 
they  rank  his  supposed  discovery  far  above  Jenner’s,  classing 
the  latter  (somewhat  unjustly,  we  think)  as  “purely  acci¬ 
dental.” 

1  bey  conjecture  that  the  active  principle  of  the  Koch 
liquid  is  a  ptomaine  produced  by  the  Bacillus  tuberculosis , 
which,  they  say,  is  “  killed  by  an  excess  of  its  own  poisonous 
Excreta.”  Two  engravings  are  inserted  to  show  the  effect  of 
the  injection  on  the  microscopical  appearance  of  the  bacilli  in 
the  sputa.  The  authors  seem,  therefore,  to  believe,  contrary 
to  Koch  himself,  that  the  remedy  acts  on  the  bacilli ;  and  they 
explain  its  action  as  that  of  an  “  overtaking  treatment  ”  (Each 
impfung ),  denying  its  analogy  to  the  operation  of  Pastqur’s 
inoculations  with  attenuated  virus.  This  theory  can  hardly  be 
either  accepted  or  rejected  without  reserve  until  we  have  posi¬ 
tive  information  as  to  the  nature  of  Koch’s  liquid— information 
which,  as  we  have  before  remarked,  ought  not  to  be  delayed 
much  longer. 


*  Handbook  to  [sic]  Dr.  Koch's  Treatment  in  Tubercular  Disease 
By  Edward  F.  Griin,  M.  R.  C.  S.,  L.  R.  C.  P.,  and  Walter  D.  Severn 
Assoc.  Roy.  Coll.  Sci.  London :  J.  &  A.  Churchill. 


Elsewhere  in  this  issue  we  print  some  extracts  from  this 
very  interesting  pamphlet.  The  work  contains  a  goodly  num¬ 
ber  of  detailed  histories  of  cases,  with  particularly  full  tem¬ 
perature  records,  although  the  authors  state  that  they  found  it 
impossible  to  induce  the  hospital  officials  in  Berlin  to  have  the 
patients’  temperature  observed  at  night. 

Several  deaths  have  occurred  in  Berlin  and  elsewhere  as 
the  apparent  result  of  the  injections,  and  this  has  emphasized 
the  necessity  of  caution  in  their  employment.  A  cable  dis¬ 
patch  received  on  Monday,  the  15th  inst.,  from  Dr.  John 
Guiteias,  of  I  hiladelpbia,  who  is  now  in  Berlin,  is  summar¬ 
ized  as  follows  in  a  supplement  to  the  December  number  of  the 
University  Medical  Magazine ,  of  Philadelphia:  “A  greater  de¬ 
gree  of  caution  is  being  observed,  especially  as  to  the  selection 
of  cases  of  pulmonary  phthisis  subjected  to  the  lymph  treat¬ 
ment.  I  he  results,  in  this  disease  at  least,  are  as  yet  inconclu¬ 
sive.  Many  cases  are  not  decidedly  improved.  There  is  some 
tisk  of  complication.  Both  pneumonia  and  meningitis  have 
been  observed.  The  general  situation  may  be  summed  up  by 
stating  that  a  spirit  of  caution  prevails  in  Berlin  to-day.”  A 
press  dispatch  from  St.  Petersburg,  dated  the  17th  inst.,  states 
that  the  use  ot  the  method  in  Russia  has  been  prohibited  until 
it  has  been  properly  investigated  under  the  direction  of  the 
Government.  A  death  has  occurred  in  New  York  within  a 
few  hours  after  an  injection,  but  it  was  that  of  a  child  almost 
moribund  with  tubercular  meningitis,  and  the  procedure  is  not 
thought  to  have  hastened  the  death. 

Swelling  of  the  spleen  and  pain  in  the  region  of  that  organ 
are  said  to  have  accompanied  the  febrile  reaction  in  some  of 
the  New  York  experiments,  but  Dr.  Gibney,  of  the  Hospital 
for  the  Ruptured  and  Crippled,  and  Dr.  Kinnicutt,  of  St.  Luke’s 
Hospital,  say  that  those  phenomena  have  not  occurred  in  the 
patients  under  their  observation. 

In  cases  of  pulmonary  tuberculosis,  the  cough  and  expecto¬ 
ration  are  usually  increased,  and  this  increase  is  one  of  the 
primary  results  of  the  injection,  and  haemoptysis  is  apt  to  oc¬ 
cur.  In  one  of  Dr.  Gibney’s  patients,  a  child  whose  lungs  had 
been  pronounced  sound  by  Dr.  Thacher,  cough  or  “  snuffles  ” 
came  on  in  nine  hours  after  the  injection.  If  this  should  prove 
to  be  a  common  occurrence,  there  may  be  some  ground  for  en¬ 
tertaining  the  idea  that  the  remedy  has  an  affinity  for  the  pul¬ 
monary  tract  independently  of  its  supposed  affinity  for  tubercu¬ 
lous  tissue  ;  but  there  are  some  excellent  observers  who,  like 
Di .  Kinnicutt,  do  not  believe  that  an  individual  affected  with 
a  tuberculous  disease  can  be  said  to  be  absolutely  free  from 
pulmonary  tuberculosis,  although  the  deposit  may  be  so  small 
that  no  physical  examination,  however  carefully  made,  will 
reveal  it. 

Lupus  seems  still  to  constitute  the  most  favorable  field  for 
experiment.  No  definitive  cure  of  that  disease  by  the  new 
treatment  has,  so  far  as  our  information  goes,  yet  been  record¬ 
ed;  but  the  various  observers  here  and  abroad  are  substantially 
unanimous  in  their  descriptions  of  the  local  and  constitutional 
lesults  ot  the  injections — the  affected  part  becomes  swollen, 
red,  and  painful,  and  eczematous  exudation  follows,  this  is  sue- 


Dec.  20,  1800.] 


LEADING  ARTICLES.— MINOR  PARAGRAPHS. 


687 


c.eeded  by  incrustation,  and,  when  the  crust  falls  or  is  detached, 
the  surface  shows  decided  improvement.  The  University  of 
Pennsylvania’s  commission,  consisting  of  Dr.  William  Pepper, 
Dr.  James  Tyson,  Dr.  J.  William  White,  and  Dr.  John  II.  Mus- 
ser,  cite  Nencki  and  Sahli  as  having  shown  that  the  local 
changes  are  very  similar  to  those  produced  by  the  inoculation 
of  lupous  patients  with  erysipelas;  and  this  suggests  that  the 
products  of  more  than  one  micro-organism — in  other  words, 
more  than  one  medicinal  agent — may  prove  antagonistic  to  the 
tuberculous  processes. 

In  conclusion,  the  main  question  of  the  curative  efficacy  of 
the  Koch  liquid  seems  hardly  nearer  a  solution  than  at  first, 
but  our  stock  of  facts  in  regard  to  its  effects  is  accumulation 
satisfactorily. 

THE  ABUSE  OF  MEDICAL  CHARITY. 

We  are  glad  to  see  so  strong  and  able  a  protest  against  the 
abuse  of  medical  charity  in  our  large  cities  as  that  of  Dr. 
Gould,  published  in  the  Medical  News  for  the  22d  ultimo. 
Evidently  he  has  spent  much  more  thought  on  this  subject 
than  most  of  us,  who,  while  bemoaning  the  medical  beggary 
that  exists,  continue  to  degrade  ourselves  and  our  patients  by 
indiscriminate  medical  almsgiving,  for  he  has  suggested  a 
means,  it  not  of  cure,  at  least  of  prophylaxis.  His  statements 
would  seem  to  be  the  embodiment  of  exaggeration  to  one  not 
acquainted  with  the  actual  state  of  things  in  our  large  cities, 
but  the  worst  of  the  paper  is  that  it  so  accurately  portrays  the 
truth.  Every  physician  of  a  clinic  can  cite  cases  from  his  own 
experience  which  are  evidences  of  the  pauperization  of  people 
able  to  pay  him  a  fair  price  for  his  services.  The  case  of 
curvature  of  the  spine  in  a  person  who  made  the  rounds  of 
several  hospitals  and  was  given  salicylates  for  probable  muscu¬ 
lar  rheumatism,  until  finally  examined  by  a  more  conscientious 
physician,  may  be  an  extreme  and  humiliating  example  of  care¬ 
less  snap  diagnosis  and  routine  treatment  induced  by  the  hurry 
of  the  clinic  room  ;  but  we  fear  that  similar  cases  are  only  too 
common,  and  we  know  that  habits  of  haste  and  carelessness 
are  engendered  thereby. 

Regarding  the  effect  of  this  abuse  upon  the  young  practi¬ 
tioners,  Dr.  Gould  says:  “When  they  enter  upon  their  career 
they  find  that  the  older  physicians  treat,  free  of  charge,  thou¬ 
sands  and  hundreds  of  thousands  of  patients  who  could  pay 
something,  and  that  the  younger  physicians  who  need  encour¬ 
agement  and  practice,  and  to  whom  these  patients  would 
naturally  fall,  are  left  to  starve  for  years,  until  somehow  they 
wriggle  into  a  properly  compensated  practice.  It  is  brutally 
unjust  to  the  young  practitioner.”  The  truth  of  this  needs  no 
affirmation  to  one  who  is  or  has  been  a  young  practitioner  in  a 
large  city. 

This  abuse,  he  maintains,  has  arisen  as  the  combined  result 
ot  several  confluent  causes,  pre-eminent  among  which,  be  it 
ever  remembered,  are  the  tender  solicitude  and  unselfish  kind¬ 
ness  toward  the  sick  on  the  part  of  medical  men  generally. 
Prominent  among  the  other  causes  are  the  carelessness  of  alms- 
givers  and  testators  in  not  providing  against  a  misuse  of  their 


bouuty,  the  neglect  of  trustees  and  managers  of  hospitals  to 
cause  a  proper  investigation  of  the  alleged  poverty  of  appli¬ 
cants  for  the  benefits  of  the  charity,  the  foolish  competition 
among  hospitals  to  treat  the  largest  number  of  patients,  the  de¬ 
sire  tor  clinical  material  for  teaching  purposes,  the  desire  on 
the  part  of  the  visiting  physician  to  see  many  patients  in  order 
to  study  disease  in  its  infinite  diversity  and  gain  perfected  tech¬ 
nique,  and,  most  active  perhaps,  the  desire  on  the  part  of  the 
chief  and  assistant  physicians  to  build  up  a  private  practice  in¬ 
directly. 

The  results  Dr.  Gould  partially  enumerates  as :  1.  The  en¬ 
couragement  of  pauperism,  dependence,  and  deceit  in  a  large 
class  of  the  community.  2.  The  danger  that,  if  it  is  ignored 
until  it  becomes  still  further  exaggerated,  when  the  knowledge 
of  its  enormity  finally  bursts  upon  the  community,  all  forms  of 
praiseworthy  and  necessary  charity  will  suffer.  3.  Injury  to 
both  physician  and  patient  from  a  hurried  and  routine  diagno¬ 
sis  and  treatment.  4.  The  degradation  of  the  medical  profes¬ 
sion  by  encouraging  envy  and  subtle  methods  of  advertising 
and  by  depriving  the  younger  members  of  their  proper  clien¬ 
tele. 

The  remedy  he  suggests  is  that  a  codicil  to  all  wills  and  be¬ 
quests  be  prescribed,  worded  in  such  a  manner  that,  unless  the 
trustees  of  the  institutions  named  exercise  stringent  care  that 
only  truly  needy  persons  receive  the  benefit  of  the  bounty,  the 
bequests  shall  revert  to  the  heirs.  The  practicability  of  this 
proposition  we  do  not  care  to  discuss  at  this  time,  but  we  are 
glad  to  have  a  definite  suggestion  made,  and  if  it  is  practicable 
its  efficiency  can  hardly  be  doubted. 

We  can  not  agree  to  all  that  Dr.  Gould  says  regarding  the 
sufferings  of  the  country  practitioner  from  this  cause,  for  we 
have  known  of  too  many  cases  in  which  the  country  practi¬ 
tioner  has  caused  imposition  and  deceit  to  be  practiced  upon 
his  city  brother  by  advising  his  patient  to  attend  the  clinic, 
poorly  dressed,  and  to  get  the  benefit  of  a  consultation  for 
nothing.  If  such  patients  should  thereafter  choose  to  attend 
the  clinic  to  the  pecuniary  loss  of  the  practitioner  who  gave 
such  advice,  the  latter  would  suffer  poetic  retributive  justice. 
But  as  to  the  main  points  in  his  paper  we  heartily  agree  with 
him.  The  same  effective  inquiry  that  has  been  found  neces¬ 
sary  in  all  other  forms  of  charity  should  be  insisted  on  regard¬ 
ing  the  fitness  of  applicants  to  receive  medical  charity,  and  the  - 
rights  of  the  younger  members  of  the  profession  should  be 
regarded. 

MILS  OR  PARAGRAPHS. 

THE  ABORTIVE  TREATMENT  OF  ERYSIPELAS. 

In  the  Gazzetta  degli  ospitali  for  October  22, 1890,  Dr.  Natale 
Amici  adds  some  remarks  to  those  first  published  by  him  in 
1885  upon  this  subject.  His  method  of  treatment  consists  in 
destroying  the  streptococcus  of  erysipelas  in  the  shortest  possi¬ 
ble  time.  He  insists  that  the  infection  is  not  always  limited  by 
the  border  of  the  erysipelatous  blush,  but  often  extends  beyond 
this  into  the  apparently  sound  skin,  even  to  a  distance  of  40 
centimetres.  This  latent  erysipelas  should  be  treated  as  well 
as  that  which  is  visible,  and  herein  lies  the  success  of  his  metb- 


6S8 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Joor., 


od.  The  chief  symptom  of  latent  infection  is  tenderness  on 
pressure  in  the  apparently  healthy  skin  contiguous  to  that  which 
is  already  red  and  inflamed.  Amici  has  succeeded  best  with 
carbolic  acid  and  corrosive  sublimate.  In  using  carbolic  acid, 
he  formerly  combined  it  with  alcohol,  taking  equal  parts  of 
each.  This  application  was  effective,  but  caused  smarting  and 
discoloration  of  the  skin.  He  has  therefore  replaced  the  alco¬ 
hol  with  glycerin,  the  proportions  remaining  the  same.  The 
mixture  is  to  be  applied  every  two  hours  over  the  whole  of  the 
affected  parts,  and  its  use  continued  so  long  as  there  are  auy 
symptoms  of  extension  of  the  infection.  With  persons  with  a 
very  delicate  skin,  or  with  children,  the  intervals  may  be  made 
longer.  Under  this  treatment  all  symptoms  of  erysipelas  dis¬ 
appear  within  two  or  three  days.  Should  the  subcutaneous 
tissues  be  involved  (phlegmonous  erysipelas),  hypodermic  in¬ 
jections  of  a  1-,  2-,  or  3-per-cent,  aqueous  solution  of  carbolic 
acid  are  to  be  made  with  a  Pravaz’s  syringe,  according  to  Hue- 
ter's  method.  The  urine  should  always  be  carefully  watched, 
and,  should  it  show  too  great  an  absorption  of  carbolic  acid,  the 
applications  must  be  diminished  in  number  or  even  entirely 
abandoned.  Amici  has  never  seen  any  bad  results  when  this 
precaution  was  observed.  Some  individuals  can  not  tolerate 
the  odor  of  carbolic  acid.  In  such  cases  Amici  employs  a  1- 
per-cent.  solution  of  corrosive  sublimate  in  glycerin,  to  be  used 
in  the  same  manner.  The  patient’s  gums  should  be  carefully 
observed,  to  avoid  mercurial  stomatitis. 


THE  ANNUAL  REPORT  OF  THE  SURGEON-GENERAL  OF 

THE  ARMY. 

This  Annual  Report  for  the  Year  ending  June  SO,  1890,  shows 
that  32,880  cases  were  under  treatment,  the  rate  of  admission 
to  sick  report  being  1,315-02  to  the  thousand  of  strength, 
44-12  men  to  the  thousand  being  constantly  non-effective  from 
sickness,  and  the  death  rate  being  6-33.  The  volume  contains 
the  usual  reports  on  the  health  of  the  military  departments  and 
on  that  of  the  individual  posts,  on  the  prevalence  of  special  dis¬ 
eases,  on  field  operations,  and  on  the  general  sanitary  condition 
of  the  army.  The  medical  officers  of  the  national  guards  of  the 
various  States  may  find  Captain  Brechemin’s  criticisms  on  this 
arm  of  the  militia  interesting,  and  his  advice  as  to  a  more  care¬ 
ful  study  of  certain  text-books  should  be  followed.  The  pub¬ 
lication  of  special  reports  of  medical  and  surgical  cases  has 
been  omitted  ;  this  seems  advisable,  for  reports  of  interesting 
cases  should  have  wider  dissemination  than  the  necessarily  lim¬ 
ited  circulation  of  an  official  report  affords,  and  such  papers 
unnecessarily  increase  the  bulk  of  the  volume.  The  efficiency 
of  the  medical  corps  of  the  army  is  in  no  way  better  shown 
than  by  the  very  nearly  constant  annual  average  of  the  sanitary 
statistics,  and  there  is  every  reason  to  believe  that  its  high 
standard  of  excellence  will  continue. 


THE  ANNUAL  REPORT  OF  THE  SURGEON-GENERAL  OF 

THE  NAVY. 

During  the  fiscal  year  ending  June  30,  1890,  12,029  patients 
were  treated,  and  9-89  in  a  1,000  died  ;  of  13,444  persons  ex¬ 
amined  for  enlistment,  more  than  a  third  were  rejected.  The 
Museum  of  Hy  giene  at  Washington  has  improved  satisfactorily 
during  the  year,  and  its  field  of  usefulness  is  constantly  becom¬ 
ing  better  appreciated.  Reference  is  made  to  the  failure  of 
Congress  to  enact  a  bill  for  improving  the  rank  and  pay  of  as¬ 
sistant  surgeons,  and  it  seems  impossible  to  obtain  a  sufficient 
number  of  qualified  physicians  to  fill  existing  vacancies.  The 
volume  concludes  with  the  usual  statistical  tables  and  reports 
of  medical  officers  attached  to  the  different  vessels. 


SALICYLIC  ACID  AS  A  PROPHYLACTIC  OF  SCARLET  FEVER. 

In  an  October  number  of  the  Centralblatt  fur  kliniache 
Medicin  Dr.  G.  Sticker  reports  the  observations  of  Dr.  G.  de 
Rosa,  as  published  in  the  Giornale  internazionale  delle  scienze 
mediche ,  as  to  the  value  of  salicylic  acid  as  a  preventive  of  scar¬ 
let  fever.  Out  of  sixtv-six  children  exposed  to  the  infection, 
twenty-seven  eases  existing  in  one  house,  only  three  took  the 
disease  after  the  administration  of  the  drug,  and  in  those  the 
failure  was  attributed  to  the  fact  that  its  administration  had 
been  begun  too  long  after  exposure.  Its  use  is  to  be  begun 
when  there  is  danger  of  infection,  giving  from  0-l  to  03  gramme 
(l-5  to  4-5  grains)  daily,  until  the  possibility  of  infection  is  past. 
It  is  not  necessary  to  isolate  the  patients,  for  fear  of  their  com¬ 
municating  the  disease,  under  this  regime. 


EUPHORINE. 

The  name  euphorine  has  been  suggested  by  Professor  Gia- 
cosa  for  phenylurethrane,  ^^x^fl/ceH  )’  a  comPountl  result¬ 
ing  from  the  action  of  ethyl  ether  on  aniline.  It  is  a  white 
crystalline  powder,  with  a  faint  aromatic  odor  and  a  slight 
taste,  almost  insoluble  in  water,  but  soluble  in  weak  alcohol. 
Dr.  Sansoni,  of  Turin,  in  the  Therapeutische  Monatshefte  for 
September,  as  mentioned  in  the  Internationale  klinische  Rund¬ 
schau  for  November  2d,  gives  the  result  of  a  number  of  observa¬ 
tions  on  the  action  of  euphorine  in  disease.  Summing  up  the 
results  of  such  investigation,  the  antipyretic,  antirrheumatic, 
and  analgesic  actions  seem,  he  says,  to  be  inferior  to  those  of 
many  of  the  better-known  remedies  of  the  same  group. 


THE  FIRST  AUTOPSY  IN  NEW  ENGLAND. 

The  Boston  Medical  and  Surgical  Journal  has  a  note  re¬ 
garding  the  first  post-mortem  performed  in  New  England.  It 
recounts  the  pathological  examination  of  the  body  of  a  child, 
eight  years  old,  Elizabeth  Kelly  by  name,  who  died  in  March, 
1662,  at  or  near  Hartford.  The  child  undoubtedly  died  of  some 
acute  disease,  but  there  was  a  charge  of  witchcraft  about  it, 
the  death  being  imputed  to  the  malign  influences  of  the  gude- 
wife  Ayers,  as  a  wdtch.  This  good  lady  and  her  husband  were 
compelled  to  flee  from  their  home  lest  they  be  made  to  suffer 
the  penalty  of  the  charge,  which  was  hanging.  They  left  be¬ 
hind  them  a  child,  who  became  the  ancestor  of  one  of  the  pres¬ 
ent  families  of  Hartford.  This  event  was  recently  brought  to 
light  by  Mr.  O.  J.  Hoadley,  librarian  of  the  State  Library  of 
Connecticut,  and  made  the  basis  of  a  paper  read  by  him  before 
the  Hartford  County  Medical  Society. 


MENTHOL  FOR  CHAPPED  HANDS. 

A  writer  in  the  Provincial  Medical  Journal  offers  the  fol¬ 
lowing:  Menthol,  15  grains;  salol,  £  drachm;  olive  oil,  | 
drachm ;  lanolin,  1-|  ounce,  as  a  soothing  application  for 
chapped  hands.  The  pain,  he  says,  is  at  once  allayed  after  the 
first  application  and  the  skin  at  the  same  time  is  softened.  The 
fissures  will  heal  promptly  under  a  systematic  use  of  the  appli¬ 
cation  once  or  twice  daily. 


CHLOROFORM  OINTMENT. 

Kittei,,  according  to  the  Druggists'1  Circular,  recommends 
the  use  of  chloroform  externally  in  the  form  of  an  ointment. 
For  this  purpose  he  prescribes  one  part  of  chloroform,  one  part 
of  wax,  and  two  or  three  parts  of  lard.  This  mixture  will  keep 
the  chloroform  unaltered,  and,  when  spread  upon  linen  and  ap- 


Dec.  20,  1890. J 


MINOR  PARAGRAPHS.— ITEMS. 


689 


plied  to  the  unbroken  cutaneous  surface,  acts  quickly  and  with 
certainty  as  a  local  analgesic.  Its  mode  of  preparation  is  sim¬ 
ple .  The  wax  and  lard  are  melted  together,  and,  when  some¬ 
what  cooled  superficially,  poured  into  a  bottle,  the  inside  of 
whose  neck  as  well  as  its  glass  stopper  have  been  well  greased 
to  make  it  perfectly  air-tight;  then  the  chloroform  is  stirred  in. 
The  bottle  must  be  kept  in  a  cool  place  until  the  mixture  stiff¬ 
ens,  being  occasionally  rotated  without  being  opened. 


A  CASE  OF  VISCERAL  NEURITIS. 

Dr.  John  Ferguson,  of  Toronto,  reports  in  the  Alienist  and 
Neurologist  the  case  of  a  woman,  aged  forty,  who  had,  follow¬ 
ing  an  attack  of  influenza,  the  most  (rightful  paroxysms  of  pain, 
which  nothing  could  allay,  and,  despite  the  efforts  to  relieve 
her,  died  after  two  weeks  of  great  suffering.  Examination  of 
the  nerves  and  ganglia  throughout  the  abdomen  showed  them 
to  be  in  a  highly  inflamed  state.  Microscopically,  there  was 
marked  degeneration  in  some  of  the  nerve  tissues.  The  author 
said  that,  while  peripheral  neuritis  was  a  recognized  condition, 
he  saw  no  reason  why  neuritis  might  not  affect  the  viscera,  and 
that  this  cause  might  account  for  some  of  the  violently  painful 
and  obscure  conditions  occasionally  met  with. 


TUBERCULOUS  ABSCESSES  TREATED  BY  IODOFORM 

INJECTIONS. 

Dr.  Bullitt,  of  Louisville,  writing  from  Bonn  to  the  Ameri¬ 
can  Practitioner ,  speaks  of  the  plan  of  treating  tuberculous  ab¬ 
scess,  now  used  to  a  considerable  extent  in  Germany,  by  the 
injection  of  iodoform  in  olive  oil,  one  part  of  the  former  to  ten 
of  the  latter.  A  rather  large  needle  is  used,  and  the  pus  is 
allowed  to  escape  through  the  needle  before  the  injection  is 
made;  but  no  great  stress  is  laid  on  this  evacuation  of  the  pus. 
The  injection  of  the  iodoformed  oil  is  then  performed,  varying 
in  quantity  according  to  the  size  of  the  abscess.  This  is  re¬ 
peated  once  or  twice  a  week.  Marked  improvement  has  seemed 
to  follow  this  treatment  in  two  classes  of  cases,  one  being  that 
of  patients  suffering  from  tuberculous  testis,  and  the  other,  that 
of  those  having  abscesses  in  the  vicinity  of  diseased  joints. 


ITEMS,  ETC. 


Infectious  Diseases  in  New  York. — We  are  indebted  to  the  Sanitary 
Bureau  of  the  Health  Department  for  the  following  statement  of  cases 
and  deaths  reported  during  the  two  weeks  ending  December  16,  1890  : 


DISEASES. 

Week  ending  Dec.  9. 

Week  ending  Dec.  16. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Tvphus  fever . 

0  ’ 

0 

0 

o 

Typhoid  fever . 

19 

6 

15 

s 

Scarlet  fever . 

11 

6 

78 

4 

Cerebro-spinal  meningitis. .  . 

2 

1 

6 

3 

Measles . 

2S4 

15 

292 

19 

Diphtheria . 

114 

35 

113 

25 

Small-pox . . 

0 

0 

0 

0 

Varicella . 

4 

0 

9 

0 

Gruen  and  Severn’s  Observations  of  the  Koch  Treatment  in  Berlin. 

— With  some  verbal  changes,  the  following  consists  of  extracts  from  a 
brochure  recently  issued  in  London  by  Mr.  Edward  F.  Griin  and  Mr. 
Walter  D.  Severn : 

The  Liquid. — The  active  principle  is  so  excessively  powerful  in  its 
action  that  the  actual  maximum  strength  of  the  liquid  as  at  first  ob¬ 
tained  would  be  far  too  great  for  use ;  the  strongest  solution  which  is 
actually  used  in  the  injections,  even  in  the  most  extreme  cases,  is  a 
ten-per-cent,  dilution  of  this  “  original  ”  liquid  with  distilled  water,  to 
.  which  one  per  cent,  of  phenol  has  been  added.  The  maximum  quan¬ 
tity  injected  in  one  place  is  a  cubic  centimetre. 


VV  hen  the  liquid  is  once  diluted,  its  keeping  properties  are  consid- 
eiably  diminished.  Not  only  is  it  more  subject  to  chemical  change — 
presumably  of  the  ptomaine  in  solution  undergoing  decomposition  or 
rearrangement  of  the  atoms  in  the  molecule — but  also  it  is  nearly  sure 
during  previous  operations  to  have  derived  bacterial  impurities  from 
the  atmosphere  or  surrounding  objects,  so  that  before  use  each  time 
the  solution  should  be  heated  to  kill  any  spores  of  bacteria  which  may 
have  sprouted  in  the  intervening  time.  But  after  a  certain  number  of 
heatings  it  is  observed  that  the  activity  is  much  diminished,  and  this 
is  also  owing  probably  to  a  chemical  decomposition  or  change  which 
goes  on,  promoted  by  the  repeatedly  raised  temperature,  so  that  freshly 
diluted  lymph  must  be  prepared  every  few  days.  Taken  by  the  mouth, 
the  liquid  is  absolutely  inert ;  inhaled,  it  is  very  powerful,  but  in  this 
method  the  dosage  is  so  difficult  to  control  that  tor  purposes  of  general 
convenience  and  scientific  accuracy  it  is  in  every  way  better  to  admin¬ 
ister  the  fluid  by  means  of  the  hypodermic  syringe. 

The  Injection. — The  fluid  is  of  such  an  intensely  active  nature,  so  prone 
to  undergo  decomposition  through  careless  manipulation,  that  almost 
certainly,  unless  careful  antiseptic  precautions  are  observed,  abscesses 
of  excessively  severe  nature,  with  or  without  general  pyaemia,  or  even 
fatal  septicaemia,  would  result.  The  antiseptic  precautions  necessary 
are  the  following :  First,  the  syringe  must  be  carefully  sterilized ;  sec¬ 
ond,  the  place  where  the  injection  is  to  be  made  must  be  washed  with 
absolute  alcohol  (the  hands  of  the  operator  after  well  washing  should 
also  be  rinsed  with  absolute  alcohol) ;  and,  third,  the  cotton-wool  plug 
in  the  tube  of  diluted  liquid  ought  only  to  be  removed  for  so  long  a 
time  as  will  allow  a  certain  quantity  to  be  removed  by  the  syringe,  and 
then  quickly  replaced.  The  needle  must  be  cleansed  before  and  after 
every  operation  with  the  silver  wire  and  absolute  alcohol.  The  injec¬ 
tion  must  be  made  on  the  opposite  side  to  that  on  which  the  patient 
habitually  lies,  below  the  shoulder  blade,  in  the  region  of  the  latissimus 
dorsi ;  otherwise  the  subsequent  local  tenderness  interferes  considerably 
with  sleep.  The  injections  are  preferably  made  early  in  the  morning* 

9  a.  m.  is  the  time  adopted  in  Berlin,  and  would  be  a  good  hour  at  all 
times.  The  weakest  injections  must  be  begun  with  a  solution  of  such 
strength  that  on  injecting  a  cubic  centimetre  the  patient  shall  receive 
0-001  of  the  strong  original  liquid.  The  temperature  must  then  be 
observed  every  four  hours,  in  order  that  the  time  when  the  reaction 
sets  in  (usually  in^six  hours)  may  be  observed,  and  that  any  other  re¬ 
sults  of  this  reaction  may  not  escape  notice.  When  no  further  injec¬ 
tion  reaction  sets  in  the  strength  of  the  solution  must  be  increased,  for 
the  reason  that,  if  a  strong  solution  is  at  first  made  use  of,  the  reaction 
is  great,  but  a  tolerance  is  the  sooner  established  and  the  succeeding 
treatment  produces  little  or  no  benefit.  This  does  not,  however,  apply 
to  lupus  cases,  where  a  solution  as  strong  as  0-01  may  be  begun  with 
at  the  first  trial.  In  injecting,  the  needle  must  be  pushed  right  home, 
and  the  fluid  slowly  forced  in  and  allowed  fully  two  minutes  for  its 
total  expulsion. 

The  Effects  of  the  Injection. — The  effect  of  the  injection  used  for 
the  first  time  is  to  produce  in  the  course  of  about  three  hours,  accord¬ 
ing  to  the  nature  of  the  case,  a  decided  rigor  followed  by  a  fairly  sud¬ 
den  rise  in  the  temperature,  which,  as  exemplified  in  a  case,  rose  from 
98-2°  F.  at  3  p.  m.  to  101 -8°  at  6  p.  m.,  and  at  9  p.  m.  to  104°— sinking 
again  by  morning  to  99-2°.  If  the  case  presents  a  local  lesion  of  tu¬ 
berculous  nature,  this  lesion  swells  and  becomes  tender,  and  the  skin 
over  it  becomes  somewhat  inflamed.  The  patient  feels  drowsy,  disin¬ 
clined  to  stir,  and  nauseated,  and  loses  his  ap.petite  for  the  time  being. 

In  cases  of  advanced  phthisis  the  temperature  has  risen  to  105-8°,  fatal 
collapse  has  come  on,  and,  the  temperature  sinking,  the  patient  has 
died.  This  has  only  taken  place  in  cases  of  very  advanced  phthisis 
with  cavities.  The  temperature  often  becomes  subnormal,  and  it  may 
be  stated  that  the  higher  the  temperature  of  the  reaction  the  lower  will 
it  subsequently  fall.  An  increase  in  the  dose  by  no  means  always  pro¬ 
duces  an  increased  temperature,  but  it  is  advisable  to  begin  with  the 
lowest  possible  dose,  otherwise  the  limit  of  dosage  is  soon  reached,  and 
the  patient  becomes  tolerant.  It  does  not,  however,  follow  that  be 
cause  the  patient  becomes  tolerant  and  no 'reaction  follows,  the  injection 
ceases  to  produce  benefit,  although  the  physicians  treating  the  cases  at 
present  are  rather  inclined  to  adopt  this  view.  The  rapidity  of  the 
pulse  rises  considerably  during  the  reaction,  and  often  reaches  a  rate 


690 


ITEMS. 


of  130  or  140  to  the  minute.  Dr.  Kohler  has  reported  it  as  having 
gone  up  as  high  as  160  without  failure  of  the  heart’s  action.  Where 
patients  have  previously  suffered  from  asthma  an  attack  often  sets  in 
during  the  reaction.  Other  patients  who  had  not  previously  suffered 
from  asthma  have  been  troubled  with  some  dyspnoea  during  the  reac¬ 
tion.  At  a  meeting  of  the  Berlin  Medical  Society  on  November  20th 
two  cases  were  shown  where  a  well-marked  exanthematous  rash  ap¬ 
peared  over  the  front  of  the  chest,  the  legs,  and  the  arms,  which  rash 
lasted  about  two  days. 

In  cases  of  phthisis,  when  an  injection  is  made,  there  are  an  increase 
in  frequency  of  the  cough,  more  distress  with  the  same,  and  a  feeling 
of  restlessness  and  shortness  of  breath ;  at  first  the  patient  feels  un¬ 
doubtedly  worse,  and  there  is  occasionally  some  slight  collapse,  which, 
if  necessary,  must  be  treated  with  the  free  administration  of  stimu¬ 
lants  in  shoit,  the  patient  must  be  watched.  The  intensity  of  the 
reaction  is  in  ratio  to  the  stage  of  the  disease ;  in  the  advanced  cases 
the  reaction  is  so  great  as  occasionally  to  produce  dangerous  symptoms, 
and  these  cases  must  be  treated  with  very  dilute  solutions  to  insure 
perfect  safety.  When  there  has  been  a  previous  elevation  of  tempera¬ 
ture,  what  is  called  a  “disease  fever”  ( Krankheitsfieber ),  the  reaction 
rise  is  marked,  and  there  then  follows  a  fall  which  includes  both  the 
reaction  temperature  and  the  disease  fever.  The  sputum  becomes 
much  more  fluid,  loses  its  yellow  color,  and  diminishes  in  amount,  being 
at  the  same  time  much  easier  to  expectorate.  The  cough  becomes 
softer  and  moister.  The  patient  begins  to  improve  in  weight.  The 
bacilli  undergo  an  early  diminution  in  numbers  and  also  an  alteration 
of  form  when  seen  under  the  microscope,  many  slides  exhibiting  these 
changes  in  a  marked  degree.  The  special  changes  are  a  lessening  of 
the  size,  a  breaking  up  into  debris,  and  a  bending  into  a  half-moon 
shape,  some  exhibiting  a  swelling  at  either  end  ;  not  only  is  this  noticed 
in  one  or  two  of  the  specimens  on  the  slide,  but  the  whole  slide  is  in 
this  condition,  a  healthy,  well-developed  bacillus  being  difficult  to  find 
in  other  words,  the  bacilli  evidently  undergo  a  species  of  degenera¬ 
tion.  Sufficient  are  probably  left,  however,  to  form  a  fresh  nidus  of 
infection  if  the  treatment  were  discontinued  at  this  stage,  and  it  must 
be  assumed  that  it  will  in  all  cases  be  necessary  to  continue  the  treat¬ 
ment  until  the  sputum  is  entirely  free  from  bacilli.  The  influence  upon 
the  percussion-note  is  well  marked.  In  some  cases  the  dullness  has 
been  found  much  diminished  in  area.  The  crepitation  disappears.  The 
night  sweats  entirely  disappear  in  most  cases  after  the  first  fortnight, 
and  this  may  account  for  the  increase  in  weight. 

The  Local  Reaction. — In  lupus  the  first  effect  is  to  produce  within 
three  hours  a  feeling  of  burning,  tightness,  and  heat  over  the  face  and 
nose,  and  at  the  time  of  the  commencement  of  the  rigor  the  nose  be¬ 
comes  noticeably  reddened.  In  six  hours  the  swelling  and  redness  reach 
their  highest  point ;  they  are  not  confined  to  the  affected  part,  but  impli¬ 
cate  the  skin  for  some  distance  around ;  at  about  the  same  time  there  is 
an  ample  exudation  of  a  yellow  fluid  similar  to  that  found  upon  an  ec¬ 
zematous  surface,  which  dries  into  crusts  upon  the  surface.  The  exuda¬ 
tion  continues  for  about  forty-eight  hours.  After  two  days  the  redness 
and  swelling  begin  to  subside,  and  after  five  days  are  only  apparent 
upon  the  affected  part,  and  even  this  becomes  considerably  paler  dur¬ 
ing  the  following  three  weeks.  Five  days  after  the  injection  the  scales 
begin  to  dry  up  and  fall  off.  On  the  ninth  day  they  may  be  taken 
freely  off  their  bases.  The  affected  part  now  appears  quite  shrunken, 
ted,  and  shiny,  just  as  those  parts  of  a  lupous  patch  appear  which  have 
been  tieated  with  a  A  olkmanu’s  spoon.  After  a  certain  number  of 
dais  the  swelling  of  the  nose  subsides,  and  the  organ  regains  its  natu. 
ral  shape  and  outline ;  however,  a  number  of  small  tuberculous  spots 
remain,  most  of  them  of  about  the  size  of  a  pin-head,  forming  a  soft 
red  prominence  whose  center  often  carries  a  small  scale.  These  spots, 
in  a  case  under  observation,  increased  considerably  in  size  before  the 
day  of  the  second  injection.  The  second  injection  was  made  twenty- 
seven  days  after  the  first,  and  repeated  three  times  at  intervals  of  two 
days.  Alter  each  injection,  redness,  swelling,  and  exudation  took  place, 
although  not  to  the  same  intensity  as  the  first  time.  At  the  time  when 
the  patient  was  shown,  the  swelling  and  scaling  had  still  not  completely 
finished.  In  one  case  exhibited,  some  tubercles  imbedded  deep  in  the 
skin  had  so  far  resisted  the  treatment,  and  Dr.  Kohler  gave  it  as  his 
opinion  that  this  resistance  was  due  to  the  thickness  of  the  elastic  tis. 


[N.  Y.  Med.  Jouh. 

sue  of  this  part  of  the  skin  preventing  the  outlet  of  the  exudation  to 
the  surface,  and  thought  it  highly  probable  that  absorption  of  the 
masses  would  take  place.  The  only  example  shown  in  which  an  abso¬ 
lutely  complete  cure  had  been  established  was  that  of  a  woman  on 
whom  Volkmann’s  spoon  had  been  freely  applied  before  injection. 
This  rather  spoiled  the  scientific  value  of  the  evidence  it  supplied.  In 
a  case  of  enlarged  tuberculous  glands,  after  injection,  swelling  and  pain 
took  place  at  the  seat  of  enlargement.  At  the  same  time  all  the  en¬ 
larged  glands  were  not  equally  affected ;  some  of  the  glands  became 
very  enlarged  and  painful  ;  others  were  not  nearly  so  much,  if  at  all, 
affected. 

Dr.  Abbe’s  Case  of  Gonorrhoea  in  a  Child. — In  the  history  of  this 
case,  published  in  our  last  issue,  on  page  666,  the  strength  of  the  solu¬ 
tion  of  corrosive  sublimate  employed  as  an  injection  was  erroneously 
stated  as  1  to  8,000.  It  should  have  been  1  to  80,000. 

The  Medical  Society  of  the  County  of  Kings  held  a  reception  on 
Friday  evening,  the  12th  inst.,  at  its  rooms,  in  Bridge  Street,  Brooklyn. 

A  Public  Bath-house  is  to  be  built  by  the  New  York  Association 
for  Improving  the  Condition  of  the  Poor,  on  land  in  Broome  Street 
given  for  the  purpose  by  the  City  Mission  and  Tract  Society.  It  is  an¬ 
nounced  that  the  house  will  be  built  after  plans  prepared  by  Dr.  Simon 
Baruch. 

The  Ravages  of  Epidemic  Influenza. — Dr.  Benjamin  Lee,  secretary 
of  the  Pennsylvania  State  Board  of  Health,  has  reported  to  his  board 
an  estimate  of  the  extraordinary  losses  of  life  by  influenza  during  the 
recent  epidemic.  The  number  of  cases  in  the  State  was  probably  not 
less  than  1,120,000,  and  the  number  of  deaths  was  7,880,  or  at  the 
rate  of  one  death  in  every  142  cases. 

The  Turin  Academy  of  Medicine. — The  subject  chosen  bv  the 
Academy  for  the  Ribieri  prize  is  Researches  on  the  Nature  and  Pro¬ 
phylaxis  of  the  Infectious  Diseases  of  Man.  The  value  of  the  prize  is 
18,000  lire,  over  $3,500.  It  is  open  to  international  competition,  but 
the  competing  essays  are  limited  to  the  three  languages,  Latin,  French, 
and  Italian. 

Leprosy  at  Cape  Breton. — Two  more  cases  of  this  disease  have  been 
discovered  near  Lake  Ainsiie,  at  Cape  Breton.  The  patients  are 
women  who  have  until  quite  recently  mingled  freely  with  their  neighbors. 
The  attention  of  the  Government  has  been  called  to  the  question  of  the 
greater  or  less  latency  of  leprosy  among  certain  families  at  the  Cape, 
with  a  view  to  the  isolation  of  all  residents  discovered  ,to  be  leprous. 

Changes  of  Address.— Dr.  Peter  J.  Gibbons,  from  Pittston,  Pa.,  to 
No.  324  Warren  Street,  Syracuse,  N.  Y. ;  Dr.  H.  N.  Yineberg,  to  No. 
167  East  Sixty-first  Street. 

The  Death  of  Dr.  Glover  Perin,  of  the  Army,  is  announced  as  hav¬ 
ing  taken  place  at  his  home,  in  St.  Paul,  Minn.,  on  Monday,  the  15th 
inst.  Dr.  Perin  served  in  the  Mexican  War  and  in  the  War  of  the 
Rebellion,  and  afterward  as  a  medical  director.  Three  years  ago  he 
was  retired  with  the  rank  of  colonel. 

The  Death  of  Dr.  William  N.  Hibbard,  of  Chicago,  on  October  29t'n, 
is  thought  to  have  been  due  to  ptomaine  poisoning  consequent  upon  the 
ingestion  of  oysters.  He  was  one  of  the  junior  attaches  of  the  Chicago 
Medical  College,  and  a  young  man  of  brilliant  promise. 

The  Death  of  Dr.  Sidney  Allan  Fox,  of  Brooklyn,  occurred  on 
December  10th.  He  was  thirty-three  years  old,  a  native  of  Kentucky, 
a  graduate  of  Bellevue  Hospital  Medical  College,  and  an  ex-interne  of 
Charity  Hospital.  He  had  lived  in  Brooklyn  since  1882,  and  was 
widely  known  as  a  specialist  in  diseases  of  the  throat  and  nose.  He 
was  largely  instrumental  in  the  inauguration  of  a  special  hospital  fot 
the  treatment  of  those  diseases. 

Army  Intelligence. —  Official  List  of  Changes  in  the  Stations  and 
Duties  of  Officers  serving  in  the  Medical  Department,  United  States 
Army,  from  November  30  to  December  13,  1890 : 

Swift,  Eugene  L.,  First  Lieutenant  and  Assistant  Surgeon,  is,  by 

direction  of  the  Secretary  of  War,  relieved  from  further  duty  and 


Dec.  20,  1890.  j 


ITEMS— LETTERS  TO  TII3  EDITOR. 


691 


station  at  Fort  McDowell,  Arizona  Territory,  and  assigned  to  Fort 
Thomas,  Arizona  Territory,  where  lie  is  now  on  temporary  duty. 
Par.  16,  S.  O.  282,  A.  (1.  0.,  Washington,  December  3,  1890. 

Pilcher,  James  E.,  Captain  and  Assistant  Surgeon,  now  on  leave  of 
absence,  will,  by  direction  of  the  Secretary  of  War,  report  in  person 
to  the  commanding  general.  Division  of  the  Atlantic,  for  temporary 
duty  at  Fort  Columbus,  New  York  Harbor,  during  the  absence  on 
leave  of  Captain  William  E.  Hopkins,  Assistant  Surgeon.  Par.  3, 
S.  0.  278,  A.  G.  0.,  Washington,  D.  C.,  November  28,  1890. 

Hopkins,  William  E.,  Captain  and  Assistant  Surgeon,  is,  by  direction 
of  the  Secretary  of  War,  granted  leave  of  absence  for  six  months. 
Par.  2,  S.  0.  278,  A.  G.  0.,  Washington,  D.  C.,  November  28,  1890. 

Taylor,  Marcus  E.,  Captain  and  Assistant  Surgeon,  is  relieved  from 
further  duty  at  Boise  Barracks,  Idaho,  by  direction  of  the  Secretary 
of  War,  and  will  proceed,  at  the  expiration  of  his  present  sick  leave 
of  absence,  to  Vancouver  Barracks,  Washington,  and  report  in  per¬ 
son  to  the  commanding  officer  of  that  post  for  duty,  reporting  also, 
by  letter,  to  the  commanding  general,  Department  of  the  Columbia. 
Par.  17,  S.  0.  287,  A.  G.  0.,  Washington,  December  9,  1890. 

Gandy,  Charles  M.,  Captain  and  Assistant  Surgeon,  now  on  leave  of 
absence,  will,  by  direction  of  the  Secretary  of  War,  report  in  person, 
without  delay,  to  Colonel  Eugene  A.  Carr,  Sixth  Cavalry,  at  Rapid 
City,  South  Dakota,  for  duty  with  troops  in  the  field,  reporting  also, 
by  letter,  to  the  commanding  general,  Department  of  Dakota.  Par. 
14,  S.  0.  287,  A.  G.  0.,  Washington,  December  9,  1890. 

Naval  Intelligence. —  Official  List  of  Changes  in  the  Medical  Corps 

of  the  United  States  Navy  for  the  two  weeks  ending  December  13,  1890 : 

Atlee,  L.  W.,  Assistant  Surgeon.  Ordered  to  examination  preliminary 
to  promotion. 

Martin,  H.  M.,  Surgeon.  Placed  on  Retired  List,  December  4,  1890. 

Alfred,  A.  R.,  Assistant  Surgeon.  Ordered  to  the  Naval  Hospital, 
Norfolk,  Ya. 

Whitfield,  J.  M.,  Assistant  Surgeon.  Relieved  from  duty  ?.t  the  Naval 
Hospital,  Norfolk,  and  ordered  to  the  U.  S.  Steamer  Chicago. 

McCormick,  A.  M.  D.,  Assistant  Surgeon.  Detached  from  the  U.  S. 
Steamer  Chicago,  and  to  wait  orders. 

Keeney,  J.  F.,  Assistant  Surgeon.  Ordered  to  the  U.  S.  Steamer  Min¬ 
nesota. 

Harris,  H.  N.  T.,  Assistant  Surgeon.  Detached  from  the  U.  S.  Steamer 
Minnesota,  and  wait  orders. 

Bloodgood,  Df.lavan,  Medical  Director.  Ordered  to  Charleston,  S.  C., 
to  represent  the  medical  corps  of  the  U.  S.  Navy  at  the  meeting  of 
the  American  Public  Health  Association. 

Ames,  H.  E.,  Passed  Assistant  Surgeon.  Ordered  as  a  delegate  to 
Charleston,  S.  C. 

Bertelotte,  D.  N.,  Surgeon.  Detached  from  the  Naval  Hospital,  Phila¬ 
delphia,  and  ordered  to  special  duty  in  connection  with  the  World’s 
Columbian  Exposition. 

Dickson,  S.  H.,  Passed  Assistant  Surgeon.  Detached  from  the  Atlanta 
and  granted  two  months  leave  of  absence. 

Wentworth,  A.  R.  Ordered  to  the  U.  S.  Steamer  Atlanta. 

Marine-Hospital  Service.—  Official  List  of  Changes  of  Stations  and 

Duties  of  Medical  Officers  of  the  United  States  Marine- Hospital  Service 

for  the  two  weeks  ending  December  6,  1890 : 

Fessenden,  C.  S.  D.,  Surgeon.  Leave  of  absence  extended  seven  days. 
December  4,  1890. 

Bailhache,  P.  H.,  Surgeon.  Granted  leave  of  absence  for  twenty 
days.  November  28,  1890. 

Hutton,  W.  H.  H.,  Surgeon.  To  proceed  to  Solomon’s  Island,  Md.,  on 
special  duty.  November  29,  1890. 

Sawtelle,  H.  W.,  Surgeon.  Granted  leave  of  absence  for  ten  days. 
December  2,  1890. 

Peckham,  C.  T.,  Passed  Assistant  Surgeon.  Granted  leave  of  absence 
for  ten  days.  December  1,  1890. 

Hussey,  S.  H.,  Assistant  Surgeon.  When  relieved,  to  proceed  to  New 
Orleans,  La.,  for  duty.  November  24,  1890. 

Groenevelt,  J.  F.,  Assistant  Surgeon.  When  relieved,  to  rejoin  station. 
November  24,  1890. 


Cofer,  L.  E.,  Assistant  Surgeon.  Ordered  to  temporary  duty  at  Bos¬ 
ton,  Mass.  November  24,  1890. 

Society  Meetings  for  the  Coming  Week: 

Monday,  December  22d:  Medical  Society  of  the  County  of  New  York  ; 
Boston  Society  for  Medical  Improvement ;  Lawrence,  Mass..  Medical 
Club  (private) ;  Cambridge,  Mass.,  Society  for  Medical  Improve¬ 
ment  ;  Baltimore  Medical  Association. 

Tuesday,  December  23d :  New  York  Academy  of  Medicine  (Section  in 
Laryngology  and  Rhinology) ;  New  York  Dermatological  Society 
(private) ;  Buffalo  Obstetrical  Society  (private) ;  Jenkins  Medical 
Society,  Yonkers,  N.  Y. ;  Medical  Society  of  the  County  of  Lewis 
(quarterly),  N.  Y. 

Wednesday,  December  2/fh :  New  York  Surgical  Society;  New  York 
Pathological  Society;  American  Microscopical  Society  of  the  City  of 
New  York  ;  Medical  Society  of  the  County  of  Albany;  Philadelphia 
County  Medical  Society. 

Thursday,  December  25th:  New  York  Academy  of  Medicine  (Section 
in  Obstetrics  and  Gynmcology) ;  New  York  Orthopaedic  Society; 
Brooklyn  Pathological  Society;  Roxbury,  Mass.,  Society  for  Medical 
Improvement  (private);  Pathological  Society  of  Philadelphia. 

Friday,  December  26th  :  Yorltville  Medical  Association  (private);  New 
York  Society  of  German  Physicians ;  New  York  Clinical  Society 
(private) ;  Philadelphia  Clinical  Society  ;  Philadelphia  Laryngologi- 
cal  Society. 

Saturday,  December  27th:  New  York  Medical  and  Surgical  Society 
(private). 


Setters  to  tlje  (Stottor. 


THE  TREATMENT  OF  ABORTION. 

Point  Pleasant,  N.  J.,  November  12,  1890. 

To  the  Editor  of  the  New  York  Medical  Journal: 

Sir:  In  your  issue  of  the  8th  inst.,  page  520,  under  the  head 
of  The  Treatment  of  Abortion,  is.  a  communication  from 
Thomas  A.  Elder,  M.  D..  of  Seaton,  Ill.  In  referring  to  the 
use  of  the  tampoo,  as  advised  by  Professor  T.  Gaillard  Thomas, 
he  scores  him  in  these  words:  “This  is  no  doubt  classical 
and  efficient  and  sufficiently  dogmatical .”  I  don’t  understand 
his  use  of  the  word  classical,  unless  he  may  mean  that  it 
is  good  teaching  to  give  to  a  class  (referring  to  Dr.  Thomas’s 
lectures). 

Fie  has  no  doubt  of  its  efficiency ,  and  yet  he  characterizes  it 
as  dogmatical.  I  think  the  term  decidedly  misapplied,  unless 
le  is  so  ignorant  of  Dr.  Thomas’s  methods  as  to  think  that  he 
uses  and  recommends  the  tampon  in  all  cases  without  regard  to 
existing  conditions,  as,  for  example,  that  he  would  apply  the 
tampon  when  the  products  of  conception  were  presenting  and 
removable  through  a  dilated  os. 

He  next  proceeds  to  give  his  method,  which  has  not  failed 
in  twenty-two  years,  and  which  is  the  removal  in  every  case  and 
immediately  of  all  the  products  of  conception  by  the  finger  in¬ 
troduced  into  the  uterus  and,  if  necessary,  the  whole  hand  in 
the  vagina. 

I  should  like  to  ask  which  is  the  most  dogmatical.  Dr. 
Thomas  gives  a  method  which  any  one  of  ordinary  deftness  can 
apply  successfully  in  every  case  if  necessary,  and  of  the  efficacy 
of  which  there  is  no  question,  the  only  objection  to  it  being 
that  it  increases  the  strength  of  the  uterine  pains,  is  difficult  of 
application,  and  uncomfortable  to  the  patient,  all  of  which,  even 
if  true,  which  they  are  not,  except  the  increase  in  efficiency  of 
the  uterine  pains,  would  not  overbalance  the  good  accomplished 
jy  its  use. 


692 


LETTERS  TO  TEE  EDITOR. 


[N.  Y.  M>tr>.  Jour., 


Dr.  Elder  gives  a  method  which,  notwithstanding  his  state¬ 
ments,  every  practitioner  of  any  experience  in  that  line  of 
work  knows  to  be  utterly  impossible  of  execution  in  a  great 
number  of  cases  by  the  general  practitioner,  and  indeed  I  be¬ 
lieve  by  any  one.  Dr.  Thomas  has  probably  tried  every  meth¬ 
od  that  could  promise  any  assistance  in  such  cases  during  his 
long  and  fruitful  career,  while  Dr.  Elder  professes  only  to 
have  found  necessary  the  use  of  this  one  (his)  method  during 
all  of  his  twenty-two  years’  practice.  He  is  to  be  envied  if 
such  is  the  case. 

After  the  uterus  is  emptied  he  gives  half  a  drachm  of 
Squibb’s  fluid  extract  of  ergot  and  directs  that  twenty  drops  be 
given  every  four  hours  or  oftener,  if  necessary  to  control  haem¬ 
orrhage,  for  thirty-six  or  forty-eight  hours. 

He  says,  liI  next  impress  upon  the  mind  of  the  patient  the 
importance  of  keeping  quiet  in  a  bed  for  a  week  or  ten  days, 
direct  her  to  keep  her  person  and  bed  scrupulously  clean,  to 
keep  her  bowels  open  with  mild  laxatives,  to  sit  on  the  chamber 
when  passing  urine,  and  to  take  her  accustomed  food.”  He 
next  gives  seven  reasons  in  support  of  his  method,  as  follows : 

“  1.  It  is  sufficiently  simple. 

“  2.  It  is  not  very  difficult. 

“3.  I  have  found  no  great  difficulty  in  passing  the  finger 
into  the  uterus  at  the  fifth  or  sixth  week  of  pregnancy. 

£‘  4.  It  is  the  best  method  of  arresting  the  haemorrhage.  It 
ceases  or  becomes  practically  harmless  as  soon  as  the  finger 
passes  the  cervix,  especially  if  the  finger  fits  the  cervical  canal 
tightly. 

“5.  It  saves  the  woman  the  hours  of  exquisite  suffering  of 
uterine  contractions,  and  the  pressure  of  the  tampon. 

“6.  It  terminates  the  case  in  about  the  time  it  would  take 
to  make  ready  the  tampon. 

“7.  In  a  fair  experience  of  over  twenty-two  years  1  have 
never  met  with  a  case  in  which  it  failed,  or  in  which  there  were 
after-complications.” 

He  says  he  never  has  trouble  in  introducing  the  whole  hand 
into  the  vagina  or  in  emptying  the  uterus  afterward.  The  only 
way  in  which  I  can  reconcile  his  statement  with  the  facts  as  I 
find  them  is  by  taking  it  for  granted  that  he  lives  in  a  com¬ 
munity  the  moral  tone  of  which  is  only  to  be  equaled  by  that 
of  fabled  Acadia,  and  which  never  has  use  for,  or  is  disturbed 
by,  certain  meddlesome  old  women  or  the  professional  abortion¬ 
ist.  Consequently,  all  his  cases  have  been  normal  cases,  and 
that  his  appearance  on  the  scene  has  been  timed  with  unusual 
consideration;  and,  last,  but  by  no  means  least,  that  he  must  be 
equipped  with  a  perfect  gynecological  hand  and  not  have  to 
depend,  as  some  of  us  unfortunately  do,  on  a  broad  hand  with 
short,  blunt  pointed  fingers;  or  else  he  must  have  discovered 
some  method  of  inducing  the  os  to  dilate  which  I  am  sure  the 
profession  at  large  would  be  glad  to  have  him  explain. 

Taking  his  reasons  in  order,  I  w'ould  say,  so  far  as  my  ex¬ 
perience  goes  and  from  what  I  can  learn  from  the  writings  of 
others — 

1.  It  is  not  sufficiently  simple.  I  may  be  indextrous  or 
lacking  in  experience  or  something,  as  I  have  found  that  when 
there  was  any  dilating  to  do,  it  was  usually  anything  but  suf¬ 
ficiently  simple. 

2.  When  no  dilatation,  or  very  little,  is  necessary,  it  may  he 
not  very  difficult.  But,  again,  I  have  lound  it  extremely  diffi¬ 
cult  and  often  impossible,  and  I  have  found  that  in  these  same 
cases  the  tampon  stopped  the  flow  of  blood  and  quickly  brought 
the  case  to  a  safe  and  successful  termination,  and  without  any 
more  pain  than  was  necessary  for  the  dilatation  of  the  os. 

3.  Nor  would  any  one  find  it  difficult  if  he  found  it  wide 
open  always. 

4.  When  the  os  is  open  or  easily  dilatable,  the  vagina  large, 


,  the  subject  not  very  sensitive,  it  is  undoubtedly  often  compara¬ 
tively  easy  to  remove  the  cause  of  the  trouble  with  the  finger. 
On  the  other  hand,  when  the  os  is  not  soft  and  open,  but  is 
rigid  and  only  open  enough  to  permit  a  stream  of  blood  to  es¬ 
cape,  I  think  every  woman  will  agree  with  me  and  prefer  to  he 
tamponed  with  a  well  fitting  tampon  made  from  proper  mate¬ 
rial,  rather  than  with  the  hand  of  the  physician. 

5.  If  the  os  is  not  sufficiently  open  for  the  escape  of  the 
offending  mass  or  for  its  easy  extraction  with  the  finger,  then 
I  believe  that,  although  the  os  may  be  comparatively  easy  of 
dilatation,  so  far  as  actual  pain  and  discomfort  are  concerned, 
the  tampon  is  the  less  disagreeable  and  offensive  t<»  the  patient, 
and  certainly  there  can  be  no  comparison  by  those  who  have 
tried  both  methods,  between  attempting  to  dilate  a  rigid,  un- 
dilatable  os  with  the  finger  and  the  tampon.  There  can  be  but 
one  decision,  and  that  emphatically  in  favor  of  the  tampon. 

6.  It  the  doctor  should  not  go  prepared  for  all  emergencies, 
he  might  be  able  to  stop  the  flow  by  a  tampon  composed  of  a 
finger  in  the  cervical  canal  and  the  hand  in  the  vagina  a  little 
quicker  than  with  the  regulation  material,  but,  to  transpose  an 
old  saying,  “to  take  the  shortest  road  is  not  always  the  quick¬ 
est  way  to  get  to  a  certain  point,”  and  it  might  be  so  in  this 
case.  The  os  might  not  be  open  or  dilatable,  and  it  would  be 
unpleasant,  to  say  the  least,  to  all  concerned  to  leave  such  a 
tampon  in  place  long  enough  to  do  any  good  ;  consequently  it 
would  have  to  be  removed  and  other  proper  measures  used, 
either  rapid  instrumental  dilatation  or  the  tampon.  Time 
would  have  been  lost  and  the  patient  subjected  to  unnecessary 
pain  and  annoyance. 

Before  the  introduction  of  the  tampon  I  doubt  not  many  of 
us  were  nearly  at  our  wits’  end  many  times.  It  is  certain  that 
we  now  frequently  meet  with  cases  which  are  wholly  uncon¬ 
trollable  (so  far  as  we  are  concerned)  by  the  doctor’s  method. 

I  think  I  can  speak  for  many  brother  practitioners  when  I  say 
we  should  be  only  too  happy  if  we  might  have  so  fair  an  expe¬ 
rience;  but,  alas!  it  is  not  so. 

Taken  altogether,  the  treatment  of  abortion  is  one  of  the 
most  unpleasant  and  unprofitable  of  the  duties  of  our  profession, 
as  its  successful  treatment  too  often  brings  a  reputation  the  re¬ 
verse  of  enviable.  One  other  point.  As  it  takes  longer  for 
the  uterus  to  undergo  subinvolutiou  than  at  term,  his  time  is 
rather  short  and  should  be  two  or  three  weeks. 

The  rest  of  his  treatment  is  not  to  be  complained  of  in  an 
uncomplicated  case,  but  I  am  sure  that  he  would  be  ['leased 
with  the  results  if  he  would  continue  small  doses  of  ergot  three 
times  a  day  for  three  or  four  weeks. 

I  have  not  had  so  long  or  so  fair  an  experience  as  the  doc¬ 
tor,  but  what  I  have  had  tends  to  convince  me  that  there  is  no 
royal  road  by  which  an  abortion  may  always  be  conducted  to  a 
successful  termination.  At  the  same  time,  I  believe  the  sys¬ 
tematic  use  of  the  tampon  to  be  as  near  as  it  is  possible  to  get 
to  such  a  method.  I  believe  that  in  those  cases  where  the  doc¬ 
tor  is  compelled  to  dilate,  it  could  be  accomplished  quicker, 
easier,  and  with  less  pain,  discomfort,  and  embarras-ment  to 
the  patient,  by  the  use  of  instrumental  dilatation  with  the  aid  of 
a  few  diops  of  chloroform,  and  also  that  there  would  be  less 
danger  of  after-complications. 

To  sum  up  briefly,  I  would  say: 

1.  In  those  cases  where  the  os  is  within  reach  and  is  dilated, 
and  the  contents  of  the  uterus  are  protruding,  undoubtedly  the 
thing  to  do  is  to  remove  the  mass  as  speedily  as  possible  with 
the  finger  or  otherwise. 

2.  When  the  os  is  dilated,  but  not  enough  and  soft,  the  best 
method  is  instrumental  dilatation  and  removal. 

3.  \\  hen  the  os  is  not  dilated,  but  rigid,  and  is  giving  forth 
a  stream  of  blood  more  or  less  regular  and  large,  unless  there  is 


Dec.  20,  1890.] 


PROCEEDINGS  OF  SOCIETIES. 


693 


some  special  reason  for  haste  when  instrumental  dilatation  may 
be  advisable,  the  tampon  is  the  remedy  for  the  arrest  of  the 
haemorrhage,  and  also  for  the  safe  and  rapid  dilatation  of  the  os 
and  expulsion  of  the  offending  mass. 

F.  W iiitakek,  M.  D. 


Jjroceriimp  of  So  rictus. 


AMERICAN  LARYNGOLOGICAL  ASSOCIATION. 

Twelfth  Annual  Congress ,  held  at  Baltimore ,  on  Thursday , 
Friday ,  and  Saturday ,  May  29 ,  30 ,  and  31,  1890. 

The  President,  Dr.  John  N.  Mackenzie,  of  Baltimore, 
in  the  Chair. 

(  Continued  from  page  363. ) 

A  New  Operation  for  Deviation  of  the  Nasal  Septum, 
with  Report  of  Cases. — Dr.  Morkis  J.  Asoh,  of  New  York, 
read  a  paper  on  this  subject.  (See  page  675.) 

Dr.  J.  C.  Mulhall  said :  I  am  very  much  interested  in  this 
subject,  for  one  reason  at  least,  because  we  have  in  our  city  (St. 
Louis)  the  gentleman  who  first  introduced  the  instrument  which 
is  generally  used  for  overcoming  the  resiliency  of  a  deviated 
septum.  I  refer  to  Dr.  Steele,  the  inventor  of  Steele’s  forceps. 
I  have  performed  a  number  of  operations,  some  fifteen  or 
twenty,  with  this  instrument,  and  I  may  say  that  I  have  not 
been  entirely  pleased  with  it.  I  am  therefore  much  interested 
in  Dr.  Asch’s  operation,  which  promises  so  much  from  a  single 
incision  of  the  septum,  while  Dr.  Steele’s  forceps  makes  six  in¬ 
cisions.  One  objection  to  the  latter  is  that  at  the  center  of 
the  crucial  incisions  a  perforation  not  infrequently  results,  upon 
which  crusts  form,  to  the  great  annoyance  of  the  patient.  In 
maintaining  the  septum  in  position  after  operation,  I  have  found 
nothing  answer  the  purpose  so  well  as  a  small  rubber  nipple, 
adapted  to  the  size  of  the  nostril  and  stuffed  with  cotton,  so  as 
to  accommodate  it  to  the  cavity.  This  is  the  best  plug  to  retain 
the  septum  in  proper  place.  With  regard  to  the  recurrence  of 
the  stenosis,  I  may  say  that  I  have  been  uniformly  successful 
in  establishing  breathing  through  the  stenosed  side  by  this 
method. 

Dr.  Jarvis:  The  remark  with  regard  to  the  occurrence  of 
perforation  leads  me  to  say  that,  some  time  since,  I  constructed 
a  modification  of  Steele’s  forceps  which  makes  six  radiating 
incisions,  but  leaves  an  uncut  island  in  the  center,  thus  avoid¬ 
ing  the  accident  just  referred  to.  I  have  not  published  a  de¬ 
scription  of  the  instrument,  but  it  is  figured  in  Reynders’s  cata¬ 
logue.  In  this  connection  I  might  call  attention  to  a  sugges¬ 
tion  concerning  the  after-treatment.  Finding  that  plugs  of 
hard  rubber,  glass,  ivory,  or  gauze  gave  rise  to  pain  and  irrita¬ 
tion,  I  have  abandoned  all  internal  splints  and  devised  an  ex¬ 
ternal  nasal  splint,  coated  with  very  soft  leather,  or  a  soft  kid 
pad  containing  metallic  mercury,  which  have  given  just  as  good 
results  without  intranasal  irritation. 

Dr.  Ingals  :  The  operation  proposed  by  Dr.  Asch  is  not  new, 
but  is  a  modification  of  the  usual  plan  of  treatment.  The  late 
Professor  Moses  Gunn,  of  Chicago,  was  accustomed  to  make  a 
crucial  incision  through  the  greatest  convexity  of  the  cartila¬ 
ginous  septum,  m  iking  the  incisions  obliquely,  and  then  forcing 
over  the  segments  and  retaining  them  by  means  of  a  rubber 
tube  passed  through  the  obstructed  side.  When  the  septum  is 
bent  nearly  horizontally  across  the  naris,  I  still  prefer  the  re¬ 
moval  of  a  triangular  piece,  so  as  to  allow  it  to  fall  into  proper 
position,  as  recommended  in  my  paper  read  at  the  Boston  meet¬ 


ing  of  this  association.  When  there  is  simple  bending,  with 
little  or  no  hypertrophy,  I  use  a  small  trephine,  3  mm.  in  diam¬ 
eter,  with  which  I  remove  beneath  the  mucous  membrane  three 
or  four  cylindrical  pieces  from  the  convex  portion  of  the  sep¬ 
tum,  sufficient  to  completely  destroy  its  resiliency.  It  is  then 
comparatively  easy  to  place  the  septum  in  its  normal  position 
and  keep  it  there  with  some  kind  of  splint.  My  own  custom  is 
to  introduce  into  the  nasal  chamber  of  the  affected  side  a  pledget 
made  with  a  long  strip  of  antiseptic  gauze  saturated  with  a 
thick  mixture  of  tannin  and  water.  The  other  nostril  is  left 
open.  Twenty-four  hours  afterward  I  have  the  pledget  removed 
and  then  cleanse  the  nose  and  insert  a  tube  made  of  gutta¬ 
percha,  molded  to  fit  the  cavity.  This  should  not  be  large 
enough  to  cause  the  patient  discomfort.  I  use  the  ordinary 
sheet  gutta  percha  employed  by  dentists,  which  may  be  easily 
molded  when  warm  to  suit  the  requirements  of  each  case.  It 
has  proved  to  me  more  satisfactory  than  either  ivory,  soft  rub¬ 
ber,  or  any  of  the  rigid  clamps,  and  it  is  infinitely  superior  to 
cotton,  which  not  only  fails  to  keep  the  septum  in  proper  posi¬ 
tion,  but  speedily  becomes  offensive. 

Dr.  Roe:  This  method  seems  more  particularly  directed  to 
the  cartilaginous  septum.  A  somewhat  similar  plan  which  I 
have  followed  is  to  make  an  incision  on  the  convex  side  in  the 
direction  of  the  greatest  convexity,  either  vertical  or  diagonal. 
Then,  taking  an  Adams’s  forceps,  I  bend  the  septum  forcibly 
over  to  the  opposite  side  until,  when  left  to  itself,  it  keeps 
a  perfectly  straight  position.  Upon  the  side  of  the  convexity 
is  placed  a  plug,  consisting  of  metal  covered  with  absorbent 
cotton.  After  all  haemorrhage  has  been  checked,  I  thoroughly 
disinfect  with  iodoform,  and  then  introduce  a  plug  as  large  as- 
can  possibly  he  put  into  the  nostril,  adding  sufficient  absorbent 
cotton  to  keep  it  in  place.  No  plug  is  placed  on  the  opposite  side. 
The  plug  should  be  as  wide  as  the  nostril  will  permit,  and,  by 
dipping  it  in  a  l-to-2,000  solution  of  bichloride  of  mercury,  it 
is  kept  thoroughly  aseptic.  It  may  be  left  in  position  for  from 
four  to  six  days;  if  necessary  to  renew  it,  the  same  method  is- 
followed.  When  there  is  deviation  also  in  the  bony  septum,  I 
break  that  up  with  a  forceps,  and  afterward  keep  the  septum 
in  place  in  the  manner  described.  I  have  found  that  these 
soft  plugs  are  far  better  than  the  hard  ones,  either  of  rubber 
or  of  metal,  which  are  very  apt  to  cause  destruction  of  the 
mucous  membrane  by  pressure.  In  the  cases  of  deviation  of 
the  bony  septum  there  is  almost  always  an  ecchondrosis  or  an 
exostosis  on  the  convex  side,  which  must  be  removed.  For 
this  I  generally  use  the  nasal  saw,  so  that  the  septum  is  of  the 
normal  thickness  before  attempting  to  restore  it  to  its  normal 
position. 

The  President:  With  reference  to  the  principle  of  this  op¬ 
eration,  it  is  of  course  old.  As  1  showed  in  a  communication 
presented  some  years  ago,  it  was  first  suggested  by  Bolton,  of 
Richmond.  Dr.  Bosworth  gives  Ohassaignac  the  honor,  al¬ 
though  I  can  not  see  why  he  should.  With  regard  to  Steele’s 
forceps,  I  have  used  it  a  good  many  times  and  have  not  been 
satisfied  with  it.  I  find  that  it  does  not  cut  through  the  srp- 
tum.  The  only  forceps  made  on  that  plan  that  I  use  is  that 
made  by  Gemrig,  of  Philadelphia,  which  is  called  Steele’s  for¬ 
ceps,  but  is  really  a  modification  of  the  original.  This  is  the 
only  really  practical  instrument  I  have  ever  used.  I  invented 
an  instrument  myself  which  cut  through  the  septum,  but  it  was 
very  difficult  to  get  out  of  the  nose,  especially  where  the  pa¬ 
tient  was  a  little  unruly  ;  I  afterward  discarded  it  for  the  in¬ 
strument  made  by  Gemrig. 

This  class  of  cases  is  one  of  much  interest.  In  some  you  will 
operate,  and  in  the  course  of  a  few  months  the  patients  return 
in  just  as  bad  condition  as  before.  Therefore  any  operation 
which  promises  the  restoration  of  the  septum  to  the  median 


694 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  M.ki>.  Jouk, 


line  should  be  well  received  and  carefully  tried.  Dr.  Asch’s 
paper  is  very  well  timed  and  his  method  is  worthy  of  trial. 

With  regard  to  Dr.  Jarvis’s  external  nasal  splint,  I  am  sorry 
to  make  an  unfavorable  report.  It  has  not  pYoved  satisfactory 
in  ray  experience.  The  plug  seems  necessary,  and  yet  I  have 
comparatively  rarely  seen  a  patient  who  could  endure  it  for  six 
days  or  more,  as  some  advise.  So  early  as  the  second  day  there 
is  profuse  secretion,  more  or  less  purulent,  and  the  patient 
begs  to  have  it  out.  There  is  no  need  of  plugging  both  nostrils. 
I  have  tried  all  kinds  of  plugs,  and  generally  remove  them  the 
day  after  they  are  introduced.  I  think  that  absorbent  cotton 
with  glycerin  or  vaseline  is  about  as  good  as  any  you  can  get 
for  this  purpose.  In  children  it  is  infinitely  superior  to  the  ivory 
plug.  I  have  had  one  case  in  which  the  introduction  of  an 
ivory  plug  caused  convulsions  of  the  corresponding  side  of  the 
body.  This  phenomenon  was  repeated  several  times.  On  this 
account  I  was  obliged  to  abandon  the  use  of  the  plug,  and  I  rec¬ 
ommended  in  place  of  it  pressure  by  the  little  finger  inserted 
into  the  nostril  to  push  the  cartilage  over  and  keep  it  in  the 
median  line.  By  doing  this  frequently,  the  patient  obviated  the 
necessity  of  using  the  plug.  The  cutting  of  the  septum  is  really 
the  smallest  part  of  the  treatment;  it  is  necessary  to  retain  the 
septum  in  place,  and  the  after-treatment  presents  the  real  diffi¬ 
culty,  and  is  often  the  cause  of  failure.  Orthopaedic  appliances 
are  of  but  little  value  here. 

Dr.  Langmaid:  It  does  not  matter  so  much  how  you  break 
down  the  septum.  The  problem  is  analogous  to  that  presented 
by  a  case  of  hare  lip,  to  prevent  the  recurrence  of  the  deformity. 
You  may  adopt  any  operation,  but  the  septum  must  remain  in 
the  new  position  or  the  operation  will  be  a  failure.  In  order 
to  prevent  recurrence,  I  insist  that  the  operation  must  have 
the  result  of  destroying  the  resiliency  of  the  deviated  septum, 
so  that  it  will,  of  itself,  remain  in  proper  position  without  being 
held  there  by  a  plug  or  splint.  I  must  bear  testimony  to  the 
value  of  the  black  rubber-nipple  plug  stuffed  with  cotton.  In 
small  children  a  very  small  plug  may  be  used,  and  it  need  not 
be  soft:  but  in  older  children  it  may  be  filled  with  cotton  and 
iodoform  and  answers  the  purpose  very  well  In  addition,  the 
expedient  mentioned  by  the  president— of  making  pressure  with 
the  finger — is  useful,  the  patient  being  instructed  how  he  may  aid 
the  treatment  by  inserting  his  little  finger  several  times  a  day. 
In  many  cases  a  purulent  discharge  is  set  up,  and  there  may 
be  neuralgia  and  other  nervous  symptoms.  The  size  of  the 
nostril  should  be  borne  in  mind  in  making  the  plug  so  that  it 
will  go  in  easily  ;  as  the  septum  will  remain  in  place,  there 
should  be  no  pressure  and  no  pain  or  inconvenience. 

Dr  Jarvis:  With  regard  to  the  external  nasal  splint,  I 
would  only  add  that,  although  I  have  used  it  in  a  number  of 
cases,  I  have  lately  discarded  it  in  favor  of  a  new  crown  drill 
which  quickly  cuts  away  the  septal  distortion.  I  agree  with 
the  president  that  orthopaedic  appliances  are  out  of  place  in  in¬ 
tranasal  surgery.  The  rule  is  always  to  remove  sufficient  tissue 


W.r.FORD  SURG.INST  CO.NX 


to  give  plenty  of  room.  By  using  transfixion  needles  to  guide 
the  drill,  I  avoid  perforating  the  septum.  If  there  is  an  exos¬ 
tosis,  I  riddle  and  remove  it ;  if  I  can  not  get  sufficient  room  by 
this  procedure,  I  take  away  part  of  the  turbinated  tissues  or 
bone. 

Dr.  Bosworth  :  I  must  compliment  Dr.  Asch  for  presenting 
a  most  ingenious  intranasal  splint.  It  corrects  not  only  verti¬ 
cal  displacement,  but  horizontal  displacement  as  well. 

In  reply  to  the  last  remark  of  Dr.  Jarvis  in  regard  to  remov¬ 
ing  the  turbinated  bodies,  I  wish  to  ask  if  it  is  not  unjustifiable 


to  remove  an  important  organ  of  the  body  simply  for  the  pur¬ 
pose  of  admitting  air  through  the  nose?  The  object  of  the 
treatment  is  to  restore  normal  function,  not  to  straighten  a  de¬ 
viated  septum.  I  deny  that  it  is  primarily  for  the  purpose  of 
giving  more  breathing  space.  It  is  not  justifiable  to  remove  this 
organ,  the  functions  of  which  are  for  the  time  not  hampered, 
any  more  than  it  would  be  justifiable  to  remove  a  kidney  for 
functional  disorder.  I  do  not  admit  that  the  primary  object  is 
to  admit  more  air;  that  idea  is  based  upon  an  entirely  erroneous 
conception  of  the  purpose  of  the  operation. 

Dr.  Jarvis:  The  primary  object  is  not  cosmetic;  in  my 
mind  it  is  to  remove  an  obstruction  and  afford  more  breathing 
space. 

Dr.  Mulhall  :  I  wish  to  say  a  word  in  defense  of  Steele’s 
forceps.  The  objection  has  been  raised  that  it  does  not  cut 
through  the  septum.  It  is  evident  from  the  discussion  that  the 
gentlemen  have  been  talking  about  two  entirely  different  things, 
a  deviated  septum  and  a  thickened  septum.  Steele’s  forceps 
will  not  pass  through  a  thickened  septum,  it  is  true.  When  I 
get  such  a  case,  I  first  treat  the  hypertrophy  and  reduce  the 
thickened  septum  to  its  normal  size,  and  then  apply  the  forceps, 
and  find  no  difficulty  in  making  the  blades  meet.  Then,  again, 
the  Chair  has  stated  that  there  was  a  great  tendency  to  recur¬ 
rence  of  the  deformity  after  operation.  This  is  true,  but  I  have 
never  seen  the  recurrence  complete.  After  the  cutting  I  push 
the  septum  over  and  make  it  project  upon  the  opposite  side, 
using  the  handle  of  a  tooth-brush  to  force  it  over.  I  then  plug 
the  affected  side  with  a  rubber  nipple  stuffed  with  cotton. 
There  may  be  some  return,  but  never  to  the  original  extent. 

Dr.  Ingals  :  As  intimated  by  the  author,  the  secret  of  suc¬ 
cessful  treatment  is,  destruction  of  the  resiliency  of  the  septum 
during  the  operation,  which  renders  the  after-treatment  simple, 
but  if  this  is  neglected  the  patient  can  not  tolerate  suitable  plugs 
or  splints,  and  imperfect  results  must  follow.  I  have  had  pa¬ 
tients  wear  tubes  of  gutta-percha  from  four  to  six  weeks  with¬ 
out  discomfort,  and  I  have  found  the  results  of  the  operation 
very  satisfactory.  Where  there  is  great  thickening  of  the  sep¬ 
tum  with  deflection  the  excess  of  tissue  must  be  removed. 

The  President  :  I  did  not  mean  a  thickened  septum,  but  in 
ordinary  cases  of  deformed  septum  I  have  used  Steele’s  forceps 
and  could  not  get  it  to  close.  I  could  not  cut  through  thick 
paper  with  Steele’s  forceps,  but  with  other  forceps  I  cut 
through  six  thicknesses  of  chamois  skin. 

Dr.  Daly  :  The  object  beiDg  to  get  rid  of  the  resiliency  of 
the  septum,  it  can  be  accomplished  with  Steele’s  forceps.  I 
have  never  experienced  any  difficulty,  but  I  do  not  satisfy  my¬ 
self  with  a  single  cut;  I  make  two  or  three  incisions  irregularly 
in  the  septum  to  break  up  the  cartilage.  The  fact  that  the  cut¬ 
ting  blades  of  the  forceps  do  not  perforate  the  septum  is  an  ad¬ 
vantage.  The  operation  should  not  be  done  too  early  in  life, 
f  we  wait  until  the  patient  is  old  enough  to  appreciate  the  im¬ 
portance  ot  the  operation  and  co-operate  with  us  in  our  after- 
management,  we  shall  usually  be  successful. 

Our  success  in  operating  depends  sometimes  upon  very  sim¬ 
ile  things.  I  wish  to  show  my  plan  of  plugging  the  nostril. 
r’nke  some  absorbent  cotton  and  make  a  little  roll  about  as 
arge  as  my  middle  finger;  around  this  wrap  some  ordinary 
grocer’s  white  cotton  cord  from  one  end  to  the  other  in  a  loDg 
spiral.  Now.  if  we  fold  this  in  the  middle,  and,  after  tying  the 
ends,  apply  vaseline,  with  a  styptic  or  antiseptic,  and  carry  it 
deep  into  the  nasal  chamber,  the  ends  with  the  cotton  twine 
are  external  and  may  be  cut  off.  When  it  is  desired  to  remove 
the  plug,  it  is  only  necessary  to  pull  both  ends  of  the  cotton 
string  and  it  comes  out  entire  with  the  cotton  plug  in  its  em¬ 
brace.  I  have  found  this  expedient  a  great  saver  of  time  and 
trouble.  I  have  also  used  it  in  cases  of  nasal  hiemorrhage.  It 


Dec.  20,  1890. J 


PROCEE DIN  OS  OF  SOCIETIES. 


ean  be  dipped  in  iodoform  or  some  styptic,  if  desired.  I  con¬ 
sider  it  a  very  good  point  in  practice. 

Dr.  Holden:  As  the  discussion  is  upon  deviated  septum,  it 
may  be  of  interest  to  present  a  case  illustrative  of  the  difficul¬ 
ties  one  may  encounter  from  recurrence.  It  is  that  of  a  young 
lady,  an  artist,  of  fine  appearance,  but  who  unfortunately  had 
a  seriously  deviated  septum.  She  was  very  much  annoyed  by 
it  and  was  willing  to  submit  to  any  operation  for  its  correction 
provided  there  should  be  no  perforation.  The  septum  was  thin 
and  rather  mobile,  and  crackled  like  parchment  under  the  finger 
when  it  was  moved.  It  was  so  thin  that  I  feared  a  cutting 
operation  might  produce  a  perforation.  With  a  periosteal  ele¬ 
vator  the  cartilage  was  set  over  and  retained  with  an  antiseptic 
cotton  compress.  In  three  months’  time  the  deviation  had  re¬ 
curred.  I  then  repeated  the  operation,  forcibly  pressing  the 
septum  over  to  the  opposite  side.  The  relief  was  all  that  could 
be  desired,  but  in  two  months  there  was  again  deviation.  She 
was  resolutely  determined  to  have  the  deformity  corrected,  and 
I  now  made  two  semi-lunar  incisions  and  removed  an  ovoid 
piece  of  the  cartilage  by  careful  dissection,  and  used  compresses 
as  before.  The  deformity  returned.  The  redundant  portion  of 
the  (fortunately  now  thickened)  septum  was  sawed  off  without 
perforation.  The  result  was  good  for  several  months,  but  she 
returned  just  as  bad  as  she  was  before.  I  then  resorted  to 
Steele’s  forceps,  crushed  the  septum  at  two  points,  set  it  over 
in  place,  and  also  crushed  the  osseous  septum  at  its  junction 
with  the  cartilage,  making  in  all  three  incisions.  An  ivory 
plug  was  introduced  slightly  hollowed  out  on  one  side  for  the 
turbinated  bone.  TLis  was  wrapped  with  a  very  thin  film  of 
bichloride  cotton.  She  wore  this  ivory  for  five  days  before  re¬ 
moval,  and  continued  to  wear  it  altogether  for  five  weeks.  The 
result  is  satisfactory  save  that  there  is  some  projection  at  the 
base  of  the  cartilaginous  septum,  which  may  yet  require  an¬ 
other  operation  by  saw  or  drill. 

Dr.  Ason:  I  feel  very  much  pleased  that  the  paper  has  pro¬ 
voked  so  much  discussion  ;  it  shows  that  I  was  not  mistaken  in 
my  estimate  of  the  importance  of  the  subject.  Part  of  the  dis¬ 
cussion,  however,  seems  based  upon  a  misunderstanding  of  my 
remarks,  or  perhaps  I  may  not  have  expressed  myself  clearly. 

I  said  that  the  success  of  the  operation  depended  upon  overcom¬ 
ing  the  resiliency  of  the  septum,  and  placing  it  in  proper  posi¬ 
tion.  The  resiliency  being  overcome,  the  splint  is  introduced, 
which  causes  no  irritation  ;  the  nostril  is  plugged  lightly  ;  there 
is  no  trouble  whatever,  and  in  a  very  few  days  the  parts  are 
healed.  With  regard  to  Steele’s  forceps,  it  was  owing  to  my 
failure  to  succeed  with  that  instrument  that  I  was  led  to  devise 
these  scissors.  I  found  that  it  did  not  completely  penetrate 
the  cartilage.  In  the  plan  of  operating  recommended  by  Dr. 
Jarvis,  the  resiliency  of  the  cartilage  is  not  overcome,  and  the 
deformity  will  therefore  be  reproduced.  With  reference  to  his 
criticism  upon  the  plug,  I  may  say  that  I  never  experienced  any 
difficulty  arising  from  it,  or  observed  any  signs  of  septic  infection. 

The  Early  Diagnosis  of  Malignant  Disease  of  the  Lar¬ 
ynx.— Dr.  D.  B.  Delavan  read  a  paper  with  this  title.  (See 
page  508.) 

The  President:  This  is  an  exceedingly  important  subject. 
Upon  the  early  diagnosis  the  life  or  death  of  a  patient  may  de¬ 
pend. 

Dr.  Daly  :  This  subject  is  certainly  an  important  one— not 
only  involving  questions  of  diagnosis  of  a  very  interesting  char¬ 
acter,  but  the  safety  and  happiness  of  our  patients.  I  may  say 
at  once  that  I  am  not  very  favorable  in  these  cases  to  much  in¬ 
terference  unless  of  a  radical  surgical  character.  I  think  that 
there  comes  a  time  when  a  benign  sore  becomes  irritated  by 
harsh  interference,  and,  where  the  conditions  are  predisposed, 
may  be  made  malignant  by  such  harsh  interference.  We  want  I 


695 

to  learn  more  about  this  point  and  how  to  avoid  this  dread  evil. 
I  have  no  very  pronounced  views  of  treatment,  except  that  I 
am  not  an  advocate  of  extirpation  of  the  larynx  ;  it  is  a  ghastly 
operation,  the  result  is  not  happy  for  the  patient,  and  statis¬ 
tics  do  not  prove  that  it  is  justifiable. 

Dr.  Ingals  :  I  would  ask  what  the  difference  is  in  the  ap¬ 
pearance  of  the  parts,  in  transillumination  of  the  larynx,  be¬ 
tween  a  benign  and  a  malignant  growth. 

Dr.  Delavan  :  The  only  use  to  which  transillumination  can 
be  put  is  to  demonstrate  a  cloudy  area  around  the  growth  cor¬ 
responding  with  the  amount  of  infiltration,  which,  of  course, 
would  not  exist  in  benign  lesions.  In  the  normal  larynx  the' 
electric  light  transmitted  in  this  way  gives  a  rosy  illumination 
of  the  parts  with  a  certain  definite  distribution  of  the  lights  and 
shadows.  If  one  side  of  the  larynx  is  invaded  by  a  growth,  and 
its  appearance  is  contrasted  with  that  of  the  healthy  side  by 
transillumination,  the  difference  will  be  perceived.  Where 
there  is  exudation  or  infiltration,  the  conducting  power  of  the 
tissues  is  much  diminished.  Of  course,  by  this  method  no  fine 
diagnosis  is  possible,  but  it  may  be  of  some  assistance  in  mak¬ 
ing  a  diagnosis  between  a  simple  condition  of  tumefaction  and 
the  actual  presence  of  a  new  growth,  although,  of  course,  other 
means  would  be  required  to  confirm  it.  It  would  determine 
whether  the  transparency  of  the  tissues  is  normal,  and,  if  not 
normal,  the  extent  of  the  lesion.  The  mode  of  applying  it  is 
very  simple.  An  electric  lamp  is  attached  to  a  cylinder  of  solid 
glass  \frhich  may  be  as  loog  as  convenient,  two  inches  being  suf¬ 
ficient.  The  light  is  focused  at  a  spot  at  the  end  of  the  cylin¬ 
der,  which  is  placed  directly  against  the  larynx,  externally  to 
the  point  to  be  examined.  A  lamp  of  three  or  four  candle  power 
will  afford  a  brilliant  illumination.  Of  course,  the  relative  thick¬ 
ness  of  the  wall  of  the  neck  will  affect  the  light,  in  a  stout  per¬ 
son  the  amount  of  light  transmitted  being  less  than  in  a  thin 
one.  The  light  being  placed  directly  below  the  cricoid,  a  good 
illumination  is  afforded  in  average  cases. 

Dr.  Ingals:  Would  the  transillumination  of  a  malignant 
growth  make  it  appear  very  different  from  a  benign  tumor?  I 
can  see  that  there  would  be  a  difference,  for  instance,  between 
a  cyst  and  an  ordinary  infiltration,  but  I  can  not  understand 
why  there  could  be  much  difference  in  appearance  between  a 
simple  inflammatory  exudation  and  malignant  disease.  I  am 
much  interested  in  the  discussion  of  the  early  diagnosis  between 
lupus,  syphilis,  and  malignant  disease,  because  of  a  case  that  I 
saw  early  this  past  winter.  The  patient,  about  twenty-two  \  ears 
of  age,  married,  came  to  me  breathing  with  much  difficulty,  the 
right  ventricular  band  much  thickened,  the  cord  scarcely  visi¬ 
ble,  owiDg  to  the  swelling  above  it.  I  introduced  a  large-sized 
O’Dwyer  tube,  which  she  wore  for  several  days ;  I  then  removed 
it,  and  breathing  was  perfectly  easy.  I  afterward  examined  her 
larynx  and  found  two  or  three  small  nodules  protruding  from 
the  ventricle,  having  the  appearance  of  a  papillary  growth.  The 
patient  afterward  had  la  grippe,  followed  by  typhoid  fever.  I 
did  not  see  her  again  for  two  or  three  months,  during  which 
time  tracheotomy  had  been  performed.  When  she  returned 
there  were  no  distinct  nodules  at  the  orifice  of  the  ventricle, 
but  general  thickening  of  the  right  side  of  the  larynx,  particu¬ 
larly  in  the  region  of  the  false  cord,  which  might  have  been  ac¬ 
counted  for  by  a  simple  benign  growth  within  the  right  ven¬ 
tricle. 

The  difficulties  of  diagnosis  are  well  illustrated  by  a  case  that 
I  treated  some  years  ago,  that  had  been  under  the  care  of  the 
late  Dr.  Elsberg  and  another  prominent  laryngologist,  I  do  not 
remember  whom.  One  had  pronounced  it  a  cancer,  the  other 
not.  I  found  extensive  thickening  which  certainly  had  a  ma¬ 
lignant  appearance.  No  possible  evidence  of  syphilis  could  be 
found.  The  iodides  were  tried,  though  without  much  effect. 


696 


[N.  Y.  Med.  Jooh., 


PROCEEDINGS  OF  SOCIETIES. 


He  remained  in  much  the  same  condition,  and  I  think  is  still 
living. 

Dr.  Holden  :  I  should  like  to  ask  if  I  understood  the  author 
correctly  in  stating  that  one  of  the  points  of  diagnosis  was 
that  the  zone  of  redness  surrounding  the  growth  was  charac¬ 
teristic  of  malignancy.  I  recall  the  case  of  a  gentleman  who 
came  to  me  some  time  ago,  and  entirely  recovered  after  anti¬ 
syphilitic  treatment.  The  character  just  mentioned  — of  a  zone 
of  redness — was  well  marked  in  this  case.  I  have  seen  other 
cases  in  which  the  zone  of  redness  existed  in  non-malignant 
growths. 

Dr.  Ason  :  My  experience  is  that  cancer  of  the  larynx  is 
comparatively  infrequent;  but  1  can  not  recall  that  in  the  cases 
I  have  seen  there  was,  as  a  rule,  any  diagnostic  peculiarity  in 
the  appearance  at  the  outset.  There  is  nothing  to  indicate  ma¬ 
lignant  disease.  There  is  first  swelling  in  the  larynx  withoutany 
redness,  and  no  change  in  the  external  appearance  of  the  mu¬ 
cous  membrane.  Most  of  my  cases  were  well  developed  when 
they  presented  themselves.  I  usually  fall  back  upon  the  clas¬ 
sical  way  of  diagnosis  by  treatment.  If  the  growths  yield  to 
syphilitic  treatment,  they  are  not  cancer.  If  we  could  diag¬ 
nosticate  these  cases  early,  it  might  be  possible  to  save  life  by 
operation.  I  do  not  understand  that  Dr.  Delavan  gives  any¬ 
thing  which  enables  us  to  make  this  early  diagnosis  except  the 
reddened  zone  of  infiltration.  We  can  exclude  lupus  and  tuber¬ 
cle,  because  in  them  the  appearance  of  the  mucous  membrane 
is  changed  and  they  are  located  differently.  The  cases  of  oancer 
I  have  seen  have  not  occu*-ed  in  the  posterior  part  of  the  larynx, 
but  elsewhere. 

Dr.  Mulhall  :  1  wish  to  corroborate  the  point  made  by  Dr. 
Daly,  which  is  of  great  interest.  I  have  had  two  cases  of  can 
cer  of  the  larynx,  which  greatly  improved  under  iodide  of  po¬ 
tassium  for  a  time.  I  also  wish  to  remark  that  we  should  be 
very  careful  of  our  prognosis  in  cases  of  suspected  cancer  of 
the  larynx.  I  recall  a  case  seen  by  an  eminent  laryngologist 
and  pronounced  a  case  of  undoubted  malignancy.  There  was 
paralysis  of  the  muscles  of  the  larynx,  aphonia,  the  patient 
was  losing  flesh,  and  strength  was  failing.  I  saw  the  case  a 
year  later.  The  patient  came  to  me  completely  aphonic  with 
this  same  growth.  The  treatment  proved  that  it  was  a  case  of 
chronic  laryngitis,  limited  to  one  side.  The  treatment  consisted 
in  applications  of  solid  nitrate  of  silver  for  the  reduction  of  in¬ 
filtration,  and  the  galvano-cautery  to  the  growth.  Her  voice, 
returned,  and  she  went  home  much  relieved  in  body  and  mind 
Therefore  I  remark  that  we  should  be  careful  in  the  diagnosis 
of  cancer  of  the  larynx.  1  quite  agree  with  Dr.  Daly  that  the 
operation  of  extirpation  of  the  larynx  is  unjustifiable. 

Dr.  Swain:  I  wish  to  remark  upon  the  infiltration  and  the 
consequent  immobility  of  the  parts  involved  as  a  point  in  the 
diagnosis  of  malignancy.  In  a  recent  case  which  I  recall  there 
was  a  diagnosis  to  he  made  between  cancer  of  the  larynx  and" 
infiltration  due  to  perichondritis  or  tuberculosis.  With  very  little 
hesitation,  owing  to  the  mobility  of  the  parts  and  non-involve¬ 
ment  ot  the  vocal  cords,  I  decided  that  it  was  non-malignant. 
The  subsequent  course  of  the  disease  showed  it  to  be  a  simple 
perichondritis  with  abscess,  which  was  evacuated,  and  the  pa¬ 
tient  is  now  better. 

Dr.  Bosworth:  It  is  very  interesting  to  listen  to  a  paper 
which  considers  practical  points,  such  as  diagnosis  or  treatment. 
In  addition  to  the  points  mentioned,  there  is  yet  another  which 
has  not  been  named  it  is  the  diagnostic  instinct  which  enables 
us  to  look  at  the  case  comprehensively  and  say  that  this  is  a  case 
of  cancer,  or  this  is  not  malignant. 

Dr.  Langmaid:  Some  years  ago  I  supposed  that  cancer  of 
the  larynx  was  comparatively  frequent.  I  do  not  now  believe 
it  to  be  rare.  Two  diagnostic  points  occur  to  me  which  may 


be  of  interest.  When  you  see  the  growth  early  you  find  infil¬ 
tration,  the  lumen  of  the  glottis  is  diminished,  and  its  general 
aspect  is  changed.  The  other  point  is  the  occurrence  of  a  stab¬ 
bing  pain  in  the  ear;  it  comes  early  in  the  disease. 

Dr.  Daly  :  A  further  word  I  would  say  with  regard  to  a 
subject  of  importance  to  laryngologists.  It  is  a  word  of  injunc¬ 
tion  as  to  the  use  of  irritating  local  applications  while  the  case 
is  still  being  studied.  I  have  in  mind  a  very  glaring  case  of 
malpractice  where  the  patient  was  burned  with  the  galvano- 
cautery  every  day  for  seven  or  nine  days,  sufficient  of  itself  to 
develop  cancer  of  the  larynx,  where  the  germs  were  already 
budding.  If  our  case  is  one  of  cancer  of  the  larynx,  irritating 
measures  short  of  total  destruction  or  extirpation  of  the  af¬ 
fected  tissues  do  no  good  ;  if  it  is  not  cancer  of  the  larynx,  we 
have  only  to  await  developments.  But  if  interference  is  prac¬ 
ticed,  let  it  be  by  early  ablation  or  extirpation  of  the  suspected 
tissue,  and  only  by  the  knife  and  not  the  cautery. 

Dr.  Ingals:  With  regard  to  the  treatment  of  cancer  in  the 
throat,  I  have  been  fully  convinced  that  the  application  of  car¬ 
bolic  acid,  tannin,  and  glycerin  has  given  much  relief  to  pa¬ 
tients  for  whom  at  best  we  can  do  but  little.  I  think  that, 
applied  in  this  way,  tannic  acid  hardens  the  tissues,  and  thus 
prolongs  the  anaesthetic  action  of  the  carbolic  acid.  I  use  for 
this  purpose  a  combination  of  morphine  four  grains,  tannin  and 
carbolic  acid  each  thirty  grains,  in  four  drachms  each  of  glycer¬ 
in  and  water. 

the  President:  During  this  discussion  the  question  of  the 
rarity  of  cancer  of  the  larynx  has  come  up.  As  far  as  my  own 
experience  goes,  I  have  seen  very  few  cases  in  this  city  (Balti¬ 
more),  but  abroad,  especially  in  London,  it  seems  to  me  that 
the  disease  is  more  common.  With  regard  to  extirpation  of 
the  larynx,  I  do  not  think  it  an  unjustifiable  operation,  because 
many  lives  have  been  saved  and  prolonged  by  it.  The  startling 
results  in  the  experience  of  Hahn  make  us  believe  that  we  may 
have  to  look  upon  this  operation  as  one  to  be  more  frequent¬ 
ly  used  than  it  is  to-day.  There  is  one  form  of  hypertrophic 
laryngitis  where  the  membrane  becomes  very  much  thickened. 
Such  a  case  might  possibly  be  mistaken  for  incipient  carcinoma. 
The  fibroid  degeneration  of  the  larynx  in  tertiary  syphilis  might 
also  be  mistaken  for  the  early  stage  of  carcinoma,  especially  as 
on  this  affection  the  iodides  do  not  have  the  slightest  effect. 
These  cases  drift  on  to  the  performance  of  tracheotomy  as  the 
only  hope  of  relief.  In  such  a  case,  if  ulceration  takes  place, 
the  lesion  might  very  readily  be  taken  for  cancer,  and  this  mis¬ 
take  has  very  probably  been  made.  One  feature  which  increases 
the  liability  to  mistake  is  the  early  swelling  of  the  lymphatics 
of  the  neck.  We  all  know  that  the  main  rendezvous  for  the 
lymphatics  coming  from  the  larynx  is  at  the  cornua  of  the  hyoid 
bone.  Strange  to  say,  even  in  some  of  the  worst  cases  of 
tuberculosis  of  the  larynx,  and  of  syphilis  of  the  larynx,  these 
glands  have  not  been  found  affected.  When  enlarged,  they  can 
readily  be  felt  by  deep  pressure  in  this  locality.  They  become 
enlarged  in  cancer  of  the  larynx  at  a  very  early  day  more 
frequently  than  is  generally  taught.  Although  this  is  not 
diagnostic,  yet  if  I  found  in  a  suspicious  case,  at  the  cornua  of 
the  hyoid  bone,  a  mass  of  enlarged  indurated  glands,  I  should 
consider  it  probably  malignant.  An  old  gentleman  was  brought 
to  me  the  other  day  for  me  to  decide  upon  the  propriety  of  ex¬ 
tirpation  of  the  larynx.  The  diagnosis  was  very  difficult,  and 
lay  between  cancer  and  tuberculosis.  Something  in  the  appear¬ 
ance  ot  the  growth  suggested  the  idea  of  malignancy.  His 
physician  reported  to  me  that  he  had  also  a  cavity  in  the  apex 
of  the  right  lung.  He  had  a  number  of  glands  enlarged  in 
the  superior  cervical  triangle^  exceedingly  hard  and  flattened. 
Tracheotomy  had  been  performed,  but  the  tube  had  been  re¬ 
moved,  as  the  obstruction  had  become  less  since  the  operation* 


•Dec.  20,  1890.  j 


PROCEEDINGS  OF  SOCIETIES. 


697 


On  the  strength  of  the  appearance  of  the  larynx  and  the  nod¬ 


ules  on  the  outside,  I  made  a  diagnosis  of  cancer  of  the  larynx 
with  bronchial  dilatation  on  the  left  side,  asking  for  two  weeks’ 
time  in  which  to  change  it  if  I  thought  fit  after  further  obser¬ 
vation.  I  also  warned  against  the  danger  of  sudden  oedema, 
and  advised  a  second  tracheotomy.  I  am  now  awaiting  develop¬ 
ments.*  The  case  is  hopeless  in  any  event,  and  the  proposed 
operation  is  out  of  the  question.  We  do  not  know  how  far  the 
infiltration  may  extend,  and  even  extirpation  of  the  larynx 
might  fail  to  remove  it  all.  Any  growth  proceeding  from  the 
ventricle  upon  either  side  is  a  suspicious  one,  for  this  is  the  most 
frequent  mode  of  invasion  of  the  larynx  by  malignant  disease. 
I  think  that  Dr.  Daly  is  a  little  too  severe  upon  the  use  of  the 
galvanocautery.  It  certainly  destroys  tissue. 

Dr.  Daly  :  Not  necessarily ;  it  depends  altogether  upon  how 
it  is  used.  It  will  at  a  white  heat  destroy  tissue,  but  at  a  dull 
cherry- red  heat  it  only  stimulates  and  is  not  caustic;  its  action 
is  only  superficial.  The  parts  become  the  seat  superficially  of 
an  acute  inflammation  which  is  rapidly  followed  by  absorption. 

The  President:  I  am  thoroughly  in  accord  with  Dr.  Daly 
about  the  harsh  treatment  of  any  disease,  whether  seated  in  the 
larynx  or  not.  One  point  of  historical  interest  I  might  refer 
to;  Voltolini  is  supposed  to  have  been  the  first  to  suggest  trans¬ 
illumination  of  the  nasal  cavities  and  the  antrum  of  Highmore. 

I  would  call  your  attention  to  the  fact  that  the  second  year  that 
I  was  a  member  of  this  society  I  proposed  this  method.  Two 
years  before,  the  S.  S.  White  Dental  Manufacturing  Company, 
of  Philadelphia,  had  submitted  to  me,  for  examination,  an  in¬ 
strument  for  transilluminating  the  larynx  with  an  electric  lamp. 
This  instrument  had  been  before  the  public  for  some  years,  and 
was  in  use  by  American  dentists  to  detect  caries  of  teeth  by 
transillumination.  I  am  not  positive  whether  or  not  this  had 
been  used  for  the  antrum  of  Highmore,  but  it  certainly  had 
been  used  for  examining  the  mouth  and  teeth.  The  suggestion 
was  made  that  it  might  be  useful  for  transillumination  of  the 
larynx.  I  did  not  think  that  it  possessed  much  value  for  the 
larynx,  but  thought  that  it  would  be  valuable  in  examining  the 
nose.  It  was  a  small  Edison  light  which  gave  the  illumination. 
As  a  result  of  my  observations,  I  proposed  this  method  in  the 
diagnosis  of  antral  disease  and  deep-seated  lesions  in  the  nasal 
passages.  I  might  also  say,  in  justice  to  another  member  of 
this  society,  that  at  the  same  meeting  Dr.  Carl  Seiler,  of  Phila¬ 
delphia,  said  that  he  had  tried  this  method  of  illuminating  the 
larynx,  but  that  he  had  given  it  up,  I  believe,  because  it  burned 
the  patient’s  throat. 

Dr.  Seiler:  My  objection  was  that  there  was  no  shadow,  as 
in  the  ordinary  method  of  illumination,  and  the  distinction  be¬ 
tween  projecting  parts  and  the  rest  of  the  larynx  was  lost.  The 
whole  inner  surface  glowed  with  a  dull-red  light,  which  was  not 
sufficient  for  careful  examination. 

The  President:  I  simply  mentioned  these  facts  to  show 
that  Yoltolini  was  not  the  first  to  pursue  this  method  of  exam¬ 
ining  the  larynx  and  nasal  passages. 

Dr.  Delavan :  The  object  in  bringing  this  communication 
before  you  was  simply  because,  of  all  the  practical  observations 
resulting  from  the  searching  investigations  lately  made  in  this 
department,  these  alone  seemed  to  be  of  any  value.  Thickening 
and  infiltration  are  certainly  of  diagnostic  value.  The  reddened 
zone,  a  point  to  which  attention  has  been  called  by  several  Ger- 

T - - - - - - - 

Since  this  was  spoken  the  patient  has  died,  death  occurring  sud¬ 
denly  from  laryngeal  (edema,  the  operation  not  having  been  performed. 
Microscopical  examinations  showed  the  laryngeal  and  cervical  growth 
to  be  cancerous.  On  dissection,  there  was  extra-tracheal  cancer,  with 
considerable  pressure  on  the  windpipe.  There  was  also  left  bronchia 
dilatation. 


man  writers,  and  which  I  also  have  observed  in  several  cases,  is 
not  without  a  certain  amount  of  significance.  My  intention, 
however,  was  simply  to  bring  it  forward  for  discussion  and  con¬ 
sideration. 

With  regard  to  extirpation  of  the  larynx,  its  success  depends 
very  largely  upon  the  selection  of  the  case  and  upon  the  opera¬ 
tor.  Some  tew  men  can  perform  it  and  do  it  well,  whereas 
with  others  failure  seems  to  have  resulted  from  lack  of  ex¬ 
perience  in  the  operation  itself,  or  from  lack  of  care  in  the 
after-management  of  the  patient.  In  the  case  I  have  referred 
to  the  patient  lived  for  several  years  and  was  comfortable. 
Several  years  ago,  before  the  statistics  of  recent  operations  had 
been  published.  Dr.  0.  II.  Knight,  of  this  association,  read  a 
paper  in  which  he  stated  that  the  propriety  of  the  operation 
must  be  decided  by  the  statistics.  Since  then  statistics  have 
accumulated,  and  we  are  in  a  better  position  to  judge  as  to  the 
actual  value  of  the  operation. 

The  points  of  diagnosis  which  I  referred  to  were  not  posi¬ 
tive  but  suggestive.  There  is,  as  has  been  said,  a  training  of 
the  observation  by  which  we  may  be  enabled  to  strongly  sus¬ 
pect  malignancy  without  being  able  to  say  upon  what  the  opin¬ 
ion  is  based — something  about  the  locality  and  appearance 
which  stamps  its  character  upon  it. 

With  regard  to  the  astringent  applications  mentioned  by  Dr. 
Ingals,  I  have  found  them  of  decided  value;  they  afi'ord  great 
relief  to  pain  in  swallowing,  and  I  think  that  they  sometimes 
delay  the  development  of  the  growth.  They  can  not  have  much 
effect  upon  the  deeper  portions,  but  they  appear  to  harden  the 
surface  and  protect  it.  I  have  seen  a  great  many  cases  of  can¬ 
cer  of  the  larynx  in  the  last  fifteen  years  in  private  and  hospital 
practice,  and  believe  that  in  our  city  (New  York)  it  is  not  such 
a  very  rare  disease.  The  swelling  of  the  glands  of  the  front  of 
the  neck  which  has  been  mentioned  may  be  found  in  other 
lesions.  It  may  be  absent  in  cancer,  especially  early  in  the 
case.  Finally,  it  the  paper  has  succeeded  in  demonstrating  the 
poverty  of  our  resources  in  the  early  diagnosis  of  laryngeal 
cancer,  and  if  it  will  serve  to  stimulate  investigation  in  this  di¬ 
rection,  it  will  have  been  of  some  use.  Certainly,  little  sub¬ 
stantial  has  been  learned  from  the  much-discussed  case  of  the 
late  Emperor  of  Germany. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  OBSTETRICS  AND  GYNAECOLOGY. 

Meeting  of  November  28,  1890. 

Dr.  R.  A.  Murray  in  the  Chair. 

Exploratory  Puncture  of  the  Female  Pelvic  Organs.— 

Dr.  G.  M.  Edeboiils  read  a  brief  summary  of  his  points  for  the 
benefit  of  those  who  were  not  present  at  the  reading  of  the 
original  paper  at  the  previous  meeting. 

Dr.  A.  F.  Currier  said  he  thought  with  the  author  of  the 
paper  that  the  only  cases  in  which  the  puncture  was  admissible 
were  those  in  which  a  diagnosis  could  be  made  in  no  other  way, 
and  even  then  the  question  of  danger  would  have  to  be  taken 
into  consideration.  The  danger  might  not  exist  in  the  hands  of 
the  experienced,  but  the  procedure  was  liable  to  be  adopted  by 
those  who  were  incompetent,  and  then  disastrous  results  would 
be  sure  to  follow.  One  of  the  first  dangers  was  that  of  punct¬ 
uring  the  intestines,  an  accident  that  could  scarcely  be  avoided 
in  these  cases,  as  adhesions  binding  down  the  intestines  were 
so  often  found  in  laparotomies.  It  was  a  grave  question  when 
one  considered  that,  in  puncturing,  the  needle  was  liable  to  pass 
through  the  intestines,  allowing  some  of  the  contents  to  escape 
into  the  peritoneal  cavity,  and  in  cases  of  pyosalpinx  for  pus  to 
find  its  way  along  the  line  of  puncture  to  the  same  dangerous 


698 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour., 


situation.  The  speaker  thought  that  if  this  method  was  called 
for  at  all,  it  would  certainly  be  limited  to  a  very  small  number 
of  cases.  He  felt  that  with  careful  antisepsis  and  the  use  of 
anesthetics  the  pelvic  cavity  could  be  fully  explored  and  a  diag¬ 
nosis  made  without  subjecting  the  patients  to  the  dangers  of 
puncture. 

Dr.  A.  H.  Buckmaster  was  not  in  favor  of  the  operation. 
He  gave  the  history  of  a  case  of  ovarian  cyst  where,  after  punct¬ 
ure  of  the  sac,  suppuration  had  taken  place,  general  peritonitis 
following,  and  death.  The  puncture  had  been  made  with  the 
greatest  care,  a  small-sized  needle  being  used.  The  speaker  was 
surprised  at  the  good  results  reported  by  Dr.  Edebohls  in  using 
this  method.  He  thought  that  in  searching  for  pus  in  the  pelvic 
cavity  he  would  much  prefer  to  make  an  incision,  as  in  using 
the  puncturing  needle  in  one  case  for  this  purpose  he  had  opened 
the  bladder. 

Dr.  Jewett’s  views  were  in  accord  with  those  of  the  last  two 
speakers.  He  thought  that  if  puncture  could  be  made  directly 
into  the  sac  the  operation  might  be  available,  but  that  if  the 
needle  had  to  pass  through  the  intestines  and  twice  through  the 
peritonaeum  it  was  decidedly  dangerous. 

Dr.  A.  P.  Dudley  said  that  he  rarely  opened  an  abdomen 
without  finding  the  intestines  were  in  front  or  adherent  in  the 
pelvis,  and  in  position  to  be  punctured  if  that  operation  were 
performed,  and  he  thought  passing  a  Deedle  through  the  intes¬ 
tines  was  always  dangerous,  let  alone  passing  it  twice  through 
the  peritonaeum.  It  was  his  practice,  in  cases  in  which  the  op¬ 
eration  was  called  for,  to  puncture  through  the  vagina.  The 
history  of  a  case  was  related  where  an  enlargement  presented 
behind  the  uterus.  A  satisfactory  history  could  not  be  obtained, 
but,  as  far  as  could  be  learned,  there  was  nothing  to  indicate 
tumor,  haematocele,  or  inflammation.  He  had  punctured  per 
vaginam.  and  drawn  off  twelve  ounces  of  blood.  To-day  he  had 
made  another  puncture  with  a  needle  an  eighth  of  an  inch  in 
caliber,  but  had  been  unable  to  discover  anything.  After  an  in¬ 
cision  he  had  drawn  off  three  ounces  of  pus.  He  concluded  that 
the  case  had  originally  been  one  of  hematosalpinx  resulting  in 
pyosalpinx,  and  that  if  he  had  been  satisfied  with  an  exploratory 
puncture  the  bad  results  would  have  been  obvious. 

Dr.  H.  J.  Boldt  said  that,  as  a  rule,  lie  was  opposed  to  punct¬ 
ure  of  any  kind,  for  the  reason  that  it  was  possible  to  tell  in 
almost  every  case  whether  the  trouble  was  intraperitoneal  or 
extraperitoneal  without  doing  this.  For  a  positive  diagnosis  to 
be  made  the  needle  would  have  to  be  larger  than  would  be 
proper  to  use,  because  the  pus  would  Dot  pass  through  the  fine 
ones.  An  incision  was  preferable  in  cases  where  pus  and  cheesy 
masses  were  supposed  to  he  present.  He  thought  that  with  the 
patient  under  an  anaesthetic  a  good  diagnosis  could  be  made, 
and  for  this  purpose  he  did  not  like  the  puncture  at  all.  He 
had  been  surprised  to  hear  Dr.  Edebohls  say  that  it  did  no  harm 
to  puncture  the  intestines. 

Dr.  H.  0.  Coe  thought  that  in  puncturing  through  the  ab¬ 
dominal  wall  there  was  always  danger  of  injuring  the  intestines 
and  blood-vessels,  and  that  this  could  almost  always  be  avoided 
by  operating  through  the  vagina;  but  even  this  was  not  with¬ 
out  its  drawbacks.  He  preferred  the  exploratory  incision  to 
puncture.  He  could  not  think  that  Dr.  Edebohls’s  method 
would  be  generally  accepted. 

The  Chairman  said  that  it  was  always  a  temptation  to 
puncture  to  find  out  what  the  tumor  was  in  such  a  case,  but  in 
his  hands  the  method  had  not  been  successful.  Of  course  Dr. 
Edebohls  had  used  every  precaution  in  his  cases,  but  the  result 
of  puncture  of  the  intestines  was  well  known.  He  thought 
that  puncture  ought  never  to  be  done  by  persons  who  were  not 
competent  to  do  laparotomy  if  it  was  necessary,  and  that  under 
any  precaution  the  operation  was  fraught  with  grave  dangers. 


Dr.  Edebohls  had  expected  objection  to  his  method,  but  he 
thought  that  the  points  in  his  paper  had  been  overlooked  by 
most  of  the  speakers,  as  his  method  did  not  refer  to  large  tu¬ 
mors,  but  to  small  masses  which  lay  deep  in  the  abdominal 
cavity.  He  did  not  mind  the  intestines  being  punctured.  He 
had,  after  operating,  kept  the  patients  under  observation  from 
a  day  to  fourteen  days,  and  had  never  bad  any  bad  results.  He 
did  not  recommend  the  method  to  the  general  practitioner,  but 
only  to  the  expert,  and  it  was  only  to  be  employed  in  those 
cases  in  which  a  diagnosis  could  be  made  in  no  other  way. 
1  be  method  had  never  been  used  for  its  therapeutic  value,  al¬ 
though  some  patients  had  been  cured  by  the  removal  of  the 
contents  of  the  sac.  He  only  used  an  anaesthetic  in  puncturing 
when  he  could  not  do  without  it.  About  three  quarters  of  his 
patients  had  been  operated  on  without  an  anaesthetic.  He  in¬ 
sisted  again  that  his  method  was  not  for  the  general  practitioner, 
but  for  the  expert,  and  that,  if  perfect  asepsis  was  practiced, 
the  needle  introduced  steadily,  and  the  inclination  to  move  the 
needle  about  resisted,  the  results  could  not  fail  to  be  good. 

Dr.  Dudley  asked  whether  an  operation  had  ever  been  done 
on  one  of  the  patients  that  had  been  previously  punctured,  and 
if  so,  whether  any  adhesions  or  thickening  had  been  found  along 
the  line  of  puncture? 

Dr.  Edebohls  said  that  he  had  had  no  opportunity  to  make 
such  an  examination,  but  that  it  was  well  known  that,  even  in 
gunshot  wounds  of  the  intestines,  them  ucosa  filled  up  the  gap 
very  rapidly,  and  that  he  did  not  think  that  the  small  needle 
which  he  used  would  allow  any  fecal  matter  to  flow  out  and 
cause  general  peritonitis. 

The  Manikin  in  the  Teaching  of  Practical  Obstetrics.— 

Dr.  J.  C.  Edgar  read  a  paper  with  this  title.  (To  be  published.) 

Dr.  Jewett  said  that  this  subject  was  one  of  great  interest 
and  one  that  had  not  received  the  attention  which  it  ought.  It 
was  almost  impossible  to  get  sufficient  material  for  students, 
and  the  well-made  manikins  and  appliances  that  could  now  be 
procured  were  of  great  value  in  teaching  obstetrics.  It  was  his 
opinion  that  this  was  the  only  way  in  which  the  student  could 
be  trained  in  this  branch. 

Dr.  H.  T.  Collyer  related  the  history  of  a  case  of  forceps 
delivery  which  he  had  been  called  to  see,  after  it  had  been 
worked  at  by  several  other  physicians,  in  which  the  mutilation 
of  the  patient  was  simply  fearful.  It  was  the  opinion  of  the 
speaker  that  if  his  colleagues  had  had  manikin  training  such 
things  could  not  have  happened. 

The  Chairman  had  had  twelve  years’  experience  in  the  use 
of  the  manikin  as  a  means  of  teaching  practical  obstetrics  and 
he  was  convinced  that  it  was  the  only  means  by  which  it  could 
be  properly  impressed.  In  the  first  place,  even  if  one  had  a 
patient  for  the  purpose,  it  was  impossible  to  let  a  whole  class 
examine  her,  and  if  they  did  they  could  not  see  into  the  uterus 
and  appreciate  what  was  going  on.  It  was  the  same  thing  in  the 
application  of  the  forceps  on  the  human  subject.  The  student 
had  to  take  the  word  of  the  instructor  as  to  what  position  it  was 
in  in  the  uterus,  and  it  was  a  pretty  hard  thing  to  understand 
without  seeing.  In  the  use  of  the  manikin  a  foetal  cadaver 
could  be  used,  and  the  forceps  be  applied  and  the  student  see 
what  he  was  doing.  In  this  same  way  all  the  capital  proced¬ 
ures  might  be  performed.  He  strongly  advised  this  method  of 
teaching  obstetrics,  as  only  one  out  of  every  twelve  physicians 
could  get  the  opportunity  of.having  maternity  training.  He 
thought  that  the  gynaecologists’  material  was  supplied  by  the 
obstetricians,  and  that  this  was  due  to  a  lack  of  knowledge  of 
eveD  the  first  principles  of  midwifery.  One  of  the  most  impor¬ 
tant  things  that  a  student  should  know  was  pelvimetry.  With 
this  fact  in  mind,  an  examination  should  always  be  made  before 
labor  came  on.  In  spite  of  the  large  number  of  obstetrical 


Dec.  20,  1890.] 


BOOK  NOTICES. 


699 


operations  done,  the  mortality  was  kept  down  pretty  low  ;  but 
in  all  teaching  of  obstetrics  the  student  must  be  told  to  use  the 
forceps  only  when  it  was  necessary. 

Dr.  Coe  had  had  considerable  experience  in  the  use  of  the 
manikin  and  cadaver  in  teaching  operative  gynaecology,  but 
thought  that  the  well-appointed  manikins  were  to  be  preferred, 
for  the  reason  that  work  on  the  cadaver  was  not  compatible 
with  that  of  the  practitioner,  obstetrician,  or  gynecologist. 

Transperitoneal  Hysterorrhaphy ;  a  New  Method  of 
Ventro-fixation  of  the  Uterus  without  opening  the  Ab¬ 
dominal  Cavity.— This  was  the  title  of  a  paper  by  Dr.  Florian 
Krug.  (To  be  published.) 

Dr.  H.  J.  Boldt  thought  that  one  of  the  disadvantages  of 
the  operation  was  the  introduction  of  a  sound  into  the  uterus, 
and  the  force  necessary  to  hold  the  uterus  against  the  abdominal 
wall,  which  was,  the  speaker  thought,  in  some  cases  a  dangerous 
proceeding,  as  some  uteri  were  so  soft  that  the  sound  would 
penetrate  them.  Taken  altogether,  he  could  not  see  the  ad¬ 
vantage  of  the  operation  ;  for  his  part,  he  should  prefer  to  make 
the  regular  incision.  As  for  ventral  fixation,  no  matter  what 
operation  was  done,  he  was  not  prepared  to  comment  on  its 
merits,  as  the  permanent  results  were  not  known,  and  cer 
tainly,  from  theory  alone,  he  could  not  say  he  thought  it  suc¬ 
cessful. 

Dr.  Dudley  thought  that  Dr.  Krug’s  operation  was  inge¬ 
nious;  that  if  the  uterus  would  remain  adherent,  and  if  the  re¬ 
sults  were  good,  he  should  be  glad  to  indorse  it.  But  he  thought 
adhesion  of  the  uterus  to  the  abdominal  wall  quite  as  much  of 
a  pathological  condition  as  the  retro-displacement,  and  that 
with  the  uterus  firmly  fixed  in  this  position,  it  would  be  sub¬ 
jected  to  a  great  deal  of  pressure,  both  from  above  and  from 
below.  There  was  no  doubt  that  if  an  operation  could  be  per¬ 
formed  years  after  such  fixation,  the  adhesions  would  be  found 
stretched  and  dragged.  He  thought  any  operation  which  would 
straighten  up  the  uterus  without  fastening  it  to  the  abdominal 
wall  would  be  preferable ;  still,  it  he  had  a  case  of  movable  uterus 
that  had  resisted  other  means  of  treatment,  he  should  be  in 
dined  to  try  this  method. 

Dr.  Currier  thought  that  the  objections  to  the  operation 
were  very  considerable.  In  the  first  place,  he  saw  no  need  of 
exposing  the  woman  to  dangers  the  result  of  which  one  could  not 
be  sure  of.  Then,  again,  he  thought  that  puncturing  the  uterus 
was  not  without  danger,  and  that  scraping  or  denuding  it,  when 
it  could  not  be  observed  to  what  extent  this  was  done,  was  also 
unsafe.  He  should  be  glad  to  know  of  something  that  would 
cure  those  cases  of  retro-displaced  uteri  of  non-inflammatory 
origin.  For  his  part,  he  did  not  feel  like  doing  an  abdominal 
section  in  such  cases.  About  the  merits  of  the  new  operation 
he  was  not  prepared  to  speak,  but  Dr.  Polk  had  said  that  in  uteri 
which  had  been  previously  so  attached  he  had  found  the  ad¬ 
hesions  loosened  after  a  time. 

Dr.  Edeboiils  said  that  the  success  of  such  operations  de¬ 
pended  upon  the  firmness  of  the  peritoneal  adhesions,  but  if 
this  could  be  avoided,  so  much  the  better.  In  his  own  practice 
he  did  a  modification  of  Alexander’s  operation.  Twenty-one 
patients  in  all  had  been  operated  upon,  and  the  results  had  been 
very  satisfactory. 

Dr.  Jewett’s  experience  in  this  operation  had  been  limited 
to  one  case  only,  but,  from  what  he  had  seen  and  heard,  he  did 
not  think  the  operation  devoid  of  danger. 

Dr.  Dudley  would  like  to  know  how  it  could  be  told 
whether  the  uterus  was  adherent  or  not.  He  had  performed 
laparotomy  in  three  cases  after  operation  for  the  purpose  of 
fastening  the  uterus  to  the  abdominal  wall,  and  had  never  been 
able  to  find  any  adhesions. 

The  Chairman  thought  that  considerable  good  might  be 


done  to  the  uterus  by  having  it  held  in  position  for  a  while, 
even  if  the  adhesions  did  loosen  after  a  time;  at  any  rate,  he 
thought  it  a  good  thing  to  try. 


§ook  Uotkfs. 

A  Manual  of  Modern  Surgery :  an  Exposition  of  the  Accepted 
Doctrines  and  Approved  Operative  Procedures  of  the  Pres- 
sent  Time.  For  the  Use  of  Students  and  Practitioners.  By 
John  B.  Roberts,  A.  M.,  M.  D.,  Professor  of  Surgery  in  the 
Woman’s  Medical  College  of  Pennsylvania,  etc.  With  Five 
Hundred  and  One  Illustrations.  Philadelphia:  Lea  Broth¬ 
ers  &  Co.,  1890.  Pp.  xvi-33  to  800.  [Price,  $4.50.] 

This  book  is  a  most  excellent  one  for  speedy  and  satisfac¬ 
tory  reference.  It  is  essentially  a  work  expressive  of  its  genial 
and  learned  author’s  well-digested  thought  and  experience,  and 
may  therefore  be  received  as  a  guide  in  practice  fully  up  to  the 
period,  and  philosophically  conservative.  For  medical  students, 
especially  the  overworked  American,  and  those  who  have 
neither  the  inclination  nor  the  leisure  to  prune  and  plod  for 
themselves,  the  book  is  invaluable.  The  initial  chapter,  on  in¬ 
flammation  and  kindred  subjects,  is  a  clear  and  concise  resume 
of  modern  views,  and  could  not  well  be  more  happily  worded 
or  adapted  to  easy  understanding.  The  chapters  on  injuries  of 
the  brain  and  spinal  cord  and  their  treatment  are  particularly 
worthy  of  commendation  and  evince  the  nicest  discretion  in 
their  preparation  and  much  original  labor.  The  book  abounds 
in  useful,  well-selected,  and  well-drawn  illustrations.  It  is  not 
only  worth  its  selling  price,  it  is  worth  ownin'g  and  reading. 

BOOKS  AND  PAMPHLETS  RECEIVED. 


Lehrbucb  der  Auscultation  und  Percussion  mit  besonderer  Beriick- 
sichtigung  der  Besichtigung,  Betastung  und  Messung  der  Brust  und  des 
Unterleibes  zu  diagnostischen  Zwecken.  Von  Dr.  C.  Gerhardt,  Pro¬ 
fessor  der  Medicin  und  Geh.  Med.-Rath  in  Berlin.  Fiinfte,  vermehrte 
und  verbesserte  Auflage.  Mit  49  in  den  Texte  gedruckten  Holzschnit- 
ten.  Tubingen:  H.  Laupp.  Pp.  viii-363. 

The  Physician’s  All-requisite  Time-  and  Labor-saving  Account  Book. 
Designed  by  William  A.  Seibert,  M.  D.,  of  Easton,  Pa.  Philadelphia 
F.  A.  Davis. 

The  Medical  Bulletin  Visiting  List,  or  Physician’s  Call  Record.  Ar¬ 
ranged  upon  an  Original  and  Convenient  Monthly  and  Weekly  Plan  for 
the  Daily  Recording  of  Professional  Visits.  New  Edition.  Philadel 
phia  :  F.  A.  Davis. 

Treatment  of  Uterine  Fibro-myomata  by  Abdominal  Hysterectomy 
By  J.  C.  Irish,  M.  D.,  Lowell,  Mass.  [Reprinted  from  the  Boston  Mcdi 
cal  and  Surgical  Journal .] 

The  Regimental  Red  Cross  Corps.  A  Manual  for  Medical  Officers 
of  the  U.  S.  Militia.  By  W.  Thornton  Parker,  M.  D.,  etc. 

How  the  Physicians  of  Johnstownpvere  relieved  after  the  Flood- 
A  Paper  read  at  the  Annual  Meeting  of  the  Pennsylvania  State  Medi¬ 
cal  Society,  Pittsburgh,  Pa.,  June  10,  1890.  By  George  W.  Wagoner, 
M.  D.,  of  Johnstown.  [Reprinted  from  the  Transactions  of  the  Medical 
Society  of  Pennsylvania.'] 

Report  of  Fifteen  Cases  of  Puerperal  Eclampsia.  By  John  G. 
Meachem,  M.  D.,  of  Racine,  Wis.  [Reprinted  from  the  Journal  of  the 
American  Medical  Association.] 

Cocaine  Analgesia;  its  Extended  Application  in  General  Surgery, 
when  hypodermically  employed.  By  Thomas  H.  Manley,  M.  D.,  New 
York.  [Reprinted  from  the  Boston  Medical  and  Surgical  Journal.] 
Flat-foot.  I.  Clinical  Lecture:  Post-graduate  Course,  Edinburgh, 
October,  1889.  II.  Paper  read  before  Edinburgh  Medico-chirurgical 
Society,  May,  1890.  By  A.  G.  Miller,  F.  R.  C.  S.  Ed.,  etc.  [Reprinted 
from  the  Edinburgh  Medical  Journal .] 


700 


MISCELLANY. 


[N.  Y.  Mkd.  Joi'E- 


Exploratory  Puncture  of  the  Female  Pelvic  Organs.  A  Diagnostic 
Study.  By  George  M.  Edebohls,  A.  M.,  M.  D.  [Reprinted  from  the 
Medical  Record.'] 

Neurasthenia  and  Neuralgia  from  Traumatism  of  the  Nasal  Pas¬ 
sages.  By  W.  F.  Chappell,  M.  D.,  M.  R.  C.  S.  Eng.  [Reprinted  from 
the  Medical  Record.] 

Contribute  alia  chirurgia  cerebrale.  1.  Leptomeningite  circoscritta, 
trapanazione,  guarigione.  2.  Tumore  del  cervelletto  con  idrocefalia, 
trapanazione  esplorativa,  morte.  Pel  Dott.  I.  Lampiasi.  (Comunica- 
zione  fatta  alia  VI  adunanza  della  Society  italiana  di  chirurgia  in 
Bologna  il  16  Aprile,  1889.) 

Contributo  alia  chirurgia  della  colonna  vertebrale.  1.  Lussazione  e 
frattura  delle  vertebre  dorsali,  operazione,  morte.  2.  Frattura  della 
10a  vertebra  dorsale,  operazione,  guarigione.  Pel  Dott.  I.  Lampiasi. 
(Comunicazione  fatta  alia  VI  adunanza  della  Society  italiana  di  chirur¬ 
gia  in  Bologna  il  16  Aprile,  1889.) 

Les  microbes,  les  ferments  et  les  moisissures.  Par  le  Dr.  E.  L. 
Trouessart.  Deuxieme  edition,  revue,  corrigee  et  considerablement 
augmentee.  Avec  132  figures  dans  le  texte.  Paris  :  Felix  Alcan, 
1891.  Pp.  xi-282. 

Contributo  alia  chirurgia  cerebrale.  1.  Epilessia  jacksoniana  da 
pachimeningite,  operazione,  guarigione.  2.  Epilessia  jacksoniana  da 
prodotti  tardivi  di  sifilide,  operazione,  guarigione.  Pel  Dott.  I.  Lam¬ 
piasi,  etc.  [Estratto  dalla  Riforma  medica.] 


JUigrTlIang. 


Mortality  in  Cities  in  the  United  States. — The  following  table  rep¬ 
resents  the  mortality  in  the  cities  named,  as  reported  to  Dr.  John  B. 
Hamilton,  Surgeon-.General  of  the  Marine-Hospital  Service,  and  pub¬ 
lished  in  the  Abstract  of  Sanitary  Reports  for  December  12th  : 


DEATHS  FROM— 


CITIES. 

a 

»3 

a 

V 

8 

V 

* 

Estimated  poj 
lation. 

Total  deaths  i 
all  causes 

Cholera. 

|  Yellow  fever. 

|  Small-pox. 

Varioloid. 

|  Varicella. 

Typhus  fever. 

Enteric  fever. 

Scarlet  fever. 

Diphtheria. 

i 

<V 

S 

Whooping- 

cough. 

New  York,  N.  Y . 

1,652,748 

672 

t 

..  8 

5  31 

10 

5 

Chicago,  Ill . 

1,100,000 

258 

5 

1  15 

5 

1 

Philadelphia,  Pa . 

Nov.  29. 

1,064,277 

385 

. .  15 

5  11 

i 

St.  Louis,  Mo . 

Dec.  C). 

460,000 

141 

1 

1 

5 

Baltimore,  Md . 

Dec.  fi. 

455'427 

159 

1 

1 

3 

4 

i 

Boston,  Mass . 

Dec.  fi. 

446,507 

186 

4 

7 

i 

Cincinnati,  Ohio . 

Dec.  5. 

325,000 

106 

2 

7 

New  Orleans,  La . 

Nov.  22. 

254’0iX) 

131 

1 

1 

1 

New  Orleans,  La . 

Nov.  29. 

254^000 

155 

i 

1 

Detroit,  Mich . 

Nov.  30. 

250^000 

76 

10 

Washington,  D.  C _ 

Nov.  29. 

250^000 

68 

i 

3 

1 

3 

i 

Washington,  D.  C. . . . 

Dec.  6. 

250^000 

78 

4 

2 

Pittsburgh,  Pa . 

Nov.  29. 

240’0C0 

83 

6 

12 

1 

Milwaukee,  Wis . 

Dec.  6. 

220'000 

69 

1 

9 

2 

Newark,  N.  J . 

Dec.  6. 

184,880 

54 

4 

1 

Minneapolis,  Minn... 

Dec.  6. 

164,738 

41 

2 

5 

Rochester,  N.  Y . 

Dec.  0. 

138|327 

31 

1 

1 

2 

4 

Providence,  R.  I . 

Dec.  6. 

132,043 

39 

1 

i 

Richmond,  Va . 

Nov.  29. 

ioo'ooo 

43 

.. 

1 

4 

Toledo,  Ohio . 

Dec.  5. 

82^652 

23 

2 

Nashville,  Tenn . 

Dec.  G. 

76,309 

26 

i 

Fall  River,  Mass . 

Dec.  6. 

75’000 

26 

1 

2 

Portland,  Me . 

Dec.  6. 

42.000 

13 

Galveston,  Texas .... 

Nov.  14. 

40.000 

13 

1 

Galveston,  Texas.... 

Nov.  21. 

40,000 

tl 

Galveston,  Texas .... 

Nov.  28. 

40,000 

17 

1 

Binghamton,  N.  Y. .  . 

Dec.  6. 

35,000 

10 

" 

1 

Auburn,  N.  Y . 

Nov.  29. 

25,887 

9 

Auburn,  N.  Y . 

Dec.  6. 

25,887 

9 

Newton,  Mass . 

Nov.  22. 

24,375 

2 

Newton,  Mass . 

Nov.  29. 

24,375 

7 

Newport,  R.  I . 

Dec.  4. 

20,000 

4 

Rock  Island,  III . 

Nov.  30. 

17^000 

4 

San  Diego,  Cal . 

Nov.  29. 

16,000 

3 

Pensacola,  Fla . 

Nov.  29. 

15^00 

6 

1 

The  New  York  Academy  of  Medicine. — At  the  next  meeting  of  the 
Section  in  Laryngology  and  Rhinology,  on  Tuesday  evening,  the  23d 
inst.,  Dr.  J.  W.  Gleitsmann  will  read  a  paper  entitled  Experience  with 
Trichloracetic  Acid  in  Two  Hundred  Cases  of  Affections  of  the  Throat 
and  Nose,  with  Demonstrations  of  Instruments. 

At  the  next  meeting  of  the  Section  in  Obstetrics  and  Gynaecology, 


on  Friday  evening,  the  26th  inst.,  Dr.  Malcolm  McLean  will  read  a 
paper  on  The  Placenta,  Funis,  and  Membranes — some  Remarks  on 
their  Influence  in  Gestation  and  Parturition,  and  Dr.  R.  A.  Murray  will 
open  a  discussion  on  The  Diagnosis  and  Management  of  Concealed 
Haemorrhage  during  Labor. 

Tomato  Poisoning.  —  “  Under  this  title  Dr.  Mills  ( International 
Dental  Journal)  describes  a  form  of  recession  of  the  gums  of  the  supe¬ 
rior  molars,  which  he  believes  to  be  due  to  the  use  of  tomatoes  as  food. 
The  affection  is  most  marked  on  the  palatine  surfaces.  Great  sensi¬ 
tiveness  is  manifested  along  the  line  of  recession,  similar  to  that  of  an 
exposed  nerve.  The  only  remedy  was  found  to  be  abstinence  from 
tomatoes.  If  the  disease  continues,  the  teeth  fall  out,  not  usually 
more  than  one  being  lost  in  a  season.” — Druggist's  Circular  and 
Chemical  Gazette. 


ANSWERS  TO  CORRESPONDENTS. 

No.  338. — Half  an  hour. 

No.  339. — There  is  no  essential  difference. 

No.  34-0. — It  is  not  known.  The  active  constituent  is  conjectured 
to  be  a  ptomaine. 


To  Contributors  and  Correspondents. — The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow¬ 
ing  : 

Authors  of  articles  intended  for  publication  under  the  head  of  “  original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles ,  we  always' do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (1)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical ,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  (8)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of — we 
can  not  engage  to  publish  an  article  in  any  specified  issue  ;  (3)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
stated  in  a  communication  accompanying  the  manuscript ,  and  no 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors,  are 
not  suitable  for  publication  in  this  journal ,  either  because  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  profession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter ,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving, 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number ,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem¬ 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and, 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 
inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


THE  NEW  YORK  MEDICAL  JOURNAL,  December  27,  1890. 


(Original  Communtmtions. 


THE  MANIKIN  IN  THE 
TEACHING  OF  PRACTICAL  OBSTETRICS* * 

By  J.  CLIFTON  EDGAR,  A.  M„  M.  D., 

ADJUNCT  PROFESSOR  OF  ORSTETRICS  IN  THE  MEDICAL  DEPARTMENT  OF 
THE  UNIVERSITY  OF  THE  CITY  OF  NEW  YORK  ; 

ATTENDING  PHYSICIAN  TO  THE  OUTDOOR  POOR  DEPARTMENT  OF 
BELLEVUE  HOSPITAL,  DISEASES  OF  WOMEN  ; 

ATTENDING  PHYSICIAN  TO  THE  MIDWIFERY  DISPENSARY. 

This  subject  will  be  discussed  under  three  headings: 

I.  The  necessity  for  practice  upon  the  manikin  or  ca¬ 
daver  before  actual  attendance  upon  labor  cases. 

II.  A  description  of  the  various  manikins  and  their  ac¬ 
cessories  now  in  use. 

III.  What  may  be  accomplished  with  the  improved  ob¬ 
stetric  manikins. 

I.  The  Necessity  for  Practice  upon  the  Manikin  or 
Cadaver  before  Actual  Attendance  upon  Labor  Cases. — 
What  relation  do  demonstration,  practice,  and  operation 
upon  the  manikin  bear  to  clinical  instruction  in  mid¬ 
wifery  ? 

It  is  the  belief  of  the  writer  that  practice  upon  suitable 
manikins  should  precede  actual  attendance  upon  labor 
cases  and  the  performance  of  obstetric  operations.  We  are 
told  f  that  in  a  collection  of  100,000  labors  occurring  in  the 
maternity  hospitals  of  St.  Petersburg,  Berlin,  Dresden, 
Leipsic,  Marburg,  Munich,  Wurzburg,  Prague,  Vienna, 
Graz,  and  Laibach,  6,555  operations  were  demanded — in 
other  words,  one  operation  in  every  15-2  labors.  The  rela¬ 
tive  frequency  of  these  operations  is  variously  distributed 
over  the  performance  of  such  operations  as  the  application 
of  the  forceps,  internal  version,  detachment  of  the  placenta, 
extraction  in  breech  cases,  reposition  of  the  prolapsed  funis, 
induction  ot  premature  labor,  perforation,  cephalotripsy, 
Caesarean  section,  reposition  of  prolapsed  extremities,  etc. 
The  operations  just  cited  are  named  in  the  order  of  the 
frequency  in  which  they  were  demanded. 

In  606  cases  of  labor  occurring  in  the  Nursery  and 
Child’s  Hospital  during  the  time  my  friend,  Dr.  Irwin  H. 
Hance,  was  house  physician  in  that  institution,  operative 
interference  was  demanded  in  59  cases,  or  1  operation  in 
every  10*2  labors.  These  figures  take  no  account  of  17 
cases  of  pelvic  presentations,  where  undoubtedly  some  in¬ 
terference  was  resorted  to  for  the  extraction  of  the  after¬ 
coming  head  or  arms.  These  operations  included — 


Forceps  (low  operation) .  42 

“  (high  operation) .  7 

Correction  of  face  presentations .  3 

V  ersion .  3 

Craniotomy . 1 

Induction  of  premature  labor .  3 

Total .  59 


*  Read  before  the  Section  in  Obstetrics  and  Gynaecology  of  the  New 
York  Academy  of  Medicine,  November  28,  1890. 

f  PIoss,  quoted  by  Winckel,  Text-book  of  Midwifery,  Philadelphia, 

1889,  p.  602. 


Dr.  Hance  further  informs  me  that  in  a  recent  twelve 
weeks’  service  at  the  Maternity  Hospital  on  Blackwell’s 
Island  the  total  number  of  deliveries  was  106.  In  this 
number  operative  interference  was  resorted  to  25  times,  or 
1  operation  in  every  4-2  cases.  These  operations  included— 


Forceps  (low  operation) .  19 

“  (high  operation) .  2 

Version .  4 

Total .  oc, 


In  the  service  of  the  Midwifery  Dispensary  of  this  city _ 

a  lying-in  service  carried  on  in  the  tenement-house  districts 
of  the  east  side  for  purposes  of  clinical  instruction,  in 
which  the  patients  are  delivered  at  their  own  homes,  and  in 
which  the  practice  of  the  attending  physicians  has  been  a 
conservative  one— during  the  first  ten  months  of  its  exist- 
tence,  recently  completed,  there  were  160  cases  of  confine¬ 
ment  attended,  or  131  cases  at  full  term,  if  all  cases  of  pre¬ 
mature  labor,  abortion,  and  those  seen  during  the  puer- 
perium  are  omitted.  In  the  131  cases  of  labor  where 
delivery  occurred  at  full  term,  operative  interference  was 
demanded  in  8  instances,  or  1  opeiation  in  every  16-3  cases 


of  labor.  These  operations  included — 

Forceps  (high  operation) .  1 

“  (low  operation) .  1 

Podalic  version .  2 

Manual  extraction  in  pelvic  presentations .  4 

Total .  o 


Since,  in  estimating  the  frequency  of  operative  interfer¬ 
ence  in  the  606  cases  of  labor  occurring  at  the  Nursery 
and  Child  s  Hospital,  in  the  106  at  the  Maternity  upon 
Blackwell  s  Island,  and  in  the  131  in  the  service  of  the 
Midwifery  Dispensary,  no  account  is  taken  of  the  operation 
for  the  manual  extraction  of  the  placenta  from  the  uterine 
cavity,  it  is  quite  evident  that,  should  this  operation  be 
added  to  the  above  named,  the  frequency  of  operation 
would  consequently  be  somewhat  greater  than  the  foregoing 
figures — 1  in  10*2  cases,  1  in  4-2  cases,  and  1  in  16‘2  cases, 
respectively — would  indicate. 

In  private  practice  Floss  found  that  in  almost  every 
country  the  frequency  of  operation  gradually  increases.* 
He  ascribed  this  increase  to  the  greater  number  of  male 
obstetricians,  and  stated  further  that  ‘  more  operations  were 
performed  in  cities  than  in  the  country,  and  that  the  fre¬ 
quency  of  operation  bore  a  direct  relation  to  the  relative 
number  of  obstetricians.’  ” 

If  the  foregoing  statement— namely,  that  operative  in¬ 
terference  is  demanded  in  maternity  hospitals  once  in  every 
15-2  labors — is  true  (and  this,  from  the  figures  quoted,  is 
not  by  any  means  a  high  estimate),  the  question  naturally 
comes  home  to  each  one  of  us  :  How  may  the  student,  how 
may  the  practitioner  who  has  had  no  maternity  service, 
obtain  the  requisite  amount  of  practice  and  skill  for  the 
performance  of  obstetric  operations  in  private  practice  ? 
Is  one  justified  in  simply  waiting  for  such  cases  to  ari^e  jn 
his  practice  that  may  demand  operative  interference  in 
order  to  obtain  the  necessary  dexterity  ? 

:  '  ! - - - . - -J - ; _ : _ : _ :  '  _ -  ■  •  ■  •  l 

*  Winckel’s  Text-book  of  Midwifery,  Philadelphia,  1889.  . 


702 


EDGAR:  TEE  MANIKIN  IN  TEACHING  OBSTETRICS. 


[N.  Y.  Med.  Joub., 


It  goes  without  saying  that  the  student,  for  instance,  is 
scarcely  liable  to  obtain  an  insight  into  operative  obstet¬ 
rics  by  attending  the  two,  four,  six,  or  eight  cases  of  mid¬ 
wifery  that  are  prescribed  by  his  college  course.  The  sur¬ 
geon  who  has  a  certain  operation  before  him  has  already 
made  himself  familiar  with  the  technique  of  the  same  by 
reason  of  his  labors  in  the  dissecting-room  and  repeated 
practice  upon  the  cadaver.  Instruction  in  operative  sur¬ 
gery  upon  the  cadaver  is  common  enough.  It  is  the  excep¬ 
tion  for  a  medical  college  to  be  without  it. 

Has  every  medical  college  its  course  in  operative  ob¬ 
stetrics  ? 

In  Germany  the  performance  of  obstetric  operations 
upon  the  manikin  goes  hand  in  hand  with  the  student’s  ob¬ 
servation  and  practice  in  the  delivery  and  puerperal  wards. 
The  surgeon,  and  to  a  certain  extent  the  gynaecologist,  ob¬ 
tain  their  preliminary  training  by  operating  upon  the  cada¬ 
ver.  Can  not  the  obstetrician  do  the  same?  Most  assured¬ 
ly  he  can.  Practically,  however,  this  is  only  possible  in 
large  maternity  hospitals,  where  the  service  is  enormous 
and  where  deaths  are  constantly  occurring  among  the  re¬ 
cently  confined,  a  state  of  affairs  not  often  met  with  in  the 
present  state  of  obstetric  medicine  and  surgery. 

Because  so  difficult  to  obtain  in  a  proper  state  and  be¬ 
cause  repeated  operation  soon  renders  the  resistance  offered 
by  the  soft  parts  practically  useless  for  demonstration,  and 
since  the  supply  of  subjects  is  so  exceedingly  small,  we  find 
the  cadaver  of  the  puerperal  woman  but  seldom  resorted  to 
for  purposes  of  obstetric  demonstration  and  operation. 

Upon  some  other  means,  therefore,  are  we  forced  to  fall 
back,  and  necessity,  the  mother  of  invention,  has  called 
into  existence  the  obstetric  manikin.  Brought  first  into 
prominence,  in  all  probability,  some  time  in  the  latter  part 
of  the  seventeenth  century,  the  obstetric  manikin  has  passed 
through  many  changes,  and  numerous  improvements  have 
been  made  in  its  construction,  until  to-day  we  have  at  our 
command  manikins  which,  according  to  many  of  the  best 
German,  French,  English,  and  American  authorities  upon 
the  subject,  are  in  no  way  inferior,  for  purposes  of  diag¬ 
nosis,  demonstration,  and  operation,  to  the  cadaver  of  a 
puerperal  woman,  in  the  recent  state,  whose  pelvis  is  still 
covered  by  the  soft  parts. 

Indeed,  some  go  further  and  maintain  that  the  later  im¬ 
proved  obstetric  manikins  that  permit  of  the  production  of 
normal  and  deformed  pelves  at  will,  together  with  a  num¬ 
ber  of  still-born,  full-termed  children,  are  even  more  desir¬ 
able  than  the  cadaver  and  answer  every  requirement. 

II.  A  Description  of  the  Various  Manikins  and  their 
Accessories  now  in  Use. — Two  obstetric  manikins  are  to-day 
well  known  and  in  general  use. 

These  are  the  French  manikin,  known  as  the  Budin- 
Pinard,*  and  the  German  one,  known  as  the  manikin  of 
B.  S.  Schultze,!  of  Jena. 

Fig.  1  shows  the  Budin-Pinard  manikin  closed,  and  in 
Fig.  2  a  longitudinal  mesial  section  of  the  same  is  shown, 
bringing  into  view  the  internal  arrangement. 

*  Manufactured  by  Raoul  Mathieu,  Paris.  Price,  500  francs. 

f  Manufactured  by  Ed.  Schilling,  Jena,  Germany.  Piice,  120 
Marks. 


The  Budin-Pinard  manikin  is  carved  from  one  solid 
piece  of  wood,  and  represents  that  portion  of  the  female 
body  extending  from  a  point  just  above  the  mammary 


Pio.  1. — The  Budin-Pinard  manikin.  External  surface,  presenting  rubber  vulVa, 
anus,  and  inflated  anterior  abdominal  wall. 

glands  to  within  a  few  inches  of  the  knee  joints..  The 
thighs  are  widely  separated  for  convenience  in  operating* 
and  the  anterior  abdominal  wall  is  made  of  rubber  capable 
of  being  distended  with  air,  and  so  arranged,  upon,  a 


frame  hinged  to  the  upper  part  of  the  body  (Fig.  2)  that 
the  whole  may  be  thrown  back,  thus  bringing  the  abdomi¬ 
nal  cavity  and  pelvic  inlet  into  view.  The  pelvic  excava¬ 
tion  is  so  carved  as  to  roughly  represent  the  normal  bony 
pelvis,  and  one  piece  of  India  rubber  lines  the  abdominal 
and  pelvic  cavities,  and  at  the  pelvic  outlet  is  so  molded 
and  secured  to  the  margin  of  the  inferior  strait  as  to  form 
the  vulva,  ostium  vaginae,  and  perinseum. 

The  rubber  soft  parts  are  replaceable  by  means  of  metal 
plates  and  screws  when  worn  out,  and  this  must  be  at¬ 
tended  to  not  infrequently  if  the  manikin  is  in  constant 
use.  A  false  sacrum  is  so  arranged,  by  means  of  a  rod 
running  in  a  groove  at  the  posterior  part  of  the  abdominal 
cavity,  together  with  a  thumb-screw  at  its  extremity,  that 
any  required  diminution  of  the  antero-posterior  diameter 
at  the  inlet  may  be  produced. 

A  recent  improvement  has  been  added  to  this  manikin 


Dec.  27,  1890.] 


EDGAR:  THE  MANIKIN  IN  TEACHING  OBSTETRICS. 


in  the  shape  of  a  rubber  rectum,  by  means  of  which  recto¬ 
vaginal  and  recto-abdominal  palpation  may  be  practiced,  as 


703 


Fig.  3.— The  rubber  vulva,  vagina,  and  rectum,  and  part  of  the  uterus  used  in 
the  Budin-Pinard  Manikin. 


well  as  various  obstetric  operations  that  require  rectal  ma¬ 
nipulation,  for  example,  Ritgen’s  method  of  manual  extrac¬ 
tion  of  the  head,  when  lying 
low  in  the  pelvic  cavity  (Fig. 
3).  Various  methods  of  per¬ 
ineal  protection  may  likewise 
be  practiced  by  means  of  this 
improvement.  Another  im¬ 
provement,  not  so  recent  in 
character,  is  that  of  a  rubber 
uterus  shown  in  Fig.  4. 

It  consists  of  an  India- 
rubber  pocket  containing  two 
compartments,  one  of  which 
is  closed  by  a  metal  clamp  at 


Fig.  4. — The  rubber  uterus  (French 
model).  B,  cavity  to  contain  foe¬ 
tus  and  water ;  C,  cavity  dis¬ 
tended  with  air  ;  D,  tube  open¬ 
ing  into  C  ;  E,  tube  opening  into 
B  ;  F,  metal  clamp  to  close  B. 


F,  and  is  intended  to  contain  a  foetal  cadaver  together  with 
a  quantity  of  water,  which  latter  is  to  represent  the  liquor 
amnii.  The  other  compartment,  which  partially 
surrounds  the  first,  is  to  be  distended  with  air 
by  means  of  a  Davidson  syringe,  in  order  to  imi¬ 
tate  the  resistance  of  the  intestines  partially  dis¬ 
tended  with  gas. 

The  above-mentioned  rubber  uterus  with  its 
inclosed  foetus  and  fluid,  and  partially  surrounded 
by  air,  is  valuable  for  abdominal,  vaginal,  and 
combined  palpation,  for  diagnosticating  the  pres¬ 
entation,  position,  and  attitude  of  the  foetus  by 
these  means,  and  for  practicing  and  appreciating 
that  sign  of  pregnancy  known  as  ballottement. 

The  objections  made  against  the  Budin- 
Pinard  manikin  are  numerous.  So  much  rubber 
enters  into  its  construction,  both  in  the  anterior 
abdominal  walls  and  the  lining  to  the  abdominal 
and  pelvic  cavities,  and  in  the  formation  of  the 
vulva,  and  the  material  is  of  such  light  quality, 
that  repairs  are  constantly  demanded  if  the 
manikin  is  used  at  all  continuous!}’. 

The  writer’s  experience  at  the  University 
Medical  College,  where  two  of  these  French 
manikins  are  in  constant  use,  has  been  that  one 
co  1 1  e0  e  session  is  quite  sufficient  to  pretty  thoroughly  use 
up  the  rubber  representing  the  soft  parts,  and  to  necessi¬ 
tate  its  entire  renewal.  These  parts  are  as  yet  not  to  be 
obtained  in  this  country,  and  considerable  delay  and  in¬ 


convenience  at  times  attend  the  importing  of  them.  More¬ 
over,  the  manikin  can  be  used  in  but  one  position — the 
dorsal  one.  Because  there  is  no  motion  at  the  hip  joints, 
nor  attempt  to  imitate  nature  in  the  construction  of  the 
back  of  the  figure,  neither  abdominal  nor  thoracic  bandages 
can  be  properly  applied.  The  pelvis  itself  is  so  rougldy 
constructed  that  only  an  approach  to  the  normal  condition 
is  obtained. 

This  manikin,  however,  has  many  advantages.  It  is 
comparatively  light  and  readily  moved  from  one  table  to 
another.  It  is  compact,  and,  when  kept  in  constant  repair, 
one  of  the  best  manikins  we  have  at  our  disposal.  It  is 
alleged  for  it  that  it  is  the  best  manikin  known  to  the  pro¬ 
fession  for  the  purpose  of  practicing  abdominal  palpation. 
This,  however,  is  better  and  more  easily  taught  and  learned 
upon  the  pregnant  woman,  and  rarely  is  there  any  difficulty 
in  securing  suitable  cases  from  the  dispensaries  for  this 
purpose. 

In  Germany  to-day  the  most  popular  obstetric  manikin 
in  use  in  the  various  universities  is  that  designed  by  Pro¬ 
fessor  B.  S.  Schultze,  of  Jena. 

It  is  the  belief  of  the  writer  that  the  Schultze  manikin 
possesses  more  advantages  and  fewer  disadvantages  than 
the  Budin-Pinard  figure. 

As  may  be  seen  from  the  cuts,  the  figure  consists  prac¬ 
tically  of  a  square  box  so  arranged  upon  segments  of  circles 
as  to  be  capable  of  being  rotated  in  either  lateral  direction 
90°.  Set  into  this  box,  which  is  made  of  hard  wood,  is  a 
true  bony  pelvis,  covered  throughout  its  whole  extent  with 
strong,  heavy  leather.  The  angle  which  the  plane  of  the 
pelvic  inlet  makes  with  the  horizon  is  the  same  as  that 
made  when  the  woman  reclines  in  the  ordinary  dorsal  post¬ 


Fig.  5.— B.  S.  Schultze’s  manikin  seen  from  the  front.  The  forceps  applied  to  the  head  lying 

in  the  first  oblique  diameter. 


ure.  An  apron  of  chamois  skin  represents  the  anterior 
abdominal  wall,  and  is  so  adjusted  as  to  inclose  the  pelvic 
cavity  and  enough  additional  room  to  give  space  for  two 
foetuses  if  need  be. 


704 


EDGAR:  TEE  MANIKIN  IE  TEACHING  OBSTETRICS. 


[N.  Y.  Med.  Jour., 


Schultze  manikin  or  that  of  the  writer,  is  a  rubber  uterus,* 
invented  and  first  used  by  Professor  F.  Winckel,  of  Mu¬ 
nich  (Fig.  7). 

Fig.  8  represents  an  outline  cut  of  the  same. 

It  makes  with  either  manikin  an  exceedingly  useful 
combination,  as  it  possesses  a  dilatable  cervix  and  vagina, 
and  many  obstetric  manoeuvres,  not  otherwise  easily  demon¬ 
strated,  may  be  shown — e.  g.,  the  introduction  of  Barnes’s 
rubber  dilators  and  manual  dilatation  of  the  cervix. 

Another  advantage  of  the  German  manikin  is  that  the 
pelvis  may  be  readily  and  quickly  placed  in  the  lateral  post¬ 
ure  during  any  step  of  an  operation,  which  is  practically 
impossible  with  the  French  figure. 

Here  again,  however,  as  in  the  French  manikin,  the  hip 
joints  are  fixed.  The  thighs  must  remain  in  the  same  posi¬ 
tion  for  each  and  every  operation. 


The  pelvic  outlet  is  partially  closed  by  one  solid  piece 
of  India  rubber,  which  represents  the  vulva  and  pelvic  floor. 
In  order  to  imitate  pelvic  deformity,  zinc  castings  of  vari- 


Fig  6.— B.  S.  Schultze’s  manikin,  as  seen  from  above,  looking  down  into  the 

pelvic  inlet. 


ous  shapes  and  sizes  are  brought  into  use,  which  by  a  sim¬ 
ple  contrivance  may  be  fastened  to  the  sacral  promontory, 
or  removed  from  the  same  in  a  very  short  space  of  time. 
The  thighs,  widely  separated,  are  covered  with  thick, 
smooth  leather,  and  the  whole  figure  may  be  securely  fast¬ 
ened  to  a  table  or  a  pair  of  chairs  by  means  of  strong 
clamps. 

Such  an  obstetric  manikin  as  this  possesses  many  ad¬ 
vantages  and  very  few  disadvantages.  It  contains  a  true 
bony  pelvis  in  its  construction,  which  gives  us  much  greater 
accuracy  than  in  the  case  of  the  Budin-Pinard  figure.  It 
is  durable.  Tt  rarely  requires  repair.  With  the  exception 
of  the  pelvic  floor,  no  rubber  enters  into  its  construction, 
all  the  remaining  parts  being  made  of  hard  wood,  leather, 
or  bone. 

One  of  these  Schultze  manikins,  of  the  later  improved 
pattern,  the  writer  has  had  in  almost  daily  use  in  various 
classes  at  the  University  Medical  College  for  over  two 
years,  and  it  still  shows  no  bad  results  of  the  severe  usage 
to  which  it  has  been  subjected  ;  while,  in  the  case  of  two 
Budin-Pinard  manikins,  used  for  the  same  length  of  time, 
repeated  repairs  have  been  called  for. 

A  useful  accessory,  which  may  be  used  with  either  the 


*  Manufactured  by  Metzler  &  Co.,  8  Kaufinger  Strasee,  Munich, 
Bavaria. 

f  Ed.  Schilling,  Jena,  Germany. 


Fig.  7.— Rubber  uterus,  cervix,  and  vagina  (Winckel).  For  use  in  the  Schultze 
manikin,  or  that  of  Professor  Parvin  and  the  writer. 

The  pelvis  being  placed  in  a  square  case,  no  opportunity 
is  offered  for  the  application  of  bandages,  either  abdominal 
or  thoracic,  or  for  measuring  the  various  external  pelvic 
diameters  with  the  pelvimeter. 

Another  valuable  accessory  to  the  Schultze  manikin, 
and  one  which  may  now  be  obtained  from  the  manufactur¬ 
er,!  consists  of  segments  of  the  lower  uterine  segment,  in¬ 
cluding  the  cervix.  These  segments  come  in  sets  of  five, 
are  made  of  good  rubber,  and  are  so  arranged  as  to  fit 
accurately  into  the  pelvic  cavity  of  the  Schultze  manikin 
or  that  of  the  writer.  Each  segment  represents  the  os  in 
a  different  stage  of  dilatation,  so  that,  by  simply  changing 


Dec.  27,  1890.] 


EDGAR:  THE  MANIKIN  IN  TEACHING  OBSTETRICS. 


705 


ttiem  in  the  manikin,  the  entire  coarse  of  the  first  stao-e  of 

labor  may  be  demonstrated  to  the  person  palpating,  as  well 
as  the  effect  of  such  dilatation  upon  the  presenting  part  of 


of  a  complete  human  form,  with  movable  joints  that  would 
permit  of  the  figure  being  placed  in  any  desired  position, 
originated  with  Professor  Theophilus  Parvin,  of  Philadel¬ 
phia,  and  it  was  at  Dr.  Parvin’s  suggestion  that  the  writer 
undertook  the  production  of  the  present  manikin. 

After  considerable  planning,  directing,  and  supervising, 
suffice  it  to  say  that  we  obtained  from  a  model-maker  a  life- 
sized  figure,  possessing  a  form  proportioned  with  the  near¬ 
est  approach  to  nature  possible. 

In  Figs.  9,  10,  and  11  the  manikin  is  seen  in  different 
postures. 

The  joints  are  mobile,  so  as  to  permit  of  all  the  various 
movements  and  to  allow  of  the  figure  being  placed  in  any 
desired  posture — dorsal,  lateral,  semi-prone,  or  knee-chest. 
The  pelvis  is  an  exact  reproduction  in  brass  of  the  most 
perfect  bony  pelvis  obtainable,  and  is  completely  and 
smoothly  covered  with  soft  leather,  which  leaves  all  the 
elevations  and  depressions  of  the  original  bony  pelvis  un¬ 
changed.  This  permits  of  the  effect  of  these  elevations  and 
depressions  upon  the  mechanism  of  labor  being  demon¬ 
strated,  and  of  the  various  diameters  and  circumferences  of 
the  pelvis,  external  and  internal,  being  measured  with  the 
pelvimeter.  The  coccyx  is  so  arranged  by  means  of  a  hinge 
and  spring  at  the  rear  that  it  is  movable  to  the  extent  of 
allowing  recession  of  this  bone  one  inch.  A  false  sacrum 
is  provided,  controlled  by  a  rod  and  thumb-screw  in  the 
lower  dorsal  region,  by  means  of  which  any  desired  con¬ 
traction  of  the  conjugate  diameter  of  the  brim  may  be  pro¬ 
duced  (Fig.  10). 

Further,  a  soft  leather  pelvic  floor  is  added,  which  readi¬ 


Fig.  9.— Manikin  of  Professor  Theophilus  Parvin  and  the  writer.*  Anterior  view. 

ly  allows  the  exit  of  the  foetus,  or  the  use  of  instruments, 
palpation,  or  manual  extraction,  as  desired  (Fig.  10). 

For  the  anterior  abdominal  wall,  instead  of  the  inflata¬ 
ble  rubber  covering  of  the  Budin-Pinard  manikin,  which 
constantly  needs  replacing,  a  simple  leather  apron  is  pro¬ 
vided,  which  experience  has  shown  answers  every  pur¬ 
pose. 

The  joints  are  so  made  that  a  single  bolt  controlled  by 
a  key  tightens  or  loosens  them  at  pleasure.  The  abdominal 
cavity  (Fig.  9)  is  made  large  enough  to  admit  two  foetuses, 
if  need  be,  or  the  rubber  uterus  of  Winckel  (Fig.  7)  or  of 


Fig.  8. — Kiibber  uterus,  cervix,  and  vagina  (Winckel),  showing  mode  of  attach' 
ment  by  means  of  cords  to  the  pubes,  vulva,  and  lumbar  region  of  the 
Schultze  manikin. 


the  foetal  cadaver,  whatever  that  presenting  part  may  hap¬ 
pen  to  be. 

With  these  rubber  cervices  many  conditions  heretofore 
difficult  of  demonstration  may  be  easily  and  readily  made 
plain.  The  protrusion  of  the  bag  of  waters  (using  the 
French  rubber  uterus  for  the  mem¬ 
branes),  the  characteristics  of  the 
presenting  part  during  the  several 
stages  of  dilatation,  the  application 
of  cervical  dilators,  or  the  perform¬ 
ance  of  obstetric  operations  through 
a  partially  dilated  cervix,  as  well  as 
many  other  conditions,  may  be  fully 
and  clearly  demonstrated. 

Objection  has  been  raised  against 
the  Schultze  manikin  that  the  pelvic 
floor  is  too  hard  and  resisting;,  that 
there  is  no  attempt  to  imitate  nature 
in  the  construction  of  the  vulva,  that 
there  is  no  vagina  within  the  pelvis, 
and  that,  consequently,  the  Budin- 

Pinard  manikin,  which  has  none  of  these  so-called  objec¬ 
tions,  is  to  be  preferred  of  the  two. 

For  those  who  desire  it,  a  rubber  vulva  and  vagina 
may  now  be  procured  *  which  are  somewhat  similar  to  the 
same  parts  in  the  French  manikin,  and  which  may  be  at¬ 
tached  to  or  removed  from  the  Schultze  manikin  at  will. 

The  manikin  that  the  writer  desires  to  present  to  the 
Section  this  evening  is  one  which  he  believes  more  fully 
fulfills  the  requirements  for  obstetric  teaching  and  demon¬ 
stration  than  any  other  now  in  use. 

The  idea  of  producing  an  obstetric  manikin  in  the  shape 


*  From  Metzler  &  Co.,  8  Kaufinger  Strasse,  Munich,  Bavaria. 


*  Parvin-Edgar  manikin. 


706 


EDGAR:  TEE  MANIKIN  IN  TEACHING  OBSTETRICS. 


[N.  Y.  Med.  Jouk., 


the  French  school  (Fig.  4),  or  both  may  with  advantage  be 
used. 

The  entire  external  surface  of  the  manikin,  with  the  ex- 


Fig.  10.— Manikin  of  Professor  Theophilus  Parvin  and  the  writer. 

Head  of  fcetal  cadaver  seen  distending  the  vulva 

ception  of  the  head,  is  covered  with  soft  leather  ;  and  the 
figure  itself  is  light  enough  to  be  freely  movable  upon  the 
operating  table,  or  carried  from  place  to  place. 

Since  we  have  in  this  obstetric  manikin  a  complete  hu¬ 
man  form,  that  may  be  placed  in  any  desired  posture  (Figs. 
9,  10,  11),  that  will  permit  of  the  application  of  any  band¬ 
age,  binder,  or  dressing,  that  possesses  all  the  advantages, 
and  few,  if  any,  of  the  disadvantages,  of  the  Budin-Pinard 
and  Schultze  manikins,  it  is  the  belief  of  the  writer  that  the 


The  pelvis  is  practically  indestructible  and  is  so  mount¬ 
ed  (Fig.  12)  upon  the  upright  of  a  tripod  as  to  permit  of 
rotation  in  an  entire  circle  in  a  horizontal  plane,  and  this 

permits  the  pelvic  outlet  or  inlet 
being  directed  to  any  point  desired. 

Besides  complete  rotation  in 
the  plane  of  the  horizon,  partial 
rotation  upon  a  transverse  axis  is 
also  easily  and  quickly  secured,  and 
a  simple  device  (Fig.  13)  in  the 
shape  of  a  small  wheel  at  the  side 
enables  one  to  fix  the  planes  of  the 
pelvis  (represented  by  card-board 
if  need  be)  at  any  desired  angle 
with  the  horizon. 

If  desirable,  for  greater  con¬ 
venience  and  accuracy,  a  simple 
scale  may  be  added  at  the  side, 
,eft  lateral  posture.  which  will  enable  one  to  read  off  at 

a  glance  the  angle  produced.  A 
movable  coccyx  permits  recession 
duiing  the  passage  of  the  foetus,  and  a  spring  throws  it 
back  again  to  its  true  position.  A  false  sacrum,  con¬ 
trolled  by  a  thumb-screw  passing  through  the  true  sa¬ 
crum,  enables  one  to  illustrate  contraction  of  the  pelvis 
in  its  antero-posterior  diameter,  or  to  fix  the  presenting 
part  of  the  puppe  or  foetal  cadaver  in  any  desired  posi¬ 
tion.  A\  ith  such  material  as  the  foregoing — the  four  mani¬ 
kins,  with  their  several  accessories,  together  with  an  abun¬ 
dant  supply  ot  foetal  cadavers  of  various  sizes — there  is 
scarcely  an  obstetric  operation  or  procedure 
that  may  not  be  performed  or  demonstrated. 


CONCLUSIONS. 

1.  Practice  upon  the  obstetric  mani¬ 
kin  should  supplement,  not  supplant,  clini¬ 
cal  instruction.  The  former  should  go  hand 
in  hand  with  instruction  at  the  bedside. 

2.  Skill  in  determining  the  attitude,  the 
various  presentations  and  positions  of  the 
foetus,  by  external  and  internal  palpation, 
should  be  obtained  by  the  student  or  practi¬ 
tioner  before  actually  undertaking  the  care 
ot  a  woman  during  confinement. 

3.  Familiarity  with  the  construction  and 
the  application  of  the  various  obstetric  in- 


Fig.  11.  Manikin  of  Professor  Theophilus  Parvin  and  the  writer.  Knee-chest  posture.  struments,  as  well  as  with  the  performance 


improved  manikin  contains  the  most  desirable  factors  ne¬ 
cessary  for  instruction  and  class-room  demonstration. 

lor  demonstrating  the  mechanism  of  labor  before  a  large 
class  the  application  of  the  forceps,  cranioclast,  cephalo- 
tribe,  and  other  obstetric  instruments;  the  various  meth¬ 
ods  of  performing  version  ;  the  different  methods  of  man¬ 
ual  extraction,  whether  by  the  head,  shoulders,  breech,  or 
lower  extremities — the  gun-metal  pelvis,  covered  with  leather 
and  mounted  upon  a  tripod,  and  devised  by  the  writer  of 
this  paper,  has  proved  itself  exceedingly  useful  (Figs.  12, 


of  each  operation,  should  be  acquired  before 
subjecting  the  pregnant  or  parturient  woman  to  these 
operative  procedures. 

4.  Both  of  the  foregoing — viz.,  skill  in  diagnosis  and 
dexterity  in  operating — can  undoubtedly  be  obtained  by 
practice  either  upon  the  cadaver  of  a  puerperal  woman, 
together  wdth  the  foetal  cadaver,  or  upon  suitable  mani¬ 
kins. 

5.  The  recent  improvements  in  obstetric  manikins  have 
lendered  them  more  practical  than,  and  quite  as  satisfactory 
as,  the  cadaver. 

6.  W  ith  the  material  at  our  command,  there  is  scarcely 


Doc.  27,  3890..] 


EDGAR:  THE  MANIKIN  IN  TEACHING  OBSTETRICS. 


707 


ad  obstetric  procedure  or  operation  that  may  not  be  demon-  II.  Vaginal  Palpation  ;  Rectal  Palpation  : 


strated  or  performed. 

III.  What  mag  be  accomplished  with  the  Obstetric  Mani¬ 
kin. — With  a  view  to  showing  those  who  are  interested  in 
midwifery  what  one  is  able  to  accomplish  with  the  obstetric 
manikin  in  the  matter  of  demonstration,  practice,  and  op- 


1.  Internal  ballottement.  2.  Diagnosis  of  vertex,  breech, 
face,  brow,  and  shoulder  presentations.  3.  Diagnosis 
of  vertex,  breech,  face,  brow,  and  shoulder  positions. 


HAZARD. 
HAZARD  &C0 


W.F.FORD . 
N.Y. 


Fig.  12. — The  writer’s  metal  pelvis  and  tripod.  Useful  for  demonstrating 
the  mechanism  of  labor  and  obstetric  operations. 

eration,  the  writer  of  the  foregoing  paper  has  taken  the 
liberty  of  appending  to  it  his  “  Scheme  of  Instruction'1'1  that 
it  has  been  his  custom  to  follow  for  the  past  two  years  in 
his  various  sections  and  classes  at  the  University  Medical 
College  of  this  city : 

WHAT  MAY  BE  ACCOMPLISHED  WITH  THE  OBSTETRIC 

MANIKIN. 

DEMONSTRATIONS  AND  OPERATIONS. 

A.  Pregnancy. 

I.  Abdominal  Palpation  : 

1.  Location  of  the  head,  breech,  shoulder,  small  parts, 
dorsal  plane.  2.  Attitude,  presentation,  and  position 
of  the  foetus  (normal,  .abnormal).  3.  Abdominal  bal¬ 
lottement;  fluctuation.  4.  Diagnosis  of  twins,  triplets. 
5.  Height  of  fundus. 


Fig.  13.— The  writer’s  metal  pelvis  and  tripod,  showing  head  of  puppe  at  pelvic 

outlet. 

4.  Height  of  presenting  part  in  pelvis.  5.  Conjugata 
diagonalis ;  conjugata  vera.  6.  Antero-posterior  diam¬ 
eter  of  outlet ;  distance  between  spines  of  ischii. 

III.  Conjoined  Palpation : 

1.  Abdomino-vaginal.  2.  Abdomino-rectal.  3.  Va- 
gino-rectal.  4.  Abdomino-recto-vaginal. 

B.  Labor. 

I.  False  Pelvis  ;  True  Pelvis : 

1.  Inlet.  2.  Cavity.  3.  Outlet.  4.  Planes.  5.  Axes. 
6.  Angles.  7.  Diameters.  8.  Circumferences. 

II.  Characteristics  of  Foetal  Head  and  Body  : 

1.  Shape.  2.  Movements.  3.  Compressibility.  4.  Di¬ 
ameters.  5.  Circumferences.  6.  Fontanelles.  7.  Sut¬ 
ures. 

III.  Attitude  ;  Presentation  ;  Position. 

IV.  Classification  of  Presentations. 

Y.  Characteristics  of  Vertex ,  Breech ,  Face ,  Brow ,  Shoulder , 
Trunk,  Ear ,  Hand ,  Elbow ,  Foot ,  Knee ,  Mouth ,  Anus, 
Genitals. 

VI.  Mechanism  of  Labor  : 

1.  Vertex.  2.  Breech.  3.  Face.  4.  Brow.  5.  Shoul¬ 
der.  6.  Occipito-posterior  positions.  7.  Mento-pos- 
terior  positions.  8.  After-coming  head.  9.  Doubled 
foetus.  10.  Spontaneous  version.  11.  Spontaneous 
evolution.  12.  Lateral  obliquity  of  head  (Nagele). 
13.  Placental  delivery  (Schultze,  Duncan). 


708 


EDGAR:  THE  MANIKIN  IN  TEACHING  OBSTETRICS. 


[N.  Y.  Med.  Jouk., 


VII.  Management  of  Labor  : 

1.  Preparation  of  labor-bed.  2.  Posture  of  parturient 
during  several  stages.  3.  Effect  of  posture  of  woman 
upon  presentation.  4.  Treatment  of  second  stage.  5. 
Method  of  following  down  the  fundus.  6.  Protection 
ot  perinaeum  (various  methods).  7.  Management  of 
the  funis  about  the  neck.  8.  Delivery  of  shoulders 
and  trunk.  9.  Ligature  of  the  funis;  care  of  child; 
various  methods  for  grasping  and  holding  the  child. 
10.  I  reatment  of  third  stage.  11.  Abdominal  binder. 
12.  Vulva  pad.  13.  Breast  binders. 

VIII.  Asphyxia  Neonatorum: 

1.  Rapid  delivery  (various  methods).  2.  Removal  of 
foreign  substances  from  air  passages :  a,  inversion  of 
child  ;  b ,  mouth-to-mouth  method;  c,  use  of  gauze;  d , 
catheter ;  e,  various  aspirators.  3/  Restoration  of  respi¬ 
ration  :  (1)  Reflex  stimuli  (various) ;  (2)  artificial  respi¬ 
ration  :  a,  mouth  to  mouth  ;  b,  catheter ;  c,  Ribemont- 
De  ssaignes  insufflator;  d,  aspirator  of  Jawisch  ;  e,  Syl¬ 
vester  method ;  f  Schultze  method  ;  g ,  Marshall  Hall’s 
method  ;  h ,  Byrd’s  method  :  i,  faradization  ;  j,  gavage. 

IX.  Haemorrhages : 

1.  Accidental  Haemorrhage  : 

(l)  Varieties;  (2)  aetiology  ;  (3)  diagnosis;  (4)  prog¬ 
nosis;  (5)  treatment :  o,  tampon  ;  b,  Barnes’s  bags; 
c,  vaginal  colpeurynter. 

2.  Unavoidable  Haemorrhage  ;  Placenta  Praevia  : 

(1)  Varieties;  (2)  aetiology;  (3)  diagnosis  by  pal¬ 
pation;  (4)  prognosis  ;  (5)  treatment :  a,  tampon; 
b,  Barnes’s  bags  ;  c,  vaginal  colpeurynter;  d,  Barnes’s 
method  ;  e ,  Cohen-Crede  method ;  f  Simpson’s 
method  ;  g,  Pfeiffer’s  method  ;  h,  rapid  delivery. 

3.  Post-partum  Haemorrhage  : 

(1)  Varieties;  (2)  aetiology;  (3)  diagnosis  by  pal¬ 
pation  ;  (4)  prognosis;  (5)  treatment:  a,  simple 
compression  ;  b,  Breisky’s  method  ;  c,  Gooch’s  meth¬ 
od  ;  d,  intra-uterine  applications  (heat,  styptics, 
packing  with  gauze) ;  e,  faradization. 

X.  Pelvic  Deformity : 

1.  Varieties.  2.  Etiology.  3.  Diagnosis:  a,  Pel¬ 
vimetry,  external  and  internal ;  b,  manual  pelvimetry. 

4.  Prognosis.  5.  Treatment :  a,  induction  of  abor¬ 
tion  ;  b ,  induction  of  premature  labor;  c ,  forceps;  d, 
version  ;  e,  advantages  and  disadvantages  of  fore'eps 
and  version  ;  f  choice  between  forceps  and  version  ;  g , 
embryotomy;  h,  Caesarean  section. 

XI.  Presentation  and  Prolapse  of  the  Cord  : 

Definitions  ;  Frequency ;  sEtiology  ;  Symptoms ;  Diagnosis  ;  Prognosis. 
Treatment :  a ,  postural  reposition ;  b ,  manual  reposi¬ 
tion  ;  c,  instrumental  reposition  ;  d ,  rapid  delivery  of 
foetus. 

XII.  Retention  of  the  Placenta  : 

Treatment :  a,  Crede’s  method  of  expression  ;  b,  man¬ 
ual  extraction. 

C.  Obstetric  Operations. 

Operations  performed  during  Pregnancy. 

I.  Induction  of  Abortion  : 

1.  Bougie.  2.  Cervical  dilators. 


II.  Induction  of  Premature  Labor  : 

1.  Bougie.  2.  Cervical  dilators.  3.  Gavage.  4.  Cou- 
veuse. 

Operations  performed  during  Labor. 

I.  Expression  of  the  Foetus — Expressio  Foetus. 

IT.  Forcible  Delivery — Accouchement  force. 

III.  Manual  Extraction  of  Head  (Ritgen's  Method). 

IV.  Extraction  in  Pelvic  Presentations : 

1.  Expressio  foetus.  2.  Traction  with  finger.  3. 
Manual  extraction  :  a,  Winckel’s  method  ;  b ,  A.  Mar’s 
method.  4.  Blunt  hook.  5.  Fillet:  a,  single  sling; 
b,  Galabin’s  double  sling.  6.  Traction  on  one  or  both 
legs.  7.  Forceps. 

V.  Extraction  of  After-coming  Head  : 

1.  Manual  rotation  of  transversely-placed  head.  2. 
Delivery  of  arms  (Winckel’s  method,  Barnes’s  meth¬ 
od).  3.  Methods  of  Smell ie,  Veit,  Mauriceau  (Veit- 
Smellie).  4.  Wigand — A.  Martin’s  method.  5.  Prague 
method.  6.  Forceps. 

VI.  Forceps : 

1.  Actions  (5).  2.  Indications.  3.  Conditions  neces¬ 

sary.  4.  Dangers  (foetus,  mother).  5.  Varieties  :  a, 
long;  b,  short;  c,  straight;  d,  axis-traction  (Tarnier, 
Breus,  Hubert,  Albert  H.  Smith  method).  6.  Opera¬ 
tions  :  a,  low ;  b,  high ;  c,  axis-traction ;  d,  adapta¬ 
tion  of  the  forceps  ;  e ,  vertex  presentations  (anterior 
positions)  ;  f  face  presentations  (mento-anterior 
positions)  ;  g ,  pelvic  presentations  ;  h,  occipito- 
posterior  positions  ;  i,  mento  posterior  positions  ; 
ji  incomplete  flexion  of  head;  k,  incomplete  exten¬ 
sion  of  head :  l,  after-coming  head ;  m,  use  of  dyna¬ 
mometer. 

VII.  Version : 

1.  Varieties:  a,  cephalic;  b,  pelvic;  c,  podalic.  2. 
Methods:  a ,  postural;  b,  external;  c,  internal;  d, 
combined.  3.  Description;  conditions  necessary ;  in¬ 
dications;  contra-indications;  dangers;  time  for  op¬ 
erating;  preparation;  position  of  parturient;  choice 
of  hands  ;  choice  of  part  to  be  seized  ;  instruments.  4. 
Postural  version.  5.  External  version.  6.  Combined 
version  (external  and  internal):  a,  Hohl’s  method;  b, 
Braxton-Hicks’s  (Wright’s)  method.  7.  Internal  ce¬ 
phalic  version:  a,  D’Outrepont’s  method;  b,  Busch’s 
method;  c,  Vienna  method.  8.  Internal  podalic  ver¬ 
sion  :  a,  in  cephalic  presentations ;  b,  in  shoulder  pres¬ 
entations.  9.  Internal  podalic  version  in  impacted 
shoulder  presentations:  a,  position  of  parturient;  b, 
choice  of  hand  for  operating ;  c,  use  of  sling  to  pro¬ 
lapsed  arm  ;  d ,  choice  of  leg  to  be  seized  (upper  or 
lower,  one  or  both,  knee  or  foot)  ;  e,  blunt  hook;  f 
sling  to  leg;  g,  Foster’s  method  when  the  arm  is  pro¬ 
lapsed.  10.  Combined  postural  (knee-chest),  internal 
and  external,  cephalic  or  podalic  version  in  shoulder 
presentations. 

A  III.  Rectification  of  Face  and  Brow  Presentations : 

1.  Schatz’s  method.  2.  Playfair,  Humphrey-Partridge 
method.  3.  Fillet.  4.  Breus’s  forceps.  5.  Baude- 
locque’s  method. 


Deo.  27,  1890. 


STEARNS:  THE  CLINICAL  ASPECTS  OF  KOCH'S  METHOD  IN  BERLIN. 


Brea ftnen t  of  Mento-postcrior  Positions  : 

1.  Extreme  extension  of  head:  a,  position  of  partu¬ 
rient;  b,  hand;  c,  Breus’s  forceps.  2.  Resistance  sup¬ 
plied:  a,  hand;  b,  blade  of  forceps;  c,  vectis.  3. 
Straight  iorceps.  4.  Ordinary  forceps.  5.  Version. 
6.  Perforation;  extraction. 


i  09 


XIV.  Porro's  Operation  : 

Definition;  Object  ;  Indications  ;  Conditions  necessary  ;  Dangers. 

1.  Operation  (manikin). 

115  East  Thirty-fifth  Street. 


X.  Treatment  of  Occipito-posterior  Positions  : 

1.  Extreme  flexion  of  head  :  a,  position  of  parturient; 
b,  hand ;  c ,  Breus  s  forceps.  2.  Resistance  supplied  : 
a,  hand  ;  b,  blade  of  forceps ;  c,  vectis.  3.  Straight 
toiceps.  4.  Ordinary  forceps.  5.  Version.  6.  Per¬ 
foration  ;  extraction. 

XI.  Ti  cat  men  t  of  Difficult  Shoulder  Delivery  in  Head¬ 

first  Cases : 

1.  Expressio  foetus.  2.  Traction  on  posterior  shoul¬ 
der.  3.  Rotary  motion  with  head.  4.  Traction  on 
both  shoulders  (Winckel’s  method).  5.  Pushing  an¬ 
terior  shoulder  behind  symphysis.  6.  Use  of  blunt 
hook. 

XII.  Embryotomy : 

1.  Perforation  ;  Craniotomy. 

Definition ;  Object  ;  Indications  ;  Conditions  necessary ;  Dangers. 

(1)  Advantages  and  disadvantages  of  the  cranioclast. 

(2)  Perforation  accomplished  by:  a,  knife;  b,  scis¬ 
sors  ;  c,  trephine.  (3)  Extraction  or  expulsion  ac¬ 
complished  by  :  a,  crotchet ;  b,  hand  ;  c,  bone  forceps 
(craniotomy  forceps);  d ,  cranioclast  (Braun’s);  e, 
cephalotribe  (Breisky’s,  Lusk’s)  ;  f  obstetric  forceps; 
g,  version ;  h ,  uterine  forces  ;  i,  expressio  foetus.  (4) 
Perforation  of  after-coming  head. 

2.  Cephalotripsy,  before  and  after  Perforation. 

Definition  ;  Object;  Indications;  Conditions  necessary  ;  Dangers. 

(1)  Advantages  and  disadvantages  of  the  cephalotribe. 

(2)  Crushing  accomplished  by:  a,  cephalotribe;  or  b, 
cranioclast  and  cephalotribe.  (3)  Extraction  or  ex¬ 
pulsion  accomplished  by:  a,  cephalotribe;  cranio¬ 
clast ;  c,  obstetric  forceps;  d,  crotchet;  e,  hand;/, 
bone  forceps;  g,  uterine  forces;  h,  expressio  foetus. 


THE  CLINICAL  ASPECTS 
OF  KOCH’S  METHOD  IN  BERLIN. 

By  HE.NRY  S.  STEARNS,  M.  D. 

When  at  the  last  International  Medical  Congress,  held 
in  Berlin,  Professor  Robert  Koch  gave  a  few  hints  in  re¬ 
gard  to  his  investigations  on  tuberculosis,  great  anxiety  was 
evinced  by  the  entire  profession  to  have  his  results  made 
public  as  soon  as  possible.  There  is  no  doubt,  however, 
that  any  formal  statement  would  not  have  been  made  had 
it  not  been  for  the  sensationalism  thrown  around  the  mat¬ 
ter  and  the  false  impressions  being  given  of  it  by  the  pub¬ 
lic  press.  To  correct  this  state  of  affairs  he  was  compelled 
to  publish,  on  November  13th,  in  the  Deutsche  medicinische 
Wochenschnft ,  his  now  historical  article  entitled  Mittheil- 
ungen  liber  ein  Heilmittel  gegen  Tuberculose.  This  was 
immediately, translated)  and  published  in  this  country,  and, 
instead  of  allaying  excitement,  raised  it  to  a  still  higher 
pitch,  which  culminated  in  the  emigration  to  Berlin  of 
quite  a  number  of  physicians  from  different  parts  of  this 
country,  their  primary  object  being,  of  course,  to  gain  pos¬ 
session  of  some  of  the  famous  “  lymph, ”'and  after  that  to 
study  the  clinical  aspects  of  the  treatment. 

By  the  courtesy  of  Professor  Leyden  and  Professor  von 
Bergmann  I  was  enabled  to  go  into  the  hospital  wards  at 
almost  any  hour  and  to  watch  closely  several  of  the  most 
interesting  cases.  The  form  of  tuberculosis  showing  the 
most  incontrovertible  evidences  of  the  value  of  the  inocula¬ 
tions  or  injections  is  lupus.  A  large  part  of  Professor  von 
Bergmann’s  private  hospital  is  given  over  now  to  the  treat¬ 
ment  of  lupus  patients,  and,  without  a  single  exception,  re¬ 
sults  are  there  seen  which  six  months  ago  would  have  been 
beyond  a  specialist’s  most  enthusiastic  hopes. 


3.  Decapitation. 

Definition  ;  Object ;  Indications ;  Conditions  necessary  ;  Dangers. 

(1)  Decapitation  accomplished  by:  a ,  Braun’s  hook; 
b,  Schultze’s  sickle  knife;  c,  silk  sliug  and  scalpel;  d, 
whip-lash  (Pajot) ;  e,  wire  ecraseur;  f  chain  saw  ;  g , 
ordinary  scissors ;  h,  Dubois’s  scissors.  (2)  Extrac¬ 
tion  of  body:  a,  manual;  b ,  instrumental.  (3)  Ex¬ 
traction  of  head:  a,  manual;  b,  instrumental. 

4.  Evisceration. 

Definition  f  Object ,  Indications  ,*  Conditions  necesscivy  *  Dangevs • 

(!)  Perforation:  a,  knife;  b ,  scissors;  c,  trephine. 

(2)  Extraction:  «,  manual;  b,  instrumental. 

5.  Amputation  of  Extremities. 

XIII.  Improved  Ccesarean  Section: 

Definition  ,*  Object  /  Indications  ,*  Conditions  necesscn'y  ,*  Dangevs, 

1.  Operation  (manikin). 


A  most  interesting  case  was  that  of  a  young  Englishman 
whose  treatment  had  been  completed  before  I  left  Berlin.  He 

was  twenty-two  years  of  age,  and  the  disease  was  of  six  years 
duration,  growing  steadily  worse  in  spite  of  between  fortv  and 
fifty  curettings  and  cauterizations,  several  of  the  operations 
having  been  severe  enough  to  require  the  administration  of  an 
anaisthetic,  until  both  alee  of  the  nose  were  destroyed,  together 
with  a  portion  of  the  septum  and  a  small  part  of  the  cheek. 
There  was  an  ulcer  on  the  left  cheek  1*5  ctm.  in  diameter,  the 
septum  was  perforated,  suppurating  glands  at  the  right  angle 
of  the  jaw  underlay  lupus  patches,  and  other  small  patches  bad 
made  their  appearance  on  the  gums,  hard  palate,  tonsils,  and 
uvula.  lie  suffered  no  pain  and  had  no  pulmonary  infection. 

While  the.  general  course  of  the  disease  had  been  from  bad 
to  worse,  still  he  had  noticed  that  when  his  general  health  im¬ 
proved  temporarily  there  would  at  the  same  time  be  a  very 
slight  improvement  in  the  sores.  The  treatment  was  begun  on 
November  16th  with  an  injection  of  0-01  c.  c.  of  the  lymph,  at  8 
a.  m.  In  about  seven  hours  he  was  seized  with  a  rather  severe 
chill,  intense  headache,  rapid  gasping  breathing,  and  fever, 
which  by  11  p.  m.  had  risen  to  104-2°  F.  The  temperature  re- 


710 


STEARNS:  THE  CLINICAL  ASPECTS  OF  KOCH'S  METHOD  IN  BERLIN.  [N.  Y.  Med.  Joub., 


mained  at  this  height  for  only  half  an  hour,  and  then  fell  with 
sharp  variations  to  normal  by  the  evening  of  the  next  day.  By 
3  p.  m.  on  the  day  of  the  injection  all  of  the  lupus  patches  had 
become  swollen,  intensely  congested,  and  painful,  and  had,  as 
he  described  it,  a  yellowish  pustule  form  over  each  one.  This 
appearance  was  changed  in  twenty-four  hours  by  the  drying  up 
of  the  pustules  and  the  formation  ot  a  scab,  the  redness,  swell¬ 
ing,  and  pain  also  gradually  disappearing  as  the  temperature 
fell.  At  no  time  subsequent  to  the  first  injection  was  there  any 
chill,  and  after  each  succeeding  injection  the  pain,  redness, 
swelling,  and  temperature  were  less  than  during  the  reaction  of 
the  preceding  one.  The  duration  of  the  treatment  was  eight¬ 
een  days,  in  which  time  the  patient  received  fifteen  injections, 
the  quantity  being  gradually  increased  to  0  1  c.  c.  On  the  eight¬ 
eenth  day  of  the  treatment  all  the  lupus  patches  were  com¬ 
pletely  healed  over ;  the  right  nostril  was  closed  to  such  an  ex¬ 
tent  that  only  an  ordinary-sized  probe  could  be  passed  through, 
but  the  opening  of  the  left  nostril  was  large  enough  to  do  duty 
for  both  sides.  The  ulcer  on  the  septum  had  healed,  but  of 
course  the  perforation  remained.  The  ulcer  on  the  left  cheek 
had  a  glazed  appearance,  and  wherever  the  lupus  had  existed 
the  healed  spots  were  still  somewhat  red,  resembling  a  fresh 
cicatrix.  The  fauces,  tonsils,  hard/palate,  and  uvula  showed 
only  an  intense  redness. 

This  case  was  ^elected  out  of  a  number  placed  at  my 
disposal  by  Dr.  De  Ruyter,  first  assistant  to  Professor  von 
Bergmann,  as  being  as  nearly  as  possible  a  typical  one,  and 
showing  bow  even  increasing  doses  caused  less  and  less  re¬ 
action  as  the  tuberculous  tissue  was  gradually  destroyed. 
In  ten  cases  the  reaction  began  in  from  four  to  eight  hours 
after  the  injection,  remained  at  its  height  ordinarily  less 
than  an  hour,  and  had  in  the  majority  of  cases  entirely  dis¬ 
appeared  in  twenty-four  hours.  A  very  interesting  feature 
in  one  of  these  cases  was  the  intense  pain  felt  in  a  hip  joint 
that  had  been  the  seat  of  tubercular  arthritis  for  nine  years, 
but  for  the  last  fourteen  years  had  given  no  sign  of  trouble. 
In  two  other  cases  enlarged  glands  at  the  angle  of  the  jaw 
and  in  the  neck  swelled  and  became  very  painful  during  the 
reactions.  In  another  case  a  curious  eruption  made  its  ap¬ 
pearance,  principally  on  the  legs.  This  at  first  consisted 
of  moderately  red  spots  about  1  ctm.  in  diameter,  sharply 
outlined  and  very  slightly  elevated  above  the  surface.  In 
a  few  days  these  became  of  a  dull  copper  color  and  remained 
so  as  long  as  the  patient  was  under  my  observation.  In 
every  case  of  lupus  seen  the  cure  of  the  infected  areas  was 
either  progressing  rapidly  or  was  entirely  completed.  Of 
course  it  is  too  soon  to  say  how  permanent  these  cures  are, 
but  if  the  lupus  returns  in  time  we  have  here  a  therapeutic 
resource  by  which  the  frightfully  disfiguring  effects  of  this 
disease  can  be  permanently  held  in  check  by  subsequent  in¬ 
jections,  and  if  there  was  no  other  use  to  which  the  “lymph” 
could  be  put  it  would  still  be  one  of  the  most  important  ad¬ 
ditions  to  therapeutics  received  in  a  great  many  years.  But 
that  it  has  other  and  far  more  important  applications  is  al¬ 
leged  for  it  by  its  discoverer,  and  these  are  :  1.  The  cure 
of  tuberculous  disease  when  seated  internally  as  well  as  ex¬ 
ternally.  2.  Almost  invariable  ability  to  diagnosticate  the 
presence  of  tubercular  disease  wherever  situated. 

As  regards  the  first  of  these  allegations,  there  was  noth¬ 
ing  seen  during  my  stay  in  Berlin  which  would  warrant 
the  assertion  that  internal  tuberculosis  could  be  cured  by 


this  method,  unless  it  might  be  the  more  or  less  logical 
deduction  from  the  results  gained  in  lupus  and  in  tubercu¬ 
lous  ulcers  of  the  larynx.  But  at  the  same  time  it  must  be 
borne  in  mind  that  a  cure  of  pulmonary  tuberculosis  would 
of  necessity  be  a  more  prolonged  process  than  in  external 
cases,  where  the  necrotic  tissue  can  be  immediately  thrown 
off,  and  in  none  of  the  cases  seen  had  the  treatment  been 
carried  on  long  enough  to  say  authoritatively  whether  much 
benefit  would  result  from  it  or  not.  On  the  contrary,  in  a 
ward  of  thirty-six  beds,  with  twenty-seven  patients  under¬ 
going  the  treatment,  there  were  only  two  whose  weight  had 
increased,  most  of  the  others  having  remained  stationary 
or  having  lost  from  one  to  two  kilogrammes,  and,  besides 
that,  there  was  in  nearly  every  case  a  decidedly  worse  con¬ 
dition,  as  shown  by  the  physical  signs.  This  condition, 
however,  it  is  maintained,  is  due  to  the  necrotic  changes 
caused  by  the  treatment,  and  is  a  necessary  preliminary  to 
the  final  cure.  Whether  this  is  the  case  or  not,  only  a  much 
more  extended  experience  with  the  remedy  will  show. 

To  cite  one  instance  of  the  possible  detrimental  effects 
of  the  remedy,  the  case  may  be  mentioned  of  a  man  who 
was  admitted  into  the  Charite  Hospital  on  November  21st. 

He  was  suffering  from  the  effects  of  a  pleurisy  on  the  left 
side,  contracted  seven  months  before,  when  he  had  had  removed 
by  aspiration  four  litres  of  sero-fibrinous  fluid  from  the  left 
pleural  cavity.  Since  then  he  had  been  steadily  losing  flesh 
and  streugth.  On  admission  he  was  rather  emaciated,  but  had 
no  cough  and  no  fever.  The  left  side  of  the  chest  was  mark¬ 
edly  depressed,  measurement  showing  a  difference  of  4  ctm.  in 
favor  of  the  right  side.  The  respiratory  movement  on  the  left 
side  was  almost  imperceptible,  and,  on  auscultation,  a  few 
rough  friction  sounds  were  audible  over  the  lower  half  of  the 
lung  on  that  side.  On  November  23d  the  first  injection  was 
given,  for  diagnostic  purposes,  0-003  c.  c.  being  the  amount 
used.  The  temperature  rose  in  ten  hours  to  103°,  with  all  the 
usual  effects  of  reaction,  such  as  severe  headache,  slight  chill, 
and  pains  in  the  bones,  and  in  this  case  there  was  a  rather 
severe  pain  on  the  left  side  of  the  chest  over  the  seat  of  the 
old  pleurisy.  On  November  25th  the  second  injection,  of  the 
same  amount  of  the  “  lymph,”  was  given,  and  the  temperature 
only  rose  to  100-2°.  Cough  now  made  its  appearance,  and,  on 
examination,  the  sputum  was  found  to  contain  tubercle  bacilli, 
which  of  course  confirmed  the  diagnosis  of  tuberculosis.  On 
November  26th  the  third  injection  was  given,  the  amount  this 
time  being  0-006  c.  c.  Moderate  reaction  resulted,  and  the 
cough  was  very  severe  until  this  had  subsided.  On  November 
28th  the  fourth  injection  was  given,  the  amount  being  0-01  c.  c. 
The  temperature  rose  to  102-2°.  On  November  29th  the  pa¬ 
tient  showed  a  loss  of  two  kilogrammes  in  weight,  and,  besides, 
a  number  of  moist  friction  sounds  had  made  their  appearance 
at  the  base  of  the  left  lung,  being  most  marked  anteriorly.  On 
November  30th  the  fifth  injection,  the  same  in  amount  as  the 
last,  was  given  with  no  decided  reaction.  On  December  2d  the 
sixth  injection  was  given,  the  quantity  being  0-02  c.  e.  The 
temperature  rose  to  1016°,  and  the  whole  front  of  the  chest 
gave  loud,  moist  friction  souads.  On  December  4th  physical 
examination  of  the  chest  revealed  the  presence  of  a  moderate 
effusion  in  the  left  pleural  cavity,  and  on  the  last  day  I  saw  the 
patient.  On  December  6th  the  level  of  the  fluid  was  slightly 
above  the  angle  of  the  scapula. 

In  another  case,  in  which  there  was  a  moderately  large 
spot  of  consolidation  in  the  upper  lobe  of  the  right  lung, 


Dec.  27,  1890.J 

with  tubercle  bacilli  in  the  sputum,  under  the  treatment  a 
portion  of  the  consolidated  area  softened  rapidly  and  a 
■cavity  was  formed. 

These  results  at  first  appear  very  discouraging  and  de¬ 
cidedly  dangerous,  but  it  must  be  remembered  that,  if  we 
are  to  accept  Koch’s  explanation  of  what  he  believes  to  be 
the  pathological  changes  caused  by  his  treatment,  the 
above-mentioned  effects  are  exactly  what  must  make  their 
appearance  before  the  cure  can  go  on  to  completion,  and, 
besides,  the  duration  of  the  treatment  in  these  cases  is  too 
short  to  more  than  carry  the  patient  well  on  into  what  may 
be  termed  the  first  stage  of  the  cure.  What  the  succeed¬ 
ing  stages  will  be  no  man  to  my  knowledge  can  state  au¬ 
thoritatively.  We  can  only  trust  that  the  future  will  bear 
■out  the  discoverer’s  statements,  and  bear  in  mind  that  after 
all  tubercular  tissue  has  become  necrotic  it  should  be 
quickly  got  rid  of,  where  possible,  by  surgical  interference. 

•  In  cases  of  phthisis  this  process  will  necessarily  be  a  slow 
one,  and  in  these  cases  there  is  great  danger  of  further  in¬ 
fection,  as  the  bacilli  are  not  destroyed  ;  to  use  Koch’s  own 
words,  “  The  endangered  living  tissue  must  be  protected 
from  fresh  incursions  of  the  parasites  by  continuous  appli¬ 
cations  of  the  remedy.” 

In  the  use  of  the  “  lymph  ”  a  point  always  requiring  the 
most  anxious  consideration  is  the  more  immediate  dangers. 
These  arise  from  two  of  the  results  of  the  inoculations:  L 
Necrotic  changes.  Here  it  is  apparent  that  where  there 
are  tubercular  ulcers  of  the  intestines  it  is  entirely  within 
the  bounds  of  possibility  that  perforation  and  fatal  perito¬ 
nitis^  may  occur,  and  there  has  already  been  a  death  in 
Berlin  from  this  cause.  2.  The  swelling  of  the  infected 
tissue  may  seriously  menace  life,  and  several  tracheotomies 
have  already  been  required  where  tubercular  ulcers  of  the 
ilarynx  were  present,  the  swelling  so  nearly  closing  the  rima 
glottidis  that  without  prompt  surgical  interference  the  pa¬ 
tients  would  have  died  from  suffocation. 

There  can  be  no  doubt  that  we  have  in  this  “lymph” 
a  most  powerful  agent  and  a  very  dangerous  one  as  well, 
when  used  carelessly,  but  there  would  seem  to  be  no  reason 
why  in  careful  and  competent  hands  it  should  not  do  an 
inestimable  amount  of  good,  more  particularly  in  laryngeal 
tuberculosis,  lupus,  and  tuberculous  joint  diseases.  That 
it  will  give  as  beneficial  results  in  the  early  stages  of  phthi¬ 
sis  there  would  seem  to  be  great  possibility,  but  when 
cases  of  advanced  phthisis  come  under  consideration  it  may 
be  seriously  doubted  whether  it  would  be  advisable  to  sub¬ 
ject  the  patients  to  the  decided  dangers  that  must  accom¬ 
pany  its  use,  at  least  by  the  present  method,  where  the 
agent  is  used  in  ever-increasing  doses  in  order  that  the  re¬ 
action  may  be  as  marked  as  possible.  Perhaps  it  may  be 
found  advisable  in  these  advanced  cases  to  use  smaller 
•doses,  thereby  making  the  treatment  slower  but  far  safer. 

A  few  words  as  to  the  method  of  administration  as  fol¬ 
lowed  in  Berlin.  The  usual  dose  to  begin  with  in  lupus 
cases  with  no  apparent  pulmonary  or  lan  ngeal  complica¬ 
tions  is  0-01  c.  c.,  and  in  phthisis  from  0*001  to  O'OOM  c.  c. 

As  soon  as  the  reaction  has  ceased  and  the  temperature  re¬ 
turned  to  normal,  or  nearly  so,  the  same  or  only  a  slightly 
ancreased  amount  is  again  injected,  and  this  plan  is"  fol¬ 


lowed  until  the  temperature  fails  to  rise  above  101°,  when 
the  dose  is  usually  doubled,  and  so  on,  until  in  some  cases 
as  high  a  dose  as  0*1  c.  c.  is  reached.  This  amount,  how¬ 
ever,  is  exceptional;  I  have  seen  it  used  only  once,  and 
then  it  was  the  final  injection  in  the  case  of  lupus  cited 
above  and  gave  absolutely  no  reaction.  Ordinarily  0-04 
c.  c.  would  be  considered  a  large  dose,  even  if  the  treat¬ 
ment  was  well  advanced. 


HYDROGEN-  DIOXIDE;  A  RESUME. 

By  JOHN  A  TILDE,  M.  D., 

PHILADELPHIA, 

MEMBER  OF  THE  AMERICAN  MEDICAL  ASSOCIATION 
OF  THE  MEDICAL  SOCIETY  OF  THE  STATE  OF  PENNSYI  VANIA 
OF  THE  PHILADELPHIA  COUNTY  MEDICAL  SOCIETY,  ETC. 


Within  the  past  ten  years  the  use  of  hydrogen  dioxide 
(peroxide  of  hydrogen)  has  become  quite  general  amornr 
practitioners  whose  business  has  led  them  to  give  special  ap 
tention  to  some  particular  class  of  disorders.  Many  general 
practitioners,  however,  have  not  availed  themselves^of  the 
benefits  afforded  by  this  comparatively  recent  addition  to 
our  therapeutic  resources,  owing  to  the  expense  and  the  care 
required  in  looking  after  details,  together  with  the  uncer¬ 
tainty  which  attended  its  employment.  These  difficulties 
no  longer  exist;  but,  when  we  consider  the  advantages  to  be 
gained  from  its  use,  the  process  of  evolution  has-been  re¬ 
markably  slow,  notwithstanding  the  sporadic  attempts  which 
have  been  made  to  attract  the  attention  of  the  medical  pro¬ 
fession.  Novel  methods  of  treatment  are  too  frequently 
shunned  without  investigation  by  regular  physicians,  while, 
on  the  contrary,  these  innovations  are  readily  adapted  to 
the  wants  of  the  quack. 

In  the  present  instance,  although  the  furore  for  antisep¬ 
tics  continues  unabated,  the  true  position  of  oxygen  has  been 
ignored  by  those  who  should  have  given  it  their  first  atten¬ 
tion.  Long-continued  and  persistent  effort  has  erected  an 
imposing  superstructure  upon  a  theoretical  foundation,  los¬ 
ing  sight  of  the  marvelous  influences  constantly  at  work  in 
nature.  The  corner-stone  of  this  ornate  edifice  originally 
adopted  was  carbolic  acid  ;  the  pilasters  which  gave  strength 
and  beauty  to  its  walls  were  composed  of  carbolated  gauze, 
while  cornice  and  roof  were  made  of  protective  which  had 
been  submitted  to  a  carbolizing  process.  This  highly  fla¬ 
vored  substance  has  given  place  to  a  number  of  others, 
some  of  which  are  safer,  but  no  more  useful ;  others  are 
more  efficient  than  carbolic  acid,  but,  as  usually  employed, 
are  far  more  dangerous.  As  the  foundation  for  asepsis  rests 
upon  absolute  cleanliness,  so  the  foundation  for  antisepsis 
must  rest  upon  an  equally  safe  basis  as  regards  the  patient. 
The  only  agent  known  at  the  present  time  which  fully  meets 
our  requirements  is  oxygen  in  some  of  its  forms.  While 
the  spores  of  anthrax  bacilli  resist  our  most  poisonous  prod¬ 
uct* — such  as  solutions  of  hydrochloric  acid  (two  per  cent.), 
boric  and  salicylic  acids  in  concentrated  solutions — oxygen¬ 
ated  water  alone,  in  sufficient  quantity,  was  shown  by  Paul 
Bert  and  Regnard  to  possess  the  power  of  destroying  the 
bacteria. 

The  wonderful  properties  of  ozone  are  but  partly  under¬ 
stood  ;  like  some  other  powerful  agents,  it  can  not  be  safely 


712 


[N.  Y.  Med.  Jour., 


AULDE:  HYDROGEN  DIOXIDE. 


handled,  but  it  gives  great  promise  of  usefulness  in  the  fu¬ 
ture.  The  statement  has  been  made  that  ozone  is  but  an 
allotropic  form  of  oxygen,  and  that  it  is  identical  with  hydro¬ 
gen  dioxide  (the  subject  of  the  present  article),  and  for  all 
practical  purposes,  from  a  therapeutic  standpoint,  they  may 
be  considered  substantially  the  same.  Having,  then,  at  our 
command  a  remedy  possessing  such  remarkable  properties 
as  a  bactericide,  one  which  is  perfectly  harmless  when 
brought  into  contact  with  healthy  tissues,  it  will  be  worth 
while  to  study  the  indications  for  its  use  in  the  treatment 
of  disease.  In  the  first  place,  however,  I  should  say  a  word 
with  reference  to  the  causes  which  have  contributed  to  pre¬ 
vent  its  universal  employment  by  physicians — causes  already 
referred  to  incidentally. 

1.  The  expense  of  an  outfit  and  material  for  administra¬ 
tion  of  this  ao-ent  need  not  exceed  five  dollars  for  sufficient 
to  cover  a  period  of  from  six  weeks  to  two  months.  I  he 
medicinal  peroxide  can  be  purchased  in  original  packages 
at  about  the  cost  of  filling  a  prescription  at  a  first-class 
drug-store.  An  atomizer  and  vaporizer  combined,  especially 
required  for  this  substance,  costs  no  more  than  one  equally 
complete  for  ordinary  use. 

2.  The  inconveniences  attending  the  exhibition  of  hy¬ 
drogen  dioxide,  by  means  of  the  vapor  or  spray,  are  purely 
imao-inai-v.  The  use  of  these  instruments  by  patients  re- 
quires  but  little  manual  dexterity,  and  the  instructions  in 
regard  to  inhalations  may  be  comprehended  by  the  merest 
tyro.  Children  rather  enjoy  the  mechanical  features  of  the 
apparatus  with  the  novel  phenomenon  of  having  the  vapor 
expelled  through  the  nostiils. 

3.  The  uncertainty  following  the  employment  of  the 
peroxide  has  arisen  from  various  causes,  and,  as  this  is  a 
subject  of  paramount  importance,  the  items  will  be  consid¬ 
ered  in  detail.  In  the  pure  state  hydrogen  peroxide  is  ex¬ 
ceedingly  unstable,  and,  in  order  to  render  it  less  suscepti¬ 
ble  to  the  action  of  heat,  which  causes  it  to  part  with  nascent 
oxygen  rapidly,  minute  quantities  of  hydrochloric  and  phos¬ 
phoric  acids  are  added  to  the  usual  fifteen-volume  solution ; 
but  this,  instead  of  retarding,  rather  heightens  the  effect  of 
the  remedy  when  applied  to  unhealthy  structures,  especially 
mucous  surfaces.  When  the  container  is  allowed  to  remain 
in  a  warm  room,  or  when  it  is  not  properly  stoppered,  the 
activity  of  the  preparation  is  materially  lessened,  it  not  en¬ 
tirely  lost.  An  excess  of  acid  is  objectionable,  however,  as 
it  renders  the  peroxide  irritating  instead  of  soothing. 

Commercial  peroxide ,  which  is  used  extensively  for 
bleaching  purposes  and  in  the  arts,  is  doubtless  responsible 
for  unsatisfactory  results,  but,  as  compared  with  the  medici¬ 
nal  preparation,  it  is  a  very  inferior  product,  sold  at  a  cost 
of  about  eight  cents  a  pound.  Physicians  should  know 
that  this  product  always  contains  a  large  proportion  of  acids 
(two  to  five  per  cent.),  hydrofluoric,  sulphuric,  hydrochloric, 
oxalic,  and  nitric  acids,  and,  knowing  this  to  be  the  case, 
they  should  be  careful  to  examine  the  reactions  and  see 
that  the  medicinal  preparation  obtained  by  patients  is  sup¬ 
plied  in  original  packages.  The  commercial  product  is  not 
“just  as  good”  nor  will  it  “  do  as  well  ”  for  the  patient; 
and  if  these  suggestions  are  kept  in  view,  the  success  of  the 
peroxide  is  assured. 


Another  important  thing  which  I  have  learned  is,  that 
the  mixture  of  the  peroxide  with  glycerin  does  not  make 
“  glycozone,”  but,  instead,  a  mixture  which  generates  slowly 
but  constantly  secondary  products,  which  appear  to  possess 
irritating  properties  almost  as  toxic  as  those  of  formic  acid,, 
well  known  in  Central  Africa  as  a  deadly  arrow-poison.  I 
am  of  the  opinion  also  that  when  the  peroxide  is  used  in 
the  form  of  an  inhalation  by  heating  with  water,  a  consid¬ 
erable  proportion  of  the  nascent  oxygen  is  transformed 
into  ordinary  oxvgen  before  reaching  the  affected  tissues, 
and  while  1  can  readily  understand  how  this  must  detract 
from  its  efficiency,  remarkably  prompt  results  have  attended 
its  administration  in  this  manner.  I  he  only  obstacle  in 
the  way  of  securing  immediate  and  favorable  results  from 
the  exhibition  of  this  agent  is  our  inability  to  command  at 
all  times  a  freshly  prepared  and  thoroughly  reliable  product, 
free  from  the  impurities  incident  to  its  manufacture;  but 
that  difficulty,  I  believe,  is  no  longer  an  excuse,  as  it  can 
be  supplied  by  the  principal  druggists  throughout  the 
country. 

Pharinacoloyy. — In  order  to  estimate  with  some  degree 
of  accuracy  the  ultimate  changes  effected  in  living  tissues 
from  the  employment  of  oxxgen,  and  especially  nascent 
oxygen,  our  study  must  embrace  a  recapitulation  of  the 
metamorphoses  taking  place  in  the  protoplasm,  i  his  seems 
all  the  more  necessary  for  the  purpose  of  meeting  objec¬ 
tions  which  have  been  urged  against  the  use  of  oxygen,  owing 
to  the  supposed  dangers  of  hyperoxygenation  and  a  con¬ 
sequent  increased  rapidity  of  combustion,  although  these 
notions  are  altogether  fanciful.  Alkalinity  of  the  blood  en¬ 
hances  the  oxygen-carrying  capacity  of  the  red  corpuscles; 
hence  the  utility  of  alkaline  mineral  waters,  which  increase 
cell-activity.  Ehrlich  has  shown  that  the  function  of  the 
cell  is  to  generate  acid  products  of  tissue-waste;  but  when 
these  waste  products  accumulate,  cell  function  is  diminished 
or  arrested,  no  more  combustion  taking  place  until  acid 
products  are  removed  or  neutralized,  thus  indicating  that 
we  have  to  deal  with  a  species  of  cell-automatism.  An¬ 
other  significant  question  presents  itself  in  this  connection, 
viz..  If  increased  alkalinity  of  the  blood  favors  oxidation, 
how  does  it  happen  that  the  cell  is  not  entirely  consumed  ? 
This  is  explained  by  Ehrlich  on  the  assumption  that  alj 
protoplasm  is  enveloped  by  cell-juice  (paraplasm),  which 
expands  or  contracts  in  proportion  to  the  demand  of  the 
cell  for  oxygen.  Contraction  of  the  cell  takes  place  when 
there  is  no  demand  for  oxygen,  and  at  the  same  moment 
the  increased  thickness  of  the  paraplasm  prevents  the 
absorption  of  oxygen.  Alternate  contraction  and  dis¬ 
tention  of  the  cel i  affects  the  thickness  of  the  layer  of 
cell-juice,  and  increases  or  decreases  cell  combustion  ;  in 
other  words,  it  prevents  the  too  rapid  oxidation  of  proto¬ 
plasm. 

In  the  light  of  the  foregoing  demonstration  there  can 
be  no  hesitancy  in  ascribing  the  therapeutical  value  of  oxy¬ 
gen,  in  whatever  form  employed,  to  its  influence  upon  cell 
activity.  The  entire  organism  being  composed  of  cells,  the 
conclusion  is  inevitable  that  all  agents  which  increase  the 
normal  function  of  the  cell  increase  in  like  manner  the  re¬ 
sistance  of  the  organism  to  the  inroads  of  disease.  This  is 


Dec.  27,  1890.] 


A  UI.D E:  HYDROO EX  DIOXIDE. 


713 


further  exemplified  by  the  active  oxidation  (combustion) 
which  takes  place  when  the  peroxide  is  brought  into  con¬ 
tact  with  unhealthy  tissues,  and  still  no  deleterious  action 
is  noticeable  upon  the  normal  structures,  a  statement  of 
fact  which  can  be  applied  to  no  other  known  antiseptic. 
Pus  and  all  other  unhealthy  discharges  are  promptly  de¬ 
stroyed,  the  affected  structures  being  left  clean  and  per¬ 
fectly  free  from  micro-organisms. 

Therapeutics. — From  the  peroxi.le  of  hydrogen  we  may 
obtain,  in  the  form  of  a  vapor  or  spray,  the  therapeutic  ef¬ 
fects  of  nascent  oxygen,  and  as  a  surgical  application  or 
antibacterial  substance  this  product  is  far  superior  to  the 
gas  itself.  Used  in  the  form  of  a  vapor  by  inhalation,  it  in¬ 
creases  the  secondary  assimilation  bv  favoring  the  eliraina- 
tion  of  excrementitious  products  through  the  stimulating 
effect  upon  internal  respiration.  Just  as  pure  mountain  air 
arouses  the  activity  of  functions  which  have  been  depressed 
and  promotes  health,  so  oxygen  evolved  in  this  manner  in¬ 
creases  tissue  change  and  prevents  the  suboxidation  which 
attends  upon  the  arrest  of  cell  function.  Oxvgen  is  a  tissue- 
builder  as  well  as  an  oxidizer  of  carbonaceous  and  excre¬ 
mentitious  products.  When  it  is  introduced  into  the  ali¬ 
mentary  tract,  abdominal  fermentations  are  arrested  by  the 
destruction  of  the  germs  which  produce  them  ;  unhealthy 
mucous  secretions  are  destroyed,  while  the  vitality  of  the 
cells  lining  the  walls  of  the  intestine  is  augmented,  and  their 
power  against  the  absorption  of  ptomaines  and  leucomaines 
greatly  increased.  The  surgeon  will  find  the  peroxide  an 
efficient  and  most  convenient  antiseptic,  as  it  can  be  freely 
used  in  cavities,  in  discharging  sinuses,  and  upon  the  most 
delicate  tissues,  without  danger  of  producing  the  slightest 
irritation.  In  all  cases  of  threatened  collapse,  in  low  con¬ 
ditions  of  the  system,  and  during  convalescence  from  severe 
illness,  the  physician  should  bear  in  mind  the  wonderful 
revitalizing  properties  of  this  remedy.  Perhaps  the  reader 
will  gain  a  more  practical  idea  of  the  applications  by  a 
reference  to  some  of  the  more  prominent  indications,  and 
I  shall  briefly  pass  in  review  some  of  the  diseases  in  which 
it  may  be  used  with  beneficial  results. 

In  ancemia  and  chlorosis ,  along  with  suitable  diet  and 
exercise  as  adjuvants,  the  inhalations  will  prove  most  val¬ 
uable;  appetite  increases,  digestion  improves,  and  there  is 
a  marked  change  for  the  better  in  the  appearance  and  in 
strength.  The  feeling  of  malaise  disappears  within  a  few 
days  after  beginning  treatment,  listlessness  is  banished,  and 
the  patient  takes  an  active  interest  in  amusements  which 
require  considerable  exercise,  and  seemingly  wdth  the 
greatest  zest.  Erysipelas  is  a  disease  in  which  the  vapor 
may  be  used  internally  and  the  spray  locally,  apparently 
with  the  best  results,  as  the  progress  of  the  disease  is  ar¬ 
rested  by  destroying  the  germs,  increased  resistance  being 
given  at  the  same  time  to  the  organism.  In  septicaemia, 
along  with  diffusible  stimulants  and  suitable  vascular  tonics, 
it  will  be  found  an  efficient  adjuvant,  and  whenever  it  can 
be  used  locally  in  this  affection  the  results  will  be  brilliant 
indeed.  Lithcemia,  accompanied  by  cough,  highly  acid 
urine,  with  large  quantities  of  uric  acid  and  a  diminution 
of  the  normal  urea,  is  quickly  benefited  by  the  exhibition 
of  the  vapor.  It  is  also  a  valuable  adjuvant  in  the  treat¬ 


ment  of  rheumatism ,  but  with  it  should  be  combined  the 
liberal  use  of  alkaline  waters,  a  judiciously  selected  dietary, 
and  appropriate  medication.  It  is  also  of  decided  bene¬ 
fit  in  the  treatment  of  diabetes  mellitus  and  in  albuminuria , 
w  hen  it  may  be  presumed  to  have  some  active  influence  in 
eliminating  morbid  products. 

Since  it  has  been  determined  that  in  yellow  fever  and 
cholera  the  poison  germ  is  found  only  in  the  intestine,  the 
peroxide  promises  to  afford  exceptional  relief  in  these  dis¬ 
eases.  When  it  is  introduced  into  the  rectum,  the  heat  of 
the  t>ody  will  cause  oxygen  gas  to  be  evolved,  while  the  local 
action  of  the  drug  will  destroy  all  unhealthy  products  which 
may  be  present  in  the  lower  bowel.  The  nascent  oxygen  will 
be  taken  up  by  the  absorbent  structures  and  enter  the  gen¬ 
eral  circulation;  but  if  we  accept  the  doctrine  of  phagocy¬ 
tosis,  it  will  do  even  more  than  this,  by  reason  of  its  stimu¬ 
lating  action  upon  the  modified  white  corpuscles,  which  are 
now  regarded  as  the  special  enemies  of  bacteria  escaping 
through  the  walls  of  the  intestines.  And  for  the  same  rea¬ 
son  it  may  be  used  with  advantage  as  a  lavement  in  the 
treatment  of  diarrhoea,  dysentery,  and  in  typhoid  fever.  In 
the  latter  disease  I  have  used  the  pure  oxygen  gas  with 
very  great  satisfaction,  and  have  found  a  solution  of  the 
peroxide  superior  as  a  mouth  wash  during  the  progress  of 
this  most  tedious  disorder. 

The  peroxide  should  be  used  in  all  forms  of  indigestion , 
more  especially  when  the  stomach  is  weak  and  depressed  to 
such  an  extent  that  the  usual  antiseptics  are  not  well  toler¬ 
ated.  Those  who  use  it  once  for  the  relief  of  indigestion, 
gastritis,  gastralgia,  and  for  the  arrest  of  fermentation  or 
an  abnormal  flow  of  mucus,  will  have  no  cause  to  regret 
the  selection.  A  large  number  of  cutaneous  affections  are 
dependent  upon  an  unhealthy  condition  of  the  alimentary 
tract,  such  as  urticaria,  eczema,  etc.,  and,  of  course,  are 
benefited  by  the  use  of  the  peroxide. 

Pulmonary  affections  have  long  claimed  the  attention  of 
those  who  dabbled  with  oxygen  inhalations,  and  it  is  in 
this  class  of  cases  where  faithful  attention  to  details  will 
produce  most  marked  effects,  although  I  can  not  be  con¬ 
vinced  that  any  medicament  in  itself  can  arrest  the  progress 
of  the  disease.  The  continued  use  of  the  peroxide  in¬ 
ternally  improves  the  primary  assimilation  ;  the  regular 
and  systematic  inhalation  of  the  vapor  will  not  only  im¬ 
prove  the  secondary  assimilation,  but  will  also  destroy  any 
morbid  products  with  which  it  comes  into  contact  in  the 
pulmonary  tissues,  and,  judging  from  my  own  experience 
with  this  agent,  I  have  no  hesitancy  in  saying  that  its  value 
is  not  yet  appreciated  by  a  large  number  of  physicians  who, 
with  it,  might  be  the  means  of  prolonging  human  life.  My 
observations  with  the  vapor  and  spray  in  asthmatic  condi¬ 
tions  have  been  surprising,  and  I  have  found  them  of  signal 
service  in  meeting  emergencies,  such  as  asphyxia  from  coal 
gas,  sudden  collapse  ftom  haemorrhage,  typhoid,  and  other 
fevers.  The  long-continued  use  of  the  vapor  lias  a  marked 
effect  in  restoring  the  resiliency  of  the  air-vesicles  in  em¬ 
physema  when  it  occurs  along  with  asthma  in  young  per¬ 
sons.  A  gentlemen  now  under  treatment  has  suffered  from 
asthma  since  he  was  six  weeks  old,  and  is  now  twenty-five, 
but  under  this  treatment  he  has  gained  weight,  is  able  to 


714 


CLINICAL  REPORTS. 


[N.  Y.  Med.  Jour.t 


sleep  regularly  every  night,  and  has  increased  sixteen 
pounds  in  weight  during  the  past  three  weeks,  while  the 
chest  measurement  has  appreciably  decreased.  This  meth¬ 
od  of  treatment  is  valuable  in  phthisis  at  all  stages,  but  it 
should  be  used  as  an  adjuvant  to  other  treatment  and  atten¬ 
tion  given  to  diet.  In  this  connection  should  be  mentioned 
the  usefulness  of  the  vapor  in  the  treatment  of  bronchitis, 
subacute  and  chronic,  and  at  the  same  time  the  value  in 
aborting  attacks  of  acute  catarrh. 

Inhalations  of  the  vapor  will  prove  useful  as  an  adjuvant 
in  neuralgia,  anaemic  headaches,  general  debility,  malarial 
toxaemia,  and  corpulence,  combined  with  diet  adapted  to 
the  various  disorders  mentioned. 

In  surgical  practice ,  when  the  solution  of  the  proper 
strength  is  brought  into  contact  with  diseased  tissues,  a 
brisk  etfervescenee  takes  place  and  continues  until  all  the 
pus-corpuscles  present  are  destroyed.  This  solution  may 
be  used  topically  in  nearly  all  cases  of  catarrh  of  the  upper 
air  passages  in  the  form  of  a  spray,  and  it  may  be  used  as 
an  antiseptic  after  the  removal  of  pus  in  empyema.  The 
substance  possesses  the  advantage  over  other  antiseptics  of 
being  harmless,  and  can  therefore  be  used  freely  in  diph¬ 
theria  and  croup.  There  are  so  many  indications  for  its 
employment  that  it  would  be  difficult  to  mention  all  the 
topical  uses ,  although  the  following  may  be  referred  to, 
viz.,  boils,  carbuncles,  indolent  ulcers,  carcinoma,  and  ve¬ 
nereal  diseases  as  an  injection. 

The  gynaecologist  will  find  numerous  applications  for  this 
agent.  It  may  be  used  in  the  form  of  a  douche  in  leucor- 
rhoea,  elytritis,  and  vaginismus,  and  a  cotton-wool  tampon 
may  be  saturated  with  it  and  placed  in  a  gelatin  capsule 
(veterinary  size)  and  introduced  into  the  vagina  in  the  case 
ot  ulceration,  vesico-vaginal  fistula,  and  endometritis.  The 
ophthalmologist  and  aurist  will  likewise  find  that  it  furnishes 
them  the  most  complete  and  safe  antiseptic  that  can  be  had, 
and  gradually  its  employment  will  extend  to  every  depart¬ 
ment  of  medicine  and  surgery. 

The  most  flattering  commendations  of  “  Marchand’s  per¬ 
oxide  of  hydrogen  (medicinal)”  have  been  given  volunta¬ 
rily  by  numerous  well-known  authors  and  contributors  to 
medical  literature  within  the  past  few- years,  some  of  whom 
may  be  mentioned  as  additional  evidence  that  the  methods 
here  recommended  are  worthy  of  further  investigation  :  Dr. 
W.  B.  Clarke,  of  Indianapolis,  Ind. ;  Dr.  George  B.  Hope, 
Surgeon  to  the  Metrop  ditan  Throat  Hospital,  New  York; 
Dr.  J.  Mount  Bleyer,  of  New  York;  Dr.  Robert  T.  Morris, 
of  New  York;  Dr.  Paul  Gibier,  Director  of  the  New  York 
Pasteur  Institute;  Dr.  R.  Charest,  of  St.  Cloud,  Minn.; 
Dr.  E.  R.  Squibb,  of  Brooklyn,  N.  Y. ;  and  others  whose 
names  can  not  now  be  recalled.  Dr.  Morris  refers  to  it  as 
‘‘the  necessary  peroxide  of  hydrogen,”  and  I  have  found 
Marchand’s  product  to  possess  in  a  remarkable  degree  the 
properties  so  essenlial  to  success — viz.,  uniformity  in 
strength,  purity,  and  stability. 

1910  Arch  Street. 


A  Case  of  Acromegaly,  the  first  noted  in  Ireland,  has  lately  been 
under  the  care  of  Dr.  Joseph  Redmond  in  the  Mater  Misericordiac  Hos¬ 
pital  in  Dublin. 


Clinical  JLeports. 


A  WARD  CLINIC  IN  TIIE  MONTREAL  GENERAL 

HOSPITAL. 

By  R.  L.  MacDonnell,  M.  D., 

Professor  of  Clinical  Medicine  in  McGill  University. 

{Reported  by  Nurse  Alice  Hall.) 

Question.  Mr.  R.,*  what  cases  were  under  consideration  at 
the  last  clinic  ? 

Answer.  A  case  of  gall-stone  colic  and  a  ease  of  chronic  pul¬ 
monary  tuberculosis. 

Q.  What  was  the  history  of  the  first  case? 

A.  The  patient,  a  man  of  fifty,  was  at  work  laying  down 
pavement  a  week  ago,  when  he  suddenly  felt  intense  pain  in  the 
abdomen,  he  became  collapsed,  and  was  sent  to  the  hospital 
directly.  On  admission,  the  pulse  was  slow,  the  temperature 
subnormal,  the  abdomen  tense.  Pain  and  tenderness  were  ex¬ 
treme  but  worse  in  the  right  hypochondrium. 

Q.  What  did  we  say  were  the  common  causes  of  sudden,  se¬ 
vere  abdominal  pain  in  a  man  of  fifty,  who  had  left  his  home  in 
good  health  and  after  two  hours  became  seized  as  this  patient 
was  ? 

A.  Renal  or  biliary  colic;  stoppage  of  the  bowels  from  her¬ 
nia  or  some  less  common  cause;  sudden  peritonitis  from  per¬ 
foration  of  an  ulcer,  especially  in  the  neighborhood  of  the 
appendix;  and  ordinary  intestinal  colic. 

Q.  What  cause  was  diagnosticated  in  this  case? 

A.  Gall-stone  colic. 

Q.  Why? 

A.  I  here  was  no  evidence  of  hernia.  There  was  no  general 
peritonitis,  for  the  abdominal  pain  very  soon  became  confined  to 
the  right  hypochondriac  region.  The  pain  resembled  that  ex¬ 
perienced  in  gall-stone  colic,  being  paroxysmal  and  very  severe, 
there  was  no  intestinal  stoppage,  for  the  patient  passed  both 
flatus  and  faeces  during  the  first  twenty-four  hours  he  was  in 
the  hospital. 

Q.  Can  you  exclude  renal  colic? 

A.  No. 

Q.  Were  there  any  further  evidences  of  gall  stone? 

A.  After  forty-eight  hours  there  was  slight  yellowness  of 
the  conjunctiva,  and  bile  was  found  in  the  urine. 

Q.  Was  there  any  jaundice  of  the  skin? 

A.  None  was  evident. 

Q.  therefore  you  think  you  have  evidence  of  gall-stone 
colic  ? 

A.  Not  complete  evidence,  for  the  stone  was  not  found. 

Q.  the  nurse  says  that,  though  the  stools  have  been  most 
carefully  examined  and  strained,  yet  no  stone  lias  been  found. 
What  may  have  occurred  ? 

A.  1  he  stone  may  have  slipped  back  or  it  may  have  been 
arrested  in  the  duct,  allowing  the  bile  to  pass  it,  which  may  ac¬ 
count  for  the  absence  of  jaundice. 

Q.  Then  in  what  respects  did  this  man  Duffield’s  attack 
differ  from  renal  colic? 

A.  In  the  character  of  the  pain  and  its  locality ;  and  in  the 
fact  that  it  was  unaccompanied  by  frequency  of  micturition  or 
by  shooting  pains  into  the  groin. 

Q.  How  was  he  treated? 


*  At  McGill  University  two  complete  years  of  study  are  devoted  to 
clinical  work.  Professor  MacDonnell’s  class  is  composed  only  of  those 
who  have  spent  three  years  already  in  medical  study  and  who  will  be 
candidates  for  the  degree  in  March,  1891. 


Dec.  27,  1890.] 


CLINICAL  REPORTS. 


715 


A.  On  admission  a  hypodermic  injection  of  morphine  (gr. 
i)  was  given,  and  several  times  repeated.  He  was  also  given 
small  doses  of  calomel. 

Q.  And  the  result  ? 

A.  The  symptoms  are  entirely  relieved. 

Q.  Do  you  remember  the  condition  of  his  liver  ? 

A.  The  liver  was  enlarged,  extending  two  inches  below  the 
margin  of  the  ribs,  and  measuring  six  inches  in  the  right  mam¬ 
mary  line. 

Q.  How  was  this  accounted  for? 

A.  You  said  it  was  possible  that  this  might  be  the  result  of 
an  early  stage  of  cirrhosis  of  the  liver. 

Q.  What  right  had  I  to  assume  such  a  thing? 

A.  Because  the  patient  owned  up  to  having  been  all  his  life 
most  intemperate,  especially  in  the  matter  of  gin,  and  you 
pointed  out  the  stellate  veins  upon  his  nose. 

Q.  Were  there  any  other  evidences  of  cirrhosis  of  the 
liver  ?  * 

A.  No. 

Q.  Mr.  C.  D.,  what  were  the  physical  signs  present  in  the 
second  case  we  examined? 

A.  Diminished  expansion  of  the  right  side  of  the  chest; 
dullness  on  percussion  of  the  left  apex  as  far  down  as  the  third 
rib ;  and  dullness  at  the  right  apex,  extending  to  a  lower  level, 
but  with  a  less  defined  lower  margin  and  a  corresponding  area 
of  dullness  posteriorly. 

Q.  And  with  the  stethoscope? 

A.  The  breath  sounds  were  harsh  and  subcrepitant  rales 
were  audible,  especially  at  the  right  apex. 

Q.  What  important  aid  to  diagnosis  was  unmeniioned  ? 

A.  Examination  of  the  sputum. 

Q.  Mr.  Farwell,  you  are  the  clinical  clerk  in  charge  of  this 
case;  what  report  have  \ou  to  make? 

A.  {Mr.  Farwell.)  I  have  examined  the  sputa  in  the  patho¬ 
logical  laboratory.  The  mass  brought  up  in  the  morning  is 
muco-purulent  and  nummular,  and  contains  elastic  tissue,  also  a 
few  tubercle  bacilli  in  every  slide  examined. 

Q.  Mr.  0.  D.,  of  what  use  is  this  report  ? 

A.  It  is  positive  eCdence  of  the  nature  of  the  disease. 

Q.  Were  any  important  symptoms  of  pulmonary  tubercu¬ 
losis  absent  ? 

A.  Ilasrnoptysis,  night-sweats,  and  fever. 

Q.  What  symptoms  were  present? 

A.  Cough,  debility,  loss  of  weight. 

Case  1. — Dr.  MacDonnell :  The  new  case  I  present  to  you 
to-day  is  that  of  John  Farrell,  aged  sixty-six,  a  laborer,  who 
was  admitted  on  the  24th  of  October — i.  e.,  thirteen  days  ago. 
He  was  sent  in  from  the  out-patient  room  because  he  had  sci¬ 
atica.  He  complained  of  pain  down  the  back  of  the  left  thigh, 
which  was  very  severe  and  kept  him  from  earning  his  living. 
There  were  also  pains  in  the  shoulders  and  arms,  but  there  was 
no  stiffness  of  the  joints.  He  owns  to  having  been  very  intem¬ 
perate,  but  he  says  that  he  has  never  had  rheumatism. 

The  family  history — which  is  given  in  detail  in  the  repot t  I 
have  here,  furnished  by  Mr.  Morrow,  the  clinical  clerk  in  charge 
— is  negative. 

After  his  admission  we  found  physical  signs  of  an  emphy¬ 
sematous  condition  of  his  lungs,  and  some  of  you  will  remem¬ 
ber  that  I  pointed  this  out  as  being  not  uncommonly  found  in 


*  The  temperature  rose  from  97°  on  the  morning  of  admission 
steadily  to  100°  on  the  following  morning.  On  the  fourth  evening  it 
was  102‘5°,  on  the  fifth  101 '5°,  and  did  not  come  to  normal  until  the 
end  of  the  first  week,  when  it  suddenly  fell,  coincident!)'  with  the  dis¬ 
appearance  of  the  abdominal  pain. 


old  people.  The  area  of  cardiac  dullness  was  not  encroached 
upon,  but  it  was  increased  in  extent,  the  apex  beating  under 
the  nipple,  and  I  said  that  probably  the  heart  was  much  larger 
than  the  area  of  dullness  represented,  owing  to  the  emphysema 
of  the  lungs.  The  sounds  were  somewhat  weak,  but  there  were 
no  murmurs.  There  were  no  evidences  of  disease  elsewhere. 
The  pains  were  disappearing  gradually,  and  the  general  condi¬ 
tion  was  improving,  when,  upon  the  night  of  the  80th  of  Octo¬ 
ber,  a  certain  change  took  place,  of  which  the  patient  will  tell 
us  himself.  What  happened  to  you  on  the  night  of  the  30th  of 
October? 

The  Patient:  I  went  to  bed  as  well  as  ever  I  was,  with  the 
exception  of  the  old  pains  in  my  leg.  About  eleven  o’clock  I 
was  seized  with  a  violent  pain,  which  ran  from  the  pit  of  my 
stomach  up  to  my  neck.  I  could  not  get  any  breath  on  account 
of  the  pain,  and  I  thought  I  was  going  to  die.  I  was  in  a  fear¬ 
ful  state  with  shortness  of  breath.  The  nurse  saw  I  was  bad 
and  sent  for  the  house  doctor. 

Q.  What  did  he  do  ? 

A.  He  ordered  hot  poultices  and  put  something  sharp  into 
my  arm.  and  after  that  I  felt  better. 

Q.  Did  you  have  any  chill  ?  Did  your  teeth  chatter,  and  did 
you  feel  cold  ? 

A.  No,  sir. 

Q.  Did  you  have  any  sharp  pain  in  either  side  of  your 
chest  ? 

A.  No,  sir.  It  was  just  in  the  middle  and  ran  from  there 
to  there  (from  the  top  of  the  sternum  to  the  epigastrium). 

Q.  Mr.  E.  F.,  here  is  an  old  man  who,  apparently  in  good 
health,  for  his  sciatica  was  nearly  well,  goes  to  bed  and  awakes 
in  urgent  pain  and  dyspnoea.  Can  you  suggest  a  cause? 

A.  It  might  be  pneumonia. 

Q.  Why  pneumonia  ? 

A.  Because  pneumonia  is  sudden  in  old  people. 

Q.  Would  your  stethoscope  help  you  ? 

A.  It  might  not,  because  the  physical  signs  may  not  be 
present. 

Q.  What  else  might  it  be? 

A.  Angina  from  old  heait  affection. 

Q.  What  else  ? 

A.  Acute  pleurisy. 

Q.  One  serous  membrane  can  be  affected,  so  can  another? 

A.  Yes.  It  might  be  acute  pericarditis 

Q.  What  symptoms  of  a  sudden  pneumonia  are  absent? 

A.  Chill  and  pain  in  the  side. 

Dr.  Mac  Donnell :  The  report  of  the  night  nurse  and  that 
of  the  house  physician  corroborate  that  of  the  patient,  which 
he  has  giv<-n  remarkably  clearly.  Dr.  McKechnie  found  no 
cause  for  the  pain  until  the  following  day,  when  a  very  loud 
friction  murmur  became  evident.  I  heard  it  on  the  morning  of 
the  1st  of  November,  and  I  have  never  heard  any  pericardiac 
friction  sound  so  loud  and  distinct.  There  was  no  evidence  of 
fluid  in  the  pericardium.  The  friction  sound  was  limited  to  an 
area  of  about  the  size  of  a  half  dollar,  situated  just  where  the 
fourth  rib  meets  the  sternum  on  the  right  side.  It  accompanied 
both  sounds  of  the  heart  and  was  unaffected  by  a  cessation  of 
breathing. 

On  the  night  of  the  attack  he  went  to  bed  with  a  normal 
temperature,  but  by  the  following  morning  it  had  lisen  two  de¬ 
grees  and  remained  high  until  two  days  ago.  The  pulse  ran  up 
from  66  to  104.  The  respirations  were  not  at  all  increased  in 
number.  (A  point  against  the  diagnosis  of  pneumonia.) 

Q.  Examine  the  chest  thoroughly.  What  is  the  condition 
of  the  lungs?  Are  there  any  evidences  of  pleurisy  or  pneu¬ 
monia  ? 

A.  No. 


716 


CLINICAL  REPORTS. 


[N.  Y.  Med.  Jouk., 


Q.  Now  pat  your  stethoscope  just  here  (at  the  junction  of 
the  fourth  right  costal  cartilage  and  the  sternum)  and  make 
slight  pressure  with  it.  What  do  you  hear? 

A.  A  friction  sound. 

Q.  With  what  sounds  is  it  synchronous? 

A.  With  the  heart  sounds.  It  accompanies  both. 

Q.  Have  yt>u  found  a  cause  for  the  illness  of  the  30th  of 
October  ? 

A.  ^  es.  He  probably  had  acute  pericarditis. 

Q.  Can  you  positively  exclude  pneumonia  ?  Remember  that 
pneumonia  and  pericarditis  often  go  together  in  the  same  sub¬ 
ject. 

A.  The  subsequent  history  is  not  that  of  pneumonia. 

Q.  Are  you  satisfied  that  he  has  acute  pericarditis  and  that 
the  onset  of  this  disease  was  the  cause  of  this  attack  on  the 
night  of  the  30th  of  October? 

A.  Yes. 

Q.  Do  you  think  it  probable  that  acute  pericarditis  coulc 
occur  without  a  cause,  and  until  to-day  we  can  not  find  one? 
Remember  he  has  been  ill  for  three  days.  Wrhat  is  the  most 
common  cause  of  pericarditis? 

A.  Rheumatism. 

Pr.  MacDonnell:  The  other  causes  are  traumatism,  which 
we  need  not  consider;  infectious  diseases,  which  he  has  not; 
and  Bright’s  disease,  which  we  can  exclude  by  the  examination 
of  the  urine.  The  cause  became  apparent  yesterday  morning, 
when  he  began  to  complain  of  pain  in  the  left  great  toe  joint 
and  afterward  of  pain  in  the  right  toe  joint.  Although  he 
denies  ever  having  had  rheumatism,  yet  he  acknowledges  an  old 
ft  iend  in  this  s welling  of  his  left  foot.  He  says  he  had  an  af  tack 
just  like  this  in  his  left  foot  seven  years  ago.  It  never  touched 
any  other  joint. 

There  is  evidently  now  an  acute  joint  affectiou  to  accom¬ 
pany  the  pericarditis,  and  that  joint  affection  looks  to  me  very 
much  like  gout.  Acute  rheumatism  does  not  usually  attack 
people  for  the  first  time  at  the  age  of  fifty-nine ;  on  the  contrary, 
it  is  very  rare  for  it  to  attack  after  thirty.  And  this  old  man,’ 
whom  we  have  no  reason  for  disbelieving,  declares  that  he  never 
had  any  joint  affection  in  his  life  except  this  one  attack  in  the 
left  toe  joint  seven  years  ago. 

1.  Age  is  one  point  against  acute  rheumatism. 

2.  The  joint  affected  is  gout’s  own  joint.  It  has  attacked 
both  of  them.*  Rheumatism  prefers  the  medium  joints,  like 
the  elbow  and  wrist. 

3.  The  character  of  the  swelling  resembles  that  of  gout. 
The  tissues  are  red  and  glazed  all  round  the  joint.  It  looks  hot 
and  angry,  and  you  can  perceive  it  is  exquisitely  painful. 

1  he  points  against  the  diagnosis  of  acute  gout  are  these: 

1.  The  absence  of  previous  attacks  save  the  one  mentioned. 

2.  I  he  presence  of  pericarditis,  which  is  so  common  a  com¬ 
plication  of  rheumatism  and  which  is  so  rarely  mentioned  in 
connection  with  gout. 

3.  l'he  rapid  relief  which  followed  the  administration  of  the 
salicylates. 

Altogether  it  is  most  probable  that  we  are  dealing  with 
acute  rheumatism,  modified  by  the  age  of  the  patient  and  by  a 
previous  attack,  as  well  as  by  the  fact  that  he  met  with  his  ill¬ 
ness  in  hospital  where  appropriate  treatment  was  immediately 
at  hand.f 

Pr.  MacDonnell :  This  patient,  whom  I  present  to  you  for 
the  firr-t  time  to-day,  is  John  Jougb,  aged  seventy-seven,  for- 

*  The  joints  subsequently  involved  were  the  metacarpo-phalangeal 
joint  of  the  right  hand  and  the  metatarso-phalangeal  joints  of  both  feet. 

f  1\  ovembei- ij,  1890. — No  appreciable  effusion  into  the  pericardium 
has  taken  place.  The  joint  affection  has  quite  subsided. 


merly  a  sailor  in  the  Royal  Navy,  latterly  a  journeyman  tailor. 
He  was  admitted  on  the  30th  of  October,  1890.  He  says  that 
he  enjoyed  good  health  until  about  four  years  ago,  when  his 
sight  began  to  fail  him  and  he  could  no  longer  work  at  his  trade. 
For  about  the  same  period  he  has  suffered  from  cough,  pains  in 
the  chest,  and  breathlessness  upon  exertion.  Od  the  30t,h — that 
is,  four  days  ago — he  went  to  get  some  medicine  at  the  out-pa¬ 
tient  department  of  the  hospital,  and  on  (he  way  home  was 
seized  with  severe  pain  in  the  right  side,  shivering,  and  a  sense 
of  very  great  weakness,  so  that  he  could  no  longer  walk,  but 
was  obliged  to  lie  down  on  the  pavement.  The  ambulance  was 
summoned  and  he  was  brought  to  the  hospital. 

Q.  Mr.  F.  G.,  can  you  suggest  a  cause  for  chill,  pain  in  the 
side,  and  sudden  prostration  in  a  feeble  old  man? 

A.  It  might  be  pneumonia. 

Dr.  MacDonnell:  He  was  accordingly  given  a  bed  in  this 
ward,  and  the  following  state  on  admission  is  noted  in  the  re¬ 
port  handed  to  me  now  by  Mr.  Dewar,  the  clinical  clerk:  The 
patient  presented  an  anxious  appearance  and  was  evidently 
short  of  breath.  There  was  a  very  distinct  malar  blush.  He 
complained  of  weakness  and  pain  at  the  pit  of  the  stomach. 
The  temperature  was  100°;  pulse  86;  respiration  36.  There 
was  no  cough. 

Q.  What  physical  signs  are  present? 

A.  The  left  side  of  the  chest  expands  better  than  the  right. 

Q.  Can  you  find  the  apex  beat  of  the  heart? 

A.  It  is  here,  a  good  inch  outside  the  nipple  line. 

Q.  What  other  signs  are  there? 

A.  The  area  of  superficial  dullness  of  the  heart  is  increased. 
It  begins  above  at  the  third  rib  in  the  middle  line;  laterally,  it 
extends  from  the  right  border  of  the  sternum  to  the  apex  beat, 
just  one  inch  outside  the  nipple  line. 

Q.  Now  listen  to  the  heart  sounds.  What  do  you  hear? 

A.  A  very  loud  systolic  murmur  at  the  apex  and  a  double 
murmur  at  the  aortic  cartilage.* 

Q.  Now  percuss  the  lungs. 

A.  Both  lungs  are  clear  in  front  on  percussion.  Behind,  the 
left  lung  is  quite  clear  to  the  base,  but  the  right  lung  is  dull 
from  the  angle  of  the  scapula  to  the  base. 

Q.  The  stethoscopic  signs  ? 

A.  Bronchial  breathing  is  very  well  marked  over  the  dull 
area  at  the  right  pulmonary  base.  The  respiration  is  hurried. 
There  are  mucous  rales  on  inspiration  and  expiration.  The  vo¬ 
cal  resonance  is  increased. 

Q.  Now  the  liver  and  spleen? 

A.  No  signs  of  enlargement. 

Q.  The  urine  is  reported  to  afford  negative  evidence  of  dis¬ 
ease  ;  what  is  your  diagnosis ? 

A.  Acute  pneumonia  with  heart  disease. 

Q.  What  is  the  nature  of  ihe  heart  disease? 

A.  Valvular  disease  with  hypertrophy. 

Q.  Of  old  standing  ? 

A.  Yes. 

Q.  Why  ? 

A.  Because  there  is  evident  enlargement  of  the  heart. 

Q.  How  does  that  tally  with  the  history  ? 

A.  He  said  that  he  had  cough,  dyspnoea,  and  pain  in  the 
chest  for  several  years. 

Dr.  MacDonnell :  There  are  many  instructive  points  in  con¬ 
nection  with  this  case.  The  diagnosis  is  plain.  First,  most 
rrobably  as  a  result  of  atheromatous  change,  the  valves  have 
recoine  incompetent;  an  hypertrophy  of  the  walls  of  the  heart 
tas  occurred  which  has  completely  compensated  for  the  valvu- 


*  Capillary  pulse  was  well  marked  in  the  finger-nails  during  the  pe¬ 
riod  of  pyrexia,  but  after  the  temperature  became  noimal  it  was  lost. 


Pec.  27,  1890.] 


LEADING  ARTICLES. 


71 


lar  defect,  as  is  evidenced  by  the  fact  that  he  lias  never  had 
dropsy  of  the  feet,  but  probably  compensation  is  beginning  to 
fail  and  he  applies  for  relief  at  the  out  patient  room.  Probably 
the  exertion  of  getting  home  brought  about  a  condition  of  pul¬ 
monary  stasis  which  may  have  predisposed  to  pneumonia,  or 
the  lungs  may  habitually  have  been  in  an  engorged  condition, 
ready  to  take  on  that  disease.  When  an  old  person  is  attacked 
with  severe  pain  in  the  side  and  chill,  the  diagnosis  of  pneu¬ 
monia  is  almost  certain.  The  malar  flush  in  an  old  person  is 
very  suggestive,  and  here  it  was  coupled  with  hurried  breathing 
and  fever.  Even  in  the  absence  of  physical  signs  the  diagnosis 
would  be  almost  complete. 

Twoimportant  symptomsof  pneumonia  were  absent — cough 
and  rusty  expectoration.  Both  these  symptoms  are  often  ab¬ 
sent  in  pneumonia,  and  are  generally  absent  in  senile  pneu¬ 
monia. 

Q.  {To  patient).  How  is  your  cough  since  you  came  in  ? 

A.  Better. 

Q.  Do  you  cough  at  all  ? 

A.  Scarcely  at  all. 

Q.  Did  you  cough  much  before  you  came  in  ? 

A.  Yes,  a  great  deal. 

Dr.  MacDonnetl :  It  would  appear  as  if  his  acute  pneumonia 
had  cured  his  cough,  and  this  has  often  been  noticed.  Patients 
who  have  chronic  bronchitis  with  winter  cough  and  who  con¬ 
tract  pneumonia  are  often  relieved  of  their  cough  while  the 
pneumonia  is  in  progress. 

Q.  Are  you  short  of  breath  now  ? 

A.  Ho,  sir. 

Q.  Were  you  short  before  you  came  in — more  than  you  are 
now  ? 

A.  Yes. 

Dr.  MacDonnell :  The  same  is  true  of  dyspnoea.  Persons 
habitually  short-winded  do  not  appear  to  be  so  breathless  when 
pneumonia  attacks  them  as  those  whom  the  disease  strikes  when 
in  good  health. 

{The patient' 8  heel  is  removed.)  In  senile  pneumonia  the  pa¬ 
tient  may  die  before  physical  signs  have  time  to  develop.  Our 
pathological  friends  very  often  find  pneumonias  of  whose  ex¬ 
istence  we  were  not  aware.  Pneumonia  is  a  very  common  cause 
of  death  in  elderly  people,  and  is  frequently  overlooked. 

The  physical  signs  differ  from  those  of  ordinary  pneumonia. 
The  dullness  may  not  be  perceptible.  The  crepitant  rale  is 
nearly  always  entirely  absent  and  is  replaced  by  the  mucous 
rile  such  as  we  have  heard  here.  But  the  breathing  readily 
takes  on  a  blowing  character. 

As  to  the  prognosis  of  this  case — when  I  examined  the 
patient  the  day  before  yesterday  I  told  my  house  physician  that 
I  thought  the  old  man  would  die.  He  was  very  feeble;  he 
already  bad  advanced  cardiac  disease  which  would  be  likely  to 
impede  the  action  of  the  lungs,  which  were  now  seriously  at¬ 
tacked.  But  to-day  he  seems  better.  There  is  improvement 
in  every  symptom  and  the  disease  does  not  appear  to  have 
spread.  This  is  the  fifth  day,  and  w'e  may  expect  a  crisis  be¬ 
fore  many  more. 

The  treatment  in  these  cases  is  not  one  of  drugs.  A  patient 
in  this  condition  must  have  the  most  nourishing  diet  and  a  free 
supply  of  stimulants.  I  ordered  him  twelve  ounces  of  whisky 
in  the  twenty-four  hours  and  no  medicine.* 


The  New  York  Polyclinic.— Dr.  James  P.  Tuttle  has  been  ap¬ 
pointed  lecturer  on  diseases  of  the  rectum  and  anus,  and  an¬ 
nounces  that  he  will  hold  clinics  on  Tuesdays  and  Fridays,  at 

7  P.  M. 


*  The  patient  eventually  made  a  good  recovery. 


THE 

NEW  YORK  MEDICAL  JOURNAL, 

A  Weekly  Review  of  Medicine. 

Published  by  Edited  by 

D.  Appleton  &  Co.  Frank  P.  Foster,  M.  D. 

NEW  YORK,  SATURDAY,  DECEMBER  27,  1890. 


LABORATORY  RESEARCHES  REGARDING  EPHEMERAL 

FEVERS. 

The  causation  of  febriculte  has  been  the  subject  of  some 
original  experiments  by  Roussy,  whose  contributions  have  re¬ 
cently  been  published  in  the  Archives  de  physiologie.  His 
paper  is  a  significant  addition  to  our  knowledge  of  the  febrile 
process  in  certain  minor  affections  that  have  hitherto  received 
very  little  attention  at  the  hands  of  biologists.  He  has  ob¬ 
served,  in  the  first  place,  the  frequent  occurrence  of  cases  of 
high  temperature  of  short  duration,  the  cause  of  which  has 
been  the  ingestion  of  stale  beer,  decayed  fish,  or  stagnant  water 
containing  vegetable  matter,  such  as  hay,  leaves,  etc.  The 
author  holds  the  opinion  that  the  cause  of  this  kind  of  pyrexia 
is  not  a  specific  micro-organism,  but  a  soluble  chemical  sub¬ 
stance.  Animals  were  experimented  upon  by  intravenous  in¬ 
jections  of  water  containing  decaying  organic  substances,  with 
the  result  of  producing  intense  fever,  the  temperature  going  as 
high  as  107'5°  F.,  with  decided  symptoms  of  gastro-intestinal 
disturbance.  A  like  quantity  of -the  same  fluid  taken  into 
the  stomach  produced  neither  febrile  nor  digestive  derange¬ 
ment. 

Roussy  paid  particular  attention  to  the  high  fever  caused 
>y  the  yeast  of  beer.  That  substance,  when  rubbed  up  with 
distilled  water  and  after  twenty-four  hours  filtered,  yielded 
a  filtrate  which,  injected  under  the  skin,  was  followed  by 
sharp  pyrexia  lasting  from  twelve  to  fifteen  hours.  That 
uhis  fever  was  not  due  to  the  mechanical  or  other  effects 
of  the  contained  germs  was  proved  by  the  fact  that  when 
a  quantity  of  the  yeast  cells  was  collected  on  a  filter  and  dried 
at  270°  F.,  and  then  prepared  for  subcutaneous  injection  in  dis¬ 
tilled  water,  no  pyrexial  action  was  observed.  That  the  fever 
was  caused  by  the  product  of  the  living  cell  was  shown  by  cul¬ 
tivating  the  yeast  in  bouillon  and  then  carefully  washing  the 
cells  at  the  bottom  of  the  glass  with  sterilized  water  and  allow¬ 
ing  them  to  stand  for  three  days.  The  injection  of  this  mate¬ 
rial  was  followed  by  the  same  febrile  agitation  as  that  already 
observed  to  be  due  to  the  stale-beer  injections.  By  a  some¬ 
what  laborious  process,  Roussy  was  able  to  isolate  a  granular 
mass  of  a  light-yellow  color  which  caused  febrile  action  when 
injected.  This  mass  deliquesced  upon  exposure,  forming  a 
syrupy  substance  that  adhered  tenaciously  to  the  sides  of  the 
vessel  when  dried.  In  a  desiccator  the  precipitate  became 
white  and  slightly  scaly,  and  was  readily  pulverized;  placed 
upon  the  tongue,  it  rapidly  melted,  at  first  giving  a  resinous 
taste,  and  after  that  a  biting  sensation  which  rose  to  a  sense  of 
strangulation.  To  this  substance  the  author  has  given  the 
name  of  pyretogenin.  Small  subcutaneous  injections  of  this 


718 


MINOR  PARAGRAPHS. 


[N.  Y.  Med.  Joub., 


fever-producer  caused  in  animals  a  rise  of  temperature  within 
an  hour  or  half-hour,  often  as  high  as  107°  F.,  and  accom¬ 
panied  by  chills,  vomiting,  and  diarrhoea.  The  pulse  was  fre¬ 
quent,  hard,  and  small,  and  the  skin  was  dry.  There  was  an 
increase,  during  the  febrile  movement,  in  the  amount  of  urea 
and  carbonic  acid  eliminated.  After  six  or  seven  hours  the 
animal  was  again  in  a  normal  condition. 


MINOR  PARAGRAPHS. 

DIABETIC  PARAPLEGIA. 

The  London  Medical  Record  quotes  from  a  recent  lecture  by 
Charcot  on  the  organic  or  dynamic  affections  of  the  lower 
limbs,  in  the  course  of  which  the  subject  of  diabetic  paraplegia 
was  considered.  Since  1880,  when  Jules  Worms  wrote  of  the 
symmetrical  neuralgias  of  diabetic  patients,  other  writers,  such 
as  von  Ziemssen,  Buzzard,  and  Bernard,  have  pointed  out  other 
neuropathic  conditions,  such  as  formication,  hypersesthesia, 
dysaestbesiae,  and  even  absence  of  the  knee-jerk,  as  the  result 
of  diabetes.  The  absence  of  the  knee-jerk,  in  cases  that  are 
grave  but  not  of  necessity  grave  because  of  the  large  quantity 
of  sugar  excreted,  is  apparently  the  result  of  a  peripheral  neu¬ 
ritis,  the  spinal  cord  being  found  intact.  In  some  cases  loco¬ 
motor  ataxia  is  simulated  by  this  symptom,  by  the  lightning 
pains,  by  other  sensory  disturbances,  and  by  the  ataxic  gait. 
But  neither  in  the  diabetic  ataxia  nor  in  the  alcoholic  variety 
is  the  gait  really  that  of  tabes,  the  muscular  paralysis  being 
most  marked  in  the  extensors  of  the  foot.  In  fact,  in  all  the 
forms  of  pseudo-tabeo,  whether  diabetic,  alcoholic,  saturnine, 
arsenical,  or  from  beri-beri,  we  see  the  “  steppage,”  not  the 
true  ataxic  walk.  The  front  part  of  the  foot  falls,  and  the  pa¬ 
tient  is  obliged  to  step  higher  than  usual  to  prevent  the  toes 
from  catching  the  ground.  The  paralyzed  muscles  show  the 
electrical  reaction  of  degeneration.  The  spinal  cord,  however, 
is  not  the  site  of  serious  alteration,  the  posterior  columns  espe¬ 
cially  remaining  quite  free  from  impairment.  In  diabetic  para¬ 
plegia  there  is  not  that  pain  on  pressure  of  the  limb  found  in 
the  alcoholic  variety,  but  the  feet  fall  even  when  the  patient  is 
seated.  Taken  as  a  whole,  the  case  exhibited  by  the  lecturer 
bore  the  closest  resemblance  to  the  alcoholic  cases,  but  there 
was  no  alcoholism  about  it. 


THE  NEW  SURGEON-GENERAL  OF  THE  ARMY. 

Among  the  nominations  sent  to  the  Senate,  by  the  Presi¬ 
dent,  on  the  23d  inst.,  was  that  of  Dr.  Charles  Sutherland,  to 
be  Surgeon-General  of  the  army.  Dr.  Sutherland  entered  the 
medical  department  of  the  army  in  1852  and  is,  to-day,  the 
ranking  Colonel  in  that  department.  Ilis  services  during  the 
war  of  the  rebellion  won  for  him  the  brevets  of  Lieutenant- 
Colonel  and  Colonel ;  and  his  appointment  to  the  highest  posi¬ 
tion  in  the  department  is  but  a  just  recognition  of  those  serv¬ 
ices.  In  1866  he  was  appointed  Assistant  Medical  Purveyor, 
and  his  experience  in  that  capacity  fits  him  for-  the  office  which, 
we  feel  assured,  he  will  fill  with  credit  to  himself  and  to  the 
corps  which  he  represents. 


THE  LIBRARY  OF  THE  NEW  YORK  HOSPITAL. 

On  the  1st  of  January  the  librarian,  Dr.  John  L.  Vander- 
voort,  will  retire  from  the  office  of  which  he  has  discharged  the 
duties  almost  continuously  since  1837.  At  the  time  of  his  ap¬ 
pointment  the  library  consisted  of  only  4,166  volumes,  and  was 


open  for  the  delivery  of  books  to  those  privileged  to  use  them 
only  on  stated  days,  and  for  from  an  hour  and  a  half  to  two 
hours  at  a  time.  It  was  Dot  for  some  years  after  that  that  a 
daily  service  was  established.  From  the  time  of  the  dis¬ 
mantling  of  the  old  hospital  building  in  Broadway  to  the  open¬ 
ing  of  the  present  building  in  Fifteenth  Street,  the  library  was 
moved  several  times,  but  during  all  that  time  Dr.  Vandervoort 
managed  to  make  it  available  to  those  who  had  occasion  to 
make  use  of  it.  It  is  soon  to  be  moved  into  a  new  building  ad" 
jacentto  its  present  quarters.  More  than  14,000  volumes  have 
been  added  to  it  during  Dr.  Vandervoort’s  tenure  of  office. 
We  learn  that  his  son  will  continue  to  discharge  the  duties  of 
assistant  librarian.  Both  the  hospital  authorities  and  the  medi¬ 
cal  profession  of  New  York  are  indebted  to  Dr.  Vandervoort 
for  his  long  and  intelligent  service. 


A  CHRISTMAS  SENTIMENT  REGARDING  THE  MEDICAL 

PROFESSION. 

The  following  seasonable  tribute  to  our  profession  may  be 
found  in  the  Christmas  number  of  All  the  Year  Round  in  a 
story  by  Fargeon:  “Surely  there  must  be  some  beneficent  in¬ 
fluence  at  work  that  humanizes  and  softens  the  heart,  that 
makes  it  respond  willingly  and  cheerfully  to  the  appeals  of 
those  who  suffer!  Numberless  are  the  instances  that  can  be 
adduced  of  the  wonderful  goodness  of  physicians,  renowned 
and  eminent,  who  sacrifice  their  time  without  expectation  or 
desire  of  return  for  the  inestimable  services  they  render.  I 
have  no  hesitation  in  saying  that  of  all  arts  it  is  the  most  en¬ 
nobling  and  beautiful,  and  that  its  record  of  kind  deeds  is 
matchless  and  unapproachable.  With  all  my  heart  I  say, 
‘  Heaven  bless  the  doctors  for  all  the  good  they  do,  for  the  good 
they  are  enabled  to  do.’” 


A  CONTRIBUTION  TO  THE  ETIOLGY  OF  JACKSONIAN 

EPILEPSY. 

In  the  Archiv  fur  pathologische  Anatomie  und  Physiologie 
und  fur  Minische  Medicin,  Dr.  K.  Yamagiwa  calls  attention  to 
two  cases  of  severe  cortical  epilepsy  in  which  post-mortem 
sections  of  the  brain  revealed  disseminated  patches  of  Distoma 
pulmonale  in  the  cortex.  Microecopic  examination  showed,  in 
connection  with  the  parasites,  giant-cell  and  round-cell  infiltra¬ 
tion,  thickened  blood-vessel  walls,  and  new  connective-tissue 
growth.  Further  research  disclosed  the  Distoma  in  the  lungs. 


HEMIANOPSIA  FOLLOWING  UTERINE  HEMORRHAGE. 

Dr.  A.  Chevat.lereau,  in  the  October  number  of  the  Ar¬ 
chives  de  tocologie,  details  the  histories  of  two  cases  of  hemi¬ 
anopsia  which  came  on  after  severe  uterine  hfemorrhage.  The 
author  was  of  the  opinion  that  the  prolonged  syncope  which 
followed  the  hmmorrhage  might  have  given  rise  to  blood  co- 
agula  in  some  of  the  branches  of  the  cerebral  arteries  which 
supplied  that  part  of  the  cortex  governing  vision,  or  some  of 
the  fibers  of  the  optic  tract. 


THE  TETANUS  GERM. 

Dr.  M.  Reynier,  in  the  Revue  de  chirurgie ,  gives  the  result 
of  various  experiments  on  animals  with  a  culture  of  tetanus 
germs.  In  every  instance,  after  the  inoculation  the  typical 
symptoms  were  developed,  and  death  followed  in  a  short  time. 
The  microscope  demonstrated  the  bacilli  of  Nicolaier  in  every 
case. 


Dec.  27,  1890.] 


MINOR  PARAGRAPHS.— ITEMS. 


719 


THE  CORROSIVE-SUBLIMATE  TREATMENT  OF  GRANULAR 

CONJUNCTIVITIS. 

The  treatment  of  different  forms  of  granular  conjunctivitis 
with  various  strengths  of  corrosive-sublimate  solution  seems  to 
have  given  good  results  in  the  hands  of  Guaita  ( Annales  d'ocu- 
listique).  Ihe  details  of  the  treatment  are  published  in  the 
Union  medicate.  The  sublimate  is  used  in  strengths  of  from 
1  to  300  to  1  to  500,  and  it  is  applied  to  the  palpebral  conjunc¬ 
tiva  with  a  camel’s-hair  brush  every  two  hours  or  according  to 
the  severity  of  the  case.  If  the  disease  is  slight,  a  collyrium  of 
1  to  1,000  is  given.  There  have  been  no  symptoms  of  poison¬ 
ing  or  complications  to  the  cornea  from  this  method,  but  very- 
prompt  amelioration  of  the  symptoms  has  followed  its  employ¬ 
ment  in  every  instance. 

AN  EPIDEMIC  OF  TUBERCULAR  PNEUMONIA.  ' 

Dk.  Kussner,  in  the  Gentralblatt  fur  Jclinische  Medicin,  men¬ 
tions  five  cases  of  this  affection,  the  histories  of  which  had  been 
previously  published  by  Dr.  L.  Dor,  in  the  Province  medicate. 
The  cases  had  occurred  in  close  connection  in  a  hospital  ward. 
Four  of  them  were  rapidly  fatal;  the  fifth  ended  in  recovery. 
Autopsies  disclosed  the  fact  that  tubercle  bacilli  were  present, 
though  no  marked  symptom  had  existed  during  life.  There 
was  great  infiltration  of  the  lung  tissue,  and,  besides  the  char¬ 
acteristic  bacilli,  there  was  another  micro-organism  present,  the 
one  which  had  evidently  caused  the  rapid  course  of  the  pneu¬ 
monia. 


ITEMS,  ETC. 

The  Koch  Treatment  at  the  County  Medical  Society— On  Monday 
evening,  the  22d  inst,,  a  very  large  audience  of  physicians  assembled  at 
the  monthly  meeting  of  the  Medical  Society  of  the  County  of  New  York 
to  listen  to  the  first  public  report  made  in  New  York  on  the  subject  of 
Koch’s  treatment  of  tuberculous  disease  as  observed  by  Dr.  John  H. 
Linsley  in  Berlin.  The  speaker,  who  had  followed  the  treatment  in 
Gerhardt’s  clinic  at  the  Charite,  prefaced  his  statements  by  an  effective 
word  picture  of  the  daily  scenes  at  the  opening  of  each  clinic.  He  de¬ 
scribed  the  halls  and  approaches  to  the  clinic  rooms  as  so  thronged  by 
physicians  as  to  be  almost  impassable  to  the  patients  as  they  elbowed 
their  way  to  the  professor’s  table,  each  with  a  glass  containing  the  in¬ 
dividual’s  sputum.  If  examination  demonstrated  the  presence  of  tu¬ 
bercle  bacilli,  each  patient  received  as  a  first  injection  one  milligramme 
of  the  liquid.  The  patients  were  then  put  to  bed  and  the  changes  in 
their  condition  were  carefully  noted.  No  previous  histories  of  the  cases 
were  taken,  and  no  effort  was  made  to  obtain  them.  The  inoculating 
needle  was  used  from  one  patient  to  another,  and  no  attempt  was  made 
at  cleansing  or  disinfecting  it.  No  local  irritation  at  the  site  of  the 
puncture  had  followed  in  any  of  the  cases  observed.  The  only  precaution 
taken  was  the  immersion  of  the  needle  and  syringe  in  absolute  alcohol 
before  this  general  use.  The  characteristic  results  usually  made  their 
appearance  in  from  two  to  thirty  hours  after  the  inoculation.  The  first 
symptom  of  reaction  was  the  rise  of  temperature,  which  varied  from 
100°  to  106°  F.,  though  occasionally  it  became  subnormal.  This  was 
followed  by  persistent  headache,  pain  in  the  back  and  limbs,  and  usu¬ 
ally  a  sharp  chill.  These  disturbances  generally  subsided  within  twenty- 
four  hours.  The  second  injection  was  not  given  until  all  symptoms  of 
the  initial  reaction  had  entirely  disappeared,  and  all  subsequent  injec¬ 
tions  were  administered  upon  this  basis.  The  dose  in  pulmonary  cases 
was  gradually  increased  to  ten  milligrammes.  The  patients  were  ex¬ 
amined  as  to  their  general  condition  every  two  hours. 

The  reactions  were  of  so  varied  a  character  that  the  speaker  thought 
the  treatment  should  only  be  carried  on,  at  least  at  present,  in  a  prop¬ 
erly  officered  institution.  Gerhardt  had  not  discharged  as  cured  any  of 
his  patients  with  phthisis  pulmonalis.  He  had  stated  that  the  sputum 
in  this  class  of  cases  was  at  first  increased  in  quantity  and  became 
thicker,  and  then  got  thinner  and  mucoid  in  character.  The  number 
of  bacilli  was  often  found  to  be  increased,  but  they  gradually  seemed 


to  undergo  a  certain  involution  process ;  they  would  become  club-shaped 
and  appeared  to  be  suffering  from  an  insufficient  or  improper  pabulum. 
The  weight  of  many  of  the  patients  increased  and  there  was  a  cessation 
of  night  sweats,  with  apparent  improvement  in  the  general  health. 
Professor  Gerhardt  had  stated  that  the  effects  in  these  cases  of  phthisis 
could  not  be  demonstrated  for  many  months.  He  had  expressed  him¬ 
self  as  considering  the  prospects  most  encouraging.  Dr.  Linsley  then 
detailed  what  he  had  seen  of  the  lupus  cases  in  the  clinic,  and  his 
statements  agreed  with  those  made  by  Dr.  Stearns,  whose  observations 
are  recorded  in  full  in  this  issue.  While,  he  said,  there  was  little  doubt 
that  ere  long  the  liquid  would  be  made  on  a  large  scale  by  the  German 
Government,  still  it  was  hinted  that  there  existed  at  present  points  of 
detail  on  which  Koch  and  the  Government  were  not  quite  in  accord. 
It  was  very  doubtful,  in  the  speaker’s  opinion,  if  the  actual  composi¬ 
tion  of  the  liquid  would  be  made  known  for  a  long  time.  It  had  been 
suggested  by  the  German  physicians  that  Koch  was  not  quite  satisfied 
with  the  therapeutical  effects  so  far  achieved,  and  that,  if  by  further 
work  he  could  find  some  other  ingredient  to  add  to  its  efficacy,  it  would 
be  to  his  interest  to  do  so,  and  until  then  he  should  abstain  from  any 
direct  statements  as  to  the  composition. 

Dr.  F.  Warner,  who  had  on  that  day  returned  from  Berlin,  where  he 
said  he  had  had  ample  opportunity  to  make  the  injections  and  to  watch 
the  results,  substantiated  Dr.  Linsley’s  remarks  in  general  terms.  Of 
the  pulmonary  cases,  he  stated  that  he  had  not  observed  any  results 
worth  recording,  though  it  must  be  admitted  that  many  of  the  cases 
treated  had  been  in  very  advanced  stages.  He  had  seen  some  very  good 
results  in  cases  of  laryngeal  tuberculosis. 

Dr.  S.  Baruch  said  that  he  had  made,  so  far,  sixty-six  injections  on 
thirteen  patients.  The  injections  had  been  given  by  his  house  physi¬ 
cian,  Dr.  Max  Rosenthal,  at  the  Montefiore  Home.  While  it  was  too 
soon  to  hazard  any  conclusions,  he  might  say  that,  as  a  general  propo¬ 
sition,  the  cough  and  expectoration  had  decreased  in  the  pulmonary 
cases.  Two  of  the  Home  patients  who  were  about  to  be  discharged  as 
cured  of  pre-existing  pulmonary  lesions  had  been  given  an  injection  of 
one  milligramme,  under  which  they  had  undergone  immediate  reaction. 
He  thought  these  experiments  confirmed  very  prettily  the  allegations 
made  as  to  the  diagnostic  value  of  the  injections. 

The  University  Medical  Magazine. — It  is  announced  that  the  size 
of  this  excellent  journal  is  soon  to  be  increased  by  the  addition  of  from 
sixteen  to  twenty-four  pages  to  each  number,  mainly  to  give  space  for 
fuller  abstracts  of  current  literature  under  the  direction  of  Dr.  William 
Pepper  and  Dr.  James  Tyson  (medicine),  Dr.  D.  Hayes  Agnew  and 
Dr.  J.  William  White  (surgery),  Dr.  Horatio  C.  Wood  (therapeutics), 
Dr.  William  Goodell  (gynascology),  and  Dr.  Barton  C.  Hirst  (obstetrics). 

The  Brooklyn  Post-graduate  Undertaking. — Articles  of  incorpora¬ 
tion  have  been  filed  in  Brooklyn  as  a  first  step  toward  the  establish¬ 
ment  of  a  post-graduate  hospital  and  school  in  that  city.  The  manage¬ 
ment  of  the  institution  will  be  vested  in  a  board  of  medical  councilors, 
among  whom  are  Dr.  Charles  Jewett,  Dr.  Fowler,  Dr.  Jeffrey,  Dr. 
Evans,  and  Dr.  Butler.  The  aim  of  the  faculty  will  be  to  cover  every 
field  of  study  in  surgery  and  practical  medicine.  An  outdoor  depart¬ 
ment  is  included  in  the  future  scope  of  the  enterprise. 

Society  Meetings  for  the  Coming  Week : 

Tuesday,  December  30th:  Boston  Society  of  Medical  Sciences  (private). 
Wednesday,  December  31st:  Auburn,  N.  Y.,  City  Medical  Association; 

Berkshire,  Mass.,  District  Medical  Society  (Pittsfield). 

Thursday,  January  1st:  New  York  Academy  of  Medicine;  Brooklyn 
Surgical  Society  ;  Society  of  Physicians  of  the  Village  of  Canandai¬ 
gua  ;  Boston  Medico-psychological  Association  ;  Obstetrical  Society 
of  Philadelphia ;  United  States  Naval  Medical  Society  (Washing¬ 
ton);  Washington,  Vt.,  County  Medical  Society  (annual — Mont¬ 
pelier). 

Friday,  January  2d:  Practitioners’  Society  of  New  York  (private) 
Baltimore  Clinical  Society. 

Saturday,  January  3d :  Clinical  Society  of  the  New  York  Post¬ 
graduate  Medical  School  and  Hospital ;  Manhattan  Medical  and  Sur¬ 
gical  Society  (private) ;  Miller’s  River,  Mass.,  Medical  Society. 


720 


LETTERS  TO  THE  EDITOR. 


[N.  Y.  Med.  Joor.. 


fetters  to  %  Cbitor. 


ALVEOLAR  ABSCESS;  A  REJOINDER  TO  DR.  M.  L.  RHEIN. 

New  York,  December  15,  1890. 

To  the  Editor  of  the  Hew  York  Medical  Journal: 

Sir:  In  your  issue  for  December  6th  a  letter  appears,  writ¬ 
ten  by  Dr.  M.  L.  Rhein,  criticising  my  article,  The  Importance 
of  Prompt  Treatment  in  Alveolar  Abscess,  published  in  your 
Journal  for  Xoveinber  22d.  I  should  like  to  reply  to  the  same. 

I  am  aware  that  oral  and  dental  surgery  have  been  recog¬ 
nized  as  specialties  in  medicine,  but  I  am  also  aware  that  large 
numbers  of  patients  suffering  from  alveolar  abscess  present 
themselves  every  year  in  all  the  large  hospitals  and  dispensaries 
and  to  the  general  surgeon  for  relief,  and  that  they  require 
“  prompt  treatment.” 

The  aetiology  of  the  fistulae  resulting  from  these  cases  has 
sometimes  puzzled  the  ablest  surgeons,  so  it  is  not  strange  that 
patients  should  consult  their  physicians  about  them  and  not  the 
dentist. 

I  regret  that  I  can  not  accept  the  compliment  the  writer 
pays  me  when  he  calls  the  classification  of  these  abscesses 
which  I  have  chosen— viz.,  into  superficial  and  deep  — “  origi¬ 
nal”  with  me. 

He  will  find  the  same  division  given  in  an  article  by  Dr. 
Briggs,  entitled  Diseases  and  Injuries  of  the  Jaws,  in  the  Refer¬ 
ence  Hand-look  of  the  Medical  Sciences. 

This  division  seems  a  most  natural  one,  and  the  dividing 
line  to  be  the  fold  of  mucous  membrane  passing  from  the  cheek 
to  the  gum.  In  the  superficial  form  the  apex  of  tooth-root 
does  not  pass  below  this  fold ;  in  the  deep  form  it  does. 

This  is  a  point  made  by  both  Bryant  and  Holmes  in  their 
Systems  of  Surgery. 

As  these  abscesses  have  a  tendency  to  point  in  a  direction 
horizontal  to  the  point  of  origin,  the  former  usually  burst  into 
the  mouth  and  the  latter  (when  on  the  outer  alveolar  surface) 
externally  upon  the  face.  Of  course,  either  of  these  may  be 
acute  or  chronic.  To  call  one  abscess  chronic  simply  because 
it  opens  into  the  mouth  and  another  acute  because  it  penetrates 
the  deeper  tissues  and  burrows  in  all  directions  seems  absurd. 
The  first  attack  of  the  superficial  form  is  certainly  an  acute 
affair,  and  when  abscesses  of  the  deep  form  burst  externally 
they  are  generally  chronic  enough  to  suit  the  most  fastidious. 
The  writer’s  “embarrassment”  over  the  lack  of  information  of 
the  profession  on  dental  topics  is  truly  touching,  but  I  have 
yet  to  know  that  a  fair  knowledge  of  dental  pathology  in  its 
relation  to  diseases  of  the  jaw  is  not  of  far  more  importance  to 
the  suigeon  than  the  anatomy  of  the  lower  extremities  is  to 
the  student  of  dentistry. 

Speaking  of  the  pathology  of  these  cases,  I  remarked  that 
the  “products  of  decomposition  pass  through  the  tooth  canal 
and  set  up  an  acute  inflammation  of  the  circumdental  mem¬ 
brane,”  and  the  word  periosteum  was  not  used,  as  the  writer 
hints. 

He  hopes  to  instruct  the  profession  by  use  of  the  word  peri¬ 
cementum,  but,  according  to  the  American  System  of  Dentistry , 
vol.  iii,  page  660,  pericementum,  peridental  membrane,  dental 
periosteum,  etc.,  are  synonyms. 

We  are  further  informed  that  this  inflammation  is  due  to  a 
putt efaction  of  the  dead  pulp.  Dr.  Rhein  might  have  gone  a 
step  further  and  spoken  of  the  micro  organisms  which  cause 
this. 

Although  a  tooth  may  be  fairly  well  nourished  by  its  cir¬ 
cumdental  membrane,  when  the  pulp  of  a  tooth  is  dead,  pro¬ 
ducing  the  characteristic  discoloration,  wheu  there  is  insensi¬ 


bility  to  heat  and  cold  and  the  tendency  to  periodontitis,  the 
tooth  is  generally  designated  as  dead. 

In  speaking  of  the  treatment  of  these  cases  hardly  anything 
was  said  about  the  superficial  form,  or  “gum-boil.”  Its  course 
is  usually  short,  and  rupture  into  the  mouth  occurs  either  spon¬ 
taneously  or  from  slight  pressure.  The  patient  consults  his 
dentist  about  these  matters;  they  are  of  little  or  no  interest  to 
the  physician.  It  is  “  the  dangerous  and  insidious  cases”  in 
which  there  is  “  great  danger  .  .  .  from  septic  symptoms  .  .  . 
due  to  the  absorption  of  pus”  (as  the  writer  remarks)  that 
concern  the  physician. 

The  writer’s  desire  to  save  the  tooth  is  a  laudable  one,  and 
the  method  of  treatment  he  prescribes  should  have  been  men¬ 
tioned  in  my  article  when  speaking  of  abortive  measures. 
That  more  particularly  concerns  the  dentist,  however. 

If  the  cases  could  be  seen  in  time,  I  have  no  doubt  many 
teeth  might  be  saved  ;  but  there  lies  the  difficulty.  Frequently 
these  patients  consult  no  one  until  suppuration  has  taken  place, 
considerable  of  the  alveolar  process  has  been  absorbed,  and  the 
surrounding  tissues  are  infiltrated. 

In  such  a  case  I  doubt  if  any  injections  of  hydrogen  perox¬ 
ide  or  bichloride  of  mercury  are  alone  enough  to  stop  the  pro¬ 
cess.  Moreover,  many  of  these  abscesses  are  due  to  the  stump 
of  a  root  wholly  or  in  part  covered  up  by  the  gum. 

I  infer  from  Dr.  Rhein’s  letter  that,  even  after  the  most 
careful  treatment,  the  trouble  may  recur,  and  I  believe  this  is 
the  case  much  oftener  than  he  is  willing  to  admit.  I  have  seen 
several  patients  lately  in  private  practice  who  had  had  this  very 
experience,  and,  after  weeks  of  treatment,  finally  became  dis¬ 
gusted  and  had  the  teeth  drawn,  when  the  trouble  ceased  at 
once.  I  have  had  a  little  personal  experience  also  in  this  mat¬ 
ter  which  I  am  not  likely  to  forget.  Following  the  treatment 
of  a  tooth  in  a  similar  condition,  alter  the  manner  described  by 
him,  I  had  a  number  of  mild  attacks  of  alveolar  abscess  which 
were  aborted,  but  in  January  last  one  came  on  which  could  not 
be  cut  short.  In  an  almost  incredibly  short  time  the  face  be¬ 
came  frightfully  swollen  and  the  temperature  rose  to  103°  F. 

A  professional  friend  was  called,  who,  after  other  means 
had  failed,  ordered  the  tooth  extracted.  A  free  incision  was 
made  within  the  mouth,  when  quite  exten-ive  periostitis  of  the 
Jaw  was  found.  Two  weeks  and  a  half  of  careful  treatment 
were  required  before  it  was  healed  up. 

It  is  hardly  necessary  to  say,  I  wish  the  tooth  had  been 
drawn  some  time  before.  My  critic  remarks  that  he  has  never 
known  extraction  to  be  delayed  when  it  has  been  “determined 
upon.”  There  is  just  the  point ;  when  is  it  determined  upon  ? 

Desire  to  save  a  useful  organ  may  cause  delayed  extraction, 
but  not  infrequently,  I  am  afraid,  there  is  another  reason. 

There  seems  to  be  (with  many)  a  dread  of  some  impending 
danger  if  the  tooth  is  drawn  while  the  inflammatory  process  is 
at  its  height. 

In  an  article  by  Heath,  in  his  Diseases  and  Injuries  of  the  Jaws , 
Mr.  Oattlin,  F.  R.  0.  S.  (who  was  then  president  of  a  dental  asso¬ 
ciation  in  England),  is  quoted  as  follows:  “It  was  the  erring 
practice  of  some  to  wait  until  the  inflammation  had  subsided; 
but  if  the  tooth  be  retained  .  .  .  sometimes  causes  necrosis 
.  .  .  often  ending  in  abscess  .  .  .  permanently  disfigures  the 
face.” 

This  is  no  “misconception  of  facts,”  but  frequently  when 
such  a  patient  is  directed  to  a  dentist  by  his  physician,  a  mes¬ 
sage  must  be  sent  by  the  latter  saying  that  he  will  take  the 
responsibility  of  extraction.  This  is  a  fact  well  known  to  phy¬ 
sicians,  and  since  the  publication  of  the  article  in  question  I 
have  had  letters  from  several  members  of  the  profession  saying 
this  had  been  their  experience  also. 

Trouble  may  follow,  it  is  true,  in  rare  instances,  as  after  any 


Dec.  27,  1890.] 


PROCEEDINGS  OB1  SOCIETIES. 


721 


other  surgical  procedure,  even  the  most  trivial.  The  remark 
of  the  doctor  about  extraction  being  only  useful  in  dispensary 
practice  would  seem  to  imply  that  these  teeth  are  only  retained 
in  the  wealthy,  who  can  afford  to  pay  for  weeks  of  treatment 
(even  if  the  tooth  has  to  come  out  in  the  end). 

The  writer's  comparison  of  false  teeth  to  artificial  eves  shows 
alack  of  appreciation  for  that  marvelous  and  beautiful  organ 
which  is  so  well  called  ‘'the  light  of  the  soul.'’  The  artificial 
eye,  no  matter  what  material  it  maybe  made  from,  never  at¬ 
tempts  to  replace  the  function  of  the  natural  organ,  but  is  only 
for  appearance,  whereas  1  know  of  several  instances  in  which 
troublesome  teeth  have  had  much  to  do  with  the  patients’ ill- 
health,  and  in  which,  after  they  were  extracted  and  replaced 
by  artificial  ones,  the  digestion  and  general  health  rapidly  im¬ 
proved.  Surely  in  these  cases  the  artificial  teeth  were  better 
than  the  natural  ones. 

in  reference  to  the  treatment  of  these  abscesses  by  extrac¬ 
tion,  T  will  quote  a  few  authors:  Holmes,  System  of  Surgery. 
says:  “In  all  cases  of  alveolar  abscess,  extraction  of  the  dis¬ 
eased  or  dead  tooth  is  the  cure.”  Tomes,  Dental  Surgery , 
says  :  “  If  inflammatory  action  has  gone  on  for  a  day  or  two,  it 
is  probable  that  suppuration  can  not  be  avoided,  ...  in  that 
case  the  tooth  should  be  removed.” 

Heath,  Diseases  and  Injuries  of  the  Jaws ,  says:  “If  there 
be  an  obvious  source  of  local  irritation,  extraction  of  the  tooth, 
or  stump  of  a  tooth,  should  be  immediately  performed.”  Bry¬ 
ant,  System  of  Surgery,  says  :  “  In  alveolar  abscess  of  the  lower 
jaw,  a  prominence  passing  out  from  any  diseased  tooth  .  . 
will  point  to  the  tooth  which  should  be  extracted.” 

Garretson,  in  bis  System  of  Oral  Surgery ,  1890,  gives  many 
cases  in  which  fistulse  due  to  alveolar  abscess  were  treated  by 
extraction,  and  rapid  recovery  followed. 

In  the  Deference  Damd-book  of  the  Medical  Sciences ,  article 
on  Diseases  and  Injuries  of  the  Jaws,  Dr.  Briggs  says:  “The 
treatment  of  alveolar  abscess  is  free  incision  and  extraction  of 
the  peccant  tooth.” 

Many  other  authors  might  be  quoted  if  time  and  space  per¬ 
mitted. 

However,  there  are  two  sides  to  every  question,  notably  so. 
in  medicine,  and  the  treatment  of  alveolar  abscess  is  no  excep¬ 
tion  to  the  rule. 

Any  number  of  works  on  dentistry  could  be  referred  to,  I 
presume,  telling  bow  these  abscesses  have  been  treated  by  in¬ 
jections  of  carbolic  acid,  etc.;  how  the  tooth  has  been  extracted, 
more  or  less  of  its  root  amputated,  the  alveolar  cavity  cleansed, 
and  the  tooth  returned  to  its  socket,  where  it  has  reunited  ;  in 
others,  how  the  roots  have  been  amputated,  and  nore  or  less  of 
the  alveolar  process  removed  with  the  tooth  in  situ,  and  many 
other  forms  of  treatment.  But,  nevertheless,  the  fact  remains 
that  the  shortest,  surest,  and  quickest  treatment  of  alveolar  ab¬ 
scess  (when. the  trouble  can  not  be  aborted)  is  early  extraction. 

J.  D.  MacPiierson,  M.  D. 


Proceebtngs  of 

SOUTHERN  SURGICAL  AND  GYNAECOLOGICAL 
ASSOCIATION. 

Thiid  Annual  Meeting ,  held  in  Atlanta ,  Georgia ,  November  11. 

12.  and  IS.  1890. 

The  President,  Dr.  George  J.  Engelmann,  of  St.  Louis, 

in  the  Chair. 

How  shall  we  treat  our  Cases  of  Pelvic  Inflamma¬ 
tion?— A  paper  on  this  subject,  by  Dr.  R.  B.  Maury,  of  Mem¬ 


phis,  Tenn.,  gave  a  comprehensive  resume  of  the  pathology  of 
chronic  pelvic  inflammation  as  it  had  been  clearly  demonstrated 
by  Bernutz,  Polk,  Coe,  and  others,  and  by  the  results  of  ab¬ 
dominal  section.  This  pathology  was  that  of  pelvic  peritonitis 
dependent  upon  tubal  disease,  not  cellulitis.  The  author  de¬ 
clared  the  term  chronic  cellulitis  a  misnomer,  a  pathological 
condition  which  existed  only  in  the  imagination  of  the  physi¬ 
cian,  a  term  which  had  been  productive  of  pernicious  results 
in  practice,  and  which  should  no  longer  be  used  in  connection 
with  non-obstetric  pelvic  inflammation. 

M  hen  the  pathology  rested  upon  such  positive  and  abundant 
evidence  the  question  might  be  asked,  Why  reopen  a  discus¬ 
sion  upon  it  now  ?  Because  it  was  evident  from  our  society 
proceedings  and  hospital  reports  that  great  confusion  existed 
in  the  medical  mind  to-day  in  regard  to  it.  Dr.  Byrne’s  case, 
discussed  in  the  New  York  Obstetrical  Society  during  the  pres¬ 
ent  year,  was  taken  as  an  illustration.  In  speaking  of  such 
cases,  the  great  tendency  to  relapses  in  chronic  pelvic  inflamma¬ 
tion  was  illustrated  by  two  cases  in  which  purulent  tubes  were 
found  five  and  seven  years  after  attacks  of  peritonitis  and  when 
it  was  supposed  the  patients  had  been  entirely  restored  to 
health.  Upon  the  subject  of  treatment,  the  writer  admitted 
that  by  non-surgical  therapeutic  measures  large  intraperitoneal 
exudations  were  often  absorbed,  and  even  some  tubal  and  ova¬ 
rian  inflammations  entirely  disappeared,  and  recovery  seemed 
complete.  But  this  was  the  exception  and  by  no  means  the 
rule.  For  the  radical  cure  ot  chronic  pelvic  inflammation 
non-surgical  treatment  failed  in  a  majority  of  the  cases.  A 
great  many  women  suffering  to  a  moderate  degree  continued  to 
do  so  in  spite  of  the  best-directed  non-surgical  measures,  and 
perhaps  wisely  elected  not  to  undergo  operation.  As  a  rule, 
the  only  radical  and  permanent  relief  was  afforded  by  removal 
ot  the  diseased  appendages.  The  treatment  of  pus  collections, 
of  course,  required  abdominal  section. 

The  Motive  and  Method  of  Pelvic  Surgery.— Dr.  Joseph 
Prtce,  of  Philadelphia,  followed  with  a  paper  in  which  he 
said  that  pelvic  surgery  must  be  considered  apart  from  abdom¬ 
inal  surgery.  It  was  distinct  from  it  in  the  nature  of  the 
lesions  dealt  with,  in  the  difficulties  it  presented,  and  in  the 
complications  and  embarrassments  to  routine  technique.  No 
where  as  much  as  in  pelvic  surgery  did  the  distinction  between 
the  general  surgeon  and  the  specia’ist  in  pelvic  disease  stand 
out  clearly.  Pelvic  adhesions  in  appendicitis,  for  instance,  Mr. 
Treves  would  deal  with  by  the  knife.  If  this  was  feasible, 
why  not  put  the  knife  to  ovarian  and  tubal  abscess,  to  all  intes¬ 
tinal  fixation  by  inflammatory  processes,  and  the  like?  The 
very  suggestion  of  such  method  to  the  mind  of  the  specialist 
accustomed  to  deal  with  all  the  complexities  of  pelvic  sur¬ 
gery  was  fraught  with  evil,  and  this  mere  suggestion  only 
made  it  clear  that  general  surgeons,  in  so  far  as  they  were 
entirely  wedded  to  the  knife  in  removing  disease,  tell  short 
of  the  demonstrated  harmfulness  of  its  application  in  pelvic 
work. 

Relative  to  electricity,  the  speaker  said  that  electricians  yet 
talked  learnedly  of  the  undetermined  place  of  electricity  in  the 
treatment  of  ovarian  cysts,  but  tar-water  and  tractors  had  gone 
to  their  long  rest.  The  time  must  yet  come  when  the  allegations 
made  for  electricity  as  a  universal  panacea  must  be  exploded, 
and  its  real,  limited,  and  narrow  horizon  of  usefulness  be  well 
defined.  The  pernicious  effect  of  so-called  cures  of  reported 
complicated  cases,  adhesions,  inflammations,  and  the  like,  by 
men  without  training,  who  looked  only  at  the  amperemeter 
while  they  adjusted  a  clay  pad  or  introduced  a  galvanic  sound, 
was  not  to  be  overestimated.  He  had  repeatedly  shown,  by  ex¬ 
hibited  specimens,  the  fallacy  of  the  pretense  of  exact  diagnosis 
made  by  these  men,  and  the  arguments  were  irrefutable.  He 


722 


PROCEEDINGS  OF  SOCIETIES. 


[N.  Y.  Med.  Jour.,. 


believed  that  the  only  position  assumed  by  t lie  electricians  that 
had  the  slightest  foundation  in  fact  was  that  electricity  would 
sometimes  control  haemorrhage  and  relieve  pain.  That  it  cured 
either  was  not  proved. 

In  dealing  with  adhesions,  the  first  point  to  be  sought  after 
was  to  find  a  crease  or  crevice  into  which  some  progress  could 
be  made.  In  separating  intestinal  adhesions,  they  should  be 
broken  as  far  from  the  bowel  as  possible.  The  strings  of  ad¬ 
hesions  might  be  dealt  with  according  to  their  size;  some¬ 
times  it  was  best  to  remove  them  ;  at  others  there  was  no  neces¬ 
sity  for  this.  In  doubtful  cases  their  removal  was  the  better 
surgery.  Once  the  adherent  mass  was  removed,  the  ligature 
should  be  applied  close  to  the  cornu  uteri. 

In  the  treatment  of  extra-uterine  pregnancy  his  urgent  ad¬ 
vice  was  to  operate  without  delay  when  the  symptoms  pointed 
to  the  disease,  with  the  assurance  that  delay  would  only  compli¬ 
cate  matters  and  sacrifice  the  life  of  the  mother. 

Suprapubic  Cystotomy  in  a  Case  of  Enlarged  Prostate. 

Dr.  W.  H.  H.  Cobb,  of  Goldsboro,  N.  C  ,  read  a  paper  on  a 
case  of  this  affection.  The  patient,  a  farmer,  married,  aged 
forty-nine  years,  of  a  rheumatic  diathesis,  had  dated  his  troubles 
back  to  1881.  While  attending  to  the  duties  of  Register  of  Deeds, 
he  had  carelessly  allowed  overdistention  ot  his  bladder  to  occur, 
and  had  suffered  more  or  less  since  that  time.  In  1882  he  had 
had  an  attack  of  nephritic  colic  and  had  passed  a  small  calcu¬ 
lus,  similar  in  size  and  shape  to  a  grain  of  wheat.  On  three 
different  occasions  he  had  passed  dark,  gritty  deposits.  In  1883 
he  had  suffered  much  inconvenience  and  some  pain  in  urinating. 
In  1887  he  had  passed  a  dark,  gristly,  bloody  substance  of  about 
the  size  of  a  corn-pea,  accompanied  by  much  pain  and  bloody 
urine.  For  the  past  three  years  he  had  suffered  much  with 
cystitis  in  a  very  aggravated  form,  with  great  pain  and  difficulty 
in  defecation;  the  urine  contained  much  blood,  pus,  and  mucus. 
The  patient’s  efforts  to  relieve  his  bladder  and  bowels  had  been 
tormenting,  and  night  after  night  had  been  spent  in  walking 
over  his  premises,  with  groanings  so  severe  as  to  disturb  his 
neighbors.  The  patient  had  consulted  the  author  on  June  15th 
last,  and,  from  the  history  of  the  case,  he  had  suspected  vesical 
calculus,  but  had  failed,  upon  examination  with  the  sound,  to  de¬ 
tect  any  stone.  A  digital  examination,  however,  per  rectum  had 
disclosed  the  right  lobe  of  the  prostate  greatly  t  nlarged,  rough, 
indurated,  exceedingly  tender,  and  sensitive.  After  consulta¬ 
tion  by  letter  with  Dr.  Hunter  McGuire,  he  had  decided  upon 
suprapubic  cystotomy  as  the  only  hope  of  permanent  relief, 
which  had  been  done  after  the  method  of  Dr.  McGuire  on  June. 
23d.  At  the  expiration  of  two  months  (August  23d)  he  had 
found  the  prostate  perfectly  normal,  with  no  symptoms  of  cys¬ 
titis,  and  had  withdrawn  the  plug,  allowing  the  fistula  to  unite, 
which  it  did  in  about  ten  days.  His  patient  now  performed  the 
act  of  urination  and  defecation  without  the  slightest  trouble, 
expressed  himself  as  entirely  relieved,  and  was  at  present  fol¬ 
lowing  his  usual  vocation. 

Inflammation  in  and  about  the  Head  of  the  Colon.— Dr. 

L.  S  MoMurtry,  of  Louisville,  read  a  paper  on  this  subject. 
He  said  the  teachings  to  be  found  in  systematic  treatises  on  sur¬ 
gery  and  practical  medicine  upon  inflammation  and  its  I’esults 
in  and  about  the  caput  coli  were  not  only  worthless,  but  posi¬ 
tively  misleading.  This  was  true  not  only  as  to  pathology  and 
treatment,  but  even  as  to  the  anatomy  and  relations  of  the  cte 
cum  and  its  appendix.  It  was  well  known  that  inflammatory 
changes  in  the  vermiform  appendix  were  in  almost  every  ca-e 
the  origin  and  seat  of  the  inflammatory  diseases  about  the  caput 
coli.  Inflammation  of  the  caecum  was  very  rare,  yet  the  testi¬ 
mony  of  surgeons  and  pathologists  was  abundant  that,  in  a 
certain  proportion  of  cases,  caecitis,  with  perforation,  occurred 
without  involvement  of  the  appendix.  R<  gnier,  in  1K8<>,  bad 


operated  in  a  case  presenting  symptoms  of  intestinal  obstruc¬ 
tion  with  peritonitis,  doing  an  abdominal  section.  At  the  au¬ 
topsy,  caecitis,  with  perforation,  had  been  discovered.  In  1888 
the  speaker  had  operated  in  a  case  of  perforative  caecitis,  and 
sutured  two  perforations  in  the  caecum.  His  patient  had  recov¬ 
ered,  and  had  been  present  in  the  surgical  section  of  the  Ameri¬ 
can  Medical  Association  in  May  of  that  year. 

Faecal  impaction  had  been  mentioned  by  surgical  writers  as 
a  cause  of  inflammation  about  the  head  of  the  colon.  Pain  over 
the  caecum,  with  a  faecal  mass  perceptible  on  pressure,  often  oc¬ 
curred,  but  rarely,  if  ever,  associated  with  peritonitis.  A  few 
weeks  since,  the  reader  had  seen  a  case  in  conjunction,  with  Dr.. 
H.  II.  Grant,  of  Louisville,  in  which  a  localized  peritonitis  had 
existed  in  the  right  iliac  fossa,  with  a  well  defined,  firm  tumor. 
Abdominal  section  bad  been  done,  and,  instead  of  eephyaditis, 
they  had  found  the  disease  to  be  cancer  of  the  caput  coli.  Irri¬ 
gation  and  drainage  had  rescued  the  patient  from  the  immedi¬ 
ate  danger  begotten  by  active  peritonitis.  The  patient  was  a 
woman  of  middle  age,  and  the  ingrafted  peritonitis  had  pre¬ 
sented  the  symptoms  of  an  acute  condition.  Malignant  disease 
of  the  caecum  had  nor,  so  far  as  the  writer  was  aware,  been 
mentioned  by  writers  upon  this  subject  as  a  probable  condition 
in  the  diagnosis  of  deep  seated  inflammations  of  the  right  iliac 
fossa.  The  decision  to  operate  should  be  determined  more  by 
the  grade  of  the  inflammation  than  by  the  time  it.  had  existed. 
When  a  diagnosis  had  been  made,  and  three  days  had  elapsed 
without  subsidence  of  pulse  and  temperature,  the  operation- 
should  be  done. 

The  reader  submitted  the  following  conclusions:  1.  Inflam¬ 
mation  about  the  caput  coli  was  as  a  rule,  inflammation  of  the 
appendix.  2.  A  certain  proportion  of  cases  would  end  in  spon¬ 
taneous  recovery  by  resolution.  In  these,  recurrence  of  the 
disease  wax  common.  3  In  the  larger  proportion  the  disease 
would  endanger  life,  and  might  at  any  moment  assume  a  con¬ 
dition  practically  hopeless.  4.  Early  operative  interference  in¬ 
volved  less  dinger  than  delay,  and  should  be  resorted  to  in  a  III 
cases  in  which  a  high  grade  of  inflammation  was  persistent'.. 
5.  The  essentials  of  the  operative  technique  were  brief  an¬ 
aesthesia,  quick  and  thorough  work,  remo'al  of  the  appendix, 
irrigation,  and  drainage.  The  lateral  incision  was  preferable  to 
the  median. 

The  Causes  of  Ill  Health  in  American  Girls,  and  the  Im¬ 
portance  of  Female  Hygiene,  was  the  subject,  of  the  Presi¬ 
dent’s  address.  He  showed  that  the  health  of  the  American 
girl  was  threatened  and  impaired  by  causes  more  or  less  avoid¬ 
able,  as  they  were  due  to  our  methods  of  life,  our  methods  of 
training  and  education  ;  that  the  physique  of  this  girl,  most  fa¬ 
vorably  situated  amid  auspicious  possibilities,  was  imperfect;  her 
brain  overworked,  her  nerve  power  exhausted,  her  functions 
impaired,  and  reproduction  endangered — all  by  reason  of  the 
susceptibility  of  her  peculiar  organization,  and  the  increased 
impressibility  of  the  sensitive  system  during  the  years  of  de¬ 
velopment,  in  which  it  was  subjected  to  the  severest  strain. 
The  remedy  was  attention  to  woman’s  peculiar  organization  and 
the  cyclical  waves  of  her.  dominant  function  ;  or,  in  other 
words,  harmonious  development  and  occupation  of  nerve  and 
muscle;  diminished  brain  work  and  nerve  stimulation  with  in¬ 
creased  and  co-ordinate  physical  exercise  ;  increased  protection.’ 
and  diminished  compression  by  dress;  self-knowledge  and  indi¬ 
vidual  care  during  periods  of  heightened  susceptibility.  Changes 
were  necessary  in  custom  and  fashion,  in  meth<  ds  of  labor  and 
education.  A  harmonious  eo  education  of  mind  and  body  should 
be  approximated,  with  coincident  maintenance  of  proper  hygi¬ 
enic  conditions. 

Indications  for  Operation  in  Ectopic  Gestation.— Dr.  0. 

A.  L.  Reed,  of  Cincinnati,  rend  a  paper  with  this  title.  He 


Dec.  27,  1890.) 


PROGEEDTNOS  OF  SOCIETIES. 


723 


started  with  the  assumption  that  the  only  proper  treatment  of  moved,  provided  the  condition  of  the  patient  would  permit  of 
ectopic  gestatiou  was  by  laparotomy,  or,  more  properly,  cceli-  the  extension  of  the  operation. 

otoiny.  While  the  profession  had  become  practically  unanimous  The  Local  and  General  Treatment  of  Gangrenous 
that  this  was  the  proper  line  of  treatment,  the  indications  for  Wounds  and  Diseases.— Dr.  Bedford  Brown  of  Alexandria 


operation  had  been  less  definitely  decided  upon.  This  convic¬ 
tion  had  been  forced  upon  the  observer,  not  only  by  a  study 
of  the  literature  of  the  subject,  but  by  encountering  patients 
that  had  been  advised  against  operation  by  their  attending 
physicians,  until  haemorrhage  within  the  pelvis  had  threatened 
a  fatality,  which  was  but  too  frequently  realized.  The  most 
legitimate  excuse  for  this  dilatory  practice  was*  to  be  found  in 
the  confusion  which  had  arisen  with  regard  to  the  supposed 
uniform  causal  relationship  of  ruptured  ectopic  gestation  sacs  to 
pelvic  hematocele,  and  the  division  of  the  latter  into  “  pri¬ 
mary  ”  and  “secondary”  rupture.  These  terms  were  unfortu¬ 
nate,  and,  as  used  in  this  connection,  might  be  entirely  arbi¬ 
trary.  Primary  rupture  was  made  to  mean  rupture  beneath 
the  peritoneum,  instead  oi  first  rupture,  as  the  etymology  of  the 
word  would  imply,  while  secondary  rupture  was  made  to  mean 
rupture  within  the  peritoneum  instead  of  second  rupture; 
whereas  an  intraperitoneal  rupture  might  be,  and  frequently 
was,  a  primary  rupture  when  spoken  of  with  reference  to  the 
sequence  of  events  in  ectopic  gestation.  There  would  be  no 
serious  confusion  even  here  if  we  were  not  also  taught  to  leave 
extraperitoneal  haematoceles  alone  to  be  taken  care  of  by  ab¬ 
sorption,  and  if  we  did  not  add  that,  as  these  hasmatoceles  were 
generally  caused  by  ruptured  ectopic-gestation  sacs,  we  were  to 
relegate  these  cases  also  to  the  expectant  plan  of  treatment. 
This  conclusion  was  without  warrant,  and  was  responsible  for 
hundreds  of  deaths  annually  from  this  one  cause. 

The  treatment  of  ectopic  gestation  premised  the  diagnosis 
of  this  condition.  This  was  obviously  difficult,  and  in  the  ma¬ 
jority  of  instances  could  not  be  arrived  at  at  all,  or,  if  at  all. 
onl}r  presumptively  ;  but  in  all  these  cases  conditions  could  be 
found  in  the  pelvis  which,  if  not  conclusive  of  extra-uterine 
pregnancy,  yet  constituted  conclusive  indications  for  explora¬ 
tory  operation.  The  presumption  of  ectopic  pregnancy  could 
be  arrived  at  before  rupture  chietiy  by  a  history  of  previous 
sterility,  by  a  previous  amenorrhoea,  followed  alter  a  few  weeks 
by  irregular  haemorrhage.  by  increased  tumefaction  at  either  side 
of  or  behind  the  uterus,  and  by  the  existence  of  a  false  decidua 
within  the  uterus.  The  latter  fact  might  be  salely  determined 
by  the  judicious  use  of  the  Emmet  curette  forceps.  The  diag¬ 
nosis  after  rupture  was  essentially  the  diagnosis  of  internal 
haemorrhage.  Time  wasted  either  to  determine  the  cause  of 
that  haemorrhage  or  to  find  out  it  it  was  primary  or  secondary 
was  criminal.  The  thing  to  do  was  to  operate.  The  posiiion 
had  been  taken  that  time  should  be  allowed  for  the  patient  to 
rally  from  the  shock.  One  of  the  author's  own  patients  had 
died  simply  because  he  had  waited  twelve  hours  for  reaction — 
a  lesson  that  had  taught  him  the  fallacy  of  the  old  teaching,  and 
that  had  since  saved  lives  at  his  hands.  The  best  way  to  over 
come  shock  from  internal  haemorrhage  was  to  stimulate  the 
patient  by  giving  ether,  stop  the  drain  by  ligating  the  bleeding 
vessels,  and  rouse  the  nervous  system  by  washing  out  the  belly 
with  hot  water. 

The  author’s  conclusions  were:  1.  The  only  proper  treat¬ 
ment  of  ectopic  gestation  was  that  by  abdominal  section.  2. 
The  operation  should  be  done  in  cases  before  rupture  so  soon  as 
the  condition  could  be  presumptively  diagnosticated.  3.  The 
operation  should  be  done  in  cases  after  rupture  so  soon  as  the 
evidences  of  internal  haemorrhage  became  apparent.  4.  In  cases 
in  which  the  period  of  viability  had  already  been  reached  with¬ 
out  rupture,  pregnancy  should  be  allowed  to  advance  to  term 
before  operation,  but  only  under  the  closest  possible  vigilance. 

5.  In  all  cases  the  appendages  from  both  sides  should  be  re 


Virginia,  read  a  paper  thus  entitled.  Many  years  ago,  previous 
to  the  late  war,  Dr.  Brown  had  determined  to  institute  a  series 
of  experiments  to  ascertain  the  capability  of  local  and  general 
treatment  of  all  gangrenous  wounds  and  diseases  that  came 
under  his  care  either  for  their  prevention  or  arrest.  The  object 
was  to  find  local  agents  possessing  active  properth  s  as  stimu¬ 
lants  of  vital  action  in  the  affected  parts;  also  as  means  of  dis¬ 
infecting  and  deodorizing  gangrenous  >longhs,  of  hastening  their 
final  separation,  and  for  the  establishment  ol  a  healthy  basis  for 
granulation.  In  cases  coming  under  his  care  he  had  found  that 
the  old  deodorizers  failed  to  accomplish  these  objects.  He  had 
then  employed  a  solution,  almost  saturated,  of  sulphate  of  zinc 
and  dilute  sulphuric  acid  as  a  local  application,  which  had 
seemed  to  meet  all  the  requirements.  The  first  case  in  which 
it  had  been  applied  was  according  to  the  following  formula: 


R  Zinci  sulphatis .  |  j; 

Aquas  .  Oj  ; 

Acidi  sulph.  dil .  ^  ss.  M. 


After  the  free  application  ot  hot  water  at  110°  F.  the  solu¬ 
tion  had  been  applied  evetv  three  hours  on  bats  of  raw  cotton. 
In  the  course  of  two  days  the  sloughs  had  separated  rapidly, 
leaving  a  perfectly  clean,  healthy  basis  for  granulation.  This 
solution  evidently  possessed  active  antiseptic  properties.  It 
was  an  admirable  deodorizer,  it  was  clean,  and  cleansed  the 
parts  effectually.  In  cases  of  great  loss  of  sensation  in  the 
parts,  weak  circulation,  reduction  of  vital  action,  and  depressed 
vitality  he  knew  of  no  agents  better  calculated  to  arouse  nerv¬ 
ous  action  and  stagnant  circulation,  for,  as  soon  as  the  living 
basement  structure  was  exposed,  it  gave  rise  to  intolerable  pain. 
He  had  used  this  solution  in  all  forms  of  gangrenous  wounds 
and  diseases — some  limited,  others  extensive  and  a-sociated 
with  septicaemia — with  benefit. 

The  Treatment  of  General  Septic  Peritonitis.— Dr.  W.  L. 
Robinson,  of  Danville,  Va.,  read  a  paper  on  this  subject,  iD 
which  be  called  attention  to  those  cases  which  tended,  by  ab¬ 
sence  of  pain  and  a  seemingly  improved  condition  after  chill 
and  fever,  to  mislead  as  to  the  necessity  of  operating,  and  in¬ 
stanced  two  cases  of  recent  date,  seen  in  consultation,  in  which 
septic  peritonitis  and  secondary  abscess  had  existed  in  spite  of 
the  seemingly  favorable  condition  of  the  patient.  He  said  that 
often  there  was  an  utter  dispr->p  rtion  between  the  patho¬ 
logical  condition  and  the  amount  of  p-iin  and  tenderness— a 
condition  so  often  seen  in  puerperal  peritonitis.  He  stated  that 
traumatic  abdominal  injuries,  eephyaditis,  and  pelvic  inflam¬ 
mations  were  the  chief  causes  of  septic  peritonitis,  while,  of 
course,  any  internal  or  external  influence  which  produced  sup¬ 
puration  might  he  the  indirect  cause.  He  agreed  with  Dr.  G. 
Frank  Lydston,  ot  Chicago,  that,  in  children,  falls,  blows,  etc., 
were  the  causes  generally  of  peritonitis,  and  that,  because  they 
were  too  young  to  direct  attention  to  the  seat  of  injury,  we 
often  diagnosticated  the  disease  too  late.  The  author  took  the 
stand  that  gonorrhma  was  a  frequent  cause  of  septic  peritonitis, 
and  the  reason  why  it  did  not  always  produce  it  was  that 
it  did  not  invariably  invade  the  uterus,  and,  even  when  it  en¬ 
tered  the  tubes,  the  adhesions  to  the  ovary  rendered  it  sell- 
limiting. 

Removal  of  Stones  from  the  Female  Bladder  through 
the  Urethra,  with  Cases.— Dr.  W.  O.  Roberts,  of  Louisville, 
read  a  paper  on  this  subject,  which  was  devoted  simply  to  his 
individual  experience.  The  cases  thus  treated  were  six  in 
number;  the  ages  of  the  patients  ranged  from  fifteen  to  fifty- 
six  years.  Four  were  married,  but  two  only  had  borne  chil- 


PROCEEDINGS  OF  SOCIETIES. 


724 

dren.  The  stone9  were  phosphatio  in  four  cases,  uric  acid  in 
one,  and  an  incrusted  foreign  body  in  another.  In  one  case,  in 
a  very  hysterical  patient,  the  stone  had  for  its  nucleus  a  piece  of 
soft  wood.  In  one,  the  patient  had  had  a  vesioo- vaginal  fistula, 
which  had  been  closed  by  an  operation  some  months  prior  to 
the  occurrence  of  the  symptoms  of  stone.  In  another  the  blad¬ 
der  had  been  opened  by  a  surgeon  in  doing  an  ovariotomy  upou 
the  patient  a  year  before  the  stone  was  discovered.  In  four  of 
the  cases  the  stones  were  single,  in  one  there  were  two,  and  in 
one  nine.  In  this  case  the  patient  had  passed  at  various  times  a 
number  of  small  stones — from  two  to  seven  at  a  given  micturition. 
These  stones  had  varied  in  size  from  that  of  a  grain  of  wheat  to 
that  of  a  grain  of  coffee.  Iii  two  years  she  had  collected  one 
hundred  and  eighty-four  stones,  a  number  not  representing  all 
she  had  passed.  The  exlraction  was  done  in  every  case  under 
chloroform,  the  patient  being  profoundly  anaesthetized.  The 
urethral  dilatation  was  begun  with  forceps,  and  completed  by 
means  of  the  fingers,  the  little  finger  being  first  introduced,  the 
ring  finger  next,  and  finally  the  index  tinger.  The  fingers  were 
well  oiled.  In  Case  I  the  stone  had  been  found  to  be  almost  an 
inch  and  a  half  in  diameter.  In  Case  II  the  stone  had  been 
found  in  the  urethra,  and  had  proved  to  be  a  piece  of  soft  wood 
heavily  incrusted  with  urinary  salts.  In  Case  III  the  stone  had 
been  spherical,  and  had  had  a  diameter  of  about  half  an  inch. 
In  Case  IV  the  stone  had  been  ovoid,  its  long  diameter  being  an 
inch,  the  shorter  three  quarters  of  an  inch.  In  Case  V  there 
had  been  nme  stones,  the  smallest  measuring  circumferentially 
two  inches  and  two  inches  and  a  quarter;  weight,  eighty-four 
grains. 

Wet  Antiseptic  Dressings  in  Injuries  of  the  Hand.— Dr. 

V  illiam  Perrin  Nicolson,  of  Atlanta,  Georgia,  presented  a 
paper  with  this  title. 

After  dwelling  upon  the  importance  of  the  subject,  both 
from  the  standpoint  of  the  future  earning  capacity  of  the  pa¬ 
tient.  and  the  large  amount  of  financial  compensation  demanded 
from  corporations,  he  stated  that  tor  seven  or  eight  years  past 
lie  had  looked  after  the  surgery  of  several  railroads  and  rnanu- 
f  icturing  establishments, and  in  that  time  had  been  called  upon 
to  treat  more  than  three  hundred  hand  injuries,  representing 
all  grades  of  injury  from  slight  contusion  to  complete  destruc¬ 
tion  of  the  larger  pai  t  of  the  hand.  The  special  point  that 
was  urged  in  the  paper  was  the  doctrine  formulated  by  Ver- 
neuil— never  to  use  a  scalpel  in  a  hand  injury.  The  old  teach¬ 
ing  that  when  a  finger  was  crushed  you  should  go  far  enough 
behind  the  injury  to  secure  a  sound  flap  and  amputate,  was  per¬ 
nicious  in  the  extreme,  and  had  cost  thousands  of  fingers  that 
could  have  been  restored  to  usefulness.  Only  such  parts  as 
svere  actually  destroyed  and  pulpified  should  be  removed,  and 
all  the  tissues  to  come  away  could  be  amputated  with  the  scis¬ 
sors.  Projecting  pieces  of  bone  could  be  removed  with  pliers 
until  reduced  to  the  level  of  the  fleshy  parts.  In  compound 
fractures  the  parts  should  be  coaptated  as  well  as  possib’e  and 
the  line  of  separation  be  determined  by  Nature  and  under  strict 
antiseptic  dressings.  Such  a  slough  was  harmless  Another 
point  to  which  attention  was  forcibly  called  was  the  utilization 
of  blood-clot  in  filling  up  ragged  injuries,  and  by  its  substitu¬ 
tion  the  restoration  of  lost  parts.  When  a  finger  was  crushed 
off,  the  end  should  be  trimmed  with  scissors  and  the  clot  util¬ 
ized  in  building  up  a  tissue  over  the  bone.  In  reference  to 
dre-sings  the  author  said  that  he  had  tried  almost  all  varieties, 
and  had  finally  obtained  the  most  satisfactory  results  from 
keeping  the  parts  constantly  bathed  in  a  non-poisonous  anti¬ 
septic  solution. 

In  dealing  with  these  wounds,  they  were  first  cleansed  as 
well  as  possible  and  then  bathed  in  a  sublimate  solution.  Over 
all  wounds  a  piece  of  aseptic  rubber  tissue  or  oiled  silk  was 


[N.  Y.  Med.  Jour., 

placed,  then  iodoform  and  sublimate  gauze,  and  finally  over  all 
a  covering  of  rubber  tissue,  into  which,  at  some  convenient 
point,  a  small  opening  was  made.  The  patient  was  then  given 
a  bottle  of  antiseptic  solution,  to  be  carried  in  his  pocket  if 
moving  about,  and  instructed  to  pour,  at  frequent  intervals, 
enough  into  this  opening  to  saturate  the  dressings.  lie  used 
almost  exclusively  listerine,  combined  with  a  small  amount  of 
carbolic  acid,  in  the  proportion  of  half  an  ounce  of  the  former 
and  hall  a  drachm  of  the  latter,  in  a  six-ounce  mixture.  If 
there  was  much  pain,  a  small  amount  of  aqueous  extract  of 
opium  was  added.  These  dressings  were  not  disturbed  until 
the  third  day,  when  they  were  removed  under  strict  antisepsis 
to  preserve  the  integrity  of  the  blood-clot.  The  wet  dressings 
were  replaced  at  the  end  of  about  a  week  by  the  ordinary  anti¬ 
septic  dre-sings,  kept  moist  by  an  external  covering  of  rubber 
tissue.  Should  sloughing  occur,  it  was  kept  wet  for  a  longer 
time  with  the  antiseptic.  Under  this  treatment  pain  was  re¬ 
duced  to  the  minimum.  Suppuration  never  occurred,  and  the 
separation  of  sloughs  was  facilitated  by  the  warm  moisture. 

Uterine  Moles  and  their  Treatment.— Dr.  J.  T.  Wilson, 
of  Sherman,  Texas,  read  a  paper  on  this  subject. 

In  the  few  cases  that  had  come  under  his  observation  they 
had  been  more  troublesome  and  elicited  more  anxiety  than 
most  writers  indicated  they  should,  and  the  hiemorrhages  in 
some  of  the  cases  had  been  alarming;  then,  too,  there  were 
some  points  noticed  in  his  cases  which  he  had  failed  to  find  de¬ 
scribed  in  test- books.  All  authorities  seemed  agreed  upon  the 
{etiological  and  pathological  view  generally  taken  of  a  mole — that 
it  was  a  blighted  or  altered  conception;  the  ovum  having  per¬ 
ished,  its  covering,  or  the  placenta,  if  formed  when  this  change 
took  place,  became  attached  to  and  continued  to  receive  nour¬ 
ishment  through  the  uterine  walls  and  remained  or  became  an 
organized  product  until  it  was  thrown  off;  and  this  condition 
was  attributed  by  some  to  the  vitality  retained  in  the  villi  of 
the  chorion. 

His  experience  had  taught  him  to  believe  that  if  these  cases 
did  not  receive  treatment  at  a  proper  time  there  were  two 
grave  dangers  to  be  apprehended — viz.,  haemorrhage,  which,  if 
not  an  immediate  cause  of  death,  was  capable  of  leading  indi¬ 
rectly  to  that  end,  and  septic  poisoning.  In  the  treatment,  if 
the  cervix  wras  sufficiently  dilated  and  haemorrhage  troublesome, 
the  mass  should  be  promptly  removed.  If  this  could  not  be  done, 
a  hot  antiseptic  vaginal  douche  should  be  given,  followed  by  a 
careful  and  efficient  tampon,  with  the  internal  administration 
of  ergot  and  anodynes  if  required,  directing  quiet,  rest,  and  a 
simple  diet.  In  from  twelve  to  sixteen  hours  the  tampon 
should  be  removed  and  the  foreign  body  extracted  as  complete¬ 
ly  as  practicable;  this  would  require  a  good,  stout  forceps. 
He  had  used  the  ordinary  dressing  forceps  and  placental  for¬ 
ceps  for  the  purpose.  An  excellent  instrument  in  some  cases 
was  Emmet’s  curette  forceps.  The  surface  should  be  well  cu¬ 
retted  with  a  wire  curette,  the  uterus  thoroughly  washed  out 
with  a  hot  solution  of  bichloride  of  mercury,  and  Squibb's  crude 
carbolic  acid  or  Churchill’s  tincture  of  iodine  well  applied  to 
the  surface.  If  much  bleeding  ensued — and  this  was  not  usual 
— the  application  of  persulphate  or  perchloride  of  iron  gave 
good  results.  The  patient  was  put  to  bed  and  kept  there  as 
long  as  the  indications  in  each  special  case  might  require;  she 
was  put  upon  a  tonic  treatment  and  the  use  of  hot  vaginal  anti¬ 
septic  washes.  In  from  three  to  five  days  the  uterus  might  need 
curetting  again  and  another  intra-uterine  douche;  then  the  ap¬ 
plication  of  iodine  about  twice  a  week,  alternated  occasionally 
perhaps  with  carbolic  acid  as  long  as  might  Seem  necessary,  and 
the  cure,  if  possible,  completed  of  any  uterine  disease  that 
might  exist.  The  patient’s  general  health  was  carefully  looked 
after  and  her  mind  tranquillized. 


Dec.  27,  1890. J 


PROCEEDINGS  OF  SOCIETIES. 


A  Review  of  the  Treatment  of  Varicocele.— Dr.  G.  Frank 
Lydston,  of  Chicago,  read  a  very  elaborate  paper  on  this  sub¬ 
ject.  lie  said,  in  discussing  the  various  merits  of  operative  pro¬ 
cedure,  it  was  unnecessary  to  take  them  up  in  detail.  The  rai¬ 
son  d'etre  of  many  specially  devised  and  named  operations  was 
apparent  only  to  the  operator.  For  practical  purposes  the  va¬ 
rious  methods  might  be  divided  into  (1)  acupressure,  (2)  subcu¬ 
taneous  deligation,  (3)  open  deligation,  (4)  deligation  with  re¬ 
section  of  veins,  (5)  deligation  with  resection  of  scrotum,  (6) 
resection  of  the  scrotum.  The  employment  of  acupressure,  to 
the  author’s  mind,  was  an  evidence  of  a  lack  of  faith  in  modern 
antisepsis.  Gradual  obliteration  of  veins  bad  all  the  dangers  of 
immediate  deligation  in  a  marked  degree  and  had  none  of  its 
advantages,  I'he  term  acupressure  covered  practically  all  meth¬ 
ods  of  gradual  obliteration  of  the  veins,  of  which  Davat’s  opera¬ 
tion  was  an  illustration.  Subcutaneous  deligation  was  not  es¬ 
sentially  dangerous  in  skillful  hands.  Simple  as  the  operation 
appeared,  however,  accidents  had  occurred.  The  operation  was 
done  in  the  dark  and  more  tissue  was  included  in  the  ligature 
than  was  necessary.  Strangulation  of  tissue  was  not  conducive 
to  safety.  Scrotal  hmmatocele,  phlebitis,  septic  infection,  throm¬ 
bosis,  and  embolism  w7ere  possible.  The  vas  deferens  had  been 
included  in  the  ligature.  He  did  not  condemn  the  subcutaneous 
operation  in  suitable  cases  and  in  skillful  hands,  but  he  believed 
there  were  better  and  safer  methods  on  the  average.  There 
was  little  choice  between  deligation  without  disturbance  of  the 
veins  and  deligation  with  resection  of  the  veins,  excepting  the 
remotely  greater  danger  of  sepsis  in  the  latter.  Gould's  method 
of  division  by  cautery  he  believed  to  be  the  most  dangerous  op¬ 
eration  yet  devised.  The  dangers  of  the  open  method  wrere  in 
a  less  degree  those  of  the  subcutaneous  deligation.  If  open  deli¬ 
gation  -was  determined  upon,  the  operation  should  be  done  as 
high  as  pos.-ible  in  the  straight  portion  of  the  veins  and  a  single 
ligature  applied  to  the  vein.  Deligation  with  resection  of  the 
scrotum  he  considered  to  be  the  ideal  operation,  in  the  majority 
of  cases  requiring  surgical  interference. 

Silicate  of  Sodium ;  some  New  Methods  of  its  Use  in  Sur¬ 
gery. — Dr.  George  A.  Baxter,  of  Chattanooga,  read  a  paper 
in  which  he  said  the  jacket  of  baked  silicate  of  sodium  which  he 
would  present  to  the  association  possessed  all  the  qualities  to  be 
found  in  the  plaster  jacket,  firmness  and  support,  and  weighed 
actually  one  pound  and  six  ounces.  It  was  neater  in  appearance 
and  finish,  and  could  be  perforated  like  leather  for  ventilation 
which  plaster  could  not.  It  was  even  lighter  than  leather  with¬ 
out  its  costly  process  of  construction,  and  had  the  same  advan¬ 
tage  over  the  woven  wire  jacket,  with  the  additional  advantage 
over  both  these  latter  and  all  others  of  this  class,  that  it  could 
be  constructed  by  any  surgeon  at  any  time  or  in  any  place.  The 
patient  was  suspended  and  a  plaster  jacket  roughly  placed 
around  her  and  cut  as  soon  as  it  had  hardened  enough  to  retain 
its  shape,  thereby  lessening  materially  the  time  ot  suspension, 
the  most  trying  ordeal  with  this  or  the  plaster,  and  not  without 
its  dangers  when  long  continued  ;  the  cut  edges  were  bound 
together  where  it  had  been  cut  down  directly  in  front  with 
cords,  and  then  a  core  of  paper  placed  in  the  center.  This  pa¬ 
per  core  was  used  for  two  reasons  :  (1)  to  lighten  the  cast  and 
take  as  little  plaster  as  possible,  and  (2)  to  dry  it  the  more 
readily  by  heating  the  inside.  Thisdoue,  the  plaster  was  poured 
around  the  core  and  inside  the  cast,  which  gave  him  a  mold  of 
the  body  in  extension  and  counter-extension,  exact  in  every  re¬ 
spect.  Around  this  was  made  the  silicate  jacket  after  the 
manner  of  the  plaster  roller  bandage,  weaving  half-inch  metal 
strips  in  the  meshes  of  the  bandage  at  a  distance  of  four  inches 
apart  around  the  whole  cast,  an  inside  lining  of  a  knit  shirt  hav¬ 
ing  been  first  placed  over  the  cast.  The  whole  was  then  placed 
over  a  coal-oil  stove  and  allowed  to  dry  out,  which  it  did  in 


m 

from  half  an  hour  to  two  hours  or  less,  especially  if  the  ca~t 
had  been  previously  dried.  This  process  of  heating  not  only 
dried  the  silicate,  but  baked  it  as  well,  rendered  it  impervious 
to  the  action  of  water  or  the  perspiration,  and  gave  it  sufficient 
strength  to  allow  of  its  being  perforated  for  ventilation.  It  was 
then  cut  from  the  mold  with  a  straight  incision  down  the  cen¬ 
ter,  two  pieces  of  leather,  to  which  button-hooks  or  eyelet* 
had  been  previously  attached,  were  sewed  up  and  down  the  front 
on  each  side,  then  the  whole  could  be  laced  up  solid  or  loosened 
and  taken  off  at  will.  The  necess  ty  of  taking  off  a  jacket  or 
leaving  it  on  during  the  whole  course  of  treatment  would,  of 
course,  depend  upon  the  character  of  the  disease  or  the  injury 
under  treatment. 

The  Surgery  of  the  Gall  Bladder.  — Dr.  Edwin  Ricketts, 
of  Cincinnati,  contributed  a  paper  on  this  subject,  in  which  he 
said  that  to  Langenbueh  was  due  the  credit  of  totally  extirpating- 
the  gall  bladder,  and  to  J.  Marion  Sims  we  owed  a  debt  of  grati¬ 
tude  for  establishing  the  operation  of  cholecystotomy.  He  re¬ 
ported  seven  cases  of  gall  stones. 

Rectal  Medication.— Dr.  W.  Hampton  Caldwell,  of  Lex¬ 
ington,  Ky.,  read  a  paper  in  which  he  said  that  several  years 
ago  he  had  been  convinced  of  the  utility  and  safety  of  rectal  ad¬ 
ministration  of  medicine,  and  that  he  had  ever  since  regarded  it 
as  a  most  important  plan  of  treatment.  Since  we  accepted  the 
theory  of  the  local  origin  or  manifestation  of  the  majority  of 
diseases,  this  idea  of  rectal  administration  of  medicines  was 
more  readily  accepted  as  scientific  in  its  applications  than  at 
any  time  heretofore.  The  rectal  supposit  >ry,  consisting  of  cacao 
butter,  incorporated  with  the  various  therapeutical  agents,, 
afforded  the  most  efficient  and  pleasant  mode  of  administration 
in  our  possession.  Rectal  suppositories  satisfied  all  require¬ 
ments  as  a  local  or  constitutional  remedy.  They  were  Deat, 
convenient,  and  in  almost  every  instance  preferred  by  the  pa¬ 
tient  to  the  administration  of  the  same  drug  by  the  mouth. 

Vaginal  Cystotomy  in  a  Child  of  Six  Years.— Dr.  Thad. 
A.  Reamy,  of  Cincinnati,  reported  a  case  in  which  he  had 
removed  a  stone  weighing  365  grains,  by  vaginal  cystotomy, 
from  the  bladder  of  a  child  six  years  of  age,  with  injury  of  the 
ureter.  Operations  done  for  closing  the  bladder  had  been  diffi¬ 
cult,  but  ultimately  successful,  lie  exhibited  the  stone,  and 
made  some  comments  on  the  case. 

The  Surgical  Treatment  of  Empyema.— Dr.  James  A. 
Goggana,  of  Alexandria  City,  Alabama,  read  a  paper  on  this 
subject  in  which  he  said  that  during  the  last  eighteen  months 
he  had  treated  six  cases  of  empyema  which  had  developed  in 
the  wake  of  pneumonia,  all  of  which  had  gone  on  to  perfect  re¬ 
covery.  The  patients  had  varied  in  age  from  three  to  thiriy- 
five  years.  Surgical  treatment  was  the  one  which  had  been  the 
most  successfully  employed.  Spontaneous  cures,  he  said,  were 
rare — so  rare  that  surgical  interference  was  the  rule.  There 
were  many  methods  of  operating  for  the  removal  of  pus  from 
the  pleural  cavity,  but  they  might  be  classified  under  two  gen¬ 
eral  headings:  1.  The  closed  method,  which  consisted  in  re¬ 
moving  the  pus  by  simple  puncture  with  some  kind  of  trocar  or 
modern  aspirator,  and  allowing  the  puncture  to  heal  at  once. 
2.  The  open  method,  which  consisted  in  making  an  incision 
more  or  less  free  with  the  introduction  of  some  kind  ofdrainage- 
tubes  to  maintain  the  perfect  evacuation  of  the  fluid,  and  admit 
of  medicated  washings,  and  to  promote  free  ingress  and  egress. 
of  air  that  had  been  passed  through  an  antiseptic  dressing,  l’he 
surgical  treatment,  then,  being  an  absolute  necessity,  we  could 
not  overestimate  the  importance  of  making  the  diagnosis  cer¬ 
tain  by  resorting  to  exploratory  puncture  with  a  hypodermic 
syringe.  We  could  assure  the  paHent  and  friends  that  no  evil 
results  could  come  from  this  procedure,  and  that  the  prognosis 
positively  depended  upon  this  means  of  settling  the  diagnosis. 


7  26 


REPORTS  ON  TEE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Mkd.  Jourm 


Officers  for  the  Ensuing  Year  were  elected  as  follows: 
President,  Dr.  L.  S.  MoMurtry,  of  Louisville,  Ky. ;  first  vice- 
president,  Dr.  McF.  Gaston,  of  Atlanta,  Ga. ;  second  vice- 
president,  Dr.  J.  T.  Wilson,  of  Sherman,  Tex. ;  secretary,  Dr. 
W.  E.  B.  Davis,  of  Birmingham,  Ala. ;  treasurer,  Dr.  Hardin  P 
Cochrane,  of  Birmingham,  Ala.  Place  of  meeting,  Richmond, 
Va.,  on  the  second  Tuesday  in  November,  1891. 


Reports  mt  tjj*  IJragr^ss  of  fjjletrttm*. 

ANATOMY. 

By  MATTHIAS  L.  FOSTER,  M.  D. 

The  Fissure  of  Rolando. — Professor  Cunningham  (Jour,  of  Anat, 
and  Physiol .,  October,  1890)  furnishes  an  account  of  the  fissure  of  Ro¬ 
lando  in  man  and  the  lower  animals  which  is  worthy  of  careful  study. 
Regarding  the  time  of  its  development  in  the  human  foetus  there  is 
some  variability.  The  more  usual  time  is  the  last  week  or  ten  days  of 
the  fifth  month,  but  it  is  not  uncommon  to  meet  with  hemispheres  well 
on  in  the  sixth  month  of  development  with  no  sign  of  the  fissure.  As 
a  general  rule  it  appears  to  be  developed  in  two  separate  and  distinct 
portions.  The  lower  portion  always  appears  before  the  upper  in  the 
form  of  a  shallow,  oblique  groove  which  represents  the  lower  two  thirds 
of  the  complete  fissure.  Its  lower  end  is  placed  close  to  the  coronal 
suture,  perhaps  subjacent  to  it,  while  the  upper  end  lies  farther  back 
and  reaches  a  point  midway  between  the  upper  margin  of  the  hemi¬ 
sphere  and  the  Sylvian  fossa.  The  upper  portion  of  the  fissure  makes 
its  appearance  in  the  form  of  a  deep  pit  or  depression  between  the 
upper  end  of  the  lower  portion  and  the  margin  of  the  hemisphere.  It 
is  separated  from  the  lower  portion  by  an  eminence,  over  which  a  faint 
furrow  is  soon  to  be  found  running  over  its  summit  and  partially  unit¬ 
ing  the  two  portions  ot  the  fissure.  As  development  progresses  the 
union  becomes  more  complete  and  the  intervening  eminence  is  borne 
down  into  the  bottom  of  the  fissure.  This  union  of  the  two  portions 
takes  place  rapidly,  as  a  rule,  though  in  many  cases  the  process  is  re 
tarded.  The  intervening  portion  of  the  cortex  is  not  obliterated  ;  it 
disappears  from  the  surface  but  can  be  found  even  in  adult  brains  at 
the  bottom  of  the  fissure  at  the  junction  of  its  upper  and  middle  thirds 
in  the  form  of  the  deep  annectant  gyrus.  In  some  rare  cases  the  two 
original  portions  remain  distinct  throughout  life.  In  these  the  inter 
vening  bridge  of  cortex  remains  on  the  surface. 

This  view  is  quite  different  from  the  one  usually  entertained,  which 
pictures  the  fissure  of  Rolando  as  beginning  as  a  slight  furrow  midway 
between  the  upper  border  of  the  hemisphere  and  the  margin  of  the  Syl 
vian  fossa  and  extending  gradually  and  continuously  in  an  upward  and 
downward  direction.  That  this  may  be  the  course  of  development  in 
certain  cases  the  writer  does  not  deny,  but  he  maintains  that  there  is  no 
■  direct  evidence  to  show  that  it  is  so.  In  one  rather  advanced  hemisphere 
he  found  a  clean-cut  straight  fissure  with  its  extremities  equally  distant 
from  the  superior  border  of  the  hemisphere  and  from  the  fissure  of  Syl¬ 
vius,  of  uniform  depth,  and  at  no  point  interrupted  by  an  elevation  of 
the  bottom.  This  appearance  leads  him  to  believe  that  this  fissure 
may  have  developed  in  the  manner  which  is  usually  attributed  to  it. 

From  an  analysis  of  fifty-two  hemispheres,  taken  from  children  and 
adults,  it  was  found  that  in  sixty  per  cent,  the  upper  end  of  the  fissure 
cut  the  upper  border  of  the  hemisphere  and  appeared  on  the  inner  sur¬ 
face  ;  in  twenty-one  per  cent,  it  just  reached  the  upper  border,  but  did 
not  show  upon  the  inner  surface,  and  in  nineteen  per  cent,  it  fell  short 
of  the  upper  border.  The  upper  end  of  the  fissure  does  not  overstep 
the  upper  border  of  the  hemisphere  until  the  beginning  of  the  last 
month  of  intra-uterine  development.  In  the  eighth  month  it  just 
reaches  the  margin. 

From  the  seventh  month  onward  the  growth  of  the  two  bounding 
banks  of  the  fissure  does  not  proceed  at  an  equal  pace.  There  appears 
t0  bo  a  greater  growth  energy  in  the  posterior  central  convolution,  and 


this  leads  to  a  partial  overlapping  of  the  ascending  frontal  convolution 
by  the  ascending  parietal  convolution.  This  is  more  obvious  in  the 
lower  two  thirds  of  the  fissure,  and  it  is  owing  to  this  that  in  the  adult 
the  fissure  cuts  into  the  cerebral  surface  in  an  oblique  direction  from 
before  backward. 

The  position  of  the  fissure  of  Rolando  on  the  surface  of  the  brain 
is  subject  to  very  slight  alterations,  and  in  all  probability  it  becomes 
absolutely  fixed  at  the  third  month  of  extra-uterine  life,  but  its  rela¬ 
tions  to  the  coronal  suture  are  very  different.  The  parietal  bone  and 
the  area  of  brain  immediately  subjacent  do  not  grow  at  an  equal  rate. 
In  the  early  stages  of  its  development  the  fissure  of  Rolando  lies  close 
to  the  coronal  suture,  because  the  parietal  bone  forms  at  a  later  stage  a 
relatively  greater  extent  of  the  cranial  vault.  The  maximum  amount  of 
the  district  in  front  of  the  fissure  of  Rolando  covered  by  the  parietal  bone 
is  reached  at  the  third  month  of  extra-uterine  life.  From  this  stage  on 
the  coronal  suture  in  its  upper  part  falls  back  a  little,  and  after  a  slight 
oscillation  assumes  at  the  fourth  or  fifth  year  of  childhood  a  fixed  posi¬ 
tion  with  reference  to  the  fissure  of  Rolando.  Its  lower  end  is  subject 
to  very  considerable  variations  regarding  its  relative  position  to  the 
fissure  which  are  not  easy  to  understand. 

In  contradiction  to  Huschka,  Riidinger,  and  Passet,  Professor  Cun¬ 
ningham  deduces  from  his  observations  that  the  lower  end  of  the  fis¬ 
sure  of  Rolando  holds  relatively  the  same  place  on  the  cerebral  surface 
in  the  two  sexes,  and  that  at  no  period  of  growth  does  it  exhibit  in  its 
position  what  might  be  safely  regarded  as  sexual  differences. 

The  Development  of  the  Anterior  Portion  of  the  Human  Brain  from 
the  End  of  the  First  to  the  Beginning  of  the  Third  Month. — According 
to  an  abstract  in  the  Fortschritte  der  Medicin  for  November  1,  1890, 
Wilhelm  His  has  obtained  the  following  points  from  observations  on 
the  foetal  brain : 

Like  the  spinal  cord  and  medulla  oblongata,  the  anterior  half  of  the 
brain  appears  at  first  as  a  tube  whose  lateral  walls  are  thicker  than  the 
dorsal  or  ventral.  Each  lateral  wall  is  divided  into  dorsal  and  ventral 
halves,  each  of  which  ends  anteriorly  in  front  of  the  chiasma.  During 
the  course  of  development  the  ventral  half  inclines  to  bend  inward, 
while  the  dorsal  arches  outward.  The  optic  tract,  of  which  a  portion 
exists  on  the  border  of  each  division,  behaves  in  a  similar  manner  to 
the  ascending  roots  of  the  nerves  of  sensation.  From  the  ventral  divi¬ 
sion  the  regio  subthalamica  of  the  mid-brain  originates  together  with 
the  regio  mamillaris  and  the  optic  vesicle ;  therefore  the  retina  is  in 
correspondence  with  the  anterior  horns  of  the  gray  matter  of  the  spinal 
cord  and  the  motor  ganglionic  regions  of  the  hind  and  mid  brain. 
From  the  dorsal  division  the  optic  thalamus  and  the  hemisphere,  includ¬ 
ing  the  olfactory  bulb  and  the  corpus  striatum,  originate.  After  the 
formation  of  the  optic  vesicle  the  hemispheres  develop  from  the  dorsal, 
terminal  portion  of  the  fore-brain  and  are  separated  from  each  other  by 
two  fissures,  one  on  either  side  of  a  crest  which  springs  from  the  vertex 
of  the  skull.  The  fissure  of  Sylvius  first  appears  during  the  fifth  week 
as  a  shallow  depression  which  corresponds  internally  to  a  convex  swell- 
ing,  the  corpus  striatum.  A  depression  in  the  dorsal  layer,  the  falci¬ 
form  fold,  begins  the  separation  of  the  lateral  ventricles  and  the  forma¬ 
tion  of  the  median  walls  of  the  hemispheres.  The  remainder  of  the 
undivided  ventricle  of  the  fore-brain  occupies  the  space  between  the 
corpora  striata. 

The  lateral  wall  of  the  third  ventricle  is  divided  into  dorsal  and 
ventral  halves,  which  are  best  designated  as  the  pars  thalamica  and  the 
pars  subthalamica,  by  a  fissure  which  extends  from  the  radicular  fissure 
of  the  optic  vesicle  to  the  mid-brain,  the  sulcus  of  Monro.  Longitu¬ 
dinal  eminences  grow  inward  from  both  parts.  The  roof  of  the  third 
ventricle  remains  epithelial,  and  gives  origin  to  the  pineal  gland,  the 
tuberculum  subpineale,  and  the  pars  h'abenularis.  The  floor  of  the 
third  ventricle  is  divided  into  an  anterior  and  a  posterior  portion,  the 
latter  including  the  mammillary  and  infundibular  regions.  The  gradual 
development  of  the  floor  of  the  ventricle  and  of  the  pituitary  gland  is 
accomplished  mechanically. 

«  The  olfactory  lobe,  which  is  separated  from  the  lower  portion  of  the 
hemisphere  in  the  fifth  week  by  a  fissure  which  extends  out  from  the 
fissure  of  Sylvius,  divides  into  an  anterior  (trigonum,  tractus,  bulbus) 
and  a  posterior  portion.  In  the  interspace  between  the  brain  and  the 
olfactory  plate  lie  at  first  neither  nerve  fibers  nor  ganglion  cells.  In 


Dec.  27,  1890.] 


REPORTS  ON  THE  PROGRESS  OF  MEDICINE. 


727 


the  olfactory  plate  neuroblasts  appear,  which  form  the  commencement 
of  the  olfactory  ganglion,  and  this,  later  on,  joins  the  brain  and  origi¬ 
nates  the  olfactory  nerve.  Probably  all  of  the  ganglion  cells  which 
originate  in  the  olfactory  plate  finally  become  connected  with  the  cov¬ 
ering  of  the  trigonum.  By  the  fifth  week  the  walls  of  the  brain  have 
become  here  and  there  thickened  or  thinned,  but  each  external  depres¬ 
sion  eoiresponds  to  an  internal  protrusion,  and  each  external  foi  l  to 
an  internal  sulcus.  The  increase  in  the  thickness  of  the  wall  is  mainly 
due  to  the  increase  in  the  white  substance.  Single  formations,  as  the 
corpus  striatum,  stand  out  more  prominently  from  their  surroundings, 
while  others  disappear  in  the  depth  of  the  tissue.  Structures  which 
are  originally  separated  become  secondarily  united,  as  the  corpus  stria¬ 
tum  with  the  regio  subthalamica  and  with  the  median  plate  which  origi¬ 
nates  from  the  falciform  fold. 

Abnormal  Arrangement  of  the  Veins  about  the  Popliteal  Space. 

— Davidson  describes  the  following  abnormity  (Jour,  of  Anat.  and 
Physiol .,  October,  1890):  The  popliteal  vein  occupied  its  normal  posi¬ 
tion  and  relations  in  the  space  itself,  but  at  the  opening  in  the  adductor 
magnus  it  gave  off  a  very  small  branch  which  accompanied  the  femoral 
artery,  while  the  main  trunk  of  the  vein  passed  up  the  back  of  the 
thigh,  lying  between  the  origins  of  the  adductor  magnus  and  the  short 
head  of  the  biceps.  It  reached  the  front  of  the  thigh  by  piercing  the 
adductores  magnus  and  brevis  immediately  above  the  insertion  of  the 
adductor  longus,  and  accompanied  the  femoral  artery  for  the  rest  of  the 
course.  It  was  joined  at  the  upper  part  of  Scarpa’s  triangle  by  the 
small  branch  given  off  at  the  opening  in  the  adductor  magnus. 

The  short  saphenous  vein  lay  to  the  outer  side  of  the  middle  line  in 
the  lower  part  of  the  popliteal  space  and  soon  pierced  the  fascia  to  lie 
on  the  posterior  ligament  of  Winslow.  It  had  no  connection  with  the 
popliteal  vein  at  this  point,  but  continued  vertically  upward  until  it 
reached  a  point  three  inches  above  the  condyle  of  the  femur,  where  it 
pierced  the  origin  of  the  short  head  of  the  biceps,  ran  for  a  short  dis¬ 
tance  in  the  substance  of  that  muscle,  emerged,  and  joined  the  main 
trunk  in  the  back  of  the  thigh.  The  long  saphenous  vein  was  double, 
but  occupied  its  usual  position. 

Absence  of  the  Vagina. — Garde  reports  in  the  Australasian  Medical 
Gazette  a  case  in  which  the  lower  portion  of  the  vagina  was  absent,  leav¬ 
ing  a  vesico-rectal  septum  about  three  inches  long.  The  other  genital 
organs  were  present  and  active.  Menstrual  blood  had  accumulated  in 
the  upper  part  of  the  vagina  about  the  cervix,  forming  a  tumor  about 
the  size  of  an  orange  in  the  hypogastric  region.  An  artificial  vagina 
was  made  between  the  layers  of  the  vesico-rectal  septum  on  the  lines 
laid  down  by  Dupuytren  and  Amussat,  and  menstruation  was  afterward 
without  pain.  . 

Pseudo-hermaphroditism.  —  Winter  describes  the  following  case 
(Zcitsch.  f.  Geburts.  u.  Gyn.  ;  Am.  Jour,  of  Obs.,  October,  1890):  The 
patient,  twenty-three  years  old,  was  of  moderate  size,  rather  large¬ 
boned,  with  large  hands  and  feet,  muscles  moderately  developed,  sub¬ 
cutaneous  adipose  slight.  The  face  was  somewhat  coarse-featured  but 
distinctly  feminine,  and  had  no  trace  of  beard.  She  was  feminine  in 
manner  and  had  a  broad,  slightly  projecting  larynx,  and  well-developed 
breasts  with  retracted  nipples.  The  pelvis  w  as  broad,  the  hips  were  well 
arched,  and  the  symphysis  pubis  was  more  pointed  than  in  the  female. 
The  abdomen  was  flat  and  not  hairy.  The  external  genitals  resembled 
at  first  glance  a  perfect  scrotum,  with  a  small  cleft  opening  below.  The 
skin  of  the  genitals  was  pigmented  and  corrugated,  and  the  corruga. 
tions  could  be  intensified  by  mechanical  irritation.  Testicles  as  large 
as  pigeon’s  eggs  were  in  the  two  halves  of  the  scrotum  ;  they  moved 
upward  on  contraction  of  the  abdominal  muscles,  but  a  cremasteric  re¬ 
flex  was  waniing;  they  could  be  pushed  up  to  the  inguinal  openings 
but  not  through  them  ;  the  left  testicle  was  the  more  prominent  and 
hung  the  lower.  Both  halves  of  the  scrotum  were  connected  by  a  dis¬ 
tinctly  feminine  frenulum.  At  the  posterior  surface  the  epididymis 
could  be  felt  closely  applied,  the  enlarged  part  lying  at  the  lower  pole 
of  the  testicle,  and  continued  above  into  the  vas  deferens,  which  could 
be  followed  to  the  inguinal  ring  with  the  other  constituents  of  the  cord. 
On  holding  the  scrotal  valves  apart,  it  could  be  seen  that  the  internal 
surface  of  the  latter  contained  cutis,  only  the  parts  in  the  median  line 
having  a  mucous-membrane  character.  The  only  trace  of  a  penis  was 
a  moderately  developed,  imperforate  clitoris,  hardly  projecting  beyond 


the  level  of  the  surroundings;  the  two  superior  roots  were  folds  of 
mucous  membrane,  the  lower  ones  being  more  prominent  from  small 
caruncles.  In  the  middle  of  this  rhomb-shaped  figure  was  a  small  open¬ 
ing,  and  a  small  sound  introduced  into  this  glided  upward  half  a  centi¬ 
metre  to  the  clitoris.  More  posteriorly  the  lateral  borders  of  the  un¬ 
closed  part  of  the  urethra  came  together  as  a  small  projection  which 
was  imperforate.  Below  this  the  folds  again  separated  and  surrounded 
the  sinus  urogenitalis,  which  was  so  wide  that  a  finger  could  enter;  if 
the  side-wall  of  the  latter  was  drawn  upon,  the  opening  into  the  closed 
urethra  could  be  seen ;  the  mucous  membrane  of  this  part  of  the  sinus 
was  smooth,  that  corresponding  to  the  vagina  more  folded.  The  closed 
urethra  was  7  ctm.  long  (the  cleft  portion  remaining  2-5  etm.),  and 
wound  around  the  symphysis  with  the  usual  curve.  In  the  closed 
urethra  two  symmetrical  openings  could  be  seen  several  millimetres 
from  the  median  line  on  the  posterior  wall,  which  could  be  penetrated 
by  a  sound  about  1  ctm.  backward  and  outward ;  these  he  considered 
to  be  the  ejaculatory  ducts.  The  surroundings  of  the  sinus  urogeni¬ 
talis  looked  almost  like  a  hymen  at  the  posterior  periphery.  Under 
anaesthesia  the  vas  deferens  of  either  side  could  be  distinctly  traced 
from  the  inguinal  ring ;  both  ureters  could  be  felt  through  the  rectum  . 
there  was  no  trace  of  a  prostate  and  no  organ  resembling  the  uterus. 

A  Sternopagous  Monster.— Frazer  (Am.  Jour,  of  Obs.,  August,  1890) 
reports  the  birth  of  a  monster  consisting  of  two  male  children  united 
from  the  upper  part  of  the  sternum  to  the  umbilicus.  There  were  two 
heads,  four  perfectly  developed  arms  and  hands,  four  legs  and  feet,  one 
thoracic  cavity,  two  vertebral  columns,  and  two  sterno-costal  walls,  each 
wall  formed  by  half  the  sternum  and  ribs  of  one  foetus  and  half  of  the 
other. 

The  Mucous  Membrane  of  the  Uterus.— Boldt  (Annals  of  Gyn.  and 
Peed.,  November,  1890)  found,  while  studying  the  uterine  mucous  mem¬ 
brane  during  menstruation,  that  all  the  utricular  glands  were  surrounded 
with  rod  and  spindle  forms,  which  could  be  traced  from  the  base  of 
the  glands  up  to  the  surface.  These  forms  were  evidently  rod  and 
spindle  shaped  nuclei  of  smooth  muscular  fibers,  the  protoplasm  of 
which  was  obscured  by  the  treatment  with  Canada  balsam.  It  ap¬ 
peared  from  this  that,  at  the  boundary  between  muscle  and  mucous 
membrane,  the  former  sends  out  processes  into  the  latter,  so  that  the 
tubes  forming  the  glands  seemed  to  be  surrounded  by  wide  muscle  pro¬ 
cesses,  between  which  only  moderately  small  portions  of  adenoid  or 
lymphatic  tissue  remained  visible.  Between  contiguous  glands,  rela¬ 
tively  to  their  terminations  in  their  cul-de-sacs ,  only  muscular  tissue  and 
no  lymphatic  tissue  could  be  discovered.  The  nearer  the  surface,  the 
thinner  were  the  glands  accompanying  the  muscular  processes. 

In  the  cervix  uteri  of  a  virgin  the  mucous  membrane  is  richly  pro¬ 
vided  with  adenoid  or  lymphatic  tissue,  and  traversed  by  numerous 
small  muscular  bundles.  The  glands  are  tubular,  irregular  in  outline, 
small  in  caliber,  and  covered  with  a  single  layer  of  columnar  epithe¬ 
lium.  Between  the  epithelium  and  the  contiguous  tissue  no  structure¬ 
less  membrane  can  be  seen,  but  the  boundary  layer  shows  smooth  mus¬ 
cular  fibers  in  layers  of  varying  width  and  sometimes  wanting.  In  the 
latter  case  the  boundary  zone  is  formed  of  lymphatic  tissue.  The 
spindle  formation  of  the  individual  muscle  fiber  can  be  demonstrated, 
but  the  rod  formation  of  the  nuclei  may  not  be  apparent.  Sometimes 
in  the  muscular  layer  there  are  formations  which  resemble  lymph  cor¬ 
puscles,  which  are  surrounded  by  branching  processes. 

In  a  multipara  the  cervical  mucous  membrane  has  a  basis  of  fibril¬ 
lary  connective  tissue,  interspersed  with  a  small  quantity  of  lymphatic 
tissue.  Many  of  the  connective-tissue  bundles  are  extensively  infil¬ 
trated  with  a  ground  substance  of  collagen,  which  makes  them  strongly 
refractive  of  light.  The  gland  ducts  are  wider  and  more  branching 
than  in  the  virgin.  The  boundary  layer  between  the  epithelium  and 
the  surrounding  tissue  consists  of  a  structureless  membrane  and  a  deli¬ 
cate  fibrillary  connective  tissue,  whose  irregular  elevations  are  covered 
with  columnar  epithelium.  Between  the  basal  and  the  boundary  layers 
there  is  a  layer  of  smooth  muscular  fibers.  Each  gland  has  an  accom¬ 
panying  layer,  sometimes  wanting,  of  muscular  fiber,  composed  of  two 
or  more  muscle  spindles.  Occasionally  a  section  of  the  gland  is  found 
with  no  muscle  layer  in  its  surroundings.  The  muscle  layer  which  ac¬ 
companies  the  glands  is  not  continuous,  but  is  pierced  in  many  places, 
and  surrounds  the  glands  in  a  kind  of  woven  formation. 


728 


REPORTS  OR  THE  PROGRESS  OF  MEDICINE. 


[N.  Y.  Med.  Jour. 


The  mucous  membrane  from  the  fundus  of  a  virgin  uterus  is  com¬ 
posed  of  moderately  wide  muscle  bundles  within  the  adenoid  or  lym- 
phatic  tissue,  which  are  often  combined  with  muscular  processes  which 
appear  to  be  woven  around  the  tube-like  glands.  These  webs  are  never 
very  wide,  and  are  composed  of  only  two  or  three  muscle  spindles. 
Muscle  fibers  may  be  absent,  and  then  the  boundary  zone  is  made 
up  of  adenoid  tissue,  while  a  structureless  membrane  is  rarely  de¬ 
finable. 

The  utricular  glands  from  the  corpus  uteri  of  a  multipara  show  the 
attendant  web  of  muscular  tissue  much  more  clearly  defined  than  the 
same  structure  in  a  virgin  uterus. 

As  the  result  of  his  studies,  Boldt  concludes  that  not  only  is  the 
adenoid  or  lymphatic  tissue  interwoven  with  muscular  tissue,  but  the 
utricular  glands  of  the  cervix  and  of  the  body  of  the  uterus  are  as¬ 
sociated  with  a  layer  of  smooth  muscular  fibers  arranged  in  a  web¬ 
like  manner.  These  muscular  processes  have  a  relation  to  the  muscle 
bundles,  the  uterine  wall,  as  well  as  to  those  which  are  associated  with 
the  lymphatic  tissue  of  the  mucosa.  These  gland  muscles  are  devel¬ 
oped  most  at  the  border  zone,  between  mucous  membrane  and  muscu- 
laris,  and  become  less  pronounced  near  the  surface  of  the  mucous 
membrane,  but  accompany  the  glands  as  far  as  their  openings  into  the 
uterine  cavity. 

The  Utero-placental  Blood-vessels. — Bumm  {Arch.  f.  Gyn. ;  Fort- 
schritte  der  Medicin,  Oct.  1 ,  1890)  describes  the  utero-placental  vessels  as 
follows  :  The  veins  are  the  more  easily  seen.  They  lie  mainly  upon  the 
cotyledons,  seldom  on  their  borders,  and  never  in  their  septa.  In  the 
superficial  layers  of  the  serotina  they  appear  as  tortuous,  thin-walled 
sinuses,  0'5  to  1  mm.  in  diameter  in  the  fresh  state,  and  always  are  filled 
with  blood.  The  upper  part  of  their  walls  has  sometimes  remained  at¬ 
tached,  and  then  they  resembled  canals  on  the  serotinal  covering  of  the 
placenta.  Injection  of  colored  gelatin  makes  them  more  distinct.  The 
nuclei  of  the  endothelial  cells  which  form  the  inner  layer  are  rather  dis¬ 
tant  from  one  another.  The  endothelial  layer  ends  at  the  opening  of 
the  vein  into  the  placental  spaces.  External  to  this  layer  is  a  layer  of 
filiform  connective  tissue  with  spindle  cells.  After  several  tuins  it 
turns  crosswise  against  the  final  layer  of  the  serotina  to  open  into  the 
placental  spaces.  The  tips  of  villi  are  always  found  at  the  borders  of 
the  venous  openings,  and  the  blood  in  the  spaces  is  continually  con¬ 
nected  with  the  veins  by  means  of  the  villous  tips. 

The  arteries  usually  lie  in  the  septa  between  the  cotyledons,  less 
often  with  the  veins.  They  are  more  convoluted  and  tortuous  than  the 
veins  and  usually  do  not  divide.  They  are  lined  by  endothelium  resem¬ 
bling  that  of  the  veins,  outside  of  which  is  a  layer  of  fibrous  connective 
tissue  with  round  and  sometimes  rod-shaped  nuclei,  thicker  and  more 
compact  than  in  the  veins.  Outside  of  this  is  the  large-celled  decidual 
tissue.  The  arteries  penetrate  the  decidua  and  after  a  very  tortuous 
course  open  into  the  placental  spaces  either  at  right  angles  or  parallel 
to  the  decidual  surface.  The  mouth  of  the  artery  is  sometimes  nar¬ 
rowed  and  causes  a  spur-like  projection.  There  are  no  villous  tips  to 
be  found  here  as  at  the  mouths  of  the  veins. 

The  nutrient  vessels  are  much  finer,  are  not  convoluted,  give  off 
branches,  and  terminate  in  a  capillary  system. 

From  these  observations  Bumm  concludes  that  the  placental  spaces 
take  the  place  of  a  capillary  system,  that  each  cotyledon  forms  a  distinct 
circulatory  field  for  the  maternal  blood,  the  current  passing  from  the 
mouth  of  the  artery  at  its  border  to  the  opening  of  the  veins  at  its  sur¬ 
face.  Lower  down  near  the  chorion  is  the  only  place  where  the  cotyle¬ 
dons  cling  together.  The  circulation  is  the  most  active  in  the  upper 
part  of  the  cotyledons  and  that  nearest  the  decidua. 

Tubal  Pregnancy.  Abel  ( Ctrlbl.  f  Gyn.  ;  Am.  Jour,  of  the  Med. 
&?.,  November,  1890)  maintains  that  in  the  beginning  a  decidual  mem¬ 
brane  is  formed  from  the  endometrium,  and  that  Friedlander’s  cellular 
layer  is  not  fully  developed  in  this.  The  superficial  layer  of  the  uterine 
decidua  is  present  in  a  degenerate  form  at  the  second  month.  The  tube 
external  to  the  foetus  usually  is  not  changed.  In  the  fcetal  sac  the 
mucous  membrane  of  the  tube  forms  a  decidua  vera  which  is  best  devel¬ 
oped  at  the  extremity  of  the  ovum  until  the  serotina  has  become  com¬ 
pletely  atrophied.  Beneath  the  serotina,  epithelium  from  the  mucous 
membrane  of  the  tube  is  often  found.  The  epithelium  of  the  villi  of 
the  chorion  is  threefold— two  layers  over  the  foetal  and  one  over  the  ma¬ 


ternal  vessels.  The  spaces  between  the  villi  are  dilated  maternal  ves¬ 
sels  whose  walls  are  not  broken  through  by  the  villi  of  the  chorion. 

The  Origin  of  the  Amniotic  Fluid. — Nagel  {Arch.  f.  Gyn.;  Am. 
Jour,  of  Ohs.,  November,  1890)  suggests  that  the  Wolffian  bodies  may  be 
the  source  of  the  amniotic  fluid.  He  bases  this  suggestion  upon  the  fact 
that  during  their  entire  existence  as  independent  organs  thev  present 
the  anatomical  characteristics  of  secreting  organs  in  full  activity,  justi¬ 
fying  us  in  considering  them  as  important  elements  in  embryonal  nutri¬ 
tion.  He  discusses  their  anatomy  at  some  length  and  concludes  that  at 
the  beginning  the  permanent  kidneys  greatly  resemble  the  Wolffian 
bodies  and  are  capable  of  functionating  in  the  second  month  of  gesta¬ 
tion.  The  Wolffian  bodies  are,  he  contends,  capable  of  performing  their 
functions  at  an  earlier  stage,  and  the  amniotic  fluid  is  in  part  a  product 
of  embryonal  metabolism  even  in  the  beginning  of  pregnancy.  Begin¬ 
ning  with  the  subinvolution  of  the  Wolffian  bodies,  the  kidneys  gradu¬ 
ally  assume  the  functions  of  the  former,  and  for  a  time  the  provisional 
and  the  permanent  organs  act  in  concert,  so  that  the  renal  activity  i3 
not  suddenly  assumed  by  the  kidney.  Before  the  sphincter  vesicae  is 
so  far  developed  as  to  permit  the  existence  of  a  urinary  bladder,  the 
secreted  urine  flows  directly  into  the  amniotic  fluid. 


To  Contributors  and  Correspondents. —  The  attention  of  all  who  purpose 
favoring  us  with  communications  is  respectfully  called  to  the  follow- 
ing: 

Authors  of  articles  intended  for  publication  under  the  head  of  “ original 
contributions  "  are  respectfully  informed  that ,  in  accepting  such  arti¬ 
cles,  we  always  do  so  with  the  understanding  that  the  following  condi¬ 
tions  are  to  be  observed:  (i)  when  a  manuscript  is  sent  to  this  jour¬ 
nal,  a  similar  manuscript  or  any  abstract  thereof  must  not  be  or 
have  been  sent  to  any  other  periodical,  unless  we  are  specially  notified 
of  the  fact  at  the  time  the  article  is  sent  to  us  ;  {2)  accepted  articles 
are  subject  to  the  customary  rules  of  editorial  revision ,  and  will  be 
published  as  promptly  as  our  other  engagements  will  admit  of— we 
can  not  engage  to  publish  an  article  in  any  specified  issue ;  (d)  any 
conditions  which  an  author  wishes  complied  with  must  be  distinctly 
staled  in  a  communication  accompanying  the  manuscript,  and  no- 
new  conditions  can  be  considered  after  the  manuscript  has  been  put 
into  the  type-setters'  hands.  We  are  often  constrained  to  decline 
articles  which,  although  they  may  be  creditable  to  their  authors ,  are 
not  suitable  for  publication  in  this  journal,  either  became  they  are 
too  long,  or  are  loaded  with  tabular  matter  or  prolix  histories  of 
cases,  or  deal  with  subjects  of  little  interest  to  the  medical  proj'ession 
at  large.  We  can  not  enter  into  any  correspondence  concerning  our 
reasons  for  declining  an  article. 

All  letters,  whether  intended  for  publication  or  not ,  must  contain  the 
writer's  name  and  address,  not  necessarily  for  publication.  No  at¬ 
tention  will  be  paid  to  anonymous  communications.  Hereafter ,  cor¬ 
respondents  asking  for  information  that  we  are  capable  of  giving , 
and  that  can  properly  be  given  in  this  journal,  will  be  answered  by 
number,  a  private  communication  being  previously  sent  to  each  cor¬ 
respondent  informing  him  under  what  number  the  answer  to  his  note 
is  to  be  looked  for.  All  communications  not  intended  for  publication 
under  the  author's  name  are  treated  as  strictly  confidential.  We  can 
not  give  advice  to  laymen  as  to  particular  cases  or  recommend  indi¬ 
vidual  practitioners. 

Secretaries  of  medical  societies  will  confer  a  favor  by  keeping  us  in¬ 
formed  of  the  dates  of  their  societies'  regular  meetings.  Brief  notifi¬ 
cations  of  matters  that  are  expected  to  come  up  at  particular  meet¬ 
ings  will  be  inserted  when  they  are  received  in  time. 

Newspapers  and  other  publications  containing  matter  which  the  person 
sending  them  desires  to  bring  to  our  notice  should  be  marked.  Mem 
bers  of  the  profession  who  send  us  information  of  matters  of  interest 
to  our  readers  will  be  considered  as  doing  them  and  us  a  favor,  and y 
if  the  space  at  our  command  admits  of  it,  we  shall  take  pleasure  in 

y  inserting  the  substance  of  such  communications. 

All  communications  intended  for  the  editor  should  be  addressed  to  him 
in  care  of  the  publishers. 

All  communications  relating  to  the  business  of  the  journal  should  be  ad¬ 
dressed  to  the  publishers. 


INDEX  TO  VOLUME  LII. 


PAGE 

Abasia,  Astasia  and .  012 

Abbe,  R.  A  Case  of  Hemiplegic  Epilepsy,  prob¬ 
ably  Diabetic,  simulating  Cerebral  Abscess.  150 

Abbe,  R.  Paranephric  Cysts .  147 

Abdominal  Operations,  Lessons  taught  by  Three 

Fatal .  470 

Abduction  of  the  Foot,  The  Treatment  of  Per¬ 
sistent .  406 

Abortion,  The  Management  of  the  Placenta  in. .  529 

Abortion,  The  Treatment  of .  520,  091 

Abortionist,  The  Conviction  of  an .  4,30 

Abscess,  Alveolar ;  a  Rejoinder  to  Dr.  M.  L. 

Rhein .  720 

Abscess,  Alveolar ;  a  Reply  to  Dr.  J.  D.  Mac- 

Pherson . 635 

Abscess,  Classification  of  the  Various  Forms  of 

Appendicitis  and  Perityphlitic .  6 

Abscess  of  the  Liver .  326 

Abscess  of  the  Parotids  complicating  Typhoid 

Fever .  413 

Abscess,  Pelvic .  514 

Abscess,  The  Importance  of  Prompt  Treatment 

in  Alveolar .  567 

Abscesses  of  the  Liver,  Multiple .  219 

Abscesses  tre  ted  by  Iodoform  Injections,  Tu¬ 
berculous .  689 

Academy  of  Anthropology,  The  New  York .  548 

Academy  of  Medicine,  The  American .  519,  548 

Academy  of  Medicine,  The  New  York. : . .  382,  448, 

,  518,  519,  634,  700 

Academy  of  Medicine,  The  Turin .  690 

'  Academy  of  Medicine’s  NevvBuilding,  The  Open¬ 
ing  Reception  in  the .  675,  607 

Accommodation  in  Healthy  Eyes  and  in  Aniso- 

metropia,  Unequal .  53 

Acids,  The  Tests  for  Stomac  . .  305 

Acknowledgment,  A  Tardy .  381 

Acne  Indurata,  Aristol  in . 392 

Acromegaly,  A  Case  of .  714 

Actinomycosis,  Successful  Operation  for .  252 

Adams,  M.  M.  A  Case  of  Invagination  of  the 

Bowel . • .  145 

Address,  Changes  of. .  20,  102,  132’  186’  245, .278,  355, 
...  382,  411,  436,  494,  519,  549,  634,  664,  690 

Adenitis  in  Children,  The  Pathology  and  Treat¬ 
ment  of  Tubercular .  472 

Adenoid  Tissue  in  the  Naso-pharynx  and  Phar- 

Aynx--V .  316 

Adjuster,  A  New,  etc .  474 

Aeration  of  Rooms  by  Open  Windows,  Permanent  585 

Air-sterilizer .  210 

Albumin,  New  Tests  for . 244 

Albuminuria  and  Nephritis,  The  Pathogeny  of  307 

Albuminuria  in  Infancy .  685 

Albuminuria,  The  Proteids  in  the  Urine  in  Va¬ 
rious  Forms  of .  244 

Alcohol  and  Childhood.  . 447 

Alcohol  in  the  Treatment  of  Puerperal  Fever. . .  193 

Alexander- Adams  Operation,  A  Modified . 400 

Alexander’s  Operation . 108 

Allen,  Dr.  Jonathan  Adams .  245 

.  Alopecia  Neurotica . 642 

Amblyopia  cured  by  Section  of  the  Supra-orbital 

Nerve,  A  Case  of  Reflex . 151 

Ambulance  System,  An  Abuse  of  the . 132 

American  Girls,  The  Causes  of  Ill  Health  in  722 
Ammonium,  The  Treatment  of  Scarlatina  by 

Acetate  of .  305 

Amceba  Coli  in  Dysentery,  A  Demonstration  of 

the.......  .  410 

Amperage  in  the  Treatment  of  Fibroid  Tumors 

by  Electricity,  The  Question  of .  498 

Amygdalitis  to  the  Cerebro-spinal  Centers,  An 

Inquiry  into  the  Relationship  of .  98 

Aniygdalotorne,  A  Galvano-cautery .  234 

Amygdalotomy,  Haemorrhage  after .  234,  325 

Anaemia,  Appearance  of  Red  Marrow  in  a  Case 

of  Acute .  139 

Amenda,  Pernicious . .  415 

Anaesthesia,  A  New  Method  of  producing  Local.  456 

Ameslhesia  by  Hypnotism .  493 

Anaesthesia  in  Frogs  by  Deficiency  of  Oxygen . .  137 
Anaesthesia,  The  Primary  Syncope  of  Chloro¬ 
form .  158 

Anaesthetic,  Dobisch’s  Local .  438 

Anaesthetics  by  Midwives,  The  Use  of !!..!!!  ”  193 

Analgesic,  Methylene  Blue  as  an .  131 

Anastomosis,  A  New  Plate  for  Intestinal ....  429 

Anastomosis  for  Faecal  Fistula,  A  Case  of  Intes¬ 
tinal . 674 

Anatomical  Demonstrations,  The  Lantern  as  an 

.  Aidto^ .  16i 

Anatomy,  Reports  on .  223,  726 

Aneurysm,  Notes  on  an  Interesting  Case  of. . . . .’  427 

Aneurysm  of  the  Arch  of  the  Aorta . 413  544 

Aneurysm  of  the  Internal  Maxillary  Artery’ 

Traumatic .  ;  129 

Angina  Pectoris . .’  583 

Anisometropia,  Unequal  Accommodation  in. . . .  53 

Ankylosis  of  the  Atlas,  Epilepsy  and .  272 

Ankylosis  of  the  Jaw . ’  666 

Anodyne,  Methylene  Blue  as  an . 410 

Anomalies  of  Development  of  the  Eyes  in  an 

Epencephalic  Monster .  54 

Anteflexion  of  the  Uterus,  Remarks  upon . 388 

Anthidrotic,  Camphoric  Acid  as  an . ’  381 

Antifebrine,  Poisoning  by . 140 

Antipyrine  in  Erysipelas . ..  .186  234 

Antipyrine  in  Malarial  Fever . ’  75 

Antipyrine  in  Typhoid  Fever .  75 

Antipyrine,  The  Treatment  of  Whooping-cough 
wlth .  305 


PAGE 

Antisepsin .  47 

Antiseptic  Methods  in  Midwifery  Practice,  The 

Application  of .  497 

Antiseptic,  Note  on  the  Action  of  Pyoctanin  as 

.  ,an  •  . .  204 

Antiseptics,  The  Comparative  Value  of  the  Bin- 
iodide  and  the  Bichloride  of  Mercury  as  Sur¬ 
gical .  558 

Antrum  of  Highmore,  Suppuration  of  the .  62 

Aortic  Insufficiency,  Muller’s  Symptom  in .  381 

Aphonia  caused  by  Lead  Poisoning  contracted 

by  the  Abuse  of  Snuff .  552 

Apoplexy,  On  Ingravescent .  80 

Appendices,  Removal  of  Diseased. . . . . 246 

Appendicitis .  215,  417 

Appendicitis,  A  Contribution  to  the  Study  of. . 

.  .  .  449,  609 

Appendicitis,  Acute .  329 

Appendicitis  and  Perityphlitic  Abscess,  Classifi¬ 
cation  of  the  Various  Forms  of .  6 

Appendicitis,  Recurrent .  247,  329 

Aphthous  Disease  in  Infants,  The  Transmission 

of . 

Anstol . "165,*  332, 

Aristol  in  Acne  Indurata 


474 
640 
392 

Aristol  in  Ozaena . . 131 

Aristol  in  the  Treatment  of  Naso-pharyiigeai 

.  Syphilis .  165 

Aristol  in  the  Treatment  of  Psoriasis .  165 

Armstrong,  S.  T.  Reports  on  General  Medicine.  304 

Armstrong,  S.  T.  Reports  on  Hygiene .  585 

Army,  Changes  of  Medical  Officers  of  the  : 

Alexander,  Charles  T .  574 

Appel,  Aaron  H . . .  "  383 

Arthur,  William  H .  102  549 

Bache,  Dallas . 549 

Bally,  Joseph  C .  436 

Ball,  Robert  R .  48 

Baxter,  Jedediah  H . . . "  324 

Benham,  Robert  B . . .  75  430 

Borden,  William  C .  47’  437 

Bradley,  Alfred  E . .....’  382 

Brooke,  John . ".  437 

Brown,  Paul  R . 383 

Burton,  Henry  G. .  606 

Byrne,  Charles  C . 436 

Caldwell,  Daniel  G . 245 

Carter,  Edward  C . ’  324 

Cherbonnier,  Andrew  V .  468 

Clarke,  Joseph  T .  47  4g 

C'lendenin,  Paul  . ....  437 

Cochran,  John  J .  382,  437 

Corbusier,  William  H .  48,  102 

Corson,  Joseph  K . 324  437 

Cowdrey,  Stevens  G . ’439’  519,’  574 

Crampton,  Louis  S .  436 

Cronkhite,  Henry  M . .  ’  ’  ’  437 

Crosby,  William  D .  ^37  549  I 

Culbertson,  Howard . 47  I 

DeWitt,  Theodore  F . '  324 

Ebert,  Rudolph  G .  ” .  437 

Edie,  Guy  L . 519 

Egan,  Peter  R .  437 

Ewen,  Clarence .  245 

Ewing,  Charles  B . ..’.’.  ”383,’ 519,  634 

Finley,  James  A .  437 

Fitzhugh,  Carter  W . 75 

Fryer,  Blencowe  E . 437 

Gandy,  Charles  M .  437,  607,  691 

Gardner,  William  H .  437 

Gardiner,  John  de  B.  W . ......  75 

G  ibson,  J oseph  R . .’ ."  383 

Gibson,  Robert  J . 435  437 

Glennan,  J.  D . .' _ ’  494 

Greenleaf ,  Charles  R . 47 

Hall,  John  D . 437 

Hartsuff,  Albert . 324 

Heizmann,  Charles  L.  . 324 

Heyl,  Ashton  B .  "47  48 

Hopkins,  William  E .  245,  324  691 

Hubbard,  Van  Buren . .’  437 

Irwin,  Bernard  J.  D . .!..!!.!  437 

Ives,  Frank  J .  245  382 

Jarvis,  Nathan  S .  324  474’  519 

Johnson,  Henry . ’.....’  607 

Keefer,  Frank  R .  47  43 

Kendall,  William  P . ’245 

Kimball,  James  P .  48,  245,  383 

LaGarde,  Louis  A .  549 

Macauley,  C.  N.  Berkeley . 433 

Mason,  Charles  F .  245 

Mans,  Louis  M . 102 

McCreery,  George . .  .  .  246’  437 

McElderry,  Henry .  332’  574 

Middleton,  Joseph  V.  D .  245,  383’  574 

Moore,  John .  ’  245 

Morris,  Edward  R . 437 

Moseley,  Edward  B . ’. .  324  606 

Munn,  Curtis  E .  437 

Norris,  Basil . 574 

Owen,  W.  O. ,  Jr . 436 

Page,  Charles . 102 

Phillips,  John  L . '  102,'  436,  606 

Pilcher,  James  E . 494  691 

Price,  Curtis  E  . .’  159 

Purrill,  Henry  S . 437 

Raymond,  Thomas  M . 47  48 

Reed,  Walter . . .  245  436 

Robinson,  Samuel  Q . .’  75 

Shillock,  Paul . 437 

Smith,  AllenM . . . 47,  48!  437 

Snyder,  Henry  D .  47,  43 


PAGE 

Army,  Changes  of  Medical  Officers  of  the  : 

Spencer,  William  G .  382 

Stephenson,  William .  245 

Sternberg,  George  M .  324,  437,  574 

Strong,  Norton . 4:37 

Suter,  William  N . 47,  382 

Swift,  Eugene  L .  690 

Taylor,  Arthur  W . 437 

Taylor,  Marcus  E  .  48,  75,  691 

Tesson,  Louis  S .  436 

Vollum,  Edward  P .  324,  437 

Wakeman,  William  J .  549 

Wales,  Philip  G .  519 

Walker,  Freeman  V .  574 

Waters,  William  E .  437 

Wood,  Leonard .  324,  437 

Woodhull,  Alfred  A .  324,  437 

Woodruff,  Charles  E . .’  519 

Army,  The  Annual  Report  of  the  Surgeon-Gen¬ 
eral  of  the .  688 

Army,  The  Medical  Corps  of  the  . .  272 

Army,  The  Medical  Department  of  the .  276 

Army,  The  New  Surgeon-General  of  the. . .  272,  718 

Arnold,  The  Death  of  Professor .  158 

Arrows  of  the  African  Pygmies,  The  Poisoned  .  392 

Arsenic,  The  Hypodermic  Use  of .  496 

Arteries,  Ligature  of  the  Uterine .  109 

Arteries,  The  Ligature  of .  524 

Artery,  Anomalous  Outlet  of  the  Coronary .  242 

Artery,  Traumatic  Aneurysm  of  the  Internal 

Maxillary .  129 

Arthrotomy  for  Fractured  Patella . ! !  328 

Asch,  M.  J.  A  New  Operation  for  Deviation  of 

the  Nasal  Septum .  675,  693 

Ashmead,  A.  8.  Letter  to  the  Editor .  102 

Asphyxia  and  Poisoning,  Nitroglycerin  in  Gas...  48 
Association  for  the  Cure  of  Inebriates,  The 

American  . 548 

Association  of  Alabama,  Georgia,  and  Tennes¬ 
see,  The  Tri-State  Medical .  382 

Association  of  New  York,  The  Ladies’  Health 

Protective .  49 

Association  of  Obstetricians  and  Gymecologists, 

The  American . ' . 245 

Association,  The  American  Climatological .  214 

Association,  The  American  Dermatological.  158,  322 
Association,  The  American  Orthopaedic. .. .  251,  364 
Association,  The  American  Public  Health  . .  75,  664 
Association,  The  American  Rhinological. . .  245,  382 

Association,  The  Harlem  Medical . 519 

Association,  The  Jenkins  Medical .  323,  664 

Association,  The  Journal  of  the  American  Medi¬ 
cal.- .  634 

Association,  The  Kings  County  Medical .  410 

Association,  The  Mississippi  Valley  Medical.. .  102, 

273  391 

Association,  The  Mount  Sinai  Hospital  Alumni!  494 
Association,  The  New  York  State  Medical.  132,  447 

Association,  The  Ontario  Medical .  75 

Association,  The  Southern  Surgical  and  Gynae¬ 
cological .  475,  493 

Associations,  Meetings  of.  See  Societies. 
Assurance,  The  Medical  Selection  of  Lives  for. .  49 

Astasia  and  Abasia . 612 

Asylum  in  Northern  New  York,  The  St.  Law¬ 
rence  . . . . 664 

Ataxia  associated  with  Nuclear  Cranial-nerve 
Palsies  and  with  Muscular  Atrophies,  A 

Case  of  Locomotor  .  79 

Athetosis,  Pathological  Findings  in  a  Case  of.  .  79 

Atlas,  Epilepsy  and  Ankylosis  of  the . .  272 

Atlas  of  Rare  Skin  Diseases,  The  International.  19 
Atrophia  Maculosa  et  Striata  following  Typhoid 

Fever .  334 

Atrophy  of  the  Liver,  Acute  Ybllow _ _ _ ! _  270 

Atrophy  of  the  Optic  Nerve .  53 

Aulde,  J.  Crude  Drugs  compared  with  Chemical 

Products .  463 

Aulde,  J.  Hydrogen  Dioxide;  a  Resume .  711 

Aulde,  J.  Studies  in  Therapeutics.  Assayed 

Galenical  Preparations . 227 

Aulde,  J.  Studies  in  Therapeutics.  The  Phar¬ 
macology  of  Ergot . , .  347 

Australia,  Overcrowding  of  the  Profession  in . . .  298 
Auto-intoxication  of  Renal  Origin .  138 


Autopsy  in  New  England,  The  First. 


688 

586 


547 

586 


Bacilli  in  Cholera,  Distinct  Species  of  Comma.. 
Bacillus,  The  Dissemination  of  the  Typhoid,  by 

Edible  Vegetables . 

Bacillus,  The  Influence  of  the  Level  of  Subsoil 

Water  on  the  Diffusion  of  the  Typhoid . 

Bacteriology,  A  Russian  Institute  of .  436 

Bacteriology,  Dr.  Nicholas  Senn’s  Surgical .  132 

Bacteriology,  Syphilis  as  an  Infectious  Disease 

in  the  Light  of  Modern .  643 

Bakers,  The  Professional  Mark  of .  354 

Ballou,  W.  R.  Giant-celled  Sarcoma  of  the 

Finger  of  Unusual  Size .  43 

Barnes’s  Bag,  Intussusception  treated  with  the 

Aid  of .  431 

Barr,  S.  D.  An  Early  Extraction  of  Cataract...  240 

Bath-house,  A  Public .  690 

Baths,  The  Vienna  System  of  Public .  633 

Beef  Extract,  Color  of . 465 

Beef  Meal,  Mosquera’s .  644 

Berlin,  The  Academy  of  Medicine’s  Delegates  to.  551 

Biceps,  Rupture  of  the  Short  Head  of  the .  665 

Biggs,  H.  M.  Accidental  Suffocation  as  a  Cause 

of  Sudden  Death .  29 

Bile  in  a  Case  of  Biliary  Fistula,  Observations 
on  the  Secretion  of .  213 


730 


INDEX  TO  Y  OLE  ME  LI I. 


[N.  Y.  Mkd.  Jock 


PAGE 


Bilirubin,  The  Toxicity  of .  186 

Birth,  A  Quintuple .  604 

Bismuth  in  the  Treatment  of  Soft  Chancre,  Sub¬ 
benzoate  of . .  185 

Bismuth  Salts  and  the  Odor  of  Garlic .  58 

Bite,  Syphilitic  Infection  from  a .  672 

Blakeman,  Dr.  William  Nelson .  183 

Blindness  after  Cerebro-spinal  Meningitis .  215 

Blindness  following  Cerebro-spinal  Meningitis, 

with  Recovery  after  Two  Years .  146 

Blood  and  Blood-vessels  in  Health  and  Disease. .  281 
Blood  in  Infectious  Diseases,  On  Lavation  of 

the .  136 

Blood,  Sugar  in  the .  279 

Blood-vessels,  The  Utero-placental .  728 

Board  of  Health,  The  West  Virginia  State .  132 

Bone  Diseases  of  Childhood,  Operative  Proced¬ 
ures  in  the. . .  181 

Bone-grafting  from  the  Dog .  518 

Book  Notices  : 

Abel,  M.  H.  Practical  Sanitary  and  Economic 

Cooking .  640 

Baudouin,  M.  Hysteropexie  abdominale  an- 

terieure . ' . 502 

Bennett,  W.  H.  Clinical  Lectures  on  Varicose 

Veins  of  the  Lower  Extremities .  51 

BjOrnstiCm,  F.  Hypnotism . 275 

Browne,  L.  The  Throat  and  Nose  and  their 

Diseases .  559 

Bryant,  T.  The  Bradshaw  Lecture  on  Coloto¬ 
my...... .  303 

Checkley,  E.  A  Natural  Method  of  Physical 

Training ,  . . , . 503 

Clevenger,  S.  V.  Spinal  Concussion .  52 

Corning,  J.  L.  A  Treatise  on  Headache  and 

Neuralgia .  164 

Cox,  C.  F.  Protoplasm  and  Life .  503 

Cragin,  E.  B.  The  Essentials  of  Gynecology.  303 

DaCosta,  J.  M.  Medical  Diagnosis . 638 

Dastre,  A.  Les  anesthesiques . 417 

Deutschmann,  R.  Beitrage  zur  Augenheil- 

kunde . . 502 

Dock,  L.  L.  Text-book  of  Materia  Medica  for 

Nurses . . . 639 

Dowse,  T.  S.  Lectures  on  Massage  and  Elec¬ 
tricity.  . .  639 

Fullerton,  A.  M.  Hand-book  of  Obstetrical 

Nursing .  303 

Gant,  F.  J.  The  Student’s  Surgery .  275 

Goodhart,  J.  F.  A  Guide  to  the  Diseases  of 

Children .  51 

Graham,  D.  A  Treatise  on  Massage .  639 

Hare,  H.  A.  Epilepsy .  639 

Henschen,  S.  E.  Ivlinische  und  anatomische 

Beitrage  zur  Pathologie  des  Gehinis  .  637 

Herve.  Ruptures  des  tendons  sus-  et  sous- 

rotuliens .  502 

Hill,  M.  B.  Chronic  Urethritis .  502 

Hugenschmidt,  A.  C.  Experimental  Studies 
relating  to  the  Action  of  Hyoscine  Hydro- 
bromate,  Nitroglycerin,  Hydrocyanic  Acid, 

etc . 303 

Jacobi,  A.  The  Intestinal  Diseases  of  Infancy 

and  Childhood .  503 

Kelsey,  C.  B.  Diseases  of  the  Rectum  and 


^*-**“o . ouo 

Keyes,  E.  L.  Some  Fallacies  concerning  Syph¬ 
ilis .  335 

Killian,  G.  Die  Untersuchung  der  hinteren 

Larynxwand .  335 

Liebig;  G.  A„.  Jr.  Practical  Electricity  in 

Medicine  and  Surgery .  335 

Macdonald.  G.  A  Treatise  on  Diseases  of  the 

Nose  and  its  Accessory  Cavities .  559 

Macfarlane,  A.  W.  Insomnia  and  its  Thera¬ 
peutics .  164 

Maddox,  E.  E.  The  Clinical  Use  of  Prisms...  52 
Morris,  M.,  Unna  P.  G.,  and  Duhring,  L.  A. 

International  Atlas  of  Rare  Skin  Diseases..  363 
Moure,  E.  J.  Le^-ons  sur  les  maladies  du 

larynx . 304 

Murrell,  W.  Chronic  Bronchitis  and  its  Treat¬ 
ment . 303 

Nettleship,  E.  Diseases  of  the  Eye .  671 

Norris,  R.  C.  Syllabus  of  the  Obstetrical  Lect¬ 
ures  in  the  Medical  Department  of  the  Uni¬ 
versity  of  Pennsylvania . 275 

Owen,  E.  A  Manual  of  Anatomy .  303 

Pringle,  A.  Practical  Photo-micrography _  164 

Prudden,  T.  M.  Dust  and  its  Dangers .  638 

Rau,  L.  S.  May’s  Diseases  of  Women .  83 

Raue,  C.  G.  Psychology  as  a  Natural  Science.  51 
Regnier,  L.  R.  L’intoxication  chronique  par 

le  morphine .  334 

Roberts,  J.  B.  A  Manual  of  Modern  Surgery.  699 
Roberts,  J.  B.  The  Cure  of  Crooked'  and 

otherwise  Deformed  Noses . .  51 

Sackett,  S.  P.  Mother,  Nurse,  and  Infant _ 303 

Satterlee,  F.  L.  Rheumatism  and  Gout .  335 

Schmiegelow,  E.  Asthma .  134 

Sevestre,  Dr.  Etudes  de  clinique  infantile _  51 

Shoemaker,  J.  V.  Ointments  and  01  eates. . .  640 

Smith,  A.  H.  Diabetes  Mellitusand  Insipidus.  335 
Smith,  J.  L.  A  Treatise  on  the  Diseases  of 

Infancy  and  Childhood .  639 

Starr,  M.  A.  Familiar  Forms  of  Nervous  Dis¬ 
ease .  417 

Start  in,  J.  The  Pharmacopoeia  of  the  London 

Skin  Hospital .  51 

Thomson,  W.  Transactions  of  the  Royal 

Academy  of  Medicine  in  Ireland .  639 

Thornton,  J.  K.  The  Surgery  of  the  Kidneys.  83 
Transactions  of  the  American  Association  of 
Obstetricians  and  Gynaecologists .  51 


PAGE 


Book  Notices  : 

Transactions  of  the  American  Orthopaedic  As¬ 
sociation .  335 

Winckel,  F.  A  Text-book  of  Obstetrics .  83 

Witthaus,  R.  A.  The  Medical  Students’  Man¬ 
ual  of  Chemistry .  639 

Wolfe.  J.  R.  Original  Contributions  to  Oph¬ 
thalmic  Surgery .  638 

Yeo,  I.  B-  Food  in  Health  and  Disease .  83 

Books,  The  New  Tariff  and  Medical .  411 

Borderland,  The .  44 

Bosworth,  F.  H.  A  Case  of  Unilateral  Paralysis 

of  the  Abductors  of  the  Larynx .  398 

Bowel,  A  Case  of  Invagination  of  the . 145 

Brailly,  The  Death  of  Dr.  Cosmo .  411 

Brain,  Microscopical  Studies  of  the . 518 

Brain,  The  Development  of  the  Anterior  Portion 

of  the  Human .  726 

Brain,  The  Surgery  of  the .  219 

Brain,  Tumor  of  the .  162 

Brandy,  Foreign  and  American .  28 

Breast,  Paget’s  Disease  of  the .  663 

Briddon,  C.  K.  Laparo-colotomy  for  Stricture 

of  the  Rectum . 310 

Bright’s  Disease,  The  Influences  of  Climate  in 

the  United  States  over .  374 

Brill,  N.  E.  A  Case  of  Pseudo-hypertrophic 

Paralysis .  283 

Brodie,  The  late  Dr.  William .  158 

Bromidia  in  the  Treatment  of  Tetanus .  504 

Bromoform  in  Whooping-cough .  157 

Brown,  F.  T.  A  Case  of  Severe  Hsematuria  ; 

Nephrectomy  by  Dr.  McBurney . -173 

Broun,  M.  R.  Suppuration  of  the  Antrum  of 

Highmore . 62 

Briicke,  The  Retirement  of  Professor  von .  132 

Brush,  E.  F.  The  Mimicry  of  Animal  Tubercu¬ 
losis  in  Vegetable  Forms .  682 

Buckmaster,  A.  H.  A  Case  of  Persistent  Vomit¬ 
ing  with  a  History  of  Chylous  (?)  Vomiting 

relieved  by  Laparotomy .  70 

Bulbo-nuclear  Disease  and  certain  Obscure  Neu¬ 
rotic  Conditions  of  the  Upper  Air-passages, 

The  Intimate  Relationship  between _  176,  187 

Bull,  C.  S.  Reports  on  Ophthalmology .  52 

Bull,  C.  S.  The  Extraction  of  Lenses  dislocated 

into  the  Vitreous .  261 

Bull,  T.  M.  The  Prescription  of  Exercise .  141 

Cachexia,  Diathesis  and . 421 

Csesarean  Operation  and  its  Clinical  Results. . . .  193 
Csesarean  Section,  The  Prognosis  as  to  the 
Probability  of  Pregnancy  following  the  Con¬ 
servative .  195 

Calculi,  The  Nuclei  of  Biliary .  569 

Calculus,  Buffalo  Lithia  Water  as  a  Solvent  for 

Vesical .  572 

Calculus,  Enormous  Vesical .  414 

Calculus  in  a  Boy  of  Three  Years,  Impacted 

Urethral . . .  100 

Calculus  of  the  Kidney .  325 

Calculus  per  Vaginavi,  Removal  of  a  Large  Ves¬ 
ical . 389 

Calomel  and  Castor-oil,  Irritation  from .  218 

Camphoric  Acid  as  an  Anthidrotic .  381 

Cancer .  197 

Cancer  in  Normandy .  585 

Cancer  of  the  Lip . . .  215 

Cancer  of  the  Pharynx  and  CEsophagus .  329 

Cancer  of  the  Rectum. . .  328 

Cancer  of  the  Stomach  in  Switzerland .  585 

Cancer,  The  Specific  Pathology  of .  518 

Cancer,  Two  Cases  of  Extirpation  of  the  Penis 

for . 328 

Cannabis  Indies  in  Diseases  of  the  Stomach ....  306 

Canton,  Native  Midwifery  in .  m 

Capsulotomy  in  the  Extraction  of  Cataract,  Pre- 


Cardiac  Affections  of  Childhood  treated  with 

Strophanthus . .  572 

Cardiac  Disease  ?  What  is  accomplished  by  the 

Use  of  Digitalis  in .  38 

Cardiac  Medicaments,  Therapeutic  Principles 


Carroll,  A.  L.  What  Influence  would  a  more 
Perfected  Obstetric  Science  have  on  the  Bio¬ 
logical  and  Social  Condition  of  the  Race  ?. .  645 

Castration,  Nervous  Derangements  after .  271 

Castration  of  Women,  The .  no 

Cataract,  An  Early  Extraction  of .  240 

Cataract  and  Strabismus  in  Children  ?  When 

shall  we  operate  for . .  .  384 

Cataract  Extractions,  On  a  Series  of  One  Hun¬ 
dred .  103 

Cataract,  Preliminary  Capsulotomy  in  the  Ex¬ 
traction  of .  320,  357 

Cataract,  Suture  of  the  Cornea  in  Extraction  of.  51 

Cataract,  The  Cause  of  Senile .  53 

Cautery  in  Good  Order,  How  to  keep  a  Paque- 

lin .  467 

Cellulitis,  Peri-urethral. .  416 

Census  of  1890,  The .  297 

Cephalsematoma . 501 

Cerebro-spinal  Centers,  An  Inquiry  into  the  Re¬ 
lationship  of  Amygdaliti  s  to .  98 

Chancre,  Subbenzoate  of  Bismuth  in  the  Treat¬ 
ment  of  Soft .  185 

Chancroid,  Creolin  in  the  Treatment  of .  410 

Chapin,  W.  B.  A  Case  of  Uterus  Bilocularis 

Unicollis .  852 

Chapin,  W.  B.  Note  on  Chloralamide .  155 

Charbon  in  Hair- workers  and  Tanners .  586 

Charbon  in  Man,  Intestinal . 304 

Charity,  Extravagance  in  the  Name  of .  466 


PAGE 


Cheatham,  W.  The  Local  Treatment  of  Diph¬ 
theria  and  Scarlet-fever  Throat .  211 

Chemical  Products,  Crude  Drugs  compared  with.  463 
Chicago,  The  Attractiveness  ot,  to  Physicians.. .  633 

Childhood,  Alcohol  and .  447 

Childhood,  On  the  Strumous  Diseases  of,  and 

their  Relation  to  Tubercle .  196 

Childhood,  Operative  Procedures  in  the  Bone 

Diseases  of . 181 

Childhood,  Peritonitis  in .  668 

Children,  Diffuse  Cortical  Sclerosis  of  the  Brain 

in  .  .  81 

Children,  Injuries  of  the  Vertebra  in .  667 

Children,  Lithotrity  in . 472 

Children,  Mitral  Stenosis  in . 473 

Children,  Pneumonia  in .  497 

Children,  Reports  on  Diseases  of .  471 

Children,  Stomach  Washing  in .  306 

Children,  Strophanthus  in  Cardiac  Disease  in. ..  473 
Children,  The  Pathology  and  Treatment  of  Tu¬ 
bercular  Adenitis  in . 472 

Children  ?  When  shall  we  operate  for  Cataract 

and  Strabismus  in.  , .  384 

Chinese,  The  Color-sense  among  the .  214 

Chloralamide,  Note  on . .. .  155 

Chloroform  by  Gaslight,  The  Administration 

of .  74 

Chloroform  Ointment .  688 

Chloroform  versus  Opium  in  Intestinal  Inflam¬ 
mations .  217 

Cholecyst-.tomy .  416 

Cholera,  A  Forecast  in  regard  to .  633 

Cholera,  A  New  Antidote  to .  298 

Cholera,  A  Treatment  of _ ‘ .  664 

Cholera,  Distinct  Species  of  Comma  Bacilli  in...  586 

Cholera  Morbus  rapidly  Fatal .  217 

Cholera,  Personal  Uncleanliness  as  a  Factor  in 

the  Causation  of .  272 

Cholera,  Salol  in .  131 

Chorea,  A  Case  of . 474 

Chorea,  Reflex .  21 

Chorea.  Unusual  Forms  of .  77 

Chorioid,  Two  Cases  of  Detachment  of  the,  af¬ 
ter  Cataract  Extraction .  52 

Circulation  in  the  Venous  Blood-current,  On  the 

Retrograde .  135 

Circumcision,  Mr.  Hutchinson  on . 381 

Cirrhosis, The  Cause  of  Haematemesis  in  Hepatic.  307 

Claiborne,  J.  H.  Letter  to  the  Editor .  356 

Clark,  B.  Letter  to  the  Editor . .  186 

Clavicle,  Fracture  of  the  Sternal  End  of  the. . . .  665 
Clavicle,  Simultaneous  Dislocation  of  both  Ends 

of  the .  272 

Climate  in  the  United  States  over  Bright’s  Dis¬ 
ease,  The  Influence  of .  374 

Clinical  Histories,  The  Publication  of  Patients’ 

Names  in .  47 

Clinics  following  the  Congress;  Special  Berlin  . .  19 

Coca  and  its  Therapeutic  Applications .  84 

Cocaine  Poisoning  from  Half  a  Drachm  of  a 

Three-per-cent.  Solution,  Symptoms  of  _ 412 

Cod-liver  Oil,  Action  of .  232 

Cod-liver  Oil  as  a  Vermifuge .  47 

Cod-liver  Oil,  Lipanine  as  a  Substitute  for . 473 

Coffee .  495 

Coffee  in  Migraine  and  Gout,  Green . .  633 

Coffee,  The  Results  of  the  Chronic  Abuse  of _  307 

Cohen,  S.  Solis-.  Look  beyond  the  Nose. .  340,  358 
Cohen,  S.  Solis-.  The  Standardization  of  Galen¬ 
ical  Preparations .  15 

Cohen,  S.  Solis-.  Therapeutic  Principles  gov¬ 
erning  the  Selection  of  Cardiac  Medicaments 

595,  617 

Colchicine  Poisoning .  663 

Cold  on  the  Human  Body,  On  Some  of  the  Ef¬ 
fects  of .  135 

College  at  Marseilles,  A  Medical .  214 

College  of  Philadelphia,  The  Medico-cbirurgical.  102 
College  of  Physicinas  and  Surgeons,  The  Chi¬ 
cago .  . 355 

College  of  Physicians  of  Philadelphia,  The  Mut¬ 
ter  Lectures  of  the .  634 

College  of  the  New  York  Infirmary,  The  Wom¬ 
an’s  Medical .  382 

College,  The  Buffalo  Medical .  634 

College,  The  Jefferson  Medical . 549 

College,  The  Rush  Medical,  of  Chicago .  47 

College  of  Baltimore,  The  Medical. .  519 

Colorado,  Nervous  and  Mental  Diseases  ob¬ 
served  in .  457 

Colorado,  Reasons  for  the  Relative  Immunity 

from  Pulmonary  Phthisis  in .  314 

Colotomy .  216 

Colotomy,  Inguinal . 496 

Coma,  The  Cause  and  Treatment  of  Diabetic. ..  307 

Compression,  Cerebral .  614 

Concretion,  A  Nasal .  75 

Condylomata,  The  Treatment  of .  664 

Confidence,  Professional  and  Commercial .  185 

Congress,  An  Address  Introductory  to  the  Re¬ 
ports  on  the  Proceedings  of  Sections  in  the 

Tenth  International  Medical . 533 

Congress  of  Hygiene  and  Demography,  The  In¬ 
ternational .  560 

Congress,  The  Cremation .  245 

Congress,  The  Daily  Bulletin  of  the  Berlin .  214 

Congress,  The  Orthopaedic  Section  of  the  Tenth 

International  Medical .  606 

Conjunctivitis,  Extirpation  of  the  Orbital  Lacrv- 
mal  Glands  for  Incurable  Lacrymation  in 

Cases  of  Granular .  54 

Conjunctivitis,  The  Corrosive-sublimate  Treat¬ 
ment  of  Granular .  719 

Consciousness,  Double .  77 


INDEX  TO  VOLUME  LI I. 


731 


PAGK 

Consumption  and  the  Board  of  Health,  Pulmo- 

„  nary .  419 

Consumption,  The  Gross  Anatomy  of  Chronic 

Pulmonary .  58 

Contraction,  On  the  Period  of  Muscular,  during 

which  Heat  begins  to  Discharge .  134 

Convulsions  following  the  Ingestion  of  Unsound 

Oysters .  583 

Convulsions,  Veratrum  Viride  in  Puerperal .  217 

Copper  in  Acute  Affections  of  the  Intestine,  Ar- 

senite  of .  307 

Copper  in  Diarrhoea,  Arsenite  of . 186 

Cornea  in  Extr  ction  of  Cataract,  Suture  of  the.  54 

Cornea,  Non-metallic  Foreign  Bodies  in  the _  52 

Cornea,  The  Size  of  the,  in  Relation  to  Age,  etc.  55 
Corning,  J.  L.  Some  Considerations  on  the  Na¬ 
ture  and  Treatment  of  Exophthalmic  Goitre.  288 
Correspondents,  Answers  to...  28,  140,  308,  336,  364, 
„  .  476, 672,  700 

Cotton-spinners.  Follicular  Dermatitis  in .  157 

Cough  ;  its  Relation  to  Intra-nasal  Disease . 495 

Cowl,  W.  Y.  The  Factors  of  the  Respiratory 
Rhythm  and  the  Regulation  of  Respiration.  268 
Crandall,  F.  M.  Impacted  Urethral  Calculus  in 

a  Boy  of  Three  Years .  100 

Crandall,  F.  M.  Reports  on  Diseases  of  Chil¬ 
dren  .  471 

Creasote  in  Phthisis,  The  Dosage  and  Adminis- 

trationof .  85,  106 

Creditor,  The  Physician  as  a  Preferred .  272 

Creolin  in  the  Treatment  of  Chancroid  . . 410 

Criminals,  The  Cranial  Development  of .  495 

Crook,  J.  K.  Clinical  Lectures  on  some  com¬ 
monly  observed  Forms  of  Pulmonary  Dis- 

„  ease .  225,  253,  254,  309 

Crossland,  J.  C.  A  Typhoid  Sequel .  543 

Crossland,  J.  C.  Letter  to  the  Editor .  48 

Croup,  Diphtheria  and .  473 

Crus  Lesion .  81 

Cullen,  William,  as  a  Student .  19 

Curetting  for  Endometritis .  110 

Currier,  A.  F.  Reports  on  Gynaecology .  107 

Currier,  A.  F.  Reports  on  Obstetrics . 192 

Curvature  of  the  Spine,  The  Treatment  of  Lat- 

„  .  eral .  539 

Cutaneous  Lesions,  The  Pathogeny  of .  641 

Cyst,  An  Intraligamentary  Ovarian,  successfully 

treated  with  Iodine  Injections .  69 

Cyst,  Pancreatic .  328 

Cyst.  The  Successful  Removal  of  a  Pancreatic . .  409 

Cystitis  in  Women,  The  Treatment  of .  224 

Cystoscopy .  329 

Cystotomy  in  a  Case  of  Enlarged  Prostate,  Su¬ 
prapubic .  ,722 

Cystotomy  in  a  Child  of  Six  Years,  Vaginal . 725 

Cystotomy,  Perineal  Cystotomy  verms  Supra¬ 
pubic  . @29 

Cysts  and  Cystic  Formations,  Abdomino-pelvic 

Serous .  528 

Cysts,  Paranephric. . . . . .  147 


Diuretic,  Glucose  as  a .  270 

Dodge,  C.  L.  Some  Points  in  the  Examination 

of  Persons  for  Life  Insurance .  206 

Donaldson,  F.  The  Laryngology  of  Trousseau 

and  Horace  Green . 229 

Douglas,  J.  H.  Letter  to  the  Editor .  636 

Douglas,  R.  Hysterectomy  for  (Edematous  Fi¬ 
broid  ;  Recovery .  71 

Douglas,  The  late  Dr.  Silas  II . 328 

Drainage  after  Laparotomy .  501 

Drainage  of  the  Male  Bladder,  Permanent .  388 

Drawings,  Medical .  382 

Drugs,  Crude,  compared  with  Chemical  Products.  463 

Drugs,  Deductions  from  Experiments  with .  272 

Drags,  Note  on  a  New  System  of  Exact  Dosage 

in  the  Cataphoretic  Use  of .  543 

Dublin,  Letters  from .  545  @85 

Duncan,  The  late  Dr.  Matthews . ’  297 

Dunn, .) .  A  Case  of  Reflex  Amblyopia  cured  by 

Section  of  the  Supra-orbital  Nerve .  151 

Dunning,  L.  H.  Pelvic  Abscess,  Report  of  Five 

Cases,  with  Comments  514 

Duodenum,  Congenital  Stenosis  of  the  ........ .  153 

Dysentery,  A  Demonstration  of  the  Amoeba 

Coli  in. . .  410 

Dysentery,  An  Opium  Pill  for . . . .  392 

Dyspepsia  and  its  Rational  Treatment  by  the 

Antiseptic  Method,  Infectious .  468 

Dystrophy,  On  Two  Cases  of  Muscular .  202 


29 


Death,  Accidental  Suffocation  as  a  Cause  of  Sud 

den . 

Death  and  Placental  Disease,  Intra-uterine . 476 

Death  from  Foot-hall  Injuries . . .  494 

Degree,  An  Honorary . .  . .  158 

Degree  of  LL.  D.,  The  Honorary .  20,  186 

Delavan,  D.  B.  On  the  Early  Diagnosis  of  Ma¬ 
lignant  Disease  of  the  Larynx .  508 

Dengue  as  observed  at  Kells,  Influenza  or .  1C5 

Dermatitis  Herpetiformis,  The  Treatment  of  . . .  331 

Dermatitis  in  Cotton-spinners,  Follicular .  157 

Dermatology,  Reports  on .  165,  @40 

Dermatoses,  Immigrant .  331 

Diabetes .  '  ' '  7@ 

Diabetes  Mellitus,  The  Principles  of  the  Treat¬ 
ment  of .  307 

Diabetes,  The  Gastric  Juice  in  .  @34 

Diagnosis,  A  Case  for .  412 

Diarrhoea,  Arsenite  of  Copper  in .  186 

Diarrhoea  of  Children,  The  Summer .  383 

Diathesis  and  Cachexia . 421 

Digestive  Preparations,  The  Fairchild . 476 

Digitalis  in  Cardiac  Disease  ?  What  is  accom¬ 
plished  by  the  Use  of .  38 

Diphtheria,  A  Submembranous  Local  Treatment 

-r..  of  Pharyngeal .  624 

Diphtheria  and  Croup .  473 

Diphtheria  and  Scarlet  Fever  Throat,  The  Local 

Treatment  of .  211 

Diphtheria,  Hydrogen  Peroxide  in .  @37 

Diphtheria,  Pineapple  Juice  in . .  543 

Diphtheria,  Recent  Investigations  in .  473 

Diphtheria,  The  Use  of  Menthol  in .  632 

Diplomas,  The  Indorsement  of  Foreign .  158 

Discharges  in  Acute  Diseases,  Precritical . ! !  27 

Disease  of  the  Hip  and  Knee  Joints  of  the  s;  me 

Limb,  The  Simultaneous  Occurrence  of _  655 

Disease,  The  Phonograph  as  a  Disseminator  of.  132 
Diseases  (Notification)  Act,  1889,  The  Infectious  189 
Diseases  Observed  in  Colorado,  Nervous  and 

Mental .  457 

Diseases,  The  Precritical  Discharges  in  Acute  . .  26 

Disinfecting  Chambers,  Public .  585 

Disinfection  by  Gases . 585 

Disinfection  by  Sulphur  Fumigation .  213 

Disinfection,  Sulphurous .  251 

Dislocation  of  a  Rib .  . 216 

Dislocation  of  both  Ends  of  the  Clavicle,  Simul¬ 
taneous  .  272 

Dislocation  of  the  Crystalline  Lens,  Traumatic".  295 

Dispensary,  The  Midwifery .  355 

Dissecting-room,  The  Hygiene  of  the .  588 

Distichiasis,  Operation  for .  428 


Ear,  The  Anatomy  of  the  Elephant’s .  548 

Edebohls,  G.  M.  A  Modified  Alexander- Adams 

Operation . 400 

Edebohls,  G.  M.  Letter  to  the  Editor .  549 

Edgar,  J.  C.  The  Manikin  in  the  Teaching  of 

Practical  Obstetrics .  698,  701 

Elder, .T.  A.  Letter  to  the  Editor . . . .’  520 

Electrical  Discharges  of  the  Human  Skin,  etc. . .  26 
Electricity  in  Diagnosis,  A  Case  of  Traumatic 

Neuritis  illustrating  the  Value  of .  489 

Electricity,  The  Question  of  Amperage  in  the 

Treatment  of  Fibroid  Tumors  by .  498 

Electricity,  Under  what  Conditions  can.  he  of 

Positive  Service  to  the  Gymecologist  ? .  440 

Electrolysis  applied  to  the  Initial  Sclerosis  as  a 
Means  for  the  Abortive  Treatment  of  Syphi¬ 
lis  .  167 

Electrotherapy  in  Slavjansky’s  Clinic .  108 

Eliot,  E.,  Jr.  Tenorrhaphy . .  88 

Emerson,  J.  H.  Congenital  Stenosis  of  the  Duo¬ 
denum  ;  Hiematemesis  ;  Death  on  the  Fifth 

Day  ;  Autopsy .  153 

Empyema,  A  Case  of  Double .  487 

Empyema  complicated  with  Pulmonary  (Edema. 

Case  of  . ’  72 

Empyema,  The  Surgical  Treatment  of . .  .  .  .  .  725 

Enchondroma  of  the  Metacarpus .  .  611 

Endometritis,  Curetting  for .  no 

Endometritis,  The  Microbiology  of  the  Cervical 

Canal  in .  194 

Endometritis  with  Chloride  of  Zinc,  The  Treat¬ 
ment  of .  no 

Enophthalmia  Traumatica .  52 

Entozoa  in  Domestic  Animals . 213 

Ependymitis  of  Bacterial  Origin .  @13 

Epiglottis,  A  Case  of  Myxoma  of  the .  263,  274 

Epiglottis,  A  New  Method  of  lifting  the .  384 

Epilepsy .  339 

Epilepsy,  A  Case  of  Hemiplegic .  150 

Epilepsy,  A  Contribution  to  the  ^Etiology  of 

Jacksonian .  743 

Epilepsy,  A  New  Treatment  for .  305 

Epilepsy  and  Ankylosis  of  the  Atlas .  272 

Epilepsy,  The  Medical  Aspect  of  Trephining  in.  070 

Episcleritis,  The  Treatment  of .  55 

Epithelioma  Adamantinum .  605 

Epithelioma  Contagiosum . "  i@@ 

Epithelioma  of  the  Nose . . .  H  *  *  |  665 

Erasion  of  the  Knee  Joint .  103 

Ergot,  The  Pharmacology  of . '  347 

Erysjpelas,  Antipyrine  in .  ig’@'  234 

Erysipelas,  The  Abortive  Treatment  of . 687 

Erysipelas,  The  Treatment  of .  332 

Erysipelas  treated  with  the  Bichloride  of  Mer¬ 
cury,  etc .  14 

Erythema,  The  Pathogenesis  of .  165 

Eskridge,  J.  T.  Nervous  and  Mental  Diseases 

observed  in  Colorado .  457 

Eskridge,  J.  T.  Some  Points  in  the  Diagnosis 
of  Certain  Simulated  Mental  and  Nervous 

Diseases .  94 

Esmarch’s  Bandage,  Injury  from  the  Use  of... .  32’i 

Ethereal  Preparations  as  Topical  Remedies . 467 

Etherization,  A  Death  during .  519 

Ethyl,  Death  after  the  Inhalation  of  Bromide  of  93 

Euphorine  .  @gg 

Examinations,  The  New  York  State  Prelimi- 

„  nary.... .  355 

Examiners  in  Life  Insurance,  The  Remunera¬ 
tion  of  Medical .  47 

Examiners,  The  New  Jersey  Board  of  Medical.  215 

Execution,  The  Electrical .  157 

Exercise,  The  Dangers  of  Excessive  Physical. '  ’  589 

Exercise,  The  Prescription  of .  141 

Exhibitionism  ;  a  Sexual  Perversion . '  101 

Exostoses  of  the  Femur . 611 

Exostosis  in  the  Septum  Narium,  Tic  Doulou¬ 
reux  resulting  from  an .  143 

Extirpation  of  the  Uterus,  Results  obtained  by 

the  Total .  109 

Extirpation  of  the  Uterus,  Total  Vaginal .  378 

Extravagance  in  the  Name  of  Charity . 4@6 

Eye  and  Ear  Diseases,  The  New  York  Institute 
for .  273 


PAGK 

Eyelids,  The  Restoration  of  the .  54 

Eyes,  Alleged  Danger  in  Artificial  Celluloid. . . .  436 
Eyes  and  Diseases  of  the  Nose,  The  Connection 

between  Diseases  of  the .  54 

Eyes  of  Eye  Surgeons,  The . ! .  . .  516 

Eyes,  Sympathetic  Affections  of  the .  54 

Eyes,  Unequal  Accommodation  in  Healthy .  53 

Faecal  Matter  in  Water,  A  Test  for .  624 

Fallacies  revived  under  New  Names,  Old  ...  221 
Faulkner,  R.  B.  A  Peculiar  Gro.vth  of  Hair  on 

the  Face .  155 

Favus,  The  Treatment  of . .  ..  .  '.  643 

Female,  Gonorrhoea  in  the . .’  573 

Femur,  Injuries  of  the  Hip  and  Absorption  of 

the  Neck  of  the .  65 

Ferguson,  J.  The  Treatment  of  Internal  Haem¬ 
orrhoids  .  488 

Fever,  Childbed . 1 .  564 

Fever,  Continued . 390 

Fever,  Nitrate  of  Potassium  in  Intermittent.. ..  133 

Fever;  V accmial . , . . .  305 

Fevers,  Continued. .  . . . . . 413 

Fevers,  The  Toxicity  of  the  Urine  in  Intermit- 

tent .  271 

Fibroid  and  Tubal  Pregnancy,  Ovarian .  247 

Fibroid,  Hysterectomy  for  (Edematous .  71 

Fibromata  of  the  Uterus .  107 

Fibromata,  The  Electrical  Treatment  of  Uter¬ 
ine .  107 

Fihromyoma  of  the  Ovary .  248 

Fibrosarcoma  of  the  Right  Nasal  Fossa,  with 

Unusual  Clinical  History .  340,  359 

Fibula,  Fractures  of  the .  469 

Fingers,  Congenital  Malformation  of  the .  23 

Fish  Supply  of  New  York  State,  A  Project  to 

increase  the .  382 

Fissures  of  the  Brain,  The  Parieto-occipital  "and 

Calcarine .  162 

Fistula,  A  Case  of  Intestinal  Anastomosis  for 

Faecal .  674 

Fitch,  C.  W.  Letter  to  the  Editor .  575 

Flint.  The  Dosage  and  Administration  of  Crea¬ 
sote  in  Phthisis .  g5,  106 

Fluid,  A  New  Culture . 322 

Fluid,  The  Origin  of  the  Amniotic .  728 

Foods,  Reed  &  Carnrick’s .  382 

Foot,  The  Treatment  of  Persistent  Abduction 

of  the.. . 406 

Forceps,  The  Universal  Needle . 446 

Foreign  Bodies  in  the  Cornea,  Non-metallic _  52 

Foster,  M.  L.  Reports  on  Anatomy .  223,  726 

Foster,  The  Death  of  Dr.  George  T.,  of  Pitts¬ 
field,  Mass .  494 

Fox,  The  Death  of  Dr.  Sidney  Allan,  of  Brooklyn  690 
Fracture  of  the  Lamina  of  the  Fifth  Cervical 

Vertebra .  283 

Fracture  of  the  Patella .  328 

Fracture  of  the  Patella  into  the  Knee  Joint,  A 

Case  of .  516 

Fracture  of  the  Patella,  The  Pin-wiring  Treat¬ 
ment  of . 159 

Fracture  of  the  Skull,  Compound . 293 

Fracture  of  the  Sternal  End  of  the  Clavicle". ....  665 

Fractures  of  the  Fibula  .  469 

Fragilitas  Ossium .  445 

Friedenwald,  H.  Recent  Investigations  in  Stra¬ 
bismus .  179 

Fumigation,  Disinfection  by  Sulphur . 213 

Fundus,  Ophthalmoscopic  Appearances  at  the 

Periphery  of  the .  56 

Fundus  Visible  with  the  Ophthalmoscope  ?  How 
far  forward  is  the . . . 55 


Galenical  Preparations,  Assayed .  227 

Galenical  Preparations,  The  Standardization  of.  15 

Gall  Bladder,  The  Surgery  of  the .  725 

Gall-stone,  Obstruction  of  the  Bowel  by  a,  fol¬ 
lowed  by  Spontaneous  Relief .  414 

Galvano-cautery  in  Throat  Practice,  The  Use 

and  Abuse  of .  177 

Ganglion,  Development  of  the  Ciliary  or  Motor 

^  Oculi . 223 

Garlic,  Bismuth  Salts  and  the  Odor  of .  58 

Gastric  Affections  in  Connection  with  Diseases 

of  the  Female  Genital  Organs .  107 

Gastroschisis .  223 

Gastroxia,  The  Causes  of .  306 

Genito  urinary  Surgery,  The  Academy  of  Medi¬ 
cine’s  Section  in .  548 

German  Students,  A  French  Student  on . .  157 

Germ,  the  Tetanus . . .  718 

Germs,  Malarial . ”  467 

Germs,  Observations  on  the  Variability  of  Dis¬ 
ease .  485 

Gerster,  A.  G.  Essay  upon  the  Classification  of 
the  Various  Forms  of  Appendicitis  and  Peri- 

typhlitic  Abscess .  6 

Gestation,  Indications  for  Operation  in  Ectopic.  722 
Gihier,  Paul.  A  New  Theory  about  Tempera¬ 
ments.  . . .  423 

Gibney,  V.  P.  Operative  Procedures  in  the 

Bone  Diseases  of  Childhood .  181 

Gillette,  H.  F.  Letter  to  the  Editor .  215 

Gilliam,  D.  T.  Total  Vaginal  Extirpation  of 

the  Uterus .  378 

Gilliam,  E.  M.  Tic  Douloureux  resulting  from 

an  Exostosis  on  the  Septum  Narium .  143 

Gland  Hypertrophy  of  the  Prostate .  57 

Glasses,  Decentered  Spectacle .  632 

Gleitsmann,  J.  W.  A  Case  of  Primary  Tuber¬ 
culosis  of  the  Pharynx . 404 

Glioma,  Peculiar  Course  of  a  Retinal .  53 

Glucose  as  a  Diuretic .  270 


732 


INDEX  TO  VOLUME  LIT. 


[N.  Y.  Mkd.  Joub 


PAGE 


PAGE 


Goitre,  Some  Considerations  on  the  Nature  and 

Treatment  of  Exophthalmic .  -88 

Goitre,  The  Therapeutics  of  Exophthalmic - -  525 

Goldenberg,  H.  A  Case  of  Hutchinson’s  “  Vari¬ 
cella  Prurigo  ” .  424 

Gonococcus  of  Neisser  and  Arthritic  Effusions.  030 
Gonorrhoea  in  a  Boy  of  Three  Years  of  Age,  etc.  000 

Gonorrhoea  in  a  Child,  Dr.  Abbe’s  Case  of . 090 

Gonorrhoea  in  the  Female .  573 

Gonorrhoea,  The  Relation  of,  to  Renal  Disease. .  433 
Gouley,  J.  W.  S.  Retention  of  Urine  from  Pros¬ 
tatic  Obstruction  in  Elderly  Men  ;  its  Na¬ 
ture,  Diagnosis,  and  Management .  477,  524 

Gout,  Green  Coffee  in  Migraine  and .  083 

Grafting  after  the  Method  of  Thiersch,  Skin. . . .  442 

Grafting,  Bone . 000 

Grafting,  Some  Observations  on  Bone  and  Skin.  528 
Grafts,  The  Disadvantages  of  Cutaneous.. .....  54 

Green,  The  Laryngology  of  Trousseau  and 

Horace . 229 

Gregory,  The  Death  of  Dr.  Justus  E.,  of  Brook¬ 
lyn  .  494 

Gynaecology,  Reports  on... . 107 


Haematemesis  in  Hepatic  Cirrhosis,  The  Cause 

of .  307 

Haematoma  Auris .  134 

Hsematuria,  A  Case  of  Severe .  173 

Hsematuria  and  Garden  Rhubarb .  185 

Haemoglobin  in  the  Blood  during  the  Last 
Months  of  Pregnancy  and  during  the  Puer- 

perium .  195 

Haemorrhage  after  Amygdalotomy .  234,  325 

Haemorrhage  into  the  Orbit .  53 

Haemorrhage,  Ligation  of  the  Limbs  in .  637 

Haemorrhoids,  The  Treatment  of .  291 

Hiemorrhoids,  The  Treatment  of  Internal . 488 

Haemorrhoids,  Whitehead’s  Operation  for .  418 

Hailstones,  Microbes  in .  185 

Hair-cutting,  The  Sexual  Perversion  of . 493 

Hair  on  the  Face,  A  Peculiar  Growth  of .  155 

Hall,  W.  H.  Letter  to  the  Editor .  325 

Hallucinations,  Homonymous  Hemiopic .  241 

Hamilton,  W.  D.  A  Report  of  Seven  Operations 

upon  the  Kidney .  170 

Hammond,  C.  N.  Aneurysm  of  the  Arch  of  the 

Aorta .  544 

Hammond,  W.  A.  A  Case  of  Brain  Surgery  and 

its  Relations  to  Cerebral  Localization .  337 

Hands,  Menthol  for  Chapped .  088 

Hardie,  T.  M.,  and  Wood,  C.  A.  Two  Cases  of 
Nasal  Hydrorrhcea,  w  ith  a  Report  on  the  Eye 

Symptoms .  264 

Harrison,  G.  F.  Letter  to  the  Editor .  438 

Hartley,  F.  Chronic  Disturbances  in  Joints _  649 

Headache,  Different  Forms  of  Refractive  and 

Muscular  Error  in  the  Causation  of .  55 

Headache,  Ocular  Defects  as  a  Frequent  Cause 

of .  233 

Health  and  Disease,  The  Blood  and  Blood-vessels 

in .  281 

“Health  Resorts,’’  Thoughts  and  Observations 

at .  603 

Heart,  Disease  of  the . 472 

“Heart-Failure,”  The  Term .  157 

Heart,  Perforating  Wound  of  the . 327 

Heart,  Rupture  of  the  . 163 

Heart,  Two  Cases  of  Congenital  Malformation  of 

the .  472 

Hemianopsia  following  Uterine  Hemorrhage. . .  718 

Hemianopsia,  Recovery  from .  55 

Hemiatrophy  of  the  Tongue  of  Peripheral  Origin  416 


Hermaphroditism,  Pseudo .  727 

Hernia,  Formation  of  a  Large  Cerebral .  293 

Hernia  of  the  Falloppian  Tube . % . 624 

Hernia,  Omental .  552 

Hernia,  Umbilical .  612 

Hibbard,  The  Death  of  Dr.  William  N.,  of  Chi¬ 
cago  .  690 

Higgins,  C.  B.  The  Treatment  of  Haemorrhoids.  291 
Hip  and  Absorption  of  the  Neck  of  the  Femur, 

Injuries  of  the .  65 

Hip  Disease,  A  Report  of  Sixty-two  Cases  of.. .  369 
Hoarseness  and  Loss  of  Voice  caused  by  Wrong 

Vocal  Method .  361,  482 

Hodgkin’s  Disease,  A  Case  of .  444 

Hodgman,  W.  H.  Letter  to  the  Editor .  551 

Holt,  L.  E.,  Acute  Primary  Broncho-Pneumonia  67 

Hospital  at  Johnstown,  The  Memorial .  297 

Hospital,  A  WTard  Clinic  in  the  Montreal  General  714 

Hospital  Censured,  A .  467 

Hospital  in  Jersey  City,  The  New  St.  Francis..  410 

Hospital  in  Sitka,  A  Missionary .  436 

Hospital,  Mt.  Sinai .  382 

Hospital,  The  Coombe  Lying-in,  Dublin .  573 

Hospital,  The  Library  of  the  New  York ....  636,  718 

Hospital,  The  Maine  Insane .  634 

Hospital,  The  Randall’s  Island .  323 

Hospital,  The  Roosevelt .  102 

Hospital,  The  Worcester,  Mass.,  Lunatic .  634 

Hospitals,  Secrecy  in  Lying-in .  157 

House,  An  Injustice  to  an  Honorable .  74 

Huber,  F.  Case  of  Empyema  complicated  with 

Pulmonary  (Edema .  72 

Hydrastis  in  Disease  of  the  Female  Organs  of 

Generation .  657 

Hydrocephalus  without  Enlargement  of  the 

Head,  Congenital .  497 

Hydrogen  and  Ozone,  Peroxide  of .  . 531 

Hydrogen  Dioxide;  a  Resume .  711 

Hydrogen  Peroxide  in  Diphtheria .  637 

Hydrophobia  ;  its  Clinical  Aspect . 529 

Hydrorrhoea,  Two  Cases  of  Nasal .  264 


Hydroxylamine  in  the  Treatment  of  Skin  Dis¬ 
eases .  165 

Hygiene,  Reports  on . . .  .  . 585 

Hygiene,  The  Importance  of  Female . 722 

Hymen,  Development  of  the. .  223 

Hyperemia  or  Anemia  of  the  Brain  and  Cord  ? 

Can  we  Diagnosticate .  553 

Hypertrophy  of  the  Prostate  Gland.  An  Addi¬ 
tion  to  McGuire’s  Operation .  57 

Hypertrophy  of  the  Turbinated  Bodies .  238 

Hypertrophy,  Prostatic . 448 

Hypertrophy,  The  Surgical  Treatment  of  Post- 

turbinated  .  241 

Hypnal  in  the  Treatment  of  Neuralgic  Insomnia  244 

Hypnotic,  Somnal,  a  New .  599 

Hypnotism . 524 

Hypnotism,  Anaesthesia  by .  493 

Hypnotism,  Government  Measures  against . 245 

Hypnotism  in  its  Relation  to  Surgery .  496 

Hysterectomy  for  (Edematous  Fibroid .  71 

Hysterectomy,  Vaginal  Fixation  of  the  Stump  in 

Abdominal .  499 

Hysteria,  On  Nutrition  in .  136 

Hysterical  and  Epileptic  Subjects,  Hsemato- 

spectroscopic  Notes  on .  138 

Hysteropexy .  467 

Hysterorrhaphy,  Transperitoneal .  699 

Icterus,  Infectious .  306 

Idiocy,  A  Case  of  Myxedematous .  472 

Illuminator,  Observations  on  a  New  Speculum. .  249 
Incontinence  of  Urine  due  to  Malposition  of  the 

Ureter .  501 

Index-Catalogue.  The  New  Volume  of  the .  518 

India,  The  Evils  of  Early  Marriage  in .  475 

Indigestion,  A  Peculiar  Case  of .  133 

Induration  of  Superficial  Veins,  Chronic .  244 

Inebriates,  An  Island  for .  518 

Inebriety  and  Life  Insurance. . . ; .  644 

Infancy,  Albuminuria  in .  685 

Infancy.  Peritonitis  in .  668 

Infant-Feeding,  A  Practitioner’s  Experience  in .  237 

“  Infant  Industries  ” .  102 

Infants,  Insomnia  in .  474 

Infants,  The  Causes  of  Laryngismus  in .  473 

Infants,  The  Transmission  of  Aphthous  Disease 

in .  474 

Infection  from  a  Bite,  Syphilitic .  672 

Infection  from  Milk .  664 

Infection,  Local  Tubercular .  185 

Infectious  Diseases,  On  Lavation  of  the  Blood  in  136 
Inflammation  ?  How  shall  we  treat  our  Cases  of 

Pelvic .  721 

Inflammations,  Chloroform  vs.  Opium  in  Intes¬ 
tinal  . 217 

Influenza  Epidemic  in  1889-’90  as  observed  in 

Dublin .  104 

Influenza  or  Dengue  as  observed  at  Kells .  105 

Influenza,  The  Ravages  of  Epidemic .  690 

Influenza,  Trance  following  .  278 

Ingals,  E.  F.  Supplemental  Report  on  Cartila- 
"  ginous  Tumors  of  the  Larynx  and  Warty 

Growdhs  in  the  Nose . . .  345,  360 

Ingals,  E.  F.  Unilateral  Paralysis  of  the  Lateral 

Crico-arytenoid  Muscle .  346,  362 

Inhalations  in  Pneumonia,  Oxygen .  101 

Inhibition,  Association  of  Cardiac  with  each  In¬ 
spiratory  Effort .  138 

Injuries  of  the  Hand,  Wet  Antiseptic  Dressings  in  724 
Injuries  of  the  Hip,  and  Absorption  of  the  Neck 

of  the  Femur . 65 

Injuries  of  the  Vertebrae  in  Children .  667 

Injuries  to  the  Pelvic  Floor,  The  Immediate  Re¬ 
pair  of .  160 

Injury,  A  Case  of  Trephining  for  Paralysis  of 

Speech  following  an.  .  42 

Injury  from  the  Use  of  Esmarch’s  Bandage .  327 

Insane  in  the  State  of  New  York,  The  Care  of 

the . 1 .  606 

Insane  of  the  State  of  New'  York,  The  Indigent.  436 
Insane  Patients,  The  Transfer  of  Public,  to  State 

Hospitals . 448 

Insane,  The  Boarding-out  System  for  the .  189 

Insanity,  Acute  Confhsional . 229 

Insanity,  Telephone .  213 

Insanity,  The  Treatment  of  Incipient .  186 

Insomnia,  Hypnal  in  the  Treatment  of  Neural¬ 
gic . 244 

Insomnia  in  Infants .  474 

Institute,  The  Paris  Pasteur . 382 

Intestine,  Arseniteof  Copper  in  Acute  Affections 

of  the .  307 

Irltracranial  Lesions,  Discussion  on .  522 

Intussusception  treated  with  the  Aid  of  Barnes’s 

Bag .  131 

Invagination  of  the  Bowel,  A  Case  of .  145 

Investigation,  Collective .  161 

Iodoform  Injections,  Tuberculous  Abscesses 

treated  by .  689 

Ireland,  Lunacy  in .  409 

Irrigation  of  the  Peritonaeum .  109 

Irrigations  subsequent  to  Parturition,  Hot .  193 

Irritation  from  Calomel  and  Castor  Oil .  218 

Irritation,  The  Relation  of  Peripheral,  to  Dis¬ 
ease,  considered  from  a  Therapeutic  Stand¬ 
point .  22 

Irritation,  The  Relation  of  Peripheral,  to  Dis¬ 
eases  of  the  Womb  and  its  Appendages .  22 

Itching,  The  Sensation  of . ! . 555 

Jackson,  G.  T.  ‘  Reports  on  Dermatology..  165,  640 
Jacobi,  A.  An  Address  Introductory  to  the  Re¬ 
ports  on  the  Proceedings  of  Sections  in  the 
Tenth  International  Medical  Congress . 533 


PAGE 


Jacobi,  A.  Letter  to  the  Editor .  551 

Jarvis,  N.  S.  A  Case  of  Rabies  from  the  Bite  of 

a  Skunk .  344 

Jaw,  Ankylosis  of  the .  666 

Jejuno-ileostomy  with  Senn’s  Bone  Plates  in  In¬ 
testinal  Obstruction,  Complete  and  Perma¬ 
nent  Recovery  by .  673 

Jenkins,  W,  T.  Accidental  Suffocation  as  a 

Cause  of  Sudden  Death .  29 

Joints,  Chronic  Disturbances  in .  649 

Jones,  J.  D.  A  Case  of  Trephining  for  Paraly¬ 
sis  of  Speech  following  an  Injury .  42 

Judson,  A.  B.  A  Criticism  of  Willett’s  Opera¬ 
tion  for  Talipes  Calcaneus .  .  . .  198 

Kammerer,  F.  Letter  to  the  Editor  .  636 

Kav,  T.  W.  Childbed  Fever . 564 

Kefir .  322 

Keloid .  641 

Kennedy,  J.  The  Relation  of  Gonorrhoea  to  Re¬ 
nal  Disease . 433 

Keratitis,  The  .Etiology  of  Neuroparalytic .  56 

Kidney,  A  Report  of  Seven  Operations  upon 

the .  170 

Kidney,  Atrophy  of  the  Right,  with  Compensa¬ 
tory  Hypertrophy  of  the  Left .  162 

Kidney,  Calculus  of  the .  325 

Kidneys,  Removal  of  the .  325 

Kidneys,  The  Elimination  of  Iodide  of  Potas¬ 
sium  by  the . .  640 

Kloman,  W.  C.  Letter  to  the  Editor .  20 

Knee  Joint,  Erasion  of  the .  103 

Knight,  C.  H.  A  Case  of  Fibrosarcoma  of  the 
Right  Nasal  Fossa,  with  Unusual  Clinical 


Knott,  J.  P.  The  Doctorate  Address  delivered 
before  the  Graduating  Class  of  the  Kentucky 

School  of  Medicine,  June  19,  1890 .  365 

Koch  Treatment  in  Berlin,  Gruen  and  Severn’s 

Observations  of  the . 689 

Koch  Treatment,  The  Progress  of  the  .  662 

Koch’s  Method  in  Berlin,  The  Clinical  Aspects 

of .  709 

Krauss,  W.  C.  Traumatic  Aneurysm  of  the  In¬ 
ternal  Maxillary  Artery  ;  Compression  ;  Re¬ 
covery .  129 

Krehbiel,  The  Death  of  Dr.  Gustavus,  A.  A .  20 

Labor,  A  Medico-legal  View  of  Painless .  272 

Labor,  Erratic  Pain  in .  218 

Labor,  Injuries  to  the  Ureters  during .  500 

Labor,  Placental  Disease  as  a  Cause  of  Prema¬ 
ture .  582 

Labor,  The  Practical  Means  employed  to  pro¬ 
voke  Premature .  192 

Lacrymal  Gland,  Extirpation  of  the  .  53 

Lacrymation  in  Cases  of  Granular  Conjunctivi¬ 
tis,  Extirpation  of  the  Orbital  Lacrymal 

Glands  for  Incurable .  54 

La  Grippe,  A  Sequela  of .  133 

Langtnaid,  S.  W  Hoarseness  and  Loss  of  Voice 

caused  by  Wrong  Vocal  Method .  482 

Laparo-colotomy  for  Stricture  of  the  Rectum...  310 
Laparotomy,  A  Case  of  Persistent  Vomiting  re¬ 
lieved  by .  70 

Laparotomy,  Drainage  after . 501 

Laparotomy  for  Intrapelvic  Pain .  558 

Laplace,  E.  Cancer .  197 

Laplace,  E.  Diathesis  and  Cachexia .  421 

Laplace,  E.  Surgical  Mycoses  .  169 

Laryngismus  in  Infants,  The  Ca  ises  of . 473 

Laryngology  of  Trousseau  and  Horace  Green 

229,  636 

Larynx,  A  Case  of  Unilateral  Paralysis  of  the 

Abductors  of  the .  398 

Larynx,  Cartilaginous  Tumors  of  the .  345,  360 

Larynx,  Lupus  of  the .  162 

Larynx.  The  Early  Diagnosis  of  Malignant  Dis- 


Larynx,  the  Physiology  of  the .  572 

Lavation  of  the  Blood  in  Infectious  Diseases. . . .  136 
Leading  Articles  : 

Abortion  Case,  The  Harlem .  131 

Acromegaly .  73 

Appendicitis  or  Ecphyaaitis  ? .  571 

Association,  The  New  York  State  Medical....  517 
Cancer  of  the  Cervix  Uteri,  Pawlik’s  Opera¬ 
tion  for .  434 

Cholera  in  London,  The  Reputed  Case  of .  296 

Congress,  The  Tenth  International  Medical. . .  156 

Constantinople,  Medical  Affairs  in .  212 

Diseases,  Errors  in  the  Diagnosis  of  Infec¬ 
tious .  353 

Diseases,  The  ^Etiological  Classification  of 

Mental .  156 

Dispensary,  The  Midwdfery .  101 

Ecphyaditis  ?  Appendicitis  or .  571 

Faith-healing  unsuitable  for  African  Fever  . . .  605 
Fevers,  Laboratory  Researches  regarding 

Ephemeral .  717 

Gastric  Disease  and  Disorders  of  the  Nervous 

System,  The  Connection  between .  270 

Ghosts,  An  Epidemic  of .  380 

Hsematemesis,  (Esophageal  Varix  as  a  Cause  of  321 

Hospital,  The  Johns  Hopkins .  100 

Hospitals,  A  Surgeon’s  Sermon  on . 353 

Hypnotism  before  the  British  Medical  Asso¬ 
ciation  .  243 

Koch’s  Berlin  Address . 434 

Legislation  in  Newr  York,  Recent  Medical .  4:1 

Leprosy,  A  Senseless  Panic  over .  180 

Medical  Charity,  The  Abuse  of .  687 

Microbial  Products,  The  Action  of,  on  Mi¬ 
crobes  and  on  the  Organism .  321 


INDEX  TO  VOLUME  LU. 


733 


PAGE 

Leading  Articles  : 

National  Guard  of  the  State  of  New  York,  The 

Medical  Service  of  the .  380 

Nephritis,  Clostridial .  409 

GJsopliageal  Varix  as  a  Cause  of  Ikemateme- 

.  321 

Paraplegia,  Rhachiotomy  for .  465 

Pasteurism  before  the  Academy .  517 

Parturition,  Normal,  complicated  by  an  Extra- 

uterine  Twin  Foetus .  466 

Peritonitis,  The  yEtiology  of .  212 

Pharmaceutical  Preparations,  False  Weights 

in  - .  271 

Pleurisy,  Acute .  492 

Pneumonia,  The  Bacteriology  of  Acute  Croup 

ous .  408 

Profession,  Surgeon  Parke  and  the  Medical. ..  184 

Reviews,  The  Ethics  of  Book .  546 

Rhachiotomy  for  Paraplegia . 465 

Rheumatism,  Acute .  492 

Sanitarium,  The  Adirondack . 434 

Singing,  Faulty  Methods  of .  ......  492 

Societies  to  Scientific  Research,  The  Relation 

of  American  Medical .  184 

Society,  The  German  Surgical .  46 

Surgeon-Generalship  of  the  Army,  The  Presi¬ 
dent’s  Nominee  for . 212 

Surgery  and  Cruelty  to  Animals .  632 

Surgery,  Further  Advances  in  Cerebral . 408 

Syphilis,  Some  Unusual  Modes  of  infection 

with .  18 

Therapeutics,  The  Renaissance  in .  604 

Tubercular  Disease,  The  Koch  Treatment  of  !  631 
Tubercular  Disease,  The  Progress  of  the  Koch 

Treatment  of .  686 

Tuberculosis,  Koch’s  Alleged  Cure  for . . .  570 

Tuberculosis,  Protective  Inoculation  against. .  296 

Uterus,  Removal  of  the  Puerperal  Septic .  243 

Visual  Center,  Munk’s . 546 

Vivisection . 662 

Water  Supply,  New  York’s  New . .  ’  73 

Lectures,  Dr.  Solis-Cohen’s . .  633 

LeFevre,  E.  What  is  accomplished  by  the  Use 

of  Digitalis  in  Cardiac  Disease  ? .  38 

Lens,  Traumatic  Dislocation  of  the  Crystalline  .  295 
Lenses  dislocated  into  the  Vitreous,  The  Ex¬ 
traction  of .  261 

Leprosy . ..*11’”'!  166 

Leprosy  at  Cape  Breton . 690 

Leprosy  in  Colombia . ! ' 633 

Leprosy,  Two  Cases  showing  the  Treatment  of  128 
Levis,  The  Death  of  Dr.  Richard  J.,  of  Philadel¬ 
phia  .  57,3 

Levis,  The  late  Dr.  Richard  J . ........  665 

Lichen  Planus .  .....  552 

Lichen  Ruber  in  its  Relation  to  Lichen  pianus. .  166 

Life  in  Organic  Heart  Disease,  A  Limit  to, 

should  be  set  with  Caution .  443 

Life  insurance,  Some  Points  in  the  Examination 

of  Persons  for . 206 

Ligation  of  the  Limbs  in  Haemorrhage. .........  637 

Ligature  of  the  Uterine  Arteries .  109 

Lilienthal,  S.  Letter  to  the  Editor . .  .  .  .  .  .  .  551 

Limbs,  The  Management  of  Fractured . !  536 

Lipanine  as  a  Substitute  for  Cod-liver  Oil.  '  ’  473 
Lippincott,  J.  A.  New  Tests  for  Binocular 

Vision .  350 

Liquor  Ferri  Subsulphatis,  On  Stomatitis  Gan¬ 
grenosa,  with  special  Reference  to  its  Treat¬ 
ment  with .  208 

Liquors,  Prescribing . 631 

Literary  Reproduction,  An  Interesting.  ..!"""  47 

Lithotrity  in  Children . '  472 

Lithotomy,  Suprapubic . . . !!!!!!!  246 

Liver,  Abscess  of  the.S . ’ . .  326 

Liver,  Acute  Yellow  Atrophy  of  the . '.‘.'..V.  270 

Liver  in  Typhoid  Fever . '  395 

Liver,  Multiple  Abscesses  of  the . 219 

Lloyd,  of  Flatbush,  The  Murder  of  Dr.  ....'!!!!  435 
Locomotor  Ataxia,  A  Modification  of  Romberg’s 

Test  in  the  Diagnosis  of . 272 

Loebinger,  H.  J.  A  New  Local  Therapy  of  Tu¬ 
berculosis  Pulmonalis .  677 

London,  Letters  from .  17  491 

Lunacy  in  Ireland . .  .7.7 _ .’  409 

Lunatics,  Precautions  against . ’ . ”  513 

Lupus  of  the  Larynx . ..!.!!.!!!!!!  162 

Lupus  of  the  Lower  Extremities . 641 

Luxation  of  the  Head  of  the  Humerus,  Irreduci¬ 
ble  Intracoracoid .  328 

Lj  mpho-sarcoma  of  the  Neck . .!...!...!!  162 

MacCoy,  A.  A  Case  of  Myxoma  of  the  Naso¬ 
pharynx  in  a  Child  Six  Years  Old .  341 

MacDonnell,  R.  L.  A  Ward  Clinic  in  the  Mont¬ 
real  General  Hospital . 

Mackenzie,  J.  N.  A  Suggestion  concerning  the 
Intimate  Relationship  between  Bulbo-nu- 
clear  Disease  and  Certain  Ooscure  Neurotic 
Conditions  of  the  Upper  Air-passages..  176  187 

MacPherson,  J.  D.  Letter  to  the  Edito . .’  720 

MaCPherson,  J.  D.  The  Importance  of  Prompt 

Treatment  in  Alveolar  Abscess .  567 

Magazine,  The  University  Medical . ’...!.'.  719 

Major,  G.  W.  Notes  on  an  Interesting  Case  of 

Aneurysm . 427 

Male  Fern,  Fatal  Poisoning  with . .  548 

Malformati  n  of  the  Fingers,  Congenital ...77  23 

Malformation  of  the  Heart,  Two  Cases  of  Con¬ 
genital . 472 

Malformations,  Branchial .  571 

Malingering,  The  Supra-orbital  Pressure  Test  of.  180 

Malone,  The  Death  of  Dr.  Edward,  of  Brooklyn.  20 

Maltine  and  Sterilized  Milk .  168 


359 

714 


PAGE 


Manikin,  The,  in  the  Teaching  of  Practical  Ob¬ 
stetrics .  698,  701 

Manslaughter,  The  Faith  Cure  and .  323 

Marcy,  H.  O.  An  Address  on  the  Present  Posi¬ 
tion  of  Antiseptic  Surgery . 5C5 

Marine-Hospital  Service,  Changes  of  Medi¬ 
cal  Officers  of  the  : 

Ames,  R.  P.  M .  215,  324,  438,  520 

Armstrong,  T.  S .  273 

Austin,  H.  W  .  ”273,  635 

Bailhache,  P.  H .  159,  273,  691 

Banks,  C.  E . . .  4?8 

Benedict,  A.  L .  159 

Brown,  B.  W .  273 

Carmichael,  D.  A .  215  324 

Carter,  H.  R . .’  574 

Cobb,  J.  0  .  273,  324 

Cofer,  L.  E .  615,  691 

Condict,  A.  W .  20,  520,  635 

Devan,  S.  C .  159,  324 

Fessenden,  C.S.D .  .  635,  691 

Gassaway,  J.  M . ■ .  20,  520 

G.eddings,  H.  D .  574 

Godfrey,  John .  159,  438 

Goodv.un,  H.  F .  324 

Guiteras,  G.  M . 574 

Groenevelt,  J.  F .  574  594 

Heath,  F.  C .  20 

Houghton,  E.  R .  459 

Hussey,  S.  H .  159,  324,  438,  574,  691 

Hutton,  W.  H.  H .  159,  273,  438,  519,  691 

Irwin,  Fairfax .  273,  520,  635 

Kalloch,  P.  C .  159,  215,  273 

Kinyoun,  J.  J .  520,  635 

Long,  W.  H .  273,  438,  519 

Magruder,  G.  M .  20,  159 

Mead,  F.  W .  273 

Peckham,  C.  T .  159,"  215,  691 

Perry,  J.  C .  215,  325,  438 

Perry,  T.  B .  159,  273,  520 

Pettus,  W.  J .  438,  520 

Purviance,  George . 438 

Sawtelle,  H.  W  .  215,  520,  691 

Smith,  A.  C .  215 

Stimpson,  W.  G .  159,  2is!  635 

Stoner,  George  W .  20,  324 

Stoner,  J.  B .  159 

Vansant,  John .  324 

Wasdin,  Eugene .  20 

Wertenbakef,  C.  P .  438 

Wheeler,  W.  A .  215,  438 

White,  J.  II .  20,  520 

Williams,  L.  L .  159,  324 

Woodward,  R.  M .  20,  635 

Wyman,  Walter .  324,  519 

Young,  G.  B .  159,  215,  325,  438 

Marine- Hospital  Service,  The  United  States _  468 

Marlow,  F.  W.  Letter  to  the  Editor .  357 

Marriage  in  India,  The  Evils  of  Early .  475 

Marriages,  A  Check  upon  Early .  112 

Marshall,  C.  R.  A  Practitioner’s  Experience  in 

Infant-feeding .  237 

Martinez,  J.  J.  Compound  Fracture  of  the 

Skull .  293 

Massage . ] !  437 

Massage  in  Sweden .  444 

Mastoiditis  in  the  Negro .  443 

Materia  Medica,  The  Value  of  Experimental. ...  600 

Maternity,  Early .  457 

Mattison,  J.  B.  Letter  to  the  Editor . 438 

McBurney's  Point  .  549,  550 

Measles,  Singular  Experience  with  Scarlet 

Fever  and .  433 

Medical  Board,  An  Army .  272 

Medical  Examiners  of  New  Jersey,  The  State 

Board  of . 382 

Medical  Progress.  Help  and  Hindrance  to . 469 

Medication,  Rectal .  725 

Medicine  of  the  Classics .  527 

Medicine,  Reports  on  General . 304 

Medicine,  Sectionalism  in .  663 

Medicine,  The  New  Jersey  Law  regulating  the 

Practice  of . .  .  213 

Meltzer,  S.  J.  Some  Remarks  on  my  Hy¬ 
pothesis  of  the  Self-regulation  of  Respira¬ 
tion,  and  Dr.  Cowl’s  Discussion  of  it .  561 

Membrane,  The  Processes  taking  Place  in  the 

Diphtheritic .  304 

Memminsrer.  A.  Letter  to  the  Editor. 77.77  412 

Memorial,  A  Novel  Form  of .  20 

Meniere’s  Disease,  The  Operative  Treatment  of.  572 

Meningitis,  A  Case  of  Cerebro-spinal .  23 

Memngitis,  Blindness  alter  Cerebro-spinal .  215 

Meningiiis,  Blindness  following  Cerebro-spinal.  146 

Meningitis,  Suppurative .  613 

Meningitis,  Tuberculous . 553 

Menstrual  Epoch,  The  Management  of  the .  162 

Mental  and  Nervous  Diseases,  Some  Points  in 

the  Diagnosis  of  Certain  Simulated .  94 

Menthol  for  Chapped  Hands .  688 

Menthol  in  Diphtheria,  The  Use  of. .  632 

Mercurial  Preparations,  The  Treatment  of  Syphi¬ 
lis  by  Subcutaneous  Injection  of .  167 

Mercury,  Erysipelas  treated  with  the  Bichloride 

.  14 

Mercury,  The  Comparative  Value  of  the  Binio- 
dide  and  the  Bichloride  of,  as  Surgical  Anti¬ 
septics .  558 

Methylene  Blue  as  an  Ana/gesic .  434 

Methylene  Blue  as  an  Anodyne . 440 

Microbes  in  Hailstones .  435 

Microbes  of  Pneumonia .  270 

Micro-organisms.  Diphtheritic .  218 

Midwifery  in  Canton,  Native .  444 


PAGE 

Midwives,  Antiseptic  Solutions  for .  93 

Midwives,  Obstetric  Operations  in  the  Practice 

of .  |Q5 

Midwives,  The  Use  of  Anaesthetics  by ...777 193 

Migraine  and  Gout,  Green  Coffee  in .  6a3 

Migraine,  The  Treatment  of  Circumorbital  and 

Ocular .  55 

Milk,  Infection  from . .".'!."!!!!!!  664 

Milk,  Maltine  and  Sterilized . ! ! .  468 

Milk,  Practical  Hints  on  Sterilizing .  668 

Milk,  Results  of  the  Use  of  Sterilized .  668 

Milk,  Thunder  and  Sour . .  420 

Mills,  W.  The  Blood  and  Blood-vessels  in 

Health  and  Disease .  281 

Moles  and  their  Treatment,  Uterine .  724 

Monod.  The  Death  of  Dr.  Gustave .  519 

Monster,  A  Sternopagous .  727 

Moore,  II.  B.  Reasons  for  the  Relative  Immuni¬ 
ty  from  Pulmonary  Phthisis  in  Colorado,  etc.  314 
Morris,  R.  T.  Hypertrophy  of  the  Prostate 
Gland.  An  Addition  to  McGuire’s  Opera¬ 
tion  .  57 

Mortality  in  Cities  in  the  United  States .' . . . .'  .  28,  112, 
140,  224,  252,  280,  308,  336,  392,  504,  672,  700 

Mountain  Disease .  466 

Mountains,  The  Catskill . !!'.!!!'.!!!’,!!!!  298 

Mulberry  Stone  in  a  Young  Child .  23 

Muscle.  Unilateral  Paralysis  of  the  Lateral  Crico- 

arytaenoid . 346,  362 

Mussels,  Fatal  Poisoning  by .  ’  322 

Mycoses,  Surgical .  169 

Myomectomy,  Vaginal  Fixation  of  the  Stump 

after...  .  499 

Myopia,  The  Heredity  of .  54 

Myxoma  of  the  Epiglottis,  A  Case  of .  268,  274 

Myxoma  of  the  Naso-pharynx  in  a  Child  Six 
Years  Old,  A  Case  of . 344,  359 

Nasal  Reflexes,  The  Relation  of  Diseased  Con¬ 
ditions  in  the  Upper  Air-passages  to  So- 

called  .  21 

Nasal  Septum,  A  New  Operation  for  Deviation 

_  of  the .  675,  693 

Nas  1  Work,  A  Few  New  Cutting  Instruments 

_  for- .  335 

Naso-pharynx,  Myxoma  of  the,  in  a  Child  Six 

Years  Old . 341,  359 

Naval  Surgeon,  An  Assault  on  an .  573 

Navy,  Changes  of  Medical  Officers  of  the  : 

Alfred,  Adrian  Richard .  6.35  691 

Ames,  II .  E . .  215,  437,  691 

Anderson,  Frank .  438 

Anzal,  E.  W .  102,  215,  468 

Arnold,  William  F .  519 

Ashbridge,  Richard .  102,549 

Atlee,  Louis  W .  20,  75,  549,  691 

Ayers.  Joseph .  215,  468,  607 

Babin,  H.  J .  432 

Bailey,  T.  B . ! ....  102 

Barber,  George  H .  215 

Bates,  N.  L . 607 

Berryhill,  3’.  A  .  324 

Bertelotte,  D.  N . 7*.  691 

Blackwood,  N.  J .  159,  438,  519 

Bloodgood,  Delavan .  691 

Bogert,  E.  S .  549 

Braisted,  William  C .  437  438 

Bright,  George  A .  186,  215,  324,  468 

Cabell,  A.  G .  403 

Cooke,  George  II . 7  102 

Cordeiro,  F.  J.  B . 494,  6,35 

Crawford,  M.  H . 324'  634 

Derr,  E.  Z . ’  i86 

Dickson,  S.  II .  691 

Drake  N.  H  . 324 

Eckstein,  A.  C .  "  102 

Edgar,  John  M . 438,  549 

Evans,  Sheldon  Guthrie .  607 

Fitts,  H  B . !....  215 

Fitzsimmons,  Paul .  304 

Gardner,  J.  E .  324  43s 

Green,  E.  H . . 574 

Harris,  H.  N.  T .  691 

Heffinger,  A.  C . 7 .  '324,  494 

Herndon,  C.  G .  43a 

Heyl,  T.  C . 7!  jm 

Hoehling,  A.  A . 402,  273 

Kennedy,  Robert  M  .  20,  48,  273,  549 

Keeney,  James  F .  324,  691 

Kershner,  Edward. .  273 

Lansdale,  Philip .  635 

Lovering,  P.  A . ! ! ! !  75,  102 

Lowndes,  Charles  H.  T .  324 

Lumsden,  George  P . 468 

Mackie,  B.  S  . ‘  436 

Marsteller,  E.  H  . . 77.  634 

Martin,  H.  M .  549  574  roi 

McClurg,  Walter  A . 273 

McCormick,  A.  M.  D . 77  691 

McMurtrie,  D .  75 

Moore  A.  M . '.’.7.7  18(3*  519,  607 

JNash,  Francis  8 .  aju 

North,  J.  II.,  Jr . .."'!".  215 

Norton,  Oliver  D.. . 7.  .  430 

Owens  Thomas . 549  574 

Page,  John  E .  20  48 

Penrose,  Thomas  N . 402  324 

Persons,  R.  C . !  ’ .  ’  433 

Price,  A.  F . 77777  438 

DixeF’  P  H . . . .7!  76,  574 

Sayre,  J.  S .  345 

Scott,  Horace  B . 7  438,  549 


INDEX  TO  VOLUME  LI I. 


|N.  Y.  Med.  Jour 


734- 


page 

Navy,  Changes  of  Medical  Officers  of  the  : 

Siegfried,  C.  A .  438 

Smith,  George  T . 215 

Smith,  Howard .  468,  574 

Spratling,  L.  W .  438,  549 

Stephenson,  F.  B . 519 

Stone,  E.  P .  215 

Stone,  Lewis  H .  20,  132,  438,  519 

Uric,  J.  F .  132 

Waggener,  J.  R .  186 

Wales,  P.  S .  159,  215,  437 

Wedekind,  L.  L.  von . 215 

Wells,  H.  M .  102 

Wentworth,  A.  R .  324,  691 

Wtiite,  Charles  N . .  102,  438,  549 

White,  S.  Stuart .  75,  102,  215 

Whitfield,  .Tames  M .  20,  102,  215,  691 

Wise,  J.  C . 324 

Woolverton,  Theoron .  75,  102,  324 

Navy,  The  Annual  Report  of  the  Surgeon-Gen¬ 
eral  of  the .  688 

Neck,  Large  Tumors  of  the .  666 

Negro,  Mastoiditis  in  the .  413 

Nephritis,  The  Pathogeny  of  Albuminuria  and..  3Q7 

Nerves  of  the  Back  of  the  Hand .  223 

Nervous  Derangements  after  Castration .  271 

Nervous  Diseases,  The  Brunswick  Home  for... .  214 

Neumer,  The  late  Dr.  Emil .  644 

Neuralgia,  So-called  Deltoid . 298 

Neuritis,  A  Case  of  Traumatic .  489 

Neuritis,  A  Case  of  Visceral .  689 

Neuritis  of  Syphilitic  Origin,  A  Contribution  to 

the  Study  of  Multiple .  1 

Neuritis,  or'  Beri-beri,  among  Seamen,  Multi¬ 
ple .  79 

Neuro-psychoses,  Traumatic .  78 

New  Haven,  Letter  from .  661 

New  York,  Infectious  Diseases  in _  20,  47,  74,  102, 

132,  158,  186,  214,  245,  273,  298,  323,  865,  382, 
410,  436,  46S,  494,  519,  548,  573,  634,  664,  689 

New  York,  The  Fountains  of .  132 

Night-sweats  of  Phthisis,  Potassium  Tellurate 

in  the .  19 

Nitroglycerin,  A  Case  of  Morphine  Poisoning 

treated  with .  545 

Nitroglycerin  in  Gas  Asphyxia  and  Poisoning-.  48 

Nitroglycerin  in  Gas  Poisoning .  20 

Nose,  Epithelioma  of  the .  665 

Nose.  Look  beyond  the .  340,  358 

Nose,  The  Connection  between  Diseases  of  the 

Eyes  and  Diseases  of  the .  54 

Nose,  Warty  Growths  in  the .  345,  360 

Nursing  Women,  The  Use  of  Spirits  and  Malted 

Drinks  in .  24 

Nussbaum,  The  Death  of  Professor  von .  519 

Nystagmus  and  the  Safety-lamp,  Miners’ .  157 

Obituaries  : 

Bigelow,  Dr.  Henry  Jacob .  549 

Obstetric  Cases,  The  After-treatment  of .  126 

Obstetric  Science,  What  Influence  would  a  more 
Perfected,  have  on  the  Biological  and  Social 

Condition  of  the  Race?.. .  645 

Obstetrics .  526 

Obstetrics,  Reports  on .  192 

Obstetrics,  The  Manikin  in  the  Teaching  of 

Practical .  698,  701 

Ocular  Defects  as  a  Frequent  Cause  of  Head¬ 
ache  .  233 

Oculomotorius  in  the  New-born  and  Adult  Cat, 

The  Number  and  Caliber  of  Nerve  Fibers  in 

the .  54 

O’Donnell,  The  late  Dr.  W.  T . ;. .  67 

Oesophagus,  Cancer  of  the . 329 

Oesophagus,  Cicatricial  Stricture  of  the .  190 

Ointment,  Chloroform .  688 

Oleum  Physeteris  seu  Chaenoceti . 640 

Operations  in  the  Practice  of  Midwives,  Obstet¬ 
ric  .  195 

Opium  Habituds,  The  Urine  of . 323 

Ophthalmology,  Reports  on  .  52 

Ophthalmoscope,  A  New .  139 

Optic  Nerve.  Atrophy  of  the .  53 

“Oristry” .  19 

Ormsby,  R .  552 

Osier,  W.  Letters  to  my  House  Physicians.  81,  163, 

191,  274,  333 

Osteitis  among  Pearl  Workers,  Recurring  Mul- 

'  tiple . 185 

Osteo-chondromata .  248 

Osteomalacia  in  Chronic  Diseases  of  the  Central 

Nervous  System . 663 

Otitis  Furunculo8a .  384 

Otitis  Media,  Catarrhal .  3S4 

Ovaries,  Removal  of  the  Tubes  and .  615 

Ovary,  Fibromyoma  of  the .  248 

Oxygen,  Anaesthesia  in  Frogs  by  Deficiency  of..  137 
Oxygen  Inhalations  on  the  Variation  of  the  Re¬ 
spiratory  Rhythm  in  Diphtheritic  Patients, 

The  Influence  of .  137 

Oxytnemoglobin  into  the  Gall-bladder  after 

Death.  The  Passage  of . 136 

Oysters,  Convulsions  following  the  Ingestion  of 

Unsound .  5S3 

Ozaena,  Aristol  in .  131 

Ozone,  Peroxide  of  Hydrogen  and .  531 

Paget’s  Disease  of  the  Breast . 663 

Paget’s  Disease  of  the  Nipple .  166 

Pain,  The  Weather  in  Relation  to  Neuralgic.. . .  77 

Pallen,  The  Death  of  Dr.  Montrose  A .  411 

Palpo-traction .  384 

Pambutano,  a  Substitute  for  Quinine . . .  572 

Paraldehyde,  The  Hypnotic  Efficiency  of . 605 


PAGE 

Paralyses  occurring  during  the  First  Twto  Years 

of  Life,  Points  in  the  Pathology  of  the .  471 

Paralysis  Agitans,  A  Clinical  Study  of  Forty- 

seven  Cases  of .  393 

Paralysis,  A  Case  of  Pseudo-hypertrophic .  283 

Paralysis  of  Speech  following  an  Injury,  A  Case 

of  Trephining  for .  ....  42 

Paralysis  of  the  Abductors  of  the  Larynx .  363 

Paralysis  of  the  Abductors  of  the  Larynx,  A 

Case  of  Unilateral .  398 

Paralysis  of  the  Lateral  Crico-arytaenoid  Muscle, 

Unilateral . . .  346,  362 

Paralysis,  The  Spinal  Cord  in  Infantile .  471 

Paraplegia  cured  by  Operation,  A  Case  of  Com¬ 
plete  .  78 

Paraplegia,  Diabetic . . .  718 

Paraplegia,  Senile .  78 

Parasites  of  Sheep,  The  Animal .  74 

Parke,  J.  R.  An  Inquiry  into  the  Relationship 
of  Amygdalitis  to  the  Cerebro-spinal  Cen¬ 
ters  .  98 

Parturition,  Hot  Irrigations  subsequent  to .  193 

Pasteur  Institute.  The  New  York .  476 

Patella,  A  Case  of  Fracture  of  the,  into  the  Knee 

Joint .  516 

Patella,  Fracture  of  the .  328 

Patella,  The  Pin-wiring  Treatment  of  Fracture 

of  the . . .  159 

Pelvic  Affections,  The  Brandt  Remedial  Meth¬ 
ods  for .  32 

Pelvic  Disease,  The  Diagnosis  of .  335 

Pelvic  Floor,  The  Immediate  Repair  of  Injuries 

to  the .  160 

Pelvic  Troubles  traceable  to  Minor  Gyntecology, 

Certain  Causes  of  Major. . .  . 446 

Pelvis,  New  Operative  Procedure  for  reaching 
the  Organs  of  the,  by  way  of  the  Perinoeum .  109 
Penis  for  Cancer,  Two  Cases  of  Extirpation  of 

the .  328 

Percussor,  The  Auscultatory .  299 

Perin,  The  Death  of  Dr.  Glover,  of  the  Army. . .  690 
Perineal  Repair,  A  Comparative  Estimate  of 

Tait’s  Method  for .  110 

Perinoeum,  New  Operative  Procedure  for  reach¬ 
ing  the  Organs  of  the  Pelvis  by  way  of  the. .  109 

Peritonaeum,  Irrigation  of  the .  109 

Peritonitis  in  Infancy  and  Childhood _ _ 668 

Peritonitis,  The  Diagnosis  and  Treatment  of 
Certain  Abdominal  Diseases  characterized 

by  Symptoms  of . . . 441 

Peritonitis,  The  Treatment  of  General  Septic. . .  723 
Peterson,  F.  A  Clinical  Study  of  Forty-seven 

Cases  of  Paralysis  Agitans .  393 

Peterson,  F.  Homonymous  Hemiopic  Hallucina¬ 
tions . . . . .  241 

Peterson,  F.  Note  on  a  New  System  of  Exact 
Dosage  in  the  Cataphoretic  Use  of  Drugs. . .  543 
Pharynx,  A  Case  of  Primary  Tuberculosis  of  the.  404 
Pharynx,  Adenoid  Tissue  in  the  Naso-pharynx 

and  .  316 

Pharynx,  Cancer  of  the .  329 

Phelps,  A.  M.  Some  New  Lateral-traction  Hip 

Splints . 511 

Phenacetin  in  Typhoid  Fever .  465,  560 

Phillips,  D.  Letter  to  the  Editor .  637 

Phonograph  as  a  Disseminator  of  Disease .  132 

Phtheiriasis  Pubis,  A  Remedy  for .  272 

Phthisis  in  Colorado,  Reasons  for  the  Relative 

Immunity  from  Pulmonary . 314 

Phthisis,  Potassium  Tellurate  in  the  Night- 

sweats  of .  19 

Phthisis,  Professor  Flint’s  Doctrine  of  the  Self¬ 
limitation  of .  495 

Phthisis,  Pulmonary,  treated  by  Inoculation 

with  Animal  Virus .  602 

Phthisis,  The  Distribution  of  the  Lesions  in 

Chronic .  414 

Phthisis,  The  Dosage  and  Administration  of 

Creasotein .  85,  106 

Phthisis,  The  Mortality  of  Widow'ers  from . 491 

Physician  as  a  Witness,  The .  528 

Physicians,  Letters  to  my  House .  81,  163,  191, 

274,  333 

Physicians,  The  Attractiveness  of  Chicago  to. . .  633 

Physician,  The  Death  of  an  Aged .  158 

Physiology,  Reports  on .  24,  134 

Pigmentation  of  the  Human  Skin .  640 

Pilocarpine  in  Dermatology,  Notes  on  .  332 

“Pink-eye” . .' .  273,  356 

Pinus  Palustris  as  a  Vulnerary,  Extract  of .  412 

Piscidia  in  Diseases  of  the  Female  Organs  of 

Generation .  657 

Placenta  in  Abortion.  The  Management  of  the. .  529 
Placental  Disease  as  a  Cause  of  Premature 

Labor .  582 

Plague  in  Turkey,  Bubonic .  214 

Plate,  The  Rawhide .  429 

Pleurisy,  Report  of  a  Case  of  Acute  Purulent ...  294 

Pleurotomy .  294 

Pleurotomy,  Double . 487 

Plica .  332 

Pneumonia,  Acute  Primary  Broncho- .  67 

Pneumonia,  An  Epidemic  of  Tubercular .  719 

Pneumonia  in  Children . 497 

Pneumonia,  Oxygen  Inhalations  in .  101 

Pneumonia,  The  Microbes  of .  270 

Poisoning  by  Mussels,  Fatal .  322 

Poisoning,  Nitroglycerin  in  Gas .  20 

Poisoning,  Nitroglycerin  in  Gas  Asphyxia  and. .  48 

Poisoning  with  Male  Fern,  Fatal .  548 

Poisoning  wi  h  Salol,  Fatal .  245 

Poisons  for  the  Bacillus  Tuberculosis .  381 

Policlinique,  The  Paris .  355 

Polyclinic,  A  Slur  on  the,  Corrected .  493 


PAGE 


Polyclinic,  The  Chicago .  132 

Polyclinic,  The  New  York .  468,  717 

Polyclinic,  The  Slur  on  the .  520 

Population,  A  Premium  on .  298 

Porencephaly .  249 

Post-graduate  Undertaking,  The  Brooklyn . 719 

Post,  S.  E.  The  Borderland .  44 

Potassium  in  Intermittent  Fever,  Nitrate  of .  133 

Potassium  Tellurate  in  the  Night-sweats  of 

Phthisis .  19 

Potassium,  The  Elimination  of  the  Iodide  of,  by 

the  Kidneys .  640 

Pregnancy  complicated  by  Circumuterine  Inflam¬ 
matory  Deposits  . .  615 

Pregnancy,  Ectopic .  194,  552 

Pregnancy,  Extra-uterine .  192 

Pregnancy  following  the  Conservative  Caesarean 
Section,  The  Prognosis  as  to  the  Probability 

of .  195 

Pregnancy,  Ovarian  Fibroid  and  Tubal .  247 

Pregnancy,  'The  Diagnosis,  Pathology,  and  Treat¬ 
ment  of  Extra-uterine .  439 

Pregnancy,  Tubal .  728 

Preservaline .  185 

Prince,  A.  E.  The  Surgical  Treatment  of  Post- 


WIUUIVU  XXJ  . . . 

Pritchard,  W.  B.  A  Case  of  Traumatic  Neuritis 
illustrating  the  Medico-legal  Value  of  Elec¬ 
tricity  in  Diagnosis .  489 

Prize,  The  Astley  Cooper .  74 

Prize,  The  Hunter  McGuire .  383 

Prize,  The  Mattison . 684 

Prize,  The  Orton . 573 

Profession,  A  Christmas  Sentiment  regarding 

the  Medical .  718 

Profession,  Sound  Advice  for  the .  56 

Prognostics  in  Medicine .  522 

Prolapse  of  the  Rectum .  611 

Prolapse  of  the  Uterus,  Artificial .  159 

Prophylaxis,  Scientific .  605 

Prostate,  Suprapubic  Cystotomy  in  a  Case  of 

Enlarged .  722 

Prostitution  in  England  and  France,  The  Regu¬ 
lation  of .  587 

Prostitution,  The  Regulation  of .  587 

Protopine .  664 

Prurigo,  Observations  on . 330 

Pruritus . .  331 

Pruritus  Hiemalis,  A  Clinical  Study  of .  331 

Psoriasis  and  Syphilis,  The  Coincidence  in .  167 

Psoriasis,  Aristol  in  the  Treatment  of .  165 

Psoriasis,  The  Pathological  Anatomy  of  .  642 

Psychoses,  Cortical  Excision  in  the  Treatment 

of .  664 

Ptosis,  A  New  Operation  for .  55 

Puerperal  Fever,  Alcohol  in  the  Treatment  of..  193 
Pulmonary  Disease,  Clinical  Lectures  on  some 


commonly  observed  Forms  of.  225,  253,  254,  309 


Puncture  of  the  Female  Pelvic  Organs,  Explora- 


Purdy,  C.  W.  The  Influences  of  Climate  in  the 

United  States  over  Bright’s  Disease .  374 

Purpura  Haemorrhagica .  557 

Pyoctanin  as  an  Antiseptic,  Note  on  the  Action 

of .  204 

Pyrexia,  Scarlet  Fever  with  but  Slight .  ...  548 

Quinan,  The  Death  of  Dr.  J.  R.,  of  Baltimore. .  573 
Quinine,  Pambutano,  a  Substitute  for .  572 

Rabies  at  the  Academy  of  Medicine,  The  Dis¬ 
cussion  on .  548 

Rabies  from  the  Bite  of  a  Skunk .  344 

Rabies,  The  Reality  of .  529 

Rabinovitch,  L.  G.  Reports  on  Physiology.  24,  134 
Rake,  B.  Two  Cases  showing  the  Treatment 
of  Leprosy  :  1  1)  by  Excision  of  Tubercles  ; 

(21  with  Ointment  of  Red  Iodide  of  Mer¬ 
cury .  128 

Ranula,  A  Rare  Case  of  Congenital  Form  of . . ..  190 

Reagent,  A  New  Alkaloidal .  173 

Reception  in  the  Academy  of  Medicine's  New 

Building,  The  Opening .  547 

Record,  The  Baltimore  Medical  and  Surgical.. .  519 

Rectum,  Cancer  of  the .  329 

Rectum,  Laparo-colotomy  for  Stricture  of  the  . .  310 

Rectum,  Prolapse  of  the .  611 

Rectum.  Simple  Ulcer  of  the. . .  889 

Rectum,  Stricture  of  the,  following  an  Opera¬ 
tion  for  Imperforate  Anus  . 497 

Red  Corpuscles  and  the  Haemoglobin,  The  Ef¬ 
fect  of  Tropical  Countries  on  the  Number  of.  587 
Register  of  New  York,  New  Jersey,  and  Con¬ 
necticut,  The  Medical .  74 

Renal  Disease,  The  Relation  of  Gonorrhoea  to  . .  433 

Reports,  Clinical .  714 

Resorcin  in  Skin  Diseases,  Another  Method  of 

using .  640 

Respiration,  Remarks  on  the  Hypothesis  of  the 

Self-regulation  of .  561 

Respiration,  The  Factors  of  the  Respiratory 

Rhythm  and  the  Regulation  of . 256 

Retina,  A  Case  of  Detachment  of  the,  etc .  53 

Retina  in  Old  People,  The  Degeneration  of  the 

Center  of  the .  53 

Retina,  The  Treatment  of  Detachment  of  the. . .  53 

Retiuoscope  and  Strabismometer  combined .  474 

Retro-displacements  of  the  Uterus  with  Adhe¬ 
sions.  New  Method  of  Treatment  for .  522 

Review,  The  Asheville  Medical .  355 

Rhein,  M.  L.  Letter  to  the  Editor .  635 

Rhett,  R.  B.,  Jr.  An  Intraligamentary  Ovarian 
Cyst  successfully  treated  with  Iodine  Injec¬ 
tions  . . . • .  69 


INDEX  TO  VOLUME  LI I. 


Rheumatism,  Cardiac  Complications  of  Gonor- 

,  \7rh0eal .  ggg 

Rheumatism  especially  involving  the  Tonsils, 

Observations  on . ’  90 

Rhubarb,  Hiematuria  and  Garden  .  185 

Richmond,  C.  II.  A  Case  of  Intestinal  Anasto¬ 
mosis  for  Fa'cal  Fistula . 674 

Rickets,  The  Nature  and  Treatment  of . !  *  470 

Ridlon,  J.  A  Report  of  Sixty-two  Cases  of  liip 

Disease . 399 

Riggs,  Dr.  C.  Eugene . !.......!....  51!) 

Ringworm,  Mr.  Hutchinson’s  Treatment  of! ... !  354 
Robinson,  K.  B.  The  Rawhide  Plate.  A  New 

Plate  for  Intestinal  Anastomosis .  429 

Robson,  A.  W.  M.  Letter  to  the  Editor .  159 

Rolando,  The  Fissure  of . . . 7^9 

Roosevelt,  J.  W.  The  Gross  Anatomy  of  Chronic 
Pulmonary  Consumption  in  Relation  to  Diag¬ 
nosis  and  Prognosis .  58 

Rupture  of  the  Heart . .!.!!.!.!!'..!!  103 

Rupture  of  the  Short  Head  of  the  Biceps  .  005 

Rupture  of  the  Vagina .  .  4.35 

Russell,  T.  II.  Complete  and  Permanent  Recov¬ 
ery  by  Jcjuno-ileostomy  with  Senn’s  Bone 
Plates  In  Intestinal  Obstruction,  etc .  073 

Sacculations  and  Cystic  Dilatations  of  Veins 

Congenital .  223 

Safety-lamp,  Miners’  Nystagmus  and  the .  157 

Salicylic  Acid  as  a  Prophylactic  of  Scarlet  Fever  088 

Salines  in  Peritonitis  .  75 

Salines  in  Typho-malarial  Fever.  . .  75 

Salipyrine.  .*. . .  . ’.!!!’.!  004 

Salol,  Fatal  Poisoning  with .  245 

Salol  in  Cholera . .!!!!".!’."..!  131 

Salol  in  Dysentery . !!!.!!.!!!!!!!  75 

Sarcoma  of  the  Finger  of  Unusual  Size,  Giant- 

celled... . 43 

Sarcoma  of  the  Testis,  Round-ceiled .  2l9 

Sawyer,  A.  Letter  to  the  Editor . 433 

Sayre,  R  H.  The  Simultaneous  Occurrence  of 
Disease  of  the  Hip  and  Knee  Joints  in  the 

same  Limb .  355 

Scalp,  Tumors  of  the . !!!.!.!!!!!..."!!!  107 

Scarlatina  by  Acetate  of  Ammonium,  The  Treat¬ 


ment  of. 


Scarlet  Fever  and  Measles,  Singular  Experience 


305 


with 


133 


81 

79 


Scarlet  Fever,  Salicylic  Acid  as  a  Prophylactic  of  088 
Scarlet-fever  Throat,  The  Local  Treatment  of 

Diphtheria  and . *. . .  211 

Scarlet  Fever  with  but  Slight  Pyrexia  ! ! ! ! . 548 

School  of  Medicine,  The  Doctorate  Address  de- 

livered  before  the  Kentucky .  305 

School,  The  Harvard  Medical. ......  .  00G 

Schools  of  New  York,  The  Public . 494 

Schweig,  H.  The  Use  and  Abuse  of  the  Gaivano- 

cautery  in  Throat  Practice .  177 

Scirrhus  of  the  Rectum  in  a  Child  of  Thirteen 

Years . .  . . .  ^  218 

Scissors,  New  Naso-pharyngeal. .  . .  250 

Sclerosis  of  the  Brain  in  Children,  Diffuse  Cor¬ 
tical . . . . . 

Sclerosis,  On  Cases  of  Postero-laterai ! . ! . 

Scott,  M.  T.  A  Case  of  Compound  Fracture  of 

the  Patella  into  the  Knee  Joint .  510 

Secrecy  in  Lying-in  Hospitals .  '  157 

Sectionalism  in  Medicine .  003 

Seibert,  A.  A  Submembranous  Local  TreaU 

ment  of  Pharyngeal  Diphtheria .  024 

Sequel,  A  Typhoid . . ‘  543 

Shropshire,  W.  Erysipelas  treated  with  the  Bi¬ 
chloride  of  Mercury,  and  the  Result  in  Four 

Cases .  14 

Sickness  as  a  Teacher . .....!!!.'  280 

Sickness  of  Africa,  The  Sleeping .  493 

Skin  Diseases,  Another  Method  of  using  Resor¬ 
cin  in . 

Skin  Diseases,  Hydroxylamine  in  the  Treatment 

of . 

Skin,  Electrical  Discharges  from  the’  Human 

Skin,  Pigmentation  of  the  Human . 

Skinner,  W .  W.  Letter  to  the  Editor. !!!!!!”'  037 

Skull,  Compound  Fracture  of  the .  293 

Skunk,  Rabies  from  the  Bite  of  a . ..!!.!.!!!  344 

T.  Observations  on  the  Variability  of 

Disease  Germs .  409 

Soaps,  Medicated .  .'.'!!..!..  221 

Societies,  Meetings  of  : 

Academy  of  Medicine  and  Surgery,  Richmond 

.  v» . 75.  133,  217,  389,  412,’  582 

Academy  of  Medicine  in  Ireland,  Royal.  Sec¬ 
tion  in  Anatomy  and  Physiology .  101 

Academy  of  Medicine  in  Ireland,  Royal,  "sec¬ 
tion  in  Medicine .  104  437  220 

Academy  of  Medicine  in  Ireland.  Royal.  ’  Sec¬ 
tion  in  Obstetrics .  248 

Academy  of  Medicine  in  Ireland!  Royal’,  "sec¬ 
tion  m  Pathology .  102  218  249 

Academy  of  Medicine  in  Ireland,  Royal.  ’  Sec- 

tion  m  State  Medicine .  49  139 

Academy  of  Medicine  in  Ireland,  Royal.’  ’  Sec- 

tion  in  Surgery  . 103,  493,  2ig 

Academy  of  Medicine,  New  York .  21,  48,  299, 

44°  5°9 

Academy  of  Medicine,  New  York.  Section  in 

Obstetrics  and  Gynaecology . 159  944 

Academy  of  Medicine,  New  York.  Section  in 

Paediatrics .  23  497 

Academy  of  Medicine,  New  York!  ’  Section  in 
Surgery .  499 

Academy  of  Medicine,  New  York.  Section  in 

Theory  and  Practice  of  Medicine .  557  070 

Association,  Arneri  an  Dermatological .  330 


040 

105 

26 

640 


735 


697 

668 

665 


PAGE 

Societies,  Meetings  of  : 

Association,  American  Earyngological . 187, 

,  ...  n  274,  358,  093 

Association,  Canadian  Medical . 357  415 

Association,  Mississippi  Valley  Medical..  408,’  495 
Association,  New  York  County  Medical.  552 

Associ  .tion,  New  York  State  Medical . 521 

Association,  Southern  Surgical  and  Gynaeco¬ 
logical  . . . ; . . . . ; . . .  721 

Society,  American  Gynaecological _  439  558  498 

Society,  American  Neurological .  ’  77 

Society,  New  York  Clinical . !!!!'.  106 

Society,  New  York  Neurological .  553  o(2 

Society,  New  York  Surgical. .  215,  240,  825, 

327  009 

Society  of  Montreal,  Medico-chirurgical . .  414,’  444 
Society  of  the  County  of  New  York,  Medical. .  441 

Society  of  Virginia,  Medical .  383 

Societies  of  Louisville,  The  Medical . ! !  634 

Society  for  the  Relief  of  Widows  and  Orphans 

of  M  edical  Men .  303 

Society  of  Arkansas,  The  State  Medicai! !.’.’!!! !  355 
Society  of  Brooklyn,  The  German  Medical. . .  273 

Society  of  Central  Illinois,  The  District  Medi¬ 
cal .  log 

Society  of  Microscopists,  The  American .  27 

Society  of  Munich,  The  Red  Cross .  102 

Society  of  Northwest  Missouri,  The  District 

Medical .  449 

Society  of  Pennsylvania,  The  Medicai !!..!!”!!  034 
Society  of  the  Alumni  of  Charity  Hospital .  548, 

Society  of  the  County  of  Kings,  The  Medical.03’  090  I 
Society  of  the  County  of  New  York,  The  Medi¬ 
cal .  ...  .  494  I 

Society  of  the  County  of  Ontario,  The  Medical  411 
Society  of  the  State  of  New  York,  The  Medical.  411 

Society  of  Virginia,  The  Medical .  158 

Society,  The  American  Chemical . 102 

Society,  The  American  Gynaecological .  298,  323 

Society,  The  Brooklyn  Surgical .  468,  549,  034 

Society,  The  Chicago  Gynaecological .  47 

Society,  The  Koch  Treatment  at  the  County 

Medical . 749 

Society,  The  Luzerne  Co.  (Pa.),  Medicai!.'.'.'!!.'!  102  I 

Society,  The  Macon  (Georgia)  Medical .  603  ! 

Society,  The  Massachusetts  Medical .  604 

Society,  The  Medico-legal . . '.  548  j 

Society,  The  New  York  Obstetrical .  548  i 

Society,  The  Virginia  State  Medical .  438  ' 

Sodium,  Silicate  of,  Some  New  Methods  of  its 

Use  in  Surgery .  725 

Soil  of  Old  Cemeteries,  An  Examination  of' the!  585 

Somnal,  a  New  Hypnotic . 599 

Speech  and  Locomotion  Absent  in  a  Child  Three 

Years  and  a  Half  of  Age . 217 

Speer,  A.  T.  A  Case  of  Morphine  Poisoning 

treated  with  Nitroglycerin .  545 

Spermine . 323 

Sphygmographic  Experiments,  Some  Results  of.  26 

Spina  Bifida .  943 

Spinal  Cord,  Chronic  Softening  of  the .  78 

Spine,  The  Treatment  of  Lateral  Curvature  of 

the . 539 

Spirometry . ..."  333 

Splints,  Seme  New  Lateral  traction  Hip .  511 

Stearns,  H.  S.  The  Clinical  Aspects  of  Koch’s 

Method  in  Berlin .  709 

Stenosis  in  Children,  Mitral . ! ! . .  ".!  *.*  473 

Stenosis  of  the  Duodenum,  Congenital . 153 

Stickler,  J.  W.  Thoughts  and  Observations  at 

1  *  Health  Resorts  ” .  003 

Stjgmata,  A  Case  of . .  .  .  .  641 

Stimson,  L.  A.  A  Contribution  to  the  Study  of 

Appendicitis . . .  449 

Stones  from  the  Female  Bladder,  Removal  of, 

through  the  Urethra .  723 

Stowell,  C.  H.  The  Value  of  Experimental  Ma¬ 
teria  Medica .  600 

Strabismus,  The  Modern  Treatment  of.  !  .*’.'." '  384 

Stricture  of  the  Male  Urethra,  The  Treatment  of 

Organic . . 

Stricture  of  the  Rectum  following  an  Operation 

for  Imperforate  Anus .  497 

Stricture  of  the  Rectum,  Laparo-colotomy  for.  310 

Stricture  of  the  Urethra,  Nervous  Disorders  fol¬ 
lowing  Organic .  388 

Stridor,  Congenital  Laryngeal . .I!.!.'.’!!  473 

Strophanine,  The  Action  of . !.’.’! .  449 

StrophanthuSj  Cardiac  Affections  of  Cniidhood 

treated  with . 

Strophanthus  in  C  rdiac  Disease  in  Children 

St.  Luke,  The  Guild  of . " 

Stomach,  A  Study  of  the  Chemistry  of  the! !  !'.!*. 
Stomach,  Cannabis  Indica  in  Diseases  of  the. 

Stomatitis  Gangrenosa,  with  Special  Reference 
to  its  Treatment  with  Liquor  Ferri  Suhsul- 

phatis .  208 

Stowell,  W.  L.  Blindness  following  Cerebro¬ 
spinal  Meningitis,  with  Recovery  after  Two 

Years . 447 

Strabismus,  Recent  Investigations  in .  179 

Stricture  of  the  (Esophagus,  Cicatricial .  190 

Student,  The  Medical . ’  . . '  495 

Stump  after  Myomectomy,  The  Vaginal  Fixa¬ 
tion  of  the .  499 

Stump  in  Abdominal  Hysterectomy,  The  Vagi¬ 
nal  Fixation  of  the . 499 


PAGE 

Sugar  in  the  Urine,  Tests  for .  40 

Sugars  and  their  Effect  on  the  Organism,  The 

Fate  of . .  .  24 

Sullivan,  J.  D.  On  Stomatitis  Gangrenosa,  with 
Special  Reference  to  its  Treatment  with 

Liquor  Ferri  Subsulphatis .  208 

Sullivan,  J.  D.  Report  of  a  Case  of  Acute  Puru-  ~ 

lent  Pleurisy . . 

Sulphonal  as  a  Hypnotic .  "75 

“  Sundown  Doctors  ” . !.  !!..  .  !..  436 

Suppuration  after  Catara  ct  Extraction !!!!!.' ! .' .' !  74 
Suppuration  of  the  Antrum  of  Highmore  62 

Surgeon-General,  The  Death  of  the .  . 603 

Surgeon-General,  The  Illness  of  the. . .  034 

Surgeon,  The  Army .  543 

Surgeons,  An  Organization  of  Railway .  634 

Surgery,  A  Case  of  Brain . .  . 337 

Surgery,  Ancient,  Mediaeval,  and  Modern!’ A 

Historical  Sketch  of . j . . .  443 

Surgery,  Hypnotism  in  its  Relation  to .  499 

Surgery,  Spinal .  299 

Surgery,  The  Motive  and  Method  of  Pelvic . ! . ! .  721 
Surgery,  The  Present  Position  of  Antiseptic. . . .  505 

Suture  Reels,  Portable .  339 

Swain,  II.  L.  Adenoid  Tissue  "in'  the  Naso-  “ 

pharynx  and  Pharynx .  349 

Svmblepharon,  The  Treatment  of  ....!!!!’!!!! !  55 
S.vmonds,  B.  Tests  for  Sugar  in  the  Urine. .  40 

Syncope  of  Chloroform  Amesthesia,  The  Primary  158 

Syphilis,  A  Case  of  Second  Infection  with . 332 

Syphilis.  Aristol  in  the  Treatment  of  Naso¬ 
pharyngeal .  495 

Syphilis  as  an  Infectious  Disease  in  the  Liffit  of 

Modern  Bacteriology .  343 

Syphilis,  Electrolysis  applied  to  the  initial 
Sclerosis  as  a  Means  for  the  Abortive  Treat¬ 
ment  of .  497 

Syphilis,  Spinal . ..........I...'. . ! ! .’  445 

Syphilis,  The  Coincidence  of  Psoriasis  and .  467 

Syphilis,  1  he  Treatment  of,  by  Subcutaneous 

Injection  of  Mercurial  Preparations .  167 

Syphilitic  Infection  of  a  Wife  by  her  Husband, 


etc. 


643 


198 

606 

32 

539 

1 

280 


Syringomyelia . !!!!!!!!!!!!  613 

Tait’s  Flap-splitting  Operation . .  553 

Talipes  Calcaneus,  A  Criticism  of  Willett’s  Op¬ 
eration  for . . 

Tannic  Acid  as  an  Intestinal  Antiseptic  Remedy 
Taylor.  G.  H.  The  Brandt  Remedial  Methods 

for  Pelvic  Affections . 

Taylor,  H.  L.  The  Treatment  of  Lateral  Curva¬ 
ture  of  the  Spine . 

Taylor,  R.  W.  A  Contribution  to  the  Study  of 

Multiple  Neuritis  of  Syphilitic  Origin . 

Teacher,  Sickness  as  a . .”...!!!!!! 

Temperaments,  A  New  Theory  about. .  .  423 

Temperaments,  Dr.  Gibier’s  Theory  of  504 

Tenorrhaphy . . ' gg 

Testis,  Round-celled  Sarcoma  of  the .  219 

Tests  for  Biuocular  Vision,  New . .  350 

Tetanus,  Bromidia  in  the  Treatment  of .!!!!!!! !  504 

Tetrahydronaphthylamines,  The .  606 . 

Thayer,  W.  H.  Observations  on  Rheumatism 

especially  involving  the  Tonsils .  90 

Therapeutics  as  applied  to  Nervous  Disorders, 

Remarks  on .  34 

Therapeutics,  Studies  in . 347 

Therapeutics,  Studies  in.  Assayed  Galen’icai 

Preparations .  007 

Thiol  in  Skin  Diseases . 211 

Thomas,  F.  S.  Letter  to  the  Editor . .' .' .’ .’ ! ! ! ! .' .' .'  432 
Thompson,  W.  G.  Somnal,  a  New  Hypnotic. . .  599 
Throat  Diseases,  Trichloracetic  Acid  in  435 

Thunder  and  Sour  Milk .  ’  420 

Tic  Douloureux  resulting  from  an  Exostosis  on 

the  Septum  Narium .  443 

Tomato  Poisoning . ...... .  700 

Tompkins,  E.  L  The  Dangers  of  Excessive 

Physical  Exercise . .  539 

Tongue,  On  Exploration  of  the  Movements’ of 


the. 


1&5 


572 

473 

297 

305 

306 


Tonsils,  Supernumerary . 223 

Trance  following  Influenza .  073 

Trendelenburg’s  Operating  Chair ....’.'.!! . 409 

Trichloracetic  Acid  in  Throat  Diseases . . ! ! ! ! ! ! .  435 
Trichophytosis  Capitis,  The  Treatment  of . . . .  643 

Trephining .  "  990 

Trephining  for  Paralysis  of  Speech  following  an 

Injury,  A  Case  of . 42 

Trephining  in  Epilepsy,  The  Medical  Aspect  of.  670 
1  rousseau  and  Horace  Green,  The  Laryngology 

of .  ^  ^  229 


Sublimer. 


210 


Succi,  Signor . !.'!!!"  518 

Suffocation  as  a  Cause  of  Sudden  "Death,  Ac’ci- 

Cental . . .  29 

Sugar,  A  New  and  Rapid  Test  for. . .  .  ."  . .  206 

Sugar  in  the  Blood . , . 279 


Tubercle,  On  the  Strumous  Diseases  of  Child¬ 
hood  and  their  Relation  to .  496 

Tuberculosis  at  Meran,  The  Prophylaxis  of . 586 

Tuberculosis,  Certainty  in  the  Diagnosis  of . 496 

Tuberculosis,  Cutaneous .  334 

Tuberculosis  in  Northern  and  Southern  Coun¬ 
tries,  The  Frequency  of .  535 

Tuberculosis  in  Switzerland  according  to  Alti¬ 
tude,  The  Distribution  of .  . . 

Tuberculosis  in  Vegetable  Forms,  The  Mimicry 
of  Animal  J 


586 

682 


Tuberculosis,  Observations  of  Koch’s  Treatment 

of . .  672 

Tuberculosis  of  the  Pharynx,  A  Case  of  Primary  404 
Tuberculosis,  Poisons  for  the  Bacillus  . .  381 

Tuberculosis  Pulmonalis,  A  New  Local  Therapy  ' 

Ol . . . Qiyry 

Tuberculosis,  The  Contagiousness  of _ 904 

Tuberculosis,  The  Varieties  of  Hepatic...  307 

Tuberculosis  Verrucosa  Cutis . ’  466  641 

Tubes  and  Ovaries,  Removal  of  the . .  615 


I 


736 


[N.  Y.  Mki>.  Jour. 


INDEX  TO  VOLUME  LIT. 


PAGE 

Tumor  of  the  Bladder  diagnosticated  with  the* 

Cystoscope . 217 

Tumor  of  the  Brain .  162 

Tumor  of  the  Heart  Wall,  Sudden  Death  from 

Rupture  of  a  Gummatous .  414 

Tumor  of  the  Quadrigeminal  Region . . .  80 

Tumors  by  Electricity,  The  Question  of  Ampe¬ 
rage  in  the  Treatment  of  Fibroid . 498 

Tumors  of  tbe  Larynx,  Cartilaginous .  345,  360 

Tumors  of  the  Neck,  Large .  606 

Tumors  of  the  Scalp . 167 

Turbinated  Bodies,  Hypertrophy  of  the .  238 

Twins,  The  French  Law  regarding .  355 

Tyndale,  J.  H.  Pnlm  nary  Phthisis  treated  by 

Inoculation  with  Animal  Virus .  602 

Typhoid  Bacillus,  The  Influence  of  the  Level  of 

Subsoil  Water  on  the  Diffusion  of  the .  586 

Typhoid  Fever,  Abscess  of  the  Parotids  compli¬ 
cating. . _ .  413 

Typhoid  Fever,  Irregularities  in  the  Cutaneous 

Manifestations  of . . .  633 

Typhoid  Fever,  Phenacetin  in .  465,  560 

Typhoid  Fever,  Sudden  Death  in  the  Course  of 

Mild .  445 

Typhoid  Fever,  The  Antiseptic  Treatment  of . . .  158 

Typhoid  Fever,  The  Liver  in .  306 

Tyner,  T.  J.  Preliminary  Capsulotomy  in  the 
Extraction  of  Cataract .  320 

Ulcer  of  the  Rectum,  Simple .  389 

Uncleanliness  as  a  Factor  in  the  Causation  of 

Cholera,  Personal .  272 

Universities,  The  German .  548 

University  of  the  City  of  New  York .  74 

University,  The  Johns  Hopkins .  494,  573 

Upson,  H.  S.  On  Two  Cases  of  Muscular  Dys¬ 
trophy .  202 

Uraemia  in  Persons  apparently  Healthy,  Fa¬ 
tal . : . .•  647 

Ureter,  Incontinence  of  Urine  due  to  Malposi¬ 
tion  of  the .  501 

Ureters  during  Labor,  Injuries  to  the .  500 

Urethra,  Impervious  Penile .  330 

Urine  in  Intermittent  Fevers,  The  Toxicity  of 

the .  271 

Urine,  Tests  for  Sugar  in  the . .  . . . 40 

Urine,  Retention  of,  from  Prostatic  Obstruction 

in  Elderly  Men. .  477,  524 

Uterine  Deviations,  The  Surgical  Treatment  of 

Backward . 1 .  110 

Uterus,  Artificial  Prolapse  of  the .  159 

Uterus  Bilocularis  Unicollis,  A  Case  of . 352 

Uterus  during  the  Pregnant  and  Puerperal 
States,  The  Action  of  Hot  Water  on  the. .. .  193 

Uterus,  Fibromata  of  the .  .  . .  107 

Uterus,  Mechanical  Obstruction  in  Diseases  of 

the .  495 

Uterus,  Remarks  upon  Anteflexion  of  the.  .’ _  388 

Uterus,  Results  obtained  by  the  Total  Extirpa¬ 
tion  of  the .  109 

Uterus,  The  Mucous  Membrane  of  the . 727 

Uterus,  Total  Vaginal  Extirpation  of  the .  378 


PAGE 


Vagina,  Absence  of  the .  727 

Vagina,  Rupture  of  the . .  435 

Van  Arsdale,  W.  W.  Note  on  the  Action  of  Py- 

octanin  as  an  Antiseptic .  . 204 

Vance,  R.  A.  Injuries  of  the  Hip  and  Absorp¬ 
tion  of  the  Neck  of  the  Femur .  65 

Vander  Poel,  S.  O.  A  Case  of  Myxoma  of  the 


Vandervoort,  J.  L.  Letter  to  the  Editor .  636 

Vaporizer . 210 

“Varicella  Prurigo,”  A  Case  of  Hutchinson’s..  424 

Varicocele,  A  Review  of  the  Treatment  of .  725 

Vegetable  Forms,  The  Mimicry  of  Animal  Tu¬ 
berculosis  in .  682 

Vegetables,  The  Dissemination  of  the  Typhoid 

Bacillus  by  Edible .  547 

Veins  about  the  Popliteal  Space,  Abnormal  Ar¬ 
rangement  of  the .  727 

Veins,  Chronic  Induration  of  Superficial . 244 

Veins,  Congenital  Sacculations  and  Cystic  Dila¬ 
tations  of .  223 

Veratrum  Viride  in  Puerperal  Convulsions .  217 

Vermifuge,  Cod-liver  Oil  as  a .  47 

Vertebra,  Fracture  of  the  Lamina  of  the  Fifth 

Cervical . ., .  283 

Vertebrae  in  Children,  Injuries  of  the .  667 

Vertigo .  387 

Viburnum  in  Diseases  of  the  Female  Organs  of 

Generation .  657 

Vichy  Waters,  The  Application  of  the .  196 

Vineberg,  H.  N.  Letter  to  the  Editor .  411 

Vintage  Company,  The  California .  467 

Virus,  Pulmonary  Phthisis  treated  by  Inocula¬ 
tion  with  Animal .  602 

Vision,  New  Tests  for  Binocular .  350 

Vital  Statistics  in  France  and  Germany .  587 

Vitreous,  The  Extraction  of  Lenses  dislocated 

into  the .  261 

"Vogel,  The  Death  of  Dr.  Albert .  549 

Voice,  Hoarseness  and  Loss  of,  caused  by  Wrong 

Vocal  Method .  482 

Vomiting,  Induction  of  Abortion  for  Uncontrol¬ 
lable .  465 

Vomiting  relieved  by  Laparotomy,  A  Case  of 

Persistent .  70 

Von  DOnhoff,  E.  The  Management  of  Fractured 

Limbs .  531,  552 

Von  Urff,  C.  A.  Letter  to  the  Editor .  .  521 

Voyage,  Sea .  2~9 

Vulnerary,  Extract  of  Pinus  Palustris  as  a . 412 

Walker,  H.  O.  Perineal  Cystotomy  versus  Su¬ 
prapubic  Cystotomy .  629 

Warts,  Seborrhoeal .  643 

Warty  Growths  in  the  Nose .  345,  360 

Water  of  Zurich  and  Berlin,  The  Influence  of 

Sand  Filters  on  the .  586 

Watson,  B.  A.  A  Historical  Sketch  of  Surgery, 

Ancient,  Mediteval,  and  Modern .  113 

Webster,  D.  Traumatic  Dislocation  of  the  Crys¬ 
talline  Lens . 295 

Wedekind,  L.  L.  von.  Letter  to  the  Editor .  186 


PAGE 


Weed,  C.  R.  Hypertrophy  of  the  Turbinated 
Bodies,  and  the  Evils  resulting  therefrom  . .  238 

Weeks,  J.  E.  Letter  to  the  Editor .  273 

Weil’s  Disease .  806 

Westbrook,  G.  R.  A  Case  of  Double  Empyema. 

Double  Pleurotomy  ;  Recovery. . . .  487 

Westmoreland,  The  Death  of  Dr.  Willis  F.,  of 

Milledgeville,  Ga .  20 

Westphal’s  Successor. . . . 186 

Whitaker,  F.  Letter  to  the  Editor. . . . .  691 

Whitman,  R.  The  Treatment  of  Persistent  Ab¬ 
duction  of  the  Foot . . 406 

Whooping-cough,  Bromoform  in . .  157 

Whooping-cough  with  Antipyrine,  The  Treat¬ 
ment  of .  305 

Wilcox,  R.  W.  Hydrastis,  Viburnum,  and  Pis- 
cidia  in  Diseases  of  the  Female  Organs  of 

Generation . 657 

“  Wild  Melon  ”  of  Australia .  271 

Willett’s  Operation  for  Talipes  Calcaneus,  A 

Criticism  of . 198 

Williams,  H.  F.  A  Vaporizer,  Sublimer,  and 

Air-sterilizer .  210 

Wilmer,  W.  H.  Ocular  Defects  as  a  Frequent 

Cause  of  Headache .  233 

Wiring  the  Separated  Symphysis  Pubis,  etc  ....  496 

Witness,  The  Physician  as  a . 528 

Womb  and  its  Appendages,  The  Relation  of 

Peripheral  Irritation  to  Diseases  of  the .  22 

Women,  Functional  Disorders  of  the  Nervous 

System  of .  528 

Women,  The  Castration  of .  110 

Women,  The  Treatment  of  Cystitis  in .  224 

Women,  The  Use  of  Spirits  and  Malted  Drinks 

in .  24 

Wood,  W.  B.  The  After-treatment  of  Obstetric 

{Yoqziq  ,  1 

Wood,  The  Death  of  Dr.  R.  C  ’. ' '.  '. '. '.  1  132 

Work  at  Great  Altitudes,  Mental .  551 

Wound  of  the  Heart,  Perforating .  327 

Wound  of  the  Knee  without  Injury  to  the  Bones, 

Extensive  Bullet . 469 

Wound  of  the  Scrotum  with  Protrusion  of  the 

Testis . 415 

Wound  of  the  Thorax,  Extensive  Penetrating  . .  216 
Wounds  of  the  Abdomen,  Cases  of  Penetrating 

Stab..... .  495 

Wounds,  The  Local  and  General  Treatment  of 

Gangrenous .  723 

Wright,  J.  Haemorrhage  after  Amygdalotomy, 
with  a  Description  of  a  Galvano-cautery 

Amygdalotome . 234 

Wyeth,  J.  A.  Letter  to  the  Editor  .  520 

Yellow  Fever,  Bacteriological  Researches  in ... .  48 
Yellow-fever  Inoculation,  Freire’s .  586 

Zinc,  The  Treatment  of  Endometritis  with  Chlo¬ 
ride  of .  110 

Zoster,  Epidemic .  642 

Zurich  and  Berlin,  The  Influence  of  Sand  Filters 
on  the  Water  of .  586 


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